Remarks for Carol J. Carmody
Acting Chairman, National Transportation Safety Board
Alertness Management in Flight Operations Symposium
Enhancing Aviation Safety
May 24, 2001
Thank you for inviting me to be here today to participate in the Air Transport Association's first alertness management symposium. I'm particularly honored to have been asked to join many of the world's subject matter experts to discuss how we can manage fatigue, improve alertness, and enhance aviation safety. Six years ago, the Safety Board, together with the National Aeronautics and Space Administration, held a symposium on these same issues. It was probably the first time that so many government and private sector leaders gathered in one place to address one of the major hazards to our transportation system -- fatigue.
Meetings such as this one are important because they allow us an opportunity to review what progress has been made and what actions still need to be taken, as well as to share ideas. I trust that you have found this conference to be as educational and thought provoking as the previous gathering and that it will help us further our knowledge of fatigue issues - because most assuredly -- lives depend on it.
The problems associated with fatigue permeate every aspect of our society and take a heavy toll on our safety, our productivity, and our quality of life. Although the issue of fatigue has been with us for a long time, it was not until the industrial age and the advent of complex machinery that it became a major hazard. With the increasing industrialization of society, people became more exposed to the dangers of fatigue. Today, in cars, on trains, on airplanes, we face first-hand the potential dangers from operator fatigue.
Every one of us knows exactly how fatigue feels and what it does to us. We've all experienced its dramatic effects when we've tried to drive an hour longer than we should, tried to stay up to watch a late-night movie, or tried to act interested while listening to yet another speaker discuss fatigue and alertness on the second day of a two-day conference!
However, the effects of fatigue are often much more subtle and, therefore, more insidious. I think that everyone would agree that sleep loss or a disturbed circadian rhythm has a direct relationship to errors, accidents and safety. But, identifying fatigue as factor in an accident can be very difficult. We can test a piece of metal to find out whether it has been weakened, but human fatigue is elusive and subjective. There is no "fatigue" test for humans and we are poor judges of our own state of fatigue. In research done by NASA on international flight crews, pilots reported that they felt at their highest state of alertness just six minutes before they fell asleep. On the scientific scale, these pilots qualified as having a severe sleep debt, yet they felt very alert. For those reasons, it has been difficult to identify fatigue as a causal factor in an investigation. But we are getting better at it, and, more important, we're learning how to counteract it.
Fatigue has been of great concern to the National Transportation Safety Board for more 25 years. Recommendations on operator fatigue in all modes of transportation have been on the Safety Board's "Most Wanted List" of safety improvements since the list's inception in 1990. Just last week, we reaffirmed its importance by retaining the issue on our Most Wanted list for another year.
Over the years, we have made about 100 recommendations on this issue to operators and regulators asking for additional education and research as well as specific regulatory changes. Our first recommendation on pilot rest and duty limitations was made to the Federal Aviation Administration (FAA) in 1972. We became more concerned in the 1980s after fatigue was cited or suspected of being a factor in at least two aviation accidents -- the in-flight upset of China Airlines flight 006 on February 19, 1985, and the crash of an Arrow Air charter flight on December 12, 1985, that killed 248 American soldiers. In the past 12 years, the Board has issued more than 70 fatigue-related recommendations across all modes of transportation. During that same period, we investigated seven aviation accidents that involved fatigue-related issues.
In 1989, the Safety Board issued three major safety recommendations to the Department of Transportation (DOT), calling for an aggressive federal program to address the fatigue problem in all sectors of the transportation industry. These recommendations asked for:
Following those recommendations, DOT made a concerted effort to conduct fatigue-related research in all modes of transportation. In addition, the FAA conducted several research projects that focused not only on pilot fatigue but also on how fatigue affects air traffic controllers and aviation maintenance personnel. Other governmental agencies, including NASA and the Department of Defense, as well as academia and industry, conducted additional research that contributed to our knowledge base as well.
