the learning never stops!

Air Cargo Carriers 1260

Accident Case Study

This is a heartbreaking accident that placed a novice first officer into an airline that failed to enforce standard operating procedures, teach crew resource management, and provide enough pilot oversight of a captain who appeared to be incompetent. Add to all that a POI who appeared to be blind to all the problems. The NTSB has not yet released its final report, but there is much to be learned here.


images

Photo: N334AC, NTSB DCA17FA109, Group Chairman’s Factual Report photo 1.

Click photo for a larger image

images

Photo: KCRW VOR-A, DCA17FA109 ATC, Figure 3.

Click photo for a larger image

Accident Report

There is a fair amount of video footage available. Here are the last few seconds: Air Cargo Carriers Crash at Yeager Airport.

  • Date: May 5, 2017
  • Time: 0651 EDT
  • Type: Shorts SD 3-30
  • Operator: Air Cargo Carriers
  • Registration: N334AC
  • Fatalities: 2 of 2 crew, 0 of 0 passengers
  • Aircraft fate: Destroyed
  • Phase: Landing
  • Airport (departure): Louisville International Airport, KY (KSDF)
  • Airport (arrival): Charleston-Yeager Airport, WV (KCRW)

Narrative

There was an overcast ceiling at 500 feet at the time of the crash, 200 feet below the MDA for the VOR-A, but just above the straight-in MDA for the LOC Rwy 5. The captain appeared to be a poor instrument pilot with a history of ducking under. The airline's captains were known to deviate from standard operating procedures. While the airline had a crew resource management program in the sense that they had a PowerPoint presentation, it appears the captain never took the course and the first officer was unable to confront her captain.

images

Photo:

Photo: KCRW LOC Rwy 5, DCA17FA109 ATC, Attachment 8, p. 5.

Click photo for a larger image

[NTSB Docket, DCA17FA109, Group Chairman’s Factual Report ¶1.0]

  • The accident crew (Captain and First Officer) was operating together on a permanent (CA/First Officer) pairing as a 14 CFR Part 135 United Parcel Services (UPS) flight, with 3,874 lbs of cargo consisting of mail, packages and freight. The flight originated from the CRW base of operations and consisted of a round trip cargo flight to Louisville International Airport-Standiford Field (SDF), Louisville, Kentucky and subsequent revenue return to CRW.
  • The airline had several small bases crewed by just two pilots, who tended to fly exclusively with each other.

  • SNC1260 departed SDF at 0541 on an instrument flight rules (IFR) flight plan with an en route altitude of 9000 feet. There were no reported irregularities or operational issues reported during the takeoff and en route portion of the flight.
  • The visibility minimum for the CRW VOR-A approach was predicated on the airplane’s approach category, which was based on the VREF approach speed of the airplane, in this case, the airplane falls in the category B circling approach criteria. For the accident flight, based on recorded air traffic control (ATC) conversation, radar data and airport surveillance video, the airplane requested and flew the VOR-A approach utilizing category B altitudes and visibility requirements. During the time of the VOR-A approach to runway 5, the weather was reported as an overcast ceiling at 500 ft with 10 statute miles visibility and light winds.
  • (Below the circling MDA.)

  • The airplane was equipped with distance measuring equipment (DME) which allowed the crew to utilize FOGAG Fix Minimums, which were 1,600 ft and 1-mile visibility. FOGAG is at 6 DME from the CRW VORTAC on an approach course of 084º. It is an additional 2 DME to the MACSA missed approach point (MAP) which is a climbing left turn to 3,000 ft mean sea level (msl) via a heading of 055º and HVQ radial 069º to CAMMA intersection at 21 DME. The CRW VOR identifier (HVQ) is at navigation communications frequency 117.4.
  • The First Officer contacted CRW ATC at 0637 and advised they were at 9,000 ft msl and had information November. CRW responded, provided the CRW altimeter of 29.41 inches of mercury and advised SNC1260 to expect the localizer Runway 5 approach; several seconds later, the First Officer requested the VOR-A approach to which CRW approved and instructed SNC1260 to proceed direct to the Charleston VOR and descend and maintain 4,000 ft.
  • This may seem counterintuitive to most competent instrument pilots. A localizer straight-in approach is easier to fly than a circling approach at minimums, after all. But this captain had a history of being unable to maintain an altitude and heading in instrument conditions. A VOR radial outbound is easier to track than a localizer inbound because the radial splay outward and the tolerances for keeping a needle centered becomes easier, opposite the effect on a localizer inbound.

