Original subtitles

[Plane Engine Hums]

UPS 1354 heavy, runway 18, clear to land.

[Narrator] In a populated area, near a highway.

Oh no.

[Narrator] An Airbus A300 crashes short of the runway.

[Fire Explodes]

[Caller] Tower, did you see that?

[Narrator] Neither pilot has survived.

[Lauri] We're a very small pilot group.

So you start thinking about who it may have been,

and exactly what happened.

[Narrator] After listening to conversations in the cockpit.

We're gonna do vertical speed. He kept us high.

[Narrator] And running the flight through a simulator.

Huh! How'd she miss all this?

[Narrator] Investigators are forced to take

a different approach.

At 11 a.m., an eyewitness spots her

in the hotel restaurant.

[Greg] You can set yourself up for failure

in a safety critical job like flying an aircraft.

-[Tires Screeching] -No!

[Woman] Ladies and gentlemen, we are starting our approach.

[Man] We lost both engines.

[Woman] Place your mask over your nose, emergency descent.

[Woman] Brace for impact.

[Dramatic Music]

[Man] It's gonna crash.

[Fire Explodes]

[Dramatic Music]

[Narrator] It's an early summer morning

when UPS flight 1354 climbs over Kentucky.

[Engine Humming]

[Dramatic Music]

Autopilot one command.

Autopilot one command.

[Narrator] 58 year-old Cerea Beal Jr. has been flying

with UPS for more than 20 years.

[Controller] UPS 1354, climb and maintain flight level 280.

280, 1354.

[Narrator] 37-year-old First Officer Shanda Fanning,

has been with the delivery company for seven years.

[Lauri] They were respected.

They were experienced aviation professionals.

They were very representative of the type of pilots

that UPS hires.

-280. -28.

[Narrator] Tonight's flight from Louisville, Kentucky,

to Birmingham, Alabama, takes about an hour.

[Lauri] Overnight cargo is a very time-sensitive product.

Everybody's familiar with UPS and their

next day air product.

So if we have an airplane that's late,

it may affect scores of our outbound flights.

We don't have the luxury of booking our packages

on the next available flight, because

the next available flight might not be for 24 hours.

[Engine Humming]

[Narrator] The crew is flying the newest version

of the Airbus A300, equipped with advanced computers

and flight management systems to assist pilots.

[Man] Notice to airmen, runway 24 closed.

[Narrator] Shortly after reaching cruising altitude,

the pilots receive a NOTAM, a Notice to Airmen message.

NOTAMs provide information regarding hazards

that you may encounter, so that there are no surprises

en route, or when you arrive.

[Man] Localizer runway 18 in use.

Landing and departing runway 18.

[Narrator] The runway they were expecting is closed

for maintenance.

They'll have to use an alternate.

They're saying 24 is closed.

They want us to take runway 18.

Runway 18? It figures.

I know. Especially since we're a little heavy.

Yep. I guess I'll brief it. Briefing guide.

[Narrator] The alternate runway is shorter.

With the plane nearly at maximum weight,

they'll have to carefully manage their speed

and altitude on approach.

Verify VNAV path on the approach chart.

Pilots prefer longer runways because with a shorter runway

there's not a lot of margin for error.

Load the approach into the flight computer.

[Upbeat Music]

[Narrator] Landing on runway 18 also involves

a more demanding approach,

known as a non-precision approach.

In a non-precision approach,

pilots pre-program the flight computer to follow

a virtual glide path or descent profile

to the runway threshold.

A non-precision approach is not practiced as much.

The only times flight crews ever see them, perhaps,

would be in training in a simulator

and then maybe once in a while on the line.

Verify the glide path agrees with the approach chart

within one degree.

Verify approach to .1 degrees.

When you're shooting a non-precision approach,

your workload increases dramatically.

You have to watch your airspeed.

You have to watch your altitude.

[Narrator] 28 minutes into the flight,

UPS 1354 begins its descent towards Birmingham, Alabama.

[Controller] UPS 1354, descend at pilot's discretion.

Maintain 11000.

[Narrator] The crew is cleared to continue descending

to 11,000 feet.

