Fatigued United Parcel Service Inc. pilots committed multiple errors before their airplane slammed into a hillside last year in Alabama, investigators said.
An improper landing approach was deemed today to be the cause of the crash as a National Transportation Safety Board panel closed a yearlong investigation into the accident, which killed the two pilots of the cargo plane. The copilot hadn’t taken opportunities to sleep during time off between flights, Katherine Wilson, an NTSB investigator said at a hearing.
The crew was descending too fast, failed to properly set their navigation equipment and didn’t follow numerous UPS policies as their overnight cargo flight neared the runway, according to Wilson and others at the hearing. Such an approach is considered unstable and should have triggered an end to the landing attempt, investigator David Lawrence said.
“As this board has seen far too often, with far too costly consequences, an unstabilized approach is a less safe approach,” Acting NTSB Chairman Christopher Hart said in opening remarks. “On such an approach the risk of an adverse outcome increases substantially.”
While the accident has put a spotlight on fatigue, an issue that has plagued multiple airline crews in crashes, investigators said this instance doesn’t raise questions about U.S. regulations or UPS’s policies.
Copilot Shanda Fanning, 37, had only about nine hours of opportunity to sleep in almost two days before the crash, according to NTSB records. Her lack of sleep was due to poor management of her time off, not her schedule, Wilson said.
Captain Cerea Beal, 58, had adequate time to sleep in the day before the accident, Wilson said.
Because they were landing in the hours before dawn, when the body most craves sleep, they both probably had some decreased performance, Wilson said.
The plane hit a hillside cloaked in darkness less than 1 mile (1.6 kilometers) from a runway in Birmingham, Alabama, as it tried to land, breaking apart and bursting into flames at 4:47 a.m.local time. The flight had left from Louisville, Kentucky, the air hub for UPS, the world’s largest package- delivery company.
Persuading pilots to break off such so-called unstable approaches before they lead to accidents is “the largest, lowest hanging piece of safety fruit” in commercial aviation, according to the Alexandria, Virginia-based Flight Safety Foundation.
Beal was flying the plane during the landing attempt, and Fanning as copilot would have served as a backstop to alert Beal to any abnormalities during the approach.
He failed to properly set the navigation equipment to guide him to the runway. Later, when he reset the Airbus A300-600’s autopilot, he failed to announce the change as required in UPS guidelines,
She didn’t adequately monitor his actions and also didn’t call out altitudes, even as they went below the minimum safe height without seeing the runway and the ground, investigators said.
There is little doubt that Fanning was suffering from fatigue, said Curtis Graeber, an independent consultant on fatigue based in Kirkland, Washington.
“If she had nine hours to rest in nearly two days, she would be pushing her limits,” Graeber said.
In professions like aviation where employees are often required to work around the clock, employees bear some of the responsibility for getting rest, said Graeber, who once led a United Nations’ International Civil Aviation Organization task force on combating aviation fatigue.
“If the situation is controllable by the individual, it’s expected that they take the opportunities available to them to get sleep to get the rest they need,” he said.
One of the issues in the background of the UPS accident was the U.S. Federal Aviation Administration’s decision to exempt cargo airlines from new fatigue rules put in place this year.
The Independent Pilots Association has petitioned Congress to include its members in the new rules, which mandate longer rest periods when pilots fly late at night or across multiple time zones.
In the case of Beal and Fanning, their schedules in the weeks before the accident were in line with the new passenger- pilot rules, even though the company wasn’t required to do so, Wilson said.
The IPA union at UPS said in an e-mail statement it wouldn’t comment on the case until after the NTSB’s hearing. The union has said previously in documents filed to the NTSB that pilots weren’t comfortable telling the company they couldn’t fly because they were tired.
A UPS spokesman, Malcolm Berkley, declined to comment prior to the NTSB issuing its decision. Both the union and the airline were removed from the investigation Aug. 25 by the NTSB for making “prejudicial” comments about the case.
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