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  • 6/20/2025

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00:00UPS 1354 heavy, runway 18, clear to land.
00:06In a populated area near a highway,
00:10an Airbus A300 crashes short of the runway.
00:16Tower, did you see that?
00:20Neither pilot has survived.
00:22We're a very small pilot group,
00:25so you start thinking about who it may have been
00:27and exactly what happened.
00:30After listening to conversations in the cockpit...
00:32He's gonna do vertical speed. He kept us high.
00:35...and running the flight through a simulator...
00:37How'd you miss all this?
00:39...investigators are forced to take a different approach.
00:42At 11 a.m., an eyewitness spots her in the hotel restaurant.
00:46You can set yourself up for failure in a safety-critical job,
00:50like flying an aircraft.
00:52No!
00:54D-D, D-D!
00:58Oh, stop.
01:00It's an early summer morning
01:19when UPS Flight 1354 climbs over Kentucky.
01:23Autopilot 1, command.
01:34Autopilot 1, command.
01:3658-year-old Saria Beale, Jr.
01:39has been flying with UPS for more than 20 years.
01:43UPS 1354, climb and maintain flight level 280.
01:472-8-0, 1354.
01:492-8-0, 1354.
01:5337-year-old 1st officer Shanda Fanning
01:56has been with the delivery company for seven years.
01:59They were respected.
02:01They were experienced aviation professionals.
02:04They were very representative of the type of pilots that UPS hires.
02:072-8-0, 1354.
02:1428.
02:16Tonight's flight from Louisville, Kentucky,
02:20to Birmingham, Alabama takes about an hour.
02:22overnight cargo is a very time-sensitive product everybody's familiar with UPS and their next day
02:33air product so if we have an airplane that's late it may affect scores of our outbound flights we
02:40don't have the luxury of booking our packages on the next available flight because the next
02:45available flight might not be for 24 hours the crew is flying the newest version of the airbus a300
02:54equipped with advanced computers and flight management systems to assist pilots shortly
03:07after reaching cruising altitude the pilots receive a NOTAM a notice to airmen message
03:13NOTAMs provide information regarding hazards that you may encounter so that there are no surprises
03:20in route or when you arrive the runway they were expecting is closed for maintenance they'll have
03:36to use an alternate they're saying 24 is closed they want us to take runway 18 runway 18 figures I
03:44know especially since we're a little heavy yep I guess I'll brief it briefing guide the alternate
03:54runway is shorter with the plane nearly at maximum weight they'll have to carefully manage their speed
04:01and altitude on approach verify being a path on the approach charge pilots prefer longer runways because
04:11with a shorter runway there's not a lot of margin for error so the approach into the flight computer
04:18landing on runway 18 also involves a more demanding approach known as a non-precision approach in a non-precision
04:30approach pilots pre-programmed the flight computer to follow a virtual glide path or descent profile to
04:37the runway threshold nine precision approach it's not practice as much the only times flight crews ever see
04:45them perhaps would be in training in a simulator and then maybe once in a while on the line verify the
04:54slide path agrees with the approach chart within one degree verify approach to point one degrees
05:02when you're shooting a non-precision approach your workload increases dramatically you have to watch your
05:11airspeed you have to watch your altitude 28 minutes into the flight UPS 1354 begins its descent towards
05:21Birmingham Alabama the crew is cleared to continue descending to 11,000 feet that works we'll keep it going
05:37UPS 1354 we'll keep her going down to 11. Roger UPS 1354
05:45they're generous today usually they kind of take you up to 15 and hold you up there
05:52I know they hold you up high
05:54visibility is poor as the plane descends to 11,000 feet
06:00if you're flying in the clouds and it's already night time you have a black screen if you look out
06:08there's nothing out there it's the black abyss if you will
06:12UPS 1354 heavy Birmingham tower descend and maintain 2500 runway 24 is still closed
06:22you want one eight the controller confirms that the crew cannot use the airport's longer runway
06:30yeah yes sir one eight will work copy that turn right 10 degrees join the localizer okay turn right
06:40join the localizer
06:41the last few minutes before landing can be very busy for the flight crew
06:50a lot's going on and you have to be at the top of your game
06:54lap 15 speed checks
07:00lap 15
07:02eight miles from the airport the crew configures the plane for landing
07:09UPS 1354 heavy runway one eight clear to land
07:14one eight clear to land 1354
07:17speed brakes armed
07:22ignition continuous relight
07:25landing checklist is complete
07:27five miles from the runway the captain realizes something's not right
07:34unbelievable too high
07:37the autopilot hasn't initiated its final descent to the airport
07:43the captain tries to get the plane back on its programmed glide path
07:47if the plane remains too high this close to the runway
07:53the crew could overshoot it
07:55instruments cross checked
