Pilot Fatigue Blamed for Recent Accidents

The U.S. National Transportation Safety Board (NTSB) is urging the

Federal Aviation Administration (FAA) to take steps to manage pilot fatigue,

which the Safety Board cited as factors in two non-fatal regional jet mishaps in

2007 and one incident earlier this year.

The NTSB said a regional jet overran the end of a runway in Michigan last

year because the pilots elected to land on a snowy runway without performing the

required landing distance calculations.

The mishap occurred on April 12 when a Bombardier/Canadair Regional Jet

(CRJ) CL600-2B19 operated as Pinnacle Airline 4712 ran off the departure end of

Runway 28 after landing at Cherry Capital Airport (TVC) Traverse City, MI. There

were no injuries among the 49 passengers and three crewmembers.

NTSB Chairman Mark Rosenker said "piloting an aircraft should not be

guess work. There are rules and guidelines that need to be followed at all

times."

The probable cause determination cited the pilots' decision to land

without performing a landing distance assessment, which was required by company

policy because of runway contamination reported by ground operations personnel

The Safety Board said "this poor decision-making likely reflected the

effects of fatigue produced by a long, demanding duty day, and, for the captain,

the duties associated with check airman functions." Had the pilots made the

required calculations, using current weather information, the results would have

shown that the runway length was inadequate for the contaminated runway

conditions described.

The investigation closely examined pilot fatigue. The accident occurred

after midnight at the end of a day during which the pilots had flown over eight

hours, made five landings, been on duty more than 14 hours, and been awake more

than 16 hours. The Safety Board further notes that the pilots had also flown in

challenging weather conditions throughout the day.

Also contributing to the accident were the Federal Aviation

Administration pilot flight and duty time regulations that permitted the pilots'

long, demanding duty day; and the TVC operations supervisor's use of ambiguous

and unspecific radio phraseology in providing runway braking information.

The Safety Board also discussed an incident this past February in which a

Go! regional jet flight from Honolulu to Hilo, Hawaii, overshot its destination.

Controllers repeatedly attempted to contact the crew for over 18 minutes as it

strayed off course. The passenger jet traveled 26 nautical miles beyond its

intended destination before the flight crew responded to a controller's frantic

calls. NTSB investigators said the two Go! pilots, who were fired, had

unintentionally fallen asleep.

The NTSB previously determined that the probable cause of a Shuttle

America Embraer ERJ- 170 accident earlier this year in Cleveland was the failure

of the flight crew to execute a missed approach when visual cues for the runway

were not distinct and identifiable.

On February 18, Delta Connection Flight 6448, operated by Shuttle

America, was landing on runway 28 at Cleveland-Hopkins International, Cleveland,

Ohio, during snow conditions when it overran the end of the runway, contacted an

instrument landing system (ILS) antenna, and struck an airport perimeter fence.

The airplane's nose gear collapsed during the overrun. There were 71 passengers

and four crewmembers on board. Three passengers received minor injuries.

Contributing to the accident was the crew's decision to descend to the

ILS decision height instead of the localizer (glideslope out) minimum descent

altitude. Because the flight crewmembers were advised that the glideslope was

unusable, they should not have executed the approach to ILS minimums; instead,

they should have set up, briefed, and accomplished the approach to localizer

(glideslope out) minimums.

Also contributing to the accident was the first officer's long landing on

a short contaminated runway and the crew's failure to use reverse thrust and

braking to their maximum effectiveness. When the first officer lost sight of the

runway just before landing, he should have abandoned the landing attempt and

immediately executed a missed approach.

Furthermore, the NTSB said that had the flight crew used the reverse

thrust and braking to their maximum effectiveness, the airplane would likely

have stopped before the end of the runway.

The Board concluded that specific training for pilots in applying maximum

braking and maximum reverse thrust on contaminated runways until a safe stop is

ensured would reinforce the skills needed to successfully accomplish such

landings.

In its final report on the accident investigation, the Safety Board noted

that the captain's fatigue, which affected his ability to effectively plan for

and monitor the approach and landing, contributed to the accident.

By not advising Shuttle America of this fatigue or removing himself from

duty, the captain placed himself, his crew, and his passengers in a dangerous

situation that could have been avoided, the Board reasoned.

Another contributing factor to the accident, the Safety Board said, was

Shuttle America's failure to administer an attendance policy that permitted

flight crewmembers to call in as fatigued without fear of reprisals.

The NTSB believes the policy had limited effectiveness because the

specific details of the policy were not documented in writing and were not

clearly communicated to pilots, especially the administrative implications or

consequences of calling in as fatigued.

As a result of the aforementioned accidents/incidents, the Safety Board

has made two recommendations to the FAA addressing human fatigue within airline

operations.

The Safety Board advised the FAA to develop guidance, based on empirical

and scientific evidence, for operators to establish fatigue management systems,

including information about the content and implementation of these systems.

The Board also drafted an advisement for the U.S. aviation agency to

develop and use methodology that will continually assess the effectiveness of

fatigue management systems implemented by operators, including their ability to

improve sleep and alertness, mitigate performance errors, and prevent incidents

and accidents.

"The Safety Board is extremely concerned about the risk and the

unnecessary danger that is caused by fatigue in aviation," said Rosenker. "We

have seen too many accidents and incidents where human fatigue is a cause or

contributing factor. It is imperative that the FAA take action to reduce human

fatigue in airline operations. Addressing this safety related measure is long

overdue. We must and can correct this serious concern."

The FAA has scheduled a symposium near Washington, DC, June 17-19, that

will look at fatigue issues affecting not only pilots, but also air traffic

controllers, mechanics and flight attendants.

This symposium is the first event sponsored by the FAA that focuses

specifically on managing fatigue in aviation. The symposium will encourage

members of the aviation community to proactively address aviation fatigue

management issues. The three main symposium objectives are: provide the most

current information on fatigue physiology, management, and mitigation

alternatives; develop a common understanding of fatigue issues and identify

challenges; and, forge collaborative alliances to initiate actionable mitigation

strategies. The event is closed to the public and media.