you know how sometimes you need to make a split-second decision to change a plan only to find out that your new decision just made things much much worse well now imagine that this is happening to you as you're about to land an aircraft in the middle of the night to stay [Music] tuned being a cargo pilot is a challenging and often wonderful job now I haven't had the luck of trying it out myself but I have plenty of friends who have and whilst most of them absolutely love it there is no getting away from the fact that most carg operations happens at night and that comes with some real challenges during the early 2010s there had been a fierce debate in the United States about improvements of pilot flight time limitations and in January 2012 new rules were actually published those provided more stringent limitations specifically for Pilots conducting passenger trans but curiously not for cargo pilots the cargo airlines had successfully lobbied that these new rules would not be realistic for their type of mostly nocturnal operation and instead pointed to their own fatigue Management Systems which they had negotiated with their own unions now even though the cargo airlines might have had a point there this was obviously a source of great frustration among their pilots which we will soon see here but no matter how you turn it the responsibility for turning up rested for a flight is and has always been shared between both the pilot the airline and the regulator and if anyone of those doesn't do their part well then pilot fatigue can be the result which is worth remembering for this story I will get to the accident flight very soon but before that I want to have a look at the two pilots involved in the story and how they spent their days before this faithful flight the captain was 58 years old and had been working for UPS for almost 23 years he had started his career in the military and moved on to the Regionals and then finally to a flight engineer position on the boing 727 for Trans world now he worked in that position for a while before he upgraded to First officer and interestingly we don't know exactly how much total time he had before joining ups but once he joined he went back to being a flight engineer before again upgrading to First officer on the boing 727 now according to internal UPS record she then tried to upgrade to captain on the Boeing 757 twice in the year 2000 but ended up withdrawing voluntarily from both of those courses since he found them too overwhelming instead in 2004 he changed over to the Airbus a300 Fleet where he continued flying in the right seat for several years before finally upgrading to captain in 2009 his total flying experience in UPS was around 6,400 hours of which 3,265 had been flown on the Airbus a300 now another thing that's worth pointing out about the captain was that he had received po four grades on a few occasions on his recurrent training sessions specifically around his knowledge and execution of non-precision approaches he had for example on a few occasions flown below the minimum descent altitude among other things but that had happened during training sessions where the objective was to train to proficiency so it had never caused any actual fail check rides it was well liked by his colleagues who described him as a diligent nice and competent pilot open to taking inputs from his colleagues but during the month before this flight he had begun to complain about the roster saying that it was getting harder and harder with more and more legs having to be flown and that he doubted that he would have the energy to continue flying like that until he retired during the days before the accident flight the captain had according to his wife been sleeping normally and had before he started his duty tried to take regular naps in order to change his body Rhythm over from day to night shift during the evening before the accident flight his wife had dropped him off at the UPS facility in Charlotte North Carolina where he had then flown as a passive crew member over to Louisville once he arrived there he booked a sleep room at the ups crew facilities and napped for a few hours before the shift started which means that he was likely reasonably well rested and without any huge sleep de at that point the first officer was 37 years old and had been flying for both corporate and Regional operators before she was hired by UPS as a 727 flight engineer back in 2006 she quickly moved over to the 757 Fleet where she upgraded to First officer and she then transitioned over to the 747 on which she stayed for a few years then in 2012 she was again moved over to the Airbus a300 where she had been operating ever since her total time was just over 4,700 hours and out of those she had only flown around 400 hours on the Airbus at the time of this flight her training records were clean and she was described as a top-notch person with good flying skills and her captains liked flying with her but she had recently also started complaining about the roster and how she barely could keep her eyes open in Flight sometimes on one occasion in March 2013 a colleague had actually found her sitting with her face down on a table in the crew room complaining about being totally and completely exhausted before the accident flight she had started her shift flying One Night Flight before having a further long break she then used that break by going visiting a friend in Houston before on the following day going back on a jump seat flight to San Antonio and resuming her Duty that Duty included flying over from San Antonio to Louisville in the late evening of the 12th of August where she would be crewed together with the captain of this story now even though she had mentioned to her husband that she had been sleeping a lot when she was visiting her friend her use of personal electronic equipment showed that she really hadn't gotten that much coherent sleep there and that pattern continued throughout