07:59no flags
08:01the first officer sees no problems with the descent
08:05two miles to go
08:07I've got the runway inside out there 12 o'clock
08:15got the runway inside
08:17autopilots off
08:23the captain prepares to fly the plane manually to touchdown
08:27pilots switch off the autopilot to land the airplane manually in this situation of a non-precision approach
08:33it's a required maneuver to actually manually land the aircraft
08:41as they get closer to the airport
08:43the pilots can't control the plane as it cuts through a small grove
08:58UPS flight 1354 crashes just one mile short of the runway
09:20yes yes airport 12 there's been a crash UPS 1354 heavy crash on the hill
09:34attention aircraft crash three miles final runway 18
09:38rescue crews rush to extinguish the flames of UPS flight 1354
09:52despite the plane coming down in a populated area
10:05and crossing a highway in Birmingham Alabama
10:08no one on the ground is injured
10:11tragically both pilots are killed
10:15within hours the National Transportation Safety Board begins the investigation
10:23looks like the plane struck some trees here
10:42then crashed into the ground here and then slid for 1400 feet
10:49the wreckage is spread over a large area
10:56yes I believe we did
10:59oh yeah it's here
11:01investigators look for the four corners of the aircraft
11:08to determine if the entire plane has reached the accident site
11:12four corners refer to the nose both wings and tail
11:17you want to take all of them into account
11:21just because it tells such a story about how the airplane struck
11:24tail and right wing were found here
11:28fragments of the left wing were found here
11:35all four corners are at the crash site the plane was intact until it hit the ground
11:43it wasn't a structural problem
11:47you wouldn't see the accident
11:52if the plane was intact investigators wonder if the pilots were having difficulty controlling it prior to impact
12:01no eyewitnesses
12:05just what we documented at the crash site
12:07let's look at how they hit those trees
12:12impact marks on trees may provide additional clues
12:19it's critical for investigators to look at all the things that this aircraft may have struck
12:26in this particular accident we know that the airplane had flown through trees
12:30when you look at those trees you want to see what the attitude of the aircraft was
12:37was it wings level was it rolled one direction or the other direction
12:40was it a very steep pitch attitude
12:43what were the height of the impact marks
12:52tree 14 43.1 feet
12:57investigators use the height of the impact marks
13:04to determine the orientation of the plane when it struck the trees
13:08the plane is level
13:15these guys had control of the aircraft
13:17absolutely
13:21if the pilots were in control of a structurally sound plane
13:26what else could have caused them to crash short of the runway
13:33maybe the engines failed
13:38it's imperative to look at the engines to give us an idea of thrust levels
13:42and surprisingly if the engines are intact more or less
13:46you can you can tell this
13:50let's start with the blades
13:53investigators examined the a300's engines to see if they were generating power at the time of the accident
14:00blades were spinning
14:07you can look in the front of the engine and if the fan blades for instance are bent in the opposite direction of rotation
14:15that means that when the aircraft's engine struck the ground it was on
14:19debris is shredded
14:26the debris ingested during impact confirms to investigators that the engines were functioning
14:34was an engine failure
14:38maybe they ran to a store
14:42with no real leads to explain why the plane crashed
14:49the team considers if weather was a possible factor
14:55if the weather was poor and the pilots couldn't see the ground well at all
15:00then perhaps they made mistakes on the approach itself
15:03this is the weather from two minutes before the accident
15:10no storms wind is calm
15:13this all looks pretty good
15:16wait there is a broken cloud ceiling at the airport
15:22a thousand feet
15:24this is the ground
15:26and this is the cloud cover
15:28the cloud ceiling is the distance from the ground to the base of the lowest clouds
15:35that's pretty low
15:37flight 1354 would only descend from clouds at a thousand feet
15:43what was the decision altitude for their approach
15:46the decision altitude is the altitude at which the crew must be able to see the runway
15:53or else abandon their approach
15:56the decision heights they're all pretty much a hard floor
15:59especially in the weather should not be broken
16:02you should not go below the decision altitude
16:05unless you see the runway
16:08decision altitude was twelve hundred feet
16:14if the clouds didn't break until a thousand feet
16:23they wouldn't have seen the runway
16:25for their decision altitude
16:26so why didn't they turn around
16:29that low to the ground
16:32at night
16:33you don't have time to hidden hope
16:35you have to go around
16:37and get it together and try it again
16:39did lack of visibility
16:42cause the pilots to descend too rapidly
16:45and crash short of the runway
16:49maybe the controller knows something
17:00are they concerned at all about the approach?
