Preventing Airline Crashes by Preventing Fatigue

All opinions expressed are my own and are not representative of my current employer nor past employers. 

On February 12th, 2009 around 10:17pm EST, Continental Connection Flight 3407, operated by Colgan Air crashed on an instrument approach into Buffalo-Niagara International Airport in Buffalo, New York.  45 Passengers, 2 Pilots, 2 Flight Attendants and one person on the ground lost their lives because the Captain reacted to the Bombardier Dash 8 Q400’s stick shaker by pulling up instead of pushing.

In October 2004, a BAE J-32, Jetstream, was conducting a non-precision approach into Kirksville and they crashed.  The flight was 5966 operated by Corporate Airlines dba American Connection. Several factors played into this, including the pilots being on duty for 14 and a half hours.  Both flight crew members woke up before 5am in order to be ready for work and this was their 6thflight of the day.  A non-precision approach requires both flight crew members to be fully aware of their surroundings and able to think logically; however, they couldn’t.  Because these flight crews were not able to act professionally, think logically, and conduct their operation with accordance to the Standard Operating Procedures of the airline, it resulted in 13 fatalities and two serious injuries.

And finally, an accident happened when a pilot slept only one hour in the 32 hours preceding the crash of Delta Connection Flight 6448 operated by Shuttle America.  The Embraer ERJ-170 overran the runway in Cleveland, Ohio which, thankfully, did not result in any fatalities.   The Captain did not notify Shuttle America of his fatigued state because of one reason: punishment.  The captain had been notified by the company that he had an excessive amount of sick calls and that he would be subject to discipline, including termination, if he called in again.


All of these accidents are alike in one way; they all have some form of fatigue related symptom involved.  The National Transportation Safety Board since 1972, issued more than 117 fatigue-related recommendations to numerous industries with aviation having 32 of those recommendations.  Over 250 people have been killed in air carrier accidents that were investigated by the NTSB that were caused by the symptoms of fatigue. Fatigue related symptoms include delayed reactions, reduction in performance in both speed and accuracy, reduced situational awareness and, the most worrying, impaired logical reasoning.

The FAA has created and implemented part 117 in a way that requires both the company and the pilot to accept responsibility to mitigate fatigue. In September of 2010, the FAA published a Flightcrew Member Duty and Rest Requirements Notice of Proposed Rule Making, NPRM, which is required by federal law.  The NPRM received more than 8,000 responses which were all required to be reviewed.  The FAA made a significant number of changes from the original proposed rule to the final rule.

The final rule took several different factors into consideration, such as circadian rhythms and changes in time zones and many changes were made due to the public commenting period.  Part 117 only applies to 121 carriers and does not apply to operations which are cargo only. Part 117 contains several provisions including the fitness for duty affirmation, fatigue education and training, augmented and unaugmented operations, extensions and more.  All of these parts are important to understand and must be followed; however the majority falls on the carrier.

The rule requires several things, most notably the requirement that flight crew members receive 10 hours of rest; however, they only require 8 hours of rest opportunity.  The rules also set forth flight duty limitations which are calculated based on how many flight segments and the time of day that it was started, these calculations are found in the Flight Duty Period Table.  There are many different factors when calculating FDP, Flight Duty Period, and these can be found in Part 117.   While these are just several of the limits, I highly encourage all aviation safety professionals to be versed in all of Part 117.

Fatigue is a manageable problem; however, it requires that all of the parties involved follow the rules and accept the rules.  This requires the flight crew member to make Fitness for Duty Affirmations, and sleep during provided rest opportunities.  The carriers must provide the crew members with hotels and rest facilities that will allow for uninterrupted rest.  When pilots call out due to the fatigue,the carrier should have a fatigue review committee or program that conducts root cause analysis and makes recommendations to the company to change the location of hotels, send out awareness regarding requirements to sleep and who notify, as well as assist, pilots which may have problems that do not allow for adequate rest.

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