Aircraft Accidents and Lessons Unlearned LXXV: FedEx 1170

On June 8, 2022, FedEx flight 1170, a FedEx B757-236, registration number N949FD, landed in Tulsa International Airport at 04:13 local CST (central standard time) on an incorrect runway. The event was listed by the National Transportation Safety Board (NTSB) as an incident, since there was no damage to the aircraft – meaning it remained operational – and there were no injuries or fatalities. The NTSB assigned the event Incident Number DCA22LA126.

On page 4 of the NTSB final report, the NTSB determined, “… the probable cause(s) of this incident to be: The flight crew’s misidentification of the intended landing runway. Contributing to the incident were (1) the flight crew’s failure to perceive and correctly interpret visual and auditory indicators – including electronic guidance – that they were approaching the incorrect runway which was likely the result of a degradation in cognitive function brought on by working within their window of circadian low, increased workload, and fatigue, and (2) the air traffic controller’s failure to monitor the arriving flight after issuing a landing clearance.”

To statement (1): Nope. To statement (2): Probably not.

This was a B757, a very popular airliner. FedEx pilots have an exceptional training program. The fact FedEx 1170 was a cargo airliner should make no difference. The regulations and training qualifications a cargo flight crew and a passenger flight crew receive are comparable; the aircraft are maintained to the same degree of safety. It needs to be made clear that Air cargo operators deserve equal attention.

Why is landing on the wrong runway so important? Why would a cargo airliner landing at 04:30 AM be a concern? Among many reasons, it’s harder to see an aircraft taxiing at night. I flew with the flight crew into Memphis one night, when an airliner violated our approach runway: 9/27. I looked right at the area, as did the first officer. Nothing. The captain saw it and aborted the approach as we crossed the runway’s east end; he pivoted on the right wing, climbing above FedEx’s Hangar 10. At night, a taxiing airliner is very hard to see from the air. A small plane, like a Cessna Caravan, is little more than a shadow, almost nonexistent. Imagine if the plane I was on approached a runway it wasn’t assigned.

There are three problems with FedEx 1170 as investigated and reported. The first problem is the NTSB’s historical attitude toward air cargo events, treating these events with a less-than-urgent resolve. This approach is even more apparent with incidents because there were no lives or equipment lost, so the event becomes a forgotten event. Consider an accident I investigated in 2001 – Emery 17 – an investigation that stalled for over 1-1/2 years; where the Director at the time scoffed at providing necessary resources, saying, “It was just three pilots.” Or Atlas 3591, an air cargo accident investigation that was postponed for over two years while the NTSB focused on foreign accidents they were NOT leading on. How long did it take the NTSB to react to FedEx 1376 in Chattanooga? If the NTSB can’t take air cargo accidents seriously, how seriously will they take air cargo incidents?

The second problem: The NTSB doesn’t understand the air cargo industry, particularly overnight air carriers. The NTSB sees all cargo pilot issues the same way, that they fall under one category: Crew Rest Problems. Anything without the terms ‘Sleep Deprivation’ or ‘Circadian Rhythm,’ are not given serious attention. Unfortunately, with FedEx 1170, this meant other important safety issues were missed.

The third problem is the Probable Cause found in every NTSB report. Will the NTSB ever understand that Probable Cause is not a real thing? Never has been, never will be. Consider this: When pilots make mistakes, people die; when technicians make mistakes, people die. When the NTSB makes mistakes, people still die, but no one’s accountable for investigatory errors for missing the cause(s) of an accident. Therefore, when there’s no incentives or consequences to NTSB accident/incident investigation quality, there’s no motivation for integrity. After all, what would be the purpose?

FedEx Fatigue Monitoring Karolinska Scale

FedEx employs trending analysis data that details how sleep deprivation affects a pilot’s performance. Per the report and the FedEx flight operations manager, the FedEx Fatigue Risk Management Program (FRMP), “… was focused on predictive, proactive, and reactive risk modeling and it was done in collaboration with ALPA [the FedEx pilots’ union],” called the Karolinska Sleepiness Scale (KSS) which has information which is compared against the Psychomotor Vigilance Test (PVT) data. The report elaborated on how the FRMP works and is designed with a 1 – 9 scaled rating. These FedEx programs amount to so much talk, little substance.

No matter how much money and resources FedEx applied to these trending risk assessments, they didn’t prevent FedEx 1170 from landing on the wrong runway. Fundamentally, as a proactive tool, the FRMP, KSS, and PVT failed to prevent what it was expected to monitor. The FRMP appears more of a ‘Get-Out-of-Jail-Free’ card for FedEx. It creates the illusion that FedEx is proactive … with a feckless data crunching program.

