All language subtitles for M.2003-S21E10-Deadly.Delivery.UPS.Airlines.Flight.1354.WEBDL-1080pEAC3.5.1h264-PiTBULL_track4_[eng]

UPS 1354 heavy, runway one
eight, clear to land.

NARRATOR: In a populated area,
near a highway...

Oh, no!

...an Airbus A300 crashes
short of the runway.

WOMAN ON RADIO:
Tower, did you see that?

NARRATOR: Neither
pilot has survived.

LAURI ESPOSITO:
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...

MAN ON RADIO:
We're gonna do vertical speed.

He kept us high.

...and running the flight
through a simulator...

How'd she miss all this?

...investigators are forced
to take a different approach.

At 11:00 a.m, an eyewitness
spots her in the hotel restaurant.

GREG FEITH:
You can set yourself up for failure

in a safety critical job
like flying an aircraft.

No!

(MAN SPEAKING
INDISTINCTLY OVER RADIO)

This is a true story. It is based on
official reports and eyewitness accounts.

NARRATOR: It's an early summer morning
when UPS flight 1354 climbs over Kentucky.

- Autopilot one command.
- FEMALE PILOT: Autopilot one command.

Fifty-eight-year-old Cerea Beal
Jr. has been flying with UPS

for more than 20 years.

MAN ON RADIO: UPS 1354,
climb and maintain flight level 280.

Two eight zero, 1354.

NARRATOR: Thirty-seven-year-old
First Officer Shanda Fanning

has been with the delivery
company for seven years.

They were respected. They were
experienced aviation professionals.

They were very representative
of the type of pilots that UPS hires.

- Two eight zero.
- Twenty-eight.

Tonight's flight from Louisville,
Kentucky, to Birmingham, Alabama,

takes about an hour.

MAP: Flight Path

ESPOSITO: 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.

NARRATOR: The crew is flying
the newest version of the Airbu A300,

equipped with advanced computer
and flight management systems

to assist pilots.

MAN ON RADIO:
Notice to airmen runway two-four 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 ON RADIO: 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 one-eight? 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.

ESPOSITO: 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.

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 point one 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: Twenty-eight minutes
into the flight,

UPS 1354 begins its descent
towards Birmingham, Alabama.

MAN ON RADIO: UPS 1354,
descend at pilot's discretion.

Maintain 11,000.

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.

MAN ON RADIO:
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.

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. One-eight'll work.
- MAN ON RADIO: Copy that.

Turn right ten degrees,
join the localizer.

Okay. Turn right,
join the localizer.

ESPOSITO: 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.

- Flaps fifteen.
- Speed checks.

Flaps fifteen.

NARRATOR: Eight miles from the airport,
the crew configures th plane for landing.

MAN ON RADIO: UPS 1354 heavy,
runway 18, clear to land.

FANNING: One eight
cleared to land 1354.

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.

Instruments cross-checked.
No flags.

The first officer sees
no problems with the descent.

Two miles to go.

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

FANNING: Got the
runway in sight.

Autopilot's off.

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?

- AUTOMATED VOICE: Caution.
Terrain. -Oh, no!

Too low. Terrain.

Oh, God!

The pilots can't control the
plane as it cuts through a smal grove.

No!

Oh, my God!

NARRATOR: UPS flight 1354
crashes just one mile short of the runway.

- WOMAN ON RADIO: 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.

(SIRENS BLARING)

NARRATOR: Rescue crews rush to
extinguish the flames of UPS Flight 1354.

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.

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.

Investigators look for
the four corners of the aircraf

to determine if the entire plan
has reached the accident site.

BARRY STRAUCH:
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.

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?

MALE INVESTIGATOR: What were
the height of the impact marks?

FEMALE INVESTIGATOR:
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.

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 the
to crash short of the runway?

Maybe the engines failed.

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.

The blades were spinning.

BENZON: 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.

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.

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.

MALE INVESTIGATOR: 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, 1,000 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.

Flight 1354 would only descend
from clouds at 1,000 feet.

What was the decision altitude
for their approach?

The decision altitude is the
altitude at which the crew

must be able to see the runway
or else abandon their approach.

BENZON: Decision heights,
they're all pretty much a hard floor

especially in the weather,
that should not be broken.

You should not go below
the decision altitude

unless you see the runway.

Decision altitude was 1,200 feet.

If the clouds didn't break
until 1,000 feet,

they wouldn't have seen the
runway at their decision altitude.

FEMALE INVESTIGATOR:
So why didn't they turn 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.

