Narrative:

The following narrative shows a case of extreme and chronic fatigue and interrupted circadian rhythms negatively impacting the pilot's cognitive abilities. The following described incident occurred (for me) on the last leg of an all-week series of trips. I had been up flying, all night, every night for the previous 3 days. My first officer had just flown in from his home in sea and had been up for nearly 22 hours. The so is a new hire crew member who, as a reserve, gets worked excessively hard and was probably more tired than the rest. This particular trip is scheduled to 'wait' on the ramp at ict for approximately 1 hour 20 mins, ostensibly because the lgb airport has a XA00 curfew. That means that the crew, who has already been on the job for several hours, coming off what we fondly refer to as a 'hub-turn' in the middle of the night in mem, is required to just situation there, watching the clock in ict for the given time to launch so that we may land at lgb, after the curfew. I decided that just sitting there was just going to make us more tired and that it was better for us to keep going. We did some mental mathematics and figured if we launched early and flew a little slower than the flight plan, we could time our arrival just after the lgb airport opened. As the flight progressed, we were able to add a little time to the flight plan, but, approaching hector VOR, it was quite evident that if we continued, we would arrive at the airport prior to it opening. We requested holding and received clearance to hold at glaco intersection, on J64, 26 mi northeast of hector, 20 mi legs. Since the added flight time now made fuel a consideration, I requested holding at our cruise altitude, FL390, for fuel conservation. In retrospect, all of the above mentioned factors were the 'set up' for what transpired. Entering holding, ZLA told us to anticipate the kayoh 3 arrival into the terminal area when we were ready to continue. After 3 turns in holding we felt the time was right that we could continue on into lgb. We informed ZLA inbound to glaco and were cleared to hector. Shortly thereafter, we received a frequency change and that controller issued us 'cross dawna at and maintain 13000 ft.' we were already too high to get down to the crossing restr comfortably. At that point my head was pretty numb. There were some exchanges between the first officer and so about fuel state and arrival time, etc, that were sending up red cockpit resource management flags, distracting me from the task at hand. I hesitated a couple of mins (mistake) before starting down and when I did start down I did so at the holding speed (mistake), as I was still concerned about arriving too early. Shortly after passing hector we received another frequency change and the new controller immediately gave us a left turn, vector towards homewood VOR and a new clearance to cross 30 mi north of homewood at 13000 ft. I initiated the turn, still at holding speed in the descent. It took me a short while to figure out that there was no way we could comply with that, as homewood has no DME. I told the first officer to tell center that we did not want any 'shortcuts,' due to curfew and that we couldn't do it anyway because of the lack of DME. The controller said he thought we were INS equipped and cleared us back to dawna. I, quite frankly, do not remember whether or not he restated the 13000 ft crossing restr, which, if he didn't, would make this report moot, I suppose, but better safe than sorry. Shortly after I got reestablished on the 211 degree radial out of hector, the first officer stated in an assertive, unambiguous manner, 'are you going to make this crossing restr?' it was at this point that I realized that the first officer's VOR was dialed up on paradise, which was the correct VOR for the arrival radial, but the DME had been earlier 'locked on' to the seal beach VOR, a considerable distance beyond. I had been using the wrong DME winding down to plan my descent! I have no idea when or how this happened and I blame no one but myself. What I 'should have done' is have the PNF inform center that we were not going to make the crossing restr, requesting a 360 degree turn in the descent or ask them what they would have us do. Instead, I immediately initiated a maximum effort descent. We were given a frequency change to approach and the first officer, waiting until the last possible moment, 'checked in at dawna at 17500 ft (3500 ft high).' at the rate of descent (7000 ft FPM) we had going, we were level at 13000 ft within 30-40 seconds after check-in. Maybe everyone on the ground was as tired as we were. Perhaps their equipment can't keep up with a descent that steep. Possibly we no longer had the restr. Who knows, but no one said anything. At the time of the morning this occurred (XA40Z) I was already in bed, asleep for 3 plus hours on the previous 3 days. Some days I could probably do better 'in my sleep' than my performance of this particular day. My fix for this would be to require airports like lgb to be open for stage 3 aircraft, whenever they arrive so that our schedules would not have to be 'convoluted' to fit into someone's curfew. Barring that eventuality, the flight should be scheduled to depart mem at such a time that would allow the 'normal' 25-30 min turn at ict (no holding on the ramp) and land lgb after curfew. Or, go nonstop to mem-lgb, allowing the crew to get some quality crew rest in mem prior to departure. This stop and go and wait in the middle of the night is very debilitating and adds to the fatigue factor.

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Original NASA ASRS Text

Title: ALTDEV ALT UNDERSHOT. ALT XING RESTR.

