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POSTED: Friday, December 26, 2008

The captain who fell asleep on a go! Airlines flight to Hilo from Honolulu said he regularly napped about once a week for about 20 minutes at a time while in flight prior to a Feb. 13 incident when the plane overshot the Hilo airport, according to a National Transportation Safety Board report.

               

     

 

 

FLIGHT 1002 PILOTS         The 53-year-old captain had 20 years of experience with between 20,000 to 25,000 flight hours, including 8,000 hours as pilot-in-command. He completed his last training on July 19, 2007, and his last proficiency check on Jan. 4.         His most recent medical certificate was issued on Dec. 18, 2007, and he described his health as fair.           The 23-year-old first officer was hired on May 8, 2007, and completed his training on July 14, 2007, and his initial operating experience on Sept. 1, 2007. He had 1,250 flight hours.         His most recent medical certificate was issued on Feb. 2, 2007, and he described his health as good.

Both the captain and first officer admitted to investigators that they fell asleep while the plane was on autopilot, and the captain initially lied about the incident to air traffic controllers, according to the 11-page factual report posted on the NTSB Web site.

The report summarizes what an NTSB team found during its investigation of go! Airlines Flight 1002, which took off from Honolulu at 9:16 a.m. Feb. 13 carrying 40 passengers, a flight attendant and the pilot and co-pilot.

About halfway through the flight, the pilots stopped responding to air traffic control communications and passed over Hilo Airport at 21,000 feet, continuing straight for nearly 30 miles past the airport over the open ocean.

The report says there was an 18-minute gap from about 9:40 until 9:58 a.m. when air traffic controllers and pilots on other planes tried but could not communicate by radio with the go! pilots.

When he woke up, the first officer realized the plane was off course, and checked to make sure there was enough fuel before waking up the captain.

When asked by flight controllers whether they had experienced an emergency, the captain replied, “;No, we must have missed a hand-off or missed a call or something.”;

After the plane landed in Hilo at 10:15 a.m., the captain initially told controllers that they had selected the wrong radio frequency. The controllers told the pilot they would be reporting the incident to Mesa Airlines, the parent company of go! Airlines.

The pilots discussed the incident and decided they could fly the plane back to Honolulu. But when they landed in Honolulu, they removed themselves from duty.

The captain declined on the telephone to provide a reason for going off duty and filed a written report several hours later.

Mesa Airlines did not conduct a toxicology test until Feb. 14, one day after the incident, because the senior director of flight operations said he did not receive information about it until the night of Feb. 13.

The tests were negative for drugs.

The captain said he did not drink alcohol the night before the flight. The first officer told investigators he had “;one beer”; at about 5 p.m. on Feb. 12.

The report notes several stress factors that the pilots experienced. The flight attendant assigned to work their first flight was late on Feb. 13, which meant the flight crew had to rush their first three flights to get back on schedule.

That might have been a factor in the captain letting down his guard, he told investigators.

“;Working as hard as we had, we tend to relax,”; he said. “;We had gotten back on schedule, it was comfortable in cockpit, the pressure was behind us. The warm Hawaiian sun was blaring in as we went eastbound. I just kind of closed my eyes for a minute, enjoying the sunshine, and dozed off,”; he told investigators.

The 53-year-old pilot of the plane, who is not named in the report, also told investigators he had never inadvertently fallen asleep before, but admitted to regular napping while in flight.

After the incident, the captain was diagnosed with severe obstructive sleep apnea, a condition that his physician said could cause “;significant fatigue.”;

The 23-year-old first officer, who is also not named, said he had never fallen asleep before on a flight. But on Feb. 13 he entered what he described as a sleeplike state where he could “;hear what was going on but could not comprehend or make it click.”;

The flight attendant on the plane said she wore a watch but did not recall whether she looked at it during the flight. She said she did not notice anything unusual and did not feel there was anything unsafe.

The captain also told investigators that he was feeling “;burned out”; in recent months because of his working conditions - including less time off and frequent changes to his schedule.