the following day and night as well so this meant that it is likely that the first officer had a substantial sleep death when her shift with the accident Captain started on the 13th of August the day before the accident the two pilots met up in the ups crew room in Louisville around 7 2:30 in the morning and started preparing their flights together everything looked fine so they eventually just walked out the aircraft prepared it for departure and then took off for their first flight over to General Downing Peoria and then their second to Chicago Rockford where they had their scheduled night stop these lights were completely uneventful and they ended up signing into their hotel rooms at around 7 6:30 in the morning but already at around 10:45 only 4 hours later the first officer was seen having breakfast in the hotel restaurant and she then was active on and off during the day until it was time to sign in for their next Duty it is likely that she had a few naps during the day but not enough to cancel out that sleep that that she was now undoubtedly carrying with her the captain on the other hand seemed to have rested properly during the night stop so he was in a quite good mood as the hotel shuttle brought them out to the airport at around 10 minutes past 8 in the evening the duty that they had ahead of them was what's known as a split Duty where they would be operating two flights in the late evening followed by a few hours of rest and then another flight in the very early morning they again started by going through the planning documents which their dispatcher had prepared for them and saw that there would be no major issues during at least their first two flights they decided on fuel to take and then they walked out to the aircraft and started it up as normal having no idea what was soon about to happen and I'll tell you all about that after this I have spent weeks researching everything I could about this accident and that work would have been so much harder if it wasn't for today's sponsor nordvpn my whole team and I used nordvpn a lot both from its VPN function that helps us bypass irritating GE restrictions and to find better prices on everything from rental cars to flights and hotels but also lately because of their great cyber security tools you see Nord has turned into a veritable Shield against annoying ads pesky malware and potential cyber attacks keeping your online experience smooth very free and really really fast I think we all know that there are just so many ways to make mistakes in today's hyperconnected world so for me it feels great to have a tool like nordvpn by my side but don't take my word for it check them out yourself using the link here below which is nordvpn.com pilot this will give you four free months of the 2-year plan and remember you can test it risk-free for up to 30 days and then you get a full refund if they don't meet your expectations thank you Nord and now let's continue before they started they had decided that the captain would be Pilot Flying for the first flight from Rockford over to Peoria and then the first officer was going to fly the second from Peoria over to Louisville both flights went off without any problems and when they finally landed in Louisville around midnight they saw that they would have an almost 3our long break until it was time for their last flight over to Birmingham Shuttlesworth airport this was plenty of time to get some shuty so both Pilots booked a sleep room at the UPS facilities to try to get the most out of the break now at this point you might be wondering what the routines actually were at UPS for avoiding fatigue I've already mentioned that cargo airlines had been Exempted from the coming rule changes regarding crew flight some limitations but that didn't mean that there weren't any rules in place in fact UPS had negotiated with the unions rules that were supposed to mitigate the threat of fatigue and those rules were significantly stricter than the minimum required at the time one super important part of those rules was the Pilot's ability to call in fatigued whenever they felt that it was needed and in that case being taken off the roster immediately with no questions asked this facility was available for all Pilots but there were some strings attached to it you see UPS had put in Forth something known as a sick Bank where a certain amount of days were available for each pilot every year a bonus on top of their regular pay would then be paid out at the end of the year based on the amount of days that were still left in that bank if a pilot called in fatigued this would then be investigated by a dedicated manager and if it was found that the call was made unfairly as in if the pilot had actually had enough rest to avoid fatigue but hadn't used it properly well then a day would be removed from that pilot seek Bank this was supposed to work as a positive incentive for the pilots but anyone who knows humans knows how quickly something like that will start to be seen as a punishment instead and how people will try to avoid losing out on that bonus in whatever way they could at around 0245 on the 14th of August the two pilots came out of their sleep rooms and started preparing for their final flight both of them had managed maned to get a bit of sleep and they now started looking through the briefing material that their flight dispatcher had once again prepared for them on the weather side it showed a weak front that was present just north of the Birmingham area with a low pressure gradient meaning that they could expect very light winds but also some quite low clouds at around 400 ft the low clouds were clearing slowly from the south so at the time the pilots were looking at the observations the cloud ceiling was variable between 600 and 1100 ft on top of this there was also a active notice to Airman notam which indicated that the main Runway at destination Airport runway 0624 would be close for some work on the