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IN THIS VERSION OF THE PUBLISHED REPORT

AIRCRAFT ACCIDENT REPORT 

NTSB/AAR-04/02 (PB2004-910402) 

Collision With Trees on Final Approach 

Federal Express Flight 1478 

Boeing 727-232, N497FE 

Tallahassee, Florida 

July 26, 2002

• Pages iii and iv of the Table of Contents has been updated with the correct page numbers. Corrections are 

noted in the table below. 

Section Number Section Title Previous Incorrect Page 

Number Correct Page Number 

1.18 Additional Information 47 48

1.18.1 Hypoxia-Related Information 47 48

2 Analysis 52 53

2.1 General 52 53

2.2 The Accident Approach 53 54 

2.3 Fatigue 55 56

2.3.1 Role of Fatigue−Captain 55 56

2.3.2 Role of Fatigue−First Officer 56 57

2.3.3 Role of Fatigue−Flight Engineer 58 59

2.3.4 Fatigue Management Training 59 60 

2.5 Crew Coordination/Monitoring 

Information 63 64

3 Conclusions 66 67

3.1 Findings 66 67

3.2 Probable Cause 67 68

4 Recommendations 68 69

 
Aircraft Accident Report

Collision With Trees on Final Approach

Federal Express Flight 1478

Boeing 727-232, N497FE

Tallahassee, Florida

July 26, 2002

NTSB/AAR-04/02

PB2004-910402 National Transportation Safety Board

Notation 7501B 490 LíEnfant Plaza, S.W.

Adopted June 8, 2004 Washington, D.C. 20594

E PLUR IBUS UNUM

NATIONAL TRA S PORTATION

B OAR D

SAFE T Y

N
National Transportation Safety Board. 2004. Collision With Trees on Final Approach, Federal

Express Flight 1478, Boeing 727-232, N497FE, Tallahassee, Florida, July 26, 2002. Aircraft Accident

Report NTSB/AAR-04/02. Washington, DC.

Abstract: This report explains the accident involving Federal Express flight 1478, a Boeing

727-232F, N497FE, which struck trees on short final approach and crashed short of runway 9 at

the Tallahassee Regional Airport, Tallahassee, Florida. Safety issues in this report focus on flight

crew performance, flight crew decision-making, pilot fatigue, and Federal Aviation

Administration (FAA) certification of pilots with color vision deficiencies. Safety

recommendations concerning these issues are addressed to the FAA.

The National Transportation Safety Board is an independent Federal agency dedicated to promoting aviation, railroad, highway, marine,

pipeline, and hazardous materials safety. Established in 1967, the agency is mandated by Congress through the Independent Safety Board

Act of 1974 to investigate transportation accidents, determine the probable causes of the accidents, issue safety recommendations, study

transportation safety issues, and evaluate the safety effectiveness of government agencies involved in transportation. The Safety Board

makes public its actions and decisions through accident reports, safety studies, special investigation reports, safety recommendations, and

statistical reviews.

Recent publications are available in their entirety on the Web at <http://www.ntsb.gov>. Other information about available publications also

may be obtained from the Web site or by contacting:

National Transportation Safety Board

Public Inquiries Section, RE-51

490 LíEnfant Plaza, S.W.

Washington, D.C. 20594

(800) 877-6799 or (202) 314-6551

Safety Board publications may be purchased, by individual copy or by subscription, from the National Technical Information Service. To

purchase this publication, order report number PB2004-910402 from:

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(800) 553-6847 or (703) 605-6000

The Independent Safety Board Act, as codified at 49 U.S.C. Section 1154(b), precludes the admission into evidence or use of Board reports

related to an incident or accident in a civil action for damages resulting from a matter mentioned in the report. 
iii Aircraft Accident Report

Contents

Abbreviations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . vi

Executive Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ix

1. Factual Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

1.1 History of Flight . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

1.2 Injuries to Persons. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

1.3 Damage to Aircraft . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

1.4 Other Damage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

1.5 Personnel Information. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

1.5.1 The Captain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

1.5.2 The First Officer. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

1.5.3 The Flight Engineer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

1.6 Airplane Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18

1.7 Meteorological Information. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18

1.8 Aids to Navigation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20

1.9 Communications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20

1.10 Airport Information. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20

1.10.1 Airport/Approach Charts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22

1.10.2 Runway 9 Lighting. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22

1.11 Flight Recorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26

1.11.1 Cockpit Voice Recorder . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26

1.11.2 Flight Data Recorder . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27

1.12 Wreckage Recovery and Documentation Information . . . . . . . . . . . . . . . . . . . . . . . . . 27

1.13 Medical and Pathological Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30

1.13.1 Toxicological Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30

1.13.2 First Officer’s Color Vision Deficiency. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30

1.13.3 First Officer’s Postaccident Hospitalization Information . . . . . . . . . . . . . . . . . . . . 38

1.14 Fire/Explosion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39

1.15 Survival Aspects . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39

1.16 Tests and Research . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39

1.17 Operational and Management Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39

1.17.1 FedEx Flight Crew Training—General . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40

1.17.2 Postaccident FedEx Actions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47

1.18 Additional Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48

1.18.1 Hypoxia-Related Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48

1.18.2 DOT Operator Fatigue Management Program. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48

1.18.3 Crew Familiarity/Attention/Monitoring Information. . . . . . . . . . . . . . . . . . . . . . . . 49

1.18.4 Previously Issued Safety Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51

2. Analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53

2.1 General . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53

2.2 The Accident Approach . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54

2.3 Fatigue . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56
Contents iv Aircraft Accident Report

2.3.1 Role of Fatigue—Captain. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56

2.3.2 Role of Fatigue—First Officer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57

2.3.3 Role of Fatigue—Flight Engineer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59

2.3.4 Fatigue Management Training . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60

2.4 Physiological Issues That May Have Affected the First Officer’s Performance . . . . . . 60

2.4.1 The First Officer’s Color Vision Deficiency . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60

2.4.2 The First Officer’s Breathing Rate. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63

2.5 Crew Coordination/Monitoring Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64

3. Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67

3.1 Findings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67

3.2 Probable Cause . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68

4. Recommendations. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69

5. Appendixes

A: Investigation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71

B: Cockpit Voice Recorder Transcript . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72

C: Correspondence Regarding the First Officer’s Color Vision . . . . . . . . . . . . . . . . . . . . . . . 104
v Aircraft Accident Report

Figures

1. Descent profile of FedEx flight 1478. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

2. Descent profile of FedEx flight 1478, with select CVR comments overlaid. . . . . . . . . . . . . 6

3. A map overlay of FedEx flight 1478ís radar track into runway 9 at TLH, 

with excerpted CVR comments. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

4. The three crewmembersí estimated sleep schedule during the 72 hours 

before the accident. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

5. TLH airport diagram. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21

6. PAPI indications from various approach path angles.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23

7. A swath of trees damaged by impact with FedEx flight 1478. . . . . . . . . . . . . . . . . . . . . . . 28
vi Aircraft Accident Report

Abbreviations

AC advisory circular 

AD airworthiness directive 

agl above ground level

AIM Aeronautical Information Manual

ALAR approach and landing accident reduction

ARFF aircraft rescue and firefighting 

ARTCC air route traffic control center

ASOS automated surface observation system 

ATC air traffic control 

ATCT air traffic control tower 

ATP airline transport pilot

bpm breaths per minute

BUF Buffalo Niagara International Airport

CFIT controlled flight into terrain

CFM company flight manual

CFR Code of Federal Regulations

CRM crew resource management

CTAF common traffic advisory frequency

CVR cockpit voice recorder 

DOT Department of Transportation 

EGPWS enhanced ground position warning system

EPR engine pressure ratio

FAA Federal Aviation Administration 

FALANT Farnsworth Lantern

FDR flight data recorder
Abbreviations vii Aircraft Accident Report

FL flight level

FOM flight operations manual

FOTM flight operations training manual

fpm feet per minute

GAME Guide for Aviation Medical Examiners

GFK Grand Forks International Airport

GPWS ground proximity warning system 

Hg mercury 

IFR instrument flight rules 

ILS instrument landing system 

IOE initial operating experience 

MEM Memphis International Airport

msl mean sea level 

NASA National Aeronautics and Space Administration

NATCA National Air Traffic Controllers Association

nm nautical mile

NPRM notice of proposed rulemaking 

NWS National Weather Service 

PAPI precision approach path indicator

PIP pseudoisochromatic plate

pph pounds per hour

S/N serial number

SHV Shreveport Regional Airport

SODA Statement of Demonstrated Ability

TCAS traffic collision avoidance system

TLH Tallahassee Regional Airport

TRACON terminal radar approach control

USAFSAM U.S. Air Force School of Aerospace Medicine

VASI visual approach slope indicator
Abbreviations viii Aircraft Accident Report

VOR Very High Frequency Omnidirectional Radio Range

VSI vertical speed indicators

YOW Ottawa MacDonald Cartier International Airport

YWG Winnepeg International Airport
ix Aircraft Accident Report

Executive Summary

On July 26, 2002, about 0537 eastern daylight time, Federal Express flight 1478, a

Boeing 727-232F, N497FE, struck trees on short final approach and crashed short of

runway 9 at the Tallahassee Regional Airport (TLH), Tallahassee, Florida. The flight was

operating under the provisions of 14 Code of Federal Regulations Part 121 as a scheduled

cargo flight from Memphis International Airport, in Memphis, Tennessee, to TLH. The

captain, first officer, and flight engineer were seriously injured, and the airplane was

destroyed by impact and resulting fire. Night visual meteorological conditions prevailed

for the flight, which operated on an instrument flight rules flight plan.

The National Transportation Safety Board determines that the probable cause of

the accident was the captainís and first officerís failure to establish and maintain a proper

glidepath during the night visual approach to landing. Contributing to the accident was a

combination of the captainís and first officerís fatigue, the captainís and first officerís

failure to adhere to company flight procedures, the captainís and flight engineerís failure

to monitor the approach, and the first officerís color vision deficiency.

The safety issues in this report focus on flight crew performance, flight crew

decision-making, pilot fatigue, and Federal Aviation Administration (FAA) certification of

pilots with color vision deficiencies. Safety recommendations concerning these issues are

addressed to the FAA.

1 Aircraft Accident Report

1. Factual Information

1.1 History of Flight

On July 26, 2002, about 0537 eastern daylight time,1 Federal Express (FedEx)

flight 1478, a Boeing 727-232F (727), N497FE, struck trees on short final approach and

crashed short of runway 9 at the Tallahassee Regional Airport (TLH), Tallahassee,

Florida. The flight was operating under the provisions of 14 Code of Federal Regulations

(CFR) Part 121 as a scheduled cargo flight from Memphis International Airport (MEM),

in Memphis, Tennessee, to TLH. The captain, first officer, and flight engineer were

seriously injured, and the airplane was destroyed by impact and resulting fire. Night visual

meteorological conditions prevailed for the flight, which operated on an instrument flight

rules (IFR) flight plan.

The accident flight crew reported for the accident flight in MEM at least 1 hour

before the flightís scheduled departure time of 0412,2

 as required by FedEx. The airplaneís

departure from MEM was delayed slightly because of an adjustment to a cargo pallet; the

airplane was pushed back about 0424. According to postaccident pilot interviews, cockpit

voice recorder (CVR)3

 and flight data recorder (FDR) evidence, and air traffic control

(ATC) records, the climb and cruise phases of the flight were routine and uneventful. The

first officer was the flying pilot, while the captain performed the non-flying pilot duties for

the accident flight.

According to the CVR transcript, about 0511, the flight engineer received the TLH

weather information from the Gainesville Flight Service Station, which indicated:

scattered clouds at 100 feet, 18,000 feet, and 25,000 feet; wind from 120o at 5 knots;

visibility 9 statute miles; temperature and dew point 22o C (Celsius); and altimeter setting

30.10 inches of mercury (Hg). The flight engineer related this information to the captain

and first officer and asked which runway they would use at TLH. About 0512:41, the

captain stated that they would land on runway 27 at TLH.

The CVR indicated that about 0513:13, a controller at Atlanta Air Route Traffic

Control Center (ARTCC) cleared the pilots of flight 1478 to descend to and maintain

flight level (FL) 2404

 at their discretion. The captain acknowledged the clearance. The

flight engineer subsequently contacted FedEx ramp personnel at TLH and advised them

that flight 1478 was 25 to 30 minutes from TLH, ìlookiní for a parkiní spot and the

1 Unless otherwise indicated, all times are eastern daylight time, based on a 24-hour clock.

2 The flightís scheduled departure time was 0312 in MEM local time (MEM is located in the central

daylight time zone).

3 The CVR recorded the last 32 minutes and 12 seconds of cockpit communications before the

accident. See appendix B for a complete transcript of the CVR.

4 Flight level (FL) 240 is an altitude of 24,000 feet mean sea level (msl), based on an altimeter setting

of 29.92 inches Hg.
Factual Information 2 Aircraft Accident Report

power.î TLH ramp personnel advised them to use gate number 2 and to park facing south.

The flight engineer then briefed the captain and first officer regarding parking at TLH and,

in accordance with company procedures, advised them that FedEx considered TLH a

moderate controlled flight into terrain (CFIT) risk.5

About 0515:32, Atlanta ARTCC instructed the pilots of flight 1478 to contact

Jacksonville ARTCC and the captain acknowledged the instructions. At 0515:52.3, the

CVR recorded the captain, stating, ìJacksonville center uh good morning, FedEx fourteen

seventy eight, two nine oh, discretion to two four oh.î The Jacksonville air traffic

controller responded, ìFedEx 1478, Jax center roger, descend at pilotís discretion maintain

niner thousand, Tallahassee altimeter three zero one zero.î The captain acknowledged the

clearance then announced the target airspeeds6

 for the approach to the first officer. 

About 0516:38, the captain questioned the flight engineer about the weather

information, stating, ìone thousand scattered, ten miles, uhh is zat what it saidÖthere?î

About 0516:43 (while the captain was finishing his statement), the first officer began the

approach briefing for runway 27 at TLH, stating, in part, ìweíll plan on a visual to

runway 27ÖWeíll back it up with thisÖILS[7

] runway 27 full procedureÖ272 is the final

approach course inbound.î The first officer stated that the minimum safe altitude was

3,300 feet mean sea level (msl) ìall the way aroundÖmissed approach will be as

published and weíll talk to íem and see if we can get something betterÖ.runwayís 8,000

[feet long], plan on rolliní out to the endÖgot a PAPI[8

] on the left-hand

sideÖpilot-controlled lighting,[9

] so if you canÖclick it seven times Iíd appreciate it.î

About 0518:30, the first officer stated, ìall right, start on down,î and the captain

responded, ìall right.î The captain then radioed Jacksonville ARTCC, stating, ìuh,

Atlanta FedEx uh fourteen seventy eight, leaving two nine oh for uh, nine thousand.î

According to the CVR transcript, about 0519:38, the first officer asked, ìyou

wanna land on nine if we see it?î He added, ìwe got a PAPI on nine, too.î The captain

5 The Federal Aviation Administration (FAA) defines CFIT as ìan event where a mechanically normal

functioning airplane is inadvertently flown into the ground, water, or an obstacleî (see

<http://www/faa.gov/avr/avs/cfit/volume1/titlepg.pdf>). FedExís Flight Operations Manual (FOM) contains

a similar definition. For additional information regarding FedExís determination of CFIT risk, see

section 1.17.1.1.

6 The captain announced the target airspeeds as follows: ìVref one thirty sevenÖuhhh bug at uh one

forty sevenÖone fifty two, one sixty two, one ninety two, two oh two.î

7 ILS refers to the instrument landing system.

8 The PAPI, or precision approach path indicator, light system at TLH consists of four boxes of lights

that provide a visual indication of an airplaneís position on the glidepath for the associated runway. If an

airplane is on glidepath, two boxes should display white lights and two boxes red lights. If an airplane is

beneath the glidepath, more red lights are visible to the pilots; if an airplane is above the glidepath, more

white lights are visible. For additional information regarding the TLH PAPI lighting system, see

section 1.10.2.

9 During hours that TLH air traffic control tower (ATCT) is closed, all runway, taxiway, and approach

lighting systems on the airport are pilot-controlled and can be activated by a pilot keying the microphone

with the radio tuned to the airportís common traffic advisory frequency (CTAF). Keying the airplane

microphone activates the airport lighting as follows: three times (within 5 seconds) results in low intensity,

five time results in medium intensity, and seven times results in high intensity.
Factual Information 3 Aircraft Accident Report

responded, ìyeah, maybeÖbe a longer taxi for us, butÖway weíre cominí in probly two

seven be about as easy as any of íem.î The first officer said, ìokay.î The pilots initiated

the in-range checklist about 0521:57 and completed it about 0522:20. During this time, the

CVR recorded a sound similar to the microphone being keyed six times in about

1.3 seconds. 

The CVR indicated that about 0522:46, Jacksonville ARTCC cleared the pilots of

flight 1478 to descend and maintain 3,000 feet msl at their discretion. About 0523:33, the

Jacksonville ARTCC controller instructed the pilots to contact him on another frequency.

At 0523:49.2, the captain reported on the new frequency, stating, ìand Atlanta FedEx

fourteen seventy eight with you, one thirty five thirty two.î The Jacksonville ARTCC

controller asked if they had TLH weather, and the captain confirmed that they did. About

0524:03, the controller advised them to expect a visual approach into TLH and to report

when they had the airport in sight. 

According to the CVR, about 0524:23, the captain stated, ìrunway nineÖPAPI on

the left sideÖI donít know, you wanna try for nine?î The first officer responded, ìweíre

pointed in the right direction, I donít know, like you saidÖkinda a longÖtaxiback.î The

captain said, ìyeah, thatíd be all right.î The first officer further stated, ìI always thought

you were supposed to land with the prevailing windÖat an uncontrolledÖ,î and the

captain responded, ìwell, at 5 knots, it reallyÖthe only advantage you have, landing to the

west you have theÖglideslopeÖwhich you donít have to the east.î The captain asked the

first officer if he was familiar with TLH, and the first officer replied that he was not.

About 0527:47, the flight engineer advised TLH ground personnel that flight 1478

was 5 minutes out. The ramp agent indicated that ground power was available for the

airplane and that he would arrange for transportation for them to the layover hotel.10

Consistent with FedEx policy, the flight engineer then asked the captain and first officer if

they wanted to perform the approach checklist. About 0528:26, the first officer asked, ìwe

ever decide if weíre goiní nine or two seven?î The captain responded, ìyeah, we can do

nine if you want to.î About 0528:30, the first officer stated, ìokay, runway nine, visual

runway nine PAPI on the left sideÖapproach check.î The flight engineer asked,

ìbriefing?,î and the first officer responded, ìcomplete for runway nine.î 

The pilots continued the approach checklist and completed it about 0528:57.

About 0529:53, the captain asked the first officer if he wanted to tell the ARTCC

controller that they had TLH in sight. The first officer responded, ìyeah. I donít see the

runway yet, but I got the beacon.î About 0530, the captain told the ARTCC controller that

they had the airport in sight. Jacksonville ARTCC then cleared the pilots of flight 1478 for

the visual approach into TLH and asked if they were aware that runway 18/36 was

10 The pilots were scheduled to remain in Tallahassee for about 17 hours that day then depart TLH for

MEM about 2315.
Factual Information 4 Aircraft Accident Report

closed.11 The captain responded, ìno sir, butÖweíre gonna use runway nine.î

Jacksonville ARTCC repeated the visual approach clearance, adding, ìreport your down

timeÖchange to advisory [frequency] approved.î 

About 0530:32, the CVR recorded sounds similar to a microphone being keyed

five times within about 1.3 seconds. About 7 seconds later, the captain radioed

ìTallahassee uh FedEx fourteen seventy eight uh extended uh left base leg for runway

nine.î The first officer indicated that he thought he saw the runway about 0530:56; he

called for ìflaps 2î about 0531:10 and ìflaps 5î about 12 seconds later. About 0532:34,

the first officer stated, ìI hope Iím lookiní in the right spot here.î The captain responded,

ìsee that group of bright lights kinda to the south down there and you see the beacon in the

middle of it?Öright over thereÖyouíre kinda on aboutÖten mile left base or so.î The

first officer then indicated that he had been ìlooking at the wrongÖflashiní light.î12

About 0533:05, the first officer repeated, ìI was lookiní at the wrong light,î and the

captain responded, ìyeah okay, yeah.î The first officer added, ìyeah, with the direction I

took, we coulda used [runway] 27, eh?,î and the captain responded, ìyeah, it dudnít

matter. Yeah, itís aboutÖten miles south of the VOR.î13

About 0534:11, the captain stated, ìI guess the lights came on, if not Iíll click ëem

again hereÖwhen we get a little closer.î About 20 seconds later, the CVR recorded a

sound similar to a microphone being keyed five times within about 1.5 seconds, and, at

0534:35, the captain said, ìthere we go.î The first officer requested ìflaps 15î about

0535:24. About 0535:31, the first officer stated, ìgear down, before landing check;î about

2 seconds later, the CVR recorded a sound similar to the landing gear handle being

operated followed by a sound similar to the nose gear door opening. 

The CVR indicated that, about 0535:42, the captain advised TLH traffic that

flight 1478 was turning onto final for runway 9. The flight engineer began the before

landing checklist about 0535:54, stating, ìlanding gear,î to which the captain responded,

ìdown in three green.î About 0535:59, the flight engineer stated, ìautobrakes,î and, about

0536:06, the captain responded, ìnot installed.î About 0536:06, the first officer asked for

ìflaps 25,î and the captain acknowledged the request. About 0536:08, the CVR recorded

the flight engineer ask, îautospoilers?î and the captainís response of ìnot installed.î

About 0536:10, the flight engineer queried ìflight and nav[igation] instruments?,î and the

captain responded, ìcross-checked, no flags.î 

11 The National Transportation Safety Board notes that the runway 18/36 closure information was

published in the Airport Facility Directory, (on the Jeppesen-type salmon-colored page 10-10A for TLH

[which listed local ATC, airport, and radar information]), and in the remarks section of the FedEx flight

plan/release for flight 1478. In addition, Notice to Airmen 02-47 was issued on July 19, 2002, for the

closure.

12 A FedEx captain who regularly flies the MEM-to-TLH route told Safety Board investigators that a

powerplant located a few miles north of TLH has a slow white strobe light that is frequently mistaken for the

airportís rotating beacon. He stated that the powerplant light is in the line of sight for the airport for pilots

arriving from the northwest and is often visible before the rotating beacon. He also stated that the green light

of the TLH rotating beacon is ìvery hard to distinguish as green. It is very faint.î

13 VOR refers to the very high frequency omnidirectional radio range navigation aid.
Factual Information 5 Aircraft Accident Report

About 0536:20, the first officer said, ìsorry ëbout thatÖI was lininí up on that

papermill or something.î As the first officer started speaking, (at 0536:20.2), the CVR

recorded the ground proximity warning system (GPWS) announce that the airplane passed

through 1,000 feet above ground level (agl).14 About 0536:23, the captain said, ìthatís all

right, no problem.î 

About 0536:37, the airplane was slightly more than 2.5 nautical miles (nm) from

the airport and was transitioning from an angled base-to-final leg to line up with the

runway. The Safety Boardís airplane performance study indicated that, about this time, the

PAPI would have been displaying one white light and three red lights when viewed from

the cockpit. About 0536:40, the PAPI display would have shown four red lights. (Figure 1

shows the airplaneís descent profile in relation to the PAPI light indications, flap

extension, the runway, and treetops. Figure 2 shows the same information with select CVR

comments overlaid.) About this time, the power on the three engines increased from about

1.05 to 1.24 EPR (engine pressure ratio),15 then, about 0536:41, the power to the engines

decreased from 1.24 to 1.17 EPR. About 0536:43, as the airplane approached 500 feet, the

captain asked the first officer if he wanted to go to flaps 30, and the first officer responded,

ìplease.î At 0536:47.8, the CVR recorded the GPWS announcement indicating that the

airplane was passing through 500 feet agl. About 0536:49, the CVR recorded the captain

stating, ìstable.î The Safety Boardís airplane performance study indicated that, at this

time, the airplane was 1.8 nm west of runway 9, descending through 500 feet agl at a

vertical speed of 1,248 feet per minute (fpm),16 with engine power settings of about

1.17 EPR and an airspeed of 152 knots.

14 Evaluation of the accident airplaneís GPWS indicated that the unit provided altitude advisories

consistent with its design during the approach to TLH. Additionally, the investigation noted that the

airplaneís most rapid rate of descent during the later stages of the approach (more than 1,400 feet per minute

[fpm] between 700 and 500 feet) did not meet the warning annunciation threshold for those altitudes; at

those altitudes, the GPWS would have generated a ìsink rateî warning at descent rates of 2,100 and

1,800 fpm, respectively.

15 Engine pressure ratio (EPR) is a measurement of engine power output as a ratio of the total pressure

of the gases in the exhaust pipe divided by the total pressure of the air entering the engine inlet.

16 The Safety Board notes that the captainís and first officerís vertical speed indicators (VSIs) were not

instantaneous and, therefore, may have displayed vertical speed information that lagged slightly behind the

real-time vertical speed derived from the FDR data. According to the VSI manufacturerís simulation, the

pilotsí VSIs would have shown a rate of descent of at least 1,000 fpm when the airplane descended through

500 feet agl. 
Factual Information 6 Aircraft Accident Report

Figure 1. Descent profile of FedEx flight 1478.

