U.S. Department of Transportation

FEDERAL AVIATION ADMINISTRATION Office of Aviation Policy and Plans Washington, D.C. 20591

REGULATORY IMPACT ANALYSIS

Flightcrew Member Duty and Rest Requirements

PART 117 Final Rule
OFFICE OF AVIATION POLICY AND PLANS

November 18, 2011ii 

## Table of Contents

Disposition of Issues Raised by Comments...........

................................................... ...................... 1 Benefit/Cost Summary...............................

................................................... ................................ 13 Benefit Analysis...................................

................................................... ...................................... 15 The Nature of Fatigue ..............................

................................................... .............................. 15 Causes of Fatigue..................................

................................................... ..................................... 16 Fatigue and Transportation .........................

................................................... ............................... 17 Recent Findings on Fatigue and Occupational Perform ance............................................... ......... 19 ASRS...............................................

................................................... ....................................... 21 Effectiveness ......................................

................................................... .................................... 23 Quantitative Benefits..............................

................................................... ................................ 26 Base Case Estimate.................................

................................................... ................................... 32 High Case Estimate.................................

................................................... ................................... 33 Benefit Summary ....................................

................................................... ................................... 35 Cost Analysis ......................................

................................................... ....................................... 37 Flight Operations Cost .............................

................................................... .............................. 38 Note: Numbers may not sum to total due to rounding- off error.......................................... ......... 39 Crew Scheduling....................................

................................................... .................................... 39 Computer Programming...............................

................................................... .............................. 56 Cost Savings from Reducing Flightcrew Members Fatig ue................................................. ........ 57 Flight Operations Cost Summary.....................

................................................... .......................... 60 Rest Facilities ....................................

................................................... ..................................... 61 Engineering........................................

................................................... ........................................ 63 Installation.......................................

................................................... ........................................... 64 Downtime...........................................

................................................... ........................................ 65 Fuel Consumption Costs.............................

................................................... ............................... 65 Fatigue Training...................................

................................................... ...................................... 67 Cost Analysis Summary..............................

................................................... ........................... 68 Cost-Benefit Summary ...............................

................................................... ............................... 69 Accident Appendix ..................................

................................................... .................................. 70

## Disposition of Issues Raised by Comments

The following summarizes the FAA’s responses to the comments on the economic analysis. These responses address the most substant ive comments made in response to the Notice of Proposed Rulemaking (NPRM), including comments m ade by: Air Transportation Association (ATA), American Airlines, United Airlin es, Cargo Airline Association (CAA), Federal Express, United Parcel Service (UPS), Natio nal Air Carriers Association (NACA), Atlas Air Worldwide Holdings, Lynden Air Cargo, Omni Air International, Inc., and Southern Air, Inc. Commenters questioned the base year dollar and anal ysis period. The final rule analyzes current year (2011) with a two year delay in both b enefits and costs. The benefits and costs are presented in a ten year stream and we have provided sensitivity analysis based upon a discount rate of both 7% and 3%. A ten year analysis is suf ficient for the costs and benefits to be in a steady state. The FAA also received comments questioning the vali dity of the accident set. To address the criticism of using the historical twenty-year a nalysis period, the FAA narrowed the accident set to the most recent ten years. However, while t his approach addressed the issues raised by the commenters, narrowing of the analysis time period r educes the number of accidents/observations available for the benefit analysis. Consequently, while there is a sufficient accident basis to demonstrate a broad benefit basis justifying the co st of this rule, the sparse data does not permit accident analysis for every industry segment. 1 The benefit forecast includes the expected larger

1 As discussed in the Regulatory Impact Analysis, th e FAA was able to determine the societal benefit of applying this rule to all-cargo operations. The FAA ultimat ely concluded that this benefit did not justify the costs of requiring all-cargo operations to operate under par t 117.2

