IncreasingLearningfromAccidents:ASystemsApproachIllustratedbytheUPSFlight1354BirminghamAirportAccident

ShemMalmquistNancyLevesonJamesPerryGusLarard

DarrenStraker

Outline

•  WhatHappened•  WhydiditHappen?

–  NTSBConclusions–  CASTConclusions–  Comparisons

WhatHappened?(fromNTSBreport)•  OnAugust14,2013,0447CDT,UPSflight1354,anAirbusA300-600,

crashedshortofrunway18duringalocalizernonprecisionapproachtorunway18atBHM.

•  Captainandfirstofficerwerefatallyinjuredandplanedestroyedbyimpactandfire.

•  Variableinstrumentmeteorologicalcondi\onswithavariableceilingprevailedonapproachcourse.

•  FlightcamefromLouisvilleabout0503EDT

•  NOTAMineffectindictedrunway06/24,longestrunwayatairportandtheonewithaprecisionapproach,wouldbeclosedfrom0400to0500CDT.–  Becausefightscheduledtoarriveat0451,onlyashorterrunwaywitha

nonprecisionapproachwasavailabletocrew.

–  ForecastedweatheratBHMindicatedlowceilingsuponarriverequiredanalterna\veairport

–  Dispatcherdidnotdiscussthelowceilings,thesingleapproachop\ontotheairport,orthereopeningoflongerrunwayabout0500withcrew.

–  Duringflight,informa\onaboutvariableceilingsatairportnotprovidedtoFC

ATIS

•  BirminghamAirportinforma\onPapazeroeightfivethreeZuluobserva\onwind

calmvisibilityonezero.skycondi\onceilingonethousandbroken.seventhousandfivehundredovercast.temperaturetwothree.dewpointtwotwo.al\metertwo

ninerninerseven.localizerrunwayoneeightinuse.landinganddeparOngrunwayoneeight.noOcetoairmenrunwaysixtwo-fourclosed.alldepar\ngaircrabcontacttoweroneoneninerpointninerforclearancetaxiandtakeoff.advisecontrolleronini\alcontactyouhavePapa.

•  Beforedescent,whileondirect-to-KBHMlegofflight,captainbriefedthelocalizerrunway18non-precisionprofileapproach.

•  Firstofficerenteredapproachintoairplane’sflightmanagementcomputer(FMS).

•  Intendedmethodofdescent(a“profileapproach”)

•  glidepathgeneratedbytheFMStoprovidever\calpathguidancefromthefinalapproachfix(FAF)tothedecisional\tude

•  Runway18decisional\tudeof1200bmsl

•  Airtrafficcontrollerclearedtheflightforthelocalizer18approach.

•  CrossedFAF200feethigh

•  About7secondsaberthefirstofficercompletedtheBeforeLandingchecklist,thefirstofficernotedthatthecaptainhadswitchedtheautopilottover\calspeedmode;shortlythereaber,thecaptainincreasedthever\caldescentrateto1500fpm.

•  Firstofficermadetherequired1000-b-above-airport-eleva\oncallout,andthecaptainnotedthatthedecisional\tudewas1200bmslbutmaintainedthe1500fpmdescentrate.

–  AlthoughtheapproachviolatedthestabilizedapproachcriteriadefinedintheUPSflightopsmanual,theydidnotperformago-around.

–  Astheairplanedescendedtotheminimumdescental\tude,thefirstofficerdidnotmaketherequiredcalloutsregardingapproachingandreachingtheminimumdescental\tude

–  TheCaptaindidnotarrestthedescentattheminimumdescental\tude.

•  Theairplanecon\nuedtodescend.

•  At1000bmsl(about250babovegroundlevel,anenhancedgroundproximitywarningsystem(EGPWS)“sinkrate”cau\onalertwastriggered.

•  Thecaptainbegantoadjustthever\calspeedinaccordancewithUPS’strainedprocedure.

•  Hereportedtherunwayinsightabout3.5secondsaberthe“sinkrate”cau\onalert.

•  Airplanecon\nuedtodescendatarateofabout1000fpm.

