View Full Version : NTSB. Flight Crew Failures (inc. Fatigue), Tallahassee 2002

8th Jun 2004, 17:58

National Transportation Safety Board
Washington, DC 20594

June 8, 2004 SB-04-16


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.

ILS 119.5
8th Jun 2004, 18:07
Perhaps they were fatigued!

Sorry yes they were fatigued. So whats going on. All aircrew and controllers are complaining about the working hours. But nobody is doing anything about it. Therefore more accidents are occurring. I don\'t know why the authorities ignore these posts and stick their heads in the sand. I hope somebody from the media picks up all the information which has been posted lately such as:-
Extended flight crew rostering.
Extended cabin crew rostering.
ATCO\'s always breaking their maximum permitted hours.
Sickness policies.
This is now a very unsafe business we are working in due to financial/commercial pressures on our employers. I am sad to say that I would rather lose my job rather than make a descision to take a day off sick due to fatigue or illness.
In the end the Airlines and Airport Companies will pay the price of having fatigued and unfit people working for them. Look at Linate.
ILS 119.5

9th Jun 2004, 02:17
It is often said that a successful landing follows a successful approach, so...if the crew were indeed fatigued, why did they not request an ILS approach to a different runway, for safety considerations?
Pressure from management perhaps, ie; on time...every time?

'Tis the COMMANDERS responsibility to assure safe and proper operation of the aircraft, ie; the buck stops with HIM (or her), not others.

And, it will always remain thus.
So, act accordingly....period.:(

Rocket science it ain't.:ooh:

9th Jun 2004, 07:15
Good ol' 411A, as black and white as ever.

Surely one of the symptoms of fatigue is poor decision making QED.Sorry yes they were fatigued. So whats going on. All aircrew and controllers are complaining about the working hours. But nobody is doing anything about it Oh yes they are, 119.5, the EU are proposing to increaseFTLs:uhoh:

9th Jun 2004, 07:16
'why did they not request an ILS approach to a different runway, for safety considerations?'
That surely is the point! Fatigue affects the ability to make rational decisions as well as causing physiological problems.

9th Jun 2004, 07:34

Yes, fatigue surely does cause poor decisions.
But pilots, generally being the superior folks that we are :rolleyes:, generally make up for this by engaging the automatics, or at least request the best approach, under the circumstances.
At least that surely is what they are paid the rather big bucks for...:}

And, if not, maybe the beancounters are right after all.:{

9th Jun 2004, 22:03
The fact is 411A, that according to studies produced by several reliable scientific sources, the symptoms of fatigue are quite like the symptoms of inebriation, and are just as insidious. Your level of performance goes down at the same time your ability to self monitor and critique does.
You do not recognise that you are doing sh*te, on the contrary you feel that things are all hunky dory, hence no need to change the plan, all is "looking good" until the crunch.

9th Jun 2004, 22:04
Everything is soooo easy in hindsight isn't it.:hmm:

'At least that surely is what they are paid the rather big bucks for... '

So why are managers paid big bucks then ?

Is it to make decisions like employing F/O's with a colour deficiencies ? Or perhaps it is to squeeze every last drop of hours out of the legal system until there's an accident like this.
I bet the word's "but it is legal" were mentioned at some stage or another.

Perhaps they should have refused to fly due to fatigue - then they could have been said to have made a professional decision to justify there 'rather big bucks', of-course I'm sure they would have been totally supported by the management for making this decision - Right ? :yuk:

9th Jun 2004, 22:41
It's with examples like this that all EU Pilots should be sending letters to "our" representatives in European Parlament. I believe that we are on one side of the fence and the beancounters on the other. It's up to us that they don't have a matchpoint.

10th Jun 2004, 04:14
I am currently on the FDX three-holer, and this may be interesting: following TLH, stable requirements on final were raised to 1000 AGL; also, if operating into an uncontrolled field (as TLH was), crews are required to use instrument approaches, if available. Yep, the barn door's closed after the horse is out, but at least this one won't happen again....

phoenix son
10th Jun 2004, 07:27
Yep, the barn door's closed after the horse is out, but at least this one won't happen again....

