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Analysis of Crew Fatigue in AIA Guantanamo Bay Aviation AccidentFlight operations can engender fatigue, which can affect flight crew performance, vigilance, and mood. The National Transportation Safety Board (NTSB) requested the NASA Fatigue Countermeasures Program to analyze crew fatigue factors in an aviation accident that occurred at Guantanamo Bay, Cuba. There are specific fatigue factors that can be considered in such investigations: cumulative sleep loss, continuous hours of wakefulness prior to the incident or accident, and the time of day at which the accident occurred. Data from the NTSB Human Performance Investigator's Factual Report, the Operations Group Chairman's Factual Report, and the Flight 808 Crew Statements were analyzed, using conservative estimates and averages to reconcile discrepancies among the sources. Analysis of these data determined the following: the entire crew displayed cumulative sleep loss, operated during an extended period of continuous wakefulness, and obtained sleep at times in opposition to the circadian disposition for sleep, and that the accident occurred in the afternoon window of physiological sleepiness. In addition to these findings, evidence that fatigue affected performance was suggested by the cockpit voice recorder (CVR) transcript as well as in the captain's testimony. Examples from the CVR showed degraded decision-making skills, fixation, and slowed responses, all of which can be affected by fatigue; also, the captain testified to feeling "lethargic and indifferent" just prior to the accident. Therefore, the sleep/wake history data supports the hypothesis that fatigue was a factor that affected crewmembers' performance. Furthermore, the examples from the CVR and the captain's testimony support the hypothesis that the fatigue had an impact on specific actions involved in the occurrence of the accident.
Document ID
20010114272
Acquisition Source
Ames Research Center
Document Type
Preprint (Draft being sent to journal)
Authors
Rosekind, Mark R.
(NASA Ames Research Center Moffett Field, CA United States)
Gregory, Kevin B.
(NASA Ames Research Center Moffett Field, CA United States)
Miller, Donna L.
(NASA Ames Research Center Moffett Field, CA United States)
Co, Elizabeth L.
(NASA Ames Research Center Moffett Field, CA United States)
Lebacqz, J. Victor
(NASA Ames Research Center Moffett Field, CA United States)
Statler, Irving C.
Date Acquired
August 20, 2013
Publication Date
May 16, 1994
Subject Category
Aerospace Medicine
Funding Number(s)
PROJECT: RTOP 505-64-53
Distribution Limits
Public
Copyright
Work of the US Gov. Public Use Permitted.

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