737 MCC – HF HANDOUT
Issue 2 – 22 Nov 2017
Human Factors Handout
CONTENTS PAGE
Page 1
– Contents Page
Page 2
– Contact Details & ETA Access
Pages 3 - 5
– EasyJet (Threat Error Management)
Pages 6 - 8
– Air India Express (Threat Error Management)
Page 9
– Barriers To Communication Exercise
Page 10
– Communication Exercise
Pages 11 - 14
– British Airways (Communication)
Page 15
– Lost On The Moon Exercise
Pages 16 - 18
– Asiana Airlines (Culture & Automation Dependency)
Pages 19 - 23
– UPS (Fatigue)
Page 24
– NOTECH Exercise
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Human Factors Handout
CONTACT DETAILS & ETA ACCESS
Please keep the following contact numbers available while on the course. Let us
know if – exceptionally - you are going to be late for a simulator session, or have any
other problems.
▪
▪
▪
▪
▪
MCC Instructors
Multi-Pilot Coordinator
Customer Services
Security
Security
01865 840330 (0700-2100)
01865 840370 (0900-1700)
01865 841234 (0800-1700)
01865 290688 (24 hours)
07711 775971 (24 hours)
For dialling internally:
▪
▪
▪
▪
MCC Instructors
Multi-Pilot Coordinator
Customer Services
Security
5330 (0700-2100)
5370 (0900-1700)
5234 (0800-1700)
5247
ETA Talon URLs
You can access ETA talon from home. The website address is as follows:
www.talon-systems.com/cae
Try logging on with Internet Explorer. Chrome does not work with this URL. If there
are any problems, then try the following URL with Internet Explorer or Chrome.
https://apps1.talonsystems.com/tseta/servlet/content?module=home&page=homepg
&customer=eta0030&action=login_eta
Save the relevant URL as a favourite as “ETA Talon”.
Aviobook URLs
You can access Aviobook from either a desktop or ipad for the training materials.
The website address is as follows:
https://live.cae.aviobook.aero/pilot/
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Human Factors Handout
EasyJet – Airbus A319-111 (16th February 2016)
Synopsis
After lift-off, the co-pilot retracted the flap instead of the landing gear. The
commander lowered the nose attitude and selected TOGA thrust but the GPWS
Mode 3 aural alert (“don’t sink, don’t sink”) was triggered before the aircraft
recovered to climbing flight.
History of the flight
G-EZFA was operating a scheduled Commercial Air Transport (CAT) flight with six
crew and 125 passengers on board. The commander was the Pilot Flying (PF).
During the take off roll there was a “rattle” from the centre console and the co-pilot
placed his hand on it, aft of the thrust levers, to reduce the noise. After lift-off, the
commander instructed the co-pilot to raise the landing gear but the co-pilot moved
the flap lever from position 1 to 0 instead. The aircraft was 46 ft above the runway.
The commander noticed the VLS indication on the PFD increase rapidly (see Note in
the next section) but did not realise initially that the flaps were retracting. Seven
seconds after the flap lever was moved, the commander lowered the nose attitude of
the aircraft and, three seconds later, selected TOGA thrust. The GPWS aural alert
“don’t sink, don’t sink” was triggered (by the loss of altitude after take off). The
aircraft was flying at 194 kt and descending through 393 ft agl with a rate of descent
of 1,300 fpm. Two seconds later the commander applied an aft control input with the
airspeed at 205 kt and, two seconds after that, the aircraft began to climb. The flight
continued to its destination without further incident.
Information from the operator’s report
The performance calculation conducted by the pilots determined that the departure
would be flown with flaps and slats set to Configuration 1 + F (18° of slats and 10° of
flaps) and with reduced thrust.
Flight data
VLS (lowest selectable IAS) is computed by the Flight Augmentation Computer
(FAC) and displayed on the PFD as the top of a vertical amber strip along the
airspeed scale. VLS corresponds to:
a. 1.13 times the stalling speed during take off.
b. 1.28 times the stalling speed in the clean configuration.
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Human Factors Handout
When the flap lever was selected to position 0 the aircraft was at 46 ft agl, climbing
at 1,300 fpm and 158 kt. The VLS indication on the Primary Flight Display (PFD)
increased towards 197 kt, the value corresponding to flaps and slats fully retracted.
Passing through 138 ft agl, the aircraft was climbing at 1,900 feet per minute and
160 kt and the angle of attack increased to approximately 9.5°. The aircraft is fitted
with an Alpha/Speed Lock function which inhibits slat retraction at high angles of
attack (above 8.5°) and low speeds (below 148 kt). The protection is not active after
the flap lever has been moved to position 0 and did not inhibit slat retraction in this
case.
