The NTSB has long been concerned about the effects of fatigue on persons performing critical functions in all transportation industries including flight crews, aviation mechanics, and air traffic controllers. In 1989, the NTSB issued three recommendations to the Secretary of Transportation calling for research, education, and revisions to existing regulations. These recommendations were added to the NTSB's Most Wanted List in 1990, and the issue of fatigue has remained on the Most Wanted List since then. The NTSB's 1999 safety study of U.S. Department of Transportation efforts to address operator fatigue continued to show that this problem was widespread. Operating a vehicle without the operator's having adequate rest, in any mode of transportation, presents an unnecessary risk to the traveling public.
NTSB recommendations on the issue of human fatigue and hours-of-work policies have had a substantial effect on encouraging the modal agencies to conduct research and take actions towards understanding the complex problem of operator fatigue in transportation and how it can affect performance. However, the Federal Aviation Administration (FAA) has taken little, if any, action directly related to revising existing regulations and work scheduling practices.
Flight Crews
The FAA issued a notice of proposed rulemaking in December 1995 to update the flight and duty regulations for airline pilots; however, in the intervening 14 years, the regulations have not been revised. In recent years, the FAA has stated that it is developing a fatigue risk management system (FRMS) to provide an alternative to prescriptive limitations. The FAA has been working with Delta Air Lines since 2006 to develop fatigue countermeasures for crew on ultra long range (ULR) flights (flights of more than 16 hours). This fatigue countermeasure program was approved as an Operations Specification issued to Delta Air Lines for specific ULR routes. The FAA viewed Delta's fatigue mitigation strategy as a model program and proposed in November2008 to amend the Operations Specifications of other airlines with ULR routes to incorporate fatigue mitigation plans for their ULR flights. The affected airlines, as well as other airlines without ULR routes and industry associations, threatened legal action to block the FAA's action. The FAA then withdrew the proposed amendments on March 12, 2009.
In 1999, the FAA issued a report, Study of Fatigue Factors Affecting Human Performance in Aviation Maintenance. The FAA expanded this study, completing the first phase of the expanded study and issuing a report in April 2000, titled Evaluation of Aviation Maintenance Working Environments, Fatigue, and Maintenance Errors/Accidents. The expanded study looked at multiple and combined environmental factors of temperature, noise, light, vibration, and sleep, which are known to accelerate fatigue onset, as well as the effects of lifestyle habits on fatigue and human performance. The study was designed to collect data in the aviation maintenance work environment on known factors that affect human fatigue and performance. The FAA's findings suggest that fatigue is an issue in this work force. Data from "mini-logger monitors" that recorded data from the selected parameters of light, noise levels, and temperature; activity monitors that monitored physical activity, sleep, and sleep quality; and answers to background questions that employees were asked clearly indicate that sleep durations are inadequate to prevent fatigue. For most aviation maintenance technician specialties, 30-40 percent of respondents reported sleep durations of less than 6 hours, and 25 percent of respondents reported feeling fatigued or exhausted. The data were intended for use in predicting situations that are conducive to fatigue, accidents, incidents, and errors. Data collection began in August 2000, and the expanded study was planned for completion in December 2003. However, an FAA Aviation Maintenance Human Factors Project Report from January 2004 stated that the research had not progressed, nor is any broad research effort or regulatory activity currently being conducted in this area. The FAA stated its belief that the extreme complexity of the issue of maintenance crew fatigue and duty time precludes its consideration for regulatory activity. The FAA further stated that the sponsoring and support of education and training in fatigue management are the most appropriate actions for the FAA to take in response to this subject. The NTSB disagrees with the FAA's position that regulatory action is inappropriate and that the FAA's current education and training activities can achieve the intent of Safety Recommendation A-97-71. However, the NTSB is encouraged by the new FAA administrator's interest in the fatigue issue and hopes that he will reconsider the FAA's prior position related to aviation maintenance fatigue. The FAA convened a work group to research and propose changes to controller scheduling