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Asleep at the wheel

NTSB Accident No. ERA12FA572

By David Jack Kenny

Some things aren’t negotiable, and eventually the human body’s need for sleep makes itself one of them. At some point it no longer matters what you’re doing or how badly you need to keep doing it.

The buyer who picked up a Cessna 172 in Boulder, Colo., on Sept. 20, 2012, was more than qualified to fly it back to Florida. He was a professional, a European airline pilot who also held a U.S. private pilot certificate with instrument and multiengine ratings. He arrived in Denver on a commercial flight at 8:45 a.m., went to Boulder, completed the deal, and was airborne on the return trip by 2 p.m. He landed at Woodward, Okla., at about 8 p.m., checked into a motel, and had dinner.

Related links

“Tired?” Safety Pilot article

“Do the Right Thing: Decision Making for Pilots” Safety Advisor 

“Fighting Fatigue” Safety Brief

He was on the move again at 8:30 the next morning, commencing a six-hour leg to Minden, La. The NTSB report doesn’t specify how long he stayed in Minden, but it doesn’t appear to have been long: “After the airplane was serviced, he departed for Pensacola, Florida,” arriving at 7 p.m. While there, he sent several text messages to the seller, saying that the Cessna flew “very nicely” and that he planned to fly the last leg from Pensacola to Tampa that same evening.

At 9:44 p.m., he departed Pensacola. At 1:30 a.m., the pilot contacted Tampa Approach, reporting level at 7,500 feet VFR, and was cleared to enter Class B. Tampa cleared him to descend at pilot’s discretion, and the Cessna began a gradual descent. At 1:49 a.m., the Tampa controller tried to provide the pilot with a low-altitude alert after the Skyhawk descended below 1,000 feet agl, but was unable to establish contact. About a minute later, it flew into the ground under power, killing the pilot.

Examination of the wreckage found no evidence of any mechanical problem beyond impact damage, and the extent of the post-crash fire proved that fuel remained on board. The fuel selector was set to “Both.” The NTSB concluded that in the last half hour of his trip, the pilot had fallen asleep at the controls.

Given his schedule from Boulder to Tampa, that isn’t hard to believe—but as it turned out, he was almost certainly tired by the time he’d gotten to Boulder. After arriving in Newark, N.J., on a late flight from Zurich, he’d spent six hours in a hotel before boarding the flight for Denver, which left at 5:30 a.m. local time. His layover in Zurich was barely four hours and came at the end of a five-day tour back and forth between Europe and the Caribbean. He’d spent his only break in the preceding nine days with a friend in Tampa; the friend recalled that the pilot had fallen asleep during a conversation the first night, excused himself and gone to bed, and then fallen asleep again when they resumed the conversation the next morning. After breakfast he “seemed better,” but then spent the rest of the day and the following evening “working on his computer.”

The NTSB determined that the pilot had made three crossings of the Atlantic, each traversing six time zones, during the nine days before the accident. He’d then flown an unfamiliar light airplane six and a half hours the first day and more than 17 hours the next, continuing long past the time fatigue should have been expected. He’d gotten within 60 nautical miles of home before his body’s needs could no longer be deferred.

A great many accidents result from long series of choices and events that offered more than one opportunity to avoid disaster. A single good decision can break the chain. A nap in Pensacola might have been all that this pilot needed to get home safely and go on enjoying his new airplane.