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flying while fatigued

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At The Intersection Of Pilot Fatigue And Pilot Error

What's Classified As Error Could Be Avoidable Fatigue
By ANN Contributor Steven R. Lund
Assigning "Pilot Error" as the sole cause or even a contributing factor to the cause of an airliner accident is, to say the least, counterproductive. This is tantamount to declaring that Sir Isaac Newton and Albert Einstein contributed to the cause because they formulated classic laws of gravity! Obviously such a "relatively general" reason for an accident has little meaning to facilitate any remedial action to prevent future accidents. So, if any human error was suspected in the chain of events leading to an accident, the most important aspects of this fact is who committed the error, and, most importantly, why was the error committed? Only after these determinations, can investigators formulate effective corrective action. For instance, was the human properly trained to perform the task required? Or, were the proper tools provided, was the human physically capable, or medically fit?

I suspect that some accidents attributed to pilot error were actually simply the result of the pilot being too fatigued to properly perform the tasks required to prevent the accident! I know of one DC-8 freighter accident where "pilot fatigue" was implicated as the cause of the airplane wing stalling and crashing a quarter-mile short of the runway. The wording of the official probable cause was summarized in some news accounts as "pilot error!"



Experts from NASA collaborated with NTSB investigators in assessing whether fatigue was present in the 1993 crash of a US DC-8 (file photo of type, above) freighter in Guantanamo Bay, Cuba. The DC-8 crashed into level terrain during a circling approach to the landing runway in clear weather, resulting in the aircraft being damaged beyond repair, but, no fatalities to the three crew members -- the only persons aboard. The NTSB implicated fatigue as a probable cause-the first time fatigue had been so identified in an aviation accident. Three core physiological factors related to fatigue were identified (cumulative sleep loss, continuous hours of wakefulness, and circadian time of day). All three crewmembers were found to be heavily influenced by these fatigue factors.

There have been other accidents with causes I suspect could have been similarly associated with pilot fatigue, namely:



The June 1999 fatal runway accident of American Airlines Flight 1420 in which a McDonnell Douglas MD-82 (file photo of type, above) overran the end of the runway, went down an embankment, and impacted approach light structures after landing at the Adams Field Airport in Little Rock, AR. Thunderstorms and heavy rain were reported in the area at the time of the accident. There were 11 fatalities, including the aircraft captain, and numerous injuries among the 145 passengers and crew aboard the flight. The official cause of this accident was "the flight crew's failure to discontinue the approach when severe thunderstorms and their associated hazards to flight operations had moved into the airport area and the flight crew's failure to ensure that the spoilers had extended after touchdown. Contributing to the accident were the flight crew's (1) impaired performance resulting from fatigue and the situational stress associated with the intent to land under the circumstances, (2) continuation of the approach to a landing when the company's maximum crosswind component was exceeded, and (3) use of reverse thrust greater than 1.3 engine pressure ratio after landing."

Even though the weather was a factor in this accident, there was no wind shear present. But there were crosswinds compounding the difficulties faced by the pilot in performing the approach and landing and the fact that pilot fatigue was deemed a "contributing factor to the accident tends to amplify the Pilot Error cause due to the official report listing a number of failures both before and after the plane's touchdown on the runway.



The crash of KAL Flight 801 in Guam on August 6, 1997 (above), was the result of several errors by the crew, most notably a lack of situational awareness resulting in "controlled flight into terrain (CFIT)." However, the pilot in command of the flight was a senior and experienced pilot in the company. While the captain was not familiar with the terrain, and visibility at the time was reduced due to rain, the approach into Guam should not have been difficult. So what caused the Captain to lose concentration and situational awareness, and thereby fly a perfectly good 747 into a hilltop, killing 228 people? Could it be that prior to flying to Guam he had flown from Seoul to Australia, back to Seoul, to Hong Kong, and then back to Seoul again before his fateful trip to Guam, all with only a few hours of rest?

