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NTSB Cites Pilot Fatigue in 2009 Delta landing at ATL, WSJ

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Heavy Set

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Nov 28, 2002
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2,277
Wall Street Journal
* SEPTEMBER 25, 2010

NTSB Cites Pilot Fatigue in 2009 Delta Landing

By ANDY PASZTOR

Federal accident investigators have released a report indicating that cockpit fatigue, highlighted by a captain who had been awake for roughly 23 hours, likely was a big factor in a Delta Air Lines Inc. jet that mistakenly landed on an Atlanta taxiway last fall.

Released on Thursday, The National Transportation Safety Board's report provides fresh evidence about the insidious dangers of pilot fatigue—an issue that remains at the forefront of the debate over how to enhance the safety of commercial aviation in the U.S. and overseas.

The board's summary provides new information about the sequence of events before dawn on Oct. 19, when a Delta Boeing 767 widebody jet touched down on a 75-foot taxiway instead of a 150-foot wide parallel runway at Atlanta's Hartsfield International Airport. The details underscore how long-range flights can lead to sleepy and distracted pilots during the critical, final phases before touchdown.

The unusual incident involving Delta Flight 60, en route from Rio de Janeiro, Brazil, prompted widespread news coverage at the time. None of the 182 passengers aboard the Boeing 767-300 was injured, and the pilots continue to work for the airline.

But the report recounts how a series of distractions and errors led to ultimate mix-up. They included a sick crew member, last-minute changes in runway clearances and inoperative runway lights.

The safety board's report—while not officially identifying the probable cause of the incident—also indicates that Delta didn't have an official, comprehensive fatigue-management program in place last October. The report notes that the pilots told investigators they weren't aware of corporate fatigue-management guides. That information, the pilots told the board, was distributed primarily to crews assigned to fly even longer runs—called ultra-long range routes—stretching for 16 hours or more.

The difficulties for Delta Flight 60 started long before takeoff, when the captain woke up early in Brazil on Oct. 18 and then tried unsuccessfully to nap before reporting to work that evening. He had been up for roughly 11 consecutive hours before starting his workday that same evening, according to investigators.

During the early portion of the roughly 10-hour flight, the captain wasn't able to leave the cockpit to take his customary rest period, because the crew member who would have relieved him became ill and was incapacitated in the aircraft's cabin with an intestinal disorder. So the two-person crew flew the entire trip without a break.

Before descending toward Atlanta, where the winds were calm and visibility was good, the cockpit-voice recorder picked up sounds of yawns and crew-member references to lack of sleep. The captain told the first officer that for the impending approach, the "highest threat is fatigue," according to the report.

Based on the safety board's analysis, part of the crew's confusion stemmed from the fact that certain runway lights and navigational aids weren't operating that morning. When investigators conducted flights tests to precisely replicate conditions on the day of the incident, the report notes, pilots had trouble discerning the runway on which the Delta flight had been cleared to land. But the test pilots could easily identify lights associated with the taxiway, located 200 feet to the north.

Equipment in the airport tower, however, wasn't calibrated to identify such mistakes, so controllers never warned the crew of Flight 60 that the jet was lined up incorrectly. Four seconds prior to touchdown, according to the report, is when the cockpit recorder picked up the captain's first comment that the plane was about to land on a taxiway.

Delta previously said it planned to retrain the pilots and return them to flight status. FAA officials previously said they crew made an inadvertent mistake, adding that the agency was focused on fully understanding what happened and preventing a repeat of the same mistakes.

Write to Andy Pasztor
 
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Sounds like the FAA needs to read this before starting the new 10 hour transcons and 9 hour flights across the Atlantic with 2 man crews. Somebody page Babbit and the ATA!

Everyone on FI, please, have a GREAT DAY!


Bye Bye---General Lee
 
Sounds like the FAA needs to read this before starting the new 10 hour transcons and 9 hour flights across the Atlantic with 2 man crews. Somebody page Babbit and the ATA!

Everyone on FI, please, have a GREAT DAY!


Bye Bye---General Lee
Maybe we can help them....

To submit your comment on the fatigue NPRM, go here:
http://www.regulations.gov/search/Re...00006480b4ea5b


To see the comments others have already made, go here:
http://www.regulations.gov/search/Re...2009-1093-0001

I suggest just cutting and pasting the first couple of paragraphs of this WSJ article. Pretty much says it all. "Mix ups" and "distractions" are ever present. Ten hours of flying with nine hours of rest will just make this worse.
 