At 308 ft agl, the aircraft was climbing at 1,500 fpm at 167 kt and the commander
began to reduce the pitch attitude from 15°. At 418 ft agl, the pitch attitude was 9°,
the rate of climb had reduced to 700 fpm and the commander selected TOGA thrust.
At 438 ft agl, with the pitch attitude reducing through 8°, the aircraft began to
descend and the gear was selected up. The aircraft descended and accelerated
until, at 393 ft agl, the GPWS aural alert, “don’t sink, don’t sink” was triggered with a
rate of descent of 1,300 fpm.
The airspeed increased above VLS with the aircraft at 378 ft agl, the commander
began to raise the nose attitude and the aircraft transitioned into a climb.
Aircraft stalling speed
The operator calculated that the stalling speed was 128 kt with the aircraft configured
for take off and 155 kt with flaps and slats retracted. The aircraft was flying at 158 kt
when the flap was selected to position 0. At the point where the flaps had retracted
fully, the aircraft was accelerating through 183 kt and descending through 440 ft agl
with a rate of descent of 1,000 fpm.
Human factors
The operator classified the mis-selection of flap instead of landing gear as a type of
‘action-slip’ where:
‘an out-of-sequence step (the flap selection) was included in a series of
routine, well-learnt behaviours (take off procedure).’
In regard to the rattling of the console during the take off run, it commented that:
‘distractions caused by interruptions, can make operators vulnerable to task
interference, strong habit intrusion, or mis-ordering tasks.’
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Human Factors Handout
Further:
‘action slips are hard to detect as the action itself is not under conscious
control from a human information-processing perspective.’
Assessment of cause
The operator assessed that the co-pilot had been distracted by the rattling noise
during take off which caused him to make an ‘action error’ in mis-selecting the flap.
The operator noted that, in a similar event, the pilots re-selected the flap lever to
position 1 and the aircraft maintained a positive climb rate and a speed above VLS.
In the case of G-EZFA, however, the crew did not fully appreciate what had
happened until after TOGA had been selected and, by the time they considered reselecting flap, the aircraft was recovering to climbing flight.
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Human Factors Handout
Air India Express – B737-800 (22nd May 2010)
Air India Charters Limited operates a low cost airline, under the brand name of Air
India Express. It operates a scheduled daily flight on the Mangalore-DubaiMangalore route. The scheduled time of departure at Mangalore is 21:35 (Indian
Standard Time). Its return journey is scheduled for a 02:45 (Indian Standard Time).
On the 22nd May 2010 from Dubai to Mangalore there were 160 passengers
including 4 infants on board. The flight departed 9 minutes early and the take-off,
climb and cruise were uneventful.
The aircraft first came in to contact with the Mangalore Area Control at 05:32 (IST) at
FL370. The Mangalore Area Radar was unserviceable since 20th May 2010 and a
NOTAM to this effect had been issued. The First Officer, who was making all the R/T
calls, requested radar identification, to which he was informed of an unserviceable
radar.
The flight was operating during a period of Circadian Low. The CVR indicated that
there was no conversation between the two pilots for the first 1 hour and 40 minutes
and the Captain was asleep with intermittent sounds of snoring, deep breathing and
towards the end of this period, the sound of clearing the throat and coughing. The
First Officer had also shown signs of tiredness, this was indicated by the sounds of
yawning heard on the CVR.
At 05:38 the First Officer asked for the type of approach to which the ATC replied ILS
DME Arc approach. At about 130 miles from Mangalore, the aircraft requested for a
descent clearance. This was, however denied by the controller, who was using the
standard procedural control, to ensure safe separation with other air traffic. Later, the
aircraft was cleared to 7000ft and commenced its descend at 77 DME from
Mangalore at 05:47. The visibility was 6km. Mangalore airport has a table top runway
with an elevation of 334 feet above mean sea level. Due to the surrounding terrain,
Air India Express has made a special qualification requirement that only the PIC
shall carry out the take-off and landing at this airport. The Captain had made a total
of 16 landings at this airport yet the First Officer who was stationed at Mangalore,
had operated as a Co-pilot on 66 flights from this airport.
While the aircraft was in the descend there was no recorded conversation regarding
the mandatory preparation for decent and landing briefing as stipulated in the SOPs.
