ACR WDB PIC DOCUMENTS EVIDENCE THAT IF A FLT CREW IS UP ALL NIGHT THEY GET TIRED AND THAT THIS FATIGUE CAUSES THEM TO COMMIT MINOR PROCEDURAL ERRORS.

Date: 1988-02 · Aircraft: Widebody; Low Wing; 3 Turbojet Eng

Anomalies: other-unspecified

Synopsis

ACR WDB PIC DOCUMENTS EVIDENCE THAT IF A FLT CREW IS UP ALL NIGHT THEY GET TIRED AND THAT THIS FATIGUE CAUSES THEM TO COMMIT MINOR PROCEDURAL ERRORS.

Narrative

HERE IS ONE THAT LOOKS GOOD OR AT LEAST OK ON PAPER; BUT I FEEL IS A SET UP FOR PLT ERROR AND FATAL CONSEQUENCES. EVERYONE IS JUST TOO TIRED TO PERFORM. THE REASON I AM WRITING THIS IS BECAUSE PRIOR TO DEP LAX I COMMENTED THAT; 'WHILE THE FIRST LEG WAS AN UNAVOIDABLE NECESSITY; TACKING ON THE SECOND LEG BY CREW SCHEDULE IS A TIRED--ACCIDENT WAITING TO HAPPEN; AND FOOLISH ECONOMICS BY THE COMPANY.' THE FO STATED THAT HE HAD BEEN FLYING THIS PAIRING FOR SOME TIME AND HE HAD NO PROB WITH IT; 'IT'S JUST A MATTER OF GETTING USED TO IT.' ON THE SECOND LEG; I KEPT A LIST OF THE FO PERFORMANCE AS I BECAME AWARE OF IT AND READ IT BACK TO HIM BEFORE WE LEFT THE COCKPIT IN PHL. THE FLT HAD BEEN VMC MOST ALL OF THE WAY FROM LAX-JFK-PHL; AND VIRTUALLY PROB FREE. THE FO MIXED ALT AND HDG NUMBERS FROM DEP ON READBACK. FO MISSED 4 ATC CALLS ENRTE. FO SELECTED (NEVER USED) 18 DEG FLAPS INSTEAD OF STANDARD 22 DEG FLAPS. F/E CAUGHT THE ERROR AND VERIFIED 22 DEG FLAPS WERE CALLED FOR. FO HAD TO BE TOLD TWICE TO LOWER GEAR. FO DID NOT INITIALLY RESPOND TO BEFORE LNDG FINAL CHKLIST READ BY F/E. AFTER LNDG DURING TAXI IN; THE FO PERFORMED AND ANSWERED THE AFTER LNDG CHKLIST; BUT THE RADAR WAS LEFT ON NORMAL AND THE TRANSPONDER WAS LEFT ON UNTIL AFTER THE SECURE COCKPIT CHKLIST WAS COMPLETED AND RESPONDED TO. I CAUGHT THEM ON MY FINAL REVIEW BEFORE LEAVING MY SEAT. I AM CERTAIN I MISSED SOME THINGS TOO; AS WELL AS SOME OF THOSE BY THE FO. WE ALL WERE TIRED--TOO TIRED TO FLY SAFELY! I DO NOT BELIEVE WE VIOLATED ANYTHING; BUT WE SURE COULD HAVE. I FEEL THE SITUATION WOULD HAVE BEEN WORSE; HAD OTHER FATIGUING FACTORS; SUCH AS WEATHER; HOLDING; EQUIPMENT AND CABIN CONSIDERATIONS BEEN PRESENT AS WELL.

Source: NASA Aviation Safety Reporting System (public domain). Reports are voluntary submissions and are not verified by NASA.