DCA13MA133

NTSB accident investigation · Airbus A300 - F4 622R · Birmingham, AL · August 14, 2013

Accident · FatalClass 1 · MajorFinal report
Date
August 14, 2013, 04:40 local (09:40 UTC)
Place
Birmingham, AL
Injuries
2 fatal
Damage
Destroyed
Phase of flight
Approach
Aircraft
N155UPAirbus A300 - F4 622R
Defining event
Approach-IFR final approach: Controlled flight into terr/obj (CFIT)
Weather
Night/dark
Status
Completed · report February 3, 2015
Report
Board-adopted at Board Meeting
Investigation class
Class 1
NTSB office
Major Investigations Division
Parties
IPA, FAA, IBT (Teamsters), BEA, Birmingham Airport Authority, Pratt and Whitney, UPS, AIRBUS
Safety recommendations
Yes
Case key
87780

From the NTSB’s public API. By law, NTSB reports can’t be used as evidence in lawsuits over the accident.

On this page

Probable cause

the flight crew's continuation of an unstabilized approach and their failure to monitor the aircraft's altitude during the approach, which led to an inadvertent descent below the minimum approach altitude and subsequently into terrain. Contributing to the accident were (1) the flight crew's failure to properly configure and verify the flight management computer for the profile approach; (2) the captain's failure to communicate his intentions to the first officer once it became apparent the vertical profile was not captured; (3) the flight crew's expectation that they would break out of the clouds at 1,000 feet above ground level due to incomplete weather information; (4) the first officer's failure to make the required minimums callouts; (5) the captain's performance deficiencies likely due to factors including, but not limited to, fatigue, distraction, or confusion, consistent with performance deficiencies exhibited during training; and (6) the first officer's fatigue due to acute sleep loss resulting from her ineffective off-duty time management and circadian factors.

Findings · 13

NTSB’s coded findings. Those marked are part of the probable cause; the rest are factors or other findings. Under each, the cases with the same finding.

Performance/control parameters: descent/approach/glide pathAircraft › Aircraft oper/perf/capability · Not attained/maintainedAirbus A300 F4-622R: 1 caseAll aircraft: 809 casesProbable cause
Navigation system: flt management computing sysAircraft › Aircraft systems · Incorrect use/operationAirbus A300 F4-622R: 1 caseAll aircraft: 4 casesProbable cause
Use of equip/info: use of automationPersonnel issues › Task performance · Flight crewAirbus A300 F4-622R: 1 caseAll aircraft: 17 casesProbable cause
Ceiling/visibility/precipEnvironmental issues › Conditions/weather/phenomena · Awareness of conditionAirbus A300 F4-622R: 1 caseAll aircraft: 65 casesProbable cause
Ceiling/visibility/precip: low ceilingEnvironmental issues › Conditions/weather/phenomena · Accuracy of related infoAirbus A300 F4-622R: 1 caseAll aircraft: 190 casesProbable cause
Personnel issuesPersonnel issues › Task performance · PilotAirbus A300 F4-622R: 1 caseAll aircraft: 137 casesProbable cause
Alertness/Fatigue: lack of sleepPersonnel issues › Physical · CopilotAirbus A300 F4-622R: 1 caseAll aircraft: 26 casesProbable cause
TrainingOrganizational issues › Support/oversight/monitoring · OperatorAirbus A300 F4-622R: 1 caseAll aircraft: 26 cases
Oversight: oversight of operationOrganizational issues › Support/oversight/monitoring · FAA/RegulatorAirbus A300 F4-622R: 1 caseAll aircraft: 61 cases

Sequence of events

The events NTSB coded, in order, by phase of flight. The defining event is the one that best describes the accident. Under each, the cases with the same event anywhere in their sequence.