The first time that the CVR had indicated that there was any conversation between
the two pilots was just before the descent. After the aircraft was about 50 miles from
Mangalore and descending out of FL295, the conversation between the two pilots
indicated that an incomplete approach briefing had been carried out. At about 25
DME and descending through FL184, the Mangalore Area Controller cleared the
aircraft to continue their descent to 2900ft. At this stage, the First Officer requested,
if they could proceed directly to Radial 338° and join the 10 DME Arc. Throughout
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Human Factors Handout
the descent profile and DME Arc Approach for ILS 24, the aircraft was much higher
than normally expected. The aircraft was handed over by the Mangalore Area
Controller to ATC Tower at 05:52. ATC asked the aircraft to report established on a
10 DME Arc for ILS R/W 24.
Plan view of initial radial and descent profile of accident aircraft
On having reported 10 DME Arc, the ATC Tower had asked the aircraft to report
when it was established on the ILS. It appears that the Captain had realised that the
aircraft altitude was higher than normal and had selected the landing gear down at
an altitude of approximately 8,500ft with speed brakes still deployed in Flight Detent
position, so as to increase the rate of descent. The aircraft remained high and did not
follow the standard procedure of intercepting the ILS Glide Path at the correct
intercept altitude. This incorrect procedure led to the aircraft being at almost twice
the altitude as compared to a standard ILS approach.
During the approach the Captain had selected flaps 40° and completed the landing
check list. At about 2.5 DME, the radio altimeter had alerted an altitude of 2500ft.
This was immediately followed by the First Officer giving a call of “IT IS TOO HIGH”
and “RUNWAY STRAIGHT DOWN”. In reply, the Captain had called “OH MY GOD”.
At this moment, the Captain had disconnected the auto pilot and simultaneously
increased the rate of descent considerably to establish on the desired approach
path. At this stage, the First Officer had queried “GO AROUND?” To this query from
the First Officer, the Captain had called out “WRONG LOC….LOCALISER….GLIDE
PATH”.
The First Officer had given a second call to the Captain for “GO AROUND” followed
by “UNSTABILISED”. However, the First Officer did not appear to take any action to
initiate a go around. Having acquired the runway visually and to execute a landing, it
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Human Factors Handout
appears that the Captain had increased the rate of descent to almost 4000ft per
minute. Due to this, there were numerous warnings from EGPWS for ‘SINK RATE’
and ‘PULL UP’. The pilots did not report having established the ILS approach.
Instead the ATC Tower had asked the crew whether they were established or not?
The Captain forcefully prompted the First Officer to give a call of “AFFIRMATIVE”.
ATC then gave a landing clearance and indicated that the winds were calm.
The aircraft was high on approach and touched down on the runway much further
than normal. It had crossed the threshold at about 200ft with a speed in excess of
160kts when it should have been at 50ft with a target speed of 144kts for the landing
weight.
Despite the EGPWS warnings and calls from the First Officer to go around, the
Captain had persisted with the approach. Short of touchdown there was a third call
from the First Officer, this time on the VHF channel “GO AROUND CAPTAIN, WE
DON’T HAVE RUNWAY LEFT”. However the Captain continued with the landing
and the final touchdown was about 5200ft from the threshold of R/W 24, leaving
approximately 2800ft of remaining paved surface.
The Captain selected the thrust reversers soon after touchdown. Within 6 seconds of
the applying the brakes, the Captain initiated a ‘GO AROUND’, against Boeing’s
SOPs. The aircraft overshot the runway including the stopway of 196ft. There is a
downward slope from the end of R/W 24 towards the boundary fence. After
overshooting the runway and the stopway (ASDA) the aircraft continued into the
Runway End Safety Area (RESA) of 295ft. Soon after which, the right wing impacted
the localiser antenna structure located a further 278ft beyond the end of the RESA.
Then the aircraft hit the boundary fence and fell into a gorge.
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Human Factors Handout
Barriers to communications exercise
List the barriers to communication
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Human Factors Handout
Communication Exercise
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Human Factors Handout
British Airways – B777 (26th September 2009)
The aircraft was operating a scheduled service from VC Bird International Airport,
Antigua (ANU), to Robert L Bradshaw International Airport, St Kitts (SKB), and then
a return leg. The sector from ANU to SKB was uneventful. On arrival at SKB the
aircraft was not parked on a designated stand but at an angle of approximately 45°
to the terminal. This allowed the aircraft to self-manoeuvre off the stand as no
pushback tug was available. This was the first time the commander or the co-pilot
had operated to or from SKB.
Flight planning for the return sector was completed by the commander and the copilot on the flight deck. The take off performance data for both the full length and
from intersection Alpha on Runway 07 were requested via the on-board data
communications system. Once the speed and thrust setting were calculated, the
crew agreed that the take off performance was satisfactory from intersection Alpha
and that this was considered preferable to backtracking the runway for a full length
departure.
