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Plane Answers: NTSB glosses over fatigue in the Colgan crash
As a pilot, I feel the National Transportation Safety Board (NTSB) has failed me. They're tasked to investigate accidents and report on them so the aviation community can hopefully avoid similar mistakes. They also submit recommendations to the FAA for changes they feel will make air travel safer. But I have to question the impartiality of the NTSB after seeing the outcome of the Colgan 3407 investigation.
Yesterday the NTSB came out with a report on the Colgan 3407 accident in Buffalo, New York last year that puts the blame squarely on the captain.
CAPTAIN'S INAPPROPRIATE ACTIONS LED TO CRASH OF FLIGHT 3407 IN CLARENCE CENTER, NEW YORK, NTSB SAYS.
Clearly, the captain reacted to a reduction in airspeed in a way that is contrary to everything we're taught as pilots. But what caused this?
The NTSB sought to find out just why this reasonably experienced captain would respond in such a manner. Training records were examined, toxicology reports were submitted and everything that was said by the crew during the flight was analyzed.
Glossed over in the report was the fact that both the captain and first officer had very little sleep over the previous 24 hours. The NTSB says the captain had 'reduced sleep opportunities' and attempted to rest in the company crew lounge. Apparently the attempts at sleeping there weren't effective since the captain logged on to a company computer at 3:10 in the morning.
The first officer likely had a full day near her home in Seattle before commuting on an 'all-nighter' to her base in Newark. She also tried to get a nap in at the crew lounge in the morning as well.
But one of the investigators in the Colgan accident, Robert Sumwalt refuses to allow for the possibility that fatigue was even a contributing factor in the accident, saying "...just because the crew was fatigued, that doesn't mean it was a factor in their performance."
Incredible.
Numerous studies have concluded that significant sleep deprivation is equivalent to operating while under the influence of alcohol. The British Medical Journal concluded that "after 17–19 hours without sleep, performance on some tests was equivalent or worse than that at a BAC of 0.05%. Response speeds were up to 50% slower for some tests and accuracy measures were significantly poorer than at this level of alcohol. After longer periods without sleep, (up to 28 hours) performance reached levels equivalent to the maximum alcohol dose given to subjects (BAC of 0.10%)."
It's illegal to drive a car in the U.S. with a blood alcohol content at or above 0.08 to 0.10%.
The role of fatigue was mentioned during an NTSB hearing on the Colgan accident. Board chairman Deborah Hersman argued that several issues, including the crew's sleep deficits and the time of day the accident took place, were factors and said that fatigue was present and should be counted as a contributing factor to the crew's performance.
But the view of board member and former USAirways pilot Robert Sumwalt prevailed. He concluded that fatigue wasn't a factor in the accident. It didn't stop them from detailing the role it played in Colgan 3407 (PDF LINK)
So if nicotine is found to cause some cancer, but its role in a person's life expectancy cannot be determined, should we rule it out as a possible factor in a lung cancer death?
The British Medical Journal study concluded that fatigue does affect performance, finding that, "getting less than 6 hours a night can affect coordination, reaction time and judgment" and poses "a very serious risk" to drivers.
It was precisely this reaction time and judgment that are to blame in the Colgan accident. I'm sure if you had asked Captain Renslow about the proper response in a stall, he would have been able to recite the steps verbatim. But that night, he was operating in a fog caused by a lack of quality sleep for the past 36 hours.
And the copilot, Rebecca Shaw, after commuting across the country all night before starting her day, misinterpreted the stall for possible icing conditions that she thought was affecting the tail and so she retracted the flaps during the recovery, exacerbating an already difficult recovery.
Most pilots expected sleep deprivation to play the leading role in the Colgan 3407 accident. The industry has averaged nearly an accident a year for the past twenty years with fatigue listed as a contributing factor. Could this have been the first case where a lack of sleep was actually considered the cause of a crash?
If a lack of sleep can affect affect coordination, reaction time and judgment, how conclusive does fatigue have to be, to be considered a cause in an accident that lists improper reactions and judgement as the main factors?
This time the NTSB isn't even attaching fatigue as a 'contributing factor' in the Colgan accident, even though they went on to say in the report:
All pilots, including those who commute to their home base of operations, have a personal responsibility to wisely manage their off-duty time and effectively use available rest periods so that they can arrive for work fit for duty; the accident pilots did not do so by using an inappropriate facility during their last rest period before the accident flight.
There is no doubt in my mind that, if a BAC of, say, .08% were discovered in the pilots' blood that the NTSB would list this as the cause of the accident and close the case.