The NTSB’s fascination with technology finds its way into most NTSB reports where they don’t belong. They are narrow-minded with regards to the cockpit voice recorder (CVR) and flight data recorder (FDR). If the CVR and/or FDR didn’t work right, the NTSB can’t investigate. The NTSB trusts that technology fixes all problems – even those created by technology. With FedEx 1170 and other cargo airline incidents, the technology is … a problem; the inability to use the technology is … a problem; the inability to interpret and make use of raw data is … a problem. The NTSB just can’t see or understand those facts.

Technology is a tool … nothing else. Raw trend data is a tool, nothing else. The FRMP with all its colorized bar graphs, obscure what pilots’ real problems are, that technology keeps getting in the way.

Another FedEx-employed technology the NTSB investigators noted was the pilots’ failure to acknowledge the Runway Awareness and Advisory System (RAAS) alerts. RAAS was a product introduced after Comair flight 5191 took off on the wrong runway. RAAS alerts the flight crew during taxi what runway they are approaching for takeoff or for crossing. I observed the RAAS system in operation during an enroute inspection and it correctly identified each runway our aircraft crossed or approached, but that was all. From listening to the aural notifications RAAS made, it was designed specifically for takeoff alerts – as with what happened with Comair 5191 – not approach announcements.

When I was young, my house was under the approach to JFK Airport’s runway 4/22; the engines on the DC-8s, 707s, and 747s that flew over were pre-noise abatement. After a while, 24-hours of engine racket receded into the background, sleep was not interrupted by low-flying airliners. Why? Because we became immune to the noise, plain and simple. Normal sounds like traffic, airliners, helicopters, trains, they all get blocked out; they are routine; they cease to be noticed.

RAAS aural warnings are not attention-grabbing, they have a tone one would expect for conveying information – not danger. The report quotes FedEx’s 757 Aircraft Systems Manual for ‘Warning Systems’: “RAAS is a software enhancement hosted within the EGPWS [Enhanced Ground Proximity Warning System] unit to provide aural advisories to assist flight crew awareness of airplane position during ground operations, approach to landing, and go-around.” Unfortunately, the RAAS system isn’t distinguishable from other informative aural alerts, such as flight control movements. RAAS should stand alone, like digital shouts, “Terrain! Terrain!” It must capture the pilots’ attention, demanding a response.

Could the RAAS be programmed by the pilots to recognize the incorrect runway? How often do runways change during a normal descent due to traffic or wind direction? That is one root problem here, the pilots were expected to heed an instructive electronic voice that doesn’t sound like a caution alert. The pilots ignored the RAAS alert, not out of ignorance, but out of complacency; they were immune to regular informative computer voices. If the RAAS was meant to warn of an incorrect runway, it would’ve had an aural and visual status alert, such as an Aural Warning horn/claxon coupled with a red Master Warning light. Instead, the RAAS’s voice can’t be distinguished from other computer voices. The RAAS alert didn’t stand out; it was unremarkable. FedEx’s investment in RAAS showed (at least with flight 1170) that FedEx spent a lot of money on a system that could be replaced by a pilot. Not just any pilot, but one who was situationally aware. But couldn’t FedEx just train to that?

And that’s the point, or more precisely, the main problem: technology doesn’t need fixing – just removal. Instead of fixing problems, like situational awareness, airlines throw more money … for more alerts that draw more attention … to even more alerts. Pilots are trained to listen for alerts when they should be trained to be situationally aware. Think of this insanity as comparable to the Pavlov’s dog experiment, where aural prompts trigger desired responses. Isn’t that like programming the pilot?

Aircraft don’t need more technology; aircraft need less technology. Do pilots even get involved in the technology designs? Too many aural alerts make pilots deaf to them; too many visual alerts make pilots blind to them. Overreliance on aural cues causes pilots to trust the aircraft to tell them what to do, instead of looking out the window. People don’t realize how many common electronic cockpit noises there are on approach. Pilots are becoming increasingly complacent.

The NTSB missed an evolving problem with piloting – not just for overnight cargo pilots – but every pilot. Industry needs to stop ‘improving’ the aircraft by taking away the pilot’s responsibilities. Stop throwing money at technology, instead work on training issues, such as in time-utilization training, crew resource training, flight management, task priority, flight planning. Stop using sleep deprivation as the go-to excuse for training issues. Stop thinking cargo and passenger airlines are different. They’re not. Investigators need to know there are very few differences between passenger and cargo airlines. Cargo airline accidents and incidents can prevent passenger airline accidents and incidents. When that happens, maybe we’ll actually learn something about increasing safety.