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The role of fatigue in these five aviation disasters

Tuesday, November 01, 2016 by Dr Trefor Morgan

When you step on board a flight, you hand over complete trust and assurance to the flight crew. The flight attendants ensure you are comfortable and safe throughout the flight, while the pilot and co-pilots, with hours of training, aim to get you to your destination safely.

The aviation industry, just like other 24-hour operations, is, unfortunately, not exempt from the dangers of fatigue and drowsiness. And unlike truck drivers, who can pull over at a rest stop if they feel fatigue is setting in, pilots cannot pull over on the nearest cloud.

Human error, in part caused by fatigue, has been a leading cause of some terrifying airline accidents.

These five disasters were caused by fatigue in aviation.

fatigue in aviation

1. Colgan Air Flight 3407

Date: 12th February, 2009
Origin: Newark, New Jersey
Intended destination: Buffalo, New York

The role of aviation fatigue:

In the official investigation and report, the chair of the US National Transportation Safety Board (NTSB), Deborah Hersman, said she considered aviation fatigue to be a part of the pilot’s inappropriate response to the aerodynamic stall the plane had entered.

Fatigue vs. alcohol

Hersman also explained how the “performance impacts of fatigue and alcohol were similar”, a concept with which we at Optalert concur.

First officer and Captain

It’s been reported the first officer, Rebecca Shaw, may have pulled an all-nighter in order to score a free flight to work from Seattle to Newark (via Memphis).

It’s also alleged the captain, Marvin D. Renslow, was logged onto a computer at 3am. It’s unknown where he slept, but it’s alleged he was at Newark airport overnight. Also, he was known to have made attempts in the past to sleep in the crew lounge at the airport, even though Colgan Air had made threats to fire those who attempted to do so.

All 49 on board died, as well as one fatality and 4 injuries on the ground.

2. Air France Flight 447

Date: 1st June, 2009
Origin: Rio de Janeiro, Brazil
Intended destination: Paris, France

The possible role of fatigue:

Fatigue was not deemed a factor in the final official report, however independent analysis appears to suggest otherwise.

In chilling audio recovered after the crash, the plane’s captain, Marc Dubois, is heard saying, “I didn’t sleep enough last night. One hour – it’s not enough right now”.

As we know fatigue, or more specifically drowsiness, can have an adverse effect on a person, including:

  • • Trouble concentrating
  • • Slow reaction time
  • • Daydreaming
  • • The inability to remember the last few minutes

While humans require 7-9 hours of sleep per night, it’s frightening that this pilot allegedly had only one hour’s sleep in preparation for an 11-hour flight and was responsible for so many lives.

Air France flight 447 had 216 passengers and 12 crew on board (228 total). Devastatingly, there were no survivors.

3. Korean Air Flight 801

Date: 6th August, 1997
Origin: Seoul, South Korea
Intended destination: Guam, west Pacific Ocean

The crash was due to a combination of factors:

  • • The captain’s poor approach
  • • The captain’s fatigue
  • • Poor communication between crew
  • • Korean Air’s lack of training

4. American Airlines Flight 1420

Date: 1st June, 1999
Origin: Dallas-Fort Worth, Texas
Intended destination: Little Rock, Arkansas

The contributing role of fatigue

It’s alleged the flight crew was distracted by extreme weather and impacted by fatigue.

This combination is what resulted in them overlooking the automatic spoiler system that, if enabled upon landing, would have stopped the plane from overrunning the runway, causing it to crash. The plane was attempting to land in a heavy thunderstorm, and the crew struggled to gain control of the plane as it struggled to land.

The captain and 10 passengers were killed. Of the 134 survivors, 110 were injured.

Richard Klamm was a survivor of flight 1420 along with his son, Jason. His personal opinion was that:

  • • The weather was a key culprit
  • • The combination of fatigue, a late flight, and “possibly a bit of ego” influenced the pilot’s judgement

Klamm says he finds it hard to believe that a landing attempt was made in such dangerous weather conditions. You can read his full story here.

Corresponding documentation from the National Transportation Safety Board (NTSB) lists “impaired performance from fatigue” as a contributor to the accident.

5. Go! Flight 1002

Date: 13th February, 2008
Origin: Honolulu, Hawaii
Destination: Hilo, Hawaii

The role of fatigue… even during a 30-minute flight

This particular incident highlights the fact that no matter the length or distance of a flight, sleep can catch you.

Go! is a now-defunct, Hawaii-based airline that was a branch of Mesa Airlines, based in Arizona.

During a 30-minute flight from Hawaii’s capital, Honolulu (on the island Oahu) to Hilo, on the Big Island, both pilots allegedly fell asleep, resulting in the plane travelling for 48 additional kilometres at 21,000 feet.

After 26 minutes, air traffic controllers regained contact with the pilots and, fortunately, the plane safely landed and there were no casualties.

Sleep apnea

It was later determined that the Captain suffered from severe obstructive sleep apnea. According to this article, the Captain went to bed around 8pm the night before the flight, and woke up at 4am on the morning of the 13th of February.

Both pilots were fired and their licenses were suspended.

The NTSB quotes the Captain as saying, “Working as hard as we had, we tend to relax … it was comfortable in the cockpit … I just kind of closed my eyes for a minute … and dozed off.”

The NTSB concluded the accident was caused by...
"...the captain and first officer inadvertently falling asleep during the cruise phase of flight. Contributing to the incident were the captain's undiagnosed obstructive sleep apnea and the flight crew’s recent work schedules, which included several consecutive days of early-morning start times."
(Source)

Chelsey “Sully” Sullenberger speaks about the importance of adequate rest

Amongst the buzz around the latest Clint Eastwood film, Sully, we’ve been taken back to the events of 15th January, 2009.

Captain Chelsey “Sully” Sullenberger became an instant hero when he successfully ditched US Airways Flight 1549 into New York’s Hudson River after both engines failed due to bird strikes. All 155 passengers and crew survived what has been called the Miracle on the Hudson.

Just a few days after the miracle, Sullenberger told ABC news that proper rest leading up to the incident was a key facilitator into the successful ditching:

I’m convinced that had we [Sullenberger and First Officer Jeffrey Skiles] been tired, had we not gotten sufficient rest the night before, we could not have performed at the same level."

The fact that we got so much right so quickly under that sudden stress is a testament [to] the fact that we had a chance to get sufficient rest.

(You can read and watch Sully’s full interview here)

Measuring fatigue

In the past, it had always been impossible to put a number on fatigue, which has meant it’s been difficult to accurately attribute fatigue as the cause of an accident.

That’s where Optalert comes in. Using our patented technology, we can actually provide a number attributed to a user’s level of drowsiness, which means we can quantifiably answer the question, “How tired are you?”

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