Figure 2. Descent profile of FedEx flight 1478, with select CVR comments overlaid. 
Factual Information 7 Aircraft Accident Report

Also about 0536:49, the CVR recorded the first officer stating, ì[Iím] gonna have

to stay just a little bit higherÖIím gonna lose the end of the runway.î About 0536:51, the

captain responded, ìyeahÖyeah, okay.î About 0536:52, the flight engineer asked,

ìflaps?,î and the captain responded, ìthirty thirty green light.î About 0536:56, the flight

engineer asked, ìlanding clearance?,î and the captain responded, ìclear to land

runwayÖnine.î

About 0536:58, the FDR data indicated that the engine power began to increase

from 1.17 EPR, reaching 1.20 EPR about 4 seconds later. At 0536:59.7, the captain

advised TLH traffic that flight 1478 was on short final for runway 9. About 0537:09, the

captain said, ìitís startiní to disappear in there a little bit, [isnít] it? Think weíll be alright,

yeah.î The performance study indicated that, about this time, the airplane was 0.9 nm west

of runway 9, descending through about 200 feet agl at a vertical speed of 528 fpm and an

airspeed of 146 knots; the airplane performance study indicated that the PAPI indication

observed from the cockpit would have been four red lights.

About 0537:13, the flight engineer announced that the before landing checklist

was complete.17 This announcement was the last flight crewmember statement recorded

by the CVR. At 0537:14, the GPWS announced that the airplane passed 100 feet agl; FDR

and airplane performance information indicated that, at this time, the airplane was 0.7 nm

west of runway 9, descending at a vertical speed of 432 fpm and an airspeed of 144 knots

and that the engine power had increased to about 1.34 EPR. At 0537:19.9, as the GPWS

announced 50 feet agl, the engine power increased to about 1.46 EPR. At 0537:20.3, as the

GPWS announced 40 feet agl, the No. 2 and No. 3 engine EPRs began to increase rapidly.

At 0537:20.7, the CVR recorded the sound of a crunch, and, about 0537:21, the GPWS

announced 30 feet agl. About 0537:22, the CVR recorded another crunch sound, and the

No. 1 engine EPR began to increase rapidly. At 0537:22.6, the GPWS announced ìbank

angle, bank angle.î The CVR transcript indicates that, about 0537:23, the sound of

crunching began again and, about 0537:25, a loud squeal began; both sounds continued to

the end of the recording at 0537:26.2. (Figure 3 shows the accident airplaneís radar track

into TLH overlaid on a map, with excerpted CVR comments.)

The airplane collided with trees in a right-wing-low, slightly nose-up attitude

during the approach to runway 9 then impacted the ground, coming to rest on a heading of

260o degrees about 1,556 feet west-southwest of the runway. A postimpact fire ensued;

however, the three flight crewmembers exited the airplane through the captainís side

sliding cockpit window before the fire reached the cockpit. The accident occurred about

74 minutes before sunrise. 

17 Although the CVR did not record any discussion of the last four items on the 727 before landing

checklist (fuel panel, hydraulic and brake system, antiskid, and landing lights), FedExís 727 Company Flight

Manual (CFM) indicates that those items are ìto be completed silently.î 
Factual Information 8 Aircraft Accident Report

During postaccident interviews,18 all three crewmembers described a normal flight

until the last seconds of the approach. The captain stated that the airplane was established

on final as it descended through about 800 feet. He stated that during the approach, he

observed ìwhite pink, going to white redî on the PAPI and that, as the airplane descended,

ìwe started picking up a few little wispy, I want to say clouds or mist, but it didnít obscure

the airport.î The captain stated that his last recollection was of a ìwhite redî PAPI

indication, then ìwe started feeling a little bumping, and the rest of it I donít recall.î The

captain stated that the last thing he remembered about the approach was that ìeverything

visually looked normal, based on the runway and thatís why I was somewhat shocked

when I felt the thumping.î 

The first officer stated the following about the approach:

Everything was running exactly the way it was supposed to run. When we got

down closer to the field and we had slowed down and the field was in sightÖ.and

the wind was still prevailing down runway nine. And thatís when I

mentionedÖshould we go ahead and land on runway nine, since thatís where the

wind is. [The captain] said okay, thatís fine. We were kinda lined up that direction

anyway. And the speed was well within parametersÖGot the nose pointed to the

airport, started slowing down, started dirtying upÖrolled out on the centerline on

the PAPIÖI remember specifically adding a touch of power because I recall

rolling out on centerline but 2 knots slow and a hair under the bugÖthatís the last

I can rememberÖI have no memory of the remainder of the flight.

18 Safety Board investigators interviewed all three crewmembers as soon as possible after the accident.

The flight engineer was interviewed in the hospital on July 27, 2002, the day after the accident. The captain

was interviewed in the hospital on the next day, July 28. The first officer, whose injuries were more severe

than the other crewmembersí, was interviewed in his hometown of Brunswick, Maine, on August 31, 2002.
Factual Information 9 Aircraft Accident Report

Figure 3. A map overlay of FedEx flight 1478ís radar track into runway 9 at TLH, with 

excerpted CVR comments.
Factual Information 10 Aircraft Accident Report

The first officer stated that when he first saw the PAPI lights, they indicated white

next to red, showing that the airplane was on the glidepath. When investigators asked him

to describe the PAPI system, the first officer described two white lights with two red lights

next to each other. The first officer said that he would not have considered landing on

runway 9 if it did not have the PAPI light guidance. He went on to state, ìfrom the time I

rolled out, I saw that I was on glideslope, added that power for the 2 knots, and it never

changed. After that, since I have no memory of the remainder of the flight...I donít know

where the rest of the flight went.î When asked about power settings, the first officer told

investigators that fuel flow for a normal visual approach would be 3,000 to 3,500 pounds

per hour (pph) at 500 feet.19

The flight engineer told investigators that he first saw the airport about the same

time the first officer remarked that he had the runway in sight, when the airplane was on a

modified left base leg for runway 9. The flight engineer stated that, when he first saw the

runway, he observed a white, a pink, and two red lights on the runwayís four-light PAPI

system. He further stated that, throughout the approach, he was scanning his instruments

and looking outside for other air traffic and that, as they neared the runway, they could see

the runway lights ìplain as day, including the PAPI.î He stated that the visibility was good

during their approach and indicated that he did not observe any of the low, scattered

clouds that were reported in the TLH weather observation.

According to the flight engineer, the pilots were not rushed during the approach to

TLH. The flight engineer stated that, after they completed the before landing checklist, he

turned to his instrument panel to scan the instruments.20 He checked the fuel indicators,

turned off the right air conditioning pack, and ensured that temperature, hydraulic, and

electrical indications were good for landing. He stated that everything looked and felt

normal until he started to feel like they were in turbulence. He said that when he felt the

ìturbulenceî and looked out the front windshield, the airplane was in a slight

right-wing-low attitude and he realized that they were going to hit something. None of the

flight crewmembers indicated that they ever saw all red lights on the PAPI during the

approach.

19 According to the FedEx 727 CFM, fuel flows between 3,000 and 3,500 pph correspond to settings of

1.3 to 1.45 EPR. The accident airplaneís FDR data showed that between 0536:20 and 0537:07, the engine

power ranged from about 1.1 to about 1.25 EPR; the engine power did not exceed 1.3 EPR until about

10 seconds before impact. 

20 According to the FedEx 727 CFM, after the flight engineer completes the before landing checklist, he

is to turn his seat ìeither full forward or first notch to the right of full forwardî and be actively involved in

the approach for the remainder of the flight. Postaccident fire damage precluded a determination of the flight

engineerís seat position. 
Factual Information 11 Aircraft Accident Report

1.2 Injuries to Persons

Table 1. Injury chart.

1.3 Damage to Aircraft

The airplane was destroyed by impact forces and a postcrash fire.

1.4 Other Damage

Trees along the wreckage path were damaged by the impact and postcrash fire.

Some farm vehicles and equipment and a fence line were also damaged by the impact.

1.5 Personnel Information

The accident flight crew consisted of three reserve FedEx pilots. The accident

flight was the first time all three crewmembers had flown together; however, the captain

and flight engineer had flown together once previously.21

FedEx operates under 14 CFR Part 121, Subpart S (Flight Time Limitations:

Supplemental Operations), which specifies that operators may schedule flight crew

members for no more than 8 hours of flight time in a 24-hour period without a rest period

within those 8 hours. Pilots must be relieved from duty for at least 24 consecutive hours at

least once during any 7 consecutive days. Pilots working in three-person crews can be

scheduled for no more than 18 hours of duty in a 24-hour period.22 The three accident

flight crewmembers had different flight, duty, and sleep schedules before the accident.

Table 2 shows their flight schedules for the 24 hours preceding the accident. Table 3

Injuries Flight Crew Cabin Crew Passengers Other Total

Fatal 0 0 0 0 0

Serious 3 0 0 0 3

Minor 0 0 0 0 0

None 0 0 0 0 0

Total 3 0 0 0 3

21 Neither the captain nor the flight engineer had a clear recall of their prior flying experience together.

22 FedExís scheduling practices also abide by a union bargaining agreement. This agreement is more

restrictive in some respects than 14 CFR 121, Subpart S. For example, the agreement limits scheduled

domestic duty periods to between 9 and 13 hours, depending on a duty periodís start time.
Factual Information 12 Aircraft Accident Report

shows the cumulative flight and duty times for the three crewmembers at the time of the

accident, and figure 4 shows the three crewmembersí self-reported estimated sleep

schedule during the 72 hours before the accident. All times are reported in central daylight

time (the time zone in which the crewmembers were based). Sleep start and end times are

estimated from the available verbal reports.

Table 2. Crew membersí schedule for the 24 hours preceding the accident. 

Table 3. Flight and duty times since the last rest period for the crew of FedEx flight 1478.

Crew member Date Showtime Departure Arrival Block Turn

Captain 7/26/02 0212 0324 0447 1:23

First Officer 7/25/02 0300 0356 0645 2:49 12:17

7/25/02 1818 1902 1935 0:33 01:22

7/25/02 2057 2303 2:06 04:21

7/26/02 0324 0447 1:23

Flight Engineer 7/25/02 0236 0358 0553 1:55 00:28

7/25/02 0626 0714 0:48 11:52

7/25/02 1806 2139 2359 2:20 03:25

7/26/02 0324 0447 1:23

Crew Member Flight Time Duty Time

Captain 01:23 02:35

First Officer 04:02 10:29

Flight Engineer 03:43 10:41
Factual Information 13 Aircraft Accident Report

Figure 4. The three crewmembersí estimated sleep schedule during the 72 hours before 

the accident. 

1.5.1 The Captain 

The captain, age 55, was hired by FedEx on April 10, 1989. He held an airline

transport pilot (ATP) certificate (issued August 6, 1999) with a multiengine land rating

and a flight engineer certificate for turbojet-powered airplanes. The captainís ATP

certificate indicated type ratings in the 727 (issued August 6, 1999), Cessna CE-500, and

Canadair CL-600. According to FedEx training records, the captainís most recent 727

simulator proficiency check was completed on August 13, 2001; his most recent 727 line

check was completed on February 7, 2002; his most recent recurrent simulator training

was completed on February 15, 2002; and his most recent recurrent ground training was

completed on July 22, 2002. The captainís most recent Federal Aviation Administration

(FAA) first-class airman medical certificate was issued on June 17, 2002, and contained

the limitation that he ìmust wear corrective lenses.î 

The captain estimated that he had flown about 13,000 to 14,000 total flight hours.

According to FedEx records, at the time of the accident, the captain had about 2,754 flight

hours as a 727 flight crewmember, including about 861 hours as 727 pilot-in-command,

515 hours as 727 second-in-command, and 1,378 hours as 727 flight engineer. FedEx

records indicated that the captainís proficiency checks were satisfactory and that, in

accordance with the company training program, he had received training in visual

approaches, non-tower operations, fatigue management, and crew resource management

(CRM).23 The captainís training records indicated that he had not seen FedExís black

23 According to FedExís CRM training staff, all three crewmembers would have seen a presentation on

fatigue management during their baseline course for new hires. For additional information regarding

FedExís training program, see section 1.17.1.

July 23 July 24 July 25 July 26

Captain 

First Officer

Second Officer

2400 0600 1200 1800 2400 0600 1200 1800 2400 0600 1200 1800 2400

2400 0600 1200 1800 2400 0600 1200 1800 2400 0600 1200 1800 2400

2400 0600 1200 1800 2400 0600 1200 1800 2400 0600 1200 1800 2400

Sleep Awake Interrupted Sleep

Estimated Sleep Schedule

Normal Sleep Accident Occured
Factual Information 14 Aircraft Accident Report

hole24 or CFIT avoidance training modules, which were presented during recurrent

training in 1995 and 1999, because he underwent upgradeónot recurrentótraining in

those years. 

Two FedEx first officers who flew with the captain during the week before the

accident stated in postaccident interviews that he was a competent pilot who used standard

procedures and callouts. One said that the captain had a ìstandard cockpit style with good

CRM skillsî and added that he was ìupbeatî with a ìgood sense of humor.î The other first

officer stated that he was relatively new with FedEx (fewer than 100 hours in the 727)

when he flew a 2-day, four-landing trip with the captain. He stated that the captain decided

to make one landing because of foggy conditions and allowed the first officer to fly the

other flight segments and landings.

The captain stated that his general health was ìgood,î with no significant changes

in the 12 months before the accident. He stated that he did not take prescription

medications or smoke and that he drank alcohol only occasionally. Specifically, the

captain told investigators that in the days before the accident, he did not drink alcohol or

take any prescription medications.25 The captain stated that when he was not working, he

usually went to bed between 2200 and 2230 and awoke between 0700 and 0730.26

During postaccident interviews, the captain told investigators that at 0430 on

July 23, 2002, FedEx scheduling personnel contacted him by telephone to advise him that

he was assigned to fly FedEx flight 1380, from Shreveport Regional Airport (SHV), in

Shreveport, Louisiana, to MEM later that day. He arrived at SHV about 1010 on July 23

and checked into a hotel, where he rested before he returned to the airport about 2030 for

his assigned flight. When the captain arrived at MEM (on FedEx flight 1380) at 2353, he

was released from duty and returned to his home, arriving after midnight on July 24, 2002.

The captain stated that he did not sleep well that night. He reported that he stayed

awake for a ìcouple of hoursî after he got home to take care of the family dog, which was

in deteriorating health. He indicated that he slept on the couch the rest of that night so he

could more easily care for the dog during the night and stated that his sleep was

accordingly interrupted three times during the night. He stated that his rest period ended

about 0730 on July 24 and that he engaged in routine activities throughout the day. He

went to bed about 2130 that evening, again sleeping on the downstairs couch and getting

up several times during the night to care for the sick dog. He stated that he awoke about

0730 on July 25, 2002, and described his sleep quality as ìmarginal, not really good.î

Between 1800 and 1830 that day, the captain checked company scheduling using

his home computer and received notification of the TLH flight assignment. He stated that

he slept from about 2100 on July 25 to about 0030 on July 26; he described his sleep

24 The term ìblack holeî refers to approaches conducted over unlit areas, water, or other featureless

terrain. For additional information regarding FedExís black hole guidance, see section 1.17.1.1. 

25 The captain told investigators that he had taken ìa couple of [acetaminophen pills] for headachesî

72 hours before the accident.

26 All times in this section (1.5.1) are local time at the captainís residence (central daylight time). 
Factual Information 15 Aircraft Accident Report

during that 3 1/2 hours as ìpretty goodî and said that he did not feel fatigued when he

subsequently arrived at MEM for the accident flight.

1.5.2 The First Officer 

The first officer, age 44, was hired by FedEx on October 29, 1997. He held an ATP

certificate (issued October 27, 1995) with a multiengine land rating and a flight engineer

certificate for turbojet-powered airplanes. The first officerís most recent recurrent 727 line

check was completed on October 17, 2001; his most recent 727 simulator training was

completed on December 18, 2001; his most recent 727 simulator proficiency check was

completed on June 19, 2002; and his most recent recurrent ground training was completed

on July 13, 2002. The first officerís most recent FAA first-class airman medical certificate

was issued on October 9, 2001,27 with no restrictions or limitations but with a Statement of

Demonstrated Ability (SODA) for ìdefective color vision.î The medical certificate and

SODA were issued on the basis of the first officerís previous ìoperational experience.î28

The first officer estimated that he had flown about 7,500 to 8,500 total flight

hours.29 According to FedEx records, at the time of the accident, the first officer had about

1,983 flight hours as a 727 flight crewmember, including about 526 hours as a 727

second-in-command and 1,457 hours as a 727 flight engineer. FedEx records indicated

that the first officerís proficiency checks were satisfactory and that, in accordance with the

company training program, he had received training in visual approaches, non-tower

operations, CRM, fatigue management, and CFIT avoidance. 

The first officer stated that his general health was ìgood,î with no significant

changes in the 12 months before the accident. He reported that he had called in sick

July 17 through 19, 2002, because of a knee injury suffered while playing sports several

weeks before.30 He returned to his reserve duty availability on July 20. According to the

first officerís wife, on July 20 and 21, the first officer engaged in routine tasks that

included mowing the lawn, cleaning the pool, and walking the dog.

The first officer stated that he had not taken any medications, prescription or

non-prescription, in the 3 days before the accident. He stated that he smoked about half a

pack of cigarettes per day while on trips (less when he was home) and that he drank

27 In accordance with 14 CFR Section 61.23, although the first officerís first-class medical certificate

had expired, it was still valid as a second-class medical certificate.

28 For additional information on the first officerís color vision deficiency and the SODA issued by the

FAA, see section 1.13.2.

29 The first officer was a P3 pilot in the Navy between 1979 and 1995, when he was hired by FedEx.

During postaccident interviews, the first officer estimated that his total flight time included about

5,000 hours in the P3 and about 2,500 hours in the 727.

30 A review of company records confirmed that the first officer had taken sick leave as reported. The

first officer stated that he spent a lot of time with his left leg immobile during the weeks before the accident

because of his knee injury and went to his primary care physician about the injury on July 22, 2002. The

physicianís notes from that visit stated, ìinjured left kneeó6 weeks agoÖpain behind kneeÖleft knee no

swelling or crepitusÖreferral for orthopedic evaluation.î No orthopedic evaluation was performed before

the accident.
Factual Information 16 Aircraft Accident Report

alcohol at social events. When he was not working, he stated that he usually went to bed

about 2100, fell asleep about 2200, and awoke about 0600.

Two captains who flew with the first officer in the days before the accident stated

in postaccident interviews that he was personable and professional, with solid flying

skills. Neither recalled any deficiencies in his performance as a flight crewmember. 

The first officer stated that the reserve schedule he worked in July 2002 was

difficult because his sleep-wake cycle was frequently changing between day- and

night-sleep periods.31 He told investigators that on July 23, 2002, he flew a trip that he

considered very difficultóit departed MEM about 0330,32 went to Washington Dulles

International Airport in Washington, DC, then to Greater Rochester International Airport

in Rochester, New York, and arrived at MEM about 1100. After the trip, he went to an

apartment he leased with other FedEx pilots and went to sleep about 1130. The first officer

did not recall the exact times involved but stated that he awoke in the evening and went

out for dinner, then returned to the apartment and slept through the night.

The first officer reported that he awoke again on the morning of July 24 and

engaged in routine activities around the apartment during the day. According to a

roommate, during a conversation that morning, the first officer complained about the

reserve schedule he was flying because it ìreversed day and night sleeping on consecutive

days.î The first officer stated that he had dinner with his landlord that evening, went to

bed about 2100, and slept until early morning on July 25, when he had to get up to report

for duty. 

The first officer arrived at MEM about 0300 on July 25 and departed on FedEx

flight 134 about 0356, arriving at Winnepeg International Airport (YWG), in Manitoba,

Canada, about 0645. He went to a hotel and slept for about 5 to 6 hours and had dinner

before reporting for duty at YWG again about 1818. He described his quality of sleep as

ìno better or worse than most day sleeps.î The first officer departed YWG on FedEx

flight 137 about 1902 and arrived at Grand Forks International Airport (GFK), in Grand

Forks, North Dakota, about 1935. Flight 137 departed GFK about 2057 and arrived at

MEM about 2303.

After flight 137 landed at MEM, the first officer was notified that he was

scheduled to work flight 1478 to TLH, which was scheduled to depart MEM about 0312

on July 26 (about 4 hours after flight 137 arrived). The first officer stated that he accepted

the flight 1478 trip assignment after he ascertained that it did not violate existing

FedEx/pilot union agreements and would not result in his exceeding flight and duty limits.

He indicated that he slept for about 1 1/2 hours in a private sleep room in FedExís crew

rest facilities at MEM before he met the captain to prepare for the accident flight. He

stated that, although he described that rest as ìgoodî sleep, he did not recall ìfeeling

31 The first officer told investigators that he bid the reserve schedule for the month of July to optimize

his vacation time that month. He said that it had been a long time since he had flown a reserve schedule and

he would rather fly a more regular (predictable) schedule.

32 All times in this section (1.5.2) are local time in Memphis (central daylight time).
Factual Information 17 Aircraft Accident Report

alert.î A friend and roommate of the first officerís told Safety Board investigators that

before the accident trip, the first officer ìlooked tired, like everyone else at 0330.î During

postaccident interviews, the accident captain said that the first officer ìseemed tired, but

maybe it was just his personality; he seemed not as communicative, not as alert. He may

have been preoccupied.î

In response to a Safety Board investigatorís question during a postaccident

interview, the first officer stated that he did not experience shortness of breath, cough,

chest pain, or any other significant symptoms during the 24 hours before the accident. He

did note some fatigue but did not consider it to be unusual given his schedule.

1.5.3 The Flight Engineer

The flight engineer, age 33, was hired by FedEx on September 3, 2001. He held an

ATP certificate (issued December 14, 2000) with a multiengine land rating and a flight

engineer rating for turbojet-powered airplanes. The flight engineer completed his initial

ground training on September 28, 2001; his 727 initial operating experience (IOE) and

line check were completed on November 8, 2001; and his most recent 727 simulator

proficiency training was completed on April 8, 2002. His most recent FAA first-class

airman medical certificate was issued on July 8, 2002, with no restrictions or limitations. 

The flight engineer estimated that he had flown about 2,600 total flight hours.

According to FedEx records, at the time of the accident, the flight engineer had about

346 flight hours as a 727 flight engineer. FedEx records indicated that the flight engineerís

proficiency checks were satisfactory and that, in accordance with the company training

program, he had received training in visual approaches, non-tower operations, fatigue

management, and CRM. Further, postaccident discussions with the flight engineer and

FedEx management personnel indicated that the company was considering the flight

engineer for a check airman position. 

The flight engineer stated that his general health was ìgoodî and that there had been no

changes to his health during the 12 months before the accident. He stated that he did not take

prescription medications and that he drank alcohol occasionally. The flight engineer stated that

when he was not working, he usually went to bed about 2230 and awoke about 0630. 

The flight engineer stated that on July 23, 2002, he awoke between 0900 and 0930

and spent the day relaxing around the house because he had been experiencing back pain.

He reported that he went to bed about 2200. He reported that when he awoke about 0800

on July 24, his back felt better.33 He said he went boating with his children from about

0900 to about 1100, took a nap from about 1300 to about 1550, and engaged in routine

activities at home until it was time to travel to his duty station (MEM). He arrived at the

airport in Albany, New York, about 2200 to ride on a flight to MEM. He stated that he

napped for about 30 minutes during the commute to MEM, arriving at MEM about 2330.34

33 The flight engineer did not report any subsequent back pain before the accident.

34 The times in the remainder of this section (1.5.3) are local time in Memphis (central daylight time).
Factual Information 18 Aircraft Accident Report

The flight engineer stated that he slept another 90 minutes in FedExís crew rest facility at

MEM before reporting for duty at 0248 on July 25.

The flight engineer stated that FedEx flight 180 departed MEM about 0358 on

July 25 and arrived at Buffalo Niagara International Airport (BUF), in Buffalo, New York,

about 0558. The flight then departed BUF about 0626 and arrived at Ottawa MacDonald

Cartier International Airport (YOW), Ottawa, Ontario, about 0714. The flight engineer

reported that upon arrival at YOW, he checked into a hotel and slept about 6 1/2 hours. He

stated that when he awoke, he was notified of his assignment to flight 1478 to TLH on

July 26. As a result of his assignment to the accident flight, the flight engineer postponed a

job interview for a FedEx 727 line check airman position, which was originally scheduled

to occur at MEM the morning of July 26. He stated that he engaged in routine activities at

the hotel and returned to YOW about 1806 on July 25 for flight 181. Flight 181 departed

YOW about 2139 and arrived at MEM about 2359. 

The flight engineer stated that after he arrived at MEM around midnight, he had

his fingerprints taken to satisfy a new security policy, then relaxed in a recliner chair for

30 to 60 minutes. He stated that he began preparing for flight 1478 about 0135. In

postaccident interviews, the captain stated that the flight engineer seemed to be alert

during the accident flight. 

