Tired – Again

April 24, 2008 by Bruce Landsberg

You may have read that the pilots of the go! airlines regional jet were fired after they overflew Hilo on the short flight from Honolulu. The explanation, at this point in the investigation, was that both crew members were asleep and failed to respond to repeated ATC calls for descent.

Contrary to the usual profile of a hard days night after flying all day, this incident occurred mid morning and while it may be amusing to some, especially since no injury or damage was done, the FAA and industry should look at the root cause. You couldn’t find a much more contentious issue between airline management and pilots than duty time requirements – except perhaps money.

The FAA has rules in place but some question how effective they really are in preventing both acute and chronic fatigue. There is ample anecdotal evidence that many crews are really tired. The same applies to charter operators.

You might say it’s not GA’s problem unless you happen to be sitting in the back of a jet behind one these somnambulistic crews but my reason to understand fatigue better is that it may play a significant part in GA flight operations as well.

GA Night accident rates are significantly higher than day and we have occasions where “capable and competent” pilots just lost it. Why? Hypoxia? Yes, I’ll buy that. Fatigue – yep and based on the number of car and truck accidents due to fatigue, I’d say it was a factor in quite a number of GA accidents. How many? Can’t answer that since it doesn’t leave any markers and dead pilots tell no tales.

It’s something that the AOPA Air Safety Foundation may take a look at in the future. Would sure appreciate your response to the following:

A. Not a problem for me – never fly fatigued

B. Not a problem for me – but I have friends who have done so

C. I’ve had at least one instance where my performance was significantly degraded due to fatigue

D. It’s happened several times.

Bruce Landsberg
Senior Safety Advisor, Air Safety Institute

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  • Chris O’Callaghan


    D. It’s happened several times.

    I am a competitive glider pilot. National competitions are 10 days long, preceded by three practice days. Typically, I’m up by 0700. Assembling, ballasting, weighing, and gridding the sailplane can take 2 or more hours. Then comes a break before the pilots meeting at 1000. After that, it’s out to the runway where I plan my flight. Launching will start around noon, and I’ll typically log 5 to 7 hours before crossing the finish line. After the flight, there’s cleaning, disassembling, and attending to contest administrivia. Dinner doesn’t usually start until after 2000, and I’m seldom asleep before 2300.

    Fatigue is an ever-present problem. Cross-contry flights of 250 to 400 miles competing against the best pilots in the nation require unwavering concentration. On days with marginal lift, we can spend upwards of 40% of our flights thermalling… under G, in a hot, unshaded, poorly ventilated cockpits designed for performance rather than comfort.

    I’ve never fallen asleep at the controls. And I’d like to think I’ve never let fatigue affect my safety. But in a competitive environment, it’s easy to measure in points the effects of small mistakes. Physical and psychological discomforts brought on by fatigue manifest themselves in the scoresheet at the end of each day: points lost to poor decisions and missed opportunities. And in some cases, inattention to the vagaries of your environment can put you on the ground, far, far away from home.

    The top item on my preflight checklist is the airworthiness of the pilot. Of course, it’s the toughest one to measure…


  • http://www.finalflight.info David Reinhart

    A. I can’t remember it ever being a problem. I almost never fly at night and when I do it’s usually just the end of a day trip.

  • Dan Dudeck

    Answer C.

    As an ATP rated helicopter pilot with a Commercial AMEL license I find fatigue plays a big role in the ability to juggle the daily responsibilities that pilots must handle. Decision making may be negatively affected. Having said that, the prospect of a both pilots in a two pilot crew falling asleep at the wheel is difficult to digest.

    I have been is situations after having flown many consecutive long days that most certainly affected my decision making ability. Fortunately in my case however, I haven’t ever been close to falling asleep as a result.

    In reference to the increase in night time accident rates I strongly believe that lack of proficiency, night “currency”, inexperience and poor decision making are the primary culprits. After all, there are some benefits to nighttime operations. In general, convective activity is less at night than during the day, winds are generally lighter and traffic density and ATC workload is less.

  • http://www.aopa.org/asf Bruce Landsberg


    For many GA pilots it’s not an issue as we have more flexibility to fly when and where we like. When flying on business or commercially it does become an issue. I had a personal experience years ago which I’ll share at a future time.

    Thanks much for your thoughts….Bruce

  • Dianne Robbins

    Answer A.

    I get to bed early enough to allow enough sleep before each flight. It should be part of your flight planning process. I do make it a habit to study my flight and check the weather one more time just before turning the lights out. I don’t want other distractions that might keep me awake, I want my mind on flying. No wine the night before either–even though it does help most of us sleep better.

    Even with today’s technology in the cockpit, I still don’t see how anyone could find time to fall asleep when pilots should ALWAYS be cross checking the panel. I find it entertaining to play with VOR intersections, and how many stations and HIWAS can I pick up. I also try to have the approach plate for the airport I’m about to pass over in my lap. This will all keep you busy. There are many flight/navagating ways to occupy the flight time and keep your head in the aviation mode.

    Sleep well, and fly safe!

  • Greg Hundrup

    Answer D.
    I’m a corporate pilot. Even though I’m well rested before flight duty I find myself often very sleepy and snoozing shortly after departure.
    Before the flight the stress of checking the passenger transport, catering , aircraft servicing, wx, preflighting the airplane, slots, over flight/landing permits,
    Getting ATC clearance, receiving engine start, taxi and departure instructions by the time I reach the top of climb, I’m so relaxed that all the stress portions of the flight have passed,t I’m so relaxed I find it difficult to stay focused and can easily snooze during the enroute portion of the flight.

