|37000 Feet||Browse and search NASA's
Aviation Safety Reporting System
|Local Time Of Day||0001 To 0600|
|Locale Reference||atc facility : zoa.artcc|
|Controlling Facilities||artcc : zoa.artcc|
tower : mmmx.tower
|Operator||common carrier : air carrier|
|Make Model Name||B767 Undifferentiated or Other Model|
|Operating Under FAR Part||Part 121|
|Flight Phase||cruise : level|
|Affiliation||company : air carrier|
|Function||flight crew : captain|
oversight : pic
|Affiliation||company : air carrier|
|Function||flight crew : first officer|
|Qualification||pilot : multi engine|
pilot : instrument
pilot : commercial
|Anomaly||non adherence : far|
non adherence : company policies
non adherence : published procedure
other anomaly other
|Independent Detector||other flight crewa|
other flight crewb
|Resolutory Action||none taken : anomaly accepted|
Flight Crew Human Performance
|Primary Problem||Flight Crew Human Performance|
Fatigue impairment during all-night transoceanic flight. Location: over pacific ocean, dfw arrival, en route. The following is a debrief of my sequence XXX dfw-hnl-dfw on may/xa/01. The sequence was augmented. However, the relief pilot became ill after arriving in hnl. During the return flight to dfw, he was present in the cockpit only during takeoff and landing. As such, this leg was operated without relief breaks for the captain and first officer. Summary: the dfw/hnl leg did not present any fatigue risk because it was flown during normal waking hours. This was not the case with the return hnl-dfw flight which departed hnl at XQ41 and arrived dfw at XA19. Sequence history departed dfw at XE11 arrived hnl XM09. During the layover in hawaii, I made a concerted effort to rest, eat, and exercise to be in the best condition for the flight back to dfw. Dinner at XO00 went to bed XS00, wake-up call XC00. 8 hours of good sleep. Did some paperwork, recreation, exercise, and had lunch. Returned to my room at XL00 to take a nap and was able to sleep for about 2 hours before being awoken by the sound of a maid vacuuming the adjacent room. Could not go back to sleep due to street noise. Closed my eyes and relaxed until the wake-up call. Pick-up at XP15. The relief pilot didn't feel well, so the first officer and I decided to fly the leg back to dfw without any rest breaks. The relief pilot was in the cockpit for takeoff and landing only. The first officer flew the hnl-dfw leg and also took notes on my performance during the flight. Takeoff XQ41. No problem with fatigue until about XT00, when I began to yawn and feel tired. That was when I had my first cup of coffee. I had 4 more cups during the flight. By XU00 I was having difficulty keeping my eyes open. The first officer and I engaged in continual conversation to help fight off the effect of sleep deprivation. At XU30 I had my first involuntary micro-sleep experience that lasted a couple of seconds. These continued throughout the rest of the flight, with increased frequency and duration. The first officer said that he observed me having at least 8 micro-sleep encounters during the flight. I struggled to stay awake during the last 2 hours of the flight. My instrument scan was poor. I found myself fixating on each instrument for longer periods, had trouble reading back clrncs, and found it difficult to remember our flight number during ATC communications. I exhibited some of the classic symptoms of fatigue -- impaired vigilance, memory, and fixation. Landing at dfw XA19 uneventful. After gate arrival, the relief pilot reported that I had taxied up to 25 KTS but I didn't realize it. I don't normally taxi faster than 10 KTS. The drive home from the airport was uneventful. In retrospect, I don't think it was prudent to have driven an automobile in my condition. Comments: the first officer said he felt very tired at XU00 and his eyes were watery and burning, but it was obvious that compared to me, he was in much better condition throughout the flight. The reason for this may be twofold: 1) his normal sleep/rest pattern was very different from mine. As a single parent of 2 young children, he routinely spends time with them until XO00, then he handles his own affairs, remaining awake until about XI00. On the other hand, I get up around XB00 every morning and retire at around XQ00. The difference in our habitual sleep times may have enabled the first officer to cope with sleep deprivation better than I was able to. 2) the first officer was much younger than me. Research has found that people are more susceptible to fatigue as they get older. Fortunately, the WX was excellent and the flight was routine. I hesitate to think how serious the situation could have been if the first officer had been as impaired as I was, or if my cognitive skills/judgement and decision making were required in dealing with bad WX, a low approach, or an emergency. Conclusions: 1) this anecdotal evidence indicates that there is considerable fatigue risk for pilots flying between hawaii and dfw during the window of circadian low without a relief pilot on board to provide in-flight sleep opportunities. 2) safety dictates that transoceanic flts departing lateat night and operating through the circadian low (a time period when human performance is degraded and at its lowest level) should be manned with a relief pilot to provide in-flight sleep opportunities to the operating crew. Starting jun/xa/01, dfw-hawaii sequences are scheduled without a relief pilot. This is ill-advised and will significantly compromise flight safety. There are other transoceanic sequences that are now being flown through the circadian low without relief pilots on board. They include jfk-lhr and bos-lhr. These should be augmented, also.
