Learning From A Heavy-Iron Accident

FedEx flight 1478, was en route from Memphis International Airport (MEM) to Tallahassee Regional Airport (TLH). It was on an IFR flight plan, but was flying in VMC. The scheduled departure time was 4:12 a.m. When investigators asked the captain about his sleep history during the two nights before the accident flight, he said that it was "not really good" or "marginal" because his sleep was interrupted to take care of the family's dog. When investigators examined the first officer's sleep history, they found that he had some difficulty sleeping during the past two days as well.

As the airplane neared Tallahassee at 5:16:38 a.m., the captain questioned the flight engineer about the weather. The first officer, who was the flying pilot, began the approach briefing by saying, "We'll plan on a visual to runway 27. We'll back it up with this ILS runway 27 full procedure."

He added that the minimum safe altitude was 3,300 feet MSL. "Missed approach will be as published. Runway is 8,000 [feet long]; plan on rolling out to the end. Got a PAPI on the left-hand side, pilot-controlled lighting, so if you can click it seven times, I'd appreciate it."

The PAPI (precision approach path indicator) at Tallahassee consists of four boxes of lights. If an airplane is on the proper glidepath, two boxes should display white lights, while the other two show red lights. If an airplane is beneath the glidepath, more red lights are visible to the pilots; if an airplane is above the glidepath, more white lights are visible.

At about 5:19:38, the first officer asked, "Do you want to land on nine if we see it? We've got a PAPI on nine, too."

The captain responded, "Yeah, it may be a longer taxi for us, but the way we're coming in, two-seven probably would be about as easy as any of them."

"Okay," the first officer replied.

At 5:22:46, the Jacksonville Center controller cleared flight 1478 to descend and maintain 3,000 feet MSL at the pilot's discretion. The controller asked if they had the Tallahassee weather, and the captain confirmed that they did. About 5:24:03, the controller advised them to expect a visual approach and to report when they had the airport in sight.

According to the CVR, about 5:24:23, the captain stated, "Runway 9. PAPI on the left side. I don't know, you want to try for nine?"
The first officer responded, "We're pointed in the right direction. I don't know. Like you said, it's a long taxi back."

The captain said, "Yeah, that would be all right."

Consistent with FedEx policy, the flight engineer then asked the captain and first officer if they wanted to perform the approach checklist. At 5:28:26, the first officer asked, "We ever decide if we're going nine or two-seven?"

The captain responded, "Yeah, we can do nine if you want to."

The first officer said, "Okay, runway 9 visual. Runway 9 PAPI on the left side. Approach check."

At 5:29:53, the captain asked the first officer if he wanted to tell the
controller that they had TLH in sight. The first officer responded, "Yeah. I don't see the runway yet, but I've got the beacon."

The captain told the controller that they had the airport in sight at 5:30:00. The controller cleared the pilots for the visual approach into TLH and asked if they were aware that runway 18/36 was closed. The captain responded, "No sir, but we're going to use runway 9." Notification of the closure had been included in the paperwork the flight crew received before departure.

At 5:30:32, the CVR recorded sounds that were similar to a microphone being keyed five times within 1.3 seconds. Seven seconds later, the captain issued an advisory call to any traffic at Tallahassee. The first officer indicated that he thought he saw the runway at 5:30:56, later adding, "I hope I'm looking in the right spot here."

The captain responded, "See that group of bright lights kind of to the south down there and the beacon in the middle of it? Right over there. You're on about a 10-mile left base or so."

The first officer then indicated that he had been "looking at the wrong flashing light." A FedEx captain who regularly flies the MEM to TLH route told investigators that a power plant located a few miles north of TLH has a slow white strobe light that's frequently mistaken for the airport's rotating beacon. He also said that the green light of the TLH rotating beacon is "very hard to distinguish as green. It's very faint."

The CVR indicated that at 5:35:42, the captain gave a radio call on the common traffic advisory frequency advising TLH traffic that flight 1478 was turning onto final for runway 9. The flight engineer then began the before-landing checklist.

At 5:36:20, the first officer said, "Sorry about that. I was lining up on that paper mill or something."The captain said, "That's all right. No problem."

At 5:36:37, the airplane was slightly more than 2.5 nm from the airport and was transitioning from an angled base-to-final leg to line up with the runway. The Safety Board's airplane performance study indicated that the PAPI would have been displaying one white light and three red lights when viewed from the cockpit. At 5:36:40, the PAPI display would have shown four red lights. The CVR recorded the captain stating "stable" at 5:36:49.

The first officer said, "[I'm] going to have to stay just a little bit higher. I'm going to lose the end of the runway."

The captain said, "Yeah. Yeah. Okay."

The performance study indicated that about this time, the airplane was 0.9 nm west of runway 9, descending through about 200 feet AGL at a vertical speed of 528 fpm and an airspeed of 146 knots. The airplane performance study indicated that the PAPI indication observed from the cockpit would have been four red lights.

At 5:37:13, the flight engineer announced that the before-landing checklist was complete. The announcement was the last crewmember statement recorded by the CVR. At 5:37:20, as the ground proximity warning system (GPWS) announced 40 feet AGL, the number-two and number-three engine power began to increase rapidly. The CVR then recorded the sound of a crunch and then the GPWS announced 30 feet AGL. The CVR recorded another crunch sound, and the number-one engine power began to increase rapidly. The GPWS announced, "Bank angle, bank angle."

The sound of crunching and a loud squeal began; both sounds continued until the end of the recording. The airplane collided with trees in a right-wing-low, slightly nose-up attitude, then hit the ground, coming to rest on a heading of 260 degrees about 1,556 feet west-southwest of the runway. A fire broke out. The three crewmembers got out of the airplane through the captain's sliding-cockpit window before the fire reached the cockpit.

The approach took the airplane over a protected national forest area that had no ground lights or other visible references by which the pilots could judge their height above terrain. FedEx's recurrent training module on black-hole approaches, which the first officer received in 1999 (but was not received by the captain and flight engineer), warned that pilots who are conducting visual approaches like this often perceive the airplane to be higher than its actual altitude. Data showed that the first officer flew a concave approach with a steeper-than-normal initial descent, which is characteristic of a black-hole approach.

The Safety Board learned that the first officer's color vision was deficient. He had been issued a medical certificate with a SODA (Statement of Demonstrated Ability) based on an eye test, which showed mild red-green color blindness. The chief of the U.S. Air Force School of Aerospace Medicine, Aerospace Ophthalmology Branch, told the NTSB that the first officer's color-vision discrimination was impaired to the extent that would "limit him to nearly a gray-blue-yellow world. We believe that he would definitely have had problems discriminating the PAPIs, as they were designed because the red lights wouldn't appear to be red at all, but some other wavelength that would make them more indistinguishable from white."

The NTSB determined that the probable cause of the accident was the captain's and first officer's failure to establish and maintain a proper glidepath during the night visual approach to landing. Contributing to the accident was a combination of the captain's and first officer's fatigue, failure to adhere to company flight procedures and to monitor the approach, and the first officer's color-vision deficiency.

Peter Katz is editor and publisher of NTSB Reporter, an independent monthly update on aircraft accident investigations and other news concerning the National Transportation Safety Board. To subscribe, write to: NTSB Reporter, Subscription Dept., P.O. Box 831, White Plains, NY 10602-0831.