NTSB · Safety Recommendation
Safety Recommendation A-94-106
Recommendation
TO THE FEDERAL AVIATION ADMINISTRATION: Expedite the review and upgrade of flight/duty time limitations of the Federal Aviation Regulations to ensure that they incorporate the results of the latest research on fatigue and sleep issues. (Superseded by A-95-110 through -113)
Safety Issue and Context
On august 18, 1993, at 1656 eastern daylight time (EDT), a Douglas DC-8-61 freighter, N814CK, registered to American International Airways (AIA), in., d/b/a Connine Kalitta Services, Inc., and operating as AIA flight 808, collided with level terrain approximately 1/4 mile from the approach end of runway 10, after the captain lost control of the airplane while approaching the Leeward Point Airfield at the U.S. Naval Air Station, Guantanamo Bay, Cuba. The airplane was destroyed by impact forces and postaccident fire, and the three flight crewmembers sustained serious injuries. Visual meteorological conditions prevailed, and an instrument flight rules (IFR) flight plan had been filed.
The flight was conducted under 14 code of federal regulations (CFR), part 121, supplemental air carriers, as an international, nonscheduled, military contract flight.
Response History
June 19, 1996 · NTSB Correspondence · FAA
Notation 6694: Attention: Rules Docket (AGe-200), Docket No. 28081 The National Transportation Safety Board has reviewed your Notice of Proposed Rulemaking (NPRM), "Flight Crewmember Duty Period Limitations, Flight Time Limitations and Rest Requirements," which was published in 60 FR 244 on December 20, 1995. The notice proposes to modify the rules governing mandatory rest periods and maximum flight and duty times for pilots and flight engineers conducting air transport flights under the provisions of Title 14 Code of Federal Regulations (CFR) Parts 121 and 135.
Background On May 10, 1994, the Safety Board met to consider the draft report of the accident that occurred on August 18, 1993, involving a DC-8-61 operated by American International Airways that crashed during an attempted landing at the U.S. Naval Air Station in Guantanamo Bay, Cuba. The Safety Board determined that fatigue among the flightcrew members impaired their judgment and their decisionmaking and flying abilities, and that thoese impairments led to the mishandling of the approach and attempted landing.
In addition, the Safety Board determined that, among oilier factors, "the inadequacy of the flight and duty time regulations applied to 14 CFR, Part 121, Supplemental Air Carrier, international operations... contributed to the accident.
The Safety Board, at that meeting, addressed the current flight and duty time rules, their role in this accident, and how deficiencies in the rules could allow additional fatigue-related accidents to occur. The Safety Board identified the need for a complete revision of the FAA's flight and duty time regulations, Dr. John Lauber, then a member of the Safety Board, said the following at that meeting: “I think we have a basis here for just throwing the whole problem out on the table.
The regulations, as they exist, do not reflect our current state of understanding, scientific understanding, of the effects on human performance of fatigue and circadian problems and related kinds of things, they simply don't. I think the time has come for the FAA to recognize that they're never going to be able to get consensus among the user community because every time you make a ruling on these issues that has enormous economic consequences, and you get involved in labor management issues and everything else.
November 14, 1995 · NTSB Correspondence · FAA
(GREENSHEET) BECAUSE OF THE FATIGUE ISSUES UNCOVERED IN THIS & OTHER ACCIDENTS, THE BOARD BELIEVES THAT IT IS CRITICAL FOR THE FAA TO EXPEDITE THE FINALIZATION OF THE REVIEW OF CURRENT FLIGHT & DUTY TIME REGULATIONS & TO REVISE THE REGULATIONS, AS NECESSARY, WITHIN 1 YEAR TO ENSURE THAT FLIGHT & DUTY TIME LIMITATIONS TAKE INTO CONSIDERATION RESEARCH FINDINGS IN FATIGUE & SLEEP ISSUES. FURTHER, THE NEW REGULATIONS SHOULD PROHIBIT AIR CARRIERS FROM ASSIGNING FLIGHTCREWS TO FLIGHTS CONDUCTED UNDER 14 CFR PART 91 UNLESS THE FLIGHTCREWS MEET THE FLIGHT & DUTY TIME LIMITATIONS OF 14 CFR PART 121 OR OTHER APPROPRIATE REGULATIONS.
ACCORDINGLY, THE BOARD IS CLASSIFYING A-94-105 & -106 "CLOSED--ACCEPTABLE ACTION/SUPERSEDED" & IS ISSUING NEW RECOMMENDATIONS A-95-110 THRU -113.
August 11, 1994 · NTSB Correspondence · FAA
THE BOARD NOTES THAT THE FAA MAY ISSUE A NOTICE OF PROPOSED RULEMAKING TO ADDRESS THE SUBJECT OF THE THREE RECOMMENDATIONS. AS A RESULT, THE SAFETY BOARD CLASSIFIES A-94-105 THROUGH -107 "OPEN--ACCEPTABLE RESPONSE," PENDING RULEMAKING ACTION.
July 13, 1994 · Recipient Response · FAA
THE FAA IS CONSIDERING THE ISSUANCE OF A NOTICE OF PROPOSED RULEMAKING TO ADDRESS THESE RECOMMENDATIONS.