While pilot napping is a standard safety practice throughout the industry, particularly for long-haul flights, as it helps ensure the flight crew are well rested for the approach and landing, at least one pilot must be awake and at the controls at all times.
In a survey by the British Airline Pilots’ Association, 43% of the 500 participants said they had involuntarily fallen asleep in the cockpit and of those 31% said that they had woken on at least one occassion to also find the other pilot asleep. (BBC, 2012)
Plane crashes, especially when a commercial airline is involved, attract more attention than many other types of industrial accidents. However, fatigue poses a serious risk no matter the location of the accident. Impaired decision-making, reduced situational awareness, and substandard performance are experienced by fatigued workers in all work environments. In order to improve safety, optimize productivity and performance, and reduce the risks associated with accidents and errors, it’s essential that companies acknowledge fatigue as a serious issue and implement systems to assess, manage, and overcome it.
1. 1993 Kalitta International Flight 808, Guantanamo Bay
The American cargo plane departed Norfolk, Virginia for Guantanamo Bay, Cuba carrying food and mail to the navy base. As the 3 crew members approached the runway, at 200-300 feet above ground level, the right side wing stalled, the aircraft rolled to 90 degrees and crashed and burned just short of the runway. The three crew members survived the accident.
Causes: “The impaired judgment, decision-making, and flying abilities of the captain and flight crew due to the effects of fatigue; the captain’s failure to properly assess the conditions for landing and maintaining vigilant situational awareness of the airplane while maneuvering onto final approach; his failure to prevent the loss of airspeed and avoid a stall while in the steep bank turn; and his failure to execute immediate action to recover from a stall.” (NTSB, 1994)
2. 1994 Air Algérie Flight 702P, Coventry, UK
The aircraft ignored minimum decision height at Coventry Airport, hit an electricity pylon, causing the aircraft to roll and hit the ground inverted. All 5 crew members died.
Causes: “The performance of the flight crew was impaired by the effects of tiredness, having completed over 10 hours of flight duty through the night during five flight sectors which included a total of six approaches to land.” (Department of Transport, 1994)
3. 1997 Korean Air Flight 801, Guam
The Korean Air flight crashed into a hill after a missed approach near Guam killing 228 of the 254 occupants on board.
Causes: “The captain’s failure to adequately brief and execute the non-precision approach and the first officer’s and flight engineer’s failure to effectively monitor and cross-check the captain’s execution of the approach. Contributing to these failures were the captain’s fatigue and Korean Air’s inadequate flight crew training.” (NTSB, 1997)
4. 1999, American Airlines Flight 1420, Little Rock, USA
The short flight from Dallas to Little Rock ended in tragedy when, attempting to land in a thunderstorm, the plane slid off the runway killing 11 of 145 occupants.
Causes: “The flight crew’s failure to discontinue the approach when severe thunderstorms and their associated hazards to flight operations had moved into the airport area and the flight crew’s failure to ensure that the spoilers had extended after touchdown. Contributing to the accident were the flight crew’s (1) impaired performance resulting from fatigue and the situational stress associated with the intent to land under the circumstances, (2) continuation of the approach to a landing when the company’s maximum crosswind component was exceeded, and (3) use of reverse thrust greater than 1.3 engine pressure ratio after landing.” (NTSB, 1999)
5. 2001, Crossair Flight 3597, Zurich, Switzerland
The aircraft departed from Berlin, Germany and crashed after the aircrew descended below the minimum descent altitude and struck trees.
Causes: “The accident is attributable to the fact that on the final approach…the flight crew deliberately continued the descent under instrument flight conditions below the minimum altitude for the approach without having the necessary prerequisites. The flight crew initiated the go around too late… Over a long period of time, the responsible persons of the airline did not make correct assessments of the commander’s flying performance. Where weaknesses were perceptible, they did not take appropriate measures. The commander’s ability to concentrate and take appropriate decisions as well as his ability to analyse complex processes were adversely affected by fatigue.” (Federal Department of Environment, Transport, Energy and Communications, 2001)
6. 2002 AgcoCorp, Challenger 604, Birmingham, UK
The Birmingham flight meant for Bangor, Maine crashed after take-off when the aircraft banked to the left and the winglet hit the runway and detached. All 5 occupants died.
Causes: “The crew did not ensure that N90AG’s wings were clear of frost prior to takeoff.; 2. Reduction of the wing stall angle of attack, due to the surface roughness associated with frost contamination, to below that at which the stall protection system was effective.; 3. Possible impairment of crew performance by the combined effects of a non-prescription drug, jet-lag and fatigue.” (Department for Transport, 2002)
7. 2004 MK Airlines Flight 1602, Halifax, Canada
The cargo flight from Halifax, Canada headed for Spain crashed shortly after take-off when it hit an earthen berm. The tail detached and the rest of the aircraft crashed after flying another thousand feet.
Causes: “Crew fatigue likely increased the probability of error during calculation of the take-off performance data, and degraded the flight crew’s ability to detect this error. Crew fatigue, combined with the dark take-off environment, likely contributed to a loss of situational awareness during the take-off roll. Consequently, the crew did not recognize the inadequate take-off performance until the aircraft was beyond the point where the take-off could be safely conducted or safely abandoned.” (Transportation Safety Board of Canada)
2004 Corporate Airlines Flight 5966, Kirksville, Missouri
The plane took off from Saint Louis, Missouri and crashed in Kirksville, Missouri while attempting to land. While in descent towards the runway, the aircraft struck trees, crashed, and caught fire. 13 of the 15 occupants died.
