submission - Independent Pilots Association

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Crew fatigue factors in the Guantanamo Bay aviation accident
Mark R. Rosekind, PhD.
NASA Ames Research Center
Kevin B. GregorY, Donna L. lvfiller
Sterling Software
Etizabeth L. Co
Sæ Jose State Universþ Fou¡d¡tion
J. Vrctor l-ebacqa PtiD.
NASA Ames Research Center
Malcolm Brenner
National Transportation Safety Boa¡d
, f'me, ¿ military contract fltght crashed while
on, Guantanamo Bay, Cuba. The airplane, a
'impact forces and fire. The three flight
National Transportation Safetv Board
(NTSB), an indøpendent agenry of the united States goverDment, conducted an official
ùvestrganon to áetermine the cause of the accident and to make recommendations to
pre!'enr a recufrence ( I ). At the request of the NTSB, the NASA Ames Fangue
Countermeasures program anzly?ßd the crerr fatigue factors to examine ther¡ potentral
role in the accideot. Tbr." principal sources of information *'ere made available from the
\TSB accident inrestigation to NASA Ames for analysis: 1) Hrman Perforrnance
Investigator's Factual RePort,
2¡ Opeiauons Group Chairman's Factual Report, and 3) Flight 808 Crew Statements.
Based on scientific data r.elated to sleep and crcadian rh¡hms, the NASA Ames Fangue
Countermeasures program idcntified three core physiological factors to ex¡mirre when
investiganng the role óf f"tigue in an incident or accidsnt. These factors have zubsequently
been eipanã.¿ to four, to explicitly include a factor examined but not previously' reported-
The for¡¡ fatigue factors 1s sxemine in rncident/accident investigatiorls are: l) acute sleep
loss/cumulative sleep debt, 2) continuous hor¡rs of wakefulness, 3) time of dayrç¡cadian
effects, and 4) pr.r"o* of sleep disorder. These factors were e¡amined and the
sleep/wake histories for the flight crew prior to the accident are presented in Figure l.
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