37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 881578 |
Time | |
Date | 201003 |
Local Time Of Day | 1201-1800 |
Aircraft 1 | |
Make Model Name | Large Transport |
Operating Under FAR Part | Part 121 |
Flight Plan | IFR |
Person 1 | |
Function | Pilot Not Flying Captain |
Qualification | Flight Crew Air Transport Pilot (ATP) |
Experience | Flight Crew Last 90 Days 150 Flight Crew Total 16000 Flight Crew Type 150 |
Events | |
Anomaly | Flight Deck / Cabin / Aircraft Event Other / Unknown |
Narrative:
Day one and two of our four day trip went according to schedule and we arrived at our second layover close to scheduled arrival time around XA30; or XC30 home domicile and body clock time. That night was not as restful as usual due to me just not being able to sleep well that night and that my hotel room was adjacent to the airport ramp. The hotel is well built for noise and normally not a problem; but around XA00 local time I woke up to aircraft and ramp noise. I tried; but was unable to go back to sleep. Our scheduled departure time was XQ15 local (XS15 home domicile time) and we were planning an on time departure. The aircraft arrived at the gate with a mechanical problem of the right main gear door not retracting. Local maintenance worked on it for a couple of hours but was unable to fix it. We waited around operations for a while to see what the plan was going to be for our flight. We learned that we would be waiting for the next aircraft to arrive and we would use that plane for our flight. We waited around operations which has no crew rest facilities. We finally departed at XU00 local time and then received an ACARS message that had us reassigned to fly an additional leg upon arrival at our destination. We noticed a turn time of 25 minutes and thought that was unrealistic and later in the flight we were able to study the sequence closer and based on our calculations we were over max duty day time. We sent a message to the crew desk alerting them to this. We received no response. As our flight began we started to notice many small and irregular habit patterns emerge and as the flight continued they became more numerous and we started to discuss the problems and related cause. The pattern of fatigue was strongly evident. Just a few of the items noticed by us were the failure to turn the aircraft beacon on at the proper time and by myself not understanding simple instructions from the ground controller. I had asked the first officer for clarification several times about our taxi clearance. As we climbed out I noticed the first officer was delayed in normal flow activities. I also noticed that I was not thinking as sharp and clearly as I should be. I was frequently missing frequency changes and after acknowledging them to ATC I would forget what the frequency was before I was able to change it on the radio head. We discussed these and several other occurrences that were happening and realized we could be suffering from the long day we had. Then we received an ACARS message from dispatch inquiring what our fuel was that he showed us being 5;000 pounds short. This really scared me but we soon realized that the amount of fuel onboard was as planned and that we had entered the pre-departure fuel quantity incorrectly into ACARS. I had the flight plan on the clipboard in front of me as I always do and realized that I had not been keeping up with it and it showed (because of the incorrect ACARS entry) us arriving with 300 lbs of fuel. Again; I did not catch this when it printed. That was the point our discussions became serious about fatigue and we sent a message to the crew desk that we were too tired to continue. If I had accepted our reassignment; I would have been awake for nearly 22 hours when on approach and landing. There have been times in the past when we all have flown while tired as this is a common occurrence in today's field of aviation and we are mostly able to 'deal with it' safely. This was my thinking. As I look back on the events of our day another one of the things that strike me as curious is that I really can't remember in any detail our departure; climb and cruise. I have outlined just a few of the items that I can remember and do recall saying a few times after doing a task something to the effect of: 'aha! That must be fatigue'! How could this be averted in the future? I know that I will personally be more observant to the details that can lead up to potential fatigue. The reassignments could be thought out more by the schedulers and perhaps even by a phone call to discuss what kind of day did the crew have and what the plans were. Better communication could help schedule reliability when all people involved stay in touch. In retrospect; this entire flight to me was an 'eye-opener' to the effects of fatigue not only in myself but how it affects the entire crew.
Original NASA ASRS Text
Title: An air carrier Captain related fatigue issues associated with a long four day assignment which included maintenance delays; interrupted sleep; diurnal inefficiencies and a refused reassignment at the end of a long day.
Narrative: Day one and two of our four day trip went according to schedule and we arrived at our second layover close to scheduled arrival time around XA30; or XC30 home domicile and body clock time. That night was not as restful as usual due to me just not being able to sleep well that night and that my hotel room was adjacent to the airport ramp. The hotel is well built for noise and normally not a problem; but around XA00 local time I woke up to aircraft and ramp noise. I tried; but was unable to go back to sleep. Our scheduled departure time was XQ15 local (XS15 home domicile time) and we were planning an on time departure. The aircraft arrived at the gate with a mechanical problem of the right main gear door not retracting. Local Maintenance worked on it for a couple of hours but was unable to fix it. We waited around Operations for a while to see what the plan was going to be for our flight. We learned that we would be waiting for the next aircraft to arrive and we would use that plane for our flight. We waited around operations which has no crew rest facilities. We finally departed at XU00 local time and then received an ACARS message that had us reassigned to fly an additional leg upon arrival at our destination. We noticed a turn time of 25 minutes and thought that was unrealistic and later in the flight we were able to study the sequence closer and based on our calculations we were over max duty day time. We sent a message to the crew desk alerting them to this. We received no response. As our flight began we started to notice many small and irregular habit patterns emerge and as the flight continued they became more numerous and we started to discuss the problems and related cause. The pattern of fatigue was strongly evident. Just a few of the items noticed by us were the failure to turn the aircraft beacon on at the proper time and by myself not understanding simple instructions from the Ground Controller. I had asked the First Officer for clarification several times about our taxi clearance. As we climbed out I noticed the First Officer was delayed in normal flow activities. I also noticed that I was not thinking as sharp and clearly as I should be. I was frequently missing frequency changes and after acknowledging them to ATC I would forget what the frequency was before I was able to change it on the radio head. We discussed these and several other occurrences that were happening and realized we could be suffering from the long day we had. Then we received an ACARS message from Dispatch inquiring what our fuel was that he showed us being 5;000 pounds short. This really scared me but we soon realized that the amount of fuel onboard was as planned and that we had entered the pre-departure fuel quantity incorrectly into ACARS. I had the flight plan on the clipboard in front of me as I always do and realized that I had not been keeping up with it and it showed (because of the incorrect ACARS entry) us arriving with 300 lbs of fuel. Again; I did not catch this when it printed. That was the point our discussions became serious about fatigue and we sent a message to the crew desk that we were too tired to continue. If I had accepted our reassignment; I would have been awake for nearly 22 hours when on approach and landing. There have been times in the past when we all have flown while tired as this is a common occurrence in today's field of aviation and we are mostly able to 'deal with it' safely. This was my thinking. As I look back on the events of our day another one of the things that strike me as curious is that I really can't remember in any detail our departure; climb and cruise. I have outlined just a few of the items that I can remember and do recall saying a few times after doing a task something to the effect of: 'Aha! That must be fatigue'! How could this be averted in the future? I know that I will personally be more observant to the details that can lead up to potential fatigue. The reassignments could be thought out more by the schedulers and perhaps even by a phone call to discuss what kind of day did the crew have and what the plans were. Better communication could help schedule reliability when all people involved stay in touch. In retrospect; this entire flight to me was an 'eye-opener' to the effects of fatigue not only in myself but how it affects the entire crew.
Data retrieved from NASA's ASRS site as of April 2012 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.