Narrative: THE FOLLOWING NARRATIVE SHOWS A CASE OF EXTREME AND CHRONIC FATIGUE AND INTERRUPTED CIRCADIAN RHYTHMS NEGATIVELY IMPACTING THE PLT'S COGNITIVE ABILITIES. THE FOLLOWING DESCRIBED INCIDENT OCCURRED (FOR ME) ON THE LAST LEG OF AN ALL-WK SERIES OF TRIPS. I HAD BEEN UP FLYING, ALL NIGHT, EVERY NIGHT FOR THE PREVIOUS 3 DAYS. MY FO HAD JUST FLOWN IN FROM HIS HOME IN SEA AND HAD BEEN UP FOR NEARLY 22 HRS. THE SO IS A NEW HIRE CREW MEMBER WHO, AS A RESERVE, GETS WORKED EXCESSIVELY HARD AND WAS PROBABLY MORE TIRED THAN THE REST. THIS PARTICULAR TRIP IS SCHEDULED TO 'WAIT' ON THE RAMP AT ICT FOR APPROX 1 HR 20 MINS, OSTENSIBLY BECAUSE THE LGB ARPT HAS A XA00 CURFEW. THAT MEANS THAT THE CREW, WHO HAS ALREADY BEEN ON THE JOB FOR SEVERAL HRS, COMING OFF WHAT WE FONDLY REFER TO AS A 'HUB-TURN' IN THE MIDDLE OF THE NIGHT IN MEM, IS REQUIRED TO JUST SIT THERE, WATCHING THE CLOCK IN ICT FOR THE GIVEN TIME TO LAUNCH SO THAT WE MAY LAND AT LGB, AFTER THE CURFEW. I DECIDED THAT JUST SITTING THERE WAS JUST GOING TO MAKE US MORE TIRED AND THAT IT WAS BETTER FOR US TO KEEP GOING. WE DID SOME MENTAL MATHEMATICS AND FIGURED IF WE LAUNCHED EARLY AND FLEW A LITTLE SLOWER THAN THE FLT PLAN, WE COULD TIME OUR ARR JUST AFTER THE LGB ARPT OPENED. AS THE FLT PROGRESSED, WE WERE ABLE TO ADD A LITTLE TIME TO THE FLT PLAN, BUT, APCHING HECTOR VOR, IT WAS QUITE EVIDENT THAT IF WE CONTINUED, WE WOULD ARRIVE AT THE ARPT PRIOR TO IT OPENING. WE REQUESTED HOLDING AND RECEIVED CLRNC TO HOLD AT GLACO INTXN, ON J64, 26 MI NE OF HECTOR, 20 MI LEGS. SINCE THE ADDED FLT TIME NOW MADE FUEL A CONSIDERATION, I REQUESTED HOLDING AT OUR CRUISE ALT, FL390, FOR FUEL CONSERVATION. IN RETROSPECT, ALL OF THE ABOVE MENTIONED FACTORS WERE THE 'SET UP' FOR WHAT TRANSPIRED. ENTERING HOLDING, ZLA TOLD US TO ANTICIPATE THE KAYOH 3 ARR INTO THE TERMINAL AREA WHEN WE WERE READY TO CONTINUE. AFTER 3 TURNS IN HOLDING WE FELT THE TIME WAS RIGHT THAT WE COULD CONTINUE ON INTO LGB. WE INFORMED ZLA INBOUND TO GLACO AND WERE CLRED TO HECTOR. SHORTLY THEREAFTER, WE RECEIVED A FREQ CHANGE AND THAT CTLR ISSUED US 'CROSS DAWNA AT AND MAINTAIN 13000 FT.' WE WERE ALREADY TOO HIGH TO GET DOWN TO THE XING RESTR COMFORTABLY. AT THAT POINT MY HEAD WAS PRETTY NUMB. THERE WERE SOME EXCHANGES BTWN THE FO AND SO ABOUT FUEL STATE AND ARR TIME, ETC, THAT WERE SENDING UP RED COCKPIT RESOURCE MGMNT FLAGS, DISTRACTING ME FROM THE TASK AT HAND. I HESITATED A COUPLE OF MINS (MISTAKE) BEFORE STARTING DOWN AND WHEN I DID START DOWN I DID SO AT THE HOLDING SPD (MISTAKE), AS I WAS STILL CONCERNED ABOUT ARRIVING TOO EARLY. SHORTLY AFTER PASSING HECTOR WE RECEIVED ANOTHER FREQ CHANGE AND THE NEW CTLR IMMEDIATELY GAVE US A L TURN, VECTOR TOWARDS HOMEWOOD VOR AND A NEW CLRNC TO CROSS 30 MI N OF HOMEWOOD AT 13000 