The official probable cause of this accident was "The captain's failure to adequately brief and execute the nonprecision approach and the first officer's and flight engineer's failure to effectively monitor and cross-check the captain's execution of the approach. Contributing to these failures were the captain's fatigue and Korean Air's inadequate flight crew training. Contributing to the accident was the Federal Aviation Administration's intentional inhibition of the minimum safe altitude warning system and the agency's failure to adequately to manage the system." Again, a list of human failures without specific mention of why! It's no wonder that this accident could be relegated to the "Pilot Error File" without meaningful remedial action and the very predictable non-zero probability of repeat accidents.

Going back a bit to March 1969 when a United Arab Airlines, Russian built Ilyushin 18 tried to land at Aswan, Egypt after 2 previous attempts in a sandstorm. Rising sand in the Aswan area caused the visibility to drop from 10km to 2-3km. The right wing contacted the left side of the runway 1120m from the threshold. The wing broke off and the aircraft crashed in flames killing 100 passengers and crew of the 105 total persons aboard.

The official cause of this accident was: "Pilot descended below the minimum safe altitude without having the runway lights clearly in sight. A contributory factor was fatigue arising from continuous working hours without suitable rest periods."

By now it should be obvious that the root cause of these accidents where the human pilot made errors was fatigue, not pilot error! So, what can be done about fatigue?

(Steven R. Lund is the retired director of flight safety investigations in flight operations for the Douglas Products Division of the Boeing Commercial Airplane Group in Long Beach, California. He has spent over 36 years in the US aerospace industry, the last 32 of which have been at the Douglas Aircraft Company (now Boeing). His entire career at Douglas/Boeing has been devoted to flight test, flight safety, and commercial jet transport incident and accident investigation. Steve has some very definite thoughts on that question -- and we'll share them in tomorrow's edition of Aero-News. -- ed.)
 
Part II

Part II: At The Intersection Of Pilot Fatigue And Pilot Error



What's Classified As Error Could Be Avoidable Fatigue

By ANN Contributor Steven Lund

Read Part One

Following a Congressional request in 1980, the NASA Ames Research Center created an on-going program to examine whether "there is a safety problem of uncertain magnitude, due to transmeridian flying and a potential problem due to fatigue in association with various factors found in air transport operations." Such as: flying across numerous time zones.



Reporting in a Hearing on pilot fatigue, before the Aviation Subcommittee of the US House of Representatives' Committee on Transportation and Infrastructure in the summer of 1999 NASA's Deputy Associate Administrator, Office of Aero-Space Technology said "The NASA Ames Fatigue/Jet Lag Program (now the Fatigue Countermeasures Program)… was created to collect systematic, scientific information on fatigue, sleep, performance in flight operations, and circadian rhythms-the biological "time clock" that regulates the body's daily sleep-wake patterns NASA established three program goals, which continue to guide research efforts to:



Determine the extent of fatigue, sleep loss and circadian disruption in flight operations.

Determine the impact of these factors on flight crew performance.

Develop and evaluate countermeasures to mitigate the adverse effects of these factors and maximize flight crew performance and alertness."

The NASA Program gathered data regarding the existence and extent of fatigue in aviation from several realistic sources, including actual flying, laboratory studies, high fidelity simulations, and surveys. These data have been consistent in showing that fatigue is an issue with complex, diverse causes and potentially critical consequences. Field studies specific to different aviation environments and using a range of measures (e.g., performance, physiology, and behavior) have revealed a number of factors related to fatigue. For example, in long-haul operations, the non-24-hr duty/rest cycles, the circadian desynchronization associated with transmeridian flights, and the sleep loss accompanying night-time flying are all associated with fatigue.



It has been evident, throughout this research program, that pilot fatigue is a significant safety issue in aviation. Rather than simply being a mental state that can be willed away or overcome through motivation or discipline, fatigue is rooted in physiological mechanisms related to sleep, sleep loss, and circadian rhythms. These mechanisms are at work in flight crews no less than others who need to remain vigilant despite long duty days, transmeridian travel, and working at night when the body is programmed for sleep.



