Government Affairs

The National Transportation Safety Board and Fatigue – A Timeline

This timeline represents more than 25 years of NTSB activity in the area of operator fatigue.

  • NOTES:
    • The two major NTSB recommendation packages of 1989 and 1999 covered all modes of transportation. The Board has issued about 180 recommendations dealing with operator fatigue in all modes of transportation.
    • Given the nature of our work we are most interested in pilot fatigue, and have limited the accidents in the timeline to aviation. These are certainly not the only aviation accidents where fatigue was considered, or even found to be a factor, but we believe that it contains the most notable ones.
    • The 2009 Colgan Air crash and the 1985 China Air event did not result in fatigue findings by the NTSB, even though fatigue was discussed at length in both. We have included a finding from the Board's Colgan report that all but cites fatigue.
  • 2009 – Atlanta GA. Delta Airlines B767. Landed on taxiway with 182 passengers and 11 crew. "The captain and first officer did not take their rest breaks during flight because a third pilot became ill and was unable to perform any cockpit duties during flight from Rio de Janeiro to ATL." The National Transportation Safety Board determines the probable cause(s) of this incident as follows: The flight crew's failure to identify the correct landing surface due to fatigue.

    http://www.ntsb.gov/aviationquery/brief.aspx?ev_id=20091020X05636&key=1

  • 2009 – near Buffalo NY (actually Clarence Center). Colgan Airways DHC-8. Crash on approach. 50 dead. Pilots within existing flight/duty times but likely fatigued (although NTSB could not agree on fatigue finding). Nevertheless, the Board adopted the following finding: "The pilots' performance was likely impaired because of fatigue, but the extent of their impairment and the degree to which it contributed to the performance deficiencies that occurred during the flight cannot be conclusively determined."

    http://www.ntsb.gov/doclib/reports/2010/AAR1001.pdf

  • 2008 – Owatonna MN. East Coast Jets flight 81, Hawker-Beechcraft 125-800A. Attempts go around and crashes. 8 dead. Pilot fatigue cited as contributing factor.

    http://www.ntsb.gov/doclib/reports/2011/AAR1101.pdf

  • 2008 – Hilo HW. Go Airlines flight 1002. Bombardier CL-600. Honolulu to Hilo flight, pilots fall asleep and overfly island by 26 miles before they wake up. Both fatigued.

    http://www.ntsb.gov/aviationquery/brief.aspx?ev_id=20080222X00229&key=1

  • 2007 – Cleveland OH. Shuttle America ERJ-170. Runway overrun. Captain's fatigue cited as contributing factor.

    http://www.ntsb.gov/aviationquery/brief.aspx?ev_id=20070223X00215&key=1

  • 2004 – Kirksville MO. Corporate Airlines BAE-J3201. Crashed on approach. 13 dead. Pilot fatigue contributing factor.

    http://www.ntsb.gov/doclib/reports/2006/AAR0601.pdf

  • 1999 – NTSB report: "Evaluation of U.S. DOT Efforts in the 1990s to Address Operator Fatigue."
    • FAA says 21% of ASRS reports involve fatigue.
    • NTSB finding: Despite acknowledgement that fatigue is a significant factor in transportation accidents, little progress has been made by DOT to revise the hours of service regulations to incorporate results of latest research.
    • New NTSB recommendation (A-99-45) to FAA: Within 2 years (that would have been 2001) establish scientifically based hours of service regulations that set limits on hours of service for flight crews.

    http://www.ntsb.gov/doclib/reports/1999/SR9901.pdf

  • 1995 – Kansas City MO. Air Transport International DC-8. 3-engine cargo aircraft ferry flight, crash on takeoff. All three crew fatal. Inadequate flight crew rest cited as contributing factor.

    http://www.ntsb.gov/aviationquery/brief.aspx?ev_id=20001207X02949&key=1

  • 1993 – Guantanamo Bay CUBA. American International Airways flight 808, DC-8. On approach, cargo airliner crashed. "The NTSB determines that the probable causes of the accident were the impaired judgment, decision making and flying abilities of the captain and flight crew due to the effects of fatigue..."

    http://www.ntsb.gov/aviationquery/brief.aspx?ev_id=20001211X13127&key=1

  • 1990 – NTSB puts operator fatigue on its Most Wanted List. It is still there.

    http://www.ntsb.gov/safety/mwl-1.html

  • 1989 – NTSB recommendations to the Department of Transportation to set new operator fatigue requirements in all modes of transportation based on latest scientific findings of circadian rhythm and hours of service.

    http://www.ntsb.gov/doclib/recletters/1989/I89_1_3.pdf

  • 1985 – China Airlines flight 006, B747. Taipei to LAX flight at 41,000 feet, lost engine. When attempting to restore power aircraft nosed over and plummeted to 9,500 feet. Pilot fatigue suspected but not proved.

    http://www.ntsb.gov/aviationquery/brief.aspx?ev_id=20001214X35672&key=1

  • 1980 – NASA created a program to determine the extent of fatigue in flight operations and its effect on safety.

