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AOPA
pilot commented on the non-standard approach profile. The initial impact with trees occurred 1.25 miles short of the threshold to Runway 18. Neither pilot survived.
That captain reported 8,600 hours of flight time on his most recent first- class medical. The first officer had approximately 4,700 hours of flight time. Though the captain’s flying skills were described as “average to above- average” by company pilots who had flown with him, he also had a some- what checkered training background. The first officer had a clean training record and a reputation as a solid crew- member. With better than 13,000 hours between them, the crew flew a per- fectly good aircraft into the ground 8,000 feet short of the touchdown zone.
Post-Accident Investigation
The captain of FedEx 1478 told in- vestigators that he had not slept well the two nights before the accident trip. The family dog had deteriorat- ing health, which interrupted his sleep both nights. He could only account for 3.5 hours of “pretty good” sleep prior to the accident flight. The first officer had not anticipated operating the accident flight. He had arrived at Memphis (the departure airport) at 2300 following what he believed to be his last flight of the day. Instead of going home, he received a message that he had been reassigned to the accident f light. He contacted crew schedulers questioning whether the assignment was legal. He was told it was and agreed to accept it, though he told NTSB investigators that he planned to object to it via a union grievance.
Since they were unable to interview the captain and first officer of UPS 1354, the NTSB primarily utilized the crew’s electronic devices in order to determine their sleeping habits. The captain’s “opportunity for sleep” was determined to be generally suf- ficient for basic rest needs. The first officer’s, however, was pronouncedly inadequate. She arrived for duty two nights prior to the accident having been awake 13 hours; her duty day following arrival was scheduled for 9.5 hours. During a 14.5 hour layover following the first night of her trip,
she obtained around 4 hours of sleep. She would get a limited nap before the accident in a UPS sleep room but was clearly carrying a substantial deficit of sleep into the accident f light.
Insidious Fatigue
In 2004 the FAA conducted a study to determine the relationship between flight test failures and enforcement actions. They found a “very low [cor- relation]...less than one percent.” The general conclusion was that training records can be somewhat meaningless as it relates to predicting the accident record (particularly when a pilot only has a few failures). This is not the case with fatigue. Scientific research has demonstrated that fatigue results in reduced alertness, degraded response time, inaccurate responses to stimuli, the inability to prioritize tasks in a coherent manner, a reduction in lead- ership skills, and an overall loss of motivation. Fatigue has been shown to contribute to impulsive decisions, fixation on only one aspect of an en- countered problem, and slow or non- existent reactions to emerging dan- gers. In other words, fatigue degrades the skills required to safely operate an aircraft. It is simply not possible to overcome its debilitating effects.
A companion study by the NTSB found that while only 1 percent of pro- fessional aircrews schedules exceed- ed 13 hours of duty, those schedules produced 5 percent of accidents. In nominal parlance, f lying after a 13- hour workday increases the risks of an accident by 500 percent. Flying after a long day represents one of the most significant risks that pilots encounter, every bit as ominous as thunderstorms or volcanic ash. Yet, in aviation, the answer is not as simple as drawing a hard line on hours of service. Like it or not, aviation is a 24-hour business. Fatigue is simply another peril that pilots must mitigate.
Countermeasures can take a variety of forms. For short bursts of energy, coffee or naps are effective in coun- tering the loss of alertness that insuf- ficient sleep produces. A nap (even as short as 15 minutes) increases alert- ness and mental functioning for a cou- ple hours. Coffee has a similar impact.
July 2021 / TWIN & TURBINE • 7