1.6 Airplane Information

The accident airplane, N497FE, a Boeing 727-232F series airplane, was

manufactured in September 1974. FedEx purchased the airplane from Delta Airlines in

1990. According to FedEx records, the accident airplane had about 37,980 total hours of

operation (23,195 flight cycles)35 at the time of the accident. The accident airplane was

equipped with two Pratt & Whitney (P&W) JT8D-15 engines (engines No. 1 and No. 2)

and a P&W JT8D-15A engine (engine No. 3).36

According to FedExís dispatch documents for the accident flight, the airplaneís

estimated landing weight was 159,000 pounds, including about 44,350 pounds of cargo

and about 19,000 pounds of fuel.

1.7 Meteorological Information 

The National Weather Service (NWS) surface analysis chart for 0500 on July 26,

2002, depicted no fronts or other boundaries over the route of flight. The chart indicated

that a ridge of high pressure was centered over central Florida. The NWS weather

depiction chart for 0600 on July 26, 2002, indicated that, except for a small area of

35 A flight cycle is one complete takeoff and landing sequence.

36 The JT8D-15 and JT8D-15A engines are both rated at 15,500 pounds of thrust.
Factual Information 19 Aircraft Accident Report

marginal visual flight rules conditions in north central Florida, visual flight rules

conditions existed throughout the state of Florida, including the Tallahassee area.

TLH is equipped with an automated surface observation system (ASOS).37 This

weather observation system is augmented by NWS-certified weather observers under

contract with the FAA. The following conditions were recorded around the time of the

accident: 

TLH weather at 0453, wind from 120° at 5 knots; visibility 9 statute miles; a few

clouds at 100 feet;[38] scattered clouds at 18,000 and 25,000 feet; temperature and

dew point 22° C (72° Fahrenheit [F]); and altimeter setting 30.10 inches of Hg.

Remarks: automated observation system, sea level pressure 1019.2 millibars.

TLH weather at 0553, wind calm; visibility 8 statute miles; a few clouds at

100 feet; scattered clouds at 15,000 and 25,000 feet; temperature and dew point

22° C (72° F); and altimeter setting 30.10 inches of Hg. Remarks: automated

observation system, sea level pressure 1019.2 millibars.

TLH weather at 0653, wind calm; visibility 9 statute miles; a few clouds at

100 feet; scattered clouds at 1,500, 15,000 and 25,000 feet; temperature and dew

point 22° C (72° F); and altimeter setting 30.10 inches of Hg. Remarks: automated

observation system, sea level pressure 1019.2 millibars, sector visibility from the

southwest through northwest quadrants 1/2 mile, cumulonimbus clouds in the

distance towards the southeast and southwest, smoke scattered at 1,500 feet,

smoke plume over the approach end of runway 9.

The weather forecast for TLH that FedEx provided the pilots indicated that

between 2300 and 0459, ceilings would be above 2,000 feet, visibility greater than

3 statute miles, and winds less than 10 knots. The FedEx forecasts between 0500 and 0959

indicated, ìsky partially obscured, visibility 3 miles in mist, with occasional scattered

clouds at 500 feet and visibility 1 mile in mist.î There were no in-flight weather advisories

for around the time of the accident.

The astronomical data for July 26, 2002, indicated that the sun was more than 10°

below the horizon at the time of the accident; civil twilight began at 0626, and sunrise

occurred at 0652. At the time of the accident, the moon was located about 31° above the

37 The ASOS continuously measures wind, visibility, precipitation and obstructions to vision, cloud

height, sky cover, temperature, dew point, and altimeter setting.

38 The weather observer on duty at TLH when the accident occurred, reported that, when he completed

his observation minutes before the accident, he saw some very thin stratus clouds between about 25 feet agl

and treetop level (about 60 feet agl) in the wooded area west of the airport near the midpoint of runway

18/36. He stated that these light stratus clouds were north of the accident site. The observer stated that he

saw no restriction to visibility near the accident site. (The observer was located on the airportís south ramp,

about 1/4 mile east of the tree line and immediately north of runway 9/27, near the fire station, which is

shown on figure 5 in section 1.10.) Although the captain reported that there were ìa few little wispyÖclouds

or mistî as they neared the runway, the three pilots stated that there were no clouds obscuring their view of

the runway during their approach.
Factual Information 20 Aircraft Accident Report

horizon and was behind and to the right of the accident airplaneís approach course.

Records indicate that there was 95 percent illumination from the moon at the time of the

accident. 

1.8 Aids to Navigation

No difficulties with the navigational aids were known or reported.

1.9 Communications

No difficulties with communications were known or reported.

1.10 Airport Information

TLH is located about 4 miles southwest of downtown Tallahassee, Florida. The

official airport elevation is 81 feet. The TLH air traffic control tower (ATCT) operates part

time and is closed daily between 2300 and 0600. Control of the airspace that is normally

delegated to TLH terminal radar approach control (TRACON) and ATCT reverts to

Jacksonville ARTCC when the TLH ATCT is closed. 

The airport has two perpendicular runways. Runway 18/36 is 6,076 feet long and

150 feet wide and is located along the west side of the field. Runway 9/27 is 8,000 feet

long and 150 feet wide and is located along the south side of the field (see figure 5).

Runways 36 and 27 have ILS approaches, and runways 9 and 18 have visual approaches.

The airport layout plan indicated that the terrain west of the airport was national forest

property and was densely wooded. 

As previously indicated, at the time of the accident, runway 18/36 was closed for

construction; Notice to Airmen 02-47 was issued on July 19, 2002, for the closure. The

accident airplane was on the visual approach to runway 9. Runway 9 has an elevation of

61.2 feet msl at the approach end and 49.0 feet msl at the departure end, with a maximum

elevation of 70.5 feet msl about 2,325 feet from the approach end. There is a 0.4 percent

upslope gradient from the approach end of runway 9 to the runwayís maximum elevation

(slightly less than the first one-third of the runway).39

39 FAA Advisory Circular (AC) 150/5300-13, titled ìAirport Design,î states that ì[t]he maximum

allowable longitudinal runway gradient at airports with Approach Categories C and D, is plus or minus

1.5 percent; however, the gradient may not exceed 0.8 percent in the first and/or last quarter of the runway

length.î
Factual Information 21 Aircraft Accident Report

Figure 5. TLH airport diagram. 
Factual Information 22 Aircraft Accident Report

1.10.1 Airport/Approach Charts

The Jeppesen approach charts for TLH included a precision (that is, ILS) approach

chart for runway 27, but no precision approach for runway 9. The chart for runway 9

depicted a nonprecision radar approach for which TLH TRACON (or Jacksonville

ARTCC, depending on the time of day) would vector the airplane to a final approach

course to runway 9 using airport surveillance radar.40 The first officerís landing briefings

for runways 27 and 9 reflected the information available on those approach charts. 

FedEx provided its flight crews with two internally generated airport chart pages

to augment the published Jeppesen airport and approach charts for TLH. These FedEx

pages (10-10 and 10-10A) contained information pertinent to FedEx operations at TLH,

including airport-specific precautions, ATCT hours of operation, noise abatement

procedures, weather information, emergency contact information/procedures, and runway

lighting/traffic advisory information for hours of non-tower operation. The FedEx TLH

chart pages also characterized the CFIT risk at TLH as moderate,41 with page 10-10A

stating, ìLocal ATC and radar coverage unavailable at certain times. ILS not installed in

all directions, potential nonprecision approach. The airport has no published departure

procedure.î

1.10.2 Runway 9 Lighting 

Runway 9 was equipped with high intensity runway lights, in-pavement runway

centerline lights, and runway end identifier lights. A four-box PAPI light system was

located on the left side of runway 9 to provide lighted signal glidepath guidance relative to

the published 3° glidepath to the runwayís touchdown zone. The runway inspection log for

July 25, 2002, indicated that the runway lighting was operational.

When the TLH ATCT was open, air traffic controllers controlled the

airport/runway lighting from the tower cab. However, when the TLH ATCT was closed,

the airportís lights (with the exception of the rotating beacon) were off unless activated by

a pilot keying the airplane microphone with the airplaneís communication radio tuned to

the common traffic advisory frequency (CTAF). During the activation process, the airport

lighting systems, including runway edge lights, taxiway lights, and the PAPI, activate over

a period of a few seconds. Once activated, the airport lights remain on for 15 minutes. The

airport lighting activation log indicated that, on the day of the accident, the lights were

40 Although the TLH TRACON was closed, Jacksonville ARTCC could have provided the pilots of

flight 1478 with the necessary vectors; however, when the pilots reported that they had TLH in sight, they

were cleared for the visual approach.

41 For additional information regarding FedExís classification of CFIT risk at airports, see

section 1.17.1.1.
Factual Information 23 Aircraft Accident Report

activated about 0534:26, and all lights were on by about 0534:31.42 According to CVR and

airport lighting activation log evidence, the runway lights were activated on medium

intensity.

1.10.2.1 Runway 9 PAPI Lighting System 

The PAPI lighting system installed on the left side of the approach end of runway 9

was an ADB, ALNACO, Inc. (a subsidiary of Siemens Airfield Solutions) model L-880,

style A, and consisted of four identical light boxes mounted along a line perpendicular to

the runway centerline about 1,000 feet from the approach end of the runway. Each of the

four boxes contained two 200-watt lamps and optical apparatus to split the lamp beams

horizontally into red (lower) and white (upper) beams. The lamps in each of the four light

boxes were positioned so that each box projected a signal at a prescribed angle above the

horizon, relative to a 3° glidepath.43 An on-glidepath signal is represented by the two

left-side boxes showing white lights and the two right-side boxes showing red lights. If an

airplane is beneath the glidepath, more red lights would be visible to the pilots; if an

airplane is above the glidepath, more white lights would be visible. Figure 6 shows PAPI

indications from various approach path angles.

Figure 6. PAPI indications from various approach path angles.

42 Examination of the computer that controlled the airportís lighting log indicated that the computer

time had not been adjusted for daylight savings time and was also 3 minutes and 16 seconds ahead of the

time displayed on a handheld global positioning system receiver. Applying the 56 minute, 44 second

difference as a correction factor to the time indicated on the activation log resulted in an airport lighting

activation time of about 0534:26; all lights were activated by about 0534:31. 

43 According to the manufacturer, a narrow band of pink can normally be seen briefly by a pilot when

an airplane transitions between the PAPI unitís white and red beams during its descent. 

Runway

Environment

Display

Indication

red light

white light

Too High

Too Low

Slightly High

Slightly Low

On Slope
Factual Information 24 Aircraft Accident Report

When activated, the TLH PAPI lights are automatically regulated to operate at

100 percent intensity during daylight hours and at 20 percent intensity during nighttime

(regardless of the selected intensity of other runway/airport lights), consistent with FAA

Advisory Circular (AC) 150/5345-28D. According to the manufacturer, the red light

filters in the ADB PAPI system conform to Military Standard C-L5050 for ìaviation redî

coloring, as outlined in the AC. The filters are designed to retain accurate coloring for the

life of the PAPI system. 

The PAPI system for runway 9 at TLH was installed in 1996. According to

electrical technicians at TLH, the runway 9 PAPI system had been checked with a

manufacturer-provided and FAA-approved sighting tool ìfive to six timesî since the

system was installed, with no improper alignment observed.44 (The FAA does not require

certification of an airportís PAPI lighting system if an FAA-approved aiming device is

used to maintain the system.) 

1.10.2.2 Postaccident Flight and Ground Evaluations of the Runway 9

PAPI System 

About 1300, on July 29, 2002, the FAA conducted a flight evaluation of the

runway 9 PAPI system. According to the FAAís flight inspection report, the PAPIís

glideslope angle and obstacle clearance were satisfactory. The flight inspection report

stated, ìthis evaluation was conducted by flying one approach with on-path indications

and one approach at an angle consistent with the [fourth of four red boxes] just turning

red. On both approaches, the glidepath flown was well clear of the terrain and obstacles in

the approach zone.î

An additional postaccident flight check of the runway 9 PAPI system was

conducted between 0800 and 0900 on August 6, 2002.45 The resultant flight inspection

report indicated that the PAPIís intensity, glideslope angle, angular coverage, and focus

and adjustments were satisfactory and stated, ìfound average PAPI angle at 2.90 degrees

and angular coverage satisfactory.î46

Despite the two satisfactory flight inspections, TLH airport personnel classified

the PAPI lighting system for runway 9 as out of service as a precaution, and no

adjustments to the system were allowed until after the technical inspection and

measurement of the PAPI light units. About 1330, on October 10, 2002, the TLH

runway 9 PAPI light units were inspected using the aiming tool provided by the

manufacturer in accordance with the manufacturerís instruction manual. The observed

44 No record or log of these inspections was maintained at TLH.

45 This preliminary flight inspection indicated that the PAPI appeared to be operating normally;

however, TLH was unable to provide airport survey data at the time. Therefore, the FAA performed a second

flight inspection after it obtained the TLH airport survey data necessary to calculate precise PAPI angles for

the runway.

46 FAA Order 8200.1, ìFlight Inspection Handbook,î allows ± 0.2° variation from the 3° glidepath

between flight inspection measurements and ground settings.
Factual Information 25 Aircraft Accident Report

settings for the PAPIís four light units were consistent with the manufacturerís

recommended settings for a standard PAPI installation.

1.10.2.3 Effects of Contamination on PAPI Light Lenses

According to a research study that the FAA conducted to assess the attributes of

PAPI systems,47 ìPAPI units tended to form condensation on the exposed frontal surface

of the lenses during high humidity conditions while the system was de-energized. Upon

activation, diffusion and mixing of the projected colors created a broad ëpinkí signal,

which could not be easily interpreted.î The FAA also found that condensate on the PAPI

lenses began to evaporate as soon as the lamps were energized. (The rate at which

evaporation occurred varied based on the amount of condensate, ambient temperature,

relative humidity, and intensity of PAPI lamps.)48 The FAAís report concluded that the

transient false signals could be eliminated by: 1) energizing the system continuously;

2) energizing the system at least 30 minutes before in-flight use; and/or 3) installing

heaters in close proximity to the lenses.49

During a telephone interview conducted on August 16, 2002, a representative of

the PAPI manufacturer stated that the company was aware of an Aerodrome Safety

Circular (No. 98-2002) issued by Transport Canada that similarly concluded that ice, dew,

or frost on the PAPI front lens surface can affect the projected PAPI signal, producing

false slope indications. The Transport Canada circular also recommended that airport

operators operate the PAPI continuously or provide an adequate PAPI system ìwarm upî

period before use to prevent a false signal due to PAPI lens contamination. The PAPI

manufacturer offers optional heating units that can be installed in the light units; however,

according to the representative, ìcustomers do not often request them.î The

manufacturerís representative emphasized that the units produce substantial heat and will

ìburn off any traces of dew or frost within minutes.î He stated that the manufacturer

recommends that the lighting units be activated a few minutes before using the system. 

On December 12, 2002, the FAA issued CertAlert Number 02-08, ìPAPI

Operation,î which advised that 14 CFR Part 139-certificated airport operators should

ìrewire pilot controlled PAPI systems to make them operate continuously in order to

preclude environmental contamination of the lenses.î The TLH PAPI lights were

subsequently rewired in accordance with the CertAlert.

The Safety Board notes that the National Air Traffic Controllers Association

(NATCA) submission on this accident stated that there was a ìhigh level of physical

particle contaminationî on the runway 9 PAPI boxes at TLH. However, investigators who

47 For additional information, see the FAAís final report on this study, U.S. Department of

Transportation, Federal Aviation Administration, Evaluation of Precision Approach Path Indicator (PAPI)

DOT/FAA-RD-82/85, Bret Castle: FAA, 1983.

48 The Safety Board notes that the TLH weather observations around the time of the accident indicated

matching temperatures and dew points (conditions conducive to the formation of dew and/or fog). However,

there were no (official or unofficial) reports of dew or fog in the area at the time of the accident.

49 According to the FAAís report, the suggested 30-minute warm-up period was not based on any

scientific study but, rather, reflected a conservative estimate for reliable PAPI use.
Factual Information 26 Aircraft Accident Report

examined the PAPI boxes during the on-scene investigation (including the NATCA

representative and other members of the investigative team) noted no such contamination,

and the investigation developed no evidence to support this contention. 

1.11 Flight Recorders

1.11.1 Cockpit Voice Recorder

The CVR installed on the accident airplane was a Fairchild50 model A100, serial

number (S/N) 4549, magnetic tape CVR. The exterior dust cover was sooted; however, no

mechanical damage was observed and the tape was successfully played back. The CVR

recording consisted of four channels of good quality51 audio information: one channel

contained audio information recorded by the cockpit area microphone, and the other three

channels contained audio information recorded through the radio/intercom audio panels at

the captain, first officer, and flight engineer positions. The CVR records incoming and

outgoing radio transmissions and ìhotî microphone52 signals from the pilotsí headsets

through these audio panels.

The recording began about 0505:14 and ended at 0537:26.2, after it recorded a

series of crunching sounds. A transcript was prepared of the entire 32-minute, 12-second

recording. See appendix B for a complete transcript of the CVR recording.

1.11.1.1 CVR Sound Study

During the review and transcription of the CVR, investigators noted unusual

breathing sounds on the first officerís CVR channel (as captured by his ìhot,î or boom,

microphone) during the last 20 minutes of the CVR recording.53 The Safety Board

conducted a study to document, characterize, and measure the breathing sounds recorded

on the first officerís channel. The Boardís study and associated research indicated that the

first officerís breathing rate during that 20-minute period (on average, 30 breaths per

50 Fairchild is now known as L3

 Communications.

51 The Safety Board uses the following categories to classify the levels of CVR recording quality:

excellent, good, fair, poor, and unusable. A good quality recording is one in which most of the crew

conversations could be accurately and easily understood. The transcript that was developed may indicate

several words or phrases that were not intelligible. Any loss in the transcript can be attributed to minor

technical deficiencies or momentary dropouts in the recording system or to a large number of simultaneous

cockpit/radio transmissions that obscure each other.

52 A ìhotî microphone is always on and is being recorded by the CVR, whether or not a radio

transmission is being made. According to the CVR Group Chairmanís Factual Report, it appeared that hot

microphones were used by all three crewmembers throughout most of the recording.

53 Although it is somewhat unusual to hear breathing on a CVR recording, it is not unprecedented;

Safety Board investigators have noted sounds similar to breaths on CVR transcripts before. For example, see

National Transportation Safety Board, USAir Flight 427, Boeing 737-300, N513AU, Uncontrolled Descent

and Collision With Terrain, Near Aliquippa, Pennsylvania, September 8, 1994, Aircraft Accident Report

NTSB/AAR-99/01 (Washington, DC: NTSB, 1999).
Factual Information 27 Aircraft Accident Report

minute [bpm]) was higher than normal (about 12 to 20 bpm, according to some research54)

but was within the range of normal breathing for studies involving high stress situations.55

The Safety Boardís CVR sound study also revealed several instances of a pattern

in the first officerís breathing that was characterized by a series of breath sounds with

progressively increasing relative loudness (and in at least one case, duration) that were

followed by a series of breath sounds with progressively decreasing relative loudness. It

was not possible to determine whether this effect was the result of actual changes in depth

of breathing or some other phenomenon.56

1.11.2 Flight Data Recorder

The FDR was a solid state Universal Flight Data Recorder, part

number 980-4120-KXUS, S/N 2343, that recorded 60 parameters of airplane flight

information in a digital format using solid-state flash memory. The FDR was recovered in

good condition, and more than 27 hours of data were successfully downloaded. The

recorded parameters included altitude; airspeed; magnetic heading; control column,

control wheel, and rudder pedal position; left aileron, horizontal stabilizer, and right and

left elevator and rudder surface positions; trailing- and leading-edge flap and slat positions

on both wings; vertical, lateral, and longitudinal acceleration; pitch and roll attitude; and

EPR for all three engines.

1.12 Wreckage Recovery and Documentation 

Information

The wreckage path extended over a distance of about 2,094 feet, from the

airplaneís first impact with trees about 3,650 feet from the approach end of runway 9 to

the site where the main airplane wreckage (fuselage, left wing, and tail section) came to

rest, about 1,556 feet west-southwest of the approach end of runway 9. The airplane came

to rest oriented on a heading of 260° (about 170° from the easterly inbound course for

runway 9). The airplane first impacted trees about 50 feet above the ground. A swath of

54 J.A.Veltman, ìA Comparative Study of Psychophysiological Reactions During Simulator and Real

Flight,î Int J Aviat Psychol Vol. 12, No. 1 (Jan 2002): 33-48. The maximum breathing rate observed in this

study was 21 bpm. Other research data showed the average breathing rate of F-4 pilots during air-to-ground

missions was between 17 and 19 bpm. See also, R.L. DeHart, Fundamentals of Aerospace Medicine, 2nd ed.

(Baltimore, MD: Williams & Wilkins, 1996).

55 M. Schedlowski and U.Tewes, ìPhysiological Arousal and Perception of Bodily State During

Parachute Jumping,î Psychophysiology The Society for Psychophysiological Research, Inc. Vol. 29, No. 1

(1992): 95-103.

56 Research has shown that variations in depth of breathing similar in timing and shape to those

observed in the Safety Boardís sound study were associated with hypoxia. See (a) T.S. Chadha, S. Birch, and

M.A. Sackner, ìPeriodic Breathing Triggered by Hypoxia in Normal Awake Adults. Modification by

Naloxone,î Chest Vol. 88, No. 1 (Jul 1985): 16-23. (b) K. Fumimoto, Y. Matsuzawa, K. Hirai, and others,

ìIrregular Nocturnal Breathing Patterns at High Altitude In Subjects Susceptible to High-Altitude

Pulmonary Edema (HAPE): A Preliminary Study,î Aviation, Space, and Environmental Medicine Journal

Vol. 60, No. 8 (Aug 1989): 786-91. Also, for additional information on hypoxia, see section 1.18.1.
Factual Information 28 Aircraft Accident Report

broken trees continued to the edge of the wooded area (about 1,130 feet from the initial

impact), where the trees on the right and left sides of the swath were broken at 7.9 feet and

31.7 feet, respectively. (Figure 7 shows the swath of damaged trees, looking from east to

west, with the first ground scars and airplane wreckage in the foreground.) Pieces of the

right wing (including the right wing leading-edge flap, trailing-edge flap, wing tip, strobe

light, flap jack screws, and slat tracks) were located in the wooded area. 

Figure 7. A swath of trees damaged by impact with FedEx flight 1478.

The first evidence of ground impact was located near the edge of the wooded area,

about 170 feet from open terrain. The ground scars continued in the open terrain,

increasing in width from about 29 feet near the edge of the trees to about 120 feet near the

main wreckage. There was evidence of fire along the wreckage path for about 800 feet

leading to the main wreckage, which was destroyed by impact and postimpact fire. 

The forward fuselage was relatively intact but exhibited impact and fire damage,

some of which was severe. The cockpit was severely damaged by fire, with melted and

resolidified aluminum draped over the control wheels and pilot seats and the instrument

panels destroyed. The lower overhead lighting panel was severely burned and damaged;

however, examination revealed that the left and right inboard landing light switches

appeared to be in the down, or ìon,î position, and the left and right outboard landing light

switches appeared to be in the up, or ìoff,î position. The taxi, navigation, and strobe light

switches all appeared to be in the down, or ìon,î position.57 The five left-side cockpit

57 According to the amplified before landing checklist contained in FedExís 727 CFM, pilots should

ìuse inboard and outboard landing lights, runway turn off lights, and taxi lights for runway illumination

during landing. If weather conditions dictate, turning landing lights on may be delayed until [the flying pilot]

calls for them.î
Factual Information 29 Aircraft Accident Report

windows exhibited fire damage but were intact; the left-side sliding window was open.

One of the five right-side cockpit windows was intact but exhibited fire damage; the other

four right-side windows were missing. A portion of the nose landing gear was separated

from the fuselage and was found about 320 feet northeast of the main wreckage. 

The top of the fuselage over the cargo area was missing and believed to have been

consumed by fire; adjacent fuselage side walls exhibited severe fire damage. The left wing

remained attached to the fuselage and exhibited localized impact and fire damage. The

right wing had separated and was severely fragmented, with pieces located throughout the

wreckage path; most separated pieces of the right wing revealed no evidence of fire. One

section of the right wing that exhibited severe fire damage was located near the main

wreckage and included portions of the inboard upper and lower wing skins. A large

section of the wing rear spar from the center wing tank was also found with fire damage in

this area. The left main landing gear was found in the down and locked position and

exhibited some soot and fire damage. The right main landing gear was separated from its

attachment points and was located next to the right side of the fuselage; it showed

evidence of impact and fire damage.

The aft fuselage remained attached to the rest of the fuselage but exhibited severe

fire and impact damage. The vertical stabilizer, rudder, and rudder trim tab were heavily

sooted but remained attached to each other and the fuselage; these surfaces exhibited no

evidence of impact damage. The left horizontal stabilizer, elevator, and elevator trim tab

remained attached to each other and the vertical stabilizer; they were sooted and exhibited

some impact damage. The right horizontal stabilizer, elevator, and elevator trim tab

exhibited evidence of severe impact damage, and the outboard sections of these surfaces

were separated from the main wreckage and located in the wooded area of the wreckage

path. The separated sections of these surfaces showed impact damage but no fire damage,

whereas those sections that remained with the aft fuselage exhibited fire and impact

damage.

The No. 1 engine remained attached to the fuselage, and the No. 2 and No. 3

engines were separated from the fuselage. Examination of the three engines revealed no

evidence of preimpact malfunction; all three engines exhibited damage consistent with

operation at impact. 

