|37000 Feet||Browse and search NASA's
Aviation Safety Reporting System
|Local Time Of Day||0001 To 0600|
|Locale Reference||airport : zzz.airport|
|Altitude||agl single value : 0|
|Operator||common carrier : air carrier|
|Make Model Name||B757-200|
|Operating Under FAR Part||Part 121|
|Flight Phase||ground : preflight|
|Affiliation||company : air carrier|
|Function||flight crew : captain|
oversight : pic
|Experience||flight time last 90 days : 225|
flight time total : 20000
flight time type : 300
|Affiliation||company : air carrier|
|Function||flight crew : first officer|
|Anomaly||non adherence : company policies|
other anomaly other
|Independent Detector||other flight crewa|
|Resolutory Action||none taken : detected after the fact|
Irregular operations on the first day of a 4-DAY assignment resulted in a long duty day (within 10 mins of schedule maximum) including an unexpected all-night flight with a total sleep loss (total sleep loss defined as no sleep during the window of circadian low). The next duty period was scheduled for 2 flight segments including 7 hours 55 mins unaugmented flight hours; an ETOPS operation on the second segment; and a long duty day to be completed during late night. Company asserted we were 'required by contract' to complete the second period after a minimum day-time duty break. Contractual provisions notwithstanding; I was concerned about the safety of the operation. Absent recovery (recovery achievable only by sleep during a subsequent window of circadian low) from a total sleep loss it didn't make sense to attempt a maximum flight time/duty day; particularly in the demanding ETOPS environment. Far less onerous assignments have been deemed 'unsafe' by company and union scheduling experts. I expressed safety concerns to company. However; company's 'culture' doesn't respect opinions of experienced capts. During over 15 mins of back and forth; company's representative repeatedly dismissed the safety concerns because the contract says yada; yada; yada. Although the representative spoke to a supervisor at no time did either deem my concerns sufficient to merit discussion with the chief pilot. There should have been no question regarding the credibility of my concerns as there are numerous related scheduling provisions. Even without the previous all-night duty; such ETOPS flts are specifically prohibited by the contract without 10 hours 45 mins scheduled hours free from duty prior to the flight. Duty time is limited to 10 scheduled hours absent a previous 10 hour 45 min duty break. And an entire area of the contract is devoted to safely scheduling against circadian rhythm. So even a contractual neophyte would recognize these as safety sensitive conditions. The contract presumes each in isolation but quite obviously; in actual operations a convergence can yield extremely onerous conditions. Yet such corroboration is no match for cultural disrespect. Company representative repeatedly demanded to know if I was calling 'fatigued' and threatened to send me directly home without any replacement flying (pay) for the remaining 3 days if I did so. Each time I explained I would be unable to make the evaluation until closer to departure time from seattle; but it was my prediction that we would be unable to safely complete the assignment. I gave company an opportunity to prevent cancellation of an important flight. Company's representative didn't consider the conversation an opportunity. After a minimum duty break; we did in fact fly the segment to seattle with no significant fatigue issues. The honolulu segment was delayed by a mechanical problem and ultimately canceled due to our contractual duty limits. So why; one might ask; is there any need for a report? Absent the mechanical delay we would have flown the ETOPS flight to honolulu. My first officer and I had thoroughly discussed whether to call 'fatigued' and after considerable evaluation believed we were adequately rested. I later learned we were terribly wrong. It was unreliable to reasonably predict fatigue based on our alertness in the afternoon. At what would have been midpoint for the flight the error was unmistakable. Had we been in the airplane the absence of nearby alternates would have permitted no reasonable alternative but to continue. Less than 1 hour later; I was totally intoxicated by exhaustion. At what would have been 1 hour prior to landing; I also developed a debilitating headache with nausea. I've never been incapacitated on a flight but would have been effectively so had we operated this one. In retrospect; the first officer reported that his condition would have also been unacceptable.
Original NASA ASRS Text
Title: A B757-200 FLT CREW EXPERIENCED EXTREME FATIGUE AND CONSIDERED THEMSELVES UNSAFE TO FLY. THE COMPANY THREATENED TIME OFF WITHOUT PAY.
