Missing The Signals | FedEx Flight 1478 | Air Crash Investigation

this Boeing 727 was on an approach to Tallahassee Regional Airport it had a very fatigued crew and a flight member that had a condition that would eventually lead to disaster you're going to want to stay till the end of this one because I guarantee you'll be shocked at what this is and how it played its part on the 26th of July 2002 Federal Express flight 1478 a Boeing 727 was flying a scheduled cargo flight from Memphis international airports to Tallahassee Regional Airport in Florida the scheduled departure time was 0 4 12 or 12 minutes past four in the morning and the crew were operating on an instrument flight rules Flight Plan as this was a cargo flight there were only three crew members on board which was the captain the first officer and the flight engineer the captain who was the non-flying pilot for this trip was 55 years old and he had between 13 to 14 000 total flying hours 2754 of them were as a 727 flight crew member including 861 hours as a pilot in command on the 727. on the previous two nights leading up to this trip the captain had not had the best amount of sleep his family dog was in deteriorating health and he was staying awake longer than usual to look after the dog this also led to him sleeping downstairs on the couch to keep an eye out on the dog's health on the day of the trip the captain report is not feeling fatigued the first officer who was going to be the pilots flying for this trip was 44 years old and had about seven and a half to eight and a half thousand total flying hours 1983 of those hours was as a 727 flight crew member the first officer was currently on the reserve schedule which meant that they reversed day and night sleeping on consecutive days which meant that his sleep was very broken and he didn't really have a good sleep pattern on the day before this flight the first officer had flown from Grand Forks International Airport in North Dakota to Memphis this flight landed about four hours before Flight 1478 was due to depart and when he arrived at Memphis the first officer received a notification that he was scheduled to work this flight he first checked this did not violate existing FedEx or Pilot Union agreements and would not result in him exceeding his flights and Duty limits he then accepted the trip and slept for one and a half hours in the private sleep rooms at FedEx's crew rest facility after this time he then met with the captain to prepare for this flight the flight engineer that was on board was 33 years old and had a total of 2 600 flying hours with 346 flying hours as a 727 flight engineer on the day before this trip he had flown from Ottawa McDonald Cartier International Airport in Ottawa and rested for about six and a half hours before then returning to Memphis he arrived at Memphis at midnight and then began preparing for Flight 1478 at zero one thirty five their scheduled departure time was zero four twelve but due to the adjustment of a cargo pallets underneath the aircraft the aircraft was then pushed back at zero four twenty four the crew then subsequently taxied were cleared to take off and climbed to 32 000 feet or flight level three two zero the crew then entered the cruise and about 200 miles from their destination the flight engineer received weather information for Tallahassee Regional Airport this indicated that there were scattered clouds at 100 feet 18 000 feet and 25 000 feet wind was from one to zero at five knots visibility was nine miles and the temperature and dew points were at 22 degrees Celsius the engineer then relayed this information to the captain and the first officer and they decided that they would land on Runway 2-7 at Tallahassee flight 1478 was then cleared to descend and maintain flight Level 240 and at the same time the flight engineer contacted FedEx ramp personnel and advised them that flight 1478 was about 30 minutes from the destination and they were looking for a parking spot and Power the FedEx ramp Personnel then advised them to use gate number two and to park facing south the flights engineer then briefed the captain and the first officer regarding parking at the destination he also briefed that in accordance with company procedures the FedEx considered Tallahassee Regional Airport a moderate controlled flight into terrain risk about 0-515 Jacksonville air traffic controller approved FedEx 1478 to descend at the Pilot's discretion and maintain 9 000 feet the first officer now began his approach briefing for Runway 2-7 he stated that he planned to fly a visual approach to Runway 2-7 and he would back it up with the ILS which stands for instrument Landing system he went on and said the minimum safe altitude was 3 300 feet mean sea level and the runway length was 8 000 feet long and their plan was to roll to the end of the runway before then taxing to her parking spot they had puppies on the left-hand side of the runway and pilot controlled lighting at the Airfield he then asked the captain that if you could click seven times he would appreciate it now there's a fair amount to unpack from that briefing so for those of you that don't know the ILS stands for instrument Landing system and in its most basic form it's an approach Aid to assist the flight crew in giving them vertical and horizontal guidance so that they know if they're above or below a specific Glide path or left and right of the center line of the runway and this will show up as a marker on their instruments in front of them when the first officer mentioned Pappy's they