17:03investigators interview the air traffic controller
17:05to understand why the pilots of flight 1354
17:08descended so low while in thick clouds
17:11they didn't say anything
17:14everything seemed fine
17:18the air traffic controller can tell the investigator
17:22what he heard from the flight crew
17:24if they sounded or reported anything unusual
17:28anything that he wasn't expecting
17:30was there anything out of the ordinary that night?
17:32yeah
17:35the runway they were scheduled to land on was closed
17:39so they had to use the alternate
17:42it's a non-precision approach
17:45UPS 1354 heavy
17:48Birmingham tower descend and maintain 2500
17:51runway 24 is still closed
17:53you want 1-8?
17:55yeah
17:56yes sir 1-8 will work
17:58so they shot a non-precision with no eyes on the runway
18:04knowing what the weather was
18:09knowing what the crew thought the weather was
18:11knowing what information they were given about the weather
18:14told us a lot about how they executed the approach
18:17thank you
18:21why did the crew continue their non-precision approach in heavy clouds?
18:27do we have the data from the flight recorders?
18:31those two black boxes are very critical to investigators
18:37because they're electronic witnesses
18:44here's the approach they should have taken
18:46the plan was to come in slow and steady
18:49at about a 3 degree angle
18:53using the FDR data
18:55investigators reconstruct the final approach path of flight 1354
19:01here's what they actually did
19:08in this particular instance
19:10the critical phase of flight which was approach
19:12were they doing what they were supposed to be doing?
19:15investigators can compare that then
19:17against what the airplane was actually doing
19:20the crew's approach was far from a steady descent
19:24the controller cleared them to 2500 feet
19:29but they leveled out a little higher than that
19:32which shouldn't be a problem
19:39collapse 15
19:40speed checks
19:41collapse 15
19:42UPS 1354 heavy runway 18
19:47clear to land
19:48looks like they fly past the descent profile
19:53they pre-programmed into the computer here
19:57try to get back on track
19:58but end up descending steeply below the flight path
20:00and never recover
20:05how fast were they coming down?
20:06did the crew descend too quickly as they tried to get back on track?
20:18check this out
20:19wow
20:211500 feet per minute
20:23the descent is way too fast so close to the ground
20:25they confirmed that the plane descended at a rate outside safety guidelines for a final approach
20:32it's an important clue
20:34any pilot looking at this would understand that they were descending way too fast this close to the runway
20:41you would think that the pilot would have started bottoming out
20:46that is slowing that rate of descent a lot sooner than he did
20:55what would make him sing for me to descend that fast to get back on the glide path?
21:00investigators dig deeper into the FDR data
21:06that's a strange way to program the autopilot
21:08the team notices that just after the plane flew past the descent profile
21:14the autopilot is set to a mode called vertical speed
21:20the mode is used to descend quickly at higher altitudes
21:24not on final approach
21:27this complicates the job of the pilot very very much
21:30he has less time to think about things
21:32he has less time to react to things
21:35so it's simply not a good thing
21:38why were they descending so quickly so close to the ground?
21:45the FDR data only tells investigators what the pilots did
21:50not why
21:52we need the cockpit voice recorder
21:55when you add to that what the pilots were saying
21:59and you match that with what the airplane was doing
22:03investigators have a pretty complete picture of what was going on
22:06okay, let's hear it
22:11UPS 1350
22:14the Copkin voice recorder
22:16it tells us, more or less
22:18what's going through the minds of the flight crew
22:20runway 18
22:22they listen as the pilots make their vertical speed adjustments
22:25while they configure their landing
22:26to land 1354
22:288 brakes armed
22:30ignition continuous relay
22:32landing checklist is complete
22:34unbelievable
22:36too high?
