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Safety Recommendation Details

Safety Recommendation A-06-011
Synopsis: On October 19, 2004, about 1937 central daylight time,1 Corporate Airlines (doing business as American Connection) flight 5966, a BAE Systems BAE-J3201, N875JX, struck trees on final approach and crashed short of runway 36 at the Kirksville Regional Airport (IRK), Kirksville, Missouri. The flight was operating under the provisions of 14 Code of Federal Regulations (CFR) Part 121 as a scheduled passenger flight from Lambert-St. Louis International Airport (STL), in St. Louis, Missouri, to IRK. The captain, first officer, and 11 of the 13 passengers were fatally injured, and 2 passengers received serious injuries. The airplane was destroyed by impact and a postimpact fire. Night instrument meteorological conditions (IMC) prevailed for the flight, which operated on an instrument flight rules flight plan.
Recommendation: TO THE FEDERAL AVIATION ADMINISTRATION: Require all 14 Code of Federal Regulations Part 121 and 135 operators to incorporate fatigue-related information similar to that being developed by the Department of Transportation Operator Fatigue Management Program into their initial and recurrent pilot training programs; such training should address the detrimental effects of fatigue and include strategies for avoiding fatigue and countering its effects. (Superseded by A-08-44)
Original recommendation transmittal letter: PDF
Overall Status: Closed - Acceptable Action/Superseded
Mode: Aviation
Location: Kirksville, MO, United States
Is Reiterated: No
Is Hazmat: No
Accident #: DCA05MA004
Accident Reports: Collision with Trees and Crash Short of Runway, Corporate Airlines Flight 5966, British Aerospace BAE-J3201, N875JX
Report #: AAR-06-01
Accident Date: 10/19/2004
Issue Date: 2/7/2006
Date Closed: 6/12/2008
Addressee(s) and Addressee Status: FAA (Closed - Acceptable Action/Superseded)
Keyword(s): Fatigue,

Safety Recommendation History
From: NTSB
Date: 4/23/2013
Response: Notation 8486: On March 11, 2013, the US Chemical Safety and Hazard Investigation Board (CSB) published a request for public comment on a document released on its website titled “Draft Recommendations Evaluation for Public Comment: Fatigue Risk Management Systems (FRMS)” (CSB Evaluation). Subsequently, CSB staff invited the National Transportation Safety Board (NTSB) to share its experiences in investigating transportation accidents in which human fatigue was identified as a safety issue, and related NTSB safety recommendations. The NTSB is an independent federal agency charged with determining the probable cause of transportation accidents and issuing safety recommendations aimed at preventing future accidents. The NTSB has a long history of making recommendations to reduce fatigue and fatigue-related transportation accidents and, since its inception, has issued over 200 recommendations addressing fatigue in the aviation, highway, marine, railroad, and pipeline modes. We are pleased to share our experiences with the CSB. The CSB Evaluation comments on actions taken by the American Petroleum Institute (API) and the United Steelworkers International Union (USW) in response to Recommendation No. 2005-04-I-TX-7, issued by the CSB in 2005 to those organizations. The CSB recommendation was issued as a result of the March 23, 2005, Texas City, Texas, refinery explosion and fire. The portion of the CSB recommendation pertinent to this letter reads as follows: [D]evelop fatigue prevention guidelines for the refining and petrochemical industries that, at a minimum, limit hours and days of work and address shift work…. In April 2010, the API issued an American National Standards Institute-approved Recommended Practice titled Fatigue Risk Management Systems for Personnel in the Refining and Petrochemical Industries, First Edition (RP-755), and an accompanying technical report titled Fatigue Risk Management Systems for Personnel in the Refining and Petrochemical Industries, Scientific and Technical Guide to RP 755. The CSB Evaluation presents the results of a CSB staff review in which the CSB staff determined that RP-755 does not meet the intent of the CSB recommendation in several areas. The NTSB has reviewed RP-755 as well as the CSB Evaluation. With respect to human fatigue, the NTSB has specific experience with the following issues that are discussed in the CSB Evaluation: • The hours-of-service limits described in RP-755, which are more permissive than what is indicated by current scientific knowledge, and the suggestion that voluntary FRMS programs will compensate for the risk from excessive hours and days at work, and • The emphasis of RP-755 on voluntary efforts by industry and its lack of explicit requirements, especially with respect to elements of an effective fatigue management system. With respect to the hours-of-service limits, RP-755 describes “work sets” during normative conditions, which may include 12-hour day shifts or night shifts for 7 consecutive days, with the possibility of an additional “holdover period” beyond the duty