UPS 1354 Final Report and Video Companion
The American National Transportation Safety Board released their final report on UPS flight 1354 this week.
The tragic accident happened 14th August 2013, when a UPS Airbus A300-600 crashed short of the runway at BHM in Birmingham Alabama. The crew were killed and the aircraft destroyed in what was an entirely avoidable crash.
The National Transportation Safety Board determines that the probable cause of this accident was the flight crew’s continuation of an unstabilized approach and their failure to monitor the aircraft’s altitude during the approach, which led to an inadvertent descent below the minimum approach altitude and subsequently into terrain. Contributing to the accident were (1) the flight crew’s failure to properly configure and verify the flight management computer for the profile approach; (2) the captain’s failure to communicate his intentions to the first officer once it became apparent the vertical profile was not captured; (3) the flight crew’s expectation that they would break out of the clouds at 1,000 feet above ground level due to incomplete weather information; (4) the first officer’s failure to make the required minimums callouts; (5) the captain’s performance deficiencies likely due to factors including, but not limited to, fatigue, distraction, or confusion, consistent with performance deficiencies exhibited during training; and (6) the first officer’s fatigue due to acute sleep loss resulting from her ineffective off-duty time management and circadian factors.
I’m most impressed with a new initiative at the NTSB to release a companion video to accompany their final report. Take a look:
The eight-minute video is excellent. Experts explain the sequence of events which led to the crash to a backdrop of relevant video, including footage from the NTSB on-site investigation. It makes for compelling video with a focus on facts rather than drama.
This is the first video but the NTSB plans to produce them as standard for major accidents in the future. The Chairman, Christopher A Hart, explained: “People consume information and absorb lessons in different ways. This video is another way to reach pilots and aviation safety professionals with the lessons we learned through our investigative work.”
I’m very pleased to see them make the lessons learned from an investigation more accessible
even though it might put me out of a job. I’m looking forward to seeing more companion videos accompanying those accidents with complicated conclusions. It’s also made my post this week very easy, so I’m off to the pub! I’ve got a great guest post for you on planes and beer next Friday. The week after that, I have exciting news for you regarding the next book in the Why Planes Crash series. So watch this space!
Or, you know, just subscribe and receive once-a-week updates when I post:
Either way, I hope to see you here in two weeks for my exciting news.