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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
Gallery: Ten pilots you don't want in your cockpit
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Reader Comments (Page 4 of 4)
Jack Feb 8th 2010 11:57AM
They have limits as to how long a long haul truck driver can go with out resting. That is because it becomes easy to make mistakes when you are tired. Have you ever tried to drive a long distance with out sleep, feeling your self drifting out of the lane, and your eyes start to close. That is what happenes when you go with out sleep and try to push it.
I would not want to be on a plane when the polit had that problem. We are now cramming too many people into too few air craft and pushing the flight crew to the limit.
What we have done is forget that the best way to travel is on the ground, and we needed to build high speed rail roads. But instead we have built biger and biger air ports and air planes. In Europe they use the high speed trains. So don't have a shortage of quilified polits.
How many times have the public waited for a flight because there was not crew available. I did the other week, almost 10 hours. This week on the east coast it will be worse, so many planes and crew not where they are suppose to be.
Just think if we had high speed train, they would be moving people today, not tomorrow.
molly Feb 8th 2010 11:59AM
PLEASE MAKE YOUR COMMENTS TO CONGRESS, AND MAKE YOUR COMMENTS PUBLIC. THERE ARE SO MANY IMPORTANT COMMENTS HERE THAT SHOULD BE PART OF POLICY MAKING AT THE FEDERAL LEVEL, AND WHICH SHOULD BE CONSIDERED BY EACH AIRLINE. SO, PLEASE MAKE YOUR COMMENTS PUBLIIC, EITHER INDIVIDUALLY OR THROUGH YOUR ORGANIZATIONS. THANK YOU.
Jordan Feb 8th 2010 10:09PM
Wow really? Yeah, i would love to see one of them operate a multiengine, complex aircraft on an IFR flight plan and shoot an IFR approach at night with no sleep and let them see if flight performance is not affected. Number one thing i was taught in flight training is of the primary priorities as far as flight safety i concerned. I'm sure pilots have heard of the "I'm Safe" checklist, a mental checklist that places flight safety on the health of the pilot in command. I assure you that if you have had little to no sleep, it is difficult to even pilot an aircraft under Visual Flight Rules.
I will admit this though. It is inherently the fault of the pilot in command if they are not willing to admit that they are unfit to fly. I think it is good that the FAA has put restrictions in place to accommodate this. However, it is still the duty of the pilot make the call, but don't think for a second that flight performance is not affected by lack of sleep.
As for other comments, it is completely understandable to be stressed after a work week of 40 hours or so. Be aware that most 40 hour work weeks do not consist of a consistent work environment where hundreds of people's lives are in your hands on a regular basis (unless you are a doctor).
Scott b Kaley Feb 8th 2010 12:40PM
Kent,
While I do not currently have a DHC-8 400Q POH to make specific reference to a page number, this excerpt from NTSB alludes to the aforementioned reference about autopilot usage in icing conditions: "Steve Chealander of the National Transportation Safety Board says Colgan Air recommends pilots fly manually in icy conditions. Pilots are required to do so in severe ice. The pilot of doomed plane reported "significant" ice on his wings and windshield just before crashing Thursday night." Reference http://www.vidi.us/tag/Q400
Additionally, I have never delved into the NTSB investigation details until now. Again, upon viewing the NTSB animation, it becomes readily apparent that lack of experience is a huge contributing factor. The "boots" are never utilized manually prior to a configuration change, after the configuration change the throttles remain unchanged even with the weight increase associated with icing conditions and the extension of the gear. With the increased drag associated with a contaminated wing and subsequent gear extension, obviously, the power must be adjusted to maintain airspeed. And, it never happens. With the onset of the stall, a unilateral decision is made to raise the flaps further exacerbating the air foils stalled condition, and perhaps, making any recovery attempt beyond the realm of possibilities. Automation does not absolve the flight crew from its responsibility to monitor adverse meteorological conditions, such as icing, monitoring flight path and airspeed, and compliance with aircraft limitations. http://www.youtube.com/watch?v=lxywEE1kK6I
Moreover, the individual flight crewmember is responsible for determining his/her fitness for flight. When the captain signs the release, he acknowledges he and his crew are medically fit for flight under FAR part 67. And, Chuck is correct, the most important asset available on the flight deck is a good First Officer. It is one of the most underappreciated positions in the business, and one of the most difficult. I have had the honor to fly with FO's, many of whom were senior to me, that were simply indispensible on the flight deck. Kudos to those unsung heroes in aviation.
