NTSB Details Pilot Errors Before 2013 UPS Cargo Jet Crash

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By Andy Pasztor

Pilots of a United Parcel Service Inc. cargo jet repeatedly deviated from mandatory company safety rules and approach procedures just before their plane plowed into a hillside last August near the Birmingham, Ala., airport, federal investigators revealed Thursday.

The cockpit crew exceeded the maximum vertical descent rate for a stabilized approach, failed to verbalize critical altitude changes and violated basic safeguards by continuing the final phase of a descent using limited navigation aids even though the runway lights weren't visible, according to the National Transportation Safety Board.

But in delving more deeply into the causes of the Airbus A300 crash, which killed both pilots, NTSB staffers uncovered that the commander had what industry and government experts consider a history of training lapses and proficiency challenges stretching back more than a decade. The documents point to several mistakes in simulator sessions, but no accidents or enforcement actions. More broadly, that spotty record raises questions about the effectiveness of UPS pilot-training programs, especially when visual approaches replace automated descents, according to aviation-industry officials.

In 2000 and 2002, Cerea Beal, then a UPS first officer flying Boeing Co. 727 jets, voluntarily withdrew from training for promotion to captain, a highly unusual move. The NTSB didn't give a reason for the withdrawal, but government, industry and pilot union sources said that such moves, especially within two years of each other, typically avoid an outright failure. According to the NTSB, UPS told investigators it didn't retain those training records.

After working as a co-pilot from October 1990 to the spring of 2009--an unusually long stint by most aviator standards--the former military helicopter pilot became an A300 captain in June of that year, according to information released by the NTSB. About a year later, Capt. Beal was in command of a plane that veered off a taxiway after landing at Charlotte Douglas International Airport in North Carolina, the board disclosed at a hearing Thursday. NTSB documents didn't give any additional examples of incidents.

Reports, interview transcripts and other data released by the board also detail that in the days and hours leading up to the fiery accident, Capt. Beal complained about chronic fatigue. He told one fellow pilot the string of late-night and early-morning shifts was "killing" him.

During an early portion of the accident flight, the cockpit voice recorder captured co-pilot Shanda Fanning telling the captain that "when my alarm went off" following a rest break during the duty period, she was upset. "I mean, I'm thinking, 'I'm so tired,'" she recalled according to the transcript.

In one of the text messages retrieved by investigators, the day before the crash Ms. Fanning complained that she " fell asleep on every damn leg" of her various flights the previous night. But some of the fatigue may have been outside the company's purview. Before starting night duty that extended to almost 5 a.m. the morning of the crash, according to an NTSB analysis, Ms. Fanning opted to spend most of her free time outside her hotel room.

UPS has said Capt. Beal was experienced and fully qualified, adding that whatever training issues cropped up were " appropriately dealt with at the time." On Thursday, the Atlanta package carrier reiterated that its schedules are "well within FAA limits," noting that the Birmingham crew spent less than three hours of its final eight-hour duty period in the air.

The cargo airline also said its fatigue-prevention measures, including special sleep rooms and joint pilot- management reviews of schedules, are intended to ensure adequate rest.

The fatigue issue is bound to spark more debate about whether cargo pilots should have been covered by more- stringent fatigue rules recently implemented for pilots flying passengers. Some House and Senate members are pushing for such legislation. UPS, however, said the Birmingham crew's schedule complied with the latest requirements for U.S. passenger airlines.

Within hours of the hearing, the nation's largest pilots union stepped up calls for legislation to make cargo haulers comply with the same scheduling rules as passenger carriers.

"Pilots who operate in the same skies, take off from the same airports, and fly over the same terrain must be given the same opportunities for full rest, regardless of what is in the back of the plane," said Lee Moak, president of the Air Line Pilots Association.

The hearing underscored lax discipline and apparent confusion in the cockpit during roughly the final two minutes of the flight. Safety experts from UPS and Airbus testified that the crew improperly used the flight-management computer to try to set up a safe approach path. When that didn't work, they said, Capt. Beal violated UPS rules by abruptly switching to a different type of approach and then commanding the autopilot to maintain an excessively steep descent.

UPS officials testified that both of those events should have prompted pilots to initiate a go-around, or immediate climb away from the airport. Instead, the crew continued the approach below the safe altitude for making such a decision.

In addition to lapses by the crew, Thursday's hearing highlighted the limitations of outdated collision-avoidance technology aboard the aging A300. Barely seven seconds before impact, the ground-proximity warning system alerted the pilots that they were descending too rapidly.

Due to the way the system was configured, however, the NTSB said an explicit warning about the impending crash and a command to immediately pull up didn't come until a second after the initial sound of impact was captured by the cockpit recorder.

An updated warning system, recommended years ago by officials at supplier Honeywell International Inc., would have provided at least several precious seconds of additional warning. But it isn't clear whether that would have been enough to save the crew and the plane. "Maybe, maybe not," Federal Aviation Administration official Tom Chidester testified.

NTSB Chairman Deborah Hersman focused on whether average pilots understood that because of design limitations and older technology, "certain [safety] systems will be inhibited" or operate differently close to the ground.

As part of its continuing investigation, the NTSB determined that the plane's engines, flight controls and other onboard systems, including collision-warning technology, operated normally before impact.

In one email released by the board, an FAA official indicated three months after the crash that the visual navigation aids installed on the Birmingham runway weren't designed to handle planes as large as the Airbus A300.

Write to Andy Pasztor at andy.pasztor@wsj.com

Subscribe to WSJ: http://online.wsj.com?mod=djnwires


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  02-20-141942ET
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