That works. We'll keep it going.

UPS 1354. We'll just keep her going down to 11.

[Controller] Roger. UPS 1354.

They're generous today.

Usually, they kind of take you up to 15

and hold you up there.

I know. They hold you up high.

[Narrator] Visibility is poor as the plane

descends to 11,000 feet.

If you're flying in the clouds and it's already nighttime,

you have a black screen.

If you look out, there's nothing out there.

It's the black abyss, if you will.

[Upbeat Music]

UPS 1354 heavy, Birmingham Tower,

descend and maintain 2,500.

Runway 24 is still closed. You want 18?

[Narrator] The controller confirms that the crew

cannot use the airport's longer runway.

Yeah.

Yes, sir. 18 will work.

[Controller] Copy that.

Turn right 10 degrees, join the localizer.

Okay. Turn right, join the localizer.

[Upbeat Music]

[Thunder Storm]

[Lauri] The last few minutes before landing can be very busy

for the flight crew.

A lot's going on, and you have to be

at the top of your game.

[Upbeat Music]

Flaps 15.

Speed checks. Flaps 15.

[Narrator] Eight miles from the airport,

the crew configures the plane for landing.

[Controller] UPS 1354 heavy, runway 18, clear to land.

[Fanning] 18 cleared to land 1354.

[Plane Engine Humming]

Speed brakes armed. Ignition continuous relight.

Landing checklist is complete.

[Narrator] Five miles from the runway,

the captain realizes something's not right.

Unbelievable. Too high.

[Narrator] The autopilot hasn't initiated

its final descent to the airport.

The captain tries to get the plane back

on its programmed glide path.

If the plane remains too high this close to the runway,

the crew could overshoot it.

[Upbeat Music]

Instruments cross checked. No flags.

[Narrator] The first officer sees no problems

with the descent.

Two miles to go.

[Upbeat Music]

[Plane Engine Humming]

I've got the runway in sight out there, 12 o'clock.

[Fanning] Got the runway in sight.

[Machine Beeps]

Autopilot's off.

[Upbeat Music]

[Narrator] The captain prepares to fly

the plane manually to touchdown.

Pilots switch off the autopilot to land

the airplane manually in the situation

of a non-precision approach.

It's a required maneuver to actually manually

land the aircraft.

[Narrator] As they get closer to the airport.

[Machine Beeps]

-Did I hit something? -[Gpws] Terrain. Caution.

-Oh no! -[Gpws] Terrain.

[Gpws] Too low.

[Debris Scattering]

Oh God!

[Fanning Screams]

[Narrator] The pilots can't control the plane

as it cuts through a small grove.

[Plane Engine Humming]

No!

Oh my god!

[Plane Crashes]

[Fire Crackling]

[Narrator] UPS flight 1354 crashes just one mile

short of the runway.

[Woman] Tower, did you see that?

Yes, yes.

Airport 12, there's been a crash.

UPS 1354 heavy crashed on the hill.

Attention, aircraft crash three miles final runway 18.

[Upbeat Music]

[Siren Blaring]

[Narrator] Rescue crews rush to extinguish the flames

of UPS Flight 1354.

[Upbeat Music]

[Fire Sizzling]

[Helicopter Chuffing]

Despite the plane coming down in a populated area

and crossing a highway in Birmingham, Alabama,

no one on the ground is injured.

Tragically, both pilots are killed.

Within hours, the National Transportation Safety Board

begins the investigation.

[Camera Shuttering]

[Somber Music]

It looks like the plane struck some trees here,

then crashed into the ground here,

and then slid for 1,400 feet.

Did we find the nose?

[Narrator] The wreckage is spread over a large area.

Yes. I believe we did.

Uh yeah, it's here.

[Narrator] Investigators look for the four corners

of the aircraft to determine if the entire plane

has reached the accident site.

[Barry] The four corners refer to the nose,

both wings and tail.

You want to take all of them into account,

just because it tells such a story about

how the airplane struck.

Tail and right wing were found here.

[Upbeat Music]

Fragments of the left wing were found here.

