submission - Independent Pilots Association

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Figure I. Crevv Sleep/Wakc Histories
The crew had been offduty up to 2 days pnor to the accident trip and then flora'n
overnight cargo schedules for the two nights prior to the accident, and had been assigned
the accident trip unexpectedly on the morning of August 18, shortly after b€ing released
from duty. The e ctra trip involved segments from Atlanta to Norfolh VA to Guantanamo
Bay back to Atlanta, approximately 12 hrs of flight time in 24 hrs of duty. The figrre
provides information on the fatigue factors: l) the individual crelv members had an acute
sleep loss (i.e., 5,6,8 hrs of daytrme sleep),2) were continuously awake 19,21, and 23.5
hrs prior to the accident, and 3) the accident occu¡red just prior to 5 pm local time during
the afternoonvindow of sleepiness (this did not represent a trme zone change for this US
East coast crew). Upoo inquiry, there were no reported synptoms or signs of a sleep
disorder. Therefore, all three of the rnitial fatigue factors rvere operating in this accident.
Thsre were two principal sources of data available on flight crew performance in the
accidsnt: cocþit voice recorder (CVR) and Captain's testimony at the NTSB public
hearing. There e/sre four performance effects related to fatigue that significantly
contrr-buted to the accident: I ) degraded decision-making, 2) visuaVcognitive fixation, 3)
poor corlrmunication/coordi.tation, and 4) slowed reaction time.
A complete description of flight operations, fatigue factors, performance effects, and
accident investigation findings are available in the frrll NTSB accident report (1). Based on
the findings, the NTSB determined that the probable cause of this accident included the
impaired judgment, decision-making, and flying abilities of the caPtain and flightcrew due
to the effects of fatigue. This was the first time in a major U.S. aviation accident that the
NTSB cited fatigue in the probable cause. As a result of this investigation, the NTSB
recogrmsnded that the Federal Aviation Administration (FAA) expedite the review and
upgrade of Ftight/Duty Time Limitations of the Federal Aviation Regulations to ensure
that they incorporate the results of the latest research on fatigue and sleep issues. The
NTSB reiterated a recommendation to require U.S. air ca¡riers to include, as part of pilot
training, a progrâm to educate pilots about the detrimental effects of fatigue and strategies
trrp ://olias. arc. nasa. gov/publicationVrosekind/GB/GB. Abstract. html r2t27t98