What needs to happen to persuade the US safety agencies to take the issue of fatigue seriously instead of just talking about it?
On 24 October 2004 a Med Flight Air Ambulance Bombardier Learjet 35A crashed into high ground while following an air traffic control clearance after take-off from San Bernardino airport, California. All five people on board were killed. The air traffic control officer was warned twice by his minimum safe altitude warning system that the aircraft was in danger, but ignored it.
Flightcrew fatigue was cited as a factor in that accident but, after the report came out, National Transportation Safety Board members criticised the absence of recommendations concerning controller fatigue, despite the fact the duty ATCO had "worked an 8h shift the day before the accident, and returned 7.5h later, without any sleep, to work through the midnight shift". The fact that the ATCO had ignored two minimum safe altitude warning system alerts that could have enabled him to warn the crew in time to save their lives was detailed in the report, but the reason for this stupefying passivity was not probed nor deemed worthy of future study. It took the death of 49 people at Lexington Blue Grass airport last August to wake up the NTSB. Now, having completed the factual review of the Lexington accident, the NTSB has made multiple recommendations for Federal Aviation Administration action to deal with the causes of ATCO fatigue. The NTSB didn't mention San Bernardino, but cited other results of controller fatigue including a near-collision between two United Airlines aircraft at Chicago O'Hare.
The NTSB and the FAA both have blind spots on fatigue. In this column on 31 January 2006 we wrote: "At Kirksville, Missouri in October 2004, 13 people died because FAA regulations allowed a crew [of a British Aerospace Jetstream 41] to fly six sectors from an early start on a 15h crew duty day operating a commercial passenger schedule that terminated in a non-precision approach in marginal weather at night.
"Everybody knows that six sectors and 15h is too long a shift for a safety-critical job, but the FAA still stands by its 16h maximum for an unaugmented crew. The experts who study fatigue, however, liken the effect on a pilot's decision-making capabilities to the results of having a blood alcohol level that would see a car driver criminally convicted. The driving offence is socially unacceptable but, if a pilot is drunk on fatigue, that, apparently, is socially acceptable. [But] the NTSB...is so lacking in faith in the FAA's willingness to do anything to correct the situation...that, in the Kirksville report, it [only] recommends pilots should be given lessons in 'fatigue countermeasures'. That is, recognise that you must be seriously tired at this point in a duty day, and make due allowances for it. The situation is preposterous: it is like the NTSB's road transport department advising those car drivers who insist on getting drunk that they should recognise their inebriation and manage its effects."
There is no need to change a word of what we said. It's still true, and the FAA has still done nothing to change the rules for pilots or ATCOs.
Source: Flight International
