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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 3 of 4)
Bill G. Feb 8th 2010 12:20AM
David Kaufman,
Show me a pilot or even two who are fatigued and can ignore the "stick shaker" and that screaming stall warning and I'll show you two pilots who are not conscious. After flying for fifty years, I'm not buying into any of this. The NTSB and what little information we have would indicate that the Captain did not know and automatically initiate adding power and lowering the nose to avoid a stall. Hogwash ! As a flight instructor, I've trained thousands of pilots to fly and that becomes so instinctive, you could be almost unconscious and still perform that simple procedure.
My point is, there is something missing here. There is something else in the equation that we do not know and the NTSB has not found it or is not telling us everything they know. Yes, there is a glaring deficiency on the part of the FO that she did not have serious ice experience and ice is one of the worst demons out there, but to have an experienced Captain and FO, even though fatigued not recover from an impending stall just will not wash. And to the writer who believes turboprop airplanes cannot handle ice like pure jets, hogwash. I'll take the turboprop every time if for no other reason that I can usually see the props and wings, which is not always possible on a swept wing jet.
MM
Rob Feb 8th 2010 12:21AM
The fault lies with the airline for putting an unqualified pilot in the Captain's seat. This guy had less than 250 hours in that particular aircraft, and had failed check flights. He should have never been in charge of an aircraft carrying passengers.
Stephanie Feb 8th 2010 11:40AM
I agree that the airlines and the FAA should re-consider duty time limits for pilots and flight crews. However, the pilots, too, should take some responsibility for arriving for work rested and refreshed. If they have already flown all night from their homes on the west coast in order to arrive on time for work on the east coast, it is evident they will be awake very long periods of time before getting off duty. Most people try to live within reasonable commuting distance of their base of operations. So maybe the time limits should be refigured to include the time pilots actually spend in the air prior to reporting to work. If they did, pilots would necessarily choose to relocate closer to their bases of operation.
Kent Feb 8th 2010 1:45AM
Maybe the FAA/NTSB need to put in some rule that pilots must live within a certain distance of their crew bases. I hear stories of how long some pilots and flight attendants have to commute, and it can't be good for both flying and family life.
A friend of mine flies for a major carrier with hubs in Chicago and Miami. He lives within 45 minutes of O'Hare by car. When the amount of 757/767 domestic flying was reduced at ORD, he had to commute to MIA. Fortunately, his trips out of MIA started between 6 am and 9am, so he was flying down the afternoon before and spending the night in a hotel near MIA. But he switched to 737 domestic out of ORD after 4 months because of the extra time away from home, the extra cost of hotels in MIA, and getting tired of sitting in the jump seat between ORD and MIA.
When AA was absorbing TWA, I once flew ORD to Las Vegas with a connection in St. Louis. My flight arrived at McCarren at midnight. On the train from Concourse D to the terminal, I overhead the captain talking to some other passengers. He commuted from Tampa to STL, then flew a Houston turn before the 10pm CT depature to LAS. He got up at 3 am to catch the early TWA flight to STL.
Accounting for the time change, he had been awake for 24 hours! Assuming that his 16 hours ended at 3am PT, his day could have started as early as 1pm CT. If he lived in the St. Louis area, he could have slept until a very reasonable 7am, had breakfast, read the paper, checked on his trip at home, and left his house at 10:30 or 11:00.
Even getting up at 7 am, I'm not that alert at 10 pm. My typing stinks. My handwriting has gone south. Imagine trying to fly an airplane at 10 pm, when you got up 4 hours earlier.
Steve L. Feb 8th 2010 2:05AM
I wasn't a pilot, but I drove a bus for 28 years. Believe me when I say fatigue is a major problem not just for pilots but anyone whose job calls for erratic or long hours under boreing conditions such as just having to sit and watch the sky or road go by. If you work on call it is even worse. I have worked for 14 plus hours with little or no sleep (never driving over 10 hours total). I worked for Greyhound and you you were expected to be rested any time you were called for work, a joke if you worked extra (on call) you could come in at 1pm and be called in 8 hours to work again, plus 2 hours for prep and travel to work. You could take off if others were available, otherwise you had to take off sick under threat of having to see a doctor. If you took off every time you didn't have 8 hours rest (sleep) you would starve to death (lack of wages) or eventually be fired. If you worked for some small outfit they were very lax in going by DOT regulations. Anyone remember the Mothers Day bus crash in New Orleans Many years ago? That driver was in very poor health, used drugs and had actually been released from a hospital emergency room less than six hours before he had to report for work. As a result of this incident the DOT did crack down, but other than medical certification, much stills goes on that the DOT does little to do checks needed to keeps the small mom and pop operations in line. The bigger operations are not always in line either. I can say that when I worked at Greyhound they were strict about following hours of service, but that still didn't mean a driver was always well rested up..........
Steve Feb 8th 2010 3:28AM
Ok, let's say for a moment that the author is correct (although he is not) and fatigue caused the accident. The pilots were 100% responsible for their level of fatigue! We still end up with a pilot error accident.
The author states "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." This statement is factually incorrect. Author needs to review the applicable Federal aviation regulatons.
There are too many misleading interpretations in this article to list.
Shame on AOL for displaying the link for the public to see this analysis by a novice.
SL
ATP
Seattle, WA
John Feb 8th 2010 7:03AM
Shame on AOL for allowing YOU to post!
Kent Wien Feb 8th 2010 8:12AM
Steve,
Airlines point to their fatigue policy when arguing that no further changes are needed to the flight time/duty time regulations.