The co-pilot was the handling pilot for this sector and although, prior to engine start,
he briefed the departure from SKB and the arrival at ANU, he did not brief the taxi
routing. He considered that the aerodrome charts provided lacked clarity and
information. At the time of the incident it was daylight but the sun was low to the
west. A member of the cabin crew was also on the flight deck, sitting on the jump
seat. A trainee ATCO, under supervision, was in the ATC tower on the tower
frequency. After an uneventful start the co-pilot called for taxi at 2059 hrs 6 minutes
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Human Factors Handout
before scheduled. The following exchange then took place between G-VIIR and ATC
at 2059:57 hrs.
G-VIIR “BRADSHAW APPROACH SPEEDBIRD TWO ONE FIVE SIX REQUEST
TAXI”
ATC “SPEEDBIRD TAXI VIA ALPHA AND BACKTRACK RUNWAY ZERO SEVEN.
TAXIWAY ALPHA IS PARALLEL THE ACTIVE”
G-VIIR “OK THAT’S COPIED TAXI VIA ALPHA WE’D LIKE TO DEPART FROM
APLHA SPEEDBIRD TWO ONE FIVE SIX”
ATC “ROGER LINE UP FOR DEPARTURE STANDBY ATC CLEARANCE”
G-VIIR “OK TAXI VIA ALPHA LINE UP FOR DEPARTURE SPEEDBIRD TWO
ONE FIVE SIX”
The co-pilot commenced a right turn through 135° away from the terminal because
no taxiway markings were present to guide the aircraft from the ramp in front of the
terminal. As he did so he identified a taxiway centreline at the rear of the ramp and
assumed it to be Taxiway Alpha. The aircraft continued on this taxiway to Holding
Point Bravo, during which time the commander completed the flight controls check
and the Before Take-off checklist. By the time the commander looked up and
orientated himself, the aircraft was approaching Holding Point Bravo. The crew
informed ATC that they would hold short of Runway 07 as the passenger cabin was
not secure. After a short delay the crew notified ATC that they were ready for
departure and ATC cleared G-VIIR to line up on Runway 07.
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Human Factors Handout
The following exchange then took place between G-VIIR and ATC at 21:02:58 hrs:
G-VIIR “SPEEDBIRD TWO ONE FIVE SIX IS NOW FULLY READY FOR
DEPARTURE”
ATC “ROGER LINE UP FOR DEPARTURE CLEARED VC BIRD VIA THE GOLF
SIX THREE THREE CLIMB TO AND MAINTAIN FLIGHT LEVEL ZERO SEVEN
ZERO”
G-VIIR “SPEEDBIRD TWO ONE FIVE SIX, SORRY I STEPPED ON YOU THERE”
ATC “CLEARED TO VC BIRD VIA THE GOLF SIX THREE THREE CLIMB TO AND
MAINTAIN FLIGHT LEVEL SEVEN ZERO”
G-VIIR “SPEEDBIRD TWO ONE FIVE SIX IS CLEARED TO ERR VC BIRD VIA
THE GOLF SIX THREE THREE CLIMB FLIGHT LEVEL SEVEN ZERO
SPEEDBIRD TWO ONE FIVE SIX”
ATC “SPEEDBIRD ERR READBACK IS CORRECT LINE UP FOR DEPARTURE”
G-VIIR “LINING UP FOR ZERO SEVEN SPEEDBIRD TWO ONE FIVE SIX”
As the aircraft entered the runway the crew visually checked that the approach was
clear and the commander checked for TCAS returns on his Navigation Display. The
following exchange then took place between ATC and G-VIIR at 2103:42 hrs:
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Human Factors Handout
ATC “SPEEDBIRD TWO ONE FIVE SIX ERR DO YOU NOT REQUEST ERR
BACKTRACK RUNWAY ZERO SEVEN”
G-VIIR “ERR NEGATIVE SPEEDBIRD TWO ONE FIVE SIX WE ARE HAPPY TO
GO FROM POSITION ALPHA”
ATC “ROGER CLEARED TAKE OFF RUNWAY ZERO SEVEN WIND ZERO NINE
ZERO ONE ZERO KNOTS”
G-VIIR “CLEARED FOR TAKE OFF ZERO SEVEN SPEEDBIRD TWO ONE FIVE
SIX”
Once the co-pilot had lined up the aircraft and stopped, the commander stated that
the runway looked very short. He advised the co-pilot to “stand on the brakes” and
apply 55% N1 before brake release, which the co-pilot did.