runway lights between 0400 and 0500 now the airf flight was scheduled to arrive about 10 minutes before the runway would be reopened again so this left only Runway 18 available for landing this Runway was significantly shorter than the main one 7,99 ft instead of 11,990 and it also did didn't have an ILS Precision approach available to it instead there was a localizer and an rnav GPS non-precision approach available and with the clouds as low as they were now indicating this would require an extra alternate to be filed since it was a high likelihood that the pilots wouldn't be able to see the runway from the higher minimas of those approaches the dispatcher who had been planning this flight was well aware of this and had therefore planned for rway 1 18 to be used but he didn't reach out to the crew directly to communicate this slightly unusual circumstance he felt that it was up to the pilots to reach out to him if they had any questions and he didn't want to reach out and possibly insult the captain with information that he thought would be obvious at the time the dispatchers in the US went through annual recurrent training to keep their planning skills high and also something known as DRM dispatchers resource management but that training never included any Pilots if that would have been the case the dispatcher would have probably known that we Pilots always appreciate any help that we can get and no operational information would be seen as improper or insulting and in fact on this occasion it looks like the pilots indeed missed that notum about the closed Runway as some later discussions in the cockpit will soon show and the fact that this whole thing could have likely been avoided if the flight was just operationally delayed by about 15 minutes or so to allow the main Runway to open is just truly truly tragic in any case the pilots now finished up their preparation and then ordered the fuel for the short 45 minute hop down towards Birmingham since the first officer had flown the previous flight the captain would now be flying so as soon as they got out to the aircraft he started setting it up for departure was the first officer did to walk around and checked on the cargo loading the aircraft they were operating was a 10-year-old Airbus a300 powered by two enormous pret and Whitney 4158 turbofan engines and it was in great condition the pilots had asked for 34,600 lb of fuel and with the cargo £9,250 then continue discussing the unfairness of the fact that they cargo pilots would not be included in the new flight time limitations that were being negotiated like if there were second class Pilots or something now I want to clearly point out here that these new rules for passenger carrying Pilots was not yet in Force at this point and even if they had been these Pilots would have still been legal to fly even if they had been subjected to those new rules the captain had only had a slightly shorter rest than required under the new rules a few few months earlier and the first officer was well within these new limits anyway they soon received the last pieces of paperwork and at time 0355 flight 1354 requested push back from the gate and started moving towards their departure Runway Runway 35 right during the taxi out the discussions in the cockpit were professional and to the point and at time 0402 the captain Advanced the trust levers in the cockpit and the giant airb started accelerating down the runway the take off was complet completely normal and they initially climbed Straight Ahead toward 5,000 ft according to their departure clearance they retracted the flaps and slats on schedule and was soon headed over to the departure frequency with the controller cleared them to climb to 10,000 ft and to turned onto an easterly radar heading before finally clearing them South down towards a VR called Bowling Green the first officer entered that VR into the flight management computer and called out nav available and the captain engaged the nav mode now this mode the nav mode will play an important role in what's soon about to happen you see modern aircraft generally follow a predetermined flight plan that have been approved by a traffic control long before the flight actually starts a part of pilot flying's pre-flight preparation is to enter this flight plan into the flight management computer and after that verify it carefully and then execute it so it can be used in Flight when a traffic control then off the departure clears the aircraft to a specific point in this case the Bowling Green VR the pilot will just select that waypoint at the top of the active Flight Plan verify that it looks correct to the navigation display and then execute that routing providing that the aircraft autopilot is then active in the nav mode it will turn and follow this new routing and after that to whatever Waypoint that lies behind it according to the flight plan Air Traffic Control will assume that the aircraft is following the pre-approved flight plan so there's no need to give any further clearances unless they want to give them a shortcut for example and this is how air traffic control can actually handle thousands of flights per day because the aircraft are basically navigating autonomously Now using that flight plan the flight management computer will also be able to calculate when they should start to descend for example based on its calculated track mass and as long as nothing changes we Pilots will basically just need to ask for descent then manage the aircraft speed and configuration the navigation both laterally and vertically will be done perfectly by the computer but the FMC is not an intelligent computer and will only do exactly what it's told because of that it is susceptible to something we Pilots refer to as in out meaning that if we don't program it properly it can start showing all sorts of wrong information and that's worth keeping in mind the aircraft was eventually cleared to climb to their