Much has also been done by DOT, FAA, and others to develop and disseminate educational materials about the need for good work and rest schedules and the importance of proper health, diet, and rest regimens. NASA developed an educational and training module on "Alertness Management in Flight Operations" that:
In addition, the Allied Pilots Association recently produced a fatigue awareness training video to inform pilots about current research on fatigue and to educate them on how to recognize and avoid it.
The Board re-emphasized its concerns about the need for pilot education in a 1994 report on 37 flight crew-involved major accidents of U.S. air carriers that occurred between 1978 and 1990. In that report, the Board found that captains and first officers whose time since awakening was above the median for their crew position made more errors. We recommended that the FAA require air carriers to educate pilots about the detrimental effects of fatigue and to provide them with strategies for avoiding fatigue and countering its effects. In response, the FAA revised its advisory circular on crew management to include the requested information.
Despite these on-going research and educational endeavors, accidents have continued to occur with fatigue as a causal factor. On August 18, 1993, flight 808, an American International Airways DC-8, collided with level terrain about a quarter mile from the approach end of runway 10, at Guantanamo Bay, Cuba. The captain had lost control of the airplane while on approach to the Leeward Point Airfield at the U.S. Naval Air Station. The airplane was destroyed and the three crewmembers all sustained serious injuries.
The Board determined that the probable cause of the accident was, in part, the impaired judgment, decision-making, and flying abilities of the captain and flight crew due to the effects of fatigue. The accident investigation revealed that the flight crew had been on duty for about 18 hours and had been flying for about 9 hours at the time of the accident. The Safety Board cited the inadequacy of the flight and duty time regulations as an additional factor contributing to the cause of the accident. As a result, in May 1994, the Safety Board issued two additional safety recommendations to the FAA regarding the need to review and update current flight and duty time regulations.
In 1994, the Board also issued a safety study on commuter airline safety. The Board found that self-reports from commuter airline pilots indicated that most of the pilots surveyed had flown while fatigued. The most common reasons given were the length of duty days, early shift duty followed by late shift duty, and inadequate rest periods. The Safety Board asked the FAA to revise the federal aviation regulations so that all pilot flight time, regardless of its purpose, would be counted toward determining whether a pilot has had sufficient rest.
In a 1995 safety study on aviation safety in Alaska, the Board concluded that the consecutive, long duty days for commuter airline and air taxi flight crews in Alaska can contribute to fatigue and are a detriment to safety. In that report, the Safety Board again asked the FAA to revise the flight crew duty time regulations.
In response to those recommendations, the FAA issued an Notice of Proposed Rulemaking (NPRM) in December 1995. The NPRM discussed requirements to:
The FAA received about 2,000 comments on the NPRM and as might be expected, the reaction from respondents was mixed. Since that time, no further action has been taken to modify the duty and rest hours.
In 1999, the Board reviewed the status of our 10-year-old intermodal recommendations to DOT on the modal hours-of-service regulations. Our report examined the progress, or perhaps I should say the lack of progress, in each mode. We also reiterated our 1995 recommendations and again asked the DOT to require the modal administrations to modify their regulations to establish scientifically-based hours-of-service regulations, to provide predictable work and rest schedules, and to consider circadian rhythms and human sleep and rest requirements. We asked that this be done within two years. I should note that we just passed the two-year mark and, once again, little progress has been made.
A few months after the 1999 review, there was another fatigue-related crash. In August 1999, Korean Air Flight 801, a 747, crashed into Nimitz Hill, Guam at about 1:45 a.m. Of the 254 persons on board, 228 were killed and 23 passengers and 3 flight attendants were seriously injured. During our investigation, the Board examined a number of fatigue-related factors including time of day, the crew's recent sleeping patterns, and the number of hours they were awake, to determine whether fatigue was a factor in the accident captain's performance. Based on our findings and crew comments on the cockpit voice recorder, the Safety Board concluded that the captain was fatigued, a condition that degraded his performance and contributed to his failure to properly execute the approach.