The operator’s Station Engineer (SE) was travelling next to the operator’s Airport
Duty Manager (ADM) on the right side of the aircraft in Row 10 of the passenger
cabin. As the aircraft taxied onto the runway the SE stated that he expected it to turn
left and backtrack down the runway as he recognised that the aircraft was at
Intersection Bravo. However, the aircraft turned right and stopped. The ADM said to
the SE that the aircraft was going to take off from the wrong intersection. Agreeing
with the ADM, the SE ran up to the Cabin Manager seated by the front left door and
asked her if she had contacted the flight crew. She assumed he was referring to the
cabin secure notification and said yes. He then said he needed to contact the flight
crew immediately as “we are in the wrong position”. Hearing the engine power
increase, towards take off thrust and realising that the take off run was starting the
engineer sat down in Row 4.
Both pilots felt that the aircraft accelerated quickly to 80 kt. The co-pilot then
considered the acceleration to V1 to be much slower and noticed that the end of the
runway was approaching. V1 was achieved as the aircraft reached the touchdown
zone aiming point markers for Runway 25 and rotation was commenced. The aircraft
became airborne with approximately 300m of runway remaining.
After take off the Cabin Manager went to speak to the SE and asked him what had
been the problem. He informed her that the aircraft had taken off from the wrong
position. He did not repeat his request to speak to the flight crew and the flight to
ANU was uneventful. After the passengers disembarked, the SE spoke directly to the
commander advising that they had departed from Intersection Bravo. The
commander initially asserted that they had taken off from Intersection Alpha but
quickly established that the aircraft had departed from Intersection Bravo. He
subsequently completed an Air Safety Report in the operator’s local office and sent it
electronically to the operator’s headquarters in London. He then called the Duty
Flight Crew Manager in London to advise him of what had happened.
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Human Factors Handout
Lost on the moon exercise
Moon Survival Items
Your
Difference
Difference
NASA’s
Group
Individual NASA to
NASA to
Ranks
Ranks
Ranks
Individual
Group
Box of matches
Food concentrate
Fifty feet of nylon rope
Parachute silk
Solar-powered portable heating unit
.45-caliber pistols
Case of dehydrated milk
100-pound tanks of oxygen
Stellar map (of moon's constellation)
Self-inflating life raft
Magnetic compass
Five gallons of water
Signal flares
First-aid kit containing injection
needles
Solar-powered FM receiver
transmitter
Totals
Totals
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Human Factors Handout
Asiana Airways – B777 (6th July 2013)
Flight crew background
The Pilot Flying
The pilot flying, age 45, held an airline transport pilot certificate issued by the
Republic of Korea Office of Civil Aviation (KOCA) with a multiengine land airplane
rating and type ratings in the Airbus A320 and the Boeing 737, 747-400, and 777.
His most recent KOCA medical certificate was issued on July 4, 2013, with no
limitations and an expiration date of September 30, 2014.
Asiana records did not indicate any previous accidents, incidents, violations, or
company disciplinary actions. The records indicated that the PF had accumulated
9,684 total flight hours, including 3,729 hours as PIC. He had 33 hours of 777 flight
time and 24 hours of 777 simulator time.
The pilot flying was hired by Asiana Airlines on March 2, 1994, as a cadet pilot with
no previous flight experience, and he received ab initio (from the beginning) flight
training at a flight school in Florida from 1994 to 1996. He began first officer training
on the 737 in 1996 and served as a 737 FO and a 747-400 FO before upgrading to
737 captain on December 15, 2005. He transitioned to A320 captain on October 22,
2007.
The PF began transition training to 777 captain on March 25, 2013. He completed
ground training, full flight simulator training, a simulator check, and OE ground
school. He completed his 777 simulator proficiency check on May 18, 2013, and his
line-oriented flight training check on May 30, 2013.
The first IP, who conducted two flights with the PF, told investigators the PF made
errors that were normal for his stage of training, like not flaring soon enough when
landing, and that the PF’s overall performance was above average.
The second IP, who conducted four flights with the PF, told investigators that nothing
stood out about the PF’s performance.
A third IP, who conducted two flights with the PF 2 days before the accident, told
investigators he was not sure if the PF was making normal progress because the PF
did not perform well during their trip together. He said the PF was not well organized
or prepared, conducted inadequate briefings, poorly monitored the operation, and
deviated from multiple standard operating procedures (SOP). He said that the PF
allowed the descent rate to get a little high on short final and allowed the nose to
drop at an altitude of 200 to 100 ft. This had caused the airplane to go below the
desired glide path and forced the pilot flying to initiate the flare early. The instructing
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Human Factors Handout
pilot counselled the PF extensively on these and other issues but worried that the
pilot flying was not taking his feedback seriously enough. The instructing pilot was
not overly concerned, however, because he knew that the pilot flying had to
complete more operational exercise flights.