22:38let's see
22:39you're in vertical speed
22:41yeah, we're gonna do a vertical speed
22:43he kept us high
22:44hold up there
22:47hold up there
22:51captain thinks the plane didn't lock onto the programmed descent profile
22:55cause the controller kept them too high
22:58bring up the recommended altitude
23:01investigators check the altitude the computer required the plane to reach before commencing the automated descent
23:112300 feet
23:13that's only a few hundred feet too high
23:18even though the captain believed the plane didn't descend because the controller kept them too high
23:23the computer should have initiated its programmed descent at that higher altitude
23:28maybe there was a problem with the flight computer
23:33verify the glide path agrees with the approach chart within one degree
23:42did a malfunction in the flight computer used to program the autopilot lead to the crash of UPS flight 1354?
23:53verify approach
23:560.1 degrees
24:01the flight management system to an airline pilot in an airline operation like this is very critical because it is the automation
24:09it is the typical way of flying a large aircraft
24:12if you have bad data in
24:14that data will cause bad things to happen
24:17okay
24:20let's hook this up
24:23investigators recover the flight computer's memory card from the wreckage
24:26they prepare to test it for signs of errors or malfunctions
24:31the investigators went to great pains to figure out what exactly was loaded into the flight management computer
24:46it was damaged so they had to remove the motherboard and place it in a functioning unit and actually read it out
24:53they should tell us if the computer was working
24:57if the flight computer was operational
25:01investigators should be able to download its memory
25:05it's working
25:10turned out that there was nothing wrong with the flight management computer
25:14but had there been that could have been a very important part of the accident sequence
25:18the computer was working
25:21looks like they programmed it
25:23final approach is armed for a gradual descent of three degrees
25:27wait a minute
25:28wait a minute
25:30they've got two separate destinations programmed
25:36they forgot to clear the conflict
25:40they discover the crew missed a step in planning their route to Birmingham airport
25:46they failed to clear a previously programmed destination
25:50it's a troubling find
25:52you can load a flight plan into it
25:55and then if you deviate from that particular flight plan
25:58the flight management computer doesn't really know what's going on
26:02and can put out false data and that's called a discontinuity
26:06the crew programmed the plane to fly directly to Birmingham airport
26:1220 miles out they needed to clear their flight path
26:16and program a specific approach to runway 18
26:18but the crew didn't clear the initial plan
26:22which created the discontinuity
26:25a confusion in the system
26:27there was a conflict between where the pilots told the airplane to start the approach
26:33and where the computer knew the approach had to start
26:37and that was a flight plan discontinuity
26:39that's why the autopilot wouldn't initiate the descent path
26:44the captain basically was chasing the incorrect guidance that the display was telling him
26:50by trying to descend as quickly as he could when there was no reason for it
26:56the team knows the crew didn't clear the conflict
27:00the question is why
27:03let's listen to what was going on when they should have cleared it
27:05they focus on the moment the crew got the instruction from the controller to go to runway 18
27:16here it is
27:18you want 18
27:20the controller reminds the crew that they must use an alternate runway
27:23yep
27:25yes sir
27:26yes sir 18 will work
27:28copy that
27:30turn right 10 degrees join the localizer
27:32okay turn right join the localizer
27:35I don't think we have many choices if runway 6 is closed
27:39at that moment the crew should have cleared the discontinuity and reprogrammed the approach
27:50I know what can we do
27:52I'm like are you going to unroll another one out there for us real quick
27:56the crew make a few light-hearted comments
27:58gear down
28:00gear down
28:02gear down
28:04speed checks
28:06there was some glad handing a little bit some
28:09humorous comments being made there
28:12they should have probably knuckled down and focused strictly on what needed to be done
28:17the first officer gets distracted and forgets to clear the discontinuity
28:23look lapses in concentration happen that's why you have two pilots
28:29but did the captain really miss this too?
28:32pilots are meant to monitor each other to catch mistakes
28:37so how did they both miss such a critical step?