[Narrator] All four corners are at the crash site.

The plane was intact until it hit the ground.

It wasn't a structural problem.

Did anyone see the accident?

[Narrator] If the plane was intact, investigators wonder

if the pilots were having difficulty controlling it

prior to impact.

No eyewitnesses, just what we documented

at the crash site.

Let's look at how they hit those trees.

[Narrator] Impact marks on trees may provide

additional clues.

It's critical for investigators to look at all

the things that this aircraft may have struck.

In this particular accident, we know that the airplane

had flown through trees.

When you look at those trees, you wanna see what

the attitude of the aircraft was.

Was it wings level?

Was it rolled one direction or the other direction?

Was it a very steep pitch attitude?

[Dramatic Music]

[Investigator] What were the height of the impact marks?

Tree 14, 43.1 feet.

[Narrator] Investigators use the height of

the impact marks to determine the orientation of the plane

when it struck the trees.

[Investigator] The plane is level.

These guys had control of the aircraft.

Absolutely.

[Narrator] If the pilots were in control of

a structurally sound plane, what else could have caused them

to crash short of the runway?

[Dramatic Music]

Maybe the engines failed.

[Bob] It's imperative to look at the engines

to give us an idea of thrust levels.

And surprisingly, if the engines are intact more or less,

you can tell this.

Let's start with the blades.

[Narrator] Investigators examine the A300's engines

to see if they were generating power

at the time of the accident.

[Dramatic Music]

The blades were spinning.

[Bob] You can look in the front of the engine and

if the fan blades, for instance, are bent

in the opposite direction of rotation,

that means that when the aircraft's engine

struck the ground it was on.

[Dramatic Music]

Debris is shredded.

[Narrator] The debris ingested during impact confirms

to investigators that the engines were functioning.

It wasn't engine failure.

Maybe they ran into a storm.

[Dramatic Music]

[Narrator] With no real leads to explain why

the plane crashed,

the team considers if weather was a possible factor.

If the weather was poor and the pilots couldn't see

the ground well at all,

then perhaps they made mistakes on the approach itself.

[Dramatic Music]

This is the weather from two minutes before the accident.

No storms, wind is calm.

This all looks pretty good.

Wait, there was a broken cloud ceiling at the airport,

a thousand feet.

This is the ground and this is the cloud cover.

[Narrator] The cloud ceiling is the distance

from the ground to the base of the lowest clouds.

That's pretty low.

[Narrator] Flight 1354 would only descend from clouds

at a thousand feet.

What was the decision altitude for their approach?

[Narrator] The decision altitude is the altitude at which

the crew must be able to see the runway

or else abandon their approach.

[Bob] Decision heights, they're all pretty much a hard floor,

especially in the weather, should not be broken.

You should not go below the decision altitude

unless you see the runway.

[Dramatic Music]

Decision altitude was 1,200 feet.

If the clouds didn't break until a thousand feet,

they wouldn't have seen the runway

at their decision altitude.

[Investigator 2] So why didn't they go around?

That low to the ground, at night,

you don't have time to hint and hope.

You have to go around and get it together and try it again.

[Dramatic Music]

[Narrator] Did lack of visibility cause the pilots

to descend too rapidly and crash short of the runway?

Maybe the controller knows something.

[Dramatic Music]

Were they concerned at all about the approach?

[Narrator] Investigators interview

the air traffic controller, to understand why

the pilots of flight 1354 descended so low

while in thick clouds.

They didn't say anything.

Everything seemed fine.

The air traffic controller can tell the investigator

what he heard from the flight crew to the,

if the sounded or reported anything unusual,

anything that he wasn't expecting.

Was there anything out of the ordinary that night?

Yeah. The runway they were scheduled to land on was closed.

So they had to use the alternate.

It's a non-precision approach.

[Dramatic Music]

UPS 1354 heavy, Birmingham Tower,

descend and maintain 2,500.

Runway 24 is still closed.

You want 18?

Yeah.

Yes sir. 18 will work.

So they shot a non-precision with no eyes on the runway?