Asiana records showed that the pilot flying flew 29 trips that transited San Francisco
(SFO) as a 747 first officer from July 24, 1997, to April 29, 2004. On those 29 trips,
he made 4 landings at SFO. His most recent prior landing at SFO was on July 30,
2002, and his most recent prior flight into SFO was on April 29, 2004.
The Pilot Monitoring
The PM, age 49, held an airline transport pilot certificate issued by the KOCA with a
multiengine land airplane rating and type ratings in the Boeing 757/767 and 777. His
most recent KOCA medical certificate was issued on September 5, 2012, with no
limitations and an expiration date of September 30, 2013.
Asiana records did not indicate any previous accidents, incidents, violations, or
company disciplinary actions. The records indicated that the PM had accumulated
12,307 total flight hours, including 9,045 hours as PIC. He had a total time of 3,208
hours in the 777.
After serving as a pilot in the Republic of Korea Air Force, the PM was hired by
Asiana Airlines on February 1, 1996. He was initially qualified as a 767 FO and
upgraded to 767 captain on March 21, 2001. He transitioned to 777 captain on
January 16, 2008. He underwent 777 instructor pilot training in May and June 2013
and became qualified as an instructor pilot on June 12, 2013.
The accident flight was his first time acting as an IP.
The PM had attended Asiana’s 777 recurrent training every year since 2008. A
review of Asiana’s 777 recurrent simulator training guides from 2010 to 2013 showed
that visual approach training had been conducted each year. Specifically, the 2010
recurrent training included a visual approach at night with no ILS or PAPI, and the
2011 recurrent training included a visual approach to runway 28L at SFO with no
PAPI.
The PM’s IP training included ground school, simulator training, and operational
exercises. A review of the PM’s instructor training records showed that typical
comments were “good performance” or “very good performance.” Records indicate
that he performed a visual approach three times during the simulator stage of his IP
training in 2013, receiving a grade of “good” on each occasion.
Asiana records showed that the PM flew 33 trips that transited SFO as a 777 captain
from December 12, 2007, to May 10, 2013. On those 33 trips, he made 17 landings
at SFO. His most recent prior landing at SFO was on May 8, 2013.
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Human Factors Handout
Asiana Airways – B777 (6th July 2013)
Timeline of selected events during last 1,000 ft of approach.
With respect
to the PAPI
lights,
W=white and
R=red.Local
Time
1126:54.9
1126:58.6
1126:59.1
1126:59.5
Time to
Radio
Airspee
impact
altitude d
(seconds) (feet)
(knots)
Event
-55.3
-51.7
-51.2
-50.8
1000
917
904
891
150.5
146.7
147.2
147.6
1127:05.1
1127:07.5
1127:10.8
1127:14.8
1127:15.1
-45.2
-42.8
-39.5
-35.4
-35.2
723
658
581
500
495
146.0
144.4
141.3
136.7
135.9
1127:16.6
1127:17.5
-33.7
-32.8
465
447
133.8
134.4
1127:19.8
1127:21.2
1127:23.3
1127:24.1
1127:31.0
1127:32.3
1127:33.6
1127:34.8
1127:39.3
1127:41.6
1127:42.8
1127:43.2
1127:43.7
1127:44.7
1127:46.4
1127:47.8
1127:48.6
1127:50.3
-30.5
-29.1
-27.0
-26.2
-19.3
-18.0
-16.7
-15.5
-11.0
-8.7
-7.5
-7.1
-6.6
-5.6
-3.9
-2.5
-1.7
0
404
378
344
331
219
198
180
165
124
102
90
86
81
68
46
29
21
5
134.0
132.8
130.5
129.7
121.9
120.4
117.6
119.2
113.9
111.8
109.8
109.1
108.4
106.9
103.6
103.8
104.7
105.5
PAPI displaying WWWW
Observer: "sink rate sir"
PF: "yes sir"
PM (radio): "tower asiana two one four short
final"
Observer: "sink rate sir"
Controller issues landing clearance
PM (radio): "cleared to land two eight left"
PAPI displaying WWWR
Airspeed drops below MCP-speed (137
knots)
PF: "landing checklist"
PM: "landing checklist complete cleared to
land"
PM: "on glide path sir" / PAPI WWRR
PF: "check"
Airspeed drops below VREF (132 knots)
PAPI changes to WRRR
PAPI changes to RRRR
Electronic voice: "two hundred"
PM: "it's low"
PF: "yeah"
Sound of quadruple chime
Electronic voice: "one hundred"
PM: "speed"
Right engine thrust lever advanced
Left engine thrust lever advanced
A/T mode transition from HOLD to THR
Stick shaker engaged
PM: “go around”
Stick shaker disengaged
Impact
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Human Factors Handout
UPS Flight 1354 Birmingham, Alabama(KBHM) – A300-600 (14th
August 2013)
Overview
The aircraft, an Airbus A300-600, Reg. N155UP crashed during a night time nonprecision instrument approach to landing on the 14th August 2013.