Original NASA ASRS Text
Title: B767 CREW COMPLAINED OF CREW FATIGUE ON AN ALL NIGHT OCEANIC FLT AFTER DEPARTING WITH AN ILL RELIEF PLT.
Narrative: FATIGUE IMPAIRMENT DURING ALL-NIGHT TRANSOCEANIC FLT. LOCATION: OVER PACIFIC OCEAN, DFW ARR, ENRTE. THE FOLLOWING IS A DEBRIEF OF MY SEQUENCE XXX DFW-HNL-DFW ON MAY/XA/01. THE SEQUENCE WAS AUGMENTED. HOWEVER, THE RELIEF PLT BECAME ILL AFTER ARRIVING IN HNL. DURING THE RETURN FLT TO DFW, HE WAS PRESENT IN THE COCKPIT ONLY DURING TKOF AND LNDG. AS SUCH, THIS LEG WAS OPERATED WITHOUT RELIEF BREAKS FOR THE CAPT AND FO. SUMMARY: THE DFW/HNL LEG DID NOT PRESENT ANY FATIGUE RISK BECAUSE IT WAS FLOWN DURING NORMAL WAKING HRS. THIS WAS NOT THE CASE WITH THE RETURN HNL-DFW FLT WHICH DEPARTED HNL AT XQ41 AND ARRIVED DFW AT XA19. SEQUENCE HISTORY DEPARTED DFW AT XE11 ARRIVED HNL XM09. DURING THE LAYOVER IN HAWAII, I MADE A CONCERTED EFFORT TO REST, EAT, AND EXERCISE TO BE IN THE BEST CONDITION FOR THE FLT BACK TO DFW. DINNER AT XO00 WENT TO BED XS00, WAKE-UP CALL XC00. 8 HRS OF GOOD SLEEP. DID SOME PAPERWORK, RECREATION, EXERCISE, AND HAD LUNCH. RETURNED TO MY ROOM AT XL00 TO TAKE A NAP AND WAS ABLE TO SLEEP FOR ABOUT 2 HRS BEFORE BEING AWOKEN BY THE SOUND OF A MAID VACUUMING THE ADJACENT ROOM. COULD NOT GO BACK TO SLEEP DUE TO STREET NOISE. CLOSED MY EYES AND RELAXED UNTIL THE WAKE-UP CALL. PICK-UP AT XP15. THE RELIEF PLT DIDN'T FEEL WELL, SO THE FO AND I DECIDED TO FLY THE LEG BACK TO DFW WITHOUT ANY REST BREAKS. THE RELIEF PLT WAS IN THE COCKPIT FOR TKOF AND LNDG ONLY. THE FO FLEW THE HNL-DFW LEG AND ALSO TOOK NOTES ON MY PERFORMANCE DURING THE FLT. TKOF XQ41. NO PROB WITH FATIGUE UNTIL ABOUT XT00, WHEN I BEGAN TO YAWN AND FEEL TIRED. THAT WAS WHEN I HAD MY FIRST CUP OF COFFEE. I HAD 4 MORE CUPS DURING THE FLT. BY XU00 I WAS HAVING DIFFICULTY KEEPING MY EYES OPEN. THE FO AND I ENGAGED IN CONTINUAL CONVERSATION TO HELP FIGHT OFF THE EFFECT OF SLEEP DEPRIVATION. AT XU30 I HAD MY FIRST INVOLUNTARY MICRO-SLEEP EXPERIENCE THAT LASTED A COUPLE OF SECONDS. THESE CONTINUED THROUGHOUT THE REST OF THE FLT, WITH INCREASED FREQUENCY AND DURATION. THE FO SAID THAT HE OBSERVED ME HAVING AT LEAST 8 MICRO-SLEEP ENCOUNTERS DURING THE FLT. I STRUGGLED TO STAY AWAKE DURING THE LAST 2 HRS OF THE FLT. MY INST SCAN WAS POOR. I FOUND MYSELF FIXATING ON EACH INST FOR LONGER PERIODS, HAD TROUBLE READING BACK CLRNCS, AND FOUND IT DIFFICULT TO REMEMBER OUR FLT NUMBER DURING ATC COMS. I EXHIBITED SOME OF THE CLASSIC