Tuesday, November 3, 2009
Don’t take for granted the importance of a good night’s rest
The captain described his health as “fair” and stated that he was prone to respiratory illnesses, but hadn’t experienced any problems the week before the incident. He reported high blood pressure, and took prescription medication to control it. He stated that he hadn’t taken any medications, prescription or nonprescription, that might have affected his performance. The captain was a regular smoker and reported smoking about 25 cigarettes per day.
The captain said he had been feeling “burned out” in recent months. He attributed this to his working conditions, less time off and frequent amendments to his schedule. He said that he had encountered these challenges before, but had recently been finding it more difficult to cope with them. Although he lived in Missouri, he said he had applied for a temporary assignment in Hawaii in search of some relief, but had found the work in Hawaii no easier because he had to fly eight legs per day with few breaks. This made it tough for him to find time during work hours for coffee, eating and smoking cigarettes.
On the two days before the incident, the captain said he was going to sleep by 9 p.m., waking up at 4 a.m., reporting for duty at 5:40 a.m., flying eight legs daily with the incident first officer and going off duty by 3 p.m.
The captain said that he snored loudly at night, and that he had raised the issue with his personal physician two or three months before the incident. The doctor told him to lose weight, eat less salt and relax. He stated that, during his stay in Hawaii, he had lost 15 pounds through exercise and was “sleeping better.” After the incident, the captain underwent an evaluation by a sleep medicine specialist—he was diagnosed with severe OSA.
The first officer, age 23, has an FAA first-class medical certificate with no limitations. He described his health as “good” and he said he felt well on the morning of the incident. He stated that he didn’t normally take prescription medication and hadn’t used any medications in the 72 hours before the incident. He didn’t use tobacco. He held a commercial pilot certificate. According to company records, he had 1,250 hours, including 500 hours in the Bombardier jet. The first officer said he wasn’t experiencing any stress related to his personal life on the morning of the incident, nor had he experienced any recent changes in his health or personal life.
The first officer told investigators that he had never fallen asleep during a flight before. On the two days before the incident, he had gone to sleep by 10:30 p.m., gotten up by 5 a.m., reported for duty at 5:40 a.m., flew eight legs and got off duty before 3 p.m.
The NTSB determined that the incident’s probable cause was the captain and first officer inadvertently falling asleep during the cruise phase of flight. Also contributing were the captain’s undiagnosed OSA and the crew’s recent work schedules, which included several consecutive days of early-morning start times.
Peter Katz is editor and publisher of NTSB Reporter, an independent monthly update on aircraft accident investigations and other NTSB news. To subscribe, write to: NTSB Reporter, Subscription Dept., P.O. Box 831, White Plains, NY 10602-0831.
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