•  Firstofficerconfirmedshealsohadtherunwayinsight.

•  About2secondsaberrepor\ngtherunwayinsight,thecaptainfurtherreducedthecommandedver\calspeed,buttheairplanewass\lldescendingrapidlyonatrajectorythatwasabout1nau\calmileshortoftherunway.

•  Thecockpitvoicerecorderthenrecordedthesoundoftheairplanecontac\ngtreesfollowedbyanEGPWS“toolowterrain”cau\onalert.

GiventhisdescripOon:

•  Whatcause(s)wouldyouascribetotheaccident?

•  Arethereanyaddi\onalques\onsyouwouldwantanswered?

NTSBConclusions•  ProbableCause:

–  Flightcrew’scon\nua\onofanunstabilizedapproachandtheirfailuretomonitortheaircrab’sal\tudeduringtheapproach,whichledtoaninadvertentdescentbelowtheminimumapproachal\tudeandsubsequentlyintoterrain.

•  ContribuOngtotheaccidentwere:1.  Flightcrew’sfailuretoproperlyconfigureandverifytheFMScomputer

fortheprofileapproach2.  Captain’sfailuretocommunicatehisinten\onstothefirstofficeronceit

becameapparentthever\calprofilewasnotcaptured.3.  Flightcrew’sexpecta\ontheywouldbreakoutofthecloudsat1000b

abovegroundlevelduetoincompleteweatherinforma\on.4.  Firstofficer’sfailuretomaketherequiredminimumcallouts5.  Captain’sperformancedeficienciesduetofactorsincluding,butnot

limitedtofa\gue,distrac\on,orconfusion,consistentwithperformancedeficienciesexhibitedduringtraining

6.  Firstofficer’sfa\gueduetoacutesleeplossresul\ngfromherineffec\veoff-duty\memanagementandcircadianfactors.

System’sApproach•  Looksnotonlyathowpilot’scontributedtoaccidentbutwhythey

believeditwastherightthingtodoatthe\me.•  Safetytreatedasacontrolproblem,notafailureproblem

–  Whywerecontrolsnoteffec\veinthiscase?–  Howcantheybeimprovedforthefuture?

Hazard:ControlledFlightintoTerrain(CFIT)–  Usedtobemostcommontypeofaccident–  Muchhasbeendonetoreduceoccurrence–  Whydidn’tthesecontrolsworkthis\me?

controlstructure

Ind. Pilots

Assn.

FAA

ATO

Airport Management

Airport PhysicalCFIT

Controls

AirportOps

BHM

ATC UPS

Dispatch

Dispatch

Mgmt

Management

OEMs

FlightCrew

Electronics

Aircrab

OASS AFS Cert.

ControlsforCFIT•  Airportphysicalcontrols

–  ILS–  PAPI

•  MSAWandATC•  AircrabElectronics

–  FMS–  EGPWS–  Autopilot–  Displays

•  Capt.Flying,PilotMonitoring•  UPSDispatcher•  UPSDispatchmanagement•  Airbus/Honeywell•  Ind.Pilot’sAssocia\on•  FAA(FlightStandards,AirportSafetyandStandards,ATO,Cert.)

ComparisonofFactorsIdenOfied

•  NTSB(probablecause,contributorycauses,findings)vs.CAST

•  CASTfoundsomecontribu\ngfactorsnotiden\fiedbyNTSB

•  CASTiden\fiedallofNTSBfindings

•  CASTiden\fiedseveraladdi\onalfindings

FAAOfficeofAirportSafetyandStandards

Ind. Pilots

Assn.

FAA

ATO

Airport Management

Airport PhysicalCFIT

Controls

AirportOps

BHM

ATC UPS

Dispatch

Dispatch

Mgmt

Management

OEMs

FlightCrew

Electronics

Aircrab

OASS AFS Cert.

Flightcrew-Electronics

Ind. Pilots

Assn.

FAA

ATO

Airport Management

Airport PhysicalCFIT

Controls

AirportOps

BHM

ATC UPS

Dispatch

Dispatch

Mgmt

Management

OEMs

FlightCrew

Electronics

Aircrab

OASS AFS Cert.