Analysis

The Safety Board's full report is available at http://www.ntsb.gov/investigations/AccidentReports/Pages/aviation.aspx. The Aircraft Accident Report number is NTSB/AAR-14/02. On August 14, 2013, about 0447 central daylight time (CDT), United Parcel Service (UPS) flight 1354, an Airbus A300-600, N155UP, crashed short of runway 18 during a localizer nonprecision approach to runway 18 at Birmingham-Shuttlesworth International Airport (BHM), Birmingham, Alabama. The captain and first officer were fatally injured, and the airplane was destroyed by impact forces and postcrash fire. The nonscheduled cargo flight was operating under the provisions of 14 Code of Federal Regulations (CFR) Part 121 on an instrument flight rules flight plan, and dark night visual flight rules conditions prevailed at the airport; variable instrument meteorological conditions (IMC) with a variable ceiling were present north of the airport on the approach course at the time of the accident. The flight originated from Louisville International Airport-Standiford Field (SDF), Louisville, Kentucky, about 0503 eastern daylight time (EDT).

Factual narrative

The Safety Board's full report is available at http://www.ntsb.gov/investigations/AccidentReports/Pages/aviation.aspx. The Aircraft Accident Report number is NTSB/AAR-14/02. On August 14, 2013, about 0447 central daylight time (CDT), United Parcel Service (UPS) flight 1354, an Airbus A300-600, N155UP, crashed short of runway 18 during a localizer nonprecision approach to runway 18 at Birmingham-Shuttlesworth International Airport (BHM), Birmingham, Alabama. The captain and first officer were fatally injured, and the airplane was destroyed by impact forces and postcrash fire. The nonscheduled cargo flight was operating under the provisions of 14 Code of Federal Regulations (CFR) Part 121 on an instrument flight rules flight plan, and dark night visual flight rules conditions prevailed at the airport; variable instrument meteorological conditions (IMC) with a variable ceiling were present north of the airport on the approach course at the time of the accident. The flight originated from Louisville International Airport-Standiford Field (SDF), Louisville, Kentucky, about 0503 eastern daylight time (EDT).

Aircraft

Registration
N155UP
Reported as
Airbus A300 - F4 622R (F4 622R)
Category
Airplane
Serial number
0841
Airframe hours
11,043
Engines
P & W PW4158, 58,000 lbs thrust, turbo fanP & W PW4158, 58,000 lbs thrust, turbo fan
Damage
Destroyed
Fire
On-Ground
Flight
Part 121
Operator
United Parcel Service Co, doing business as United Parcel Service Co
Registered owner
United Parcel Service Co
Airworthiness certificate
Standard, Transport
Last inspection
Continuous airworthiness · August 14, 2013
Departed
SDF · Louisville, KY
Destination
BHM · Birmingham, AL
Flight plan
IFR
Airport
BHM · Birmingham-Shuttlesworth Inter, runway 18, 7,099 × 150 ft
Equipment
Electronic multifunction display, Data recorder, Auto-pilot, Stall warning system, Onboard weather, Electronic primary flight display

Matched to the registry by N-number and the event date; the registry’s history has gaps, so older matches can be wrong. Compare the reported make and model.

Flight crew · 2

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
58
Injuries
Fatal
Certificate
Airline transport
Airplane ratings
Multi-engine land
Instrument ratings
Airplane
Medical
Class 1, Without waivers/limitations
Last flight review
June 26, 2013
Seat
Left
Restraint
5-point
Toxicology
Performed
Flight hours
6,406 total · 3,265 in this make and model · 1,516 as pilot in command · 97 in the last 90 days · 41 in the last 30 days · 2 in the last 24 hours
Role
Co-pilot
Age
37
Injuries
Fatal
Certificate
Airline transport
Airplane ratings
Single-engine land, Multi-engine land
Instrument ratings
Airplane
Medical
Class 1, Without waivers/limitations
Last flight review
June 26, 2013
Seat
Right
Restraint
5-point
Toxicology
Performed
Flight hours
1,253 total · 403 in this make and model · 0 as pilot in command · 95 in the last 90 days · 31 in the last 30 days · 2 in the last 24 hours

Weather

Conditions
Night/dark
Wind
340° at 4 knots
Visibility
10 statute miles
Lowest ceiling
3,500 ft broken
Altimeter
29.96 inHg
Observed at
BHM, 1 nm away

Docket · 137

The files NTSB released with the investigation on February 20, 2014, on NTSB’s docket system: statements, records, photos and specialists’ reports. 151 MB in all.