  • At 0642, CRW ATC informed SNC1260 that they were twelve (12) miles from the CRW VOR and instructed them to cross the VOR at or above 3,000 ft msl and they were cleared for the VOR-A approach runway 5.
  • At 0646, CRW ATC instructed SNC1260 to contact the tower at 125.7 to which the First Officer acknowledged and subsequently contacted the tower and stated visual to VOR-A. The CRW tower cleared SNC1260 to land.
  • At 0647, CRW alerted SNC1260 to immediately check their altitude and reissued the altimeter setting of 29.41. The First Officer responded and stated they were at 2,200 ft msl and were descending to 1,600 ft, to which the tower responded and stated their alarm went off and it might have been due to SNC1260’s rate of descent. The First Officer acknowledged.
  • At 0651, the accident occurred.

[NTSB Docket, DCA17FA109, Weather Factual Report ¶2.1.1]

  • KCRW weather at 0630 EDT, wind from 170° at 4 knots, 10 miles visibility, few clouds at 100 ft agl, overcast ceiling at 500 ft agl, temperature of 14° C, dew point temperature of 13° C, and an altimeter setting of 29.40 inches of mercury. Remarks, station with a precipitation discriminator, valley fog, temperature 13.9° C, dew point temperature 13.3° C, maintenance is needed on the system.
  • KCRW weather at 0654 EDT, wind from 230° at 3 knots, 10 miles visibility, few clouds at 100 ft agl, overcast ceiling at 500 ft agl, temperature of 14° C, dew point temperature of 13° C, and an altimeter setting of 29.41 inches of mercury. Remarks, station with a precipitation discriminator, sea level pressure 995.2 hPa, valley fog, temperature 14.4° C, dew point temperature 13.3° C.

[NTSB Docket, DCA17FA109, ATC Factual Report Attachment 2] (Interview with the "Overall Controller-in-Charge" from the control tower)

  • He believed runway 23 was the calm wind runway and he had no knowledge about one of the accident pilots having a previous issue with ATC.
  • If the approach was below minimums, it’s the pilot’s choice at decision altitude to determine if they should continue the approach or go around. If the weather had changed while the aircraft was on the approach he would inform the arriving aircraft. He did not recall if he had ever done that at CRW.
  • SNC1260 contacted the tower on the VOR-A approach. He issued the wind and cleared the aircraft to land. He said that the low altitude alert (LA) alarmed, at which time he issued a low altitude alert to the pilot, telling her to check her altitude immediately and issued the CRW altimeter. The pilot responded that they could go down to 1,600 MSL but their altitude at the time was 2,200 MSL. He commented to the pilot that it may have been the rate of descent that caused the LA to alarm. The LA alarmed a couple more times but thought it may have been part of the same issue that caused the initial LA to alarm, so he didn’t restate the low altitude alert. When asked if there was anything else he should do, Mr. Jenkins said that he pulled out the approach plate and double checked the altitudes but since the pilot was within the confines of the approach chart there was nothing else to do.
  • He looked out the window and could see the aircraft lights from SNC1260 between 3 to 4 miles from the airport, but the aircraft reentered clouds and he lost sight of it. When SNC1260 broke out of the clouds again it was close to the airport and higher than normal for that part of the approach. When the aircraft reappeared, it started down and made a sharp left turn towards the runway where the left wing impacted the runway. The plane hit sideways, a wing broke off and the rest of the aircraft went over the hill. He initially thought the aircraft was going to go-around because they were too high and too close to the airport. The aircraft appeared to be in the correct position in relation to the final approach course.

Analysis

The captain had a history of busting check rides but withheld that information from the airline. He was known to be less than capable as an instrument pilot. He frequently slept during flight and had the first officer essentially fly solo.

The first officer appeared to be competent and conscientious but found herself in a dysfunctional environment that led her to accepting deviance from standard operating procedures as the normal operating mode. She accepted that she had to tolerate flying solo as the captain slept. She accepted his poor instrument skills. But she also used her cell phone to text while in flight as the captain slept. Her texts might be the best source of information for accident investigators.