A dangerous line of thought??? It may now be LESS likely to happen, and it's good to see that some positive action has come as a result of TLH, but new legislation doesn't automatically make flying safer...The training and professionalism of you guys up there makes that happen...


10th Jun 2004, 08:27
Well if the Simpson proposals are adopted in Europe, We will all be Fatigued!

However Don't Worry chaps My member of Parliment says that the proposals are only the maximum above which pilots may not work. Crewing will not roster to that of course (NOT!)

For those who have not seen the draft proposal, it would seem that a double crew can be on duty in excess of 20 hrs at night!
Before anyone says well you have bunks. Wrong! sit in the cabin with the pax it means.:mad:

A and C
10th Jun 2004, 08:44
I would sure like to go on a CRM course with 411A , now that would be interesting !.

10th Jun 2004, 15:01
You can be sure, A and C, that those that have gone to a CRM course with yours truly have received an earfull.
Take 'fatigue' for example.
I have personally done nearly as much short haul as long haul flying over the last 35 years, and can tell you for a fact that the guys I have flown with (with very few exceptions) who claimed 'fatigue' had simply not been properly rested prior to duty.
And whose fault is this?
Well, it sure as hell ain't 'management', especially when adequate hours off duty have been provided, and the crew member has not used them to the best advantage.

IF crew don't use the 'rest' hours to actually rest, they have absolutely no one else to blame but themselves...period.

10th Jun 2004, 16:02

You really are a pompous ass. Obviously one of those odd types who can adapt to ever changing patterns and sleep on demand.

Most of us are not like that, and trying to fit what is, after all, our real lives away from work causes fatigue if working routines are in constant upheval.

I'd sure hate to sit next to you unless my ear defenders were bloody effective!:yuk:

10th Jun 2004, 16:17

"IF crew don't use the 'rest' hours to actually rest, they have absolutely no one else to blame but themselves...period."

If you really feel that it shows your 35yrs of experience hasn't been in the commercial world that I've spent 30yrs in. A comment like that shows absolutely no understanding of physiology or rostering practices, you'd fail the JAA licence on CRM but you would get a job in crewing!

11th Jun 2004, 04:23

Adequate rest?
A certain asian airline that regularly flies to NRT, crew members proping up the bar at the Truck until 1am, with a 7:30am transport, is hardly making use of 'adequate rest'.
Sound familiar?

If crew members want management to listen, they had better be prepared to show cause just why their off duty time at nightstops is not put to better use.

11th Jun 2004, 05:05

A specific incident with a specific crew hardly entitles you to make broad generalisations about all crews.

11th Jun 2004, 05:34
Oh, come now, BusyB.:rolleyes:

Not simply one crew either, as i'm sure you well know.
Yes, crew do get fatigued, and mistakes are made, but I still maintain that some crew do not put the nightstop hours to proper use, ie: the use for which they were intended.

11th Jun 2004, 06:36
Whilst 411A is undoubtedly correct about what some pilots consider to be 'restful activities', the blunt facts are that crew rostering practices are run by a soulless computer which will aim to squeeze every last minute out of them which it legally can.

And yes, the perception of one's performance does indeed go rapidly downhill with the insidious onset of fatigue.

Mind you, 411A, there are also those wet-pants who whine about 'human factors' or 'CRM factors' whenever they're criticised or given direct analysis of their failings - whereas in actual fact they were just [email protected]!

11th Jun 2004, 07:01

I've no problems with the qualification "some".

