|37000 Feet||Browse and search NASA's
Aviation Safety Reporting System
|Local Time Of Day||1201 To 1800|
|Locale Reference||atc facility : smx|
airport : smk
|Altitude||agl bound lower : 0|
agl bound upper : 0
|Operator||common carrier : air carrier|
|Make Model Name||Small Transport, Low Wing, 2 Turboprop Eng|
|Flight Phase||climbout : takeoff|
|Affiliation||company : air carrier|
|Function||flight crew : captain|
oversight : pic
|Qualification||pilot : atp|
|Experience||flight time last 90 days : 200|
flight time total : 9500
|Function||flight crew : first officer|
|Qualification||pilot : instrument|
pilot : commercial
|Anomaly||non adherence : far|
|Independent Detector||other flight crewa|
|Resolutory Action||none taken : detected after the fact|
|Primary Problem||Flight Crew Human Performance|
|Air Traffic Incident||Pilot Deviation|
A daylight landing was made at santa maria airport, santa maria, ca, with passenger on board. There was a truck and men off the left runway edge at mid field. No advisory was given by tower. The first officer listened to ATIS and made no mention to me about men, equipment or field lighting. I was flying and made the landing. After a 30 min ground time we called for taxi for takeoff. With totally clear conditions I elected to depart VFR for the short 10 min flight to san luis obispo, ca. Company flight following procedures were used. The ground controller advised on taxi out that the runway lights were out of service for maintenance. At that point it did not register that they would not be in service for takeoff. As I approached the runway the situation began to take shape in my mind. It was very light with a good moon and my taxi light, landing lights, recognition lights and wing ice lights illuminated so much that it did not seem like night. There were plenty of blue taxiway lights all down the runway plus the VASI lights and I think the approach lights. The runway was clear to me. I asked the controller what time was official sunset and for some reason my mind told me that I was ok for 1 hour after sunset, which I was within. Everything was so clear that it misled my thinking. Also, another company aircraft operating under the same rules departed right in front of me. I was nearing the end of my 3RD day of duty. The previous day's duty was 13 hours and 53 mins with reduced rest of 8 hours and 45 mins and I had been on duty this day for 10 1/2 hours with 4 hours to go. I had already told my first officer that because we were tired that we needed to be cautious and watch each other closely. I made the takeoff. The actual darkness after leaving the ground and all of the airfield lights and my own aircraft lights jolted me into realizing that I had actually made a takeoff after dark west/O runway lighting as required by 135.229B (2). The boundary of the runway was clearly defined by the VASI and taxiway lights and I may have in fact been legal, but another important fact keeps bothering me. I was flying in a tired state of mind. I was totally legal by FAA rules governing part 135 commuter duty and rest periods. Company schedules routinely require long duty days followed by reduced rest and again followed by long duty days. At the urging of the raa (regl airline association) the rules were recently changed to sep charter and commuter duty time rules under part 135. We fly demanding schedules with 8-12 legs per day. We fly a fast airplane with no autoplt and must make many quick turn arounds between legs. In many yrs of military flying in much larger equipment I never experienced such a workload. While my physical ability to maneuver the airplane does not seem as effected, I find my decision making ability suffers greatly at the end of an exhausting day. Being aware of this certainly helps and this incident will slow me down even more and be another valuable lesson. I think the crew and duty time regulations are the real culprits in this incident. As soon as I broke ground and made myself evaluate the situation I knew I was wrong and should have returned to the gate. In a more rested state, I would have recognized this on the ground. Instead, I subconsciously rationalized the situation as safe (which it was) even though it broke a rule. I recognize that rules are there to make decisions like this cut and dried and take the responsibility for always insuring safety. On the other hand, a rule that allows the company to routinely schedule pilots into fatigue has to create some contempt for those same rules. Just because the aircraft are smaller under 135 does not indicate a smaller workload than under 121. The whole duty time situation of part 135 commuter operation should be re-evaluated and no comparison should be made to part 121. These are totally separate environments. The safety of the public we transport should be the only prerequisite in developing safer rules. In the meantime, I will be ever more cautious and deliberate when approaching the area of fatigue.
Original NASA ASRS Text
Title: TKOF MADE AFTER SUNSET WITH RWY LIGHTS OUT OF SERVICE.