Narrative: IRREGULAR OPS ON THE FIRST DAY OF A 4-DAY ASSIGNMENT RESULTED IN A LONG DUTY DAY (WITHIN 10 MINS OF SCHEDULE MAX) INCLUDING AN UNEXPECTED ALL-NIGHT FLT WITH A TOTAL SLEEP LOSS (TOTAL SLEEP LOSS DEFINED AS NO SLEEP DURING THE WINDOW OF CIRCADIAN LOW). THE NEXT DUTY PERIOD WAS SCHEDULED FOR 2 FLT SEGMENTS INCLUDING 7 HRS 55 MINS UNAUGMENTED FLT HRS; AN ETOPS OP ON THE SECOND SEGMENT; AND A LONG DUTY DAY TO BE COMPLETED DURING LATE NIGHT. COMPANY ASSERTED WE WERE 'REQUIRED BY CONTRACT' TO COMPLETE THE SECOND PERIOD AFTER A MINIMUM DAY-TIME DUTY BREAK. CONTRACTUAL PROVISIONS NOTWITHSTANDING; I WAS CONCERNED ABOUT THE SAFETY OF THE OP. ABSENT RECOVERY (RECOVERY ACHIEVABLE ONLY BY SLEEP DURING A SUBSEQUENT WINDOW OF CIRCADIAN LOW) FROM A TOTAL SLEEP LOSS IT DIDN'T MAKE SENSE TO ATTEMPT A MAX FLT TIME/DUTY DAY; PARTICULARLY IN THE DEMANDING ETOPS ENVIRONMENT. FAR LESS ONEROUS ASSIGNMENTS HAVE BEEN DEEMED 'UNSAFE' BY COMPANY AND UNION SCHEDULING EXPERTS. I EXPRESSED SAFETY CONCERNS TO COMPANY. HOWEVER; COMPANY'S 'CULTURE' DOESN'T RESPECT OPINIONS OF EXPERIENCED CAPTS. DURING OVER 15 MINS OF BACK AND FORTH; COMPANY'S REPRESENTATIVE REPEATEDLY DISMISSED THE SAFETY CONCERNS BECAUSE THE CONTRACT SAYS YADA; YADA; YADA. ALTHOUGH THE REPRESENTATIVE SPOKE TO A SUPVR AT NO TIME DID EITHER DEEM MY CONCERNS SUFFICIENT TO MERIT DISCUSSION WITH THE CHIEF PLT. THERE SHOULD HAVE BEEN NO QUESTION REGARDING THE CREDIBILITY OF MY CONCERNS AS THERE ARE NUMEROUS RELATED SCHEDULING PROVISIONS. EVEN WITHOUT THE PREVIOUS ALL-NIGHT DUTY; SUCH ETOPS FLTS ARE SPECIFICALLY PROHIBITED BY THE CONTRACT WITHOUT 10 HRS 45 MINS SCHEDULED HRS FREE FROM DUTY PRIOR TO THE FLT. DUTY TIME IS LIMITED TO 10 SCHEDULED HRS ABSENT A PREVIOUS 10 HR 45 MIN DUTY BREAK. AND AN ENTIRE AREA OF THE CONTRACT IS DEVOTED TO SAFELY SCHEDULING AGAINST CIRCADIAN RHYTHM. SO EVEN A CONTRACTUAL NEOPHYTE WOULD RECOGNIZE THESE AS SAFETY SENSITIVE CONDITIONS. THE CONTRACT PRESUMES EACH IN ISOLATION BUT QUITE OBVIOUSLY; IN ACTUAL OPS A CONVERGENCE CAN YIELD EXTREMELY ONEROUS CONDITIONS. YET SUCH CORROBORATION IS NO MATCH FOR CULTURAL DISRESPECT. COMPANY REPRESENTATIVE REPEATEDLY DEMANDED TO KNOW IF I WAS CALLING 'FATIGUED' AND THREATENED TO SEND ME DIRECTLY HOME WITHOUT ANY REPLACEMENT FLYING (PAY) FOR THE REMAINING 3 DAYS IF I DID SO. EACH TIME I EXPLAINED I WOULD BE UNABLE TO MAKE THE EVALUATION UNTIL CLOSER TO DEP TIME FROM SEATTLE; BUT IT WAS MY PREDICTION THAT WE WOULD BE UNABLE TO SAFELY COMPLETE THE ASSIGNMENT. I GAVE COMPANY AN OPPORTUNITY TO PREVENT CANCELLATION OF AN IMPORTANT FLT. COMPANY'S REPRESENTATIVE DIDN'T CONSIDER THE CONVERSATION AN OPPORTUNITY. AFTER A MINIMUM DUTY BREAK; WE DID IN FACT FLY THE SEGMENT TO SEATTLE WITH NO SIGNIFICANT FATIGUE ISSUES. THE HONOLULU SEGMENT WAS DELAYED BY A MECHANICAL PROB AND ULTIMATELY CANCELED DUE TO OUR CONTRACTUAL DUTY LIMITS. SO WHY; ONE MIGHT ASK; IS THERE ANY NEED FOR A RPT? ABSENT THE MECHANICAL DELAY WE WOULD HAVE FLOWN THE ETOPS FLT TO HONOLULU. MY FO AND I HAD THOROUGHLY DISCUSSED WHETHER TO CALL 'FATIGUED' AND AFTER CONSIDERABLE EVALUATION BELIEVED WE WERE ADEQUATELY RESTED. I LATER LEARNED WE WERE TERRIBLY WRONG. IT WAS UNRELIABLE TO REASONABLY PREDICT FATIGUE BASED ON OUR ALERTNESS IN THE AFTERNOON. AT WHAT WOULD HAVE BEEN MIDPOINT FOR THE FLT THE ERROR WAS UNMISTAKABLE. HAD WE BEEN IN THE AIRPLANE THE ABSENCE OF NEARBY ALTERNATES WOULD HAVE PERMITTED NO REASONABLE ALTERNATIVE BUT TO CONTINUE. LESS THAN 1 HR LATER; I WAS TOTALLY INTOXICATED BY EXHAUSTION. AT WHAT WOULD HAVE BEEN 1 HR PRIOR TO LNDG; I ALSO DEVELOPED A DEBILITATING HEADACHE WITH NAUSEA. I'VE NEVER BEEN INCAPACITATED ON A FLT BUT WOULD HAVE BEEN EFFECTIVELY SO HAD WE OPERATED THIS ONE. IN RETROSPECT; THE FO RPTED THAT HIS CONDITION WOULD HAVE ALSO BEEN UNACCEPTABLE.
Data retrieved from NASA's ASRS site as of January 2009 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.