Order of Hearing: 1AItem 1 · .PDF · 52 KBHearing Notices: Notice of Designation of Chairman of Board of Inquiry 1BItem 2 · .PDF · 62 KBDesignation of Hearing Officer: 1CItem 3 · .PDF · 58 KBDesignation of Parties to the Hearing: 1DItem 4 · .PDF · 53 KBNotice of Hearing: 1EItem 5 · .PDF · 45 KBHearing Exhibit List:: Statement of Purpose of A NTSB Investigative Hearing 1FItem 6 · .PDF · 143 KBOperations 2 Exhibit 2-A - Factual Report of Group ChairmanItem 7 · .PDF · 12 photos · 4.2 MBOperations 2 Exhibit 2-B - Attachment 1 - Birmingham Interview SummariesItem 8 · .PDF · 501 KBOperations 2 Exhibit 2-C - Attachment 2 -Louisville Interview SummariesItem 9 · .PDF · 1.1 MBOperations 2 Exhibit 2-D - Attachment 3 - Other Interview SummariesItem 10 · .PDF · 577 KBOperations 2 Exhibit 2-E - Attachment 4 – Crew RecordsItem 11 · .PDF · 5.7 MBOperations 2 Exhibit 2-F - Attachment 5 – A300 Non-precision Approach TrainingItem 12 · .PDF · 1.2 MBOperations 2 Exhibit 2-G - Attachment 6 – 2013 CQ Workshop PresentationItem 13 · .PDF · 872 KBOperations 2 Exhibit 2-H - Attachment 7 – AOM Approach Briefing GuidesItem 14 · .PDF · 1.5 MBOperations 2 Exhibit 2-I - Attachment 8 – Approach and Landing BriefingItem 15 · .PDF · 310 KBOperations 2 Exhibit 2-J - Attachment 9 – UPS A300 Descent PlanningItem 16 · .PDF · 326 KBOperations 2 Exhibit 2-K - Attachment 10 – UPS Pilot Training GuideItem 17 · .PDF · 2.2 MBOperations 2 Exhibit 2-L - Attachment 11 – Witness StatementsItem 18 · .PDF · 2.9 MBOperations 2 Exhibit 2-M - Attachment 12 – ACARS DataItem 19 · .PDF · 416 KBOperations 2 Exhibit 2-N - Attachment 13 - Weight and BalanceItem 20 · .PDF · 943 KBOperations 2 Exhibit 2-O - Attachment 14 – Dispatch PaperworkItem 21 · .PDF · 1.1 MBOperations 2 Exhibit 2-P - Attachment 15 – BHM Landing Performance DataItem 22 · .PDF · 311 KBOperations 2 Exhibit 2-Q - Attachment 16 – Flight Dispatcher InformationItem 23 · .PDF · 711 KBOperations 2 Exhibit 2-R - Attachment 17 – Dispatcher Joint Responsibility and AuthorityItem 24 · .PDF · 260 KBOperations 2 Exhibit 2-S - Attachment 18 – Dispatcher Statement and InterviewsItem 25 · .PDF · 610 KBOperations 2 Exhibit 2-T - Attachment 19 – UPS Flight Dispatcher - GeneralItem 26 · .PDF · 703 KBOperations 2 Exhibit 2-U - Attachment 20 – LIDO METAR Remarks RemovalItem 27 · .PDF · 1.6 MBOperations 2 Exhibit 2-V - Attachment 21 – BHM Chart InformationItem 28 · .PDF · 1.5 MBOperations 2 Exhibit 2-W - Attachment 22 – LIDO LOC18 NOTAM InformationItem 29 · .PDF · 531 KBOperations 2 Exhibit 2-X - Attachment 23 – Non-Precision Approach