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Scheduling stated that they had notifi ed me previously
regarding my schedule change. I was never notifi ed...There
was no phone conversation, no email, and no message,
neither written, nor voice mail, nor verbal, regarding a
change to my schedule. Scheduling notifi ed Chief Pilot
about the situation. Chief Pilot called me and I notifi ed
him that I had consumed alcohol. Chief Pilot told me to
fl y the trip...He told me that our company would waive the
12-hour alcohol regulation and apply the less restrictive
FAA 8-hour limit. Chief Pilot stated that I would receive
a faxed written statement from him that I was to ‘waive’
the 12-hour alcohol regulation and implement the FAA
339
8-hour limit in my current situation...After considering the
minimal amount of alcohol I consumed, I believe 8 hours
was adequate to operate under no infl uence of alcohol....
Fatigue
Fatigue is an important human
performance consideration within the
transportation industry. It can be a
signifi cant hazard to fl ight safety, as it
may not be recognized or detected until
a serious error has occurred. As one
indicator of the pervasiveness of this problem, almost 6,000
ASRS Database reports directly reference fatigue issues.
For a BE400 corporate fl ight crew, fatigue (and nutrition)
issues complicated what should have been a routine fl ight.
■ Nav #1 failed en route to airport. VOR/DME A approach
in use landing Runway 19. With Nav #1 inoperative,
Captain and First Offi cer decided to have First Offi cer fl y
the approach and return aircraft control to Captain when
approach completed overhead the airport. In hindsight,
this was poor decision making and was likely agreed to
due to both pilots being tired. First Offi cer was nearing
the end of a 14-hour duty period. First Offi cer was briefed
10 hours prior to show time, and between late notice and
a new baby, had been awake nearly 20 hours, not eaten
in 7 hours. In any case, the Captain was handling radios
and forgot to contact Tower, and First Offi cer relinquished
control to Captain overhead airport, thinking they were
in a position to turn downwind. First Offi cer was unable
to see the airport. Checklist was still being performed and
crew turned downwind overhead [airport], completing the
checklist. First Offi cer was now PNF and asked Captain if
he called Tower. No reply. First Offi cer called Tower, who
was already asking us what was going on, and at this time,
Captain had begun a right turn to correct course. It was
too late by now. We turned fi nal, overshot and returned to
course, landed.
The next morning, after calling in fatigued...[and] with
adequate rest, it was clear to us that we created our
own mess out of a simple instrument error. This goes
to show how two tired pilots can over-complicate what
should have been a routine fl ight with a simple VOR
out. Recommendations: (1) Call in fatigued before you
deteriorate, even if coming in from a day off. (2) When
the company knows an early show with a time change is
scheduled, [they should] not wait until the last minute to
notify a crew member.
Editor’s Note:
The ASRS Database Online (DBOL) provides a
report set of Air Carrier (FAR 121) Fatigue Incidents
that can be downloaded at http://asrs.arc.nasa.
gov/search/reportsets.html. Twenty-three other
report sets of interest to the aviation community can
be accessed at this web address.
A Monthly Safety Bulletin from
The Offi ce of the NASA
Aviation Safety Reporting
System,
P.O. Box 189,
Moffett Field, CA
94035-0189
http://asrs.arc.nasa.gov/
February 2008 Report Intake
Air Carrier/Air Taxi Pilots 2843
General Aviation Pilots 781
Controllers 76
Cabin/Mechanics/Military/Other 283
TOTAL 3983
ASRS Alerts Issued in 2007
Subject of Alert No. of Alerts
Aircraft or aircraft equipment 115
Airport facility or procedure 93
ATC procedure, operations or equipment 91
Chart, Publication, or Nav Database 18
Company policy 9
Maintenance procedure or Other 16
TOTAL 342
For the past three years, CALLBACK has presented
the “best” reporter performances in incident
reports submitted to the ASRS. Like award-winning
fi lms, these incidents have all the ingredients of
outstanding drama – compelling plots, edge-of-theseat
suspense, winning performances, and the zest
of adventure. In this, our fourth annual issue of
award-winning lessons, we present a selection of
incidents that were handled with skill, initiative,
and professionalism. We believe these incidents
　
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