I've always been a proponent of the NTSB. They look at human factor trends and educate us on ways to avoid them. As a fresh 20 year-old pilot, I even defended the local NTSB office in a KOMO4 TV news report when their numbers were reduced.
The NTSB has done as much as the FAA to ensure safe flying for the masses. I don't understand why they've been reluctant to properly address the role of fatigue in a number of accident reports.
Perhaps it's because airlines are terrified at the thought of reducing the 16-hour duty day further, which could lead to the recall of a few pilots at each company. Airlines point to a policy that allows a pilot to call in 'fatigued' if they don't feel rested. But we don't allow pilots to self diagnose when they're too drunk to fly-we simply have limits on how much time must pass before they can fly.
So the fatigue policy, while helpful, isn't the only way to ensure pilots are well rested on their next flight. Furthermore, Colgan unilaterally put new restrictions on the use of fatigue calls by its pilots.
But the FAA was confident enough that fatigue was a causal factor in the Colgan Dash 8 accident to start acting before the final NTSB report has been issued. They are working on new limits that will reduce the duty day for pilots, which includes both flight time and the time sitting around in airports between flights.
To appease the industry, the FAA may have to agree to a slight increase in flight time limits-the number of hours a pilot is allowed to be in the air in a day-currently 8 hours for a two-pilot crew-to secure improvements to the current 16 hour duty day for pilots.
I applaud the FAA's decision to take on this cause after their previous 1995 attempt failed. At least the FAA seems to recognize that, for most pilots, it's not the number of hours flown in a day, but it's the amount of time on duty, and during what time of day a pilot is on duty that affects our safety.
Because there's no way we'll solve the fatigue issue if we continue to deny it leads to accidents.
Do you have a question about something related to the pointy end of an airplane? Ask Kent and maybe he'll use it for the next Plane Answer's Plane Answers. Check out his other blog, Cockpit Chronicles and travel along with him at work. Twitter @veryjr
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Reader Comments (Page 2 of 4)
Chuck Feb 7th 2010 9:36PM
Experience and aeronautical decision making skills cannot be taught nor gained in training classes and limited simulator sessions alone. The First Officer on this flight served only as a distraction in the cockpit. The sterile cockpit rule was grossly violated by this crew and the auto-pilot was in use when it should not have been , the flight crew was without doubt suffering from fatigue and in the case of the First Officer fear of her lack of experience. We all know she should not have been in that aircraft with such limited experience. Her words on the transcipt detail the problem with regional airline hiring practices. The Q400 and other large turboprop aircraft of its type are not the appropriate place to build flight time and experience. Why not? Because of the large number of innocent lives of the unaware victims carried in the passenger cabin.The FAA can reduce accidents like this by simply mandating higher pilot experience levels, expecially in the right seat. An experienced, skilled, professional FO is the ultimate cockpit resource available to the Captain, not the auto-pilot.
Ed Samulski Feb 8th 2010 4:34AM
You are totally correct in your comments. The Captain is the ruler of the ship and it is the fault of the captain if anything goes wrong. Having said that I feel the need to address the issue of fatigue and lack of sleep. A good captain would have called in sick, knowing that it might end their career with that airline company. The company that fired such a captain would have been losing a good captain. With todays emphasis on pleasing the stockholder and screwing the passenger this is only going to happen over and over again.
The old school pilots would give up the job rather than kill the passengers, never have thought a moment about it, just tell the airline they needed more sleep, and if the airline could not wrap their minds around that they could just find a new ( unskilled, willing to kill the passengers rather than admit they where tired ) pilot.
Kent Wien Feb 8th 2010 9:25AM
Do you have any reference to the POH autopilot restriction in icing conditions?
I ask only because the NTSB made no mention of it in their report. You'd think they would have addressed that one if true.
http://www.ntsb.gov/Publictn/2010/AAR1001.htm
Brian Feb 7th 2010 9:14PM
As a Commuter Airline Person... I would have come from home the day before my trip and had a decent rest at a crash pad or Hotel..... That makes a difference.... Don't you think ? and I do have a family also.......
Tiger Lil Feb 7th 2010 9:21PM
One thing I do know for sure..it is easier to blame the dead for mistakes andn ot some live government or company official. I don't doubt that the pilots had problems that night due to weather, fatigue and such, but really there were people above them in the pecking order and why not put some of the blame on them as well as the dead. I am sure that there is enough to spread around...even to include mother nature for the bad weather.