day for training or safety meetings. The RP states that the “holdover period should not exceed 2 hours and, where possible, occur at the end of the day shift.” However, the use of the language “should” is not a requirement but is defined by the document as a “recommendation or that which is advised but not required in order to conform to the RP.” Therefore, a worker could, during a normal work set, work shifts of 14 hours or greater in a 24-hour period for several days. RP-755 also states that during planned or unplanned outages, workers may be called on to work 12-hour shifts for up to 14 consecutive days, with as little as 36 hours between 14-day, 12-hour work sets. Holdover periods of up to 2 hours are also allowed during outages. The RP also has provisions for extending work shifts up to 18 hours. In several of its accident investigations, the NTSB has recognized the relationship between long duty days and fatigue, both directly and through their effects on reduced sleep lengths during off-duty periods. For example, in the investigation of the October 2004 Corporate Airlines accident in Kirksville, Missouri, the NTSB determined that the probable cause of the accident was the pilots’ failure to follow established procedures and properly conduct an instrument approach at night, and that fatigue was one factor that contributed to the pilots’ degraded performance. The length of the pilots’ duty day (at the time of the accident, they had been on duty for 14 1/2 hours) was cited along with less-than-optimal overnight rest time, early reporting time for duty, the number of flight legs, and demanding flight conditions, as factors that resulted in the pilots’ fatigue. In the Kirksville report, the NTSB cited research showing that pilots who worked schedules that involved 13 or more hours of duty time had an accident rate that was several times higher than that of pilots working shorter schedules, and that airplane captains who had been awake for more than about 12 hours made significantly more errors than those who had been awake for less than 12 hours. As a result of the Kirksville investigation, the NTSB issued Safety Recommendation A-06-10 to the Federal Aviation Administration (FAA), which stated the following: A-06-10 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. The NTSB reiterated Safety Recommendation A-06-10 in 2008 following its investigation of the April 2007 Pinnacle Airlines accident in Traverse City, Michigan. In that accident, the NTSB determined that the probable cause of the accident was the pilots’ poor decision-making as they prepared to land the airplane. The NTSB stated that “This poor decision-making likely reflected the effects of fatigue produced by a long, demanding duty day and, for the captain, the duties associated with check airman functions.” The pilots had been on duty for more than 14 hours at the time of the accident. The effectiveness of fatigue management is directly related to the availability of work schedules that allow a sufficient period of time between work shifts for the employee to obtain sufficient restorative sleep. The NTSB has investigated several accidents and serious incidents that provided clear and compelling evidence that air traffic controllers were sometimes operating in a state of fatigue because of their work schedules and poorly managed utilization of rest periods between shifts, and that fatigue had contributed to controller errors. Consequently, the NTSB issued Safety Recommendation A-07-30 to the FAA, which stated the following: A-07-30 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. The NTSB’s consideration of how long duty days affect fatigue and safety has not been limited to the aviation mode. Recently, in our investigation of the September 2010 collision of two freight trains near Two Harbors, Minnesota, the NTSB concluded that crew fatigue was a contributing factor in train crew errors that led to the collision. The train crewmembers who made the errors had been awake between 13 and 14 hours at the time of the accident, and the accident occurred during the final hour of a 12-hour shift. In its report, the NTSB cited a study showing that 12 hour work shifts have been associated with decrements in alertness and performance, compared to 8-hour shifts. Other studies of commercial drivers have found an exponential increase in crash risk with increasing driving times, especially for driving periods that extend beyond 8 or 9 hours. The NTSB has made numerous recommendations concerning hours of service across the transportation modes. A common theme of those NTSB recommendations has been an emphasis on establishing hours-of-service limits that are scientifically based, that set limits on hours of service, that provide predictable work and rest schedules, and that consider circadian rhythms and human sleep requirements. The second issue discussed in the CSB Evaluation with which the NTSB has experience concerns the lack of explicit requirements regarding essential elements of a fatigue management program. The CSB Evaluation remarks that The use of the word ‘should’ for most elements of a Fatigue Risk Management System (FRMS) in the RP means that they are optional, not required. In what is already a voluntary standard to begin with–employers can choose to conform to them, but they are not required by force of law to do so–‘should’ statements have very little force. The lack of required FRMS elements raises additional concerns because RP-755 states that its hours-of-service limits were “developed in the context of the existence of a comprehensive FRMS” and that “Consistently working at the limits shown is not sustainable and may lead to chronic sleep debt.” Hence, while RP-755 does not require the use of an FRMS, it does ostensibly allow operators to persistently schedule workers at the noted limits. The NTSB has recommended requiring the implementation of fatigue management programs. For example, as a result of its investigation of a June 2009 multivehicle accident near Miami, Oklahoma, in which a truck driver’s fatigue resulted in his failure to react to and avoid colliding with a slowing traffic queue, the NTSB emphasized the importance of comprehensive fatigue management programs. The report described the North American Fatigue Management Program (NAFMP), which is designed to address scheduling policies and practices, fatigue management training, sleep disorder screening and treatment, and fatigue monitoring technologies. In the report, the NTSB stated that “if the NAFMP guidelines remain voluntary—and are used by some carriers but ignored by others—this important safety tool might have only a limited effect in reducing fatigue-related highway accidents.” As a result of its investigation, the NTSB called on the Federal Motor Carrier Safety Administration to implement the following NTSB safety recommendation: H-10-9 Require all motor carriers to adopt a fatigue management program based on the North American Fatigue Management Program guidelines for the management of fatigue in a motor carrier operating environment. The NTSB has also made recommendations in the highway, railroad, and aviation modes to establish ongoing programs to evaluate, report on, and continuously improve fatigue management programs implemented by operators (NTSB Safety Recommendations H-08-14, R 12-007, A-06-11, and A-08-45). I hope that this information about the NTSB’s history of investigating fatigue-related accidents and the recommendations we have issued will be useful as the CSB moves forward with the evaluation of the API and USW responses to the fatigue-related CSB recommendation resulting from the Texas City investigation.

From: NTSB
Date: 6/12/2008
Response: The Safety Board notes that, in correspondence relating to Safety Recommendation A-06-11, the FAA has stated that, in addition to issuing SAFO 06004, fatigue has always been noted in Advisory Circular (AC) 120-51, Crew Resource Management Training, as one of the most important factors degrading situational awareness and overall crew performance. However, the continued occurrences of fatigue-related accidents and incidents indicate that the information contained in AC 120-51 and the issuance of SAFO 06004 have not been effective in preventing fatigue-related events. Therefore, Safety Recommendation A-08-44 will supersede Safety Recommendation A-06-11, which is classified Closed Acceptable Action/Superseded. Once fatigue management systems are in place, it is imperative that operators, as well as the FAA, ensure that the systems are performing as intended. The FAA must be involved because of the nature of its oversight and its overarching responsibility to ensure the safety of the aviation industry. Therefore, fatigue management systems must be evaluated to determine whether they effectively mitigate fatigue and to identify key components to make them more effective. Many challenges exist to evaluating the value of fatigue management systems. For example, it needs to be determined whether a fatigue management system should be expected to improve outcomes and, if so, by how much. In the case of ULR operations, the international steering committee recommended that ULR fatigue management systems should be sufficiently rigorous to ensure operational safety equivalent to or better than that in current long range operations. Because ULR flights can be more demanding than traditional long-range operations, it may be appropriate to set a standard of no change in safety outcomes. However, the ostensible and logical goal of many fatigue management systems is to reduce fatigue and improve performance and safety. Therefore, the expected indicators of the success of such systems need to be established to properly evaluate such systems. Another challenge with evaluating fatigue management systems is that fatigue is not an objective measure. It can be very subjective, and it is not always apparent when fatigue is present and whether it contributes directly or indirectly to an error or performance. A variety of outcomes, including sleep quantity, sleep quality, knowledge of individual fatigue management strategies, and performance, have been used to assess existing