Fatigue Was A Factor

A FedEx Boeing 727 crashed on landing in Tallahassee, Florida in 2002 because of flight crew performance failures, the National Transportation Safety Board has found.

On July 26, 2002, FedEx flight 1478, a Boeing 727-232F (N497FE) struck trees on final approach to Tallahassee Regional Airport at 5:37 a.m. The flight had originated in Memphis (TN). The captain, first officer and flight engineer were seriously injured, and the airplane was destroyed by impact and resulting fire.

In its final report adopted Tuesday, the Safety Board said that the probable cause of the accident was the failure of the captain and first officer 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 and failure to adhere to company flight procedures, the captain's and flight engineer's failure to monitor the approach, and the first officer's color vision deficiency.

Although runway 09 did not have an Instrument Landing System, it was equipped with a Precision Approach Path Indicator, a series of lights that aid flight crews in determining if they are on a proper glide slope to the runway, too high or too low. The Board found that the first officer, who was the flying pilot, had a history of color vision deficiency, for which he had a waiver from the Federal Aviation Administration. Extensive post-crash evaluation of the first officer's color vision concluded that this deficiency would likely have interfered with his ability to discern the differences between the white and red lights that give the pilots their altitude clues.

The Board noted that the current process of color vision screening required for pilots will not detect certain severe color vision deficiencies. The two recommendations the Board issued in this report ask the FAA to determine the operational effectiveness of each of the color vision test protocols it currently allows and, then, establish a standard battery of color vision tests to be administered to all commercial pilots.

The Board's report cites a series of performance deficiencies exhibited by the flight crew during the approach, including continuing their unstabilized approach below 500 feet rather than executing a go-around, and errors by the captain that suggest he was not fully alert. The captain indicated after the accident that he had not slept well the two nights before the accident due to responsibilities at home, and the first officer reported that he had been having difficulty adjusting his sleep cycle to the reserve-duty schedule that he had recently been placed on.

This is the latest Safety Board investigation in which it has cited fatigue as a factor. Fatigue in transportation operations has been on the NTSB's list of most wanted safety recommendations since the inception of the list in 1990. Since that time, little progress has been made to revise the hours-of-service regulations that would incorporate the results of the latest research on fatigue and sleep issues. The Board's latest recommendations to the FAA on this subject are classified "Open - Unacceptable Response."

FMI: www.ntsb.gov