Sequence of events
At 0442:05, approach began to vector the flight, clearing the flight crew to “turn ten
degrees right, join the localizer, maintain three thousand.” During that time, the pilot
monitoring (PM) would normally configure the FMC by ‘resequencing’ the computer
to reflect only the anticipated fixes to be flown on the approach. This did not happen;
rather, the FMC produced a caption stating ‘Flight Plan Discrepancy’ which was
never cleared.
When the localizer began to capture, the crew were engaged in a conversation about
the lack of approach options to the runway and discussed their perception that ATC
had left them high.
As the airplane descended through 6,900ft the approach controller cleared the flight
for the approach stating, “maintain two thousand five hundred till established on
localizer, cleared localizer one eight approach.” However, because the flight crew did
not verify the flight plan, the FMC was still on a direct course to KBHM rather than on
a course to the approach fix.
As it descended through 3,800ft, it was established on the localizer and aligned
laterally with the extended centre-line of runway 18. When the airplane reached
2,500ft msl about 4 nm out it levelled off, even though it was established on the
localizer and could have descended to 2,300 ft.
The airplane approached the final approach fix at an altitude of 2,500ft msl, which
was 200 ft higher than the minimum crossing altitude. Because the FMC was still
sequenced for direct-to-KBHM, the airplane continued flying at 2,500ft and didn’t
capture the desired profile.
During this time and believing he had been left ‘very high’, the captain changed the
autopilot mode from the previously briefed profile approach to vertical speed mode
initially setting the vertical descent rate to about 700 ft per minute (fpm), then
increasing it to 1,000 fpm. However, he did not brief the first officer about the
autopilot mode change. Eventually she noted the change to vertical speed mode.
The captain responded, “Yeah I’m gonna do vertical speed. yeah he kept us high.”
The captain then increased the vertical descent rate to 1,500 fpm, and the airplane
continued to descend.
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Human Factors Handout
When the airplane was about 1,530ft msl, the first officer stated, “there’s a thousand
ft, instruments cross checked no flags.” The captain responded, “alright ah DA
(Decision Altitude) is twelve ah hundred.” However, the airplane continued to
descend at 1,500 fpm and passed through and continued below the desired glide
path.
As the airplane approached and then descended through the minimum descent
altitude of 1,200ft msl, neither pilot made the required callouts regarding the
minimum descent altitude.
At an altitude of about 1,000ft msl (~ 250ft agl), an
enhanced ground proximity warning system
(EGPWS) “sink rate” caution alert was triggered.
About 1 second later, the captain began to reduce
the selected vertical speed to about 600 fpm.
The captain reported the runway in sight and the
first officer confirmed she also had the runway in
sight. 2 seconds later the captain further reduced
the selected vertical speed to 400 fpm.
At 0447:31.5, the captain disconnected the autopilot, and a second later, the CVR
recorded the sound of rustling, corresponding to the airplane’s first contact with
trees. The CVR then recorded an EGPWS “too low terrain” caution alert and several
additional impact noises until the recording ended.
Competency
The captains training record showed the following points:
▪
▪
▪
Two uncompleted 757 upgrade attempts.
Multiple failures of home study programs in 1991 and 1992.
Multiple substandard elements related to non-precision approaches (most
recently June 2013).
The training deficiencies noted for the captain were during recurrent training, and for
those, the company check airman or instructor provides additional training.
Fatigue issues
The captain’s colleagues indicated that he had expressed concern that the flying
schedules were becoming more demanding. He further stated that flying 1 week on
then 1 week off made it difficult to get back into a routine the first couple of days of a
trip and that the end of a trip.
The first officer had spoken to her husband about being tired at the end of the day,
but he said that, if she was not able to, she would not fly. However, a colleague
stated that he did not think she would call in fatigued, “she was more of the type to
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Human Factors Handout
fly under the radar.” The first officer had told the colleague a month before the
accident that she’d been having trouble staying awake in the cockpit.
UPS Fatigue Risk Management Plan
The UPS fatigue risk management plan (FRMP) states the following:
The global, 24-hour nature of operations, including backside-of-the-clock
flying, flights crossing multiple time zones, and the range associated with
modern aircraft can create challenges for air carriers and pilots in managing
rest. Therefore, it is imperative that UPS Flight Operations personnel
proactively manage alertness and mitigate fatigue.
