Narrative:

This NASA report is precipitated by crew fatigue. I have no doubt that this incident would not occur with rested and alert pilots. Trip operates from sfo-sel crossing multiple time zones and back side of the clock return. Your physical body gets into sel after a 14 hour duty day at XA30. You wake up at XC00 sel time (XI00 your time) hungry and restless. We spend the day recovering and leave at XS30 sel time for another 14 hour duty day flying the all nighter back home. After a 3 day trip, 14 time zone changes, restless night in sel (maybe 4-5 hours sleep) an all nighter back with an en route time of 10 plus hours we arrive sfo during a bay area winter storm. After holding at pye for 30 mins we are vectored for the ILS runway 19L and call for 'gear down final descent checklist.' I'm the PF and find myself totally engaged in flying the aircraft on localizer and GS to touchdown. The captain is concerned with the close proximity of the B757 in front of us and the expectation of a go around. We are low on fuel and need to land. Sfo tower knows this and while all this communication continued it was all I could do to focus on just flying. We were all tired. The end result was a successful landing but we forgot to give the flight attendant landing warning. The cabin was not secured for the landing. I have flown as a captain on the B737-200 for 2 yrs and know how fatigue slowly erodes SOP and decision making performance. I have canceled several 5TH legs after 14 hours because we were just too punch happy to continue. It would not have been safe. Unfortunately, we don't have this luxury on international flts. The following list is a short example of specific performance degradation incidents in the cockpit due to fatigue. These rarely happen to rested crews. Forgetting which descent mode you are in (vs, VNAV, flch) fingers freezing at a button not knowing whether to push it or not, turning the speed knob instead of heading knob, forgetting to drop the flaps to the next slower maneuvering speed after setting speed in the window, not arming approach mode after being cleared for the ILS, missing approach descent checklist out of transition altitude, missing ATC (especially foreign), forgetting how to extend a fix, setting missed approach altitude, no arrival briefing, pushing toga instead of autothrottle disconnect (this was very interesting), loss of stick and rudder skills upon disconnect (all night, 14 hours, no sleep and all of a sudden you're hand flying), and much, much more. I can't fathom the physical demand, loss of concentration and basic airmanship loss that would occur if duty days are extended to 18 hours and augmentation reduced. We need to hang on to our current duty limits and improve upon them. Anything else will push the boundary of what is physically and ethically safe.

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Original NASA ASRS Text

Title: WDB FLC ON ALL NIGHT FLT FAILS TO GIVE CABIN LNDG WARNING. CABIN NOT SECURED ON LNDG.

Narrative: THIS NASA RPT IS PRECIPITATED BY CREW FATIGUE. I HAVE NO DOUBT THAT THIS INCIDENT WOULD NOT OCCUR WITH RESTED AND ALERT PLTS. TRIP OPERATES FROM SFO-SEL XING MULTIPLE TIME ZONES AND BACK SIDE OF THE CLOCK RETURN. YOUR PHYSICAL BODY GETS INTO SEL AFTER A 14 HR DUTY DAY AT XA30. YOU WAKE UP AT XC00 SEL TIME (XI00 YOUR TIME) HUNGRY AND RESTLESS. WE SPEND THE DAY RECOVERING AND LEAVE AT XS30 SEL TIME FOR ANOTHER 14 HR DUTY DAY FLYING THE ALL NIGHTER BACK HOME. AFTER A 3 DAY TRIP, 14 TIME ZONE CHANGES, RESTLESS NIGHT IN SEL (MAYBE 4-5 HRS SLEEP) AN ALL NIGHTER BACK WITH AN ENRTE TIME OF 10 PLUS HRS WE ARRIVE SFO DURING A BAY AREA WINTER STORM. AFTER HOLDING AT PYE FOR 30 MINS WE ARE VECTORED FOR THE ILS RWY 19L AND CALL FOR 'GEAR DOWN FINAL DSCNT CHKLIST.' I'M THE PF AND FIND MYSELF TOTALLY ENGAGED IN FLYING THE ACFT ON LOC AND GS TO TOUCHDOWN. THE CAPT IS CONCERNED WITH THE CLOSE PROX OF THE B757 IN FRONT OF US AND THE EXPECTATION OF A GAR. WE ARE LOW ON FUEL AND NEED TO LAND. SFO TWR KNOWS THIS AND WHILE ALL THIS COM CONTINUED IT WAS ALL I COULD DO TO FOCUS ON JUST FLYING. WE WERE ALL TIRED. THE END RESULT WAS A SUCCESSFUL LNDG BUT WE FORGOT TO GIVE THE FLT ATTENDANT LNDG WARNING. THE CABIN WAS NOT SECURED FOR THE LNDG. I HAVE FLOWN AS A CAPT ON THE B737-200 FOR 2 YRS AND KNOW HOW FATIGUE SLOWLY ERODES SOP AND DECISION MAKING PERFORMANCE. I HAVE CANCELED SEVERAL 5TH LEGS AFTER 14 HRS BECAUSE WE WERE JUST TOO PUNCH HAPPY TO CONTINUE. IT WOULD NOT HAVE BEEN SAFE. UNFORTUNATELY, WE DON'T HAVE THIS LUXURY ON INTL FLTS. THE FOLLOWING LIST IS A SHORT EXAMPLE OF SPECIFIC PERFORMANCE DEGRADATION INCIDENTS IN THE COCKPIT DUE TO FATIGUE. THESE RARELY HAPPEN TO RESTED CREWS. FORGETTING WHICH DSCNT MODE YOU ARE IN (VS, VNAV, FLCH) FINGERS FREEZING AT A BUTTON NOT KNOWING WHETHER TO PUSH IT OR NOT, TURNING THE SPD KNOB INSTEAD OF HDG KNOB, FORGETTING TO DROP THE FLAPS TO THE NEXT SLOWER MANEUVERING SPD AFTER SETTING SPD IN THE WINDOW, NOT ARMING APCH MODE AFTER BEING CLRED FOR THE ILS, MISSING APCH DSCNT CHKLIST OUT OF TRANSITION ALT, MISSING ATC (ESPECIALLY FOREIGN), FORGETTING HOW TO EXTEND A FIX, SETTING MISSED APCH ALT, NO ARR BRIEFING, PUSHING TOGA INSTEAD OF AUTOTHROTTLE DISCONNECT (THIS WAS VERY INTERESTING), LOSS OF STICK AND RUDDER SKILLS UPON DISCONNECT (ALL NIGHT, 14 HRS, NO SLEEP AND ALL OF A SUDDEN YOU'RE HAND FLYING), AND MUCH, MUCH MORE. I CAN'T FATHOM THE PHYSICAL DEMAND, LOSS OF CONCENTRATION AND BASIC AIRMANSHIP LOSS THAT WOULD OCCUR IF DUTY DAYS ARE EXTENDED TO 18 HRS AND AUGMENTATION REDUCED. WE NEED TO HANG ON TO OUR CURRENT DUTY LIMITS AND IMPROVE UPON THEM. ANYTHING ELSE WILL PUSH THE BOUNDARY OF WHAT IS PHYSICALLY AND ETHICALLY SAFE.

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.