He said he had asked for temporary assignment to Hawaii seeking some relief but found conditions no better because he was flying eight legs a day with few breaks and little time to drink coffee, eat and smoke cigarettes.

The captain said he went to bed between 8 and 9 p.m. on Feb. 12 after working from 5:40 a.m. to 2:47 p.m. He woke up at 4 a.m. on Feb. 13 and did not have breakfast, but snacked on cookies with his first officer later in the morning.

The first officer worked with the captain on Feb. 12 went to bed at 9:30 p.m. He woke up at about 5 a.m. and had a pastry for breakfast.

Mesa Airlines fired both pilots after the incident.

The go! flight was part of an NTSB review of the issue of employee fatigue at a meeting in June. The agency might issue a recommendation letter to the Federal Aviation Administration about “;the dangers of human fatigue within airline operations,”; an NTSB release about the meeting said.

 

Tracking the pilots' path

This is a time line of events involving the pilots of go! Flight 1002, who fell asleep on a flight to Hilo from Honolulu on Feb. 13. The time line begins the day before.

  Feb. 12

» The captain woke up at 4 a.m. and bought a fast-food breakfast. He reported for work at 5:40 a.m. The first officer said he woke between 4:50 and 5 a.m.; he reported for duty at 5:40 a.m. Their flight together was delayed because a flight attendant was late. They flew eight flights together and got off duty at 2:47 p.m.

» The captain said he went to bed between 8 and 9 a.m., after having arranged for the first officer to pick him up the next morning. He described his sleep as “;pretty good.”;

» The first officer said he went to bed at 9:30 p.m. and described his sleep as “;good.”;

Feb. 13

» The captain woke up at 4 a.m. but did not eat breakfast because the first officer was late in picking him up. The first officer woke between 4:50 and 5 a.m. and ate a pastry. They both reported for work at 5:40 a.m.

» Due to a flight attendant scheduling error, their first flight departed 30 minutes late. They shared a package of cookies on that flight.

» 9:16 a.m. - Flight 1002 departed Honolulu Airport.

» 9:30 a.m. - Captain informed the FAA's Honolulu Control Facility (HCF) that Flight 1002 was climbing through 11,700 feet to its cruise altitude. HCF confirmed communication and cleared flight to designated area near the Big Island.

» 9:33 a.m. - HCF confirmed previous instruction. Captain acknowledged transmission.

» 9:40 a.m. - As Flight 1002 crossed Maui, HCF instructed pilots to change radio frequencies. There was no response.

» For the next 18 minutes HCF attempted to contact Flight 1002 but got no response.

» 9:51 a.m. - An HCF controller asked another controller to try contacting the plane using a different frequency. The controller did so, with no response.

» 9:55 a.m. - Flight 1002 passed Hilo and headed out over the ocean. HCF asked another go! flight to contact Flight 1002 on a company radio frequency. The other flight crew tried but got no response.

» A Continental Airlines flight tried to contact Flight 1002 on an emergency frequency but also got no response.

» The first officer then awoke, checked the fuel gauge and woke up the captain, telling him that air traffic controllers were trying to contact him.

» 9:58 a.m. - Flight 1002 captain contacted air controllers, but the transmission was unintelligible. HCF asked whether there was an emergency. The captain said no. HCF then issued instructions to return to Hilo.

» 10:15 a.m. - Flight 1002 landed at Hilo Airport.

» Shortly thereafter the captain told the FAA via telephone that they had lost communication because they had selected the wrong radio frequency. FAA personnel said the incident would be reported to Mesa Airlines, the parent company of go!

» Pilots discussed whether they should fly the next flight back to Honolulu. They decided it would be “;safe to do so because they were feeling very alert as a result of the incident.”;

» 10:29 a.m. - Flight 1044 departed Hilo for Honolulu.

» During the flight to Oahu, the pilots decided to remove themselves from duty upon arrival in Honolulu.

» 11:18 a.m. - Flight 1044 landed at Honolulu Airport.

Source: National Transportation Safety Board