ProceduresItem 30 · .PDF · 3.4 MBOperations 2 Exhibit 2-Y - Attachment 24 – Descent PreparationItem 31 · .PDF · 252 KBOperations 2 Exhibit 2-Z - Attachment 25 – Stable Approach CriteriaItem 32 · .PDF · 419 KBOperations 2 Exhibit 2-AA - Attachment 26 – A300 Flight Management SystemItem 33 · .PDF · 618 KBOperations 2 Exhibit 2-BB - Attachment 27 – FMC Study GuideItem 34 · .PDF · 454 KBOperations 2 Exhibit 2-CC - Attachment 28 – EGPWS AlertsItem 35 · .PDF · 1.1 MBOperations 2 Exhibit 2-DD - Attachment 29 – Operations Specification (OpSpecs)Item 36 · .PDF · 561 KBOperations 2 Exhibit 2-EE - Attachment 30 - Party FormsItem 37 · .PDF · 442 KBOperations 2 Exhibit 2-FF - Attachment 31 – FAA ResponsesItem 38 · .PDF · 1.6 MBOperations 2 Exhibit 2-GG - Attachment 32 – Advisory Circular 120-108Item 39 · .PDF · 4.2 MBOperations 2 Exhibit 2-HH - Attachment 33 – FAA KBHM NOTAM InformationItem 40 · .PDF · 407 KBOperations 2 - Addendum 1Item 41 · .PDF · 430 KBATC 3 - Factual Report of Group ChairmanItem 42 · .PDF · 866 KBATC 3 - Attachment 1 - BAA - ATC Airport Emergency Operating Procedures Letter of AgreementItem 43 · .PDF · 251 KBATC 3 - Attachment 2 - BHM Air Traffic Controller StatementsItem 44 · .PDF · 317 KBATC 3 - Attachment 4 - FAA ATC TranscriptItem 45 · .PDF · 1.8 MBMeteorology 5 - Factual Report of Group ChairmanItem 46 · .PDF · 2.1 MBSurvival Factors Exhibit 6-A Factual Report of Group ChairmanItem 47 · .PDF · 1.4 MBSurvival Factors Exhibit 6-B FAA Tech Ops and flight inspection reportsItem 48 · .PDF · 6.7 MBSurvival Factors Exhibit 6-C Email from ASO ADO to BHMItem 49 · .PDF · 3.0 MBSurvival Factors Exhibit 6-D Airport operations personnel statementsItem 50 · .PDF · 4.3 MBSurvival Factors Exhibit 6-E InterviewsItem 51 · .PDF · 106 KBSurvival Factors Exhibit 6-F Birmingham Fire and Rescue Service (BFRS) Dispatch logItem 52 · .PDF · 7.6 MBSurvival Factors Exhibit 6-G Birmingham Fire and Rescue Service (BFRS) Command Activity LogItem 53 · .PDF · 14.1 MBSurvival Factors Exhibit 6-H - Addendum 1Item 54 · .PDF · 75 KBStructures 7 - Factual Report of Group ChairmanItem 55 · .PDF · 62 KBStructures 7 - Appendix A - FiguresItem 56 · .PDF · 729 KBPowerplants 8 - Factual Report of Group ChairmanItem 57 · .PDF · 23 photos · 3.8 MBSystems 9 - Factual Report of Group ChairmanItem 58 · .PDF · 1.8 MBFlight Data Recorder 10 - Exhibit A -Group Chairman's Factual ReportItem 59 · .PDF · 3.4 MBFlight Data Recorder 10 - Exhibit B - Factual Report - Attachment 1: FDR Tabular Data (Compressed CSV File)Item 60 · ZIP · 4.8 MB
All 137 files on NTSB’s docket