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

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Heavy Set

Well-known member
Joined
Nov 28, 2002
Posts
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?
 
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?

Many of those "Desk Jockey FAA Farts" have flown airline schedules for years before going to the FAA. I know Inspectors from many current and bankrupt carriers. The Administrator was an Eastern Airlines Captain. If your looking for bullcr@p, try the mirror.

Venting on a pilot board will give you nothing to change the system. The NPRM, media, elected officals, etc. are the way to vent for change. You want change? Find out how to work for it....Also knowing what your talking about is a good way to start.
 
Many of those "Desk Jockey FAA Farts" have flown airline schedules for years before going to the FAA. I know Inspectors from many current and bankrupt carriers. The Administrator was an Eastern Airlines Captain. If your looking for bullcr@p, try the mirror.

Venting on a pilot board will give you nothing to change the system. The NPRM, media, elected officals, etc. are the way to vent for change. You want change? Find out how to work for it....Also knowing what your talking about is a good way to start.

Instead of looking at the mirror, I am looking at the recent FAA proposal. Enough said. I have watched many "Desk Jockey FAA Farts" either in the office at a few FSDOs or currently on an inspection duty. Sorry, not impressed. The most important statement seems to be "I hope it's not taking too long, cause at four I am going home".

Who cares if the administrator was an ex Eastern Airlines Captain. Look at the ALPA president now. Don't care where he is ex- from. Once you are at a powerful position like that, you change.
 
Venting on a pilot board will give you nothing to change the system. The NPRM, media, elected officals, etc. are the way to vent for change. You want change? Find out how to work for it.

Here's the link to make a comment! Fill in the right side, left side personal information is optional. There are over 150 comments made so far. General consensus is 10 hours of flying is too much, nine hours rest to little.

http://www.regulations.gov/search/Regs/home.html#submitComment?R=0900006480b4ea5b
 
Instead of looking at the mirror, I am looking at the recent FAA proposal. Enough said. I have watched many "Desk Jockey FAA Farts" either in the office at a few FSDOs or currently on an inspection duty. Sorry, not impressed. The most important statement seems to be "I hope it's not taking too long, cause at four I am going home".

Who cares if the administrator was an ex Eastern Airlines Captain. Look at the ALPA president now. Don't care where he is ex- from. Once you are at a powerful position like that, you change.

Just curious if you read the NPRM. There were a plethora of requests throughout the proposal asking pilots to comment on the proposed solutions. The document was the most open NPRM I have ever read, in terms of stating what threats they were trying to address and how they were going to address them. It then asked for the experts (you and me?) to please comment and let them know if their logic was flawed. While nothing is perfect I believe the document is a huge improvement. I am the first to admit that my review is biased to the type of flying I have done at four different carriers and is not inclusive of long haul East West.

Having said that, the fact that duty is now limited to 60 hours a week vs. the previous 96 hours a week seems like a difficult improvement to argue with. My own experience tells me that duty and number of legs is a much bigger factor in fatigue than just flight time. Transcon turns will still not be legal, and you can only be scheduled for 13 hours a day in the most optimum scenario (unaugmented showing between 7am and 1pm). These two new duty limits are HUGE.

This flight may have been in violation under either set of rules as the Captain chose to continue on unaugmented instead of diverting when the augmented pilot fell out of rotation. I am not second guessing him personally as I was not there - just pointing out one angle. If you were on a two man crew and one pilot dropped out 2 hours in on an 8 hour flight - would you continue to destination? Required crew is required crew.

I do see the irony that a 10 hour flight will not require the third crewmembers with the new rules - but that is DAYLIGHT ONLY. The all night flights will be limited to 8 hours flight and 9 hours duty - HUGE improvement over today.

Just my opinion, but I read all 145 pages.....twice!
 
thruthemurk two different issues here.

The Delta crew on an int'l flight without an IRO. Not sure what the DL OPS or regs state in a situation like that. Fact is, the working crew couldn't rest. The captain on that flight had trouble resting adequately before. Fatigue creeps up, add a few unusual circumstances and we have a recipe for an incident. We all have been there. When fatigued, you start screwing up. Sometimes you don't even know that you are fatigued until you start making mistakes. Usually some that are not typical of yourself.

Now the FAA decides to retrain the pilots. In what? Runway lighting? Taxiway markings? Is there anything new those 10,000+ hr pilots are going to learn? This is what pisses me off about the Feds: their attitude of dealing with pilots like children. You screwed up? Back to school. Problem solved. On paper. Feds happy.

The NPRM. I agree with you 100%. Question is: Do you think an airline pilot would have come up with an extension to 10 hours? That's only from someone who's not in touch with reality. 10 hours, even daylight only is way too much.

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.

This is really dangerous. Especially when you work for a regional that is thin staffed, chaotically operated and usually intimidation to their pilots. This way they can really screw with you. Although I do see the good intend behind it, the potential of abuse is frightening, especially from management or a Fed if he has a bad day.
 
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What a crock. Fatigue? How many AF pilots fly all over the world, land in combat zones, all while being on a 24 hour duty day? Tons do. How many land on taxi ways? NONE!

I think it's just part of culture based on complacency. Maybe that's due to vastly degraded work rules/compensation...but I wish these guys could have taken their jobs more seriously. There were lots of lives at stake...and they got lucky this time.
 
What a crock. Fatigue? How many AF pilots fly all over the world, land in combat zones, all while being on a 24 hour duty day? Tons do. How many land on taxi ways? NONE!

I think it's just part of culture based on complacency. Maybe that's due to vastly degraded work rules/compensation...but I wish these guys could have taken their jobs more seriously. There were lots of lives at stake...and they got lucky this time.

Care to comment on the C17 in Alaska??

Awww, too soon?
 
What a crock. Fatigue? How many AF pilots fly all over the world, land in combat zones, all while being on a 24 hour duty day? Tons do. How many land on taxi ways? NONE!

Not sure if you can compare AF vs. civilian flying. Do AF pilots regularly fly up to 90+ hours/month?
 
Not sure if you can compare AF vs. civilian flying. Do AF pilots regularly fly up to 90+ hours/month?

Actually, some AF pilots fly up to 150 hours in a month.

Bill, I don't think they've released a cause on the C-17 accident in Alaska. I'm sure they were very professional. Especially since they were getting paid more than a Delta crew.
 

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