Boston Blackie Feb 7th 2010 9:24PM
Easy for us to say what we would do when we have not ever been in the situtation. We will never know the full story, just the part of the story that blames the dead people. What about the powers that be a the airlines, the training and certification people, the government folks that make the official rules and regs? Yes I could also say as you did but not a pilot, and have not been in the fix so who really knows.......not I for sure.
Radar Feb 7th 2010 9:40PM
I really think if the crew/Pilot had enuff legal actual sleep all of this mite not of happened,ud have crew/Pilot AWAKE 100% n sharp at the controls,being aware of da slightest difference...
George D. Feb 8th 2010 8:03AM
OK; None of us listened to the cockpit recordings, during the flight and leading up to the crash. But I believe the FAA when they say that the (young) pilot was too busy chatting with the (young female) 1st officer, to pay attention to what was going on with the plane.
Fatigue? Maybe. But more likely they need to change the policy of who gets teamed together in the cockpit, and pay more attention to the "experience match" than they have in this case.
Oh; As a pilot I have no doubt that this was "pilot error" in this case. Too bad so many had to die because of scrimping on having experienced, professional pilots in the air instead of green, foolish ones. A lot of people would be alive today, but for that factor alone.
Kent Wien Feb 8th 2010 8:14AM
After reading the transcripts, it's apparent that for two minutes prior to the accident, nothing was said at all outside of normal call-outs.
I talked about how 'chit-chat' did NOT doom this flight here:
http://www.gadling.com/2009/05/25/plane-answers-chit-chat-did-not-doom-colgan-flight-3407/
radar Feb 7th 2010 11:47PM
IF i HAD A HEAD COLD i SURELY WOULDNT FLY...AT THE CONTROLS!!!!!...DIDNT LIKE IT DRIVIN BIG TRUCK,WONT DO IT N PLANE EITHER I GOT FLYIN EXP...
Scott b Kaley Feb 7th 2010 10:21PM
Moreover, the individual flight crewmember is responsible for determining his/her fitness for flight. When the captain signs the release, he acknowledges the his and crew's medical fitness for flight. And, Chuck is right, the most important asset available on the flight deck is a good First Officer. It is one of the most under appreciated positions in the business, and one of the most difficult. I have had the honor to fly with many FO's of whom were senior to me that were simply indispensible on the flight deck. Kudos to those unsung heroes in aviation.
tbot Feb 7th 2010 10:41PM
After reading all these post, I can't believe no one bothered to realize the fatigue factor of flying IFR in known icing conditions... Though we may never know what was in the minds of those at the controls, fatigue is a factor that can be controlled and should be addressed as the danger it is...
tom Feb 7th 2010 10:54PM
I can't help but wonder if this tragic outcome could have been completely AVOIDED if the sleepless fatigued pilot had been professional enough to realize his sleep deprivation was a safety issue- and chosen to call in SICK, citing lack of sleep. Sad part is, I have the sick feeling COLGAN would have either reprimanded him, or worse, terminated him. THATS the real story here. COLGAN AIR's clueless heartless treatment of employees subsisting on peons wages and using the threat of termination as a means to push push push.
Sad part is- if this was a driver who'd fallen asleep at the wheel and killed a carload of kids or family, the sleep factor would nail him in court as a vehicular manslaughter charge(s). You don't (can't) blame the car manufacturer or NHTSA. But this pilots lack of sleep and overwork was actually caused by Colgan's relentless flying schedule. Worse, sleepless AND passengers placed in his CARE in a vehicle- a plane, as it were.
COLGAN- and the pilot bear dual accountability in this terrible tragedy. Both.
FoolsGold Feb 8th 2010 2:46AM
It would be proper for a fatigued pilot to call in sick given the awesome responsibility he has for the safety of so many lives but its difficult to impose responsible behavior on people who are making "burger flipper" wages and are subject to the same consequences a "burger flipper" would suffer if he tried to call in sick because he had slept poorly.
It is difficult to quantify the effects of sleep deprivation or determine the quality of sleep. We place the final responsibility in the cockpit and discuss situational awareness but fail to acknowledge that safety margins have been so eroded by fatigue that poor crew resource management and lack of a sterile cockpit are not the cause but are only the final straw.
LLoyd Feb 7th 2010 11:12PM
I got my pilots license back in the 60,s can fly any time anywhere I want to go. And I sure don,t fly when I,m tired or not feeling good. I don,t drink so I don,t have to worry about that. They do come up with good stuff, but sometimes I wonder where their BRAINS are
Muffine Feb 7th 2010 11:45PM
Kent,
You appear to be a fairly young pilot and in all due respect, from your comments have no clue what the NTSB is all about.