future airplanes and higher load factors. Even tho ugh the rate of accidents may have declined in the last ten years, the future consequences may wel l be more catastrophic. Commenters questioned that the historical accident rate is significantly higher than the probable accident rate for the period of analysis b ecause accidents have declined in recent years. The requirements contained in this final rule only address the rates of pilot fatigue. As Table 4 in the Regulatory Impact Analysis shows, th e preventable accident rate related to fatigue has not significantly decreased in the last ten yea rs. The Regulatory Impact Analysis also includes a listof appropriate accidents along with the final Commercial Aviation Safety Team (CAST) sc oring. The accident appendix includes detailed fatigue information and the reasoning behi nd the final CAST scoring. After considering the comments on the regulatory im pact analysis (RIA) for the NPRM, the FAA took a different approach to evaluate the f inal rule. In the analysis for the NPRM, the FAA attempted to show through statistical analysis and simulation that a broader fatigue problem existed than what could be shown through NTSB accid ent findings. In response to industry comments objecting to this approach, the FAA Office of Aviation Safety began by narrowing the set of accidents to those with a strong correlation to fatigue and hence narrowed the benefit analysis from a broader fatigue problem to the spec ific regulatory changes. As a result, the FAA re-examined every accident used in the NPRM and app lied the CAST methodology only to the accidents whose likelihood would have been reduced if the requirements in the final rule had been effective prior to the accident. Using this m ethodology, the FAA re-analyzed the effectiveness of the provisions in the final rule i n mitigating accidents where fatigue was identified as a factor in the accident, and removed accident cases that were not closely correlated with fatigue factors from the NPRM. From this exe rcise, a smaller set of accidents was3

determined appropriate for further economic analysi s of the final rule. With a smaller number of accidents, a simulation methodology was no longe r appropriate. Instead, the FAA used a commonly-used benefit methodology. This methodol ogy is grounded in NTSB findings, uses the CAST methodology, and is also transparent and e asily reproducible. The methodology is discussed in the full regulatory evaluation. Industry questioned the use of $12.6 million for a statistical life value. The use of $12.6 was for a sensitivity test. For t he final rule, the FAA uses the $6.2 million as the value of an averted fatality as used commonly by the Department of Transportation. Commenters also objected to the FAA’s assumptions regarding the 25% cost-savings resulting from long-term scheduling optimization in RIA. As the FAA stated in the RIA, the assumption of the long-term schedule optimization f actor was dropped because the operation cost was analyzed by the crew pairing optimizer. T his different approach estimates operation and scheduling cost of the final rule by building d uty and rest time restrictions changing from existing FAA regulations and industry scheduling da ta into a Cygnus, CrewPairing’s (CP) crew scheduling optimization model. Cygnus has been use d by more than 30 major airlines worldwide over the past 40 years and is currently u sed by a number of carriers. CP optimization used constraints contained in the final rule, pooli ng with the best available industrial data (wages, numbers of flightcrew members sourced from Form 41) , to estimate costs of the final rule. Commenters also contended that the FAA underestima ted the NPRM costs related to flight operation in that carriers would be forced t o hire new crewmembers and increase flight duty periods (FDP).4 The FAA has re-estimated the costs reflecting final rule modifications and used the

above-referenced crew scheduling model to better es timate whether the rule would force carriers to hire new crewmembers. The use of a crew pairing optimizer enabled FAA to more accurately model the impacts of the rule on industry crew sche duling costs than was possible during NPRM cost analysis. The data in the final rule RIA inc luded full bid line and pairing information for each flightcrew member, and included both line hold er and reserve flightcrew members. The crew pairing optimization did not show a need to hi re new crewmembers to comply with this rule because the flightcrew members currently used in re serve allow certificate holders to conduct operations under this rule without hiring additiona l flightcrew members. Commenters did not support the costs related to sch edule reliability and argued that they were underestimated. One commenter stated the cos ts would be as high as $9.6 billion. They argued that by excluding the cost of schedule buffe ring required by multiple provisions of the NPRM, the FAA omitted the major source of cost to t he industry. As stated elsewhere, the FAA has largely removed sc hedule reliability from this rule. The FAA has instead adopted provisions that limit e xtensions of the FDP and requires reporting of FDP extensions and activities that were not othe rwise permitted by the provisions of §117.11, §117.19 and §117.29 in the Final Rule. Under this amendment, costs to airline carriers are limited to reporting exceptional activities. As s uch, these costs are expected to be relatively minor. By dropping schedule reliability requirementand limiting the associated reporting burden to flight-duty-period (FDP) extension reporting req uirements, the cost in dispute by the commenters became a computer programming cost and w as estimated to be about one million dollars. Some commenters stated the appropriate average wage rate should be $297 per hour.5 The FAA notes this wage rate significantly contribu ted to the industry cost estimates.

