NTSB seeks to learn lessons from UPS 1354 crash - wave3.com-Louisville News, Weather & Sports

NTSB seeks to learn lessons from UPS 1354 crash

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WASHINGTON, D.C. (WAVE) - The National Transportation Safety Board held a one day hearing Thursday on the crash of UPS Flight 1354 that focused on three areas: non-precision approaches, human factors and flight dispatch.

Deborah Hersman, the NTSB chair, opened with this promise: to pursue every lead to prevent another crash in the future.  

"We cannot change what happened but we do have the opportunity to learn everything we can about this accident," said Hersman. 

What lessons does the crash have to teach? One: pilots Cerea Beal and Shanda Fanning were landing the Airbus A300-600 with what's called a non-precision approach, which testimony revealed is fairly rare. UPS says it's made some changes to address that. 

"We've done a few things already and we'll do more as the investigation continues and we get to the point of making conclusions," said Mike Mangeot, a UPS Airlines spokesman. "A great example would be that we have added some non-precision landing training for our A300 pilots." 

What may be more complicated is how to get tired pilots more rest. 

"A lot of times what I'll hear is I didn't know how tired I was until I got to the hotel," said First Officer Lauri Esposito, a member of the fatigue working group for the pilots union, the independent pilots association. 

Both Beal and Fanning had complained about fatigue to friends and co-workers.         

Interviews with colleagues of the PF (Beal) indicated that he was concerned about the schedules he was flying. About 7 weeks before the accident he told a colleague that the schedules were becoming more demanding because they were flying up to three legs per night. The PF told him "I can't do this until I retire because it's killing me." He had a similar conversation with another colleague the night before the accident. In that conversation, they discussed the flight schedules and the PF said the schedules were "killing him" and he could not keep it up flying day/night flops and on one week, off the next. He told another pilot he flew with that the first couple of days of a trip were tough getting back into the schedule and the end of the trip as well. –NTSB Human Performance Factual Report of Group Chairman 

She (Fanning) had told him (a friend) within the month prior to the accident that she had recently been having trouble staying awake in the cockpit. The friend stated it was something that had become an epidemic that they almost laughed about and it was hard to know which of her comments were serious and which were a joke. They also recently discussed how the schedules had deteriorated and crews were DCA13MA133/Human Performance Factual 8 flying more legs. They had this conversation often. A pilot walking through the SDF "ready room" in March 2013, witnessed the PM with her face down on the table. He approached her and she said she was "totally exhausted" and although she had a sleep room, it was an exterior room.9 He encouraged her to call in fatigued. A pilot who recently flew with the PM on a week-long trip felt that toward the end to the week, although she was responding to radio calls, she was "zoning out" during the cruise portion of the flight. He commented to her that she looked tired and she told him she was a little. –NTSB Human Performance Factual Report of Group Chairman

In the cockpit during the early morning flight from Louisville to Birmingham on August 14, 2013, the two pilots discussed rule changes that give commercial pilots more rest than their cargo counterparts. 

"I mean I don't get that. You know it should be one level of safety for everybody," said Beal according to a transcript of the cockpit voice recorder provided by the NTSB.

Fanning, the co-pilot agreed, citing the time of the overnight shifts that many UPS pilots fly.

"I was out and I slept today. I slept in Rockford. I slept good," said Fanning. "And I was out in that sleep room and when my alarm went off I mean I'm thinkin' I'm so tired..."

Tired pilots lead to missteps, Dr. Tom Chidester from the FAA said, "you'd see things missed. Something that I do that you don't catch, something that I forgot to do that you don't catch and correct."

"If a crew member feels that he is fatigued," said Jon Snyder, a UPS captain and a member of the fatigue working group said, "then he can make a call to the scheduler at any time and he is immediately and without question removed from the flight status and put into rest."

Some say that isn't enough and the board has a chance to recommend more be done. Hersman promised the families to do it in the spirit of the words etched in its own training center.

"From tragedy we draw knowledge to improve the safety of us all," Hersman said. "We will certainly endeavor to do that."

There is still work to be done. The investigation is not finished. The NTSB would like to have that work wrapped up in advance of the one year mark of the crash in August. However, Hersman said if there are recommendations that the NTSB feels to be made ahead of the final report on the crash, the board will not hesitate to do so.

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