Pilot pushing has been a problem as long as there has been flying to be done. When I was a commuter pilot for USAir Express, the company decided that Saturday's flight schedule would be a single flight crew starting at 5:00 AM with 13 legs, no more than 25 minutes between segments, and a 14 hour duty day. The response from the pilots was that this schedule would be problematic. It was. It became standard practice to call dispatch, advise them that the crew was not medically fit to fly and taking a break. We would advise them when we were ready to depart. Any complaints or discussion on the company's part further delayed any departure. And, then there was the line "Are you asking me to intentionally violate FAR 67, medical fitness for flight?" interrogative. The schedule was changed to accommodate a break for the flight crew.
There are times in one's aviation career assessments must be made that are contrary to the company's demands. Just because a flight is "legal" doesn't mean its undertaking is good judgment. Good intentions do not make bad ideas any better. This is where the "old school" pilots exhibit leadership and take a stand and say to Hell with the company's threats and intimidation. But, always document these occurrances and report them to the FAA safety hotline, which, incidentally, always requires an investigation. But, I have found that before any safety of flight issues make it to the point of becoming something that needs to be reported, most issues are resolved to the mutual benefit of the passengers, the company, and the crew.
Tailwinds and happy flying
MB Feb 8th 2010 12:46PM
Yes Kent....outstanding article! Thank you for writing it and pointing out how willing the NTSB is to turn a blind eye to public safety by addressing a very relevent issue of fatigue. Whenever they get an opportunity to blame it all on the pilot and/or crew, the NTSB always seems to take that option. I guess from where they are sitting, there is no one to dispute it since the times they choose to play that card are when it has cost the lives of the people on board...including the pilot and crew, as in this case. Having been a former airline employee, it makes me angry that the industry is represented from a safety standpoint by people who will alwyas take the easy out, instead of doing the right thing. It reflects poorly on the industry and on everyone who doesn't insist that they do better.
David Feb 8th 2010 1:03PM
I am appalled at the way our pilots are being treated in this day and age! When I hear of First Officers having to commute thousands of miles to pick up their leg of a flight and be paid less than a trash truck driver, (no offense but trash truck drivers don't hold hundreds of people's lives in their hands,) it astonishes me. But then again, why should it? It's all part of that carefree chase of the almighty dollar! Isn't that what life's all about? Not safety, care for others, quality, pride in the job....no, it's corporate greed at the expense of human life.
It's time we respected our pilots and what they do, paid them a proper equitable salary and ensured their rest so we can all fly in safety!
CO777CAPT Feb 9th 2010 4:25PM
Todays airline pilot new hires think that if they get 350 hours of time, they are ready to fly the heavy metal. Unfortunately, as we have seen time and time again, the EXPERIENCE IS GOTTEN BEFORE YOU GET INTO YOUR JET JOB. IT IS THE REWARD FOR BEING TESTED BY FIRE. I'll just sit on the beach and let the airline send me my checks for a total of 11 years before I have to retire.
Mary Feb 9th 2010 10:37PM
Accepting that fatigue can be a real factor, it is up to the pilot to know his own limits. No change in FARs, especially one regarding duty and/or flight hours, will prevent another accident like this. Anyone working on or in aircraft needs to monitor his physical condition and readiness to meet his schedule.
Stick Shaker Feb 9th 2010 11:44PM
I think that Jordan is on the right track in considering the adverse aerodynamic effects of any amount of ice on wings or tail control surfaces. As every student pilot has drilled into his or her head by their instructor, it doesn't take a lof of ice on the wings to dramatically affect the aerodynamic behavior of an aircraft. Cycling the gear and/or flaps usually makes matters worse. Do this on "T" tail and you may even further alter the aerodynamic properties of the aircraft. To the poster that said that recovering from stalls is "no big deal," that may be true when icing isn't involved you have the luxury of generous altitude, but as this tragic accident showed, it's another matter entirely when you're low & slow, iced up late at night and you're fatigued on top of having demonstrated proficiency problems with the type you're flying. They would have had to make a perfect recovery. I doubt any of us will ever know why the Captain pulled back on the yolk, or what possessed the FSO to start retracting the flaps instead of following the training that was repeatedly drilled into them during their flight training in the type (or maybe they don't actually practice real stall recoveries anymore, just push the nose over at the first activation of the stick shaker). Such a damn shame. May all their souls they all RIP. Maybe now the FAA has enough tombstomes that they'll take action on crew scheduline and more rigorous certification standards for turboprop regional aircraft that will be flown into known icing conditions. If they don't, I sure hope Congress steps in and makes them. With all due respect to the poster who prefers propjets so he can study the ice on the wings throughout the flight, I vastly prefer to spend as little time as possible in icing conditions and not be relying on pneumatic rubber boots and pumps to crack it off periodically. That technology is back there with "steam guages" on "classic" types. It's really time to insist that propjets be equipped with better anti-icing technology.