The UPS fatigue safety action group also developed a Flight Crew Alertness Guide
provided to crewmembers containing practical tips for obtaining adequate sleep,
recovering from a sleep debt, and identifying sleep problems/disorders when at
home and away.
Fatigue Training
UPS presents its pilots with fatigue training during initial CRM training and
subsequently in a one-time CRM flight crew factors seminar. The curriculum covers
the following areas:
Lessons on the causes and effects of fatigue as well as the responsibilities of
management and employees to mitigate or manage the effects of fatigue and
improve flight crewmember flight deck alertness. UPS also presented fatigue causes
and countermeasures training during its annual advanced qualification program and
continuing qualification training. Both the Captain and First officer had participated in
the company’s Fatigue Risk Management Training in the months prior to the
accident.
Evaluation of fatigue issues
On 10th August, the first officer had a sleep opportunity of 9hrs 31min, consistent
with her reported off-duty sleep habits. However, despite having over 62 hrs off duty,
Personal Electronic Device (PED) data revealed that, on the subsequent nights
leading up to the accident, she did not manage her off-duty time sufficiently to obtain
adequate sleep before resuming duty on 12th August.
Specifically, on the 10th she took a commercial flight to Houston, to visit a friend.
The first officer spent the morning of 12th in Houston and returned to base on a
commercial flight, which departed about 1325. Based on her activities that day, she
had only two opportunities to nap before returning to duty: 1 hr 2 min before
departing Houston and 1 hr 21 min after arriving back.
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Human Factors Handout
It appears that the first officer chose to revert to a diurnal schedule during her 62-hr
layover, sleeping at night and being awake during the day. UPS would have paid for
a hotel room for the layover, which the first officer could have used to adjust her
schedule to a nocturnal one.
Even if the first officer did take advantage of the sleep opportunities available on
12th August, she would not have been adequately rested for duty. She had likely
been up for about 13 hours before reporting for duty with less than a 2 1/2 hrs
opportunity for sleep, and her duty day required her to be awake for another 9 1/2
hrs.
Less than 90 min before going on duty, the first officer texted a friend stating, “I’m
getting sooo tired.” About 2 hours later, she sent another text, “hey, back in
the…office, and I’m sleepy....” The first officer went back on duty 2036 and flew with
the accident captain before landing and obtaining a sleep room where she had a
sleep opportunity of about 1 hr 51 min.
The CVR recorded the first officer telling the accident captain that she slept in the
sleep room. She further stated she was tired when her alarm went off before the
accident flight. About an hour of the flight had elapsed when this conversation was
recorded on the CVR. There was no follow-up discussion by the captain about
whether the first officer was fit for duty.
Even if the first officer had been able to take advantage of the full rest period and the
sleep opportunities, due to the excessive sleep debt acquired over the previous 2
days due to her personal choices and the accident flight occurring during the window
of circadian low, it is unlikely that she would have been able to fully recover and be
adequately rested for any of her duty period that began on the evening of 13th
August.
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Human Factors Handout
Captains Rest Period
First Officers Rest Period
NTSB Findings
Because the accident occurred during the window of circadian low, the first officer
was awake in opposition to her normal body clock and would have been more
vulnerable to the negative effects of fatigue that she was already experiencing.
Although the errors the first officer made during the accident flight cannot be solely
attributed to fatigue, the first officer made several errors consistent with the known
effects of fatigue. Specifically, the first officer did not clear the route discontinuity in
the FMC (something that should be almost automatic, as it is done on every UPS
flight), did not recognise cues suggesting the approach was not set up properly, did
not adequately cross-check and monitor the approach (especially below 1,000 ft),
and missed critical callouts.
The NTSB concludes that the first officer poorly managed her off-duty time by not
acquiring sufficient sleep, and she did not call in fatigued; she was fatigued due to
acute sleep loss and circadian factors, which, when combined with the time
compression and the change in approach modes, likely resulted in the multiple errors
she made during the flight.
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FIRST OFFICER Right Seat
NOTECH ELEMENT
CAPTAIN Left Seat
Human Factors Handout
Comments
Scores:
1 = Poor
2 = Satisfactory
3 = Good
4 = Excellent
Co-operation
Team building/ maintaining
Consideration of others
Support of others
Conflict solving
Management & Leadership
Use of authority/ assertiveness
Providing/ maintaining standards
Planning and co-ordination
Workload management
Situational Awareness
Awareness of aircraft systems
Awareness of external environment
Awareness of time
Decision Making
Problem definition/ diagnosis
Option generation
Risk assessment and option selection
Outcome review
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