Cruise level of flight level 280 and around that same time the controller also told them to continue straight towards Birmingham Airport now this clearance would wipe out all of the other points that the pilots had entered into their flight plan and just replace them with a straight line towards their destination airport in order to make that happen the first officer would have entered the airport's EA identification code kbhm into the FMC and then put that on top of the legs page as the new active Waypoint basically telling the aircraft to just fly there but of course in reality the aircraft wouldn't actually fly all the way to the airport at some point they would have to break away from this direct routing and intercept an instrument approach into whatever Runway they would use at Birmingham and the pilots obviously knew that if a direct like this is entered and nothing else is done to crop the route into something more realistic the aircraft FMC will assume that the pilots will fly all the way until they're overhead to the airport and then turn back out and fly whatever approach they had plan for adding a lot more track miles to the route than they would actually fly like I said it is a little bit stupid so the way this is normally dealt with at least in my Airline is that the pet monitoring will then create a new Waypoint which is maybe 20 nautical miles short of the airport on the direct twole and then connect that new Waypoint with whatever approach they're expecting this will then obviously have to be very closely monitored that it's not actually the clearance they have been given just an estimation but it will give a far more accurate picture of what is likely going to happen and therefore help the FMC to calculate a more accurate descent path but in this case this was not done and neither of the pilots noticed this discrepancy on the legs page in the FMC CDU this issue was shown as a rout discontinuity message after the kbhm point letting the pilots know that the FMC didn't know what they want to do after that anyway soon after this direct routing was received the first officer went off frequency to listen to the Burmingham automatic terminal information service 8s and to write down the weather and approach information8 this information Papa was active and it said that the winds were calm visibility 10 mies with a broken Cloud layer at 1,000 ft and another one at 7,000 ft on top of that it also informed the pilots that the localizer for Runway 18 was in use since Runway 0624 was closed the information of the runway closure apparently came as news to the pilots with the captain just commenting localize the 18 it figures this just showed that he probably felt a little bit frustrated with having to fly a much more complicated maneuver at 5:00 in the morning the first officer also chimed in and pointed out that this was typical because they were a little bit heavy and now they had to land on the much shorter rway 18 again this information had been available to them on the planning stage and if they would have read it they would have also known that the main Runway was scheduled to open less than 15 minutes after the scheduled arrival time another thing that I want to point out here is that even though the 80s and also some ACR messages that the crew had received showed a nice and High Cloud base of around 1,000 ft over the ground the reality was actually a bit different there were scores of lower clouds still present in the area bringing the cloud base down to as low as 300 ft in places but at the time of this observation none of those were present exactly over the runway where the cloud base was being measured the meteorologist who had sent out this weather had included this information in a special note but because of some issues with the aar's weather formatting UPS had actually stopped including those type of notes in the weather report sent out to the aircraft and the same actually went for the tower controller who had updated the 80s he could also have included those type of side notes in the 80s if he wanted but there were no clear instructions on exactly what type of weather that needed to be included in those type of notes so he had just skipped it what that all meant was that as the captain was now starting to prepare for the localizing non-precision approach he and his colleague had likely a mental model of the weather which was dramatically better than than what it actually was and that brings us to the type of approach that they were now preparing to fly like I already mentioned it was a localizer approach and as its name suggests it's flown using a localizer signal as the horizontal Guidance the localizer is obviously one half of an ILS approach but without the Glide slope vertical guidance meaning that it's much more complicated to fly and gives less guidance hence it's regarded as a non-precision approach in a few of my previous videos I've explained that non-precision instrument approaches who are flown without vertical guidance can be flown either as a constant descend approach CDA or a step down approach where the safest option is the CDA a constant descend will ensure a more stabilized approach without any large changes in trim and thrust needed to level off between the different minimum altitudes so this was what the crew were now preparing for a CDA could be flown either with a use of vertical speed and carefully verifying distances versus calculated altitudes or with the use of the vertical nav path with the aircraft would be flying a pre-programmed path down to a specific altitude over the threshold and that's what the captain was now planning for he started his briefing by going through a special non-precision approach checklist which highlighted all the important steps including which minimum descent altitude MDA to use in this case 1,200 ft and it then continued with how the approach was going to be flown including all of the relevant points on the instrument