[NTSB Docket, DCA17FA109, Group Chairman’s Factual Report ¶2.1.1]

  • The Captain was current and qualified under Air Cargo Carriers and FAA requirements. A review of FAA records found no incidents or accidents involving the Captain. A review of the Captain’s FAA complete airmen file Program Tracking and Reporting Subsystem (PTRS) data found several notices of disapproval going back to 1999.
  • During the Captain’s ATP certificate check ride, on July 22, 2016, the Captain received a notice of disapproval due to excessive deflection of both the glide slope and localizer for an instrument landing system (ILS) approach, and repeated glide slope and sink rate warnings from the ground proximity warning system (GPWS), and his subsequent failure to initiate a go-around. He passed the practical re-examination 3 days later.
  • On September 3, 2003, the Captain received a notice of disapproval for a Flight Instructor, Airplane Single Engine Land (ASEL) rating, for Area of Operations VII, Normal and Crosswind Approach and landing. He passed his practical examination 3 weeks later.
  • On January 28, 2003, the Captain received a notice of disapproval for his Commercial; Airplane Multi Engine Land rating due to lack of performance in area VIII; emergency operations and area IV; Takeoffs/Landings, and Go Arounds. He passed the practical examination 2 weeks later.
  • On July 14, 1999, the Captain received a notice of disapproval during his private pilot certificate practical examination due to lack of performance in the area of IV; Takeoffs, Landings, and Go-Arounds, VI; Navigation and IX; Emergency Procedures. He passed the practical examination 1 week later.
  • The Captain’s employment file included a standard pilot resume and shows objectives, flight time, certifications, employment history and education followed by the ACC application /questionnaire. On the ACC application/questionnaire, there are 27 questions inquiring about the applicant’s skills, willingness to work, and specific pilot information. Eight (8) of the questions ask about past failures of tests, disciplinary actions, accidents and DUI’s. Question 17 asks:
  • Have you ever failed any check rides, proficiency checks, IOE or line checks?

    The Captain answered “no.”

[NTSB Docket, DCA17FA109, Group Chairman’s Factual Report ¶2.1.1]

  • The First Officer was current and qualified under Air Cargo Carriers and FAA requirements. A review of FAA records found no incidents or accidents involving the First Officer. A review of the First Officer’s FAA complete airmen file Program Tracking and Reporting Subsystem (PTRS) data found one notice of disapproval in 2015.
  • On September 7, 2015, the First Officer received a notice of disapproval for her Airplane Single Engine Land, Instrument Airplane Commercial certificate due to lack of performance in area IV; Takeoffs/Landings and Go Arounds and VI; Ground reference maneuvers. She passed the practical exam 9 days later.

[NTSB Docket, DCA17FA109, Human Performance Factual Report ¶2.0]

  • The first officer who had flown with the accident captain prior to the accident first officer rated the accident captain’s landings as 7 on a scale of 10. He stated that 90% of the time the captain’s approaches were stabilized but sometimes they came in low. This was easy to do in the aircraft and easy to recover with engine power compared to coming in high which was much worse as the aircraft had difficulty descending. He stated that in the cases they went missed, it was because they were high on the approach. He stated that the decision to go around could come from either pilot. He had called for go arounds with the accident captain before, which he executed without question. There were also cases where the accident captain as the pilot flying would himself call for a go around. He rated the accident captain’s flying skills as “very good” and he did not see him do anything unsafe. He stated that the accident captain was very knowledgeable and often quizzed him in the aircraft. He stated that they followed the FOM and SOPs. They flew IFR most of the time. He rated the accident captain’s IFR flying skills as better than his own when he himself first started with the company.
  • In text messages with 5 of her friends, the accident first officer stated that the accident first officer had told them that while the accident captain’s VFR flying skills were “awesome,” she had concerns with the his IFR skills. She had told one friend during a phone call that the accident captain had had trouble staying on heading, speed, and course when in IMC. She also told him that the accident captain would fly at 4000 feet altitude around Charleston which her friend, a former pilot for ACC, considered dangerous because of the mountainous terrain and towers in the area. She also had told him about instances where the accident captain had “ducked” below MDA on approaches before.
  • In text messages to friends, she described a conversation with another captain she had flown with at the company. This captain had told her that that he had been sent to fly with the accident captain by the chief pilot because the accident captain “could not fly a missed approach” when the chief pilot had flown with him.

