Monday, June 16, 2008
NTSB Continues Drumbeat Against Regional Pilots
The NTSB, used the Pinnacle, Shuttle America and go! incidents to continue its more-than-year-old campaign questioning regional airline and pilot practices, said a regional jet overran the end of a runway in Michigan last year because the pilots elected to land on a snowy runway without performing the required landing distance calculations. The mishap occurred on April 12 when a Bombardier Regional Jet (CRJ) CL600-2B19 operated as Pinnacle Airline 4712 ran off the departure end of Runway 28 after landing at Cherry Capital Airport (TVC) Traverse City, MI. There were no injuries among the 49 passengers and three crewmembers.
"Piloting an aircraft should not be guess work," NTSB Chairman Mark Rosenker said. "There are rules and guidelines that need to be followed at all times.” The probable cause determination cited the fact that performing a landing distance assessment was required by company policy because of runway contamination reported by ground operations personnel.
The Safety Board said “this poor decision-making likely reflected the effects of fatigue produced by a long, demanding duty day, and, for the captain, the duties associated with check airman functions.” Had the pilots made the required calculations, using current weather information, the results would have shown that the runway length was inadequate for the contaminated runway conditions described."
The investigation closely examined pilot fatigue. The accident occurred after midnight at the end of a day during which the pilots had flown over eight hours, made five landings, been on duty more than 14 hours, and been awake more than 16 hours. The Safety Board further noted that the pilots had also flown in challenging weather conditions throughout the day.
Also contributing to the accident were the Federal Aviation Administration pilot flight and duty time regulations that permitted the pilots' long, demanding duty day; and the TVC operations supervisor's use of ambiguous and unspecific radio phraseology in providing runway braking information.
The Safety Board also discussed an incident this past February in which a go! regional jet flight from Honolulu to Hilo, Hawaii, overshot its destination. Controllers repeatedly attempted to contact the crew for over 18 minutes as it strayed off course. The passenger jet traveled 26 nautical miles beyond its intended destination before the flight crew responded to a controller’s frantic calls. NTSB investigators said the two go! pilots, who were fired, had unintentionally fallen asleep.
The NTSB previously determined that the probable cause of a Shuttle America Embraer ERJ- 170 accident earlier this year in Cleveland was the failure of the flight crew to execute a missed approach when visual cues for the runway were not distinct and identifiable. On February 18, Delta Connection Flight 6448, operated by Shuttle America, was landing on runway 28 at Cleveland-Hopkins International, Cleveland, Ohio, during snow conditions when it overran the end of the runway, contacted an instrument landing system (ILS) antenna, and struck an airport perimeter fence. The airplane's nose gear collapsed during the overrun. There were 71 passengers and four crewmembers on board. Three passengers received minor injuries.
Contributing to the accident was the crew's decision to descend to the ILS decision height instead of the localizer (glideslope out) minimum descent altitude. Because the flight crewmembers were advised that the glideslope was unusable, they should not have executed the approach to ILS minima; instead, they should have set up, briefed, and accomplished the approach to localizer (glideslope out) minima.
Also contributing to the accident was the first officer's long landing on a short contaminated runway and the crew's failure to use reverse thrust and braking to their maximum effectiveness. When the first officer lost sight of the runway just before landing, he should have abandoned the landing attempt and immediately executed a missed approach.
Furthermore, the NTSB said that had the flight crew used the reverse thrust and braking to their maximum effectiveness, the airplane would likely have stopped before the end of the runway. The Board concluded that specific training for pilots in applying maximum braking and maximum reverse thrust on contaminated runways until a safe stop is ensured would reinforce the skills needed to successfully accomplish such landings.
In its final report on the accident investigation, the Safety Board noted that the captain's fatigue, which affected his ability to effectively plan for and monitor the approach and landing, contributed to the accident. By not advising Shuttle America of this fatigue or removing himself from duty, the captain placed himself, his crew, and his passengers in a dangerous situation that could have been avoided, the Board reasoned.
Another contributing factor to the accident, the Safety Board said, was Shuttle America's failure to administer an attendance policy that permitted flight crewmembers to call in as fatigued without fear of reprisals. The NTSB believes the policy had limited effectiveness because the specific details of the policy were not documented in writing and were not clearly communicated to pilots, especially the administrative implications or consequences of calling in as fatigued.
As a result of the accidents/incidents, the Safety Board has made two recommendations to the FAA addressing human fatigue within airline operations. It advised the FAA to develop guidance, based on empirical and scientific evidence, for operators to establish fatigue management systems, including information about the content and implementation of these systems. The Board also drafted an advisement for the agency to develop and use methodology that will continually assess the effectiveness of fatigue management systems implemented by operators, including their ability to improve sleep and alertness, mitigate performance errors, and prevent incidents and accidents.
“The Safety Board is extremely concerned about the risk and the unnecessary danger that is caused by fatigue in aviation,” said Rosenker. “We have seen too many accidents and incidents where human fatigue is a cause or contributing factor. It is imperative that the FAA take action to reduce human fatigue in airline operations. Addressing this safety related measure is long overdue. We must and can correct this serious concern.”
The FAA has scheduled a symposium near Washington, DC, June 17-19, that will look at fatigue issues affecting not only pilots, but also air traffic controllers, mechanics and flight attendants.This symposium is the first event sponsored by the FAA that focuses specifically on managing fatigue in aviation. The symposium will encourage members of the aviation community to proactively address aviation fatigue management issues. The three main objectives are: provide the most current information on fatigue physiology, management, and mitigation alternatives; develop a common understanding of fatigue issues and identify challenges; and, forge collaborative alliances to initiate actionable mitigation strategies. The event is closed to the public and media.