[Dramatic Music]

Knowing what the weather was, knowing what the crew

thought the weather was, knowing what information

they were given about the weather,

told us a lot about how they executed the approach.

Thank you.

[Narrator] Why did the crew continue

their non-precision approach in heavy clouds?

Do we have the data from the flight recorders?

[Cymbal Clanging]

Those two black boxes are very critical to investigators

because they're electronic witnesses.

[Dramatic Music]

Here's the approach they should have taken.

The plan was to come in slow and steady,

at about a three-degree angle.

[Narrator] Using the FDR data, investigators reconstruct

the final approach path of flight 1354.

Here's what they actually did.

[Upbeat Music]

In this particular instance, the critical phase of flight,

which was approach, were they doing

what they were supposed to be doing?

Investigators can compare that then against

what the airplane was actually doing.

[Narrator] The crew's approach was far

from a steady descent.

The controller cleared them to 2,500 feet.

But they leveled out a little higher than that,

which shouldn't be a problem.

[Engine Humming]

Flaps 15.

[Woman] Speed checks, flaps 15.

[Controller] UPS 1354 heavy, runway 18, cleared to land.

It looks like they fly past the descent profile

they pre-programmed into the computer here.

They try and get back on track but end up

descending steeply below the flight path and never recover.

[Dramatic Music]

How fast were they coming down?

[Narrator] Did the crew descend too quickly

as they tried to get back on track?

Huh. Check this out.

Wow, 1500 feet per minute.

The descent is way too fast so close to the ground.

[Narrator] They confirm that the plane descended at a rate

outside safety guidelines for a final approach.

It's an important clue.

Any pilot looking at this would understand that

they were descending way too fast this close to the runway.

[Dramatic Music]

[Greg] You would think that the pilot would have started

bottoming out, that is slowing that rate of descent

a lot sooner than he did.

What would make him think he needed to descend that fast

to get back on the glide path?

[Narrator] Investigators dig deeper into the FDR data.

That's a strange way to program the autopilot.

[Narrator] The team notices that just after the plane

flew past the descent profile,

the autopilot is set to a mode called Vertical Speed.

The mode is used to descend quickly at higher altitudes,

not on a final approach.

[Bob] This complicates the job of the pilot, very, very much.

He has less time to think about things.

He has less time to react to things.

So it's simply not a good thing.

[Engine Humming]

Why were they descending so quickly so close to the ground?

[Narrator] The FDR data only tells investigators

what the pilots did, not why.

We need the cockpit voice recorder.

[Barry] When you add to that what the pilots were saying,

and you match that with what the airplane was doing,

investigators have a pretty complete picture

of what was going on.

[Dramatic Music]

Okay, let's hear it.

[Controller] UPS 1534.

The cockpit voice recorder, it tells us more or less,

what's going through the minds of the flight crew.

[Controller] Runway one 18-

[Narrator] They listen as the pilots make

their vertical speed adjustments while

they configure their landing.

[Fanning] Cleared to land, 1354.

Speed brakes armed. Ignition continuous relight.

Landing checklist is complete.

Unbelievable. Too high.

[Fanning] Let's see. You're in vertical speed.

Yeah, I'm gonna do vertical speed. He kept us high.

[Dramatic Music]

Hold it there.

The Captain thinks the plane didn't lock onto

the programmed descent profile

because the controller kept them too high.

Bring up the recommended altitude.

[Narrator] Investigators check the altitude

the computer required the plane to reach

before commencing the automated descent.

[Investigator 2] 2,300 feet.

That's only a few hundred feet too high.

[Narrator] Even though the captain believed the plane

didn't descend because the controller kept them too high,

the computer should have initiated its programmed descent

at that higher altitude.

Maybe there was a problem with the flight computer.

[Dramatic Music]

Verify the glide path agrees with

the approach chart within one degree.

[Narrator] Did a malfunction in the flight computer

used to program the autopilot lead

to the crash of UPS Flight 1354?

Verify approach .1 degrees.

[Dramatic Music]

The flight management system to an airline pilot

in an airline operation like this is very critical,

because it is the automation.

It is the typical way of flying a large aircraft.