SYMPTOMS OF FATIGUE -- IMPAIRED VIGILANCE, MEMORY, AND FIXATION. LNDG AT DFW XA19 UNEVENTFUL. AFTER GATE ARR, THE RELIEF PLT RPTED THAT I HAD TAXIED UP TO 25 KTS BUT I DIDN'T REALIZE IT. I DON'T NORMALLY TAXI FASTER THAN 10 KTS. THE DRIVE HOME FROM THE ARPT WAS UNEVENTFUL. IN RETROSPECT, I DON'T THINK IT WAS PRUDENT TO HAVE DRIVEN AN AUTOMOBILE IN MY CONDITION. COMMENTS: THE FO SAID HE FELT VERY TIRED AT XU00 AND HIS EYES WERE WATERY AND BURNING, BUT IT WAS OBVIOUS THAT COMPARED TO ME, HE WAS IN MUCH BETTER CONDITION THROUGHOUT THE FLT. THE REASON FOR THIS MAY BE TWOFOLD: 1) HIS NORMAL SLEEP/REST PATTERN WAS VERY DIFFERENT FROM MINE. AS A SINGLE PARENT OF 2 YOUNG CHILDREN, HE ROUTINELY SPENDS TIME WITH THEM UNTIL XO00, THEN HE HANDLES HIS OWN AFFAIRS, REMAINING AWAKE UNTIL ABOUT XI00. ON THE OTHER HAND, I GET UP AROUND XB00 EVERY MORNING AND RETIRE AT AROUND XQ00. THE DIFFERENCE IN OUR HABITUAL SLEEP TIMES MAY HAVE ENABLED THE FO TO COPE WITH SLEEP DEPRIVATION BETTER THAN I WAS ABLE TO. 2) THE FO WAS MUCH YOUNGER THAN ME. RESEARCH HAS FOUND THAT PEOPLE ARE MORE SUSCEPTIBLE TO FATIGUE AS THEY GET OLDER. FORTUNATELY, THE WX WAS EXCELLENT AND THE FLT WAS ROUTINE. I HESITATE TO THINK HOW SERIOUS THE SIT COULD HAVE BEEN IF THE FO HAD BEEN AS IMPAIRED AS I WAS, OR IF MY COGNITIVE SKILLS/JUDGEMENT AND DECISION MAKING WERE REQUIRED IN DEALING WITH BAD WX, A LOW APCH, OR AN EMER. CONCLUSIONS: 1) THIS ANECDOTAL EVIDENCE INDICATES THAT THERE IS CONSIDERABLE FATIGUE RISK FOR PLTS FLYING BTWN HAWAII AND DFW DURING THE WINDOW OF CIRCADIAN LOW WITHOUT A RELIEF PLT ON BOARD TO PROVIDE INFLT SLEEP OPPORTUNITIES. 2) SAFETY DICTATES THAT TRANSOCEANIC FLTS DEPARTING LATEAT NIGHT AND OPERATING THROUGH THE CIRCADIAN LOW (A TIME PERIOD WHEN HUMAN PERFORMANCE IS DEGRADED AND AT ITS LOWEST LEVEL) SHOULD BE MANNED WITH A RELIEF PLT TO PROVIDE INFLT SLEEP OPPORTUNITIES TO THE OPERATING CREW. STARTING JUN/XA/01, DFW-HAWAII SEQUENCES ARE SCHEDULED WITHOUT A RELIEF PLT. THIS IS ILL-ADVISED AND WILL SIGNIFICANTLY COMPROMISE FLT SAFETY. THERE ARE OTHER TRANSOCEANIC SEQUENCES THAT ARE NOW BEING FLOWN THROUGH THE CIRCADIAN LOW WITHOUT RELIEF PLTS ON BOARD. THEY INCLUDE JFK-LHR AND BOS-LHR. THESE SHOULD BE AUGMENTED, ALSO.
Data retrieved from NASA's ASRS site as of July 2007 and automatically converted to unabbreviated mixed upper/lowercase text. This report is for informational purposes with no guarantee of accuracy. See NASA's ASRS site for official report.