11th Jun 2004, 09:32

June 10, 2004

Safety Recommendations A-04-46 and -47

The National Transportation Safety Board recommends that the
Federal Aviation Administration:

Conduct research to determine the effectiveness of each of
the current Federal Aviation Administration-approved color
vision test protocols (including the color signal light
test) at effectively screening out pilot applicants with
color vision deficiencies that could impair their ability to
perform color-related critical aviation tasks including (but
not limited to) correct interpretation of glideslope
information and in-cockpit displays that use color to convey
information. The research should take into account the time
typically available to perform each task, particularly under
emergency conditions, and the potential effect of mild
hypoxia (as might occur at typical cabin altitudes) on color
vision deficiencies. (A-04-46)

Based on the results of the research requested in Safety
Recommendation A-04-46, develop a standard battery of tests
to be performed at least once on each applicant for a Class
1 or 2 medical certificate that would prevent applicants
with color vision deficiencies that could impair their
ability to perform color-related critical aviation tasks
from being certificated without limitations.

ILS 119.5
11th Jun 2004, 18:08
Your comments are aimed at crew nightstopping and not at rest days outside of work. I agree that rest should be attained to the best whilst away, and I am not one for staying up before returning home. However, rest days between duties are less now than when I first joined the game. We are pushed harder than we ever used to be and we do get tired. I am not one for flying tired, but maybe do sometimes. My point is that we are being pushed to our limits at the cost of safety. If the flying passenger was told that we were being pushed in this way then they would not fly. Please do not take the hard man attitude and say what you have done. Our job is to take "customers" from a to b without them having any doubt of our ability to do this.
The problem we are talking about rests with our employers, which must be sorted out. I am very worried that there will will be an incident in the near future due to fatigue. Unfortunately if it is fatal then the public will not find out. However, if the flight deck survive and say that they were tired then rostering will change. Hopefully, BALPA will take all this on board. Not forgetting the ATCO's on the ground, the same measures should be applied to them.
ILS 119.5

12th Jun 2004, 12:08
Mr. Simpson is proposing THE REDUCTION of max hours the pilots are allowed to work in Pizzaland (Italy)......

13th Jun 2004, 10:06
Well, as a pax, I would *much* prefer the flight crew to be "bright eyed and bushy-tailed" for the flight. As we are all human, we all know the effects of fatigue.

I would also extend this issue (fatigue) to truck drivers on the highways - too often I had to respond to a - ahhh - RA from TCAS :p - about switching lanes because of a drifting and tired truck driver.

This seems to be an ongoing issue unfortunately.

13th Jun 2004, 19:57
Our SOP on international flights has "duty" time limits of 16 hours,...but can go to "18 hours" ...but only if due to maintenance or ATC delays. ...As if somehow one would be less tired if you encountered a maintenance delay as opposed to a loading delay of sorts.

A reasonable simple solution the FAA ought to consider when adopting new international flight and duty time limitations:
1. Daily flight time(s) exceeding 8 hours could only consist of a single non-stop flight; and
2. Scheduled duty time(s) exceeding 12 hours could only consist of a single non-stop flight.

This reasonable restriction would preclude crews who have operated multi-stop flights from operating yet another leg after 8 hours of flight time, or after 12 hours of duty time.

What reasonable pax would want to embark on a flight knowing that the crew had already been on duty 12 hours...?:{

14th Jun 2004, 03:45
Recall with one south asian airline where I worked, operated a multi-stop route to LHR (15 hours flying) and was 'supposed' to have two days in hotac.
So far so good.
Then, after six hours in said hotac, BA (handling agent) calls and says...'transport in four hours, just thought you would like to know.'

Not liking the sound of this, called back and advised BA that they should tell the company that I will consider myself on annual 42 days leave now, and to please send a ticket LHR-LAX-LHR forthwith.
Twenty minutes later thay called again and said...'sorry for bothering you Captain, your rostered flight has been cancelled and your Ops Mgr would like to know just how much rest you desire, whatever you say is fine with him.'

An absolutely true story.

This particular airline was quite pleasant to work for, generally, but also had great difficulity planning beyond next Tuesday.
Come to think of it, most airlines are this way.
Wonder why?:E