A dramatic example of fatigue in U.S. aviation operations showed up when NASA researchers collaborated with NTSB investigators in assessing whether fatigue was present in the 1993 crash of a U.S. DC-8 freighter in Guantanamo Bay, Cuba [Mentioned in Tuesday's article].



NASA concluded that fatigue is a problem with diverse causes, requiring a multi-faceted and comprehensive yet integrated approach. Based on current research, such an approach should have at least the following components:



education and training

hours of service

sound scheduling practices

effective countermeasures

incorporation of appropriate design and technologies

research

A NASA/FAA countermeasure study empirically demonstrated the effectiveness of a planned cockpit rest period in improving performance and alertness in long-haul flight operations. Flight crews who were provided a planned 40-minute nap opportunity (resulting in an average of 26 minutes of sleep) subsequently exhibited improved physiological alertness and performance compared to flight crews not receiving the nap opportunity.



The crewmembers napped one-at-a-time in a three-person cockpit with minimal disruption to normal flight operations and no reported or identified concerns regarding safety. The benefits of the nap were observed throughout the critical descent, approach and landing phases of flight. The planned nap appeared to provide effective and acute relief from significant sleepiness experienced by crews in three-person flight operations



Technology continues to evolve rapidly, but humans have not changed their need for sleep, their rate of adjustment after circadian desynchronization, or the relationship between fatigue and performance. Good system design incorporates information about human physiology, its limitations and strengths, early in the process. Technological approaches that use this information can take many forms, including flight crew scheduling algorithms (i.e., the methodology of choosing flight crews) and alertness monitoring/management systems. Fatigue Program work in this area includes a project examining on-board crew rest facilities to determine the quantity and quality of sleep obtained and the factors that promote or reduce good sleep in the bunk. Onboard bunks are used in operations with extra (augmented) flight crewmembers onboard so that crews can rotate through flight deck positions and non-flying crew can obtain sleep during long flights.



A current NASA study is examining the feasibility of a video-based, automated, online system for drowsiness detection on the flight deck. Because we tend to underestimate our own degree of sleepiness, these systems have the potential to play a valuable role in detecting dangerous levels of fatigue and alerting crewmembers to their presence.



However, once crews are alerted to the presence of fatigue, the next problem is what can be done to ameliorate it? Does the industry mandate that a fatigued pilot immediately enter into a regiment of "power naps" -- designed to provide restful sleep, without negative post nap effects such as grogginess, disorientation, or headaches? Or, should airlines be required to constantly provide backup crew members to replace ones with detected levels of fatigue? Both of which would be required if modern flight decks were fitted with drowsiness detection devices. Clearly not an incentive for the industry to mandate such devices: Why measure a condition for which there is no established mitigating procedure if the Pilot's "Drowsiness Hi" light comes ON at the top of descent?



The most viable solution would be that the industry require pilots be adequately rested before the flight operations they are scheduled to work; giving due consideration to the quality of rest obtained, including their rate of adjustment after circadian desynchronization in addition to the current Federal Air Regulations (FARs) concerning crew duty cycles!



Considerable progress has been made during the last half of the 20th Century regarding knowledge about sleep, sleep need, the effects of sleep loss on performance, and related issues. Even more recently, major advances have occurred in human circadian rhythms research, leading to an improved understanding of these daily rhythms and their control by the human circadian pacemaker in the brain . However, the NASA studies concluded that more research is needed to fully understand the capabilities and limitations of the human sleep and circadian systems. An additional challenge is the appropriate application of this research to operational environments such as aviation. Given the recent development of technologies claiming to be able to detect fatigue, focused research is needed to ascertain the sensitivity, reliability, and validity of these devices.



According to NASA, research also needs to continue to address regulatory, scheduling and countermeasure questions. The area of fatigue is plagued by misconceptions about its causes and characteristics. There is no substitute for valid empirical data to guide decision making and policy.