•  AstheLOCwasprovidinglateralguidancetheaircrabcoulds\lltrackthedisplayedfinalapproachtrackdespitethelackofwaypointsequencing.

controlstructure

Ind. Pilots

Assn.

FAA

ATO

Airport Management

Airport PhysicalCFIT

Controls

AirportOps

BHM

ATC UPS

Dispatch

Dispatch

Mgmt

Management

OEMs

FlightCrew

Electronics

Aircrab

OASS AFS Cert.

Contextualfactorsexample

HowdidflightendupflyingtheLOC?FromPilotinterac\ons•  CrewmissedNOTAMFrompilotinterac\ons•  LOCapproachshownearlierinchar\ngsequenceFromATC-Pilotinterac\ons•  Controllerofferedit

DispatchrecommendaOons

•  Dispatchersshouldproac\velyprovideinforma\ontoflightcrewsregardingthestatusofapproachesandwhyapar\cularrunwayandapproachislistedinflightplan.

•  Ensurethatdispatchersconsiderifacrewmightbefa\guedandhowthatmightimpactthepilot’scogni\veprocessessodispatchercanactproac\velyaccordingly.

•  Reviewworkloadfordispatcherstoensuretheycanprovideactualjointauthorityforindividualflights.Currentworkloaddoesnotallowfortheindividualizedanen\ontodetailsthatcanpreventaccidents.

•  Providecomputerassistancethatdoesnotencouragerelianceandunques\oningacceptanceofoutputs.

FAA

Ind. Pilots

Assn.

FAA

ATO

Airport Management

Airport PhysicalCFIT

Controls

AirportOps

BHM

ATC UPS

Dispatch

Dispatch

Mgmt

Management

OEMs

FlightCrew

Electronics

Aircrab

OASS AFS Cert.

FAArecommendaOons

•  TheFAAshouldconsiderevalua\ngthecommunica\onsandcoordina\ondeficienciesimplicatedinthislossandwhethertheyaremorewidespreadthantheyarebelievedtobe.Wasthisjustaone-\meeventorarecommunica\onandcoordina\ondeficienciesmorewide-spreadthanbelieved?

•  Therolesofdispatchandpilotsandhowtheyinteractneedtobeclarified.

Systemicfactors

Ind. Pilots

Assn.

FAA

ATO

Airport Management

Airport PhysicalCFIT

Controls

AirportOps

BHM

ATC UPS

Dispatch

Dispatch

Mgmt

Management

OEMs

FlightCrew

Electronics

Aircrab

OASS AFS Cert.

SystemicFactors•  SafetyCulture(cargopilots)•  Safetyinforma\onsystem•  Dynamicsandchangeover\me•  Communica\onandCoordina\on

amongcontrollers

SystemicrecommendaOons

•  FAAandcargoaircrabpilotassocia\onsshouldinves\gatewhethertheac\onsofthecargooperatorindustryhasledtomoresuspicionandlesstrustbythepilotsofthosecarriers.

•  TheFAAandcargoaircrabpilotassocia\onsshouldins\tuteastudyofwhethercargoaircrabaretreateddifferentlybyairportsandwhetheranydifferencesresultinhigherriskforcargoaircrab.

SystemicrecommendaOons

•  Iden\fyandimplementchangestotheinforma\onsystemtoensurethataccurateweatherinforma\onisavailablewhenneededandtothosewhoneedit.

•  TheFAAandotherindustrygroupsshouldstudywhethertheincreaseincargoopera\onshaschangedorincreasedthelevelortypesofhazardssuchthattheyarenolongeradequatelymi\gatedbycurrentproceduresandcontrols.

•  Subjectchangesintheprovisionofcri\calinforma\ontoahazardanalysis.

Summary

•  U\lizedGroupChairfactualreports

•  Contribu\ngcontrolac\ons(factors)easilyiden\fiablefromcontrolstructure

•  Recommenda\onsstemmedfromcontribu\ngcontrolac\ons.