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NTSB Final Report on Corporate Airlines 5966

  • Thread starter Thread starter Rogue5
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What were the weather reports/forcast that night? Was it changing alot? I mean fatigue or not, you still cannot shoot the approach outside of the final approach fix if the weather is below mins. And going below MDA? Was that decision made because they were tired? I'm not believing that.

Fatigue is a big issue, but if they didn't dip below the MDA, your friend would still be here. I cannot express in words, on this message board how sorry I am for the famies and friends of these two, However, anyone can make mistakes. Like someone else said, it would be an even greater tragedy if we didn't learn from this. Any one who has sat thru ground school has watched video's of plane crashes. Some of the mistakes are sorta laughable, especialy if the video is old, grainy and has some cheesy comentator. When the mistakes are made closer to home, its not so funny, but still a valuable learning tool. Some of my greatest lessons in life were mistakes my parents have made, but even though they were stupid immature mistakes, I love and respect them and I don't make fun of them for it. The lesson here is to find a way to monitor our own actions and stop before we do something stupid.
 
CA1900 said:
The pilot error would not have occurred were it not for the FAA's arcane rest rules

How do you know that? It's pilot error, plain and simple.
 
mesaba2425 said:
How do you know that? It's pilot error, plain and simple.
Yes, it's pilot error. But I don't believe at all that it's "plain and simple." Pilot error is a catch-all in many accident reports. But sometimes there's an underlying cause to the pilot error, such as extreme fatigue. Ignoring things like that will not help prevent accidents, which is the purpose of these investigations.

These guys were on leg six, and had been on duty nearly 15 hours. You really don't believe that wasn't a huge part of why they made the "pilot error"?
 
FN FAL said:
That's almost an attractive nusiance.

I know....I debated for a while on whether or not to say anything....I figured everyone would be cool.....that obviously isn't the case....I don't have the full final report....but I do have a full copy of the initial report.....To respond to that very first post about learning something from it....I have....don't fly in horrible weather when you are pushing 15 hours of duty that began way before the sun came up.....it's obviously not safe....as far as the conversations being unprofessional in the cockpit during the flight....I don't think that what they said was any more unprofessional (that make sense?) than any that I have had in the cockpit in the past as well.....fact of the matter is.....13 people were killed....one was a good friend.....lets keep the bashing and other "dude" comments to ourselves.....just a request for a little professionalism............
 
"pilot error, plain and simple."

Bullcrap. An accident whose probable cause begins with the words "The pilot's failure to..." is most often the final erroneous action or decision in a long list of mistakes, oversights and latent organizational pathogens that set the killing conditions resulting in the flightcrew making the final mistake that allows the dirt into the cockpit. "Leadership Error" is what we should call it.

Kim and Jonathon are talking to us here folks, and we should honor their memory by taking this opportunity to learn as much as possible about what killed them, in an attempt to keep it from ever happening to us. We owe them that much.

Debating the importance of airlines getting serious about crew fatigue issues is wasted bandwidth guys, without the regulatory stick to beat them, they won't do it. Even when people are killed. "We here at ______ Airlines encourage our crews to call in fatigued, they are instructed repeatedly that operating an aircraft in a fatigued manner is contrary to the regulations and our stated company policy and directives." What we should be doing is talking about how we as aviators can work within the current structure to minimize the risk. In other words, the part of the equation we control!

A lot of this comes down to personal discipline. There are several coping strategies that can assist us:

Regular, cardiovascular exercise. Twenty minutes a day, three times a week, will decrease your bodies need for sleep. Being physically fit will greatly reduce the effects of fatigue during your four day from heck. Instead of watching a bunch of garbage on the hotel TV, try going to bed earlier. Get up first thing in the morning and hit the treadmill, elliptical trainer, bike, rowing machine, whatever. You'll feel better all day.

Proper diet and nutrition. Avoid refined sugar and processed foods. Potatoes, white rice, white bread, enriched anything. Avoid any substance with high fructose corn syrup in it. Instead of packing those energy bars, put a couple of apples, grapefruits, bananas or other pieces of fruit you like in your suitcase. Transfer a few out each morning into your flight bag so they'll be available in the cockpit. These "slow release" sugars are much more healthy for you, and will result in more even, consistent energy throughout the day. Sports drinks? Avoid them. Drink water throughout the day, whether you're thirsty or not. You can probably draw your aircraft's fuel system and recite all of it's limitations and EP's by heart, but do you understand how your pancreas and insulin control your metabolism and the fuel your body (which is the most important system in the jet!) uses to move, think, shoot that ILS? If the answer is no, time to head to the library or your physician and find out.