Accident Investigation Strategies

If there is any question about "Pilot Performance" being an issue in the chain of events leading to an accident, the Human Factors Group should attempt to document the quality of the Crew rest experienced by the Pilots in addition to determining adherence to the appropriate flight and duty time regulations. For instance, did the pilot experience any sleep disorders, such as Insomnia or sleep apnea [caused by relaxation of the muscles of the tongue and the soft palate at the base of the throat, allows the breathing passage to collapse in individuals with a narrow airway. Although chest movements may continue, no air flows into the lungs and oxygen levels in the blood decrease. When blood oxygen levels fall too low, the person briefly wakes to take a breath.



This cycle of sleeping, then, the repeating cycle of airway collapsing, waking, and sleeping, often occurs hundreds of times in a night. Individuals with this common sleep apnea might not remember these brief awakenings and believe they slept through the night. However, the interrupted sleep leaves the individual exhausted in the morning and sleepy throughout the day]. Even something as innocuous as trying to rest in a noisy hotel room replete with interruptions to the normal sleep cycle should be documented.



(Steven R. Lund is the retired director of flight safety investigations in flight operations for the Douglas Products Division of the Boeing Commercial Airplane Group in Long Beach, California. He has spent over 36 years in the U.S. aerospace industry, the last 32 of which have been at the Douglas Aircraft Company (now Boeing). His entire career at Douglas/Boeing has been devoted to flight test, flight safety, and commercial jet transport incident and accident investigation. -- ed.)
 
Are there any hours of service laws for you pilots? On the railroad side of things, the FRA limits train crews to 12 hours of service with 8 or 10 hours off. It's a bitch because those off hours don't factor in your commute, plus the crew caller will call you between 2 and 1.5 hrs before your next train. Thus, with a sizeable commute, you could be looking at 4 hours of sleep a night while business is booming.
 
Rules, rules, rules...

Sure there are lots of complicated rules. Too many to sum up neatly in one post. You can read that to say: "mar is too lazy to take the time."

The first thing to go when I'm dead tired are my basic math skills. Fairly remedial to begin with I find it very frustrating (and quite embarrassing) when I can't even calculate when to start down at the end of a long flight.

That's the first sign.

When I start slurring my words I know things are going downhill fast.
 
Discussion on being fatigued?

Depends. I can come to work with 2-3 hours sleep knowing that once I get to my first destination I got 6 hours in a nice hotel to catch up during the day...if; I don't have to hold, don't have to deviate, don't have a late departure due to a late jet...

Then there is routine. I can work with those 2-3-4 hours of sleep, as long as my routine doesn't get jilted. On the other hand, give me a week in MEM for sim training, then let the barometer fall to 25.XX and then throw in some wx factors at the destination and the usual alternates are fubar...and you have the recipe for disaster.

I'm working on getting my sleep down to a better cycle now, otherwise I'm going to wind up screwing up something simple or bending something. Also, my schedule is only 12 days a month, plus I have a one hour one way commute to and from work 12 days a month. But the way my schedule gets screwed up is I have to get up at 3:40 AM on one day, fly 4 hours and the duty day is 15. Then I get home and I can't sleep until after midnight. Then I got the next day off, but even if I sleep in I still feel like crap and I wind up taking a nap during the day. Then I have to figure out a way to go to sleep early enough to get up at 3:40 again. It's a never ending cycle, plus, I'm attending college full time on-line and them team projects have kept me up as late as 3:00 AM on work nights and 12:00 midnight on days off when I need to get bed earlier to because I have to be up at 3:40 AM.

This last year has been a biatch and I'm looking forward to when I don't have to worry about school work. To tell you the truth, I love my schedule, but it can be a real ass beater sometimes.
 
WARNING..."flying while fatigued"-- your job or safety first?

Sure do wish now that I had accepted my reserve assignment and flown while FATIGUED! I worked for a MAJOR 121 aircarrier and after calling in "fatigued" (1st and only time ever in my career -15 yrs.) to scheduling at 2:00 am, after 9 days(yes - 9 days) in a row of flying, I was FIRED!!!!!