stand for precision approach path indicators and it's a light system that sits on the side of the runway to provide a visual indication for the crew on where the aircraft is on the Glide path to that Associated Runway so it consists of four lights that would change between white and red if the aircraft is on the correct blood path it will show two whites and Two Reds if it is below the Glide path you will see more Reds and this can go to three Reds with one white or four Reds which is really below the Glide path the same could be said for if you are above the Glide path where it will show more white lights three or four for example and the first officer also mentioned pilot controlled lighting so during the hours the Tallahassee Regional Airport air traffic control tower was closed all Runway taxiway and approach Lighting systems on the airport are pilot controlled and the way in which this works is the pilots will tune in to a common traffic advisory frequency and then keying the aircraft microphone activates the airport lighting and it can change intensity depending on the number of times it's clicked so if it's three times it'll be low intensity lighting five times for medium intensity and seven times for high intensity the captain then contacted Jacksonville and informed them that they were leaving flight Level 240 for nine thousand feet the crew now had a discussion about changing the runway they were planning to land on the first officer asked you want to land on nine if we see it and added we've got a Papi on 9-2 the captain responded yeah maybe it'll be a longer taxi for us the way we're coming in probably 2-7 is as easy as any of them the Jacksonville controller then cleared flight 1478 to descend and maintain three thousand feet the captain then keyed the microphone six times and then asked the first officer Runway 9 Papi on the left side I don't know you want to try for nine the first officer responded by saying we're pointing in the right direction I always thought you were supposed to land with the prevailing wind and the captain responded well at five knots it really isn't too much of an issue the only Advantage you have from Landing from the West on Runway two seven is the Glide slope which you won't have on Runway 9 as there isn't an ILS the captain then asked if the first officer was familiar with Tallahassee Regional Airport and the first officer replied that he was not Flight 1478 continued its descent down to three thousand feet and at this point the flight engineer advised the FedEx Ground Personnel the flight 1478 was five minutes out the first officer then asked we ever decide if we were going for nine or two seven and the captain responded yeah we could do nine if you want to and the first officer stated okay Runway nine visual Runway 9 Papi on the left side approach check the pilots completed the approach checklist and then the captain asked the first officer if he wanted to tell the controller that they had Tallahassee in sight the first officer responded yeah I don't see the runway yet but I got the beacon the captain then reported that he had the Airfield in sight and then Jacksonville cleared flights 1478 for the visual approach the first officer now believes that you can see the runway so he calls for flaps too and then soon after flaps five the first officer then States I hope I'm looking in the right spot here and the captain responds by saying see that group of Bright Lights kind of to the South down there and you see the beacon in the middle of it right over there the first officer then confirms I was looking at the wrong light and then continues to say with the direction I took we could have used Runway two seven and the captain just responded yeah it doesn't matter now you're 10 miles south of the VOR continuing on the approach the Airfield is still difficult to see the captain says I guess the lights came on if not I'll click them again and as I get closer he clicks the microphone again five times and then says Ah there we go and all the Airfield lights come on the first officer now requests flaps 15 and then calls for the gear down before the landing checklist the first officer then said sorry about that I was lining up on that paper mill or something at the same time the ground proximity warning system announces that the aircraft is one thousand feet above ground level the pappies are indicating at three Reds and one white indicated that they are now below their Optimum Glide path as they continue their descent the first officer stated I'm gonna have to stay a little bit higher I'm going to lose the end of the runway and the captain responded yeah yeah okay the captain then advised on the common frequency that flight 1478 was on short final for Runway 9. he then stated it's starting to disappear there a little bit isn't it I think we'll be all right yeah at this point the aircraft is 0.9 nautical miles west of Runway 9 descending through 200 feet above ground level at a vertical speed of 528 feet per minute and as an airspeed of 146 knots the flight engineer now announces that the before landing checklist has now been completed and then the ground proximity warning system announced that the aircraft has passed 100 feet the aircraft now starts to hit the tops of the trees in the forest just before the runway the crew Advance the thrust levers for the engines but at this time it's too late the aircraft begins to bank to the right and then crashes into the forest just 1 500 feet west of the runway the aircraft caught fire on impact and the crew sustained serious