submission - Independent Pilots Association

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Figwe I. CreY' Sleep/Takc Histories
The crew hed been offdqy up to 2 days priot to the accident trip and then flown
overnigbt cargo schedules for the two nights ptiot to the accident, and had been assigned
the accident trip uneryectedly on the morning of August 18, shortly after being released
from duty. The erctra trip involved segments from Atlanta to Norfolk, VA to Gr¡antan¡mo
Bay back to Atlanta, approximately 12 hrs of fl.ight time in 24 hrs of duty. The figure
ptór.id"t information on the fatigue factors: I ) the individual crew members had an acute
il""p loss (i.e., 5,6,8 hrs of daytme sleep). 2) were continuousl¡' awake 19.21, and 23.5
hrs prior to the accident, and 3) the accident occured just prior to 5 pm local time during
the afternoonwindow of sleepiness (this did not rePresent a time zone change for this US
E¿st coast crew). Upon inquiry, there were no rsPorted symptoms or signs of a sleep
d.isorder. Therefore, all three of the initial fatigue factors were operating in this accident.
There were two principal sources of data available on fhgbt crew perfonnance in the
accidsnt: cocþit voice recorder (CVR) and Captain's testimony at the NTSB publ-rc
hearing. There were four performance effects related to fatigue that significantly
contrr-buted to the accident: I ) degraded decision-making, 2) visuaVcognrtive fixation, 3)
poor çps1¡armication/coordittation, and 4) slowed reaction time.
A complete description of flight operations, fatigue factors, perfonnance effects, a¡ld
accident investigation findings a¡e available in the full NTSB accident report ( I ). Based on
the findinp, the NTSB determined that the probable cause of tlus accident included the
impaired judgment decision-making, and flying abilities of the captain and flightcrew due
to the effects of fatigue. This was the fi¡st 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
recourmended that the Federal Aviation Administration (FAA) expedite the revier*'and
upgrade of Ftight/Duty Time Limitations of the Federal Aviation Regulations to ensure
that they incorporate the results of the latest resea¡ch on fatigue and sleep issues. The
NTSB reiterated a recorrrmendation to require U.S. air ca¡riers to include, as part of pilot
training a prognm to educate pilots about the detrimental effects of fatigue and strategies
http://oli¡s.arc.n¡ìs¿t.gov/publicationJrosekind/GB/GB.Abstract.html
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