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
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