[NTSB Docket, DCA17FA109, Human Performance Factual Report ¶3.0]

  • The first officer described situations in text messages to friends where the captain slept during flight. These text messages were sent, according to her, while she was flying the aircraft and he was asleep. In addition, she described a series of flights in February 2017 where the captain asked her to fly every leg for four days in addition to handling radios while he slept.
  • Each of the former ACC pilots interviewed stated that they had witnessed instances of SOPs being disregarded when they were flying at ACC. One former first officer stated that he felt that there was a culture where senior pilots with experience as captains felt like they could bend boundaries of SOPs and the FOs may not be taken seriously. When this specific former first officer encountered this behavior, he responded by doing additional training and more studying to become more confident in the aircraft and better able to speak up about issues to the captain.
  • A former ACC captain stated that he had flown with a handful of pilots at ACC who flew “way” outside of SOP. He discovered that at ACC there was a compromise between flying to standards and managing the cockpit work environment. When asked what kind of behavior he had seen outside of SOPs, he stated that some pilots wouldn’t be standardized and adhere to the established approach profile for the Shorts that determined airspeed, gear, and flap settings at specific locations on an approach. He stated he had flown with one pilot who was always in a hurry and gave the example of another pilot flying inbound to the airport at 3000 feet and fast, then diving to the airport at the last minute. Another pilot would program the GPS for the return leg even though they hadn’t landed on the outbound leg yet. He had also seen pilots pull the fuel levers to ground to get the aircraft to descend faster. He witnessed pilots slip the aircraft, which he didn’t believe was safe to do in the Shorts. He said most of what he had seen from other pilots in terms of not following SOPs was related to poor planning. He clarified that these were specific individual pilots at the operator and not a reflection of the overall culture of the airline.

[NTSB Docket, DCA17FA109, Human Performance Factual Report ¶4.2]

  • ACC’s crew assignment policies were base specific. Two pilots, one captain and one first officer, would be assigned to each base. Pilots did not rotate to different bases unless they were reassigned. A former captain who had left the company to fly for a major airline stated that he was concerned about ACC’s policy of having the same crew fly together consistency and stated that there was no way to do checks on the pilots. He stated that flying together can get monotonous and people can get into routines. Further, he stated that in a multiple crew pairing situation, if there was someone who isn’t following SOPs, there are multiple people who can catch it. There was also benefit from multiple crews so that pilots can learn from different people. He stated that it was great for low time pilots to learn from multiple people.
  • Another former captain who had flown for ACC stated that he understood that speaking up to the captain was difficult as it could have created a hostile work environment and poor CRM as he had heard of this happening with another crew pair where the first officer had an issue with the captain and “ended up in tears.” The first officer that had flown with the accident captain prior to the accident first officer stated that while he had gotten along with the accident captain, in general as a first officer “you hope you get along with the captain because you’ll be flying with him” constantly.
  • A witness who had known the accident first officer from his current job and kept in touch with her after she began flying for ACC stated that the accident first officer and accident captain seemed to get along and the first officer would be able to get along with anybody regardless of if she liked them. He had a specific conversation with the accident first officer about speaking up in the cockpit even if she wasn’t comfortable doing so. In the several months prior to the accident, he understood that she would have conversations with the accident captain and was more comfortable speaking up. Another former captain with ACC who had kept in touch with the accident first officer after she began flying for ACC also stated that the accident first officer was not the type to speak up. He assumed this was something he referred to as “new pilot syndrome” which he described as her not wanting to complain immediately after starting the job.
  • The FAA POI was asked if there were any changes to risk assessment if an operator was operating aircraft along the same route, with the same crew pairing. He considered two pilots flying exclusively together to be beneficial as “there was value in familiarity with the other person.” He stated that there was no downside to having crews flying exclusively together.

[NTSB Docket, DCA17FA109, Human Performance Factual Report ¶4.3] When asked whether ACC had a policy on PED usage in the cockpit, and if so, how that policy was communicated to the pilots, the company stated that they train FAR 135.144 on portable electronic devices and the only approved item for use was the iPad EFB. Upon review of ACC training manual, training documents, and FOM, no references to 135.144 nor personal electronic devices were found.