But we have restrictions on how many hours must pass between taking a drink and flying an airplane (8 hours). We don't simply leave it up to pilots to have a beer an hour prior to flight and then say they don't feel drunk.
Last I checked, there were no such standards regarding how much sleep we have prior to a flight. There's only a requirement for 8 hours off in a 24 hour period. But we could be commuting on the all-nighter (as the FO did) prior to starting a trip without restriction.
If I wasn't clear enough in my analogy, then I apologize.
Dave Feb 8th 2010 3:58PM
Steve,
Your ignorance is only surpassed by your arrogance. Have you ever flown a complex aircraft while fatigued? I know the answer because if you had you would not make such a useless response. The point is fatigue is just as dangerous as drugs and alcohol. And while there are very exact limits on alcohol and flying, fatigue is much more subjective, and therefore maybe even more dangerous.
You are probably an expert in everything you have never actually done.
Jim Feb 8th 2010 3:53AM
If I remember correctly this pilot had failed required tests two previous times (possibly three), and lied about it on his application. He had a 24 year old female co-pilot and he was not paying attention. The voice recorder had them talking about the weather and conditions. The co-pilot exclaimed she would be really nervous if she had to bring the plane in under those conditions. The pilot shrugged it off and was very casual and cocky about everything. If I remember he was in his mid-forties. I believe he was thinking about social plans with her later on rather than concentrating on flying the plane. Sorry, it was the pilot's fault.
Gilbert Feb 8th 2010 5:15AM
Wasnt that type plane banned at one time to flying in the north after a crash in indiana because of iceing of the wings.. ??
ZF Feb 15th 2010 2:30AM
No, different airplane. Nice try.....
nomoretoyota Feb 8th 2010 8:55AM
This plane almost fell on my house. I do blame the pilot and the little girl co pilot.
If this bozo can't figure out that in order to increase air speed is to nose down and use gravity to correct the problem that blondie forgot to look at the airspeed gauge, sleepyness has nothing to do with it.
Allin Feb 8th 2010 9:30AM
I have read some of the headlines about this tragedy, and it troubles me when we stray away from the evidence and begin to question the personal integrity of the people. I knew Marvin personally, when he and I both worked at Publix. He was a good person, loved his family, and did good work. Marvin was part time. It was one of a few jobs he had, but he didn't just do the minimum. He cared.
Maybe he did not have the corresponding training to the plane he was flying. Fatigue could have been a factor. Marvin never came off to me as someone who would use being tired as an excuse to miss work.
Let's find out what we can from this, learn from it, and impliment what we can to prevent something like this from happening again.
sam Feb 8th 2010 10:05AM
Whether or not they had enough sleep should not come into play, as neither was qualified to be in the cockpit. In fact, civil suits against the pilots,and the airline, will soon impact the airline. Tthus the need to do a complete background investigation before hiring new pilots.
I agree with the editorial about lack of sleep, but this is the wrong case to prove a point, as neither pilot should have been licensed to fly a commercail plane.
John Simpson Feb 8th 2010 10:10AM
I'm not a pilot, I'm a truck driver. My rig has a computer which tells my dispatcher how many hours I've been rolling. I am required by law to stop after 10 hours of driving and rest. If I drive and load or unload my truck and this takes 15 hours to complete in a 24 hour period, I am required to take 24 hours off by law. My dispatcher knows how long I have been working, and has control through the computer in my truck to force me to stop and rest. My logs are checked by the company and by each states DOT every time I hit a manditory scale. I seldom get home for more then 2 days a month, but I am well rested, and if I have any measureable amount of alcohal in my blood or breath I can be put out of service for 24 hours, and loose my job.
How is it you pilots aren't kept up to the same standards as I am?
Jeff K. Feb 8th 2010 10:31AM
The mandatory 8 hrs off or "rest" is just the airlines way of covering their behind. I'm sure there are no rules that state those 8 hrs MUST be spent sleeping rather than commuting or doing paper work. I feel bad for the pax and the pilots of that flight as I feel they were victims of the airline and its way of milking each pilot's value to the extreme. Saying that the its solely the Cap and FO fault is a little closed minded. Like what has been said before, fatigue is dangerous, no doubt in my mind that this was a contributing factor. I'm not saying it was the only cause but definitely not one to be overlooked and ruled out like the NTSB did.
danno Feb 8th 2010 10:48AM
They really are a joke..and in reality have not solved any air crash..merly given there opinion as too the probable cause..waste of time and money..
steve Feb 8th 2010 11:01AM
it is the crews responsibility to be fit and ready when going on duty. I agree this may be dificult, if you decide you want to commute 3 thousand miles to work. They are given time off for rest and that is what they are suppossed to be doing. If you want to work for an airline, and your based in newark that is where you need to live. This crew showed up for work fatigued, and if they told crew schedueling that they were too fatigued to fly, then the would have been released from duty with no questions asked. regardless of what this 20 year old pilot says, the crew is responsible for this accident. This is from a 65 year old retired pilot
George D. Feb 8th 2010 11:23AM
The last two minutes were apparently not the critical time to be serious and attentive. While the ice was forming and the counter-measures could have been taken to protect the plane and the passengers, is when the beginning of the end started. That certainly was not in the last two minutes of the flight.
As many have already commented, there were no doubt many factors involved. All I'm saying is that the most important failing was the lack of experience, lack of attention, and poor judgement that doomed this flight.