scheduling systems or to evaluate the impact of fatigue management systems.26 Sleep quantity is typically measured using objective wrist activity monitors that track an individual’s physical activity and movement or subjective sleep diaries. Sleep quality and knowledge of fatigue management strategies are typically assessed using interviews or surveys. In terms of performance, some studies have employed computerized performance assessments such as the Psychomotor Vigilance Task,27 which has been demonstrated to be sensitive to sleep loss. Other studies have tracked actual performance in operational settings using flight data monitoring programs or line operation safety audits. Other measures that have been proposed include tracking absenteeism rates and incident and accident rates.28 Fatigue management systems appear to hold promise as a progressive approach to addressing the problems associated with fatigue in aviation environments, especially because physiological, behavioral, self-report, and operational evidence are used to provide a scientific basis for establishing and evaluating such systems. As noted, such systems are needed as a complement to, not a replacement for, revised flight and duty time regulations, which were recommended in Safety Recommendations I-89-3, A-99-45, and A-06-10 and still have not been revised. However, the experience of the New Zealand airlines suggest that, although many individual systems appear promising in principle, refinement and ongoing oversight are necessary to ensure that they are resulting in the intended outcomes. Therefore, the Safety Board believes that the FAA should 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.

From: NTSB
Date: 11/9/2006
Response: The FAA responded that, for many years, Part 121 air carriers have been required to provide crew resource management (CRM) training to their pilots, and that for Part 135, while CRM training is not required, it is strongly recommended. The FAA plans to include a requirement for CRM training as part of the comprehensive Part 135 revision. The FAA further notes that comprehensive guidance for developing CRM training already exists in AC 120 51, "Crew Resource Management Training," and that fatigue has always been featured in the AC as one of the most important factors degrading situation awareness and overall crew performance. Finally, on April 28, 2006, SAFO 06004 was issued, directing operators to the fatigue-related information being developed by the OFM, as well as other reliable sources, such as the National Aeronautics and Space Administration. The Safety Board acknowledges that, for Part 121 carriers, fatigue training is a part of required CRM training, as directed in AC 120-51. In the Kirksville accident, which involved a Part 121 carrier and occurred several years after the FAA enacted the CRM training requirement, the Board concluded: On the basis of the less than optimal overnight rest time available, the early reporting time for duty, the length of the duty day, the number of flight legs, the demanding conditions (nonprecision instrument approaches flown manually in conditions of low ceilings and reduced visibilities) encountered during the long duty day (and the two previous days), it is likely that fatigue contributed to the pilots' degraded performance and decisionmaking. Issuance of the SAFO updates the fatigue training guidance in the AC, including a reference to the OFM. The Board notes that this recommendation specifically mentions requiring fatigue management training for Part 135 carriers. Although Part 135 does not currently require CRM training, the FAA plans to add such a requirement as part of its comprehensive Part 135 regulatory revision activity. Pending a requirement for CRM training that includes fatigue management for Part 135, Safety Recommendation A 06 11 is classified "Open-Acceptable Response."

From: FAA
Date: 5/31/2006
Response: Letter Mail Controlled 6/13/2006 10:06:23 AM MC# 2060284: Marion C. Blakey, Administrator, FAA, 5/31/06 Since March 19, 1998, 14 CFR Part 121 air carriers have been required to provide crew resource management (CRM) training to their pilots. CRM training is strongly recommended for pilots of air carriers under 14 CFR Part 135 as well, but it is not yet required. It is expected that CRM training will be explicitly required in the revised 14 CFR Part 135 rules now underway. Since 1990, comprehensive guidance for developing CRM training has been included in AC 120-51, "Crew Resource Management Training." The AC is in its sixth revision. Fatigue has always been featured in the AC as one of the most important factors degrading situation awareness and overall crew performance. The FAA plans to call attention to that important element of CRM training by issuing a SAFO and to direct operators to the fatigue-related information being developed by the Department of Transportation's Operator Fatigue Management Program, as well as other competent sources such as the National Aeronautics and Space Administration. It is anticipated that the SAFO will be issued by June 30, 2006.