28:41it's just five minutes before the accident
28:45plenty of time to see the mistake
28:47for investigators they have to try and determine why didn't they see the accident?
28:51why didn't they see this discontinuity? why didn't they remedy it?
28:56what exactly were they seeing on their displays during this five minutes?
29:00let's run it through the simulator
29:05the simulations are very helpful to investigators
29:08if the accident occurred because of crew action or inaction
29:13simulations can tell investigators what the crew encountered
29:17take it to 442 where they should have cleared the discontinuity
29:24investigators prepare to see exactly what the pilots saw during the final five minutes of the flight
29:31they scan the cockpit instruments for clues as to why the first officer didn't correct her error
29:36in this case the first officer's job really was to glue her eyes to the instruments
29:43she was the non-flying pilot and that was really her only job
29:47I know, what else can we do?
29:53gear down
29:57gear down
29:59have a look at this
30:02it's telling you to take two different approaches
30:04when the first officer didn't clear the discontinuity
30:12the flight computer displayed two routes to the airport
30:16that ought to tell you something's wrong
30:18there should never be two
30:20you can't be two places at one time
30:22should have been a single line
30:24but the computer couldn't figure out because of the discontinuity
30:26um, where to start the approach?
30:30the discontinuity message is right here on the flight computer too
30:35speed brakes armed
30:40ignition continuous relight
30:42landing checklist is complete
30:44unbelievable
30:46they kept us high
30:48how'd you miss all this?
30:56they conclude that there were plenty of signs telling the pilots what they had done wrong
31:02oh no!
31:06did I hit something?
31:08but they still don't understand how they failed to notice them
31:11in time to prevent this tragic accident
31:14oh god
31:15you can have information buried in an instrument that isn't in your focal view
31:20or in your peripheral vision
31:22that's one thing
31:23but if it's prominently displayed and you don't see it
31:25the question that we as investigators have to answer is
31:28why not?
31:30no!
31:34investigators have identified serious piloting errors in the crew of flight 1354
31:40how qualified were they?
31:42they study the pilot's personnel records
31:47captain's got more than 3,000 hours on the A300
31:52passed all his latest checks
31:55looks good
31:57first officer's a little new to the aircraft
32:02she's got plenty of experience
32:05ticks all the boxes
32:07this approach was certainly not beyond their abilities
32:11they had good records
32:13any other clues?
32:17this could be something
32:26if you're flying this time of day you always feel fatigued
32:37yep
32:39i mean i was out and i slept today
32:41i slept good
32:43me too
32:45and when my alarm went off i am still thinking i am so tired
32:47i know
32:49exactly
32:51she was tired
32:54mm-hmm
32:56question is
32:58how tired?
33:00did the first officer get enough rest before the flight?
33:05being fatigued
33:07it's been characterized like being inebriated
33:10you can see something
33:11you can recognize that there's an issue there
33:14but you're not really analyzing the gravity of the situation
33:19the schedules that cargo pilots fly can be very punishing very demanding
33:24primarily because we operate throughout the nighttime hours
33:27we know that fatigue is a significant flight risk
33:33she had 14 hour rest period before her final shift
33:37how much rest did she actually get?
33:40there's enough analytical data
33:44that demonstrates that a human needs this amount of rest period
33:49you can set reasonable rest periods
33:52and it's then up to the human
33:55to abide by that rest period
33:58in a safety critical job
33:59like flying an aircraft
34:01it says here she swiped the key into her hotel room at just after 6 a.m.
34:06but records show she was on her cell and tablet at 6 49 a.m.
34:11at 11 a.m. an eyewitness spots her in the hotel restaurant
34:15did she head back to her room for more rest after that?
34:23mmmm
34:25she didn't swipe back into her hotel room until 3 22 p.m.
34:29but
34:31she was on her cell phone and tablet until 5 p.m.
34:34from the evidence that investigators got it's clear she did not manage her rest period
34:39effectively and she could have
34:40so it looks like she had a rest period between 5 and 6 30
34:44but then she was back on her personal devices and called her husband before reporting for duty at 8 30 p.m.