If you have bad data in that data will cause

bad things to happen.

[Plane Engine Humming]

Okay.

Let's hook this up.

[Narrator] Investigators recover the flight

computer's memory card from the wreckage.

They prepare to test it for signs of errors or malfunctions.

The investigators went to great pains to figure out

what exactly was loaded into the flight management computer.

It was damaged, so they had to remove the motherboard

and place it in a functioning unit

and actually read it out.

This should tell us if the computer was working.

[Narrator] If the flight computer was operational,

investigators should be able to download its memory.

[Computer Beeps]

[Investigator 2] It's working.

[Bob] It turned out that there was nothing wrong

with the flight management computer.

But had there been, that could have been

a very important part of the accident sequence.

If the computer was working-

It looks like they programmed it.

The final approach is armed for a gradual descent

of 3 degrees.

Wait a minute.

They've got two separate destinations programmed.

[Dramatic Music]

They forgot to clear the conflict.

[Narrator] They discover the crew missed a step

in planning their route to Birmingham airport.

They failed to clear

a previously programmed destination.

It's a troubling find.

[Bob] You can load a flight plan into it,

and then if you deviate from that particular flight plan,

the flight management computer doesn't really know

what's going on and can put out false data,

and that's called a discontinuity.

[Narrator] The crew programmed the plane to fly directly

to Birmingham airport.

20 miles out, they needed to clear their flight path

and program a specific approach to runway 18.

But the crew didn't clear the initial plan,

which created the discontinuity, a confusion in the system.

There was a conflict between where the pilots told

the airplane to start the approach

and where the computer knew the approach had to start,

and that was a flight plan discontinuity.

That's why the autopilot wouldn't initiate

the descent path.

[Barry] The captain basically

was chasing the incorrect guidance

that the display was telling him by trying to descend

as quickly as he could, when there was no reason for it.

[Narrator] The team knows the crew didn't clear

the conflict.

The question is, why?

Let's listen to what was going on

when they should have cleared it.

[Narrator] They focus on the moment the crew got

the instruction from the controller

to go to runway 18.

Okay. Here it is.

[Controller] You want 18?

[Narrator] The controller reminds the crew

that they must use an alternate runway.

Yep.

Yes sir. 18 will work.

[Controller] Copy that.

Turn right 10 degrees, join the localizer.

Okay. Turn right, join the localizer.

I don't think we have many choices if runway six is closed.

[Dramatic Music]

[Narrator] At that moment, the crew should have cleared

the discontinuity and reprogrammed the approach.

[Beal] I know, what can we do?

I'm like, are you gonna unroll another one out there

for us real quick? [Laughs]

[Narrator] The crew make a few light-hearted comments.

Gear down.

Gear down. Speed checks.

There was some glad-handing, a little bit.

Some humorous comments being made there.

They should have probably knuckled down

and focused strictly on what needed to be done.

The first officer gets distracted and forgets

to clear the discontinuity.

Look, lapses in concentration happen.

That's why you have two pilots.

But did the captain really miss this too?

[Narrator] Pilots are meant to monitor each other

to catch mistakes.

So how did they both miss such a critical step?

This was five minutes before the accident.

Plenty of time to see the mistake.

[Greg] For investigators, they have to try and determine

why didn't they see this discontinuity?

Why didn't they remedy it?

What exactly were they seeing on their displays

during those five minutes?

Let's run it through the simulator.

The simulations are very helpful to investigators.

If the accident occurred because of crew action or inaction,

simulations can tell investigators

what the crew encountered.

Take it to 442, where they should have

cleared the discontinuity.

[Narrator] Investigators prepare to see exactly

what the pilots saw during the final five minutes

of the flight.

They scan the cockpit instruments for clues

as to why the first officer didn't correct her error.

In this case, the first officer's job really was

to glue her eyes to the instruments.

She was the non-flying pilot

and that was really her only job.

[Laughs]

I know. What else can we do?

[Both Laughing]

Gear down.

-Gear down. -[Dramatic Music]

Have a look at this.

It's telling them to take two different approaches.

