NTSB Aircraft Accident Report
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At the time of the accident, the first officer had been awake about 13.5 hours. Research
into quantifying performance impairment associated with sustained wakefulness found that
performance remains relatively stable throughout the time that coincides with a normal waking
day, but that prolonged wakefulness of 17 hours can result in measurable performance
impairment (comparable to having a blood alcohol concentration of 0.05 percent).
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The first
officer did not have such prolonged or otherwise excessive periods of wakefulness before the
accident.
The captain also took steps to minimize the effects of fatigue due to the circadian clock.
On the night before the accident trip, the captain went to sleep about 2200 but, to prepare himself
for the upcoming night flight, awoke about 0400 on January 26, 2009. Later that afternoon, he
napped from about 1100 to 1630, providing a 5.5-hour sleep opportunity. The captain stated that
he needed 6 to 8 hours of sleep each night to feel rested. In the 72 hours before the accident, the
captain had 22 hours of sleep opportunity (10 hours, 6 hours, and 5.5 hours). The captain stated
that he felt rested on the evening of the accident. Although research suggests that appropriately
placed naps can improve alertness for up to 24 hours,
135
because the accident occurred during the
window of circadian low, the captain was likely experiencing some fatigue at the time of the
accident. In addition, if the captain required 8 hours of sleep per night to feel rested, he may have
been experiencing as much as 4.5 hours of cumulative sleep loss on the night of the accident.
Research suggests that as few as 2 hours of sleep loss can lead to reduced performance and
alertness.
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At the time of the accident, the captain had been awake about 12 hours, which
would not be considered excessive.
2.3.6.1 Role of Fatigue in Flight Crew Performance
The negative effects of fatigue on human performance have been demonstrated in
scientific research and accident and incident investigations.
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These effects include slowed
response time, reduced vigilance, and poor decision making. The flight crew’s failure to monitor
134
(a) D. Dawson and K. Reid, “Fatigue, Alcohol and Performance Impairment,” Nature, vol. 388, no. 6639
(1997), p. 235. (b) N. Lamond and D. Dawson, “Quantifying the Performance Impairment Associated with
Sustained Wakefulness” (Woodville, South Australia: The Centre for Sleep Research, The Queen Elizabeth
Hospital, 1998). <http://cf.alpa.org/internet/projects/ftdt/backgr/Daw_Lam.html> (accessed March 21, 2011).
135
D.F. Dinges and others, “Temporal Placement of a Nap for Alertness: Contributions of Circadian Phase and
Prior Wakefulness,” Sleep, vol. 10, no. 4 (1987), pp. 313-329.
136
R. T. Carskadon, “Sleep Restriction,” ed., Sleep, Sleepiness and Performance, T. H. Monk, ed. (Chichester,
England: John Wiley & Sons, 1991), pp. 155–167.
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For the scientific research, see J.A. Caldwell, “Fatigue in the Aviation Environment: An Overview of the
Causes and Effects as Well as Recommended Countermeasures,” Aviation, Space, and Environmental Medicine,
vol. 68 (1997), pp 932-938; G.P. Kruger, “Sustained Work, Fatigue, Sleep Loss, and Performance: A Review of the
Issues,” Work and Stress, vol. 3 (1989), pp 129-141; and F.H. Previc and others, “The Effects of Sleep Deprivation
on Flight Performance, Instrument Scanning, and Physiological Arousal in Pilots,” The International Journal of
Aviation Psychology, vol. 19, no. 4 (2009), pp. 326-346. For the accident investigations, see, for example, Crash
During Attempted Go-Around After Landing East Coast Jets Flight 81 Hawker Beechcraft Corporation 125-800A,
N818MV Owatonna, Minnesota July 31, 2008, Aircraft Accident Report NTSB/AAR-11/01 (Washington, DC:
National Transportation Safety Board, 2011). <http://www.ntsb.gov/Publictn/2011/AAR-11-01.pdf>; Collision with
Trees and Crash Short of Runway, Corporate Airlines Flight 5966, British Aerospace BAE-J3201, N875JX,
Kirksville, Missouri, October 19, 2004, Aircraft Accident Report NTSB/AAR-06/01 (Washington, DC: National
Transportation Safety Board, 2006). <http://www.ntsb.gov/publictn/2006/AAR0601.pdf>.