reducing "Crew-caused"
approach and landing
accidents 

Pilot-in-charge Monitored Approach

2013 A306 CFIT Birmingham USA

Brief account : 

The A300 freighter crashed crashed short of runway during a localizer nonprecision approach. The probable cause 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 factors included crew fatigue, prior poor performance issues, and incomplete weather information.  

Crew-related factors : 

This was a classic accident with multiple PicMA-addressed factors. Fatigue played a significant part in the crew's collective poor performance. The crew were not fully aware of the runway availability state until relatively late, and were also under the impression that the weather would be better than it actually was.  

The Captain (PF) did not fully coordinate his plans for the approach with the F/O (PM). He changed his plan for using the automatics during the approach, and as he believed the aircraft was higher than he intended, turned what had originally been planned as a continuous descent final approach into a quasi "dive and drive", omitting some important steps. The F/O did not fully cross-check what was being done. The crew expected to become visual relatively early and the F/O did not make some critical callouts.

Both pilots were looking out for the runway as the aircraft passed through the MDA at a high vertical speed. One NTSB member commented that "even [with the multiple other contributory factors] the crash would not have occurred if the crew had monitored altitude and not allowed the aircraft to descend below the minimum altitude unless the runway was in sight." 

He further commented "As the report mentions, the crew likely had the expectation that, because of the reported weather, they would break out of the clouds at 1,000 feet above ground and see the runway right in front of them. It is plausible that the captain’s tunnel vision that he was high, combined with the false expectation they would break out of the clouds at 1,000 feet, allowed him to have reduced attention to altitude awareness."

If this crew had been performing a PicMA approach, it is likely that

1) The approach would have been better prepared with the active involvement of both pilots in the planning

2) The fatigue of the F/O who would have been the PF for the approach would have been more apparent to the Captain, whose alertness in monitoring deviations from the planned approach might have been further enhanced;

3) The Captain would have been more vigilant about any change of plan by the F/O while the F/O was conducting the approach 

4) The Captain would have been able to give more attention to assessing the visual cues earlier, and in particular to realising that their expectation of becoming visual early on was not materialising,

5) the F/O's attention would have been solely on adhering to the proper profile, and not looking for visual cues

6) a specific warning call approaching minima and a "Decide" call would have been made by the F/O

7) the F/O would have been monitoring instruments and in particular the increasing descent rate passing through DH.  

Type: 
A300-600
Where: 
Birmingham USA
Expected weather: 
Instrument
Pilot in charge: 
Capt
Early transition: 
Yes
Go-around : 
No
Damage: 
Serious
PicMA potential: 
Major
Year: 
2013
Time: 
Night
Deterioration: 
Yes
Vert Guidance: 
None
Both Head Up: 
Yes
LoC: 
No
Operator: 
UPS
Fully prepared: 
No
Actual Weather: 
Low Cloud
Autopilot : 
Y
CCAG: 
Normal