Narrative: A DAYLIGHT LNDG WAS MADE AT SANTA MARIA ARPT, SANTA MARIA, CA, WITH PAX ON BOARD. THERE WAS A TRUCK AND MEN OFF THE LEFT RWY EDGE AT MID FIELD. NO ADVISORY WAS GIVEN BY TWR. THE F/O LISTENED TO ATIS AND MADE NO MENTION TO ME ABOUT MEN, EQUIPMENT OR FIELD LIGHTING. I WAS FLYING AND MADE THE LNDG. AFTER A 30 MIN GND TIME WE CALLED FOR TAXI FOR TKOF. WITH TOTALLY CLEAR CONDITIONS I ELECTED TO DEPART VFR FOR THE SHORT 10 MIN FLT TO SAN LUIS OBISPO, CA. COMPANY FLT FOLLOWING PROCS WERE USED. THE GND CTLR ADVISED ON TAXI OUT THAT THE RWY LIGHTS WERE OUT OF SVC FOR MAINT. AT THAT POINT IT DID NOT REGISTER THAT THEY WOULD NOT BE IN SERVICE FOR TKOF. AS I APCHED THE RWY THE SITUATION BEGAN TO TAKE SHAPE IN MY MIND. IT WAS VERY LIGHT WITH A GOOD MOON AND MY TAXI LIGHT, LNDG LIGHTS, RECOGNITION LIGHTS AND WING ICE LIGHTS ILLUMINATED SO MUCH THAT IT DID NOT SEEM LIKE NIGHT. THERE WERE PLENTY OF BLUE TXWY LIGHTS ALL DOWN THE RWY PLUS THE VASI LIGHTS AND I THINK THE APCH LIGHTS. THE RWY WAS CLEAR TO ME. I ASKED THE CTLR WHAT TIME WAS OFFICIAL SUNSET AND FOR SOME REASON MY MIND TOLD ME THAT I WAS OK FOR 1 HR AFTER SUNSET, WHICH I WAS WITHIN. EVERYTHING WAS SO CLEAR THAT IT MISLED MY THINKING. ALSO, ANOTHER COMPANY ACFT OPERATING UNDER THE SAME RULES DEPARTED RIGHT IN FRONT OF ME. I WAS NEARING THE END OF MY 3RD DAY OF DUTY. THE PREVIOUS DAY'S DUTY WAS 13 HRS AND 53 MINS WITH REDUCED REST OF 8 HRS AND 45 MINS AND I HAD BEEN ON DUTY THIS DAY FOR 10 1/2 HRS WITH 4 HRS TO GO. I HAD ALREADY TOLD MY F/O THAT BECAUSE WE WERE TIRED THAT WE NEEDED TO BE CAUTIOUS AND WATCH EACH OTHER CLOSELY. I MADE THE TKOF. THE ACTUAL DARKNESS AFTER LEAVING THE GND AND ALL OF THE AIRFIELD LIGHTS AND MY OWN ACFT LIGHTS JOLTED ME INTO REALIZING THAT I HAD ACTUALLY MADE A TKOF AFTER DARK W/O RWY LIGHTING AS REQUIRED BY 135.229B (2). THE BOUNDARY OF THE RWY WAS CLRLY DEFINED BY THE VASI AND TXWY LIGHTS AND I MAY HAVE IN FACT BEEN LEGAL, BUT ANOTHER IMPORTANT FACT KEEPS BOTHERING ME. I WAS FLYING IN A TIRED STATE OF MIND. I WAS TOTALLY LEGAL BY FAA RULES GOVERNING PART 135 COMMUTER DUTY AND REST PERIODS. COMPANY SCHEDULES ROUTINELY REQUIRE LONG DUTY DAYS FOLLOWED BY REDUCED REST AND AGAIN FOLLOWED BY LONG DUTY DAYS. AT THE URGING OF THE RAA (REGL AIRLINE ASSOCIATION) THE RULES WERE RECENTLY CHANGED TO SEP CHARTER AND COMMUTER DUTY TIME RULES UNDER PART 135. WE FLY DEMANDING SCHEDULES WITH 8-12 LEGS PER DAY. WE FLY A FAST AIRPLANE WITH NO AUTOPLT AND MUST MAKE MANY QUICK TURN AROUNDS BTWN LEGS. IN MANY YRS OF MIL FLYING IN MUCH LARGER EQUIP I NEVER EXPERIENCED SUCH A WORKLOAD. WHILE MY PHYSICAL ABILITY TO MANEUVER THE AIRPLANE DOES NOT SEEM AS EFFECTED, I FIND MY DECISION MAKING ABILITY SUFFERS GREATLY AT THE END OF AN EXHAUSTING DAY. BEING AWARE OF THIS CERTAINLY HELPS AND THIS INCIDENT WILL SLOW ME DOWN EVEN MORE AND BE ANOTHER VALUABLE LESSON. I THINK THE CREW AND DUTY TIME REGS ARE THE REAL CULPRITS IN THIS INCIDENT. AS SOON AS I BROKE GND AND MADE MYSELF EVALUATE THE SITUATION I KNEW I WAS WRONG AND SHOULD HAVE RETURNED TO THE GATE. IN A MORE RESTED STATE, I WOULD HAVE RECOGNIZED THIS ON THE GND. INSTEAD, I SUBCONSCIOUSLY RATIONALIZED THE SITUATION AS SAFE (WHICH IT WAS) EVEN THOUGH IT BROKE A RULE. I RECOGNIZE THAT RULES ARE THERE TO MAKE DECISIONS LIKE THIS CUT AND DRIED AND TAKE THE RESPONSIBILITY FOR ALWAYS INSURING SAFETY. ON THE OTHER HAND, A RULE THAT ALLOWS THE COMPANY TO ROUTINELY SCHEDULE PLTS INTO FATIGUE HAS TO CREATE SOME CONTEMPT FOR THOSE SAME RULES. JUST BECAUSE THE ACFT ARE SMALLER UNDER 135 DOES NOT INDICATE A SMALLER WORKLOAD THAN UNDER 121. THE WHOLE DUTY TIME SITUATION OF PART 135 COMMUTER OPERATION SHOULD BE RE-EVALUATED AND NO COMPARISON SHOULD BE MADE TO PART 121. THESE ARE TOTALLY SEPARATE ENVIRONMENTS. THE SAFETY OF THE PUBLIC WE TRANSPORT SHOULD BE THE ONLY PREREQUISITE IN DEVELOPING SAFER RULES. IN THE MEANTIME, I WILL BE EVER MORE CAUTIOUS AND DELIBERATE WHEN APCHING THE AREA OF FATIGUE.
Data retrieved from NASA's ASRS site as of August 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.