FT. I INITIATED THE TURN, STILL AT HOLDING SPD IN THE DSCNT. IT TOOK ME A SHORT WHILE TO FIGURE OUT THAT THERE WAS NO WAY WE COULD COMPLY WITH THAT, AS HOMEWOOD HAS NO DME. I TOLD THE FO TO TELL CTR THAT WE DID NOT WANT ANY 'SHORTCUTS,' DUE TO CURFEW AND THAT WE COULDN'T DO IT ANYWAY BECAUSE OF THE LACK OF DME. THE CTLR SAID HE THOUGHT WE WERE INS EQUIPPED AND CLRED US BACK TO DAWNA. I, QUITE FRANKLY, DO NOT REMEMBER WHETHER OR NOT HE RESTATED THE 13000 FT XING RESTR, WHICH, IF HE DIDN'T, WOULD MAKE THIS RPT MOOT, I SUPPOSE, BUT BETTER SAFE THAN SORRY. SHORTLY AFTER I GOT REESTABLISHED ON THE 211 DEG RADIAL OUT OF HECTOR, THE FO STATED IN AN ASSERTIVE, UNAMBIGUOUS MANNER, 'ARE YOU GOING TO MAKE THIS XING RESTR?' IT WAS AT THIS POINT THAT I REALIZED THAT THE FO'S VOR WAS DIALED UP ON PARADISE, WHICH WAS THE CORRECT VOR FOR THE ARR RADIAL, BUT THE DME HAD BEEN EARLIER 'LOCKED ON' TO THE SEAL BEACH VOR, A CONSIDERABLE DISTANCE BEYOND. I HAD BEEN USING THE WRONG DME WINDING DOWN TO PLAN MY DSCNT! I HAVE NO IDEA WHEN OR HOW THIS HAPPENED AND I BLAME NO ONE BUT MYSELF. WHAT I 'SHOULD HAVE DONE' IS HAVE THE PNF INFORM CTR THAT WE WERE NOT GOING TO MAKE THE XING RESTR, REQUESTING A 360 DEG TURN IN THE DSCNT OR ASK THEM WHAT THEY WOULD HAVE US DO. INSTEAD, I IMMEDIATELY INITIATED A MAX EFFORT DSCNT. WE WERE GIVEN A FREQ CHANGE TO APCH AND THE FO, WAITING UNTIL THE LAST POSSIBLE MOMENT, 'CHKED IN AT DAWNA AT 17500 FT (3500 FT HIGH).' AT THE RATE OF DSCNT (7000 FT FPM) WE HAD GOING, WE WERE LEVEL AT 13000 FT WITHIN 30-40 SECONDS AFTER CHK-IN. MAYBE EVERYONE ON THE GND WAS AS TIRED AS WE WERE. PERHAPS THEIR EQUIP CAN'T KEEP UP WITH A DSCNT THAT STEEP. POSSIBLY WE NO LONGER HAD THE RESTR. WHO KNOWS, BUT NO ONE SAID ANYTHING. AT THE TIME OF THE MORNING THIS OCCURRED (XA40Z) I WAS ALREADY IN BED, ASLEEP FOR 3 PLUS HRS ON THE PREVIOUS 3 DAYS. SOME DAYS I COULD PROBABLY DO BETTER 'IN MY SLEEP' THAN MY PERFORMANCE OF THIS PARTICULAR DAY. MY FIX FOR THIS WOULD BE TO REQUIRE ARPTS LIKE LGB TO BE OPEN FOR STAGE 3 ACFT, WHENEVER THEY ARRIVE SO THAT OUR SCHEDULES WOULD NOT HAVE TO BE 'CONVOLUTED' TO FIT INTO SOMEONE'S CURFEW. BARRING THAT EVENTUALITY, THE FLT SHOULD BE SCHEDULED TO DEPART MEM AT SUCH A TIME THAT WOULD ALLOW THE 'NORMAL' 25-30 MIN TURN AT ICT (NO HOLDING ON THE RAMP) AND LAND LGB AFTER CURFEW. OR, GO NONSTOP TO MEM-LGB, ALLOWING THE CREW TO GET SOME QUALITY CREW REST IN MEM PRIOR TO DEP. THIS STOP AND GO AND WAIT IN THE MIDDLE OF THE NIGHT IS VERY DEBILITATING AND ADDS TO THE FATIGUE FACTOR.

Data retrieved from NASA's ASRS site as of July 2007 and automatically converted to unabbreviated mixed upper/lowercase text. This report is for informational purposes with no guarantee of accuracy. See NASA's ASRS site for official report.