The pilots' failures to take certain actions at critical points during their approach to Birmingham-Shuttlesworth International Airport ultimately caused the crash of UPS Flight 1354, the National Transportation Safety Board's acting chairman said.
The NTSB on Tuesday released the findings of its 13-month investigation into the Airbus A300's crash short of Runway 18 before dawn on Aug. 14, 2013.
Capt. Cerea Beal, Jr., and First Officer Shanda Fanning died in the crash.
During a three-hour meeting, board members discussed details of the plane's approach and contributing factors such as the incomplete weather data, the plane's systems and fatigue.
However, the pilots continuing toward landing with an "unstabilized" approach -- or one not on a constant glide path toward the airport -- is listed as the probable cause of the crash, according to the NTSB.
"They failed to monitor their altitude and communicate their respective actions during approach, and at a crucial moment, the captain failed to discontinue the unstabilized approach and go around," NTSB acting Chair Christopher Hart said.
The pilots were doing a "non-precision" approach to the shorter of the airport's two runways, or an approach in which pilots have guidance to tell them how far left or right they are but no vertical guidance.
The longer runway was closed for maintenance and due to reopen about 5 a.m. the morning of the crash.
Findings also showed pilots didn't have detailed weather information for their approach, which would have shown varying levels of cloud cover near the airport.
Weather information available to the pilots stated Birmingham had clouds at 1,000 feet. However, UPS didn't include remarks added to weather condition reports for pilots.
The morning of the crash, there was a layer of clouds at 350 feet above runway level. It is likely pilots assumed they were too high in altitude because of the low cloud deck obscuring their view of the runway, investigators said.
The plane's ground warning system acted as designed, but if it had an updated software version, a terrain warning could have sounded for the pilots 6.5 seconds earlier and 150 feet higher.
However, board member Robert Sumwalt said, investigators couldn't determine if the plane's rapid rate of descent would have allowed enough time for pilots to react.
Sumwalt issued strong words for UPS concerning the ground warning system's software, stating that publications by Airbus and quotes from the ground warning system's inventor show that the system "will only be reliable if the software and databases are kept up to date."
"So, you better believe UPS people who make decisions not to do this -- if they had an iPhone, I guarantee you they would keep their software up to date, but yet the airplanes carrying their people and passengers and packages is not up to date on a device that can prevent this accident," he said.
Fanning's widower recently filed a lawsuit against the ground warning system's manufacturer, Honeywell.
Investigators also spoke about the exclusion of cargo pilots from rules regarding pilot rest that went into effect in January.
According to their findings, if Beal and Fanning were covered by those regulations, it would not have impacted the outcome of the crash.
"To use this accident or any other accident to make a point, when the facts surrounding the accident don't support that point, that is a really good way to lose credibility," Sumwalt said, seemingly an indirect reference to pilots groups who have looked at the UPS crash as evidence of needed change. "The board is not going to lose our credibility to make a point."
The NTSB continues to recommend that the Federal Aviation Administration extend the new fatigue rules to cargo pilots.
The NTSB's final report didn't come without strong words from board members for UPS' "safety culture," based on a pilot union survey's that showed 91 percent of pilots felt that UPS doesn't strongly urge its pilots to call in fatigue when they're tired, among other results.
The board approved a list of 20 recommendations. They include 15 recommendations to the FAA on items such as flight procedures and terrain warnings.
Recommendations also include UPS working with the Independent Pilots Association to address ways to combat fatigue, and for Airbus to develop a warning system if pilots incorrectly program their flight computers.
Response
Following the release, Independent Pilots Association spokesman Brian Gaudet said the findings show "the underlying problem is that UPS' safety culture is fundamentally flawed."
Gaudet cited the survey referred to by NTSB board members on Tuesday. It was conducted in March at NTSB's request.
In the survey, 90 percent of pilots answered that UPS "fails to properly manage fatigue threats," 93 percent said it was "not uncommon" to fly with fellow pilots exhibiting signs of fatigue and 88 percent said calling in fatigue brings adverse scrutiny.
"The IPA is calling for a dramatic change in the UPS safety culture. In our submission to the NTSB, we call on UPS to adopt a robust, collaborative 'Safety Management System,' or 'SMS' that is recommended, but not currently required by the FAA," Gaudet said.
"This should include company/union collaboration in critical safety areas such as flight schedules and fatigue risk management. UPS should partner with its pilot employees, not fight them," Gaudet continued. "A punitive safety culture has no place in safety critical industries such as UPS's global flight operations."
UPS spokesman Mike Mangeot said in a statement that the company "places the highest emphasis on safety and we'll continue to collaborate with our pilots to enhance our safety practices."
UPS has made safety enhancements since the crash, including training pilots on automation, pilot monitoring duties, stabilized landings and go-arounds and new standards for flying into Birmingham at night, Mangeot said.
"Essentially, we will no longer fly nighttime visual approaches into Runway 18," he said.
UPS also provides enhanced weather information to pilots, he said.
"We will also upgrade our ground proximity warning system software," Mangeot said. "However, it's important to note that the investigation showed that the software on UPS 1354 was compliant and that an upgrade would likely not have made a difference in this accident."
Regarding fatigue, Mangeot said it is difficult to understand NTSB's findings. UPS schedules its pilots to fly about 30 hours a month, which Mangeot said is the fewest in the industry and half of passenger pilots.
Beal had not flown in 10 days and Fanning was off eight of the 10 days prior to the crash.
"We believe these facts -- and others -- don't support such a finding," he said.