NARRATOR: Did lack of visibility
cause the pilots to descend too rapidly

and crash short of the runway?

Maybe the controller knows something.

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 if they
heard 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.

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?

STRAUCH: 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?

Those two black boxes
are very critical to investigators

because they're electronic witnesses.

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.

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.

Flaps 15.

FANNING: Speed checks, flaps 15.

MAN ON RADIO: 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.

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, 1,500 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.

FEITH: 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 final approach.

BENZON: 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

MALE INVESTIGATOR: 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.

STRAUCH: 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.

- Okay, let's hear it.
- UPS 1534...

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

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

BEAL JR: Runway 18...

NARRATOR: They listen as the pilots
make their vertical spee 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.

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.

Twenty-three hundred feet.
That's only a few hundred feet too high.

Even though the captain believe
the plane didn't descend

because the controller kept the too
high, the computer should have initiated

its programmed descent
at that higher altitude.

Maybe there was a problem
with the flight computer.

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 to point one degrees.

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.

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.

FEMALE INVESTIGATOR:
It's working.

BENZON: 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 three degrees.

Wait a minute.

They've got two separate
destinations programmed.

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.

BENZON: 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.

Twenty 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.

STRAUCH: 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.

They focus on the moment the crew
got the instruction from the controller

to go to runway 18.

- Okay. Here it is.
- MAN ON RADIO: You want 18?

NARRATOR: The controller
reminds the crew that

they must use an alternate runway.

- Yep.
- Yessir, 18 will work.

Copy that. Turn right ten
degrees, join the localizer.

Okay. Turn right,
join the localizer.

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

(CHUCKLES)

NARRATOR: At that moment, the
crew should have cleared the discontinuity

and reprogrammed the approach.

I know. What can we do?

I'm like, are you gonna unroll
another one out there for us real quick?

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.

(BOTH CHUCKLE)

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.

FEITH: 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 4:42 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.

(CHUCKLES)

I know. What else can we do?

(BOTH CHUCKLE)

- Gear down.
- Gear down.

Have a look at this. It's telling them
to take two different approaches.

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.

STRAUCH: It should have been a single
line but the computer couldn't figure out,

because of the discontinuity
where to start the approach.

The discontinuity message
is right here on the flight computer too.

Speed brakes armed.
Ignition continuous relight.

Landing checklist is complete.

Unbelievable. They kept us high.

How'd she miss all this?

NARRATOR: They conclude
that there were plenty of signs

telling the pilots
what they had done wrong...

- Oh, no!
- Did I hit something?

...but they still don't
understand how they failed to notice them

in time to prevent this tragic accident.

Oh, God.

FEITH: 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.

How qualified were they?

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.

(SIGHS)

Any other clues?

This could be something.

If you're flying this time of
day, you always feel fatigued.

- BEAL JR: 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.

- She was tired.
- Mmm-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.

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.

FEMALE INVESTIGATOR: 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 6:00 a.m.

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

At 11:00 a.m, an eyewitness
spots her in the hotel restaurant.

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

Mmm. She didn't swipe back into
her hotel room until 3:22 p.m.

But she was on her cell phone
and tablet until 5:00 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 5:00 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.

She can't have slept more
than 5.5 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.

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

STRAUCH: Interpreting information
during a non - precision approach,

when you're fatigued,
when you have to do other dutie

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.

FEITH: The problem
is is that we 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.

PILOT: 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.

The flight ended in a horrific accident.

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?

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.

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.

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.

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

For a captain to be so fixated
on that one flight parameter

puts up a red flag for investigators.

It sounds like tunnel vision.

BENZON: 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.

FANNING: Okay.
Turn right, join the localizer.

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

(BOTH CHUCKLE)

NARRATOR: A tired first officer
misses a critical step

in preparing for the approach
into Birmingham...

We know she was fatigued.
We know that the non-precision approaches

increase the workload on the pilots.

...and misses the cues telling
her she made the mistake.

Final's activated.

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

Unbelievable. He kept us high.

FEITH: Safety is compromised
with distraction, complacency,

and 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.

...forces the plane into a steep
descent to get back on track...

They failed to recognize
that the automation

wasn't doing what they thought
it would be doing.

...and never recovers.

- Oh, no!
- AUTOMATED VOICE: Terrain.

FEITH: They realized
that they were in danger

only seconds before the accident.

By that point, it was too late.

NARRATOR: In their final report,

the NTSB recommend 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 you can set
yourself up or your crewmate fo failure

because of your lack of performance.

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.

Captioned by National Captioning Institute