[Dramatic Music]

[Narrator] When the first officer didn't clear

the discontinuity, the flight computer displayed

two routes to the airport.

That oughta tell you something's wrong.

There should never be two.

You can't be two places at one time.

[Barry] It should have been a single line,

but the computer couldn't figure out,

because of the discontinuity, where to start the approach.

[Upbeat Music]

The discontinuity message is right here

on the flight computer too.

[Plane Engine Humming]

Speed brakes armed. Ignition continuous relight.

Landing checklist is complete.

Unbelievable. They kept us high.

[Dramatic Music]

How'd she miss all this?

[Narrator] They conclude that there were plenty of signs

telling the pilots what they had done wrong.

[Plane Scraping]

-Oh no! -Did I hit something?

[Narrator] But they still don't understand how they failed

to notice them in time to prevent this tragic accident.

Oh God.

[Greg] You can have information buried in an instrument

that isn't in your focal view or in your peripheral vision.

That's one thing.

But if it's prominently displayed and you don't see it,

the question that we as investigators have to answer is,

Why not?

No!

[Narrator] Investigators have identified serious

piloting errors in the crew of flight 1354.

[Investigator] How qualified were they?

[Narrator] They study the pilots' personnel records.

The Captain's got more than 3,000 hours on the A300.

Passed all his latest checks. Looks good.

The First Officer's a little new to the aircraft.

She's got plenty of experience, ticks all the boxes.

This approach was certainly not beyond their abilities.

They had good records.

Any other clues?

[Dramatic Music]

This could be something.

[Fanning] If you're flying this time of day,

you always feel fatigued.

[Beal] Yep.

I mean, I was out and I slept today. I slept good.

Me too.

And when my alarm went off, I am still thinking,

"I am so tired."

I know. Exactly.

[Dramatic Music]

She was tired.

Mm hmm.

The question is, how tired?

[Narrator] Did the First Officer get enough rest

before the flight?

Being fatigued, it's been characterized

like being inebriated.

You can see something, you can recognize that

there's an issue there, but you're not really analyzing

the gravity of the situation.

[Upbeat Music]

The schedules that cargo pilots fly can be very punishing,

very demanding, primarily because we operate

throughout the nighttime hours.

We know that fatigue is a significant flight risk.

[Dramatic Music]

She had a 14-hour rest period before her final shift.

How much rest did she actually get?

There's enough analytical data that demonstrates

that a human needs this amount of rest, period.

You can set reasonable rest periods.

And it's then up to the human to abide by that rest period

in a safety critical job like flying an aircraft.

It says here she swiped the key into her hotel room

at just after 6 a.m.

But records show she was on her cell and tablet at 6:49 a.m.

At 11 a.m., an eyewitness spots her

in the hotel restaurant.

[Upbeat Music]

Did she head back to her room for more rest after that?

Mm. She didn't swipe back into her hotel room

until 3:22 p.m.

But she was on her cell phone and tablet until 5 p.m.

From the evidence that investigators got,

it's clear she did not manage her rest period effectively,

and she could have.

So it looks like she had a rest period between 5 and 6:30.

But then she was back on her personal devices

and called her husband before reporting

for duty at 8:30 p.m.

[Dramatic Music]

[Sighs] She can't have slept more than five and half hours

-in her 14-hour layover. -Yeah.

[Narrator] Five and a half hours in fits and starts

is less than the recommended eight hours

of uninterrupted sleep.

Okay. Turn right, join the localizer.

[Plane Engine Humming]

I don't think we have many choices if runway six is closed.

[Beal Scoffs]

[Barry] Interpreting information

during a non-precision approach, when you're fatigued,

when you have to do other duties such as call out altitudes

and airspeeds and so on and so forth, is very difficult.

[Narrator] Investigators conclude that

the first officer's fatigue likely contributed

to this accident.

[Greg] The problem is is that

we've have a number of accidents

in the cargo industry that have been related in some way,

shape or form to fatigue.

The first accident that actually referenced fatigue

was almost 20 years ago, Guantanamo Bay.

[Captain] One last flight guys.