policies and practices; this group has completed its review and has recommended changes primarily associated with increasing the time between shifts to provide controllers adequate opportunity to obtain sufficient sleep. However, the recommendations of this work group were not implemented, in favor of pursuing a more collaborative approach with the National Air Traffic Controllers Association (NATCA) and the establishment of a dedicated Fatigue Risk Management (FRM) Office within the Air Traffic Organization. This office plans to develop and implement, in collaboration with NATCA, a science-based controller fatigue mitigation plan. To achieve this, the office has established a work group, co-chaired by the NATCA Northeast Region Vice President, as defined in the controller collective bargaining agreement of October1, 2009. This workgroup is to address fatigue management systems and fatigue concerns in the controller work place. Additionally, the office is sponsoring a NASA Ames controller fatigue study, in collaboration with NATCA, that will survey all controllers and will include an on-site component at a select number of facilities to gather data about controller fatigue directly from the field. The FAA has also developed and implemented a fatigue awareness training program consisting of a 1-hour fatigue awareness lesson taught in the terminal and en route initial qualification courses, a 30-minute computer based instruction (CBI) lesson for refresher training and a brochure. A general notice will be issued to inform field air traffic control personnel that the CBI is a mandatory annual refresher. Although NATCA has stated that the FAA has not involved it in developing revisions to the scheduling policies and practices to address fatigue in controllers or in developing the fatigue awareness training program, the FAA has briefed NATCA on the revisions that it plans to implement and has included NATCA in the actions described above. NATCA is independently developing a fatigue awareness/countermeasures program that it will distribute to its membership. In response to the fatigue management system recommendations the NTSB issued in 2008, the FAA sponsored a symposium on fatigue management in June 2008 that provided an opportunity for subject matter experts to come together and discuss fatigue's effects on flight crews, maintenance personnel, and air traffic controllers. The FAA (1)consolidated and published on its website proceedings from the symposium, (2) attempted unsuccessfully to develop operations specification guidance for fatigue management in ULR flight operations, and (3) is collecting data on fatigue aspects of ULR and other flight operations to form the basis for improved fatigue guidance documents and standardized protocols for such data gathering. The NTSB believes that fatigue management plans may hold promise as an approach to dealing with fatigue in the aviation environment. However, the NTSB considers a fatigue management plan to constitute a complement to, not a substitute for, regulations to prevent fatigue. In June 2009, FAA Administrator J. Randolph Babbitt initiated an expedited review of flight and rest rules, saying that the FAA was making pilot fatigue a high priority and would work rapidly to develop and implement a new flight time and rest rule based on fatigue science and a review of international approaches to the issue. The FAA established an aviation rulemaking committee (ARC) to review and develop proposed regulatory revisions to address flightcrew fatigue. The ARC finished its work in September 2009, and the FAA is currently preparing a notice of proposed rulemaking (NPRM) based on the work of the ARC. The NTSB has not been advised of the planned revisions. Revise fatigue regulations that permit Part 121 and Part 135 crew members to exceed the flight time/duty time limits when flying tail end and ferry flights. Issue regulations that establish scientifically based duty time limitations for air carrier maintenance personnel and flight crews. Revise controller work-scheduling policies and practices to provide adequate rest periods, modify controller shift rotations to minimize fatigue, and develop a fatigue awareness and countermeasures training program for controllers. A-94-194 (FAA) A-95-113 (FAA) A-97-71 (FAA) A-06-10 (FAA) A-07-30 (FAA) A-07-32 (NATCA) A-08-44 (FAA) A-08-45 (FAA)Air Traffic Controllers
Fatigue Management Systems
Actions Remaining
Safety Recommendations
Issued November 30, 1994
Added to the Most Wanted List: 1995
Status: Open-;Unacceptable Response
Revise the Federal Aviation Regulations contained in 14 [Code of Federal Regulations] CFR Part 135 to require that pilot flight time accumulated in all company flying conducted after revenue operations-;such as training and check flights, ferry flights and repositioning flights-;be included in the crewmember's total flight time accrued during revenue operations.(Source: Commuter Airline Safety, [NTSB/SS-94-02]).
