Learning from a Survivor

by Ray Oyung

February 13, 1998

This Wednesday and Thursday, our program sponsored an Education Training Module Workshop to teach regulatory officials, training managers, medical officers, and safety officers in the aviation and transportation industry. The workshop is about sleep physiology, personnel scheduling strategies, and preventive and operational countermeasures to assist these representatives in making their work environment safer.

The background of these representatives include commercial and corporate airline pilots, locomotive engineers, marine pilots, aviators and doctors from each of the military branches including Coast Guard, and even folks from the Federal Bureau of Investigations (FBI) and Central Intelligence Agency (CIA)!

Each workshop brings in people from many diverse backgrounds and industries. This workshop included medical personnel from the Air Force Academy, policy makers from Transport Canada (equivalent to the Federal Aviation Administration in the United States), a flight surgeon from the Navy's Top Gun division, safety officers from various corporate and commercial airlines, and two agents from the FBI. This workshop is particularly unique because we have a special guest with us.

One of the topics we cover during the day is a briefing on the first airplane accident where fatigue was considered to play a major role. The accident occurred in Guantanamo Bay, Cuba several hundred miles off the coast of Florida. The pilots were flying an overnight cargo operation through the night. After landing at their final destination, they were called back to fly some mail to Cuba that afternoon. The pilots were awake for an average of 20.5 hours before the accident. It was a mail flight on a DC-8 cargo plane. The people on board consisted of the captain, first officer, and flight engineer. Their skills totaled almost 40,000 hours of flight experience. This is a lot of flight time and the accident did not happen because the pilots were bad pilots. When the pilots approached the airport at Cuba, several factors took place leading up to the accident. There is never one thing that causes an accident. Think of many slices of swiss cheese. There are holes in each slice, but no slice has the holes in exactly the same place. If you pick a hole in each slice of cheese and line them up so you can see through all the slices, this is how accidents occur.

Our special guest today is the first officer from that flight to Guantanamo Bay. He has healed since the accident which occurred about five years ago and has been certified to fly again. He does have a waiver allowing him to fly with a prosthetic leg. In addition to a broken arm, his right leg was lost due to the accident.

The first officer elaborated on the events described in the National Transportation Safety Board (NTSB) report on the accident. The NTSB is an independent agency that is tasked with investigating transportation accidents and providing recommendations to avoid these types of accidents in the future.

Our program provided some advice for analyzing fatigue factors in accident investigation. These factors include: the amount of sleep loss prior to the incident/accident; the number of hours awake; the time of day; known sleep disorders. These factors tagged onto the fact that the air traffic controller that day was a trainee, and that an important ground reference beacon was inoperative led to the accident.

In addition to hearing about the accident first hand, it was an invaluable experience to allow us to think about aspects of the flight and learn from the mistakes. Fortunately, no one died in order for the rest of us to gain important information. The discussion also gave us a chance to reflect on our own operations. Whether that's flying an airplane, healing people who are sick, navigating a boat, or driving a car, this exercise helps each one of us stop and think about how fragile we each are and that we can get hurt (in addition to potentially hurting others) if we're not careful.

By the end of the second day, each of the participants had plenty of material to bring back to their organization. They were able to take with them the knowledge of how important sleep is to safely operate in any environment. With this knowledge, they can make educated decisions that apply directly with crew scheduling, policy making, or other pertinent aspects of running their particular operation.