The impact- and fire-related damage to the airplane precluded the determination of

flight control continuity. However, the Safety Boardís examination of the CVR and FDR

information, the wreckage, and recovered cargo revealed no evidence of flight control or

other system or structure malfunction before the airplane impacted the trees. Further, there

was no evidence of preimpact smoke, fire, or fumes. The recovered hazardous materials

packaging showed external sooting. 
Factual Information 30 Aircraft Accident Report

1.13 Medical and Pathological Information

1.13.1 Toxicological Information

Toxicological samples obtained from the captain, first officer, and flight engineer

after they were admitted to the hospital emergency room were sent to the FAAís

Toxicology and Accident Research Laboratory in Oklahoma City, Oklahoma, for

examination. The blood specimen collected from the captain tested negative for ethanol

and a wide range of drugs, including drugs of abuse;58 however, the urine specimen

collected from the captain tested positive for morphine (1.306 ug/ml) and acetaminophen

(15.57 ug/ml). A review of emergency room hospital records indicated that the captain

was administered morphine intravenously about 0640 as part of his postaccident medical

treatment and that the urine specimen was collected from the captain about 0714. The

blood and urine specimens collected from the first officer and flight engineer tested

negative for ethanol and a wide range of drugs, including all drugs of abuse. 

1.13.2 First Officerís Color Vision Deficiency 

1.13.2.1 First Officerís Color Vision Deficiency History

According to the first officerís annual Navy medical reports, the first officer

consistently demonstrated 20/20 or better near and distant visual acuity in both eyes

without correction during his 16 years of Naval service. The records indicated that color

vision testing was performed in conjunction with the pilotís annual medical examinations

by means of the Farnsworth Lantern (FALANT)59 test (the Navyís primary color vision

screen) and that the first officer consistently passed.60

The first officer told investigators that he never had a color vision problem in the

Navy. However, during a July 24, 1995, evaluation for an FAA medical certificate,61 the

first officer did not pass a color vision screen that was conducted using pseudoisochromatic

58 The drugs tested in the postaccident analysis include (but are not limited to) marijuana, cocaine,

opiates, phencyclidine, amphetamines, benzodiazapines, barbiturates, antidepressants, antihistamines,

meprobamate, and methaqualone.

59 The FALANT is an FAA-acceptable color vision screening test for FAA pilot certification that is

intended to identify (for exclusion) people with significant red-green color vision deficiency who are unable

to name aviation (and other) signal lights correctly, while ìpassingî people with mild red-green vision

deficiency. In this test, the applicant is asked to identify the color (red, green, or white) of two lights

projected by the FALANT machine. The examinee must identify nine different light pairings.

60 The first officerís military medical records indicate that he passed the Navyís color vision test

13 times during his military careeró10 times with a documented score of 9/9, 2 times with no documented

score, and 1 time with the documented remark ìpassed-by history.î

61 According to 14 CFR Section 67.103(c), the eye standards for a first-class medical certificate include

the ìability to perceive those colors necessary for the safe performance of airman duties.î
Factual Information 31 Aircraft Accident Report

plates (PIP).62 The FAA-designated medical examiner who conducted the evaluation

contacted the FAAís Regional Flight Surgeon for advice and was told to issue the first

officerís medical certificate for use with a SODA for the color vision deficiency. In a July

25, 1995, letter to the Regional Flight Surgeon documenting their discussion, the medical

examiner stated that the results of the first officerís color vision screen indicated ìa color

vision loss on pseudoisochromatic plates, missing numbers 3, 4, 5, and 6. This suggests

mild red-green defect. Per your instructions I gave him his certificateÖ.Please notify me

about any SODA number that he is issued.î The FAA issued a SODA on August 1, 1995,

and, in a same-day letter to the first officer, the Regional Flight Surgeon stated, ìbased on

your operational experience, I have determined that you are eligible for a first-class

medical along with [a SODA] for defective color vision.î When the first officer obtained

his most recent first-class medical, dated October 9, 2001, he was again issued the

certificate with a SODA for the color vision deficiency.

 As a result of the Safety Boardís postaccident inquiry, on September 5, 2002, the

FAAís New England Regional Flight Surgeon wrote a letter to the FAAís

Recommendation and Quality Assurance Division (AAI-200) further describing the

circumstances under which the first officerís medical certificate and SODA were issued in

July/August 1995. The letter stated that the medical examiner subsequently described the

first officerís flight experience and indicated that, although the first officer had not

previously failed a color vision test, he had failed the PIP color vision test on the day of his

evaluation. After some discussion, the Regional Flight Surgeon advised the medical

examiner to issue a medical certificate with a SODA for the color vision deficiency to the

first officer. According to the September 2002 letter, a review of FAA computer records

indicated that an FAA medical examination of the first officer dated June 20, 1986,63

during which the FALANT color vision screen was administered, resulted in an indication

of normal color vision. The letter indicated that, based on the first officerís previous

medical examination results and ìoperational experience as a Naval aviatorÖa decision

was made to issue a SODA.î

During postaccident interviews, the first officerís wife told investigators that she

vaguely remembered hearing about her husbandís color vision deficiency. She stated ìI

recall this was way back when he was in training for the Navy when this came up. I think

it was like a blue/green problemÖhe was given a waiver for it.î When asked if the first

officerís color vision deficiency ever affected anything in his daily life (for example, did

she or her daughters ever have to help him match articles of clothing), the first officerís

62 PIPs used by the FAA for aeromedical certification are cards with colored spots or patterns that are

selected and arranged such that individuals with normal color vision will see a number or figure. The

examiner holds the plates about 30 inches in front of the applicant, who then has 3 seconds to identify the

figure. There are several FAA-approved versions of the PIP color vision test, ranging from 14 to 38 plates

and with different success criteria. For example, in the case of the 14-plate edition of the Ishihara PIP, no

more than five errors are allowed on plates 1 through 11.

63 Upon request after this accident, the Safety Board received the first officerís airman records from the

FAAís Civil Aerospace Medical Institute (the FAAís national repository for airman medical certification

data); these records showed consistent, periodic medical examinations dating from the first officerís 1995

application for an FAA medical certificate to his most recent preaccident medical examination. Records

maintained at the FAAís Regional Office included evidence of the earlier (1986) medical examination.
Factual Information 32 Aircraft Accident Report

wife responded, ìno.î Further, the first officer told investigators that he never experienced

any difficulty distinguishing red and white on PAPI or VASI (visual approach slope

indicator) lights.

1.13.2.2 The FAAís SODA Issuance and Requirements 

Title 14 CFR Section 67.401(a) states the following regarding special issuance of a

medical certificate:

At the discretion of the [FAAís] Federal Air Surgeon, an authorization for Special

Issuance of a Medical Certificate (Authorization), valid for a specified period,

may be granted to a person who does not meet the provisionsÖof this part if the

person shows to the satisfaction of the Federal Air Surgeon that the

duties authorized by the class of medical certificate applied for can be performed

without endangering public safety during the period in which the Authorization

would be in force. The Federal Air Surgeon may authorize a special medical flight

test, practical test, or medical evaluation for this purpose.

Section 67.401(b) further states the following regarding issuance of a SODA: 

At the discretion of the Federal Air Surgeon, a Statement of Demonstrated Ability

(SODA) may be granted, instead of an Authorization, to a person whose

disqualifying condition is static or nonprogressive and who has been found

capable of performing airman duties without endangering public safety. A SODA

does not expire and authorizes a designated aviation medical examiner to issue a

medical certificate of a specified class if the examiner finds that the condition

described on its face has not adversely changed.

According to Section 67.401(c): 

In granting an Authorization or SODA, the Federal Air Surgeon may consider the

person's operational experience and any medical facts that may affect the ability

of the person to perform airman duties includingó

(1) The combined effect on the person of failure to meet more than one

requirement of this part; and

(2) The prognosis derived from professional consideration of all available

information regarding the person. 

According to the Guide for Aviation Medical Examiners (GAME) in effect in 1995

(when the first officer failed the PIP color vision screening test), ìIf an applicant fails to

meet the color vision standard as interpreted above but is otherwise qualified, the

Examiner may issue a medical certificate bearing the limitation: ìNot valid for night

flying or by color signal control.î The GAME also states the following regarding the

process by which a color-vision-deficient applicant may be certificated: 

An applicant who holds a medical certificate bearing a color vision limitation may

request reevaluation or special issuance. This request should be in writing and

should be directed to the Aeromedical Certification Division, AAM-300. If the

applicant can perform the color vision tasks, the FAA will issue a medical
Factual Information 33 Aircraft Accident Report

certificate without limitation with a SODA. Demonstrating the ability to perform

color vision tasks appropriate to the certificate applied for may entail a medical

flight test or a signal light test. If a signal light test or medical flight test is

required, the FAA will authorize the test. The signal light test may be given at any

time during flight training. The medical flight test is most often required when an

airman with borderline color vision wishes to upgrade a medical certificate.î

Chapter 27 of FAA Order 8700.1, ìGeneral Aviation Operations Inspectorís Handbook,î instructs FAA personnel to conduct the practical color signal light test, in part, as

follows: 

1) Accompany the applicant to an area approximately 1,000 feet from the light

operator.

a) Instruct the applicant to respond to each light by stating the light color

shown within the 5-second interval when the light is displayed. 

b) Signal the light operator to begin the procedure.

c) Örecord the color displayed and the applicantís response. 

d) After a 3-minute interval, repeat the procedure until all three colors are

shown. 

2) Accompany the applicant to an area approximately 1,500 feet from the light

operator and repeat the procedures outlined above. Be sure that all three

colors have been displayed before completing the test.

3) Do not give the applicant any indication of the accuracy of his or her readings

during the test. If the applicant does not call each color correctly while the

light is being shown, the applicant has failed; however, continue until the test

is completed. 

4) An applicant who fails the signal light test during daylight hours may repeat

the test at night. 

5) Should the applicant fail the signal light test during daylight hours and at

night, the restriction, ìNot valid for flight by color signal control,î must be

placed on both the replacement medical certificate and the new SODA.

Chapter 27 of FAA Order 8700.1 also states that an applicant who fails a color

vision screening test must ìdemonstrateÖthe ability to read aeronautical charts, including

print in various sizes, colors, and typefacesÖthe ability to read aviation instruments,

particularly those with colored limitation marks, especially marker beacon lights, warning

lights...theÖability to see colored lights of other aircraft in the vicinity, runway approach

lightsÖall color signal lights normally used in air traffic control.î64

64 According to FAA records, ìa light gun signal test was administered to [the first officer] on

February 24, 2004, in accordance with FAA Order 8700.1Ö[The first officer] successfully completed the

test.î On the basis of his successful completion of this test, the first officer obtained a medical certificate

without reference to color vision deficiency.
Factual Information 34 Aircraft Accident Report

FAA database records indicate that the following SODAs were issued in 2002 (the

most recent year for which data are available): 

ï 1,576 first-class medical certificates were issued to applicants who failed an

initial FAA-acceptable color vision screening test65 and subsequently

successfully completed a practical color signal light test; 104 first-class

medical certificates were issued to applicants who failed an initial

FAA-acceptable color vision screening test and subsequently passed an

alternate FAA-acceptable color vision screening test; 13 first-class medical

certificates with restrictions were issued to applicants who failed an initial

FAA-acceptable color vision screening test and passed a subsequent practical

color signal light test; and 24 first-class medical certificates with restrictions

were issued to applicants who failed an initial FAA-acceptable color vision

screening test and a subsequent practical color signal light test administered in

the daytime, then passed a subsequent practical color signal light test

administered at night.

ï 984 second-class medical certificates were issued to applicants who failed an

initial FAA-acceptable color vision screening test and subsequently

successfully completed a practical color signal light test; 84 second-class

medical certificates were issued to applicants who failed an initial

FAA-acceptable color vision screening test and subsequently passed an

alternate FAA-acceptable color vision screening test; 37 second-class medical

certificates with restrictions were issued to applicants who failed an initial

FAA-acceptable color vision screening test and a subsequent practical color

signal light test; and 36 second-class medical certificates with restrictions were

issued to applicants who failed an initial FAA-acceptable color vision

screening test and a subsequent practical color signal light test administered in

the daytime, then passed a subsequent practical color signal light test

administered at night.

ï 3,851 third-class medical certificates were issued to applicants who failed an

initial FAA-acceptable color vision screening test and subsequently

successfully completed a practical color signal light test; 194 third-class

medical certificates were issued to applicants who failed an initial

FAA-acceptable color vision screening test and subsequently passed an

alternate FAA-acceptable color vision screening test; 246 third-class medical

certificates with restrictions were issued to applicants who failed an initial

FAA-acceptable color vision screening test and a subsequent practical color

signal light test; and 117 third-class medical certificates with restrictions were

issued to applicants who failed an initial FAA-acceptable color vision

screening test and a subsequent practical color signal light test administered in

the daytime, then passed a subsequent practical color signal light test

administered at night.

65 It was not possible to determine how many of the failed FAA-acceptable color vision screening tests

were the FALANT test. 
Factual Information 35 Aircraft Accident Report

1.13.2.3 Postaccident Color Vision Deficiency Tests/Information

At the Safety Boardís request, the first officer completed an extensive postaccident

ophthalmic evaluation at the U.S. Air Force School of Aerospace Medicine (USAFSAM)

at Brooks City-Base in Texas. In a letter to the Safety Board dated March 28, 2003, the

Chiefs of the Visual Electrodiagnostic Laboratory and the Aerospace Ophthalmology

Branch at Brooks described the nine color vision tests66 conducted and their results.

Subsequently, on September 30, 2003, the Board sent USAFSAM a letter containing

follow-up questions. On November 5, 2003, the Board received a response from

USAFSAM, which elaborated on the issues related to the first officerís color vision

deficiency.67 The March 28, 2003, letter stated, in part: 

During CV [color vision] testing, his oxygen saturation was recorded to be

between 98-99% by pulse oxymeterÖ.all test results were consistent with a

congenital severe deuteranomaly.[68] This was based on the scores, symmetry, and

consistency of his performance on a variety of red-green CV tests and ultimately

was confirmed by two different anomaloscopes, performed by two independent

examiners. 

[The first officer] did however ìpassî the FALANT [test]. When developed, the

FALANT was designed to pass about 30 [percent] of CV defectives (mild

deficiencies), which were thought to be compatible with existing aviation tasks at

the time. However, multiple studies of the FALANT indicate that it can

misclassify even the most severe types of red-green CV deficiencies, and ìpassî

themÖ.In [the first officerís] case, it also appears that the FALANT did not

correctly identify his CV deficiency throughout his entire Navy flying career, nor

when administered here at the ACS [Aeromedical Consultation Service]Ö.Thus,

we conclude that [the first officer] has a severe congenital deuteranomaly and that

this defect was not identified properly by the FALANT. This testing inconsistency

with the FALANT has been previously documented in the literature.

When a variety of CV tests were evaluated by NATO-RTO[69] and published in

RTO Technical Report 16, ìOperational Colour Vision in the Modern Aviation

Environmentî in 2001, the following observations were made. 

66 Screening tests included tests commonly used for pilot certification and general color vision

deficiency screening, including: PIP-I, PIP-II, PIP-III, FALANT, Farnsworth F2 plate, D-15, FM-100, Nagel

anomaloscope and Spectrum Colour Vision Meter anomaloscope. The anomaloscope is a laboratory

instrument used to classify color vision deficiencies with greater precision than can be obtained using the

basic screening tests. For additional descriptions, see the March 28, 2003, letter in appendix C.

67 The Safety Boardís September 2003 follow-up letter and November 2003 response letter from

USAFSAM are in appendix C.

68 A deuteranomaly is a common color vision deficiency, present in about 5 percent of the male

population, in which the pigments in the eye that typically respond to the middle range of color wavelengths

have a sensitivity shifted to longer wavelengths, resulting in different interpretation of color stimuli from

color normal individuals.

69 NATO-RTO is the North Atlantic Treaty OrganizationóResearch and Technology Organization.
Factual Information 36 Aircraft Accident Report

ìEven though lantern tests have been used for close to one

hundred years, their validation and the availability of information

on their reliability is almost nonexistent. The evaluation of most

lantern tests and the failure rates associated with normals and CV

defectives are either conflicting or simply insufficient. Test

validation for this class of tests is both complicated and perhaps

confusing. Cross validation of one lantern against another is

confounded because of the differences in intensity, wavelength,

target size, and test distances.

ìValidation of lantern tests by use of an anomaloscope has very

rarely been attempted and cross correlations with plate tests has

produced ambiguous results. In most cases, therefore, plate tests

precede lantern tests with the notable exception of the U.S. Navy

where the Farnsworth lantern was used exclusively during this

period of time.î

The March 2003 letter from USAFSAM further stated the following: 

We believe that the type and degree of [the first officerís] congenital red-green

defect could result in difficulties interpreting red-green and white signal lights that

combine color and brightness, such as PAPIs and VASIs...it is possible in this case

that the red lights of a PAPI could have been identified as ëyellowí at lower light

levels or ëwhiteí when the light was brighter.

The USAFSAM letter concluded that the first officerís ìdocumented proficiencyî

suggested that he relied on ìlearned strategiesî other than normal color vision to

determine the airplaneís position when using the PAPI/VASI during an approach.

In the November 2003 letter, the Chief of the USAFSAM Aerospace

Ophthalmology Branch stated that the first officerís color vision discrimination was

impaired to an extent that would ìlimit him to very nearly a gray-blue-yellow worldÖwe

believe that he would definitely have had problems discriminating the PAPIs as they were

designed because the red lights would not appear to be red at all, butÖsome other

wavelength that would make them more indistinguishable from white.î The letter also

stated that ìit might be possible for someone with this type of [color vision] deficiency to

use brightness differences between the white and red PAPI lights to help differentiate

between them.î

With respect to the FALANT screening test, the Chief of the USAFSAM

Aerospace Ophthalmology Branch stated, ìthe FALANT was dropped as an official USAF

air crew qualifying test in 1993.[70] It simply was not reliable and can misclassify [color

vision] defectives. By design, it intentionally was supposed to only pass ìmildî red-green

[color vision] defectives, however, it can misclassify even moderate to severe [color

vision] defectives and allow them to ëpassí.î

70 According to the November 2003 letter from USAFSAM, the current Air Force color vision

screening includes a single red/green PIP test in the field; if this screening test is passed, pilot applicants

may advance to Medical Flight Screening at Brooks Air Force Base, where they are subject to four

additional color vision tests (the PIP-I, PIP-II, PIP-III, and the F2 plate tests). 
Factual Information 37 Aircraft Accident Report

The Safety Board notes that, in 1993, the University of Melbourneís Victorian

College of Optometry conducted a study71 to determine the ability of subjects with color

vision deficiencies to correctly perceive the colors of simulated PAPI lights for use as an

indicator of similar perceptions in pilot applicants. The study indicated that in up to

29 percent of the cases, subjects with color vision deficiencies similar to the first officerís

mistakenly identified a red light signal as a white signal. According to the study, ìthis is a

particularly dangerous error since confusing red with white may lead the pilot to reduce

altitude when already too low.î The study concluded that ìcolour vision defective

subjects, with some exceptions, have difficulty distinguishing a simple two colour

red-white code when the stimuli simulate the lights used in PAPIî and recommended that

ìconsideration should be given to replacing the Farnsworth lantern by the more modern

Holmes Wright Type A lantern which is used to administer the aviation colour vision

standard in the [United Kingdom].î Additionally, the Board notes that other research72 has

shown that color vision deficiency can degrade the speed, as well as the accuracy, of

color-related responses in operational settings. For example, a recent study found that

subjects with red-green color vision deficiencies required about 30 percent more time to

identify a red traffic signal than subjects with normal color vision. In addition, the study

found that subjects with red-green color vision deficiencies misidentified a red signal as

ìyellowî more often than subjects with normal color vision.73

The Safety Board is aware of instances in which pilots who have met medical

certification standards were involved in accidents related to deficient color vision. For

example, a U.S. Navy aircraft mishap involved a pilot who passed the FALANT screen

but was involved in the loss of an aircraft due to his failure to correctly interpret the color

navigation lights of airplanes in the area (leading to the false perception of an impending

collision).74 In another case, a general aviation pilot with a medical waiver for red-green

color vision deficiency was involved in an accident because he failed to recognize an

orange-colored warning barrier indicating a closed runway.75

In addition, the Safety Board has observed color vision deficiency-related issues in

other transportation modes, including a February 1996 railroad accident in which the

71 B.L. Cole and J.D. Maddocks, A Simulation of PAPI Signals for Testing the Colour Vision of

Applicants for a Pilotís License, Final Report of an investigation undertaken for the Civil Aviation Authority.

Victorian College of Optometry, University of Melbourne, Australia, November 1993.

72 See H.W. Mertens and N.J. Milburn, ìPerformance of Color-Dependent Air Traffic Control Tasks as

a Function of Color Vision Deficiency,î Aviation, Space, and Environmental Medicine Vol. 67, No. 10

(1996): 919-927.

73 See D.A. Atchison, C.A. Pedersen, S.J. Dain, and J.M. Wood, ìTraffic Signal Color Recognition is a

Problem for Both Protan and Deutan Dolor-Vision Deficientsî Human Factors Vol. 45, No. 3 (2003):

495-503.

74 A post-mishap ophthalmological evaluation indicated that the pilot was severely color deficient. See

Department of the Navy, Office of the Judge Advocate General, ìInvestigation into the circumstances

surrounding the loss of an F-4J aircraft, which occurred on 5 August 1980 aboard NAS Cubi Point, R.P.î

75 The description for this accident, CHI92LA259, can be found at the Safety Boardís Web site at

<http://www.ntsb.gov>. The report on this accident did not contain additional information regarding the

pilotís color vision screening test that identified the pilotís deficiency, nor did it address the basis for the

SODA/waiver.
Factual Information 38 Aircraft Accident Report

Board determined that the train engineer failed ìto perceive correctly a red signal aspect

because of his diabetic eye disease and resulting color vision deficiency, which he failed to

reportÖduring annual medical examinations.î76 As a result of one of the Boardís safety

recommendations in this case (R-97-001, which was classified ìClosedóAcceptable

Actionî on July 14, 2000), the color vision testing standards within the rail industry were

revised to be consistent with the FAA color vision standards. 

1.13.3 First Officerís Postaccident Hospitalization Information

Following the accident, the first officer was treated at a local (Tallahassee) hospital

from July 26 to August 8, 2002. The hospitalís records documented significant chest

injuries, hypoxemia (decreased blood oxygenation), and right lower lobe lung

consolidation throughout the hospitalization. The records also indicated that, when he was

admitted to the hospital, the first officerís breathing rate was 16 bpm (while receiving

10 liters of 100 percent oxygen through a non-rebreather mask and before he received pain

medications).

After the first officer was discharged from the hospital in Tallahassee on August 8,

he traveled to his home in Maine, where he was subsequently hospitalized from August 10

to 23, 2002. This hospitalís records documented an infection surrounding the first officerís

right lung, a small tear in his left hemidiaphragm, and a large right pulmonary embolus

and bilateral small pulmonary emboli, which were treated with anticoagulation

medications.

The Safety Board consulted with the head of the Cardiopulmonary Division of the

Duke University Medical Center Department of Radiology regarding the first officerís

injuries and condition, based on documentation obtained from both hospitals. After

reviewing the radiographs from the first officerís first postaccident hospitalization (in

Tallahassee), the radiology consultant noted that although ì[o]n one image [obtained

July 31, 2002] the possibility of central filling defect in one of the right upper lobe vessels

is raisedÖthere is insufficient evidence to make a determinationÖthat a pulmonary

embolism is present or absent.î After his subsequent review of the documentation from

the first officerís second postaccident hospitalization (in Maine), the radiology consultant

stated the following:

Having reviewed a pulmonary embolism protocol CT [computed tomography]

scan performed on [the first officer] on [August 16, 2002], I believe it is possible

that a small filling defect seen in one of the right upper lobe pulmonary arteries on

the previous CT scan of [July 31, 2002] may in fact have represented a small

pulmonary embolus. This interpretation is made only in retrospect.

A pulmonary embolus is usually the result of a blood clot in a deep vein in the leg

(known as deep vein thrombosis) that breaks off, travels to the lungs, and blocks one or

76 See National Transportation Safety Board, Near Head-on Collision and Derailment of Two New

Jersey Commuter Trains Near Secaucus, New Jersey, February 9, 1996, Railroad Accident Report

NTSB/RAR-97/01 (Washington, DC: NTSB, 1997).
Factual Information 39 Aircraft Accident Report

more of the arteries in the lungs. Studies indicate that, in most cases, pulmonary emboli

result in no symptoms77 and are detected during autopsies in more than half of the people

who die during hospitalization.78 Studies of patients with known pulmonary embolism

indicate that more than 90 percent exhibit breathing rates greater than 16 bpm, about

88 percent report chest pain, about 84 percent report difficulty breathing,79 and that

hypoxemia is observed in about 75 percent.80 According to these studies, the most

common predisposing factor for deep vein thrombosis in patients with pulmonary

embolism is immobilization resulting from fractured extremities or trauma to a lower

extremity.

1.14 Fire/Explosion

A fuel-fed fire occurred after impact. 

1.15 Survival Aspects

The accident was survivable; the three flight crewmembers received serious

injuries. According to postaccident interviews, the captain, first officer, and flight

engineer exited the airplane through the left-side sliding window in the cockpit. 