Issued November 14, 1995
Added to the Most Wanted List: 1996
Status: Open-;Unacceptable Response
Finalize the review of current flight and duty time regulations and revise the regulations, as necessary, within 1 year to ensure that flight and duty time limitations take into consideration research findings in fatigue and sleep issues. The new regulations should prohibit air carriers from assigning flight crews to flights conducted under 14 CFR Part 91 unless the flight crews meet the flight and duty time limitations of 14 CFR Part 121 or other appropriate regulations. (Source: Investigation of an Uncontrolled Collision with Terrain, Air Transport International, Douglas DC-8-63, N782AL, Kansas City International Airport, Kansas City, Missouri, February 16, 1995 [NTSB/AAR-95-06]).
Issued September 9, 1997
Added to the Most Wanted List: 1999
Status: Open-;Unacceptable Response
Review the issue of personnel fatigue in aviation maintenance; then establish duty time limitations consistent with the current state of scientific knowledge for personnel who perform maintenance on air carrier aircraft.(Source: The Investigation of the In-flight Fire and Impact with Terrain, ValuJet Airlines Flight 592, DC-9-32, N904VJ, Everglades, near Miami, Florida, May 11, 1996 [NTSB/AAR-97-06])
Issued February 7, 2006
Added to the Most Wanted List: 2006
Status: Open-;Unacceptable Response
Modify and simplify the flight crew hours-of-service regulations to take into consideration factors such as length of duty day, starting time, workload, and other factors shown by recent research, scientific evidence, and current industry experience to affect crew alertness.(Source: Collision with Trees and Crash Short of the Runway, Corporate Airlines Flight 5966, BAE Systems BAE-J3201, N875JX, Kirksville, Missouri, October 19, 2004 [NTSB/AAR-06/01])
Issued April 10, 2007
Added to the Most Wanted List: 2007
Status: Open-;Acceptable Response
Work with the National Air Traffic Controllers Association to reduce the potential for controller fatigue by revising controller work-scheduling policies and practices to provide rest periods that are long enough for controllers to obtain sufficient restorative sleep and by modifying shift rotations to minimize disrupted sleep patterns, accumulation of sleep debt, and decreased cognitive performance. (Source: Recommendation letter to the FAA, dated April 10, 2007, regarding four runway incursions and Attempted Takeoff from Wrong Runway, Comair Flight 5191, Bombardier CL-600-2B19, Lexington, Kentucky, August 27, 2006 [NTSB/AAR-07/05])
Issued April 10, 2007
Added to the Most Wanted List: 2007
Status: Open-;Acceptable Response
Work with the Federal Aviation Administration to reduce the potential for controller fatigue by revising controller work-scheduling policies and practices to provide rest periods that are long enough for controllers to obtain sufficient restorative sleep and by modifying shift rotations to minimize disrupted sleep patterns, accumulation of sleep debt, and decreased cognitive performance. (Source: Recommendation letter to NATCA, dated April 10, 2007, regarding four runway incursions and Attempted Takeoff from Wrong Runway, Comair Flight 5191, Bombardier CL-600-2B19, Lexington, Kentucky, August 27, 2006 [NTSB/AAR-07/05])
Issued June 12, 2008
Newly Added to the Most Wanted List
Status: Open-;Acceptable Response
Develop guidance, based on empirical and scientific evidence, for operators to establish fatigue management systems, including information about the content and implementation of these systems. (Source: Recommendation letter to the FAA, dated June 12, 2008, and Collision with Trees and Crash Short of Runway, Corporate Airlines Flight 5966, British Aerospace BAE-J3201, N875JX, Kirksville, Missouri, October 19, 2004 [NTSB/AAR-06/01])
Issued June 12, 2008
Newly Added to the Most Wanted List
Status: Open-;Acceptable Response
Develop and use a methodology that will continually assess the effectiveness of fatigue management systems implemented by operators, including their ability to improve sleep and alertness, mitigate performance errors, and prevent incidents and accidents. (Source: Recommendation letter to the FAA, dated June 12, 2008, and Collision with Trees and Crash Short of Runway, Corporate Airlines Flight 5966, British Aerospace BAE-J3201, N875JX, Kirksville, Missouri, October 19, 2004 [NTSB/AAR-06/01])
