NTSB uses new media to help understand the Lessons of UPS 1354

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The NTSB has as its paramount mission safety and it aggressively pursues of the promotion of superior aviation practices. It has created a great new tool for learning “Lessons Learned” with a video recreation (a great homonym).

The UPS Flight 1354 crashed on August 14, 2013 on approach to Birmingham, Alabama and the NTSB team did its usual thorough job analyzing the accident and identifying the probable cause(s). Its final report is 170 pages long. The Board summarized its findings as follows:

“..the probable cause of this accident was the flight crew’s continuation of an unstabilized approach and their failure to monitor the aircraft’s altitude during the approach, which led to an inadvertent descent below the minimum approach altitude and subsequently into terrain. Contributing to the accident were NTSB Aircraft Accident Report

  1. the flight crew’s failure to properly configure and verify the flight management computer for the profile approach;
  2. the captain’s failure to communicate his intentions to the first officer once it became apparent the vertical profile was not captured;
  3. the flight crew’s expectation that they would  break out of the clouds at 1,000 feet above ground level due to incomplete weather information;
  4. the first officer’s failure to make the required minimums callouts;
  5. the captain’s performance deficiencies likely due to factors including, but not limited to, fatigue, distraction, or confusion, consistent with performance deficiencies exhibited during training; and
  6. the first officer’s fatigue due to acute sleep loss resulting from her ineffective off-duty time management and circadian fact.

Even the executive summary requires concentrated reading to fully comprehend the Board’s safety findings

NTSB Chair Hart, a lawyer used to parsing dense passages, made the following cogent observation:

“People consume information and absorb lessons in different ways… This video is another way to reach pilots and aviation safety professionals with the lessons we learned through our investigative work.”

The eight minute video, which uses interviews and graphic enhancements, provides very useful information about the crash and a very palatable message about how to avoid the precipitating factors to the 2013 crash.

The Washington Post article and the NTSB website both included a link to You Tube. By clicking on the hyperlink now, there is the following message:

youtubeOh no! ;-(  Tune in later. There must be some story behind this disappearance.

ARTICLE: First-ever NTSB video report on a plane crash

UPDATE (a link that works): NTSB releases new video on lessons learned from 2013 UPS plane crash in Birmingham

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