approach charts as the captain was briefing the first officer was dealing with the radios and was soon handed over to the Atlanta Center controller this new controller told them to descend to flight Level 240 at their own discretion and the first officer read that back and at the same time a FedEx aircraft with the same call sign number FedEx 1354 also appeared on the frequency and when they heard this both Pilots mentioned this Potential Threat of ATC mixing up their call signs this at least to me showed that they were both pretty switched on at this point and well into the game the captain initiated their descend at time C 432 and when they informed the controller about this he did indeed mix them up with the FedEx aircraft which the two pilots had a little Shuckle about all in all the atmosphere in the cockpit was pretty good at this point next they were handed over to the Memphis control center where they were soon clear to descend further down to 11,000 ft this was also read back by the first officer and after the captain had selected his new altitude in the mode control panel he said they're generous today you usually they kind of take you to 15 and then they hold you up high and this the captain's anticipation of being held high by ATC will soon become important next they were handed over to the Atlanta controller who gave them the latest ultimative setting for Birmingham 29. 96 in Mercury and once the crew had set this the captain asked for the approach checklist so far this flight was flown perfectly according to UPS standard procedures but that would soon change at around s 440 the background sound on the cockpit voice recorder could be heard decreasing which is a sign of the aircraft slowing down as this was happening the captain said want too which was likely said as a reminder for the first officer since it was actually her who should have called that she repeated it and then told the captain that she would ask for lower what was likely going on here was that the aircraft had been descending down towards 11,000 ft according to its pre-programmed path but as they were now getting closer the captain started to reduce use the speed to slow The Descent down but also to reduce their kinetic energy speed instead of their potential energy altitude we always tend to do it this way when we are being kept High by ATC as it will enable us to regain the path by descending with a higher speed later once a lower altitude clearance is received the first officer asked the controller for lower to which he answered that they would need to switch over to the Birmingham approach controller for that and this type of thing it happens all the time and it's super annoying to have to switch over to another frequency and check in when you see that you're already getting high on the approach PA but apart from anticipating it there is not much more you can do anyway as soon as the first officer checked in with the Birmingham approach they were immediately cleared to descend of 3,000 ft and the controller also told them that the main Runway was still closed and asked if they wanted to proceed for the localizer 18 the first officer responded a firm and the controller then told them to turn right 10° and to joined the localizer on that heading maintaining 3,000 ft now here a couple of crucial things happened first remember what I said about the importance of having the flight management computer updated to make sure the most accurate information was always there well in this case this turn to the right would have meant that the captain would have selected The Heading mode on the out the pilot and then turned the aircraft about 10° to the right and since the nav mode was now no longer used this would have enabled the first officer to go into into the flight management computer and select the first point on the approach as the active Waypoint and then execute that she could have also extended the center line which I won't go into how to do here but both of these techniques are referred to as sequencing the waypoints and are absolutely crucial to do in order to get the correct path on the coming approach but instead of doing that the first officer instead started joking about how the controllers questions regarding if they wanted to proceed for the localized Runway 18 was a little bit weird since they didn't have have much of a choice in the matter the captain agreed and some general Amusement ensued but of course if they would have actually read the notum they would have known that this question was probably asked because the main Runway would open up in around 18 minutes in any case this jittery conversation meant that the way points in the FMC was never updated or sequenc and the captain didn't notice it this in turn meant that the FMC now thought that it had a lot more track miles than it actually had and therefore started showing that the aircraft was well below the profile but curiously after the pilots had stopped laughing about the atc's silly question the captain now asked for gear down and this was very early to do that he then remarked ah and they keep you high which was followed by a few similar remarks from the first officer in reality they were not particularly high at this point so it's likely that already out here the captain had actually started gaining a faulty situational awareness of their profile it is possible that the fact that the vertical iCal profile was now showing them as very low was somehow misinterpreted by the captain as being very high instead just based on his anticipation of ATC leaving them high in any case they were now descending fast down toward 3,000 ft and the captain had armed the localizer mode to capture the inbound signal but if they would have looked closer on their navigation display and their FMC CDU they would have seen that the painted track still continued towards the airport and that there still was a flight plan discontinuity written on the CDU but this