injuries in the crash but all three crew members exited the aircraft through the captain inside sliding cockpit window before the fire reached the cockpit now in the subsequent investigation that followed this crash the probable cause of the incident is split down into three main areas the first one being the fatigue of the crew and the time in which the flight was taking place the second one being something called the black hole effect and the third one is a medical condition that the first officer was suffering from so what is a black hole approach it's explained as a visual approach over water or a dark featureless terrain that could be hazardous because of poor or misleading cues for evaluating the airplane's flight path and height above the ground an absence of ground features when Landing over darkened areas can create the illusion that the aircraft is at a higher altitude than it actually is if the pilots do not recognize this illusion as the crew in this incident didn't overflying terrain which has few lights like the approach to Tallahassee prevents the height cues that the pilots would usually be able to identify and this usually results in a lower than normal approach further compounding this issue is airfields that have up sloping runways which means they're almost going uphill it gives a false impression to the pilots who are used to seeing a particular picture when they are on a normal visual approach and this picture now gives them a false sense that they are higher than they actually are as I'm sure you've guessed at this point Runway 9 at Tallahassee Regional Airport was an upslope in Runway now for the first officer's medical condition it was discovered through this investigation that the first officer had severe color vision deficiency it was determined that he struggled to see the difference between red and white now surely this would have been picked up in a previous medical and they looked at his flying history and he had originally flown for the Navy he had 16-year Naval service and during that time he had carried out Farnsworth Lantern tests which was the Navy's primary color vision screening and he passed every single time the first time it was noticed was in July 1995 in a medical evaluation for an FAA medical certificate the first officer did not pass a color vision screen that was conducted using pseudo-isochromatic plates the FAA designated medical examiner then spoke to the faa's regional flight surgeon and the advice was to give the first officer a first-class medical along with a soda and a soda stands for statement of demonstrated ability and the soda was granted based on the operational experience of the first officer after this incident at the request of the safety board the first officer completed an extensive evaluation at the U.S Air Force School of Aerospace medicine during this evaluation the first officer passed the Farnsworth Lantern color vision screen but failed seven additional red green color vision tests it was then reported and I quote we believe that he would definitely have had problems discriminating the pappies because the red lights would appear not to be read at all but more indistinguishable from White than red it would be extremely unlikely that he would be capable of seeing even the color pink on the Papi more likely a combination of whites and yellows and perhaps not even that difference so it's fair to say that these tests were quite conclusive on his color vision problems but I don't think his color vision deficiency was solely to blame for this issue this was like most other incidents a combination of several factors there were of course two other flag crew members within the cockpit that were able to identify the colors the puppies were reading as discussed earlier in this video the events leading up to this instant flight created a crew that was not as alert as they usually would be and were quite fatigued during the flight the crew's decision to change runways to a Runway that didn't have an approach Aid and also had an upslope and the fact that the crew struggled to find the runway due to the delay in the lights coming on and the Beacon Light that the first officer mistook for the Airfield Runway 9 did have Pappy lights on the left-hand side for guidance which would have negated the black hole effect but due to the first officer's color vision deficiency obviously this guidance was pointless to him there were two members of the crew that could use this for guidance but due to fatigue and a high workload in the cockpit at the time the pappies were not double checked by anyone else in the crew and it was this combined set of events that led to the overall incident I'd love to hear what you have to say about this accident flight as always I don't make these videos to point out the mistakes of the cruise for more so we can all understand as a collective why these things happen and ultimately we can all learn from each other's mistakes if you're interested in more videos like this one check out this video here it's about a crew that pushed the limits and were unable to locate their Runway multiple times leading to an incident that could have been avoided if they just followed procedure as always thank you for watching this far I hope you enjoyed the video and I'll see you in the next one

Channel: Curious Pilot

Views: 144,754

Keywords: air crash investigation 2023, fedex flight 1478, fedex flight, fedex, curious pilot, aviation, air crash, fedex flight 80

Id: ZUh-50PS3-w

Length: 17min 21sec (1041 seconds)

Published: Sun Apr 02 2023