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Delta previously said it planned to retrain the pilots and return them to flight status. FAA officials previously said they crew made an inadvertent mistake, adding that the agency was focused on fully understanding what happened and preventing a repeat of the same mistakes.

What a bunch of bullcr@p. Retrain the pilots in what exactly? I'd like to see one of those desk-jockey FAA farts fly a regular airline schedule for one month.

How can you explain fatigue to a federal employee that lives on a 8-4 schedule?
 
What a bunch of bullcr@p. Retrain the pilots in what exactly? I'd like to see one of those desk-jockey FAA farts fly a regular airline schedule for one month.

How can you explain fatigue to a federal employee that lives on a 8-4 schedule?
Unfortunately, this little gem of a statement in the accident report is aligned correctly with the NPRM. Fatigue is now the pilot's fault, akin to alcohol abuse. Pilots will be trained in fatigue recognition not to educate the pilot, but so if a pilot is fatigued they can then blame it on the pilot. "Says right here you were trained so you shouldn't be fatigued." It seems to completely bypass the structural/institutional causes of fatigue like 10 hours of flying and 9 hours of rest.

Worse, other airline employees are going to get trained in fatigue recognition so that they can turn in pilots who looked fatigued. There will be an on site fatigue monitor who will then assess whether you are fatigued, much like getting tested for drugs/alcohol now.

Career just gets better and better.
 
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Unfortunately, this little gem of a statement in the accident report is aligned correctly with the NPRM. Fatigue is now the pilot's fault, akin to alcohol abuse. Pilots will be trained in fatigue recognition not to educate the pilot, but so if a pilot is fatigued they can then blame it on the pilot. "Says right here you were trained so you shouldn't be fatigued." It seems to completely bypass the structural/institutional causes of fatigue like 10 hours of flying and 9 hours of rest.

Worse, other airline employees are going to get trained in fatigue recognition so that they can turn in pilots who looked fatigued. There will be an on site fatigue monitor who will then assess whether you are fatigued, much like getting tested for drugs/alcohol now.

Career just gets better and better.

What is a fatigue monitor? Is this a machine or a person? What measurables are they using to determine fatigue?
 
I guess the next logical step in this insanity is for pilots not to have children any more. You know, their demands, attention, requirements (especially new additions) don't fit with the companies' schedules and rest requirements.

Question remains... If the IRS interrupts my sleep pattern/cycle can I request my money back?
 
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What is a fatigue monitor? Is this a machine or a person? What measurables are they using to determine fatigue?
page 24 of the NPRM:

"Certificate holders also must assess a flightcrew member’s state when he or she reports to work. If the carrier determines a flightcrew member is showing signs of fatigue, it may not allow the flightcrew member to fly. Flightcrew members should be cognizant of the appearance and behavior of fellow flightcrew members, including such signs of fatigue as slurred speech, droopy eyes, requests to repeat things, and attention to the length of time left in the duty period. If a flightcrew member (or any other employee) believes another flightcrew member may be too tired to fly, he or she would have to report his or her concern to the appropriate management person, who would then be required to determine whether the individual is sufficiently alert to fly safely. In addition, under today’s proposal, carriers would need to develop and implement an internal evaluation and audit program to monitor whether flightcrew members are reporting to work fatigued."
This will require fatigue monitors, here alluded to as the "appropriate management person." If someone is reported as being suspected of being fatigued, this management person will have to conduct an field evaluation of the crewmembers to see if they are fatigued or not. If they say you are, it will be akin to trying to report for work with alcohol in your system. There will probably be company punishment as well as certificate action of some kind.

From page 23 of the NPRM:

"It is unfair to place all the blame for fatigue on the carriers. Pilots who pick up extra hours, moonlight, report to work when sick, commute irresponsibly, or simply choose not to take advantage of the required rest periods are as culpable as carriers . . . "

They are going after the pilots on this, all the while increasing allowable flight time by 25% to ten hours, while still only providing 9 hours of rest. Absolutely kafkaesque.
 
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Brazil flights need 4 pilots: an additional "IDB" Pilot....Intestinal Disorder Backup Pilot...

...they got some serious hygiene problems down there!
 
Just curious, what is DAL’s policy and assumed reaction had the captain called in fatigued at the last min?
 

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