I don't want to leave the impression that the Safety Board's concern about the effects of fatigue is limited to pilots. On the contrary, we are equally concerned about flight attendants, mechanics, and all transportation professionals. In its 1997 report on the crash of Valujet Airlines flight 592 in the Everglades, the Safety Board concluded that the duty time limitations for maintenance personnel may not be consistent with the current state of scientific knowledge about factors contributing to fatigue among personnel working in safety-sensitive positions. The Safety Board asked the FAA to review the issue of maintenance personnel fatigue and to establish duty time limits for them. We've also included this recommendation in our Most Wanted list. As I mentioned earlier, the FAA has also conducted research that determined that fatigue is an issue for maintenance personnel. However, no new regulations have yet been proposed.
I wanted to take you on this historical journey through the Board's actions to highlight how much work has been done to date - and how much more remains to be done. The bottom line is that despite all of the research and educational endeavors that have been undertaken over the years, they have not yet been translated into meaningful changes in the hours-of-service regulations in any transportation mode. We have seen a lot of activity -- rulemaking initiated - but not concluded, and committees and working groups formed -- and reformed -- to examine changes to the regulations. But, the same rules are still in effect and we have made no real progress toward providing the aviation community with scientifically-based operating rules.
In the meantime, the factors contributing to fatigue are becoming increasingly prominent - along with the potential for disaster. Commuter airline pilots often fly a dozen legs in one day, and after a shortened rest period, do it again the next day. Staffing shortfalls require airlines to ask their employees to work longer hours. Faster jets make it possible for both passengers and crewmembers to experience jet lag, which can cause fatigue by rapid travel across time zones, that even rest cannot immediately alter. And, we now have jumbo jets carrying more than 500 passengers, and new aircraft on the drawing board that can accommodate more than 1,000.
The FAA has announced that, within the next six months, it intends to begin enforcing the existing regulations concerning flight time limitations and rest requirements -- regulations that date back to 1985. These rules require airlines to provide reserve pilots with a pre-scheduled and protected eight-hour rest period sometime during the 24-hour period prior to completion of a flight assignment. Because these regulations haven't been enforced, airlines could require their reserve pilots to be "on call" 24 hours a day for several consecutive days without giving them the legally mandated crew rest. Although we're pleased that the FAA intends to enforce its existing regulations, the Board is still concerned that no further rulemaking has been undertaken to resolve the overall issue of hours of service or to equalize the duty and rest requirements for Part 121 and Part 135 operations.
There are those who seem all too willing to call for further research and study as an excuse for inaction. We already know -- and have repeatedly proven -- that the current rules do not provide for an adequate sleep opportunity or the effects of irregular schedules. Individuals aren't given a sufficient period of time to get the necessary seven or eight hours of sleep. Further delays are unacceptable and endanger the traveling public as well as flight crews. It's time to move forward.
Don't misunderstand me. We applaud all that has been accomplished thus far by the government, academia and the private sector. But at some point we must decide that although some areas, such as how quickly a sleep-deprived individual recovers after getting some rest, may still need to be researched, it's time for study to yield to action. It is time to put what we have learned into use for the benefit of those who need it - the individuals who operate and maintain the equipment and the individuals they transport.
I hope that those of you involved with the ATA's Alertness Management Initiative will keep that in mind as you move forward. Your task is to move beyond these efforts to ensure that constructive, proactive, science-based actions are taken that will enhance the system's safety. We all know that there are no simple solutions - if there were, we wouldn't be here today. We also know that if we are to solve the problem, everyone in the aviation community -- the airlines, the pilots, the FAA, and the experts in the field of sleep and fatigue research - must be willing to cooperate, coordinate, and compromise. The ATA's initiative has that potential. It focuses not only on research and education, but promises results that will:
Most importantly, the action plan recognizes that one size doesn't fit all and it goes beyond developing additional educational and research programs to include:
I am encouraged by ATA's involvement in and commitment to this endeavor. You have developed an ambitious agenda - one that all of us hope you will achieve as expeditiously, efficiently, and comprehensively as possible. I also hope that others throughout the transportation community will take note and follow suit.
Thank you again for inviting me to be here today.