The $297 per hour wage rate as an average is two ti mes the wage rate from Form 41 and four times the wage rate from the 2010 Census Bureau on the airline industry. Commenters also argued that the FAA underestimates fatigue training cost described in the NPRM. All carriers already are required to comply with Pu blic Law 111-216 Section 212(b)(2)(B) with respect to the fatigue risk manag ement plan and training (FRMP). In this final rule, the FAA removed the proposed requirement thatpilots receive additional fatigue training that is not required by the FRMP. As such, the FAA expects the cost of fatigue education and training to be largely reduced. The final rule doe s expand the fatigue education and training requirements to dispatchers and certain members of management. The FAA made this change because air carriers operating under 14 CFR part 12 1 will be in compliance with the statutory pilot training requirement as part of their FRMPs. Since the final rule extends fatigue training to management and dispatchers, it is expected to be ad ded to existing fatigue risk management education and training program. Numerous commenters stated that the FAA underestima ted the cost of rest facilities due to the loss of first class seating and out-of-servi ce time required for infrastructure installation. The FAA re-analyzed the facility cost based upon th e actual numbers and types of facilities that will need to be put in by querying the inspectors for the fleet of airplanes. The FAA assumed the worst case scenario (all class 1 fa cilities). The FAA recalculated the number of airplanes needing additional upgraded rest facil ities. Based on the existing fleet, the FAA estimates 332 airplanes will need class 1 facilitie s. In addition, the FAA re-estimated compliance costs of optimizing existing equipment a nd installing first class facilities. We have6

also estimated downtime and additional fuel burn co sts. The final rule rest facility costs include purchase, design and engineering, physical installa tion of the facilities on the affected aircraft, downtime impact on revenue, and fuel burn cost. Th erefore, the cost of rest facilities was estimated to the full extent in the final rule. The commenters stated that the FAA’s cost analysis does not factor in the costs of the cumulative limits. The FAA notes that all known co nstraints including existing monthly and annual constraints were imbedded in CP optimization

. The commenters submitted that the FAA assumed for t he NPRM that the industry’s collective bargaining agreements (CBAs) will be ren egotiated to permit carriers to adapt to the new rules without any additional costs to the carri ers and also assumes that any short term costs that result from conflicts between the new rule and existing CBAs should not be “counted” as part of the NPRM. The final rule does not require renegotiation of cu rrent CBAs. In the final rule the FAA did not calculate potential gains based on the rene gotiation of CBAs. The final rule will give two years buffer for carriers to implement all provisio ns. The FAA still believes that CBA negotiations could result in a change of economic i nterests between carriers and crewmembers. Any such change is a transfer of benefits and costs between carriers and bargaining units. Such transfers would be negotiated between parties and t ransfers do not change the total cost and benefits to society. Many entities conducting supplemental operations st ated that the rule would cause the nature of their operations to significantly change, which would result in lost revenue opportunities or much higher cost, or both.7 The FAA adopted significant modifications in the fi nal rule to mitigate the impact on

supplemental operations. For example, in the fina l rule, the FAA made compliance with part 117 voluntary for all-cargo operations. With regar d to supplemental passenger operations, the FAA increased both the augmented and unaugmented FD P limits from the NPRM. The FAA also increased the split-duty credit and made that credit easier to obtain. In addition, the FAA notes that section 119.55 provides the mechanism to obtain deviation from existing regulations for military missions. Taken together the FAA has provided substantial flexibility for supplemental operations, and as a result, permits m ost existing revenue opportunities relative to flight safety risks based on past ten years of NTSB accident findings. The commenters contend that the FAA assumes, withou t any evidence, that there will be a reduction in absenteeism due to “improved fatigue management,” and that reduced absenteeism costs will offset part of the cost of the NPRM. The FAA believes that the final rule will improve p roductivity and reduce absenteeism by the enhanced fatigue management system. CDC’s rese arch shows that chronic fatigue can cause illness and even death 2 . Comments and data received from Air Line Pilots A ssociation (ALPA), the largest independent pilots’ union in the world, devoting more than 20 percent of its dues income to support aviation safety, validated the FA A’s estimation of cost saving from reducing flight-crew members fatigue and absenteeism. Commenters questioned that there is no justificatio n provided that sick leave use will be reduced by 5%. The FAA has verified this number wit h labor representatives and the supporting document verifying this information can be found in the docket.

2 CDC’ s MMWR, Weekly, February 29, 2008 / 57(08);200-2038 Commenters contended that accidents involving two p ilots and a flight engineer should

be analyzed separately because in the modern era al most all flights are operated without a flight engineer. This rule does not distinguish between accidents in volving a flight engineer and accidents without a flight engineer because it is difficult t o attribute specific amounts of fatigue and accident causality to a flight engineer. More spec ifically, it is difficult to predict in a fatiguerelated accident, how the two pilots would have han dled the aircraft in question if a flight engineer had not been present. As such, because it is unclear how much flight-engineer fatigue contributed to past accidents and that this rule do es not prohibit flight engineers from working on the flight deck, the Regulatory Impact Analysis use d for this rule does not distinguish between accidents involving two pilots and those involving a flight engineer. Some commenters stated that the FAA simply ignores flight cancellation costs despite the fact that the