1.16 Tests and Research

No technical tests or research were conducted. 

1.17 Operational and Management Information

Federal Express Corporation was incorporated in June 1971 and began operations

on April 17, 1973, operating 14 corporate-type jet airplanes from the airlineís hub at

MEM. After the deregulation of the air cargo industry in 1977, FedEx expanded and began

using larger airplanes, including 727s and McDonnell-Douglas DC-10s, for its operations.

In recent years, FedEx has added McDonnell-Douglas MD-11s and Airbus A-300s and

77 M.V. Huisman and others, ìUnexpected High Prevalence of Silent Pulmonary Embolism in Patients

With Deep Venous Thrombosis,î Chest Vol. 95 No. 3 (Mar 1989): 498-502.

78 M.T. Morrell and M.S. Dunnill, ìThe Post-Mortem Incidence of Pulmonary Embolism in a Hospital

Population,î Br J Surg Vol. 55 No. 5 (May 1968): 347-352.

79 For additional information about breathing rate and chest pain in patients with pulmonary embolism,

see W.R. Bell, T.L. Simon, and D.L. DeMets, ìThe Clinical Features of Submassive and Massive Pulmonary

Emboli,î American Journal of Medicine Vol. 62 No. 3 (Mar 1977): 355-360.

80 P.D. Stein and others, ìClinical, Laboratory, Roentgenographic, and Electrocardiographic Findings in

Patients Acute Pulmonary Embolism and No Pre-existing Cardiac or Pulmonary Disease,î Chest Vol. 100,

No. 3 (Sep 1991): 598-603.
Factual Information 40 Aircraft Accident Report

A-310s to its fleet. At the time of the accident, FedEx employed 4,256 pilots and operated

128 Boeing 727s.

1.17.1 FedEx Flight Crew TrainingóGeneral 

According to FedExís Flight Operations Training Manual (FOTM) and

postaccident interviews with FedEx training personnel, the FAA had approved single-visit

training for annual recurrent training of FedEx pilots. However, as a result of some

incidents and the October 17, 1999, FedEx accident in Subic Bay, Philippines,81 the

company decided that semiannual training was more effective and elected to return to that

schedule for its 727, DC-10, MD-11, and A-310 flight crews. The chief pilot stated that all

727 flight crewmembers received recurrent flight training at 6-month intervals, beginning

6 months after they qualified on a particular airplane. During every 12-month interval

after qualification, a FedEx pilot would complete a proficiency training course in the

simulator then, 6 months later, a recurrent ground training and a proficiency check in the

simulator. According to the FedEx 727 Instructor Guide, annual CRM training was

accomplished during the ground training before the proficiency check and would typically

focus on one topic of interest (often related to recent aviation issues), such as night visual

approaches, depth perception, black hole countermeasures, workload management, fatigue

management, conflict management, ìhurry-upî syndrome, decision-making in critical

situations, flight deck distractions, and monitoring and challenging.

The Safety Board reviewed FedExís training program/modules and other guidance

the company provided its pilots in several potentially relevant subject areas, including:

CFIT/black hole guidance, non-tower approaches, night visual approaches, stabilized

approach criteria, and fatigue management.

1.17.1.1 FedEx CFIT Avoidance/Black Hole Guidance

FedExís Flight Operations Manual (FOM) notes that the CFIT accident rate is

3 times greater at nighttime than during daylight hours and that, because many FedEx

flights occur at night, a high percentage of FedEx flights would be at risk for a CFIT

event. Therefore, FedEx developed a CFIT awareness training module, which it provided

to its pilots during initial, upgrade, transition, and recurrent training sessions. This CFIT

training identified flight crew factors involved in CFIT accidents, including poor

decision-making, deviations from standard operating procedures, crewmember failure to

challenge and monitor the performance of other crewmembers, lack of positional

awareness, and flight-handling difficulties. FedEx flight crews were encouraged to

identify CFIT risks before each approach, conduct thorough approach briefings, monitor

each otherís performance, and reduce any hesitation associated with go-around

maneuvers.

81 The description for this accident, DCA00RA002, can be found on the Safety Boardís Web site at

<http://www.ntsb.gov>. 
Factual Information 41 Aircraft Accident Report

FedEx also evaluated the airports used by its airplanes based on factors known to

contribute to CFIT accidents (including airport and ATC capabilities, instrument approach

availability, surrounding terrain, runway and approach lighting, ATC primary language

spoken, and published departure procedures). Airports judged to be high or moderate

CFIT risks were identified as such on salmon-colored approach pages, which were then

distributed to FedEx flight crewmembers. In addition, FedEx printed the CFIT risk

category of destination airports on all flight releases. TLH was identified as a moderate

CFIT risk airport because ATC and radar coverage were not always available, it had no

published departure procedures, and an ILS was not installed on all runways, which could

potentially result in a nonprecision approach. FedExís airport CFIT assessments were not

runway specific.

FedEx also developed a recurrent training module on black hole approach hazards,

which explained that visual approaches over water or dark, featureless terrain could be

hazardous because of poor and misleading cues for evaluating the airplaneís flightpath and

height above the ground.82 Additional risk factors cited in FedExís training module

included the airportís location (for example, on the edge of a small city; at a lower

elevation than a nearby city; or near city lights on a hillside) and the brightness and type of

runway lighting available. The training indicated that, without additional glideslope

information, a black hole approach would typically result in a lower-than-usual, or

concave, approach.

FedExís black hole approach training module encouraged pilots to consider the

potential for black hole illusions at specific airports, to use all available glideslope

information, to perform a thorough approach briefing addressing potential black hole

approaches, and to ensure adequate cross-check and monitoring. The training also

encouraged pilots to monitor the airplaneís glidepath using altitude and distance from the

runway during nonprecision approaches and to monitor sink rate using the vertical speed

indicator.

The captain and flight engineer had not received FedExís CFIT avoidance/black

hole trainingóin the captainís case, because he underwent upgrade training instead of

recurrent training in the years this training was presented and, in the flight engineerís case,

because the company had not offered that training module since he was hired in

September 2001. The first officer had received FedExís most recent CFIT avoidance/black

hole training during recurrent training in 1999.

82 According to chapter 8 of the FAAís Aeronautical Information Manual (AIM) (8-1-5), dated

February 21, 2002, ìan absence of ground features, as when landing overÖdarkened areas, and terrain made

featurelessÖcan create the illusion that the aircraft is at a higher altitude than it actually is. The pilot who

does not recognize this illusionÖoverflying terrain which has few lights to provide height cues may make a

lower than normal approach.î In addition, the AIM states that upsloping runways at airports (for example,

runway 9 at TLH) ìcan create the illusion that the aircraft is at a higher altitude than it actually isî with

similar results. Research indicates that flying over featureless and unlit terrain can adversely affect a flight

crewís ability to maintain adequate clearance from terrain. (Also see (a) C.L. Kraft and D.L. Elworth, ìNight

Visual Approaches,î Boeing Airliner Magazine (Mar-Apr 1969) and (b) B. Schiff, ìBlack Hole Approach,î

Boeing Airliner Magazine (Jan-Mar 1994.) 
Factual Information 42 Aircraft Accident Report

1.17.1.2 FedEx Non-Tower Approach Guidance and Procedures

FedExís Operations Specifications regarding the companyís operations at airports

without an operating control tower states the following:

a) The certificate holder is authorized to conduct these operations, provided that

the certificate holder determines that:

1) The airport is served by an authorized instrument approach procedure.

2) The airport has an approved source of weather [information].

3) The airport has a suitable means for the pilot-in-command to acquire timely

air traffic advisories and the status of airport services and facilities. 

4) The facilities and services necessary to safely conduct IFR operations are

available and operational at the time of a particular operation. 

FedExís training curriculum, chapter 6, ìNon-operational Control Tower Arrivals,î states the following:

Operations into airports during hours when the control tower is closed are not

permitted unless the flight crew possesses briefing information describing

non-tower operations for that airport. 

Briefing information may be supplied as: 

Jepp[esen chart] insert

Photocopy of information placed in trip folder

Information relayed from [Global Operations Control] with

authority of duty officer

The briefing information contains the following:

The method for obtaining current weather from an approved

source.

The Common Traffic Advisory Frequency (CTAF). 

Ramp personnel are an additional source of advisories during

tower off-hours.

The three accident flight crewmembers had received FedExís non-tower approach

training. 
Factual Information 43 Aircraft Accident Report

1.17.1.3 FedEx Visual Approach Guidance and Procedures 

According to the FedEx training program, FedEx pilots receive visual approach

training during the advanced simulation training portion of initial new-hire, initial

equipment, transition, and upgrade flight training. The three accident flight crewmembers

had received FedExís visual approach training. FedExís January 9, 2004, addendum to its

submission states the following regarding nighttime visual approach training:

Federal Express trains all its pilots in the simulator on night visual approaches

without the use of glideslope information. Crewmembers are expected to

demonstrate they can utilize the proper ësight pictureí to discern and fly a safe

visual approach at night. The first officer had successfully completed this training.

The guidance contained in FedExís FOTM indicates that visual approaches would

be accomplished during the simulator training periods. A review of the FedEx 727

Instructor Guide revealed the following:

ï The importance of getting the correct sight picture for landing cannot be

over-emphasized. 

ï Visual landingsÖmaneuvers and procedures to be accomplished during

theÖsimulator session.

ï A briefing item concerning non-tower arrival and departure operationsÖin

theÖsimulator session. 

ï A briefing containing information regarding visual approaches and visual

descent points is given to pilots in transition/upgrade training. 

FedExís FOM indicates that during a straight-in visual approach, flight crews

should ìplan to be established on the extended centerline of the runway in use NO LATER

than 4 [nautical miles] from the runway threshold.î Further, on page 7-1-7-2, the FOM

states that the airplane should be established on final approach at a position and altitude

such that it can be stabilized, with 30° flaps and on target airspeed, by the time it reaches

500 feet agl. The FOM states that at 500 feet agl, the ìpilot not flyingî83 must determine

whether the airplane is stable (in which case, the crew continues the approach) or unstable

(in which case, the crew should go-around). The FOM identifies the following common

errors in a visual approach: poor airspeed control, poor altitude control, failure to stabilize

the aircraft on a proper glidepath, late configuration (for example, excessive airspeed and

altitude too close to the runway), and failure to correct to a proper glidepath.

83 According to FedExís lead instructor for CRM training, the CRM training department wanted to

change the term ìpilot not flyingî to ìpilot monitoring,î with corresponding changes in the companyís

philosophy and training because the new term and focus would increase flight crew awareness of actively

cross-checking functions/actions within the cockpit. The FAA has addressed this issue in its revised

AC 120-71A, and, according to FedExís submission on this accident, some airlines have already

incorporated the ìpilot monitoringî concept.
Factual Information 44 Aircraft Accident Report

The FedEx 727 Company Flight Manual (CFM), chapter 7, states the following

regarding a stabilized final approach: ìa typical stabilized final approach for a 3 degree

glideslope, in no wind conditions, will be approximately 1 degree pitch, 700 [foot per

minute rate of descent], Vapp (approach airspeed), and 3,000ñ3,500 pph of fuel flow.î84

According to FedEx check airmen, for the accident airplane and engines under conditions

similar to those encountered during the accident approach, this fuel flow would likely

correspond to EPR values between 1.30 and 1.45 (this estimate was supported by data

supplied by representatives from P&W, the JT8D-15/15A engine manufacturer.)

Chapter 7 of the FedEx 727 CFM also lists the callout and monitoring duties for the flying

and non-flying pilots during a visual approach. According to this list, the non-flying pilot

is to make a callóìstableî or ìunstable go-aroundîówhen the airplane descends through

500 feet. The non-flying pilot is also to advise the flying pilot of any deviations in airspeed

(more than 5 knots off target airspeed below 1,000 feet), sink rate (no more than

1,000 fpm below 1,000 feet), and glideslope and localizer (if available) during the visual

approach. Both flying and non-flying pilots are to announce visual cues as appropriate

during a visual approach.

1.17.1.4 FedEx Stabilized Approach Criteria and Procedures 

According to Chapter 6 of FedExís FOM that was effective at the time of the

accident, the stabilized approach corridor begins at 500 feet agl for airplanes that are

cleared for a visual approach and at 1,000 feet agl for airplanes that are cleared for an

instrument approach. The stabilized approach is defined as follows: 

ï The aircraft must have landing gear down and locked; the flaps/slats must be

in the final landing configuration. 

ï The engines must be spooled-up[85] and steady at the proper approach setting. 

ï The proper descent angle and rate of descent must be established and

maintained. All available landing aids (ILS, VASI, PAPI, etc.) must be used.

Non-precision approaches may require a slightly steeper angle until reaching

the MDA (minimum descent altitude). 

ï Airspeed must be stable and within the range of target speed (+/- 5 knots of

target). Momentary and minor deviations are only tolerated if immediate

corrections are made. 

The FOM emphasized that ìthe procedures and parameters listed above are not

merely targets, THEY ARE MANDATORY CONDITIONS AND LIMITS. ANY

DEVIATION OCCURRING AT OR BEYOND THE BEGINNING OF THE

STABILIZED APPROACH CORRIDOR REQUIRES A MANDATORY

GO-AROUND.î According to FedEx policy, ìthe decision to execute a go-around is both

84 The fuel flows identified in the FedEx 727 CFM applied to the 727-100 airplane. The FedEx

Instructor Guide states that the fuel flows should be increased by 500 pph for the 727-200 airplane; all other

parameters/conditions for a stabilized approach are the same.

85 The term ìspooled upî would reflect the previously discussed engine power settings typical for a

fully configured 727 on a stabilized approachófuel flows of 3,000 to 3,500 pph, which would correspond to

about 1.3 to 1.45 EPR.
Factual Information 45 Aircraft Accident Report

prudent and encouraged anytime the outcome of an approach or landing becomes

uncertain.î Further, chapter 6 of the FOM states the following, in part:

The decision a pilot must make before descending below the minimum altitude for

the approach is not a commitment to land. 

The operational decision to continue an approach using visual means must be

based on information the pilot accumulates throughout the approach. Since many

variables are involved, the final decision to commit to a landing is the captainís

and is primarily a judgment based on all relevant factors. 

When queried about FedExís criteria for a stabilized approach, the captain of

flight 1478 told investigators, ìIf cleared for instrument approachóit has to be ëspooled

up,í fully configured, on glidepath, at 1,000 feet [msl]. For a visual approachóëspooled

up,í fully configured, on glidepath at 500 feet [msl].î He further stated that he believed the

accident airplane performance was consistent with the criteria for a stabilized visual

approach.

1.17.1.5 FedExís Fatigue Management Training and Other Fatigue-Related 

Information

In response to several Safety Board recommendations, on September 8, 1995, the

FAA revised AC 120-51D, Appendix 3, to encourage operators to provide pilots with

ìfactual information about the detrimental effects of fatigue and strategies for avoiding

and countering its effectsî as part of an airline pilot training program,86 although such

training is not required by current regulations. Research indicates that during a time period

from about midnight to 0600, and especially between 0300 and 0500, there is a higher

probability of flight crew errors and accidents because a pilotís alertness and performance

are degraded by fatigue.87 Another common effect observed in fatigue-related accidents is

a tendency to continue an approach despite increased cues indicating a need to discontinue

the approach.88

86 The inclusion of fatigue as a recommended training topic (within a CRM training curriculum) was

made in response to Safety Board recommendations that the FAA require U.S. air carriers to provide fatigue

countermeasure information to air crews in initial and recurrent training (Safety Recommendations A-94-5

and A-94-73 were classified ìClosedóAcceptable Actionî on January 16, 1996).

87 See T. Akerstedt, ìReview Article: Shift Work and Disturbed Sleep/Wakefulness,î Sleep Medicine

Reviews Vol. 2, No. 2 (1998): 117-128.

88 See (a) National Transportation Safety Board, Runway Overrun During Landing, American Airlines

Flight 1420, McDonnell Douglas MD-82, N215AA, Little Rock, Arkansas, June 1, 1999, Aircraft Accident

Report NTSB/AAR-01/02 (Washington, DC: NTSB, 2001). (b) National Transportation Safety Board,

Controlled Flight Into Terrain, Korean Air Flight 801, Boeing 747-300, HL7468, Nimitz Hill, Guam,

August 6, 1997, Aircraft Accident Report NTSB/AAR-00/01 (Washington, DC: NTSB, 2000). (c) National

Transportation Safety Board, Uncontrolled Collision With Terrain, American International Airways

Flight 808, Douglas DC-8-61, N814CK, U.S. Naval Air Station, Guantanamo Bay, Cuba, August 18, 1993,

Aircraft Accident Report NTSB/AAR-94/04 (Washington, DC: NTSB, 1994). Additionally, the Board

discussed fatigue in a 1994 safety study. See National Transportation Safety Board, A Review of

Flightcrew-Involved, Major Accidents of U.S. Air Carriers, 1978 Through 1990, Safety Study

NTSB/SS-94/01 (Washington, DC: NTSB, 1994).
Factual Information 46 Aircraft Accident Report

In 1990, FedExís CRM instructors developed and implemented a 2-hour course on

sleep and fatigue management,89 which was provided to all company pilots as recurrent

training. The training addressed causes of fatigue, circadian rhythms, sleep loss, and the

physical, social, emotional, and safety-related consequences of fatigue. This 2-hour course

was also added to FedExís indoctrination course for all new hires. In addition, in 2000,

FedEx CRM instructors distributed a fatigue management card to all FedEx pilots to be

inserted in their Jeppesen approach binders.

Additional company policies supporting the fatigue management training included

the availability of sleep/nap rooms in operational areas and a policy allowing pilots to

remove themselves from the flight schedule due to fatigue.90 According to a company

representative, feedback from pilots about the fatigue training was very positive; the only

criticism received was that some pilots wished the training occurred closer to when they

actually started flying when it would have had greater operational relevance. In addition,

discussions were held within the training department about reintroducing fatigue

management as a recurrent topic for line pilots who were not exposed recently to this

training. 

FedExís fatigue management training addressed suggested strategies for

minimizing and managing fatigue in the home environment and during trips, including

taking steps to prevent sleep interruptions, ensuring adequate rest before a trip, making

sleep a priority during layovers, sleeping two or more times a day, developing a regular

pre-sleep routine, using relaxation techniques, creating a good sleep environment, and

maintaining healthy exercise and diet habits. The training also suggested the following

strategies for in-flight management of fatigue: interact with other crewmembers, stretch,

turn on cockpit lights, maintain a proper cockpit temperature, use caffeine, and/or take a

nap (in coordination with other crewmembers). FedEx also encouraged its pilots to keep a

sleep journal, study their circadian rhythms, and determine what strategies work best for

them.

Further, in its fatigue management training and in its formal company policy,

FedEx encouraged pilots to ìcall in fatiguedî if they were unable to get adequate rest. The

agreement between FedEx and the FedEx pilotsí union stated the following regarding this

policy: 

A pilot who is unable to operate his trip or a portion thereof due to fatigue shall

notify [crew scheduling] immediately and shall be placed in sick leave status. A

89 According to FedEx training instructors, the fatigue segment was developed based on National

Aeronautics and Space Administration (NASA) models, such as the NASA Ames Fatigue Management

Training Module developed by NASA under FAA funding as a result of personal contacts and company

participation in a NASA fatigue study. 

90 This program is consistent with research literature advocating a comprehensive approach to fatigue

management in operational settings, although this program did not incorporate all potential elements of such

a comprehensive approach. For example, literature advocates developing technology in areas such as

scheduling algorithms and monitoring the effectiveness of interventions. See M.R. Rosekind, P.H. Gander,

K.B. Gregory, R.M. Smith, D.L. Miller, R. Oyng, L.L. Webbon, and J.M. Johnson, ìManaging Fatigue in

Operational Settings 2: An Integrated Approach,î Behavioral Medicine Vol. 21 (1996): 166-170.
Factual Information 47 Aircraft Accident Report

fatigued pilot shall be compensated, and his sick leave account(s) shall be debited,

for theÖmissed trip or portion thereof. The pilot shall automatically return from

sick leave status at the scheduled conclusion of his trip unless the pilot notifies the

CompanyÖto continue his sick leave status. A pilot who is fatigued shall be

considered to have an illness or injury. Nothing in this paragraph shall minimize a

pilotís responsibility to ensure that he has adequate rest prior to reporting for duty. 

During postaccident interviews, the first officer and flight engineer confirmed that

they received fatigue management training at FedEx and described some of the strategies

learned. The captain did not recall receiving formal fatigue management training but

indicated that he had received ìflyersî on the subject. The first officer stated, ìIíve flown

very tired. Iíve never flown where I felt it was unsafe.î None of the three accident flight

crewmembers had turned down a trip because of fatigue.

1.17.2 Postaccident FedEx Actions

After this accident, FedEx incorporated several changes in its systems. For

example, the company separated its quality assurance function from its training function

and initiated a ìstandards checkî on a new captainís first flight after IOE. Additionally, to

ensure that pilots do not select runways for expediency rather than safety, FedEx revised

its FOM to provide specific direction regarding the type of approach and landing aids to

be used by pilots when the destination airportís tower is closed. The companyís stabilized

approach criteria now requires pilots to ensure that the airplane is stabilized at 1,000 feet

agl for both visual and instrument approaches to allow them more time to accomplish

checklists and focus on the landing.

FedEx also revised its practices to require that only airplanes equipped with

operating enhanced GPWS (EGPWS) and traffic collision avoidance systems (TCAS) be

dispatched to non-tower and high-CFIT-risk airports. Further, the company stated that it

planned to have EGPWS and TCAS installed in all its airplanes by late 2004. The EGPWS

provides an aural ground proximity warning based on global positioning system data

rather than radio-altitude information used by the GPWS. However, the Safety Boardís

evaluation of the EGPWS software available at the time of the accident indicated that it

would not have resulted in a warning in this case because the airplaneís flightpath did not

penetrate the warning envelope.91 As a result of this accident, the EGPWS manufacturer is

developing an upgrade (expected to be approved in 2004) that would have provided the

pilots involved in this accident with an aural warning about 19 seconds before the first

sounds of impact were recorded by the CVR. 

91 The manufacturerís subsequent review supported the Safety Boardís evaluation.
Factual Information 48 Aircraft Accident Report

1.18 Additional Information

1.18.1 Hypoxia-Related Information 

Paragraph 8-1-2a of the FAAís AIM defines hypoxia as ìa state of oxygen

deficiency in the body sufficient to impair functions of the brain and other organs.î The

AIM states that ìAlthough a deterioration inÖvision occurs at a cabin altitude as low as

5,000 feet, other significant effects of hypoxia [impaired judgment, memory, alertness,

etc.] do not occur in the normal healthy pilot below 12,000 feet.î

Research92 also indicates that hypoxia can adversely affect color vision and that

individuals with defective color vision can have substantially reduced color discrimination

ability at mild levels of hypoxia (as might be expected in pilots operating at typical cabin

altitudes). According to the Chief of the USAFSAM Aerospace Ophthalmology Branch,

hypoxia could further degrade any residual red-green (white) hue discrimination ability

that a severely deuteronomalous pilot might have, and lower levels of illumination would

further degrade such a pilotís ability to discern colors.

1.18.2 DOT Operator Fatigue Management Program

The FAA recently participated (with other transportation modal administrations) in

a Department of Transportation (DOT) Human Factors Coordinating Committee, which

led the DOTís Operator Fatigue Management Program effort to develop practical tools for

use by individuals and industries to better maintain vigilance and alertness on the job. One

such tool is a fatigue management reference guide.93 The reference guide was intended to

provide basic information to operators in all transportation modes on how to develop an

effective fatigue management program using available scientific evidence and best

industry practices. For example, the reference guide notes that one of the important

components of a fatigue management training program is its ongoing evaluation and

refinement. Further, the guide suggests that conducting pilot surveys and monitoring

objective safety data to refine existing programs are among the best procedures for such

evaluation and refinement. In addition, the DOT program is developing additional

92 See (a) J.T. Ernest and A.E. Krill, ìThe Effect of Hypoxia on Visual Function. Psychophysical

Studies,î Invest Ophthalmol. Vol. 10, No. 5 (May 1971): 323-8. (b) A.J. Vingrys and L.F. Garner, ìThe

Effect of a Moderate Level of Hypoxia on Human Color Vision,î Doc Ophthalmol Vol. 66, No. 2

(Jun 1987): 171-85. (c) C. Bouquet and others, ìColor Discrimination Under Chronic Hypoxic Conditions

(Simulated Climb ìEverest-Comex 97î),î Percept Mot Skills. Vol. 90, No. 1 (Feb 2000): 169-79.

93 U.S. Department of Transportation, (In draft-2003). Commercial Transportation Operator, Fatigue

Management Reference. Washington, DC: DOT Research and Special Programs Administration. This work

follows, in part, from previous Safety Board recommendations that the DOT develop and disseminate

educational material for transportation industry personnel and management regarding shift work; work and

rest schedule; and proper regimens of health, diet, and rest (Safety Recommendation I-89-2, which was

classified ìClosedóAcceptable Actionî on May 25, 2001).
Factual Information 49 Aircraft Accident Report

products for industry use (which are expected to become available in late 2004),

including: 

ï A Fatigue Management Reference Guide: a compendium of current science

and practical information on approaches to fatigue management and

countermeasure usage; 

ï A Fatigue Model Validation Procedure: a practical and methodologically

sound approach for validating output from fatigue modeling software being

tailored for transportation application;

ï Work Schedule Representation and Analysis Software: a software tool to aid

managers and schedulers in evaluating and designing ergonomic work

schedules to promote on-duty alertness;

ï Program Evaluation Framework: a cross-modal fatigue management research

logic model that provides a blueprint for evaluating current knowledge,

information needs, and points of leverage between DOT agencies; and

ï Business Case Development Tool Suite: a documented methodology and

supporting analytical tools to aid company safety managers in building a case

for senior management support of fatigue management activities.