Guantanamo Bay, here we come.

[Narrator] In AIA flight 808, the crew had been awake

for 15 hours before flying cargo to Guantanamo Bay, Cuba.

[Plane Crashes]

The flight ended in a horrific accident.

[Camera Shuttering]

The NTSB's findings in that investigation

changed the industry's view of fatigue.

It shined light on the issue of fatigue being

as much of a safety risk as a mechanical issue

on an airplane.

[Narrator] Pilots are no longer expected to fly fatigued.

Yet 15 accidents have been attributed

to fatigue between 1993 and 2013.

Fatigue is real.

We need to recognize it. We need to mitigate it.

[Narrator] Investigators now know that the first officer's

fatigue played a part in this accident.

But a question still remains.

Why didn't the captain catch the first officer's mistakes?

Was he fatigued too?

[Dramatic Music]

The captain had seven days off.

Yeah, he went to bed early, had a nap.

[Narrator] Records show the captain of UPS 1354

met the required amount of rest before the flight.

[Plane Engine Humming]

Yeah, I'm gonna do a vertical speed. He kept us high.

The captain, he had some days off,

and so he should have been well-rested.

We don't know all of his activities,

but he should have been the most rested pilot.

[Dramatic Music]

If not fatigue, then what?

[Narrator] Investigators need to dig deeper.

They return to the CVR transcript for insight

into the captain's frame of mind.

[Dramatic Music]

Check this out.

The Captain mentions being too high four, five, six times.

[Narrator] For a captain to be so fixated on

that one flight parameter,

puts up a red flag for investigators.

It sounds like tunnel vision.

[Bob] The captain was very focused on his altitude.

He said many, many times "We're high, we're high.

We need to get down."

When you become that focused everything else kind

of flies out the window.

They did seem to be fixated on the fact that

they were too high and then, at some point of course,

they were far too low.

[Narrator] Investigators now know what happened

to UPS flight 1354.

Okay. Turn right, join the localizer.

I don't think we have many choices if runway six is closed.

[Narrator] A tired first officer misses a critical step

in preparing for the approach into Birmingham.

[Barry] We know she was fatigued.

We know that the non-precision approaches increase

the workload on the pilots.

[Narrator] And misses the cues telling her

she made the mistake.

Final's activated.

[Plane Engine Humming]

[Barry] If you put them all together, the workload,

the fatigue, her role in helping the pilot

by monitoring the instruments,

she never recognized that there was this discontinuity.

[Narrator] Because of her mistake, the plane overflies

the pre-programmed descent path.

[Beal] Unbelievable. He kept us high.

[Greg] Safety is compromised with distraction, complacency,

the fact that you get zoned out,

you get focused tunnel vision.

[Narrator] A captain already fixated on altitude,

misses the first officer's error.

Let's see. You're in vertical speed.

Yeah. I'm gonna do vertical speed. He kept us high.

[Narrator] Forces the plane into a steep descent

-to get back on track. -[Plane Engine Humming]

They failed to recognize that the automation wasn't doing

what they thought it would be doing.

[Narrator] And never recovers.

-[Plane Scraping] -[Fanning] Oh no!

[Gpws] Terrain.

[Barry] They realized that they were in danger only seconds

before the accident.

By that point, it was too late.

[Plane Crashes]

[Fire Explodes]

[Dramatic Music]

[Narrator] In their final report, the NTSB recommends

that cargo operators require a crew briefing

on the threat of fatigue before each flight.

If you're fatigued, you gotta call it out

because your performance as a human degrades.

And while we wanna push through and accomplish the mission,

the problem is is you can set yourself up

or your crew mate for failure

because of your lack of performance.

[Plane Engine Hissing]

Since our accident in Birmingham, the company has done

a fantastic job in the training department.

We've also negotiated for sleep rooms so we can

go take a mid-duty nap during the sorting

of the packages process.

Our pilots will tell you they're a game changer.

It took a lot of little errors by all

the major participants in this flight to cause

this airplane to crash.

And in that respect, it's really unfortunate

and what makes this accident so tragic.

[Plane Engine Humming]