As a commercial pilot with over 2.8 million miles and a former air traffic controller, please allow me to explain. The NTSB is famous for blaming pilots which is often quite easy since they are often dead and cannot defend themselves. Their password phrase is "Pilot Error". Over 45 years ago when I started flying, if the wings fell off the airplane - "Pilot Error". If lightning hit the airplane - "Pilot Error". The other thing the NTSB does is leak their theories to the media. While they may claim it will take years to get to the bottom of a crash, they can arrive at a crash site and supposedly tell, even without the black boxes (which are not black) that "there does not appear to have been anything wrong with the aircraft".. Now what does that imply ? "Pilot Error"...
95% of these people in the NTSB have never flown an airplane. It may also alarm you to learn that 98% of all air traffic controllers cannot fly an airplane and have no clue what pilots actually do in the cockpit.
In conclusion, pilots do make errors but the NTSB and the media would like to sensationalize the very rare incidents and occasional crashes to make all pilots look like incompetent bafoons who can't really fly a kite. This undermines the faith that the flying public has to have in these professionals.
One last myth buster. The media is always talking about "little airplanes" and how safe they are not... The fact is, the are talking about general aviation which flys 98% of all the miles flown every day. The military flies about 1/2 of a percent and the airlines fly the remaining 1.5%. General aviation including corporate pilots have the best safety record in the world and many "little planes" are as well equipped as commercial aviation jumbo jets.
Its time to tell the truth about flying !
MM
David Kaufman Feb 7th 2010 11:54PM
I'm a senior pilot, having been flying since 1969. The Cogan crash, like most air crashes, involve multiple things that go wrong. Usually small things which by themselves would not bring down a modern airliner. In this case, the airplane was "slow and low" and neither pilot noticed or did anything about it. The airplane's speed was allowed to slow to the point where a stall occurred, although there was a "stick shaker" on board which should have alerted both pilots that a stall was about to happen. This potential life-saving device was ignored. There is a stall warning alarm that went off which should have caused both pilots to immediately perform basic stall recovery. They didn't. In fact, the captain actually did the opposite of the most basic and elementry manuevers. All of the above begs a simple question-----why?
A stall is not a big deal. Simply stated, an airplane flies because air speed causes wind to flow over and under the wings. This creates lift. Whenever an airplane's speed is reduced, the flow of wind over (and under) the wings is reduced. Fly too slow and the required lift is lost and the airplane stalls. Recovery is simple and straight forward...immediately increase air speed by applying full power and lower the nose of the airplane. It is an absolute instictive manuever. In the Cogan crash, neither pilot increased power and the captain actually started to raise the airplane's nose which would further decrease air speed. Stupid, of course. Incompetent, surely. But still, the question remains....why?
The answer is simple. Both of the flight crew were too tired to fly. Their thinking was way off. Their thought process wasn't working. They were so tired, their brains were at the point where things didn't flow. Neither pilot should have been flying the airplane. Both should have been in bed, asleep. And that is the fault of their compaany, the company's senior flight safety officer, the NTSB and the FAA.
Stick Shaker Feb 7th 2010 11:57PM
While I agree that fatigue was probably a significant contributing factor, I also believe that the FAA and NTSB need to take a hard look at allowing turboprop commuter aircraft to fly into the type of known icing conditions that were encounered on this flight. Conducting additional in-flight icing studies may result in revised operational requirements for turboprop commuter aircraft in known severe icing conditions. I've never been a big fan of cracking ice that has built up on the leading edges of the wings and tail control surfaces with pneumatically activated boots as used on this type of aircraft. Give me a jet any day, because it will have a much greater rate of climb to get through an icing layer during the climbout phase as quickly as possible, heated leading edges of the wings, tail flight control surfaces and engine nacelles for use during flight through the icing layer, the ability to cruise well above mid-altitude icing layers where turboprop aircraft normally operate, and then rapidly decend through an icing layer during the decent phase. Also, I question who approved the FSO for that route given she had no known icing experience in that type of aircraft.
SD Feb 8th 2010 12:00AM
It seems to me that any accident board that looks at the circumstances of this case, and does not put fatigue as a contributing if not primary cause, has to answer then: Why DID this flight crew take such unprofessional actions?
Why aren't pilots restricted to what commercial truck drivers are? They have a lot more lives on the line each flight.
Barry A Clarke Feb 8th 2010 12:07AM
It's not only the pilots who are at risk for sleep deprivation, but also air traffic controllers who work back to back shifts ( 8 on 8 off ) What "IF" you have both a tried pilots and controllers working in the same air space ?