34:57she can't have slept more than five and a half hours in her 14 hour layover
35:00yeah
35:01five and a half hours in fits and starts is less than the recommended eight hours of uninterrupted sleep
35:12okay turn right join the localizer
35:15I don't think we have many choices if runway 6 is closed
35:21interpreting information during a non-precision approach when you're fatigued
35:26when you have to do other duties such as call out altitudes and air speeds and so on and so forth
35:32it's very difficult
35:34investigators conclude that the first officer's fatigue likely contributed to this accident
35:41the problem is is that we've had a number of accidents in the cargo industry that have been related in some way shape or form to fatigue
35:49the first accident that actually referenced fatigue was almost 20 years ago Guantanamo Bay
35:59one last break guys
36:04in AIA flight 808 the crew had been awake for 15 hours before flying cargo to Guantanamo Bay Cuba
36:13the flight ended in a horrific accident
36:24the NTSB's findings in that investigation changed the industry's view of fatigue
36:29it shined light on the issue of fatigue being you know as much of a safety risk as a mechanical issue on an airplane
36:37Pilots are no longer expected to fly fatigued
36:41yet 15 accidents have been attributed to fatigue between 1993 and 2013
36:47Fatigue is real
36:50we need to recognize it we need to mitigate it
36:54Investigators now know that the first officer's fatigue played a part in this accident
37:00but a question still remains
37:04why didn't the captain catch the first officer's mistakes?
37:09was he fatigued too?
37:15captain had seven days off
37:18yeah he went to bed early
37:20had a nap
37:21records show the captain of UPS 1354 met the required amount of rest before the flight
37:30yeah I'm gonna do a vertical speed he kept us high
37:36the captain he had some days off and so he should have been well rested
37:42he should have been well rested
37:45we don't know all of his activities but he should have been the most rested pilot
37:55if not fatigue then what?
37:58investigators need to dig deeper
38:01they return to the CVR transcript for insight into the captain's frame of mind
38:07check this out
38:10the captain mentions being too high
38:13four, five, six times
38:17for a captain to be so fixated on that one flight parameter
38:22puts up a red flag for investigators
38:25sounds like television
38:29the captain was very focused on his altitude
38:32he said many many times
38:35we're high, we're high, we need to get down
38:38when you become that focused
38:40everything else kind of flies out the window
38:43they did seem to fixate it on the fact that they were too high
38:46and then at some point of course they were far too low
38:51investigators now know what happened to UPS flight 1354
38:58okay turn right, join the localizer
38:59I don't think we have many choices if runway six is closed
39:05a tired first officer misses a critical step in preparing for the approach into Birmingham
39:13we know she was fatigued
39:16we know that the non-precision approaches increase the workload on the pilots
39:21and misses the cues telling her she made the mistake
39:25finals activated
39:28if you put them all together, the workload, the fatigue, her role in helping the pilot by monitoring the instruments
39:39she never recognized that there was a discontinuity
39:43because of her mistake the plane over flies the pre-programmed descent path
39:47unbelievable, he kept us high
39:51safety is compromised with distraction, complacency, the fact that you know, you get zoned out, you get focused tunnel vision
39:59a captain already fixated on altitude, misses the first officers error
40:04let's see, you're in vertical speed
40:07yeah, we're gonna do a vertical speed, he kept us high
40:11forces the plane into a steep descent to get back on track
40:15they failed to recognize that the automation wasn't doing what they thought it would be doing
40:20and never recovers
40:24great
40:28they realized that they were in danger only seconds before the accident
40:32by that point it was too late
40:34by that point it was too late
40:51in their final report
40:53the NTSB recommends that cargo operators require a crew briefing on the threat of fatigue before each flight
41:00if you're fatigued, you gotta call it out because your performance as a human degrades
41:10and while we want to push through and accomplish the mission
41:14the problem is, is you can set yourself up or your crewmate for failure
41:20because of your lack of performance
41:22since our accident in Birmingham, the company has done a fantastic job in the training department
41:36we've also negotiated for sleep rooms
41:40so we can go take a mid-duty nap during the sorting of the packages process
41:46our pilots will tell you they're a game changer
41:48it took a lot of little errors by all the major participants in this flight to cause this airplane to crash
41:58in that respect, it's really unfortunate, it makes this accident so tragic
42:02it's really unfortunate, it makes this accident so tragic
42:04tragic.