Recent interviews with DOT personnel working on the fatigue management

training program indicate that future efforts should involve setting up a multimodal pilot

program to test the tools they are developing. DOT personnel indicated that the Federal

Railroad Administration is beginning validation tests on some of these tools in operational

settings within the railroad industry.

1.18.3 Crew Familiarity/Attention/Monitoring Information

In a 1994 safety study of crew-related air carrier accidents,94 the Safety Board

found that 84 percent of the reviewed accidents involved inadequate crew monitoring or

challenging. Similarly, research conducted to support the Flight Safety Foundationís

Approach and Landing Accident Reduction (ALAR) efforts revealed that poor monitoring

and cross-checking were involved in 63 percent of the reviewed approach and landing

accidents.95 A 1998 National Aeronautics and Space Administration (NASA) research

project of cockpit interruptions and distractions reviewed 107 Aviation Safety Reporting

System reports to identify tasks that crews typically neglected at critical moments while

attending to other tasks.96 It found that 69 percent of the neglected tasks involved either

94 NTSB/SS-94/01, 40-41.

95 R. Khatwa and R.L. Helmreich, ìAnalysis of Critical Factors During Approach and Landing

Accidents and Normal Flight,î Killers in Aviation: FSF Task Force Presents Facts About

Approach-and-Landing and Controlled-Flight-into-Terrain Accidents. Flight Safety Digest. (Novemberó

December 1998, JanuaryóFebruary 1999).

96 K. Dismukes, G. Young, and R. Sumwalt, ìCockpit Interruptions and Distractions: Effective

Management Requires a Careful Balancing Act,î ASRS Directline (December 1998).
Factual Information 50 Aircraft Accident Report

failure to monitor the status or position of the airplane or failure to monitor the actions of

the pilot flying or taxiing.

The Safety Board notes that recent FAA guidance and industry actions emphasize

the importance of careful crew monitoring. For example, in February 2003, the FAA

revised AC 120-71A, ìStandard Operating Procedures,î to describe the philosophy of and

benefits to be derived from a ìpilot monitoringî program. AC 120-71A notes that

ìoperators should review existing standard operating proceduresÖand modify those that

can detract from monitoring. AC 120-71A also indicates that several air carrier operators

have changed the title of ìpilot not flyingî to ìpilot monitoringî because it is more

appropriately descriptive. According to the March 17, 2003, FedEx submission on this

accident, the company currently uses the pilot monitoring concept for certain approaches

and at least one other air carrier has completely incorporated the pilot monitoring concept

into its system. 

Additionally, in January 2004, the FAA revised AC 120-51E, ìCrew Resource

Management Training,î to emphasize the critical role of the monitoring pilot. This AC

states that the monitoring function is particularly essential during approach and landing

when CFIT accidents are most common. The AC suggested that operators redistribute

some of the workload items typically accomplished during the approach and landing

phase to less demanding phases of flight when possible. According to the AC, this would

allow crewmembers to focus more on monitoring airplane and crewmember performance

during a critical phase of flight. FedExís lead CRM instructor suggested that changing the

term ìpilot not flyingî to ìpilot monitoringî would result in increased pilot awareness of

the importance of the monitoring function. (Since this accident, FedEx has also developed

a new human factors course that focuses on captain leadership and pilot monitoring skills.)

Research indicates that a lack of crew familiarity can contribute to a flight crewís

failure to fly and monitor a stabilized approach. For example, in a study of major aviation

accidents involving human performance issues, in which a large number of monitoring

errors were observed, the Safety Board found that 73 percent of the accidents occurred on

the first day that the captain and first officer had flown together; 44 percent occurred on

the first flight leg.97 Simulator research supports this, showing that flight crews with recent

operating experience together communicate more frequently overall and perform better at

solving in-flight emergencies than those that did not (even when the latter crews had

completed a long rest period not available to crews with recent operating experience).98

97 These percentages are substantially higher than would be expected by chance and draw attention to

the importance of crew familiarity at preventing serious monitoring and other human performance errors. 

98 H.C. Foushee, J.K. Lauber, M.M. Baetge, and D.B. Acomb, Crew Factors in Flight Operations: III.

The Operational Significance of Exposure to Short-Haul Air Transport Operations. National Aeronautics

and Space Administration, NASA Technical Memorandum 88322, August 1986.
Factual Information 51 Aircraft Accident Report

Additionally, research shows that conscious attention can be highly selective and

that people may not respond to important objects that may be plainly visible.99 For

example, a simulator study found that pilots could become so engrossed in performing a

landing using a heads-up display that some pilots failed to see that another airplane was

blocking the runway.100 Similarly, accident data confirm that an air crew can respond to a

visual illusion of airport distance and fail to use accurate PAPI information that is directly

visible.101 Fatigue and high workload are both likely to increase selective attention and the

likelihood of missing relevant information.

1.18.4 Previously Issued Safety Recommendations

1.18.4.1 CFIT-Related Safety Recommendation

As a result of the August 1997 CFIT accident at Nimitz Hill, Guam,102 the Safety

Board issued Safety Recommendation A-00-10, which recommended that the FAA do the

following: 

Conduct or sponsor research to determine the most effective use of the monitored

approach method and the maximum degree to which it can be safely used and then

require air carriers to modify their procedures accordingly. 

Pending the results of the FAAís research on use of the monitored approach

method, on January 31, 2002, Safety Recommendation A-00-10 was classified, ìOpenó

Acceptable Response.î 

1.18.4.2 Fatigue-Related Safety Recommendations

Since 1989, the Safety Board has issued more than 70 safety recommendations

related to fatigue for all modes of transportation. In addition, human fatigue in transport

operations has been included in the Boardís annual list of Most Wanted Transportation

Safety Improvements since the listís inception in September 1990. 

99 (a) A. Mack, ìInattentional Blindness,î Current Directions in Psychological Science Vol. 12, No. 5

(2003): 180-184. (b) F.W. Hawkins, Human Factors in Flight (Aldershot, England: Ashgate Publishing

Limited, 1997) 116.

100 R.F. Haines, ìA Breakdown in Simultaneous Information Processing. In G. Obrecht & L.W. Stark

(Eds.),î Presbyopia Research (New York: Plenum Press, 1991) 171-175.

101 See Transportation Safety Board of Canada (1996). Tail Strike on Landing, Canadian Airlines

International, Boeing 767-375 C-FOCA, Halifax, Nova Scotia, 08 March 1996, Report A96A0035.

102 See National Transportation Safety Board, Controlled Flight Into Terrain, Korean Air Flight 801,

Boeing 747-300, HL7468, Nimitz Hill, Guam, August 6, 1997, Aircraft Accident Report NTSB/AAR-00/01

(Washington, DC: NTSB, 2000).
Factual Information 52 Aircraft Accident Report

In Safety Recommendation A-99-45, the Safety Board urged the FAA to: 

Establish within 2 years scientifically based hours-of-service regulations that set

limits on hours of service, provide predictable work and rest schedules, and

consider circadian rhythms and human sleep and rest requirements.[103]

The FAA issued Notice of Proposed Rulemaking (NPRM) 95-18, ìFlight

Crewmember Duty Period Limitations, Flight Time Limitations and Rest Requirements,î

in December 1995, published a notice of intent in the Federal Register to indicate the

agencyís intent to enforce regulations concerning flight time limitations and rest

requirements in June 1999, and indicated its intent to issue a supplemental NPRM in

spring 2001 (no supplemental NPRM has been issued to date). However, in April 2001,

the Safety Board indicated that it was frustrated by the FAAís lack of progress concerning

this safety issue and classified Safety Recommendation A-99-45 ìOpenóUnacceptable

Response.î In October 2001, the Board reiterated Safety Recommendation A-99-45 in its

final report on the American Airlines flight 1420 accident at Little Rock, Arkansas.104

103 See National Transportation Safety Board, Evaluation of U.S. Department of Transportation Efforts

in the 1990s to Address Operator Fatigue, Safety Report NTSB/SR-99/01 (Washington, DC: NTSB, 2000).

104 National Transportation Safety Board, Runway Overrun During Landing, American Airlines

Flight 1420, McDonnell Douglas MD-82, N215AA, Little Rock, Arkansas, June 1, 1999, Aircraft Accident

Report NTSB/AAR-01/02 (Washington, DC: NTSB, 2001).
53 Aircraft Accident Report

2. Analysis

2.1 General

The captain, first officer, and flight engineer possessed valid airman and medical

certificates. 

The captain, first officer, and flight engineer had received the training and off-duty

time prescribed by Federal regulations and company requirements. 

The accident airplane was properly certificated and maintained and was equipped

and dispatched in accordance with applicable regulations and industry practices. There

was no evidence of any preexisting powerplant, system, or structural failure. Cargo

loading for the accident flight was routine; no cargo loading anomalies were observed, and

the airplane was operating within prescribed center of gravity limits. Hazardous materials

on board the airplane were not a factor in the accident. The accident airplane and its cargo

were not factors in the accident. 

At the time of the accident, the winds were calm and visibility was unrestricted,

with a forecast of a few clouds at or below 100 feet. The pilots reported that no significant

meteorological conditions were present that adversely affected their visual approach to

runway 9 at TLH; ground observersí statements corroborated the pilotsí reports.

Additionally, the Safety Boardís review of ATC information revealed no evidence of any

ATC problems or issues related to the accident. Weather and ATC were not factors in the

accident. 

Postaccident examination of the airport lighting for runway 9, including the PAPI

lighting system (the only glidepath information available for runway 9) indicated that the

airport lighting was capable of normal operation and had been activated by the pilots

almost 3 minutes before the airplane began to impact the trees. During postaccident

interviews, all three pilots reported observing red and white lights on the PAPI display,

consistent with normal PAPI operation. Although the flight engineer and captain reported

seeing a pink PAPI signal on one of the four PAPI lights at some time during the approach,

they also reported seeing red and/or white lights (which would have provided appropriate

glidepath guidance) at the same time.105 Investigators who examined the PAPI boxes

during the on-scene investigation (including the NATCA representative and other

members of the investigative team) noted no particle contamination or condensation on

the PAPI lights, and the investigation developed no evidence to support the possibility of

such contamination. The airport lighting systems, including the PAPI lights, were not a

factor in the accident. 

105 A pilot might observe a pink PAPI signal as a result of condensation on the PAPI lenses or briefly

when the airplane is transiting the narrow zone between the red and white PAPI signals.
Analysis 54 Aircraft Accident Report

 This analysis will focus on the flight crewmembersí decisions and performanceó

as a crew and individuallyóto consider why none of the three flight crewmembers

recognized that the airplane was below the glidepath during about the last 40 seconds of

the approach and responded accordingly. 

2.2 The Accident Approach 

Postaccident interviews with the pilots and examination of the CVR and FDR data

indicated that the en route portion of the accident flight from MEM to TLH was routine

and that the pilots engaged in normal duties and discussions as the airplane neared TLH.

CVR evidence indicated that although the flight crew originally planned to land on

runway 27, when they were about 10 minutes from touchdown, they decided to land on

runway 9 instead. 

According to the Safety Boardís airplane performance study, when the airplane

became established on the final approach course about 2 1/2 miles from the approach end

of runway 9, the PAPI lights would have shown a low indication (one white and three red

lights). Almost immediately thereafter, the PAPI lights would have shown a very low

indication (four red lights), which would have been viewable from the cockpit for the

remainder of the flight. 

As the airplane descended through 500 feet agl at 1,248 fpm, 152 knots, and with

engines operating at about 1.17 EPR, the captain announced that the approach was

ìstable.î The Safety Board notes that, although the airplaneís airspeed was within the

target range, the airplane did not meet FedExís criteria for a stabilized approach because

its rate of descent was greater than FedExís recommended 1,000 fpm,106 the enginesí

power settings were less than the expected 1.3 to 1.45 EPR, and its glidepath was low as

indicated by the PAPI light guidance. According to FedEx procedures at the time of the

accident, if a visual approach was not stabilized when the airplane descended through

500 feet agl, the pilots were to perform a go-around. The Safety Board concludes that the

accident approach was not stabilized as the airplane descended through 500 feet agl and

that the pilots should have detected this and performed a go-around.

As the pilots continued the approach, the flight engineer read the before landing

checklist query items, with the captain responding, in accordance with FedEx procedures.

About 0536:49, the CVR recorded the first officer commenting that he was going to have

to stay a little higher or he was ìgonna lose the end of the runway.î The airplaneís

subsequent descent rate gradually decreased to about 960 fpm; however, the airplane

remained significantly below the proper glidepath. FDR data showed that, shortly

thereafter, the engine power began to increase further, reaching about 1.34 EPR about

0537:12. During this time, the captain stated that the runway was starting to ìdisappearÖa

littleî but then said, ìthink weíll be alright.î

106 As previously noted, the captainís and first officerís VSIs were not instantaneousóthat is, the

instruments displayed data that lagged behind the airplaneís actual rate of descent, which was derived from

the FDR data. However, the manufacturerís simulations indicated that the pilotsí VSIs would have displayed

a rate of descent of at least 1,000 fpm when the airplane descended through 500 feet agl.
Analysis 55 Aircraft Accident Report

In postaccident statements, the flight crew and ground observers indicated that

there were no obstructions to visibility along the approach path. However, the comments

made by the first officer (ìgonna lose the end of the runwayî) and captain (ìdisappearÖa

littleî) suggest that they may have encountered a temporary obstruction to visibility (for

example, clouds or mist) as they approached runway 9. If such an obstruction existed, it

may also have obscured the PAPI lights. Although a temporary obstruction might help

explain the flight crewís failure to recognize the PAPI guidance while that obstruction was

present, it does not explain why the three pilots failed to recognize the presence of four red

PAPI lights throughout the rest of the approach. Further, according to FedEx procedures

(and FAA regulations), if the approach end of the runway became obscured at any time

during the visual approach, the pilots should have performed a go-around. 

The night visual approach to runway 9 at TLH was conducted over a protected

national forest area that was devoid of ground lights or other visible references by which

the pilots could judge their height above terrain. FedExís recurrent training module on

black hole approaches, which the first officer received in 1999,107 warned that pilots

conducting visual approaches at night over terrain with minimal visible ground features or

lighting often perceive the airplane to be higher than its actual altitude. Research has

shown that in situations like this, a pilot typically flies a lower-than-normal approach until

the error starts to become apparent (usually about 2 to 3 miles from the runway), at which

point the pilot takes corrective action. Indeed, on the night of the accident, the first officer

did fly a concave approach, with a steeper-than-normal initial descent, which is

characteristic of a black hole approach. However, in the case of the accident flight, the first

officer did not modify the steepness of the approach path in time, and the airplane collided

with trees and terrain. 

The Safety Board concludes that the approach to runway 9 at TLH (which was

flown over unlighted terrain and in night visual conditions) resulted in black hole

conditions, which likely contributed to the flight crewís failure to properly perform the

approach. However, the Safety Board also concludes that PAPI lights, such as those

installed at runway 9 at TLH, are a recognized countermeasure for use in black hole

conditions and should have been, but were not, effectively used to maintain an appropriate

glidepath by the first officer (who was the flying pilot) or by the captain and flight

engineer (who, under the principles of basic crew coordination, were in a position to

receive this information and initiate a corrective response).108

107 FedEx records indicate that the captain and flight engineer had not received this training. In the

captainís case, he missed the black hole recurrent training module because he attended upgrade training

instead. The flight engineer had not been with the company long enough to attend recurrent training.

108 The Safety Board also considered the possibility that the 0.4 percent upslope on the first third of

runway 9 contributed to the flight crewís low approach. The geometric appearance of upsloping runways

can create the illusion that an airplaneís approach path is higher than desired, and a pilot might compensate

by flying a lower-than-normal approach. However, in this case, the upslope was minor and only present for

the first third of runway 9, and the remainder of the runway was a gradual downslope. Therefore, it is

unlikely that the illusion created by the runwayís slight upslope contributed significantly to the pilotsí failure

to maintain the correct glidepath.
Analysis 56 Aircraft Accident Report

2.3 Fatigue

Research109 on human alertness has shown that the early morning hours are often

associated with degraded alertness and performance; the accident occurred about 0537

local time (0437 in the flight crewís domicile time zone). However, because FedEx

conducted most of its 727 domestic operations overnight, operating at these hours was

likely a normal occurrence for the flight crew. Therefore, the Safety Board evaluated each

flight crewmemberís performance during the accident flight and their specific activities

and sleeping history in the days before the accident for evidence of routine,110 and

especially nonroutine, factors conducive to the development of fatigue.

2.3.1 Role of FatigueóCaptain 

The Safety Boardís examination of the captainís sleep history revealed evidence of

a sleep deficit. The captain was off duty from about midnight on July 24 until the accident

flight. However, he described his sleep during the two nights preceding the accident trip as

ìnot really goodî or ìmarginalî because his sleep was interrupted to take care of the

family dog. The captain stated that after he learned that he was assigned to the accident

trip, he got about 3 1/2 hours of ìpretty goodî sleep.

The CVR recording revealed that the captain made several small errors during the

accident flight that suggest he may not have been fully alert. These errors included

incorrect readback of the radio frequency, incorrect repetition of weather information,

incorrectly addressing Jacksonville Center as Atlanta Center (twice), and repeatedly

clicking the microphone button five and six times to activate the airport lighting (rather

than the seven times requested by the first officer).111 These errors were not consistent

with other pilotsí statements regarding the captainís performance on previous flights,

which described his competence, use of standard FedEx procedures and callouts, good

judgment, upbeat nature, and good CRM skills. Further, there was no evidence of previous

deficient performance in the captainís training or operational history.

Further, the captainís decision-making and monitoring during the approach were

not characteristic of his past performance. For example, although CVR evidence indicated

that the captain initially planned to land on runway 27 because it had an ILS and was more

convenient to the FedEx ramp, he agreed to land on runway 9 to accommodate the first

officerís suggestion. When the first officer subsequently began to reconsider his runway

selection, the captain said, ìyeah, it dudnít matter.î The captainís apparent indifference

about the landing runway and the ultimate decision to change to a runway that did not

109 See T. Akerstedt, ìReview Article: Shift Work and Disturbed Sleep/Wakefulness,î Sleep Medicine

Reviews Vol. 2, No. 2 (1998): 117-128.

110 The Safety Board notes that information regarding the flight crewmembersí activities and sleeping

history in the days before the accident was obtained from postaccident pilot and witness statements.

111 Keying the microphone five or six times would result in medium intensity runway lights rather than

high intensity runway lights but would not have affected the PAPI brightness/intensity. It is unlikely that this

adversely affected the flight crewís performance of the approach.
Analysis 57 Aircraft Accident Report

have a source of precision vertical guidance and provided little advantage over the

originally selected runway suggests that the captainís decision-making may have been

degraded. Additionally, although CVR evidence revealed instances in which the captain

appeared to be monitoring the first officerís performance, the captain declared the

approach ìstableî when the airplane descended through 500 feet, despite the airplaneís

excessive descent rate and reduced engine power settings. Most significantly, the captain

failed to observe and respond to the four red PAPI lights that were displayed throughout

most of the final approach. Any one of these items should have prompted the captain to

call for a go-around.

Many of the small errors made by the captain and his deficient performance during

the approach to TLH were consistent with fatigue. Research and previous accident

investigation experience indicate that fatigue can cause pilots to fixate on one aspect of a

situation and not respond effectively to warnings from other aspects, such as a stickshaker,

GPWS, or visual warnings. Further, one of the common deficiencies observed in

fatigue-related accidents is a tendency to continue an approach despite indications that the

approach should be discontinued. This fatigue-related performance inertia is evidenced by

decision-making and monitoring deficiencies. The Safety Board notes that during the

accident approach, there was not much evidence of substantive evaluation or discussion of

the consequences of the decision to change the landing runway to runway 9. For an

experienced captain to support a decision to change landing runways (when it

substantially increased cockpit workload late in the approach and removed a potentially

critical source of glideslope guidance) suggests degraded decision-making consistent with

the effects of fatigue.112

Therefore, on the basis of the early hour of the accident, the captainís sleep history,

and his performance deficiencies recorded by the CVR, the Safety Board concludes that

the captain was likely impaired by fatigue and this impairment contributed to his degraded

performance (especially in the areas of crew coordination and monitoring) during the

approach to TLH.

2.3.2 Role of FatigueóFirst Officer

The Safety Boardís review of crew interviews and the first officerís sleep history

revealed that he reported having difficulty adjusting his sleep cycle to the reserve-duty

schedule. The first officer told investigators that this was the first reserve schedule he had

flown in several years and that it was difficult on his body because the sleep-wake cycle

was frequently changing between day and night sleeping schedules. He stated that he

normally preferred to bid schedules that allowed either all-day or all-night sleep periods

over 1-week blocks.

112 For a similar example of inappropriate landing runway choice caused by fatigue, see National

Transportation Safety Board, Uncontrolled Collision With Terrain, American International Airways

Flight 808, Douglas DC-8-61, N814CK, U.S. Naval Air Station, Guantanamo Bay, Cuba, August 18, 1993,

Aircraft Accident Report NTSB/AAR-94/04 (Washington, DC: NTSB, 1994).
Analysis 58 Aircraft Accident Report

On July 23, the first officer flew an early morning trip that began about 0330 and

ended about 1100. Upon completion of this trip, he slept several hours during the day and

slept again that night. The first officer was off-duty the next day (July 24). He stated that

he awoke about 0930 to 1030 and went to sleep about 2100, sleeping for a few hours in

preparation for a trip that was scheduled to begin about 0230 on July 25. When he

completed the trip about 0830, the first officer got several hours of sleep during the day in

the layover hotel. He characterized the quality of sleep as ìno better or worse than most

day sleeps.î On the evening of July 25, he returned to duty, flew several legs, and arrived

at MEM about 2300 expecting to return home. Instead, he learned that he was assigned to

fly the accident trip in a few hours. The first officer contacted a duty officer to confirm

that the trip assignment did not result in his exceeding flight and duty time limits and

agreed to fly the trip.113 The first officer got about 1 1/2 hours of ìgoodî sleep in a

company sleep room before starting the accident trip. When asked whether he felt alert, he

stated, ìI donít recall feeling alert.î A friend and roommate stated that the first officer

ìappeared tiredî as he waited for the crew bus to take him to MEM for the accident trip.

The accident captain stated that he had an impression that the first officer ìmight be a little

tiredî and stated that the first officer discussed the rest difficulties of his reserve schedule. 

During the accident flight, the first officerís performance was deficient in ways

that appear inconsistent with characterizations of his past performance, including his

failure to request 30° of flaps until he was prompted to do so by the captain, his failure to

ìstay a little higherî on the approach (as he noted would be necessary to avoid losing the

runway), his failure to maintain appropriate engine EPR settings during the approach, and

his failure to respond to PAPI guidance that indicated the airplane was extremely low on

the approach. Further, the first officer did not recognize these deficiencies and decide to

perform a go-around. The Safety Board notes that there were times during the accident

flight that the first officerís performance was more consistent with characterizations of his

past performance; for example, he provided a comprehensive briefing for the initially

planned approach to runway 27, and he recognized his failure to correctly identify the

airport. 

Although the first officerís errors and occasionally deficient performance are

consistent with the effects of fatigue, in the case of the failure to maintain an appropriate

glidepath, the investigation revealed a potential alternate explanation. Specifically, there

was evidence that the first officerís ability to use PAPI information was limited by a

congenital color vision deficiency (see section 2.4.1).114 Therefore, the Safety Board

concludes that the first officerís schedule and his reported difficulty adapting to frequently

changing sleep cycles were conducive to the development of fatigue impairment that

contributed to his degraded performance during the approach to TLH; however, there were

also other factors affecting the first officerís performance (for example, his color vision

deficiency).

113 Although he agreed to take the accident trip, the first officer told investigators that he planned to file

a grievance regarding the assignment.

114 In addition, his color vision deficiency may have been exacerbated by hypoxia (see section 2.4.2).
Analysis 59 Aircraft Accident Report

2.3.3 Role of FatigueóFlight Engineer

In the case of the flight engineer, there was little evidence of factors conducive to

the development of fatigue in the days before the accident. He was off-duty on July 22

and 23 and reported resting at home with normal overnight sleeping and afternoon naps.

On July 24, he reported on-duty at 2200 for a deadhead trip to MEM then departed MEM

at 0230 on July 25, arriving at the layover destination about 0830. The flight engineer,

who said that he began taking naps as a result of the company fatigue management

training class, indicated that he got some rest on the deadhead flight and in a recliner chair

at MEM before this trip and that he got ìpretty solidî sleep in the layover hotel from 0900

to 1530. He returned to MEM the evening of July 25 and rested in a recliner chair with his

eyes closed for 30 minutes to 1 hour before the accident trip. The flight engineer indicated

that he felt ìpretty restedî for the accident flight. During postaccident interviews, the

captain stated that the flight engineer seemed to be alert during the accident flight.

