NTSB PRESS RELEASE.
National Transportation Safety Board
Washington, DC 20594
June 8, 2004 SB-04-16
NTSB SAYS FLIGHT CREW FAILURES LED TO
FEDEX LANDING CRASH IN TALLAHASSEE
WASHINGTON, D.C. - A FedEx Boeing 727 crashed on landing in
Tallahassee, Florida in 2002 because of flight crew
performance failures, the National Transportation Safety
Board has found.
On July 26, 2002, FedEx flight 1478, a Boeing 727-232F
(N497FE) struck trees on final approach to Tallahassee
Regional Airport at 5:37 a.m. The flight had originated in
Memphis, Tennessee. The captain, first officer and flight
engineer were seriously injured, and the airplane was
destroyed by impact and resulting fire.
In its final report adopted today, the Safety Board
said that the probable cause of the accident was the failure
of the captain and first officer to establish and maintain a
proper glidepath during the night visual approach to
landing. Contributing to the accident was a combination of
the captain's and first officer's fatigue and failure to
adhere to company flight procedures, the captain's and
flight engineer's failure to monitor the approach, and the
first officer's color vision deficiency.
Although runway 09 did not have an Instrument Landing
System, it was equipped with a Precision Approach Path
Indicator, a series of lights that aid flight crews in
determining if they are on a proper glide slope to the
runway, too high or too low. The Board found that the first
officer, who was the flying pilot, had a history of color
vision deficiency, for which he had a waiver from the
Federal Aviation Administration. Extensive post-crash
evaluation of the first officer's color vision concluded
that this deficiency would likely have interfered with his
ability to discern the differences between the white and red
lights that give the pilots their altitude clues.
The Board noted that the current process of color
vision screening required for pilots will not detect certain
severe color vision deficiencies. The two recommendations
the Board issued in this report ask the FAA to determine the
operational effectiveness of each of the color vision test
protocols it currently allows and, then, establish a
standard battery of color vision tests to be administered to
all commercial pilots.
The Board's report cites a series of performance
deficiencies exhibited by the flight crew during the
approach, including continuing their unstabilized approach
below 500 feet rather than executing a go-around, and errors
by the captain that suggest he was not fully alert. The
captain indicated after the accident that he had not slept
well the two nights before the accident due to
responsibilities at home, and the first officer reported
that he had been having difficulty adjusting his sleep cycle
to the reserve-duty schedule that he had recently been
placed on.
This is the latest Safety Board investigation in which
it has cited fatigue as a factor. Fatigue in transportation
operations has been on the NTSB's list of most wanted safety
recommendations since the inception of the list in 1990.
Since that time, little progress has been made to revise the
hours-of-service regulations that would incorporate the
results of the latest research on fatigue and sleep issues.
The Board's latest recommendations to the FAA on this
subject are classified "Open - Unacceptable Response."
A summary of the accident investigation report,
including the findings, probable cause and safety
recommendations, can be found on the Publications page of
the Board's web site,
www.ntsb.gov. The complete report
will be available in about a month.