didn't happen this was of course a serious Omission by both of the pilots and this jid the attitude that they were now showing could potentially be a sign of onsetting fatigue at time 0443 and 24 seconds the controller cleared the aircraft for approach and told them to descend to 2,500 ft to maintain until they were established on the localizer the crew complied with that and only a few seconds later the localizer came alive and captured turning the aircraft towards the runway from this point onward they were clear to descend according to the minimum altitudes on the approach short but that initially didn't happen the first charted minimum altitude was 2,300 ft to maintain until a point called Basin but instead of setting that the crew just continued descending to their last cleared altitude 2,500 ft the captain asked the first office to activate the approach in the FMC if she hadn't already done so and she answered okay you see in the Airbus a300 you need to physically activate the approach by selecting it in the FMC in order for the path to become active and the captain was likely hoping that this would fix the issue with the strange path that he was now seeing a few seconds later the first officer had completed the task but since the FMC points still weren't sequenced the vertical path deviation symbol remained pegged at the top indicating that they were more than full scale or 400 ft below the path as they descended to 3,500 ft the captain asked for the slats to be extended and he also exclaimed unbelievable likely referring to what he still perceived as being kept high the first officer just agreed with a slight Shuckle and then she extended the slats for him the captain asked for flaps 15 to be extended which the first officer also did as they were handed over to the new approach frequency with the same controller and as soon as they switched the frequency over the controller now cleared UPS flight 1354 to land R8 which would be the last message to the crew the captain continued slowing the aircraft down and asking for more flaps and at time 0 445 and 50 seconds he called for flaps 40 and the landing checklist to be completed just 5 seconds after that he also asked for the missed approach altitude of 3,800 ft to be set and setting a new altitude was important here because without that he would not be able to continue descending but since the Mis approach altitude was higher than their current altitude they would now been nothing stopping them from descending all the way down to the ground the aircraft had now leveled off for 2,500 ft and the captain must have been expecting that the vertical path would soon become alive so that he could engage the path mode but it was still sequenc strong so it just continued showing maximum fly up indications with no tendency of moving around here as they were passing overhead the Baskin point the captain must have understood that something was wrong but instead of telling this to the first officer he just selected vertical speed instead and now started descending this was not what they had briefed and he was now effectively flying an unbathed dive and drive step down approach instead of the briefed CDA he initially selected a Descent of 700 ft per minute which would have been quite okay but soon increased that to 1,000 ft per minute instead was also still muttering about being kept high the first officer had now completed the landing checklist and noticed that they were flying in vertical speed and not in part as they briefed so she said um let's see you're in ver vertical speed okay the captain responded yeah I'm going to do vertical speed yeah he kept us High all of these comments shows a captain who was unreasonably worried about the 200 fet above profile they actually were here and the fact that they actually were this High not because of ATC but because he hadn't descended down to the appropriate minimum altitude those comments just doesn't really sit right with me I think that it's way more likely that he had indeed misinterpreted the indicated vertical profile as extremely high instead of what it actually said extremely low it's very hard to know why an experienced Captain would make such a mistake but it is possible that the expectation bias of being kept High coupled with the effects of flying in the middle of the window of circadian low could maybe be an explanation in any case this misconception was further shown when a few seconds later he said and we're like way high or higher the first officer who obviously didn't suffer from the same illusion responded um about a couple of hundred feet to which the captain answered yeah but it didn't reduce his descent rate instead he increased it to about 1,500 ft per minute now he did call out uh all right so at 3.3 we should be at 1380 which indicated that he was monitoring the altitude slightly here located at 3.3 mil distance was the Point IM toy which had a 1,380 ft restriction on it and the aircraft would be Crossing that altitude almost exactly after that they would be able to descend down to their minimum descent altitude of 1,200 ft which was about 600 ft over the ground meanwhile the first officer was adjusting the M approach altitude on the mode control panel and then as they passed 1,530 ft she correctly called out there's 1,000 ft instrument cross checked no Flags indicating that they were now 1,000 ,000 ft above the ground the captain responded with uh all right uh the The Da is 1,200 showing that he knew that this was the next hard altitude but do you remember what else had been reported to be about 1,000 ft above the ground yeah the cloud base it is very likely that the crew was now fully expecting to start breaking out of the clouds and seeing the runway but what they didn't know was that a layer of lower clouds had now moved in over the Final Approach obscuring The View down to a much lower height we cannot know this for sure but it is likely that both Pilots now started scanning