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Undefeatable Fatigue
by Stan Dunn
On July 26, 2002, Federal Express f light 1478 struck trees on short final to Runway 9 at Tallahassee
Regional Airport in Florida. The cap- tain, first officer and f light engineer were the only occupants. All three survived but were seriously injured. The aircraft was destroyed by the im- pact and ensuing fire. The accident occurred in benign weather follow- ing a botched approach in nighttime VMC. The captain had over 13,000 flight hours and a reputation as a solid pilot. The first officer had 8,000 hours and was viewed as a reliable copilot. The flight engineer had 2,600 hours and was being considered for a check airman position at FedEx. Combined 24,000 flight hours, good reputations, and yet this crew failed to notice a descent profile that shorted the target runway by 3,000 feet. One final (and conspicuous) note: The accident oc- curred at 0437 CDT.
The first officer was the pilot flying. The captain had initially suggested Runway 27 since it was equipped with an ILS and offered a shorter taxi to parking. Working against 27 were mild tailwinds. Following a somewhat dis- jointed conversation, the crew settled
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on the headwind to 9 versus the ILS for 27 (Runway 9 had a PAPI but no ILS). During post-accident interviews, none of the crew recalled being low during the approach. NTSB analysis indicated that three white and one red light on the PAPI (slightly high) would have been observed when the Boeing 727 rolled onto final at 1,700 feet AGL. From this point the aircraft
trees a little more than a half-mile from the end of the runway.
Eleven years later, UPS flight 1354 crashed short of Runway 18 in Bir- mingham, Alabama. The accident oc- curred at 0447 CDT following a localiz- er approach to Runway 18. The aircraft (an Airbus A300-600) was capable of calculating a constant rate of descent for non-precision approaches (which allows a non-precision to function like an ILS), yet a mistake in programming resulted in the computer-generated glide path being unavailable.
Once he realized the error, the cap- tain elected to utilize the “dive-and- drive” method for the non-precision approach (where the crew selects a rapid descent prior to leveling off at MDA). The aircraft was slightly high crossing the final approach fix. The captain selected a 1,500 fpm rate of de- scent, which was maintained until the Enhanced Ground Proximity Warning System (EGPWS) provided an aural “sink rate” alert at 300 feet AGL. Fol- lowing this, the captain adjusted the vertical speed to 600 fpm. Three and a half seconds later, the captain reported “runway in sight” (the aircraft was around 900 feet MSL at this point – 300 feet below the charted MDA). Neither
"Neither skill nor experience provides an effective countermeasure to the debilitating
effects of tiredness."
began a steep descent which resulted in four red lights (substantially below glideslope) by 800 feet. The aircraft maintained the steeper than normal approach until 200 feet when it transi- tioned to a 500 fpm rate of descent. It continued on this profile until it struck