  • Annonymous


    I’m a corporate pilot in a two pilot crew flying air charter (air ambulance often back of the clock flying sometimes with minimum rest periods). Fortunately most of the time we operate on the buddy system. If one pilot is feeling tired, he asks the other pilot if he’s capable of watching things while he takes a nap to refresh and rejuvenate. If the other pilot becomes drowsy during this time, he wakes the first pilot and asks for the favor to be returned. I’d say that 90-95% of the time this is effective, however there are are occasions when both pilots are fatigued and although I don’t think I’ve ever fully gone to sleep while “on watch,” I have definitely found myself “resting my eyes” and even occasionally ending up with the “nods” (head falling forward bringing me back to full awareness). Often this occurs at the end of a long duty day (the “empty” leg home when we’ve been flying at/near or sometimes longer than 10 hours and often when our duty day is between 12 and 16 hours (I’ve even seen some 18 and 20 hour days).

    Recently there has been a lot of discussion with management about how we are able to fly more than 10 hours or have more than 14 hours of duty… Company argues that techincally the flying is “part 91″ at that point as we have dropped off our paying passengers (we still often have company medical crew aboard). Some argue that we were assigned, and the client paid for the aircraft to go from point A (to B to C to…) and back home to A, and because we are employed and being paid to fly from point A all the way back to A, that we should be governed by 135 rules for the entire trip.

    We’ve asked management to ask the FAA for clarification, and it has been argued that a) “everyone does it, so we have to do it to remain competitive” (and I believe there is some truth to this – until the FAA makes a strong stand and starts to enforce this will be an issue) and we’ve also been told b) that our Principal Operations Inspector (although apparently unwilling to put it in writing) has nodded and agreed that it’s part 91 flying and the 135 flight and duty limitations don’t apply.

    Those that complain are labeled as troublemakers. The official line is “If you’re really fatigued, the PIC can make a determination to stop and get a hotel” however it puts the burden on the pilots to find lodging (often) in the middle of the night, and there is a very real but unspoken expectation that we should bring the aircraft home. I also firmly believe that if we were to start to do this as frequently as we probably should, that we’d find ourselves at odds with management despite the “official” policy that its acceptable (coming back to “everyone does it and we have to remain competitive”).

    We all (pilots) realize that regardless of what part we are flying under… if we were at the end of even a 14 hour duty day (or worse something longer) in which we’d flown close (or just over) to 10 hours and something were to happen (say something that couldn’t have been avoided even if we weren’t fatigued – a blown tire on landing causing us to run off the runway or any other unlikely but possible scenario) that we as the pilots would undoubtedly be found guilty of careless and reckless operation due to how long we’d been flying, and that the ultimate responsibility to not fly that last leg does lie with us… but with little to no support from the FAA or and what only seems like lip service from management we often feel pressured into flying to our limits to “get the aircraft home.”

    The NTSB has made recommendations that the FAA should revisit flight and duty time regulations and has been ignored by the FAA so far as I can tell. I’ve seen court opinions that also beg for the FAA to more clearly define and or modify the part 135 rules which also seem to be ignored.

  • Andy Crane

    The biggest danger is confusing fatigue with exhaustion, fatigue is mental and exhaustion is physical. Not many GA pilots will take off when they are dead tired and falling asleep but everyone of us have flown after dealing with stressful personal or work issues that just consumes us mentally. When we apply full throttle on take off we feel physically fit but sometimes we are less than 100% mentally, these are the times that at rotation you realized the trim is still in the landing configuration or in my case, your cell phone is still laying on the elevator. These are the little mistakes that balloons into tragic conclusions or a request to call the tower after landing.
    Every checklist should have a hand written requirement to take a moment or two to do a brain check.

  • Rodolfo Paiz


    Planning a one-day business trip that seems very normal (flight out at 7am, arrive by 9am, work through 5pm, fly home) can be dangerous. A full day’s worth of work and business meetings can leave one short of mental energy for the IFR flight home at night. (Note: only USA allows VFR at night; everywhere else, night is defined as IMC).

    After the first couple of times this happened, I started changing my plans. But it’s very easy to have this kind of thing reduce your carefully-layered margins of safety.

  • Richard Smith

    SEVERAL TIMES. As a part 91 operator, you are pushed by your employers to make long days flights, with no FAR limitations on duty time. Not to say that there should be restrictions, but 91 commercial pilots need to realize that you can commit to these scenarios, and then find yourself pushing the limits as certain things don’t go as planned. Specific instance was a 4 am departure to the Northeast, with a 11pm arrival back in SC that night. After I committed, we took off and the autopilot failed. Hand flying in IMC the whole way with an approach to 200′ in MA. The plan to take a nap also failed because the FBO had only a couch and a busy / noisy terminal. At the days end, I was thankful that I was not taxed with an emergency and that no other mistakes were made. IT WAS STILL UNSAFE! I was extremely fatigued. The email to the boss the next day pretty much gave him a choice of a motel room or the new pilots salary. It was a statement that should have been made BEFORE the risky flight.

  • Charles Bolam

    During the mid 1990’s the Canadian Railroad authority did fatigue research on railroad operating employees. It was called the “Cicadia Study”. The results promped changes in rest and hours of service regulations on Canadian Railroads.

    U.S. Railroad Operating Unions cited the study results to petition FRA for hours of service and rest requirement changes.

    All pilots should be aware of the effect of fatigue on performance, in some ways, mimics oxygen deprivation. FAA regulations should protect Pilot employees from being forced to fly without proper rest.

  • Karin Stevens