Causes: “Contributing to the accident were the pilots’ failure to make standard callouts and the current Federal Aviation Regulations that allow pilots to descend below the MDA into a region in which safe obstacle clearance is not assured based upon seeing only the airport approach lights. The pilots’ failure to establish and maintain a professional demeanor during the flight and their fatigue likely contributed to their degraded performance.” (National Transportation Safety Board, 2004
9. 2004 Med Air, Learjet 35A, San Bernadino, California
The flight took off from San Diego and was headed for Albuquerque, New Mexico when it flew through a cloud and crashed into the Otay Mountains.
Causes: “Failure of the flight crew to maintain terrain clearance during a VFR departure,
which resulted in controlled flight into terrain and the air traffic controller’s issuance of a
clearance that transferred the responsibility for terrain clearance from the flight crew to the
controller, failure to provide terrain clearance instructions to the flight crew, and failure to advise the flight crew of the MSAW alerts. Contributing to the accident was the pilots’ fatigue, which likely contributed to their degraded decision-making.” (NTSB, 2006
10. 2005 Loganair, B-N Islander, Machrihanish, UK
The aircraft was on ambulance task carrying one passenger when it descended below the minimum altitude and struck the sea, crashed, and sank. Both occupants on board died.
Causes: “The pilot allowed the aircraft to descend below the minimum altitude for the aircraft’s position on the approach procedure, and this descent probably continued unchecked until the aircraft flew into the sea. A combination of fatigue, workload, and lack of recent flying practice probably contributed to the pilot’s reduced performance. The pilot may have been subject to an undetermined influence such as disorientation, distraction, or a subtle incapacitation, which affected pilot’s ability to safely control the aircraft’s flightpath.” (Department for Transportation, 2006)
11. 2006, Comair Flight 5191, Lexington, Kentucky
The aircraft was attempting to takeoff from Lexington, KY when it got on a runway that was too short, hit a metal fence, crashed into trees, and burst into flames on a nearby farm. 49 of 50 occupants died.
Causes: Both controller and pilot fatigue was judged to contribute to the accident. “The flight crew’s failure to use available cues and aids to identify the airplane’s location on the airport surface during taxi and their failure to cross check and verify that the airplane was on the correct runway before takeoff. Contributing to this accident were the flight crew’s nonpertinent conversation during taxi, which resulted in loss of positional awareness and the Federal Aviation Administration’s failure to require that all runway crossings be authorized only by specific air traffic control clearances.” (NTSB, 2006)
12. 2007, Cathay Pacific 747F, Stockholm, Sweden
Scheduled to fly from Stockholm to Dubai, the aircraft began to taxi before it was cleared, struck a tow vehicle, and continued taxiing for another 150 meters. There were no causalities or injuries besides the shock suffered by the tow crew. The crew had been awake for 18-20 hours and the incident occurred at 3:30am.
Causes: “Inadequate checklists for the pilots in respect of checking that an all clear signal had been received; a probable contribution was that stress and fatigue factors limited the concentration abilities of the pilots”. (Swedish Accident Investigation Board, 2008)
13. 2007, JetX, AEU804, Keflavik, Iceland
Carrying 200 passengers from Antalya, Turkiey, to Keflavik, Iceland, the aircrew failed to decelerate enough before landing and skid off the taxiway. There were no casualties.
Causes: “The rest facilities and cockpit environments were less than optimal for sleep and decreased the likelihood that rest periods would help to reduce the risk of fatigue related errors. The flight crew was likely fatigued and this had a degrading effect on their performance. The continuance of the flight from Edinburgh to Keflavik and the resulting extension of the flight duty period placed the crew at risk of experiencing fatigue related errors.” (Aircraft Accident Investigation Board, 2009)
14. 2009, Colgan Air Flight 3407, Buffalo, USA
While en-route to Buffalo International Airport, the aircraft stalled and the pilot reacted by pulling instead of pushing on the plane’s control column. The plane then crashed into a house, killing a man in the house and all 49 occupants onboard. Neither pilot recognized that the plane was slowing down too quickly, and neither pilot reacted properly.
Causes: Inadequate training, unnecessary conversation amongst aircrew during takeoff and landing, pilot flying after failing proficiency tests, fatigue. Both pilots had long commutes and slept in the crew lounge, instead of a hotel before the flight. (NTSB, 2009)
15. 2010, Air India Express Flight 812, Mangalore, India
The aircraft overran the runway while attempting to land in Mangalore and broke in two. 158 occupants of 166 were killed.
Causes: “Captain’s failure to discontinue the ‘unstabilised approach’ and his persistence in continuing with the landing…In spite of availability of adequate rest period prior to the flight, the Captain was in prolonged sleep during flight, which could have led to sleep inertia. As a result of relatively short period of time between his awakening and the approach, it possibly led to impaired judgment. This aspect might have got accentuated while flying in the Window of Circadian Low (WOCL).” (Ministry of Civil Aviation, 2010)
16. 2016, Fly Dubai Flight 981, Rostov-on-Don, Russia
The flight from Dubai missed the runway as it attempted to land in Rostov-on-Don, Russia. All 55 passengers and 7 crew members were killed.
Causes: “Incorrect aircraft configuration and crew piloting, the subsequent loss of the pilot in command’s situational awareness in nighttime …This resulted in a loss of control of the aircraft and its impact with the ground. Contributing factors were turbulence and gusty wind; the pilot’s confusion and lack of psychological readiness for a second go-around; and the possible operational tiredness of the crew; at the worst possible time in terms of the circadian rhythms, when the human performance is severely degraded and is at its lower level along with the increase of the risk of errors.” (Interstate Aviation Committee, 2016)
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