The more factors I consider, the fewer seem likely until I consider the human factor of fatigue. Automation? He was flying a B747 prior, plenty of automation there. San Francisco? Not all that different from dozens of international airports in the Pac Rim. CRM? Things didn’t go bad until the last few miles. New captain, new instructor? Happens everyday at every airline. Cultural paralysis? What? These airlines fly safely all around the world daily. Airmanship? The guys have thousands of hours flying the heavy machinery. Sure, the B777 is different from a B747, but the pilot monitoring was a B777 instructor, trained and qualified.
So why did they just stop flying, lose situational awareness, lose internal communications and CRM all at once? It seemed. like someone had whacked them in the head with a stick, like they ‘d had been incapacitated, like they were barely conscious?
What is the one factor that would interrupt motor skills,cloud judgment and block action? Only one common factor comes to mind, the human factor of fatigue.
If culture was cause, then every flight operated by this culture would crash. But that is not what the facts tell us, since pilots from this culture operate hundreds of flights safely everyday, everyweek, everymonth, everyyear. Therefore logic tells us that culture is NOT THE CAUSE.
Since most commercial aviation mishaps are related to human factors, such as fatigue, which is highly incapacitating to all humans, regardless of culture, flight crew fatigue would be one of the first places to investigate in my opinion.
If we look at the many aircraft mishaps over the years, the demographics of flight crews involved cuts squarely across every cultural line. Any attempt to “culture-bait” this investigation in my mind is an attempt to divert us from the truth. And I personnaly do not like looking in the wrong direction for truth.
Let me ask any of you who are non-flight crew persons, how many of you who are office type persons spend 14-16 hours at your desk each day? Consider this hypothetical situation because probably you have at least once spent 16 hours at your desk.
At the end of this theoretical 16 hr day, how good were your decisions, how clear was your judgment, how swift were your actions and how clear were your communications?
Fatigue can shut down the best parts of our brains. Why do we have such a hard time understanding that putting pilots in charge of a flight with 38 or more computer modes after a 14 hr day and 200+ peoples lives is not such a great idea?
And one further question, when did the crew eat their last meal before reassuming their duties on the flight deck? Did the after meal fatigue, the tendency for many of us to nod off as our digestive systems go to work, put the crew members into a food induced fatigue?
This is just my hunch, I have no facts to check this out.
Sometimes, when a crew grabs some rest, after they arise, they may eat a meal.
If after eating, they moved up to the flight deck and took over flight duties for the last 1 1/2 to 2 hrs, it is possible that the crew got hit with very human post meal drowsiness. Even with a few cups of strong coffee, many if not most people I flew with were certainly affected.
I have never seen this addressed in any FAA reg, SOP or safety note. But it is certainly very common. I know of at least one B747 incident on record where the crew ate and fell asleep, the autopilot disconnected and the plane went out of control.
We will see, again this is 100% speculation.
I just ate my lunch. I think I will take a nap now.
Safety Forecast 