Do some research on fatigue and rest. There are several good books available. Learn about your circadian rhythm, know when your two low points are during the day and why. If you're a caffeine user, consume it strategically to negate that 1500-1700 "dip" every afternoon. Understand that your short-term memory goes to heck in a handbasket when you're tired. Know that you're at risk for channelized attention. Be aware that factors such as illness and sleep debt play a big roll in fitness for flight. Realize that as the fatigued pilot, you are the LAST person in the world whose in a good position to evaluate your fitness for flight. How often have you had that "Are you good for one more, brotha?" conversation with your crewmates? "Yeah, I guess..." If you're trying to talk yourself into it and are rationalizing along the lines of "I'll just make sure we're both aware of the risk." guess what? There's nothing you can do to improve your performance when you're fatigued, no matter how aware you are you're tired.

So, what to do? Brief it up carefully, demanding careful adherence to the SOP and diligent checklist usage. You may not be able to do anything as a human machine to avoid fatigue-related errors, but by following our procedures carefully and making an effort to make every standard callout, communicate thoroughly and hit every checklist item just as if a check airman was sitting there, we increase the odds that any mistake we do make will be mitigated before it causes us any trouble. Fatigue and hypoxia are very similar. When you've got it, you're probably not aware of it. Fatigue is a much bigger killer.

Kim and Jonathon are talking to us here guys. Are we listening? Screw the company, personal discipline and good solid airmanship are where it's at.

So, there are folks far more experienced and clever than I on this board, who else wants to post something relating to their strategies on coping with fatigue?
 
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I don't want to hijack this thread, but last year Australia has it's worst airline crash is 40 years, when a Metro 23 operating a regular service in Northern Qld crashed whilst on approach. Although the final report is not complete the ATSB issued this recommendation yeaterday;

ATSB recommendations re Lockhart River fatal aircraft accident

24 January 2006


The ATSB has released recommendations to CASA relating to fitment of aircraft autopilot equipment and crew instrument approach qualifications as part of the investigation into the Lockhart River fatal accident on 7 May 2005.
The Australian Transport Safety Bureau found that the Metroliner aircraft that crashed near Lockhart River on 7 May 2005 was not fitted with an autopilot and the copilot was not qualified to conduct the instrument approach the crew were conducting. Addressing both is seen by the ATSB as desirable to improve future safety.
The aircraft was being operated on a scheduled passenger service from Bamaga to Cairns with an intermediate stop in Lockhart River. It crashed killing the two pilots and 13 passengers as the crew were attempting to carry out the instrument approach to runway 12 at Lockhart River. The ATSB issued an interim factual report on 16 December 2005 and is still investigating the accident.
ATSB recommendations have been issued to the Civil Aviation Safety Authority to review current legislation and regulations:
  • to seek to ensure that in an aircraft requiring a flight crew of two, both crewmembers are appropriately qualified to carry out an instrument approach; and
  • to provide a mechanism for the phased introduction of autopilot equipment to all aircraft on the Australian civil aircraft register engaged on scheduled air transport operations.
The ATSB will consider further recommendations in the course of its investigation including with respect to the operation and testing of cockpit voice recorders.

The ATSB has a point regarding autotpilots, it is now 2006 and we (and the USA) have passengers boarding aircraft, that have to be hand flown on every sector (and in the USA) in extreme weather. Why do 30+ seat regional aircraft ahve autopilots, but 19 seat aircraft don't. They are both 2 crew aircraft carrying passengers, flying in the same weather yet the poor 19 seat pilots have to work harder.

With reagrd to the Jetstream crash, fatigue has been identified as a factor, as the crew at spent 15 hours on duty hand flying every sector. Now perhaps if that same crew did a 15 hour duty tour flying a Jetstream fitted with an autopilot this accident may not have occured. Yes 15 hours is bloody long, but if you are only monitoring the flight, rather than flying you will be less fatigued.

You don't see 747/777 long haul pilots hand flying for 10-12 hours, so why make the 19 seat pilots do it.

Maybe the NSTB should follow our ATSB lead with the same recommendation.
 