Independent Pilots Association Involvement Addressing Fatigue in Aviation

This timeline represents more than 20 years of IPA activity in the area of pilot fatigue.

  • September 2011 – IPA meets with representatives of the Department of Defense to discuss industry lobbying efforts to exempt transportation of military men, women and material from new fatigue safety rules
  • August 2011 – IPA meets with Office of Management and Budget to discuss industry lobbying efforts to exempt cargo pilots from new fatigue safety rules
  • June 2011 – IPA participates MITRE Aviation Fatigue Symposium
  • February 2011 – IPA talks with members of Congress on The Hill pressing the importance of the FAA publishing a final pilot fatigue safety rule (talking points)
  • November 2010 – IPA Submission of Comments on Flightcrew Member Duty and Rest Requirements: Proposed Rule (submission)
  • October 2010 – IPA meets with fellow labor organizations to finalize a consensus submission to FAA FT/DT NPRM
  • August 2009 – IPA participates as panel member at DOT/FAA Call to Action on Airline Safety an Pilot Training
  • Summer 2009 – IPA member of the Aviation Rulemaking Committee (ARC) Flightcrew Member Duty and rest Requirements
  • June 2009 – IPA meets with DOT Secretary Ray LaHood on Flight Time/Duty Time regulations
  • March 2009 – IPA participates in US DOT sponsored International Conference on Fatigue Management in Transportation Operations – Boston, MA
  • June 2008 – IPA participates as panel member during first ever FAA Fatigue Management Symposium: Partnerships for Solutions (article)
  • Summer/Fall 2008 – IPA participates in FAA Working group on Ultra Long Range (ULR) Operations (flights longer than 16 hours block)
  • March 2008 – IPA publishes updated policy paper on fatigue (outline)
  • February 2005 – IPA meets with FAA Administrator Marion Blakey to discuss pilot fatigue and efforts to update existing outdated safety rules (article)
  • December 2004 – IPA participates in NASA Ultra Long Range Experiments (20 hour simulated flight - +32 hours awake)
  • September 2004 - IPA participates in NTSB Academy class on Investigating Human Fatigue Factor in Transportation Accidents
  • May 2001 – IPA applauds FAA notification of intent to enforce "Whitlow" 16-hour max duty interpretation, a regulation that had been on the books for over 15 years
  • September 2003 – IPA participates in NASA Fatigue Countermeasures Workshop
  • March 2001 – IPA notifies FAA Administrator Jane Garvey that the IPA has designated pilot fatigue as its top safety priority for 2001
  • February 2001 – IPA petitions in federal court to intervene in a lawsuit filed by Air Transport Association (ATA) attempting to block FAA from enforcing existing regulations limiting a pilot to no more than 16 hours of duty
  • June 1999 – IPA letter to Administrator Jane Garvey strongly supporting the FAA enforce FAR 121.471(b) with regard to reserve rest, as well as publication of a comprehensive revision to pilot Flight Time/Duty Time (FT/DT) regulations
  • January 1999 – IPA part of ARAC Reserve Rest Working Group Proposal of 77,789 Airline Pilots (submission)
  • Fall 1998 – IPA member of FAA Aviation Rulemaking Advisory Committee (ARAC) Reserve Duty/Rest Requirements Working Group
  • June 1996 – IPA hand delivers to FAA Administrator David Hinson NPRM Docket submission containing Scientific Review of NPRM by The Flight Duty Regulation Scientific Study Group (Scientific Review of NPRM)
  • Spring 1996 – IPA provides grant to esteemed panel of scientists and doctors to scientifically review FAA FT/DT NPRM
  • March 1996 – NASA releases draft copy of "FedEx Pilot Study" in response to out of court settlement with IPA (study) (Estabrook submission)
  • February 1996 – IPA sues NASA to release "FedEx Pilot Study" after denying FOIA request
  • February 1996 – IPA gives presentation to NTSB Chairman Jim Hall and staff documenting safety concerns with FAA NPRM Docket No. 28081
  • November 1995 – IPA supports appeal under the Freedom of Information Act (FOIA) forcing NASA to release NASA Technical Memorandum, "Crew Factors in Flight Operations VII: Psychophysiological Responses to Overnight Cargo Operations." (aka "FedEx Pilot Study")
  • May 1994 – IPA commissions scientific review of flightcrew schedule bid packages by Harvard Medical Researcher Dr. Martin Moore-Ede of Circadian Technologies, Inc (CTI) (letter/executive review)
  • March 1993 – IPA testifies before 103d Congress in support of legislation forcing the FAA to set reasonable limits on flight attendant duty time (testimony)
  • 1991–1994 – IPA member FAA Aviation Rulemaking Advisory Committee (ARAC) Flight and Duty Time Working Group