out through their cockpit Windows looking for the runway through the still dense clouds meanwhile the aircraft was descending with 1,500 ft per minute a much higher rate and the highest vertical speed approved for a stabilized approach below 1,000 ft in the UPS manuals it was clearly stated that 1,000 ft per minute was the highest rate allowed under normal un briefed circumstances and if the rate was higher than that well then a go around was mandatory anyway next it was now up to the first officer to call out approaching minimums and minimums as they approached the 1,200 ft MDA but those calls were never made instead she said it wouldn't happen to be actual which can be interpreted as her referring to the actual instrument meterological conditions they were actually inside and that would further corroborate the idea that she was likely looking outside at this point now there was an automatic call out both for 500 ft and minimums provided by Airbus for the air300 which if they were installed would have made these call outs anyway but UPS had chosen to disable that feature on their Fleet now obviously the captain was Pilot Flying and therefore in charge of managing the flight path so when he passed the MDA with no Runway ins sight he should have gone around or at least leveled off even without any call outs but that also didn't happen in that the aircraft was now well below the MDA and the correct profile and was still descending the captain soon called out 2 miles which strangely indicates that he must have been monitoring at least some of his instruments here but only 13 seconds later the gpws system delivered its first caution syn rate this was almost immediately followed by the captain mumbling there it is indicating that he now likely saw the runway and what he saw must have been utterly terrifying the was at this point at a height of only around 250 ft over the ground over a mile away from the runway so all four poies must have been glowing bright red here indicating just how low they were the captain responded by immediately reducing the vertical speed to 600 ft per minute which was obviously still too much and he then called out oh I got the runway 12:00 to which the first officer responded uh got the runway in sight uh the captain now also called that he would be disconnecting the outer part pilot but it was sadly too late 2 seconds after this the out pilot off warning could be heard and this was almost immediately followed by the first sound of impact as the wings and the AF part of the aircra smashed into trees and power lines in their path this was an immediately followed by a too low terrain gpws warning which came late because the aircraft was so close to the airport at this point that the gpws warning envelope had been reduced in order to avoid nuisance warnings the captain called out oh did I hit something immediately followed by several even louder impact sounds at the aircraft slammed into an earth Mound about one mile prior to the threshold the impact severed the aircraft into several different pieces with the cockpit and forward part being severely compressed and the aart almost immediately bursting into flames in the tower the controller hadn't received any warnings about the dire situation of the aircraft Instead at time0 447 and 41 seconds he could just see a huge Fireball Rising towards low clouds at the far end of the airport and even though he saw this it took him over 1 minute to press the crash alarm and that happened because the control screen had a different layout between the day shift and the night shift and he therefore just initially couldn't even find the button after that there was some initial telephone confusion between all of the involved rescue teams where the rescue leader didn't even realize that a crash had already taken place but that initial confusion was quickly sorted out and the fire Services rapidly reached the wreckage but there was sadly nothing they could do both Pilots had perished from the pure impact forces the investigation concluded that the probable cause of this accident was the Pilot's continuation of an unstabilized approach and their failure to monitor their aircraft altitude which led them to descend below the minimum descent altitude and then into terrain the reasons this happened included all of the factors that I've already mentioned in this video and the investigation led to several important recommendations all of which I will include on my website to which you can find a link to below but the most important lessons that came out of this included more collaborative training around the area of fatigue both between The Regulators the Airlines and the pilot unions this was to make sure that the reporting systems and prevented measures were understood by everyone involved and that their use would be strictly non-punitive the first officer was found to have been s uffing from a big sleep debt mostly because she hadn't utilized her scheduled rest time in an efficient way and this likely had a big effect on her performance it is hugely important that we realize that fatigue can affect us in a very negative way and that the responsibility for dealing with fatigue is shared between everyone including ourselves other outcomes from this included stronger call for making constant descend approaches mandatory for commercial aircraft and more information sent out to Pilots about the lower gpws warning Market margins when close to an airport Airbus was also told to improve warnings in the cockpit when the FMC is not properly set up and to make those automatic call out standard and not an option now if you have more questions about this or want something clarified then please consider joining my patreon crew we can discuss this directly with me in our next hangout and there's a link that you can use to sign up somewhere here on the screen or in the description below have an absolutely fantastic day and I'll see you next time bye-bye