During the accident flight, the flight engineer provided the captain and first officer

with pertinent weather and airport information and pertinent prompts (such as suggesting

performance of the approach and before landing checklists). However, he failed to correct

the captainís inaccurate repetition of the weather information. More seriously, he failed to

effectively monitor the airplaneís status during the final moments of descent as required

by company procedures. This failure was inconsistent with other pilotsí descriptions of the

flight engineerís performance and his reputation with the company.115 However, it is

possible that the flight engineerís poor monitoring of the late stages of the approach was

the result of his workload during the somewhat rushed approach,116 the presumption that

the two forward-facing flight crewmembers were adequately monitoring the approach, or

some combination of factors.

Although the early hour at which the accident occurred suggests the presence of

fatigue for all the crewmembers, the investigation indicated that the flight engineer

received normal rest until 1 day before the accident trip, supplemented his nightly sleep

with good quality sleep and rest at other times before the trip, and appeared to make an

adequate adjustment to an overnight flying schedule in preparation for the accident flight.

Further, there was no evidence of deficient performance that could be specifically related

to fatigue during the accident flight. On the basis of this evidence, the Safety Board

concludes that it is possible that the flight engineer was impaired by fatigue at the time of

the accident; however, it is also possible that the flight engineerís poor monitoring of the

late stages of the approach was the result of his workload during the somewhat rushed

approach, the presumption that the two forward-facing flight crewmembers were

adequately monitoring the approach, or some combination of factors. 

115 FedEx was evaluating the flight engineer for a check airman position.

116 Although the flight engineer told investigators that he did not feel rushed during the approach, the

completion of the checklist just 7 seconds before the CVR recorded the first sounds of impact resulted in less

time to focus his attention forward to monitor the final approach. 
Analysis 60 Aircraft Accident Report

2.3.4 Fatigue Management Training

The flight engineer said that as a result of the company fatigue management

training class, he began taking naps to augment his nightly sleep. Both he and the first

officer rested in the company sleep/nap areas before the accident trip. FedEx records

indicated that the captain received fatigue management training during recurrent training

in 1991, but he stated that he did not recall the training. Although the companyís policies

allowed for it, the three accident crewmembers indicated that they had never turned down

a trip due to fatigue.

The Safety Board notes that the FAA recently participated (with other

transportation modal administrations) in a DOT Operator Fatigue Management Program

effort to develop a fatigue management reference guide. The reference guide was intended

to provide basic information to operators in all transportation modes on how to develop an

effective fatigue management program using available scientific evidence and best

industry practices. In addition, the DOT program is developing additional products for

industry use (expected to become available in late 2004), such as software to aid in

designing work schedules that promote alertness. Such products can provide useful

guidelines and tools for companies that are willing to go beyond current regulations by

developing and implementing a fatigue management program (like FedEx).

Fatigue in transportation operations has been on the Safety Boardís list of most

wanted safety recommendations since the listís initiation in September 1990. In

May 1999, the Board issued a safety report that concluded that, despite acknowledgement

that fatigue is a significant factor in transportation accidents, little progress has been made

to revise the hours-of-service regulations to incorporate the results of the latest research on

fatigue and sleep issues. Thus, the Board issued Safety Recommendation A 99-45 in its

report, asking the FAA to ìestablish within 2 years scientifically based hours-of-service

regulations that set limits on hours of service, provide predictable work and rest schedules,

and consider circadian rhythms and human sleep and rest requirements.î However, the

FAAís response to this recommendation has not been acceptable, and, in April 2001,

Safety Recommendation A-99-45 was classified, ìOpenóUnacceptable Response.î The

Safety Board concludes that the circumstances of this accident, in part, demonstrate the

continuing need for fatigue management efforts similar to those being developed by the

DOT Operator Fatigue Management Program in the aviation industry.

2.4 Physiological Issues That May Have Affected the 

First Officerís Performance 

2.4.1 The First Officerís Color Vision Deficiency 

At the Safety Boardís request, the first officer completed an extensive postaccident

ophthalmic evaluation at USAFSAM, which was intended to determine the extent of the

color vision defect noted on his medical certificate and its possible significance during the
Analysis 61 Aircraft Accident Report

approach to TLH. During this evaluation, the first officer passed the FALANT color vision

screen but failed seven additional red/green color vision tests. The USAFSAM specialistsí

report stated that the first officer had a severe congenital deuteranomaly that could result

in ìdifficulties interpreting red-green and white signal lights.î The report also stated the

following: 

We believe that he would definitely have had problems discriminating the

PAPIsÖbecause the red lights would appear not to be red at all, butÖmore

indistinguishable from white than redÖ.it would be extremely unlikely that he

would be capable of seeing even the color pink on the PAPIÖmore likely a

combination of whites and yellows and perhaps, not even that difference. 

The USAFSAM conclusions are supported by the results of an Australian study,

which showed that individuals with color vision deficiencies similar to the first officerís

mistakenly identified the red light signal as white in up to 29 percent of the cases. The

Safety Board notes that this error could be especially dangerous when interpreting a PAPI

signal because it might lead a pilot to descend lower when the airplane is already too low.

The Australian study recommended that ìconsideration should be given to replacing the

Farnsworth lanternî as a color vision certification test for pilots.

The specialists at USAFSAM reported that most individuals with color vision

deficiencies develop an ability to ìdifferentiateî between normal colors based on cues

other than hue or wavelength, such as differences in shade or brightness. The length of the

first officerís military and civilian aviation career suggests that, in general, he had been

able to compensate for his deficient color vision. However, during the approach to

runway 9 at TLH, the first officer had to rely more heavily on his color vision because the

PAPI lights were the only reliable source of glidepath information in the black hole

approach environment leading to runway 9. The first officerís interpretation of the PAPI

lights would have been even more challenging because all four lights were red during

most of the final approach. As a result, there would have been no differing levels of

brightness for the first officer to perceive across the lights (as might have been apparent if

both white and red PAPI lights were visible), nor would there have been a change in

brightness to observe (as there might have been when a PAPI light transitioned from white

to red during the descent). Either of these would likely have assisted the first officerís

color interpretation.

It is possible that the first officer interpreted the uniform PAPI light indications as

ìwhiteî because that was consistent with available visual indications (for example, the

black hole illusion and the slight runway upgrade) that would lead him to perceive that the

airplane was higher on the approach than it was. Such an interpretation would be

consistent with the first officerís conduct of earlier portions of the approach, with

occasionally excessive rates of descent and lower-than-normal engine power settings.

However, just after the airplane descended through 500 feet agl, the first officer stated,

ì(Iím) gonna have to stay just a little bit higher, (or) Iím gonna lose the end of the

runway.î About this time, the FDR data indicated that the airplaneís descent rate began to

decrease from about 1,400 to 900, then to 500 fpm. It was not clear exactly why the first

officer moderated the descent rate at this time; however, it is possible that he was trying to
Analysis 62 Aircraft Accident Report

reconcile a conflict between the 500-foot GPWS callout and a mistaken illusion of the

airplaneís elevation above the field. The Safety Board considers it unlikely that the first

officer made this moderate reduction in the airplaneís descent rate because he recognized

the PAPI indication of four red lights; recognition of four red PAPI lights at such a late

stage in the approach should have resulted in a more aggressive response (such as an

immediate climb or a go-around). 

As previously discussed, the Safety Board is aware of other instances in which

pilots with valid medical certificates were involved in accidents related to deficient color

vision, including a U.S. Navy pilot who had passed the FALANT screen and a general

aviation pilot operating with a waiver for color vision deficiency. In addition, the Safety

Board has observed color vision deficiency-related issues in other transportation modes. 

It is apparent that in some situations, accurate color vision may be critical to a

degree that is not currently reflected in the application of the aviation medical certification

standards,117 specifically in those situations in which color discrimination capabilities are

critical to the safe execution of the task and there are no redundant cues to aid the

discrimination. Based on the available evidence, the Safety Board concludes that the first

officer suffered from a severe color vision deficiency that made it difficult for him to

correctly identify the color of the PAPI signal during the below-glidepath, nighttime,

visual approach to runway 9 at TLH.118

The Safety Board notes that current aviation medical certification standards for

color vision and related screening tests do not emphasize the full complexity of color in

modern operational situations, which include not only navigation lights, PAPI/VASI

displays and light gun signals, but may also involve color cockpit displays, including

weather radar, other flight instruments and gauges, and annunciator panels. Another

possible shortcoming of current color vision certification standards and related screening

tests is that they may not appropriately evaluate a pilotís ability to rapidly discriminate

among colors. Therefore, the Safety Board concludes that existing aviation medical

certification standards for color vision and use of related screening tests may not ensure

detection of color vision deficiencies that can be detrimental to safety; it is possible that in

some emergency situations, the speed of color recognition may assume an importance that

is not currently reflected in the standards.

The Safety Board further notes that some color vision screening tests currently in

use in the aviation industry are inadequate to confirm that a pilot has the ìability to

perceive those colors necessary for the safe performance of airman dutiesî as required by

the certification standards. For example, the FALANT screening test, which is an

approved color vision screening method for aeromedical certification, failed to identify

117 FAA medical standards for color vision require that pilots at all levels of certification possess the

ìability to perceive those colors necessary for the safe performance of airman duties.î

118 Another instance during the accident flight may provide an additional example of the first officerís

deficient color vision adversely affecting his ability to perform his duties. His initial mistaken identification

of a flashing white light as the rotating beacon at TLH reflected his failure to discern the color properties

(green and white) of an airport rotating beacon.
Analysis 63 Aircraft Accident Report

the first officerís severe color vision deficiency. In addition, according to the November 5,

2003, USAFSAM letter, other color vision tests (including the PIP) have failed to detect

color vision deficiencies in pilot applicants. The letter indicated that the USAF now uses a

battery of tests that it believes identifies all color vision deficiencies in applicants.

FAA records indicate that there is a substantial pilot population who, like the first

officer, have color vision deficiencies but successfully completed the FALANT or other

color vision deficiency screening test. For example, during postaccident testing, the first

officer successfully completed the FAAís light gun signal test,119 and as a result, the first

officer was issued a first-class medical with no restrictions, limitations, or SODAs. The

high success rate of the light gun signal test among individuals who have previously failed

another FAA-acceptable color vision screening test (about 95 percent) suggests that this

test may not identify all the individuals with severe color deficiencies that could affect

their ability to safely operate an aircraft. (The issuance of a color-vision-related SODA to

the first officer on the basis of operational experience appears to fall outside current and

past available written FAA guidelines regarding appropriate aeromedical disposition of an

airman who fails a color vision test.) Further, it is likely that, in some circumstances, these

color vision deficiencies may also result in unsafe conditions.

Therefore, the Safety Board concludes that one or more of the color vision

screening tests currently approved for use in the aviation industry (for example, the

FALANT) are not adequate and that these tests should be identified and their use

discontinued. The Safety Board believes that the FAA should conduct research to

determine the effectiveness of each of the current FAA-approved color vision test

protocols (including the color signal light test) at effectively screening out pilot applicants

with color vision deficiencies that could impair their ability to perform color-related

critical aviation tasks, including (but not limited to) correct interpretation of glideslope

information and in-cockpit displays that use color to convey information. The research

should take into account the time typically available to perform each task, particularly

under emergency conditions, and the potential effect of mild hypoxia (as might occur at

typical cabin altitudes) on color vision deficiencies. Further, the Safety Board believes that

the FAA should, based on the results of the research requested in the previous

recommendation, develop a standard battery of tests to be performed at least once on each

applicant for a Class 1 or 2 medical certificate that would prevent applicants with color

vision deficiencies that could impair their ability to perform color-related critical aviation

tasks from being certificated without limitations.

2.4.2 The First Officerís Breathing Rate

The Safety Board examined the breathing sounds that were recorded by the first

officerís channel of the CVR to determine whether they reflected the presence of an acute

medical condition, specifically a pulmonary embolus and resultant hypoxia. This issue is

119 Although operational use of light gun signals in the current aviation environment is very limited, the

light gun signal test is still used by the FAA to establish a color-deficient individual's ability to use color

operationally. 
Analysis 64 Aircraft Accident Report

significant because research120 indicates that any mild hypoxia could further degrade a

pilotís color vision (especially in pilots with existing color vision deficiencies) and affect

his decision-making abilities. An elevated breathing rate, as evident on the CVR, is one

symptom consistent with the diagnosis of this condition (although research shows that

people suffering from pulmonary embolus are often asymptomatic); there was also some

CVR evidence of breathing patterns consistent with those observed during hypoxia. CT

scans taken within 5 days after the accident revealed possible indications of pulmonary

embolus, the presence of which was later confirmed. Further, the first officerís reported

knee injury in the weeks before the accident and his subsequent efforts to minimize

movement of the injured limb could have been an initiating event for the development of

deep vein thrombosis, a precursor to a pulmonary embolism.

The rapid breathing rate recorded by the CVR during the last 20 minutes of the

accident flight is not sufficient evidence, when considered by itself, of pulmonary embolus

and resultant hypoxia. The first officer reported that he experienced no signs of distress,

pain, or difficulty breathing (potential symptoms of a pulmonary embolus) before the

accident. Further, there was no diagnosis of a pulmonary embolus or other physiological

abnormality immediately after the accident. Because there was no definitive evidence to

support the presence of a pulmonary embolus at the time of the accident, it was not

possible to determine whether the first officer was suffering from a pulmonary embolus

and resultant hypoxia at the time of the accident. The Safety Board was not able to

determine the cause of the elevated breathing rates recorded on the first officerís CVR

channel.

2.5 Crew Coordination/Monitoring Information

Contrary to FedEx standard operating procedures and training, the flight crew did

not work together effectively to fly and monitor a stabilized approach into TLH. There

was no evidence to suggest that the deficient crew coordination was a characteristic

pattern of performance for these three crewmembers (a review of company records and

interviews with other pilots generated positive and complimentary descriptions about their

abilities). Yet, the captain and flight engineer failed to recognize the solid red PAPI display

(although there was no evidence that either had deficient color vision) and take action to

correct the low approach. This failure might partially be the result of their accomplishment

of tasks that required their attention inside the cockpit, such as those involved in

completing the landing checklist. However, it would be normal and expected for both the

captain and flight engineer to monitor the runway environment at other times during the

final landing sequence, and it is difficult to understand why no one reacted to the visually

salient PAPI information. 

120 See (a) J.T. Ernest and A.E. Krill, ìThe Effect of Hypoxia on Visual Function. Psychophysical

Studies,î Invest Ophthalmol Vol. 10, No. 5 (May 1971): 323-8. (b) A.J. Vingrys and L.F. Garner, ìThe Effect

of a Moderate Level of Hypoxia on Human Color Vision,î Doc Ophthalmol Vol. 66, No. 2 (Jun 1987):

171-85. (c) C. Bouquet and others, ìColor Discrimination Under Chronic Hypoxic Conditions (Simulated

Climb ìEverest-Comex 97î),î Percept Mot Skills Vol. 90, No. 1 (Feb 2000): 169-79.
Analysis 65 Aircraft Accident Report

Research shows that attention can be highly selective and that people may not

respond to important objects that may be plainly visible.121 For example, a simulator study

found that some pilots became so engrossed in performing a landing using a heads-up

display that they failed to see an airplane blocking the end of the runway. Similarly,

accident data confirm that an air crew can respond to a visual illusion of airport distance

and fail to use accurate PAPI information that is directly visible. Fatigue and high

workload are both likely to increase the possibility of missing relevant information. If the

captain and flight engineer monitored the runway environment during the final approach

and if the PAPI signal was visible without obstruction, inappropriate selective attention

could help explain the failure of both crewmembers to respond to the PAPI information.

The actions of the captain and first officer added to the complexity of the final

approach and the need for careful monitoring by the flight engineer. For example, the

captain decided, at the first officerís suggestion, to change the landing runway, resulting in

the performance of a nonprecision approach instead of a precision approach. The first

officer was slow to correctly identify the airport, and the airplane was rather close to the

airport before it was aligned on final approach.

Thus, during the somewhat hurried final approach that ensued, the flight engineer

might have served as a significant defense against an accident by carefully monitoring and

crosschecking. The Safety Board notes that to accomplish the last item on the before

landing checklist (landing lights), the flight engineer would need to look forward to check

the landing light switches. According to FedEx procedures, the flight engineer should

have remained facing forward, monitoring the approach for the remainder of the flight (in

this case, 7 seconds). The flight engineerís failure to adequately monitor the approach,

either because of his workload, reliance on other crewmembers, inattention, or some

combination of factors, removed the last defense against the accident. 

Further, research indicates that a lack of crew familiarity may have contributed to

the flight crewís failure to fly and monitor a stabilized approach.122 For example, in a

study of major aviation accidents involving human performance issues, in which a large

number of monitoring errors were observed, the Safety Board found that 73 percent of the

accidents occurred on the first day that the captain and first officer had flown together;

44 percent occurred on the first flight leg. Simulator research supports this, showing that

121 See (a) A. Mack, ìInattentional Blindness,î Current Directions in Psychological Science Vol. 12,

No. 5 (2003): 180-184. (b) F.W. Hawkins, Human Factors in Flight (Aldershot, England: Ashgate

Publishing Limited, 1997) 116. (c) R.F. Haines, ìA Breakdown in Simultaneous Information Processing. In

G. Obrecht & L.W. Stark (Eds.),î Presbyopia Research (New York: Plenum Press, 1991) 171-175.

122 See (a) National Transportation Safety Board, A Review of Flightcrew-involved, Major Accidents of

U.S. Air Carriers, 1978 Through 1990, Safety Study NTSB/SS-94/01 (Washington, DC: NTSB, 1994).

(b) R. Khatwa and R.L. Helmreich, ìAnalysis of Critical Factors During Approach and Landing Accidents

and Normal Flight,î Killers in Aviation: FSF Task Force Presents Facts About Approach-and-Landing and

Controlled-Flight-into-Terrain Accidents. Flight Safety Digest. (NovemberóDecember 1998, Januaryó

February 1999). (c) K. Dismukes, G. Young, and R. Sumwalt, ìCockpit Interruptions and Distractions:

Effective Management Requires a Careful Balancing Act,î ASRS Directline (December 1998). (d) H.C.

Foushee, J.K. Lauber, M.M. Baetge, and D.B. Acomb, Crew Factors in Flight Operations: III. The

Operational Significance of Exposure to Short-Haul Air Transport Operations. National Aeronautics and

Space Administration, NASA Technical Memorandum 88322, August 1986.
Analysis 66 Aircraft Accident Report

flight crews with recent operating experience together communicate more frequently

overall and perform better at solving in-flight emergencies than those that did not (even

though, in some cases, crews without recent operating experience together were returning

to flight duty after a rest period, which was not the case with crews with recent operating

experience together). Therefore, the FedEx accident crew may have had a disadvantage

because they were engaged in their first leg as a crew123 and had not yet developed the

level of personal working relationship that facilitates effective coordination. Although

compliance with FedExís standard operating procedures should have helped eliminate

flight crew coordination errors, the lack of flight crew familiarity may help explain why

such crew coordination and monitoring was deficient during the accident sequence.

During postaccident interviews, FedExís lead instructor for CRM told

investigators that the CRM department had been lobbying the airline to change the term

ìpilot not flyingî to ìpilot monitoringî because they wanted non-flying pilots to think

more about the importance of their monitoring role. The circumstances of this accident

demonstrate the importance of flight crewmembers actively monitoring the performance

of other crewmembers, as well as their own performance. According to the ALAR study

conducted by the Flight Safety Foundation, inadequate monitoring by flight

crewmember(s) was a factor in 63 percent of approach and landing accidents.

The Safety Board notes that in February 2003, the FAA revised AC 120-71A,

ìStandard Operating Procedures,î to describe the philosophy of and benefits to be derived

from a ìpilot monitoringî program. AC 120-71A also indicates that several air carrier

operators have changed the title of ìpilot not flyingî to ìpilot monitoringî because it is

more appropriately descriptive. According to the March 17, 2003, FedEx submission on

this accident, the company now uses pilot monitoring for certain approaches, and at least

one other air carrier has completely incorporated the pilot monitoring concept into its

system. The Safety Board concludes that the circumstances of this accident support the

recent increase in emphasis on crew monitoring reflected in recent initiatives by the FAA

and aviation industry.

123 The captain and flight engineer had been paired once before but neither had a clear recall of the

experience.
67 Aircraft Accident Report

3. Conclusions

3.1 Findings

1. The captain, first officer, and flight engineer possessed valid airman and medical

certificates.

2. The captain, first officer, and flight engineer had received the training and off-duty

time prescribed by Federal regulations and company requirements. 

3. The accident airplane and its cargo were not factors in the accident. 

4. Weather and air traffic control were not factors in the accident. 

5. The airport lighting systems, including the precision approach path indicator lights,

were not a factor in the accident. 

6. The accident approach was not stabilized as the airplane descended through 500 feet

above ground level, and the pilots should have detected this and performed a

go-around. 

7. The approach to runway 9 at Tallahassee Regional Airport (which was flown over

unlighted terrain and in night visual conditions) resulted in black hole conditions,

which likely contributed to the flight crewís failure to properly perform the approach. 

8. Precision approach path indicator lights, such as those installed at runway 9 at

Tallahassee Regional Airport, are a recognized countermeasure for use in black hole

conditions and should have been, but were not, effectively used to maintain an

appropriate glidepath by the first officer (who was the flying pilot) or by the captain

and flight engineer (who, under the principles of basic crew coordination, were in a

position to receive this information and initiate a corrective response). 

9. The captain was likely impaired by fatigue and this impairment contributed to his

degraded performance (especially in the areas of crew coordination and monitoring)

during the approach to Tallahassee Regional Airport. 

10. The first officerís reported difficulty adapting to his schedule and frequently changing

sleep cycles were conducive to the development of fatigue impairment that

contributed to his degraded performance during the approach to Tallahassee Regional

Airport; however, there were also other factors affecting the first officerís

performance (for example, his color vision deficiency).
Conclusions 68 Aircraft Accident Report

11. It is possible that the flight engineer was impaired by fatigue at the time of the

accident; however, it is also possible that the flight engineerís poor monitoring of the

late stages of the approach was the result of his workload during the somewhat rushed

approach, the presumption that the two forward-facing flight crewmembers were

adequately monitoring the approach, or some combination of factors.

12. The circumstances of this accident, in part, demonstrate the continuing need for

fatigue management efforts similar to those being developed by the Department of

Transportation Operator Fatigue Management Program in the aviation industry. 

13. The first officer suffered from a severe color vision deficiency that made it difficult

for him to correctly identify the color of the precision approach path indicator signal

during the below-glidepath, nighttime, visual approach to runway 9 at Tallahassee

Regional Airport. 

14. Existing aviation medical certification standards for color vision and use of related

screening tests may not ensure detection of color vision deficiencies that can be

detrimental to safety; it is possible that in some emergency situations, the speed of

color recognition may assume an importance that is not currently reflected in the

standards.

15. One or more of the color vision screening tests currently approved for use in the

aviation industry (for example, the Farnsworth Lantern screening test) are not

adequate; these tests should be identified and their use discontinued. 

16. The circumstances of this accident support the recent increase in emphasis on crew

monitoring reflected in recent initiatives by the Federal Aviation Administration and

aviation industry. 

3.2 Probable Cause

The National Transportation Safety Board determines that the probable cause of

the accident was the captainís and first officerís failure to establish and maintain a proper

glidepath during the night visual approach to landing. Contributing to the accident was a

combination of the captainís and first officerís fatigue, the captainís and first officerís

failure to adhere to company flight procedures, the captainís and flight engineerís failure

to monitor the approach, and the first officerís color vision deficiency.
69 Aircraft Accident Report

4. Recommendations

As a result of the investigation of the FedEx flight 1478 accident, the National

Transportation Safety Board makes the following recommendations to the Federal

Aviation Administration:

Conduct research to determine the effectiveness of each of the current

Federal Aviation Administration-approved color vision test protocols

(including the color signal light test) at effectively screening out pilot

applicants with color vision deficiencies that could impair their ability to

perform color-related critical aviation tasks including (but not limited to)

correct interpretation of glideslope information and in-cockpit displays that

use color to convey information. The research should take into account the

time typically available to perform each task, particularly under emergency

conditions, and the potential effect of mild hypoxia (as might occur at

typical cabin altitudes) on color vision deficiencies. (A-04-46)

Based on the results of the research requested in Safety Recommendation

A-04-46, develop a standard battery of tests to be performed at least once

on each applicant for a Class 1 or 2 medical certificate that would prevent

applicants with color vision deficiencies that could impair their ability to

perform color-related critical aviation tasks from being certificated without

limitations. (A-04-47)

BY THE NATIONAL TRANSPORTATION SAFETY BOARD

ELLEN ENGLEMAN CONNERS

Chairman

CAROL J. CARMODY

Member

MARK V. ROSENKER

Vice Chairman

JOHN J. GOGLIA

Member

RICHARD F. HEALING

Member

Adopted: June 8, 2004

71 Aircraft Accident Report

5. Appendixes

Appendix A

Investigation 

The National Transportation Safety Board was initially notified of this accident on

the morning of July 26, 2002. A full go-team was assembled in Washington, D.C., and

traveled to the accident scene. The go-team was accompanied by representatives from the

Safety Boardís Offices of Government and Public Affairs and Transportation Disaster

Assistance. No Board Member traveled to the accident site. 

