Analysis
National Transportation Safety Board
AIRCRAFT
Accident Report
62
captain stated that, even though he received only 1 hour of sleep the night before the
accident, he did not cancel the accident trip sequence because he thought that the company
would have red him.
The Safety Board concludes that shortcomings in Shuttle America’s attendance
policy limited its effectiveness because the specic details of the policy were not
documented in writing and were not clearly communicated to pilots, especially the
administrative implications or consequences of calling in as fatigued. The Safety Board
further concludes that Shuttle America’s failure to administer its attendance policy as
written might have discouraged some of the company’s pilots, including the accident
captain, from calling in when they were sick or fatigued because of concerns about the
possibility of termination.
It is important to note that pilots have a personal responsibility to monitor their
own tness for duty and avoid ying when they have a physical deciency that could
compromise safety.
58
On the day of this accident, the captain recognized that he was
fatigued; he warned his rst ofcers that he was tired; and, because of his fatigue, he
directed the accident rst ofcer to y the accident leg. The captain did not advise Shuttle
America of his fatigue or remove himself from duty because he thought he would be
terminated if he took this action.
59
However, the Safety Board concludes that, by not
advising the company of his fatigue or removing himself from duty, the captain placed
himself, his crew, and his passengers in a dangerous situation that could have been
avoided.
60
Industry 2.5.2
With the help of the Air Transport Association and the Regional Airline Association,
the Safety Board conducted an industry survey regarding fatigue and attendance policies,
receiving responses from 6 major and 10 regional Part 121 operators that belonged to
one of these associations. The survey responses revealed that all of the major and all but
58
Title 14 CFR 61.53 and 63.19 preclude required ight crewmembers from ight duty while they have a
known medical or physical deciency. Although the regulations do not specically cite fatigue, the FAA’s AIM
discusses fatigue as a factor that pilots should evaluate as part of determining their tness for ight.
59
The Safety Board investigated a previous accident in which a pilot’s action might have resulted from
concerns about a potential disciplinary activity. Specically, according to the Board’s report on the accident,
a Piper Apache PA-23 pilot, who was an Eastern Airlines captain commuting to his duty station, was highly
motivated to land his private airplane despite the less than minimum visibility required because of his perceived
need to report to work on time. During the landing, however, the Piper airplane struck a Pan American
Boeing 727. The Board found that the pilot had previously received a disciplinary letter because he had
reported late for an assigned ight. For more information, see National Transportation Safety Board, Piper
PA-23-150, N2185P, and Pan American World Airways Boeing 727-235, N4743, Tampa Florida, November 6,
1986, Aircraft Accident Report NTSB/AAR-87/06 (Washington, DC: NTSB, 1987).
60
In its investigation of the FedEx ight 1478 accident, the Safety Board found that, even though the
company had a policy allowing pilots to remove themselves from a ight schedule because of fatigue, both
pilots involved in the accident indicated that they had never turned down a trip because of fatigue. The
Board determined that both pilots’ fatigue contributed to the cause of the accident. For more information, see
National Transportation Safety Board, Collision With Trees on Final Approach, Federal Express Flight 1478,
Boeing 727-232, N497FE, Tallahassee, Florida, July 26, 2002, Aircraft Accident Report NTSB/AAR-04/02
(Washington, DC: NTSB, 2004).