As an F/O on reserve, I was assigned 10 consecutive reserve days, and was on reserve duty 24 hrs. a day! Then, I was called for flight duty for all 10 days. I was denied the mandatory 24 / 7 FAA required rest period and the 8-in-24 "lookback" required "free of all duty" rest period. With the ever changing schedule, delays, and airport reserve duties, I never got more than 3-4 hours of sleep at a time during those 10 days of he11.
You say "Hey, wait a minute! What about ......???

ALPA - "One Level of Safety"; Contract (CBA)??
Company-rules, policies, & procedures(call in honest policy)
FAA - POI; FAR's / AIM for regulatory compliance??

Nobody seemed to care, except ALPA, and they did VERY little. WHY? Seasoned industy veterans already know why.
But, for the FNG's who may read (and learn) from this true occurence, its because I was a probationary pilot. Ten (10) years of prior ALPA dues didn't mean a thing.

In my opinion, its all a freaking **censored** joke!! It is just an illusion to deceive the flying public that their Safety comes first, when we ALL know that it is the greed of the almighty dollar that will always come first for the company. I thought that I was doing the right thing by putting SAFETY first and following the "rules". Unfortunately, I had to learn about the truth the HARD way. Career over!!! Don't let this happen to you! Make all of your decisions very carefully, it may be your last. Good luck to all of you.
 
Auburn MD Flyer said:
Sure do wish now that I had accepted my reserve assignment and flown while FATIGUED! I worked for a MAJOR 121 aircarrier and after calling in "fatigued" (1st and only time ever in my career -15 yrs.) to scheduling at 2:00 am, after 9 days(yes - 9 days) in a row of flying, I was FIRED!!!!!

As an F/O on reserve, I was assigned 10 consecutive reserve days, and was on reserve duty 24 hrs. a day! Then, I was called for flight duty for all 10 days. I was denied the mandatory 24 / 7 FAA required rest period and the 8-in-24 "lookback" required "free of all duty" rest period. With the ever changing schedule, delays, and airport reserve duties, I never got more than 3-4 hours of sleep at a time during those 10 days of he11.
You say "Hey, wait a minute! What about ......???

ALPA - "One Level of Safety"; Contract (CBA)??
Company-rules, policies, & procedures(call in honest policy)
FAA - POI; FAR's / AIM for regulatory compliance??

Nobody seemed to care, except ALPA, and they did VERY little. WHY? Seasoned industy veterans already know why.
But, for the FNG's who may read (and learn) from this true occurence, its because I was a probationary pilot. Ten (10) years of prior ALPA dues didn't mean a thing.

In my opinion, its all a freaking **censored** joke!! It is just an illusion to deceive the flying public that their Safety comes first, when we ALL know that it is the greed of the almighty dollar that will always come first for the company. I thought that I was doing the right thing by putting SAFETY first and following the "rules". Unfortunately, I had to learn about the truth the HARD way. Career over!!! Don't let this happen to you! Make all of your decisions very carefully, it may be your last. Good luck to all of you.
Sorry to hear about your delio with the regional...what are you doing now?
 
Auburn MD Flyer said:
In my opinion, its all a freaking **censored** joke!! It is just an illusion to deceive the flying public that their Safety comes first, when we ALL know that it is the greed of the almighty dollar that will always come first for the company. I thought that I was doing the right thing by putting SAFETY first and following the "rules". Unfortunately, I had to learn about the truth the HARD way. Career over!!! Don't let this happen to you! Make all of your decisions very carefully, it may be your last. Good luck to all of you.



Just totally forget about it, find a new job and move on. You did the right thing. You can always find a new job. You won't get a second chance if you meet the grim reaper. If I were you I would have sued their pants off as well for wrongful termination or at the very least annonymously notified the FSDO about this shady operator. Please tell us what company this is so the whole pilot community will know to avoid them like the plague!!!
 
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