CA1900 said:
That's a narrow view.

This is a fatigue issue all the way. The pilot error would not have occurred were it not for the FAA's arcane rest rules, and the ridiculous "exemption" for aircraft with 30 seats or fewer than let them use Part 135 duty and rest rules. I see that didn't make it into the report either. *sigh*

Fatigue didn't make the Captain to make a statement similar to, "We can all this way not to land this thing". Fatigue didn't make the crew decend blow MDA. The crew made poor decisions, violated regs, and the accident was a result of this. There was no system failure, no mechanical failure.
 
PINC (Planned Intentional Non-Compliance) that is current buzzword in pursuing a reduction in the accident rate. This sounds like classic PINC. There is good article on this in this month’s B&CA.
 
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Fatigue Training

av8er2 said:
Fatigue related training???

The FAA needs to just change the rules and change the # of legs regionals are doing.

We have all been there and the best pilot isn't worth anything when they are tired.

Get on the ball FAA before more happens like this. The experience level is going down at the regionals and no one is happy. I think there will be more accidents in the future.

I believe what the NTSB is proposing is the airline training departments train us to fly fatigued. Think about it. They could schedule all checkrides at 2 am. They could encourage the airlines to fly us 14 hrs a day for 6 months, then gear us back to 13 hrs a day... thus 'training' us for those long duty days. I think they're on to something!

They talk about fatigue like it's hypoxia or carbon monoxide. The solution to this fatigue problem is right under their noses and it's called a PILLOW. Change the duty day parameters so that fatigue is engineered out of the process. It seems so simple to me.

I guess more blood will have to be spilled in the mean time.
 
CA1900 said:
If anything comes from this crash, I hope it'll be for the rest of us to err on the side of caution when we think we might be too fatigued to be safe, instead of listening to scheduling when they say, "But you're still legal," and thinking yeah, they're right, it's only one more leg.


EXACTLY!!!
 
I think everyone is right on why this event happend... It is both fatigue AND poor airmanship. The two go hand in hand.

We have all been there... Late night, last leg. Tired as hell. Doing the approach and we dip a little below MDA, but so what, it's only a little, I can see the approach light anyway. Fatigue breeds complacency the same way that doing the same legs in the same airplane, day in and day out, can make us a little sloppy. Professionalism mitigates this to some extent and it seems this crew was caught lacking on that night. It could happen to anyone of us if we are not very careful.

On another note, this accident prompted me to ask my FO's whether they could initiate a decent from MDA with only the ALS in sight. To a man, they all said "YUP! Down to 100 feet above TDZE." Shows a lack of quality IFR training, if you ask me.
 
LowlyPropCapt said:
On another note, this accident prompted me to ask my FO's whether they could initiate a decent from MDA with only the ALS in sight. To a man, they all said "YUP! Down to 100 feet above TDZE." Shows a lack of quality IFR training, if you ask me.
Why? They're absolutely correct:


Section 91.175: Takeoff and landing under IFR.

...
(c) Operation below DH or MDA. Except as provided in paragraph (l) of this section, where a DH or MDA is applicable, no pilot may operate an aircraft ... at any airport below the authorized MDA or continue an approach below the authorized DH unless—
(1) The aircraft is continuously in a position from which a descent to a landing on the intended runway can be made at a normal rate of descent using normal maneuvers...
(3) Except for a Category II or Category III approach... at least one of the following visual references for the intended runway is distinctly visible and identifiable to the pilot:
(i) The approach light system, except that the pilot may not descend below 100 feet above the touchdown zone elevation using the approach lights as a reference unless the red terminating bars or the red side row bars are also distinctly visible and identifiable.
[etc...]
 
LowlyPropCapt said:
On another note, this accident prompted me to ask my FO's whether they could initiate a decent from MDA with only the ALS in sight. To a man, they all said "YUP! Down to 100 feet above TDZE." Shows a lack of quality IFR training, if you ask me.

I'm making some popcorn for this one.

In other news...Heard a stinker that Regions is going to fly out of CLE for CAL whether its express or connection is above my paygrade but either way...sheesh.
 
You can't descend below MDA or DH unless you have the required in flight visibility. That includes if you are using only the ALS.
 
"Fatigue-related training"?!! I have been off for a few days and I have been getting over 8 hours of "fatigue-related training" each night. It's very effective. I recommend it.
 

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