The following investigative groups were formed during the course of this

investigation: Structures, Systems, Powerplants, Air Traffic Control, Meteorology,

Operations, Human Performance, Medical Factors, Airport/Survival Factors, Airplane

Performance, Flight Data Recorder, Cockpit Voice Recorder (CVR), and Hazardous

Materials. In addition, a CVR Sound Study was conducted. 

Parties to the investigation were the Federal Aviation Administration, the Boeing

Commercial Airplane Group, Federal Express, Air Line Pilots Association, National Air

Traffic Controllers Association, Pratt & Whitney, and the Tallahassee Regional Airport. 
72 Aircraft Accident Report

Appendix B

Cockpit Voice Recorder Transcript

The following is a transcript of the Fairchild model A100 CVR installed on the

accident airplane. Only radio transmissions to and from the accident airplane were

transcribed. The CVR transcript reflects the 32 minutes and 12 seconds before power was

lost to the CVR. All times are eastern standard time, based on a 24-hour clock.
Appendix B 73 Aircraft Accident Report






























104 Aircraft Accident Report

Appendix C

Correspondence Regarding the First Officerís

Color Vision 
Appendix C 105 Aircraft Accident Report
Appendix C 106 Aircraft Accident Report
Appendix C 107 Aircraft Accident Report
Appendix C 108 Aircraft Accident Report

E P L UR IBUS U NU M

N ATI O N A L T R A S PO R TA TIO N

B O A R D

S A F E T Y

N

Office of Aviation Safety

National Transportation Safety Board 

Washington, D.C. 20594

 September 17, 2003 

Douglas J. Ivan, Col USAF, MC, CFS 

Chief, Aerospace Ophthalmology Branch 

Department of the Air Force 

USAF School of Aerospace Medicine (AFMC) 

Brooks City-Base Texas 

Dear Colonel Ivan: 

I am writing in response to the aeromedical evaluation that your branch conducted in support of 

the NTSB investigation of the FedEx B-727 accident that occurred at Tallahassee, Florida on July 

26, 2002. As summarized in your memorandum of March 28, 2003, your laboratory conducted 

extensive testing on the accident first officer’s color vision and concluded that he suffered from a 

severe congenital deficiency in red/green color perception. 

I am writing on behalf of the investigation to ask several further questions to clarify your findings 

and seek additional documentation regarding your evaluation of the first officer’s color vision. 

The questions are: 

1. In your memorandum, you stated that “clearly, it is possible in this case, that the red 

lights of a PAPI could have been identified as ‘yellow’ at lower light levels or ‘white’ 

when the light was brighter.” Based on the evaluation: 

a) What is the likelihood the first officer would perceive the color red in a PAPI as 

white, and be unable to distinguish the red and white colors of the PAPI? 
Appendix C 109 Aircraft Accident Report

b) What is the likelihood the first officer would see the color red as “yellow?” If 

so, what would be his perception of the color white and would he be able to 

distinguish the two colors? 

c) What is the likelihood that the first officer would perceive the color red in a 

PAPI as red, pink, or any color that might be readily distinguished from white? 

2. You indicated that the first officer might “employ learned strategies, other than normal 

color discrimination, to ‘interpret’ PAPIs.” What sort of learned strategies were you 

referring to? 

3. Would the first officer have difficulty perceiving the color green in a display such as an 

airport identifier beacon, and differentiating this color from white and red? 

4. How would the first officer’s ability to discriminate between red and white colors on a 

PAPI be affected by day versus night viewing conditions? 

5. How would the first officer’s ability to distinguish red and white lights in a PAPI be 

affected when these signals were viewed under high relative humidity conditions (but 

not direct obscuration by fog)? 

6. What factors would affect the first officer’s color vision capabilities? Specifically: 

a) How would aging affect this type of color vision deficiency? That is, is it likel y 

that his color perception was better earlier in his career? 

b) How would hypoxia affect this type of color vision deficiency? Would his 

ability to discriminate red and white in a PAPI be affected? Would his ability to 

discriminate green from white be affected? 

c) How would smoking history affect this type of color vision deficiency? The first 

officer had a 1⁄2 pack a day smoking history for his entire adult life. He last 

smoked about three hours before the accident. Would this smoking history 

affect his ability to discriminate red and white in a PAPI? Would this smoking 

history affect his ability to discriminate green from white be affected? 

d) What other factors would affect the first officer’s color vision capabilities and 

how? 

7. The first officer received a perfect score on the Farnsworth Lantern test but failed all 

other red/green perception tests administered by your laboratory. How was he able to 

pass the Farnsworth Lantern test? 

8. Can you provide any additional technical references concerning the validity of the 

Farnsworth Lantern test for color deficiency testing (including references regarding the 
Appendix C 110 Aircraft Accident Report

ability of pilots who pass the Farnsworth Lantern to reliably distinguish aviation signals 

and lights)? 

9. Are you aware of any pilots with similar color deficiencies who have had careers in 

military or civilian aviation? Are you aware of any pilots with similar color 

deficiencies who have been involved in events/incidents/accidents related to their color 

vision? What color vision screening methods were used for these pilots? 

10. Is it an accurate summary of your test results to state that the first officer was found to 

have a congenital color perception deficiency sufficiently severe that he could not 

reliably distinguish the red and white colors of the PAPI based on color information 

alone? 

In your answers to these questions we would particularly appreciate any additional thoughts or 

evidence based on your evaluation of the first officer. In addition, any technical references 

applicable to assessing color vision discrimination capabilities in individuals with this type and 

severity of color deficiency would be appreciated. Thank you for the very thorough and thoughtful 

support you have provided so far and for your responses to this material. 

 Sincerely, 

 Malcolm Brenner, Ph.D. 

 National Resource Specialist— 

Human Performance 
Appendix C 111 Aircraft Accident Report

DEPARTMENT OF THE AIR FORCE 

USAF SCHOOL OF AEROSPACE MEDICINE (AFMC)

BROOKS CITY-BASE TEXAS

5 Nov 03 

MEMORANDUM FOR NATIONAL TRANSPORTATION SAFETY BOARD 

 ATTN: MALCOM BRENNER, Ph.D. 

 WASHINGTON, DC 20594 

FROM: USAFSAM/FECO 

 2507 Kennedy Circle 

 Brooks City-Base Texas 78235-5116 

SUBJECT: FedEx B-727 Accident (July26, 2002), Tallahassee, FL; 

NTSB ID #: DCA 02MA054 

The USAFSAM evaluation of First Officer William Frye in Feb 2003 identified him to have a 

severe deuteranomalous color vision (CV) deficit that most probably represented a congenital 

defect based on its long standing history, the characteristics of hi s defect, and the absence of any 

other identifiable conditions that would be consistent with an acquired etiology. At the request of

NTSB, CV testing was done under monitoring by pulse oxymetry, which revealed normal 

hemoglobin oxygenation levels during testing. If First Officer Frye was alone in his visual 

interrogation and interpretation of the PAPI system, then it was the only available visible external

cue he had to land the aircraft that night. With that in mind, we will now address the specific 

questions you have posed, in sequence: 

1. His red-green CV discrimination was significantly impaired as identified on multiple 

red-green CV screening tests. Ultimately, he was characterized to be severely 

deuteranomalous, and nearly dichromatic, on anomaloscopic testing. Thus, compared 

to normal, his perceptible spectral bandwidth of colors would be quite narrow, likely 

approaching monochromatism above 540-545nm. This would essentially relegate him 

very nearly to a gray-blue-yellow world only. In that abnorm ally color shifted world, 

such an individual would have extreme difficulty, determining differences between 

greens and reds and many other colors to include whites based on wavelength or hue. 

The physiological nature of such a CV deficit is caused by an abnormal shift in the 

wavelength sensitivity of the green cone system from it’s normal position in the visible

spectrum, towards, and nearly overlapping the wavelength sensitivity curve of the red 

cone system located at the longer wavelength section of the visible spectrum. A total 

shift would completely overlap the red cone system rendering such an individual 

dichromatic and a severe enough shift would also effectively render such an individual 

to be nearly dichromatic and still make red and green lights and most colors virtually 
Appendix C 112 Aircraft Accident Report

indistinguishable. Thus, the ability to appreciate differences in colors as normally 

generated by appropriate independent and simultaneous stimulation of normally 

separated red and green cone sensitivity curves would be severely compromised and 

abnormal. That independent stimulation of separate cone sensitivity curves located in 

different parts of the visible spectrum is required by the brain to determine appropriate 

matches that eventually define normal color perception. When the cone sensitivity 

curves abnormally overlap, wholly or in part, this ability becomes aberrant. The greater 

the overlap, the greater the problem. For example, conceptually, simultaneous 

stimulation of a single sensitivity curve by a purish source with a narrow wavelength 

range, such as a laser, would normally trigger only 1 cone system. However, with 

overlapping curves, that same light source would now be interpreted by the brain to be 

stimulating two different cone systems and be centrally processed to represent a color 

other than a purish red or green, because of the two cone systems now being stimulated 

(abnormally) at the same time and processed accordingly by the brain. Therefore, a 

light source or object that would appear to be red or green to a color normal would now 

appear to be something other than red or green to someone with this type of severe cone 

sensitivity shift, and more likely be interpreted as yellow. Therefore, because of the 

severity of his CV deficit, we believe that he would definitely have had problems 

discriminating the PAPIs normally, and as they were designed, because the red lights 

would appear not to be red at all, but either yellow, or some other wavelength, that 

would make them more indistinguishable from white, especially if the light sources 

were further intensified. Therefore, given the congenital near overlap of his red-green 

cone sensitivity curves, it would be extremely unlikely that he would be capable of 

seeing even the color pink on the PAPI, but more likely, a combination of whites and 

yellows and perhaps, not even that difference. 

2. Congenital color defectives develop some ability to “differentiate” between normal 

colors based on clues other than hue or wavelength, such as by differences in shade or 

brightness. This is a learned process and is not reliable. Over time, they adjust to their 

“abnormal” color world and learn to assign typical color names to that perceived 

difference based on learned experiences. Such adjustments are not foolproof and are 

vulnerable to failure, especially when exposed to unpredictable and new color 

challenges without redundancy. Therefore, it might be possible for someone with this 

type of CV deficiency to use brightness differences between the white and red PAPI 

lights to help differentiate between them over an entire flying career. However, on the 

other hand, someone like this may also not have been able to use PAPIs effectively at 

all over their entire career, especially exclusively. If the "difference" between the white 

and red lights were somehow perceptible enough, someone could eventually learn how 

to use this information to analyze such challenges, but more likely, this would have 

caused such an individual to shy away from sole reliance on PAPIs. Such a strategy 

would be more effective in a CV defective, if the targets being interrogated, were 

limited, repeatable, and reproducible, such as in the Farnsworth Lantern (FALANT) or 

in the PAPI system, where learned strategies could be effectively tested by trial and 

error and employed. However, new and unexpected color tasks or lighting situations 

would be much more challenging or even impossible, to an individual with this level of 

CV defect, especially the first time encountered, than situations that can be uniformally 
Appendix C 113 Aircraft Accident Report

reproduced, retested, and represented over and over. That said, it is possible for an 

individual with this level of CV defect to quickly learn how to pass some color 

challenges based on limited selection options and other technical limitations, such as 

those known to be associated with the FALANT. Once someone learned how to assign 

a new color name for each particular brightness, or to any differences they might 

perceive, they could employ this strategy in order to “pass” the FALANT again and 

again. Remember, CV defectives have been trying to naturally adopt alternate 

strategies all their lives in order to adapt, function, and survive in their abnormal color 

world. However, we would expect that the first time someone with a severe red-green 

CV defect were administered the FALANT, that they would have had trouble truly 

passing it and would have needed time or additional testing to develop a strategy to 

“pass”. To “pass” the FALANT, correct responses to the presentations are required. 

The testee is trying to “pass” the test, therefore, their goal is to give “correct” 

responses. Being unaware of normal colors and of their inability to truly identify hue 

based differences during the test, they would nonetheless try to give “correct” 

responses from their perspective based on how they have learned to differentiate 

between the choices. Therefore, they are trying to give the right answers without really 

being able to normally appreciate the differences as was intended by the test. They in 

fact know no other way and have had a lifetime trying to respond to color 

differentiation tasks that are obvious to color normals. Technicians are listening for 

responses and would not easily recognize “problems” beyond “right” or “wrong” 

responses. In fact, some may unintentionally “help” in the process. With only a known 

and limited number of colors and choices in FALANT combinations, and some adopted 

strategies that "differentiates" between the three, it can be conceived that such an 

individual could have consistently “passed” the FALANT using an alternate strategy, 

rather than actually being able to truly differentiate between the red, green, and white 

wavelengths as perceived by a normal trichromat. Paulsen et al.(1966), and others 

since have reported this. It should also be kept in mind that by design, the FALANT 

test was never designed to identify only color normals, but to allow some CV 

defectives to be passed and therefore be indistinguishable from true normals who also 

pass. However, it should not in theory pass more severe CV deficits, but unfortunately 

does so.

3. An individual with Mr. Frye's type of CV defect is nearly a dichromat. As stated 

earlier, this means that the wavelength sensitivity curves of the red and green systems 

would be nearly overlapped, thus mimi cking a single responding "red-green" cone 

system and true dichromatism. Consequently, such a red-green dichromat would be 

relegated to a world of grays, blues and yellows. Someone like him would be expected 

to have problems truly differentiating between red and green wavelengths, and in fact 

possibly all wavelengths greater than 545nm. Common errors include confusing whites 

with reds and greens, e.g., calling white lights red and vice versa. 
Appendix C 114 Aircraft Accident Report

4. His ability to see the PAPIs differently during the day or at night might vary depending 

on the intensity level selected for the PAPIs. Since the perception of the PAPI lights 

would be a photopic event in either case at these light levels, the same confusion would 

likely exist day or night, with one exception. Given the scenario he was under, at an 

unfamiliar airfield, at night, in a black hole with no other visual cues available for him 

to interrogate other than the PAPIs, published literature by Smith, et al.(1973) in 

similar CV defectives, including severe deuteranomalous individuals, clearly indicated 

that hues in the range between 500-600 nm were identified as yellow at reduced 

illumination levels, but when these wavelengths were intensified, the brighter colored 

lights were now interpreted as “white”. In addition, low voltage levels of white PAPI 

lights are known to shift the white lights more towards yellow (Cole and Maddocks). 

This output driven wavelength shift would make it more difficult, or even impossible, 

for such CV defectives to distinguish differences between white, red, and yellow. 

5. We do not have enough information available to us to answer this question. There are 

studies in the literature on atmospheric haze effects, but none that we could find on 

humidity. 

6a. One of the characteristics of congenital CV defects is that they do not change over time 

unless an additional acquired etiology occurs and thereby overlays an additional 

component on the already underlying congenital defect. That would only make 

matters worse. The only age related issue that could possibly impact this case would 

be from any induced blue light filtration caused by the natural yellowing of the lens 

that occurs in everyone over time. This is a well-known UV-induced phenomenon that 

can induce an acquired blue-yellow deficiency by blocking shorter wavelengths, e.g., 

purples, and blues. We did not demonstrate any obvious cataract in his case, however, 

even a normal lens is known to have increasing levels of blue and UV filtration as a 

function of increasing age. Such an acquired blue-yellow CV disturbance would likely 

not aggravate existing red-green problems, however, could tend to aggravate the ability 

to distinguish residual differences between yellow and white, as this would be 

tantamount to wearing yellow lenses. However, he did not demonstrate an objective 

blue-yellow component at this point in time. 

b. Hypoxia can definitely degrade visual function including color vision. This has been 

well established in the literature for years. The WW2 literature available from Schmidt 

identified increased pathological color thresholds (red and green both decreased in 

sensitivity, but in different subjects) with mild hypoxia above 9800 ft. and observed 

this to be even greater if there was an already existing color deficiency. 

The following paragraph with respect to hypoxia and color vision was extracted from 

the Heino Widdel and David L. Post edited book entitled "Color in Electronic 

Displays", Defense Research Series, Vol 3, 1992: 
Appendix C 115 Aircraft Accident Report

"Several studies have reported that hypoxia results in losses in color sensitivity, 

although there is disagreement on the specific effects (see Dyer, 1988). When color 

vision has been tested foveally, the hypoxia generally produced a greater perceptual 

deficit for blue or green (Frantsen & Iusfin, 1958; Modugno, 1982; Schmidt & Bingel, 

1953; Smith, Ernest & Pokorny, 1976; Weitzman, Kinney, & Luria, 1969); when it was 

tested peripherally, it generally produced a greater deficit for yellow or red (Blum & 

Fisher, 1942; Ernest & Krill, 1971; Kobrick, 1970; Vollmer, King, Fisher, & Birren, 

1946). On the other hand, in testing the effects of hypoxia on the limits of the visual 

field, Kobrick, Zwick, Witt, and Devine (1984) found that the limits of green sensitivity 

decreased but not hose of red. Boles-Carenini and Cima (1952) noted that hypoxia 

worsened already-existing anomalies of the Nagel anomaloscope quotient." 

Therefore, hypoxia could be expected to induce or further degrade any residual hue 

discrimination by raising the color sensitivity thresholds overall and reduce any 

residual wavelength discrimination across the visible spectrum. All colors become 

further degraded under lower levels of illumination, especially with hypoxia. These 

hypoxic effects have generally been studied using the FM100, but we could not find 

any other studies addressing hypoxia as a function of any other specific CV tests 

beyond those cited using the FM100 and Nagel anomaloscope. 

c. Research has indicated that smoking also affects photopic vision, one aspect of which 

would be color perception. This can occur from related hypoxic and metabolic effects 

or from tobacco amblyopia, a type of chronic toxic optic neuropathy, usually seen in 

heavy smokers. Graefes (Arch Clin Exp Ophthal, 1999, May, pp 377-80) identified 

color vision changes in individuals who consumed more than 20 cigarettes per day. 

d. Other potential factors that could affect anyone’s color vision would include the nature, 

transmission characteristics, and color of any intervening optical interfaces, 

medications, drugs, and/or diseases that might also be present. These all would reduce 

brightness, change the spectral characteristics entering the eye or receptor sensitivities, 

and further degrade cone function. Our evaluation however did not reveal any known 

indication of any medications or diseases that would further impact his color 

perception in any way. A typical Boeing 727 windscreen would not normally be 

associated with any selective waveband filtration that would have further degraded the 

visual scene external to the cockpit in any significant way. However, specific FedEx 

modifications would need to be ruled out. 

7. We believe that the First Officer was able to “pass” the Farnsworth Lantern using 

naturally learned strategies as previously discussed. His learned experience may have 

involved some early, unrecorded test failures and perhaps, some technician “assistance” 

along the way. This could have been as benign as allowing someone like him some 

additional opportunities to change a response or even retake the test. On the other 

hand, the FALANT is known to “pass” severe CV defectives, however that occurs. 
Appendix C 116 Aircraft Accident Report

Regardless, the FALANT was the only color vision test that he could “pass” at 

USAFSAM. All other test scores were consistent with a severe red-green deficit. The 

D15 was borderline. While this may appear disconcerting, it is not surprising and is 

consistent with known problems with the FALANT. 

8. A database literature search would provide you with a complete bibliography with 

respect to the FALANT. In addition to references you already have, I would draw your 

attention to germane articles recently published in Aviation, Space, and Environmental 

Medicine in the last few years as a good start, as well as a few others linked below: 

(a) Birch and Dain, ASEM, Vol 70, No. 1, 1999. 

(b) Dain and Houson, ASEM, Vol 59, No. 4, 1988. 

(c) Laxar, Military Medicine, Sept, 1967, pp 726-731. 

(d) Cole BL and Maddocks, JD, “Colour Vision and PAPI”, Colour 

Deficiencies XII, 1995, pp 501-510. 

(e) Cole and Vingrys, Documenta Ophthalmologica, 55, 1983, pp 157-175. 

The simulated PAPI Study by Cole and Maddocks (d) in particular identified 

unexpected problems with all deutans, both deuteranopes and deuteranomalous, that led 

them to conclude that proper recognition of PAPI systems by color defectives is 

problematic and a risk in aviation. 

Because of testing inaccuracies and other flaws of FALANT testing applicable to 

modern aviation, it was dropped as an official USAF aircrew qualifying test in 1993. It 

simply was not reliable and misidentified significant CV defectives. (See below). 

9. Prior to 1993, and throughout the entire history of the use of the FALANT in the Navy 

and USAF, passing the test meant that you met applicable CV standards at the time and 

did not require any further CV testing. Therefore, since many color defectives can 

“pass” the FALANT, the true CV status of an individual who passes it, cannot be 

determined on the basis of passing that test alone. Procedurally, for decades, the USAF 

used a red-green PIP-I screener first, and then, only if you failed that test, were you 

administered the FALANT. If you failed the FALANT, you were disqualified. If you 

passed the FALANT, you were qualified and no further definitive quantitative analysis 

was required. PIP testing became the only standard used by the USAF between 1993 

and 1995, when a transition to the present methodology was adopted. 

Currently the USAF uses a four-test battery of PIP plate tests to evaluate pilot 

applicants during Medical Flight Screening (MFS) for both congenital and acquired 

red-green and blue-yellow CV deficiencies. To qualify for MFS, an applicant must 

first pass an Initial Flying Class I exam including the traditional single red/green 

screening PIP test exam done in the field. The additional four test CV battery is then 

administered to all pilot candidates during MFS at USAFSAM. It comprises the PIP I, 

PIP II, PIP III, and the F2 plate tests. Failure of any one of those four PIP plate tests 

results in additional color vision (CV) testing to determine the exact nature and degree 

of any existing CV defect and a complete ophthalmological evaluation to rule out 
Appendix C 117 Aircraft Accident Report

acquired pathology. The final CV determinant test is the gold standard anomaloscope. 

However, many additional CV tests (FM100, FALANT, APT-5, D15, etc.) are also 

performed to monitor their effectiveness and correlation with the screening test battery 

and the anomaloscope, however, their results do not impact on the final waiver 

recommendation, only the anomaloscope results count at this point. This CV screening 

methodology is consistent with the recommendation of NATO’s Working Group 24 

that was published in RTO-TR-016 in 2001. Because of many problems related to 

lantern tests, WG-24 did not recommend using any lanterns for CV screening and 

assessment for modern aircrew. Previous published studies of the FALANT have 

revealed that it “passes” between 25-40% of all color defectives while in theory it was 

designed to only pass mild deficiencies. That proven unre liability was the fundamental 

reason why the USAF dropped it as a CV qualifying test in 1993. Repeated analysis of 

the FALANT results in CV defectives at USAFSAM indicate that the FALANT does 

not distinguish or predict the magnitude of the CV deficiency and passes mild, 

moderate and severe anomalous trichromats. It is usually failed by dichromats. More 

specifically, in the most recently analyzed data submitted for presentation for AsMA 

2004, the FALANT passed 60% of subjects identified to have severe deuteranomaly on 

the anomaloscope. 

Given intended and unintended flaws associated with the FALANT, it therefore 

remains unknown how severe a color defective might be if they “passed” the FALANT. 

There is some data however on this in the literature to incl ude the additional experience 

here at USAFSAM with large numbers of applicants. Therefore, it is possible that 

aircrew with similar defects managed to escape accurate identification of their true CV 

performance because of "passing" the FALANT. It has been subsequently shown that 

some can have significant CV deficits. 

An apparent paradox exists in that, because of the absence of any disastrous accidents, 

aviators may appear, and is often argued, to have performed “successfully” throughout 

their career. This perception is likely due to a myriad of circumstances, but would 

represent a spectrum to include not being appropriately challenged, or even being just 

plain lucky! Being “successful” therefore can be misleading in some cases, as we 

believe it appears in this case. That “success” may vanish if their CV deficiency gets 

challenged in a way that their handicap fails them. We are aware of another Navy 

aircraft mishap that can be attributed to a very similar scenario involving a CV 

defective, as severe as this case, who also apparently “passed’ the FALANT many 

times over his career. Following a series of color vision misperceptions during a flight 

that resulted in the loss of the aircraft, that mishap pilot was later identified to also be 

severely red-green CV defective and quite similar to the type of the CV defect in this 

case. During the post accident investigation, he admitted that he had gotten “help” and 

used alternate strategies to “game” the FALANT in order to “pass” it. Technicians 

“helped” in assorted ways. Anomaloscope testing in his case also revealed a severe 

red-green deuteranomalous CV deficiency. 
Appendix C 118 Aircraft Accident Report

10. In summary, we believe that this case appears to be consistent with a true failure in CV 

testing methodology involving the FALANT’s inability to properly identify a severe 

red-green CV defective who found himself in a scenario when the PAPI system was 

the, main and possibly only, clue available to help him successfully land the aircraft at 

an unfamiliar airfield, despite his past history of apparent “success”. The failure to 

properly identify his CV deficit is consistent with one of the potential problems 

associated with reliance on the FALANT, and is further consistent with other research 

in CV defectives using colored lights similar to the PAPIs. In this setting, we believe 

he would not have been able to properly interpret the PAPI system as designed because 

of his severe congenital red-green color vision disturbance. 

 JOHN T. YATES, Ph.D. 

 Chief, Visual Electrodiagnostic Laboratory 

 DOUGLAS J. IVAN, Col, USAF, MC, CFS 

 Chief, Aerospace Ophthalmology Branch