[NTSB Docket, DCA17FA109, Group Chairman’s Factual Report ¶4.5.1] Crew assignment/pairings were base specific. In the case of CRW, two pilots; one Captain and one First Officer were assigned to each base. Pilots did not rotate in/out and were permanently paired with each other. There was no formal rotation schedule; they were essentially “partners.” Pilots could make a bid for other bases or they could be reassigned based on need. If a pilot called in absent, the chief pilot or designee would fill in for the absent crew member. When asked about the pros and cons of permanent crew pairings, the chief pilot stated, “a con was that people could pick up bad habits.” When the FAA POI was asked about ACC’s outstation model, he stated he was not aware of pilot experience levels or crew pairing issues; they didn’t get into that. He stated that he only looked at whether pilots were conducting a safe operation…” As a positive aspect of the permanent crew pairings, he stated he “considered two pilots flying exclusively together to be beneficial as there was value in familiarity with the other person.”

[NTSB Docket, DCA17FA109, Group Chairman’s Factual Report ¶4.6]

  • Surveillance is conducted based on risks as determined by the safety assurance system (SAS)28 model. According to the POI, ACC is considered to have a positive relationship with the FAA. When asked about the quality of the company, he stated “they [ACC] had a strong training program which is conducted in-house and they didn’t outsource any training outside of the company.” The POI expressed that recommendations/suggestions made by him were addressed “without fail.”
  • When asked about what internal oversight programs existed at ACC, he stated that “they only have a voluntary disclosure program (VSD) and do not have any formal safety programs.”
  • According to the POI, The FAA is not strictly limited to SAS checklists for determining what will be observed or surveilled. FAA inspectors can rely on “gut instinct” and their own expertise to look at an operator. In the weeks after the accident, they increased their surveillance and observed check airmen in LaGuardia [simulator] and conducted Captain upgrade check rides. In addition, the POI travelled to the outstations of Danville and Warsaw to conduct ramp inspections of the aircraft and flight crews. The POI also jump-seated on a flight on June 23, 2017.
  • When asked about any irregularities or issues he observed during these latest observations, he stated that the check ride was unsatisfactory because the pilot continued “an unstabilized approach.” He considered this an individual pilot issue and not an issue with the training or manuals. The POI was unable to recall the last time he observed CRM training.
  • When asked about top issues he’s seeing during check rides, “pilots are failing to notice an unstabilized approach and take corrective action and go around.” But he feels it’s more of a “rushing to get the check ride done.” And for “time savings” He assessed ACC training on unstabilized approaches and felt it was adequately addressed in the SOPs.

[NTSB Docket, DCA17FA109, Human Performance, Attachment 2]

These are extracts from the FO's SMS messages from a previous flight (12/31/2016).

  • The captain wanted to get out of the clouds so he immediately turned right, where I know there's all these hills
  • And he was making really really steep turns, like 60 degrees of bank and descending at like 800ft/min
  • And I couldn't see # so the whole time I'm like we're gonna hit the hills. We're gonna hit the freakin hills
  • But I definitely would've done things a little differently if I were in charge
  • So are you gonna get a new pilot? I mean, you literally could have died
  • Nah, I'm flying with him as long as I stay in Charleston with

These are extracts from the FO's SMS messages from a previous flight (1/17/2017).

  • Captain is sleeping. I'm gonna need you to keep me entertained for the rest of the flight
  • Wait wait wait. There's a pilot and a co pilot, and right now the pilot is asleep and the co pilot is texting. Is that accurate?
  • Yes
  • Wait not entirely because it's captain and first officer. I'm pilot too, you know!
  • And I'm the one flying right now
  • Jesus Christ
  • How are you texting? I mean signal wise
  • I guess I'm still getting signal. We're only at 8000

Cause

The causal factors are rather apparent, but I will leave those blank for now until the NTSB concludes its investigation. But I would like to offer some lessons to consider:

  • Pilots with poor instrument skills cannot be given the title "captain" in an airplane and operation that requires those skills.
  • Pilots who are permanently paired together are like petri dishes for the incubation of complacency. Any operation that has more than two pilots should avoid this practice. Operations with only two pilots need to bring in outsiders on a frequent basis to ensure against this complacency.
  • Crew Resource Management cannot be a classroom-only exercise. It needs to be put to the test in simulators and examined closely during line checks.

References

NTSB Aircraft Accident Docket, DCA17FA109, Air Cargo Carriers 1260, Shorts SD 3-30, N334AC, Charleston, WV, May 5, 2017

Revision: 20181028
Top