NTSB Cites Fatigue, 'Unprofessional Behavior' As Factors

Fatigue was a contributing factor in the October 2004 fatal crash of a Corporate Airlines, now RegionsAir, flight to Kirksville, Mo.

The National Transportation Safety Board (NTSB) is again calling upon the Federal Aviation Administration (FAA) to revise its 1940s-era flight-and-duty time rules for pilots, and asking the airlines to improve their training programs to deal with pilot fatigue.

Last week, the NTSB concluded that pilot error was the cause of the crash of a BAe Jetstream 32 that killed 11 passengers and the two pilots. Two passengers survived with serious injuries.

Flying as American Connection Flight 5966, the turboprop departed St. Louis at 6 p.m. and was due to arrive in Kirksville at about 7:15 p.m. The plane came down in trees about 1.3 miles short of the runway.

The pilots - Capt. Kim Sasse, 48, and First Officer Jonathan Palmer, 29 - had been on duty since 5:15 a.m. that Tuesday, and Flight 5966 was their sixth landing of the day. Two other scheduled flights that day had been canceled by bad weather. The pair was in their third day of a four-day schedule.

"The probable cause of the accident was the pilots' failure to follow established procedures and properly conduct a non-precision instrument approach at night," the NTSB concluded. "The pilots' unprofessional behavior during the flight and their fatigue likely contributed to their degraded performance."

The "unprofessional behavior" was joking and bantering and repeated use of expletives in nearly every sentence. The crew ignored "established sterile cockpit regulations" and the ban on non-essential conversation below 10,000 feet, the board concluded.

"I was extremely disappointed in what I heard," said acting NTSB Chairman Mark Rosenker. "From the beginning to the end, it was unprofessional."

Because of their chatter, the board said the pilot of the Corporate Airlines flight was not monitoring the plane's descent, which was too rapid. Furthermore, the first officer failed to challenge the captain descent below minimum descent altitude.

The plane was descending at 1,200 feet per minute, which was consistent with the carrier's guidelines. However, the NTSB noted that the FAA suggested that the descent should be no greater than 1,000 feet per minute when flying under an altitude of 1,000 feet.

It had been raining earlier in the day, and the report noted that at the time of the accident there was a low cloud cover.

The captain was looking for the Kirksville approach lights after dropping out of low-level clouds. The board said that he should have been monitoring his instruments while the first officer looked for the lights.

According to the transcript, moments after reaching 500 feet, Sasse said he could see the approach lights. Moments later Palmer shouted, "trees," and the plane crashed seconds later.

In its findings, the board said Fight 5966 dropped below the minimum descent altitude as permitted. However, the regulations can have the "unintended effect of encouraging some pilots to descend below the minimum descent altitude in an attempt" to locate visual clues, such as the approach lights or other landmarks. The board is now recommending that the regulations prohibit this type of descent unless conditions permit clear sight of all obstacles along the approach path.

The NTSB investigation revealed that the constant cockpit banter was out of character for either pilot.

Furthermore, the investigators said it was possible that fatigue could be one reason that the pair was not concentrating on the task at hand. Punchiness, moodiness and emotional behavior are all symptoms of fatigue, said Dr. Malcom Brenner, an NTSB investigator. Likewise, Sasse's fixation on finding the approach lights and both pilots' inability to concentrate on the plane's instruments are also signs of fatigue, he said.

As part of its recommendations to the FAA, the NTSB wants the flight crew hours-of-service regulations to be modified to take into consideration recent research, scientific evidence and current industry experience. Furthermore, the FAA should include in both Part 121 and 135 rules a requirement that initial and refresher training for pilots include fatigue awareness and strategies for avoiding fatigue.

It was noted that RegionsAir's pilot-training course did not include any specific discussion on fatigue.

RegionsAir has since adapted its six-hours of crew resource management training to include replaying a portion of the Flight 5966 tape as part of a discussion on maintaining a sterile cockpit environment.

Reacting to a similar NTSB recommendation in 1995, the FAA proposed a new rule for pilot on-duty time and rest periods, which would have increased the rest time from eight to 10 hours and shortened the duty day by two hours to 14 hours.

"The agency received more than 2,000 comments from the aviation community and the public," said Alison Duquette, an FAA spokeswoman. "Most of those comments did not favor the rule as proposed and there was no clear consensus on what the final rule should say."

Another attempt to craft a new rule in 1998 floundered when no consensus could be reached on five different alternatives that were presented.

The NTSB noted that if 20-year-old British duty-time rules had been applied to the RegionsAir flight, the pilots would have concluded their day at 2:15 p.m. - about four hours before Flight 5966 took off. The British rules factor in the number of landings and the pilot's starting time when determining the length of the duty day.

Flight 5966 "was tragic, but an isolated incident," said Deborah McElroy, president of the Regional Airline Association.

"If there is scientific or technical information that indicates that the regulations should be modified, we will work with the FAA and the pilot organizations on that," she said. "We don't believe that there was evidence presented in the 1995 [pilot duty time] proposal."

The FAA's Duquette noted that "the current rules are fundamentally sound but the FAA remains open to any new research or data on fatigue."

McElroy noted that many of the pilots at the regional carriers are represented by unions, who have negotiated contracts that provide the pilots with greater rest time and less duty time than what is spelled out in the FAA regulations.

The Teamsters represent the RegionsAir pilots.

>>The complete Kirksville report is available at http://www.ntsb.gov. Contacts: Alison Duquette, FAA, (202) 267-3883; Deborah McElroy, RAA, (202) 367-1170.<<