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Wed, Jun 11, 2008

NTSB Recommends FAA Look Closely At Pilot Fatigue

Safety Board Wants Measures To Keep Cockpit Crews Awake

The National Transportation Safety Board made two recommendations Tuesday to the Federal Aviation Administration (FAA) to address human fatigue within airline operations. The Board recommended that the FAA develop guidance, based on empirical and scientific evidence, for operators to establish fatigue management systems, including information about the content and implementation of these systems.

The Board also made a recommendation to develop and use methodology that will continually assess the effectiveness of fatigue management systems implemented by operators, including their ability to improve sleep and alertness, mitigate performance errors, and prevent incidents and accidents.

"The Safety Board is extremely concerned about the risk and the unnecessary danger that is caused by fatigue in aviation," said NTSB Chairman Mark V. Rosenker."We have seen too many accidents and incidents where human fatigue is a cause or contributing factor."

The Board's recommendations letter cites three accidents and an incident highlighting the danger of human fatigue within airline operations:

  • On October 19, 2004, Kirksville, MO, Corporate Airlines flight 5966 struck several trees on its final approach and crashed short of the airport. Both pilots and 11 passengers were killed. Two passengers received serious injuries.

  • On February 18, 2007, Delta Connection flight 6488, operated by Shuttle America, Inc., overran the end of the runway as it was landing at Cleveland-Hopkins International Airport. All 72 passengers and a crew of four deplaned without serious injury.
  • On April 12, 2007, Pinnacle Airlines flight 4712 ran off the runway after landing at Cherry Capital Airport (TVC), Traverse City, MI. None of the 49 passengers or crew of three were injured.

  • On February 13, 2008, Go! flight 1002, operated by Mesa Airlines, flew past its destination airport, General Lyman Field, Hilo, HI. Air traffic control repeatedly attempted to contact the crew for over 18 minutes, as it flew over Maui, crossed the big island of Hawaii and headed southeast over the Pacific Ocean. The airplane traveled 26 nautical miles beyond its intended destination airport before the flight crew responded. There were no injuries.

"It is imperative that the FAA take action to reduce human fatigue in airline operations," Rosenker said. "Addressing this safety related measure is long overdue. We must and can correct this serious concern."

In the case of the Pinnacle accident, the NTSB determined the CRJ-200's flight crew elected to land on a snow-packed runway without performing the required landing distance calculations -- a serious lapse in judgment, due at least in part to crew fatigue.

"Also contributing to the accident were the Federal Aviation Administration pilot flight and duty time regulations that permitted the pilots' long, demanding duty day; and the TVC operations supervisor's use of ambiguous and unspecific radio phraseology in providing runway braking information," the Board noted.

The NTSB findings -- which came following a public meeting Tuesday on the above-cited incidents -- also confirmed what many had suspected in the case of go! Airlines Flight 1002: that the two-man flight crew fell asleep in the short inter-island flight. "[B]both pilots unintentionally fell asleep during cruise flight," NTSB member Jena Price said during the presentation, according to the Associated Press.

The NTSB revealed the captain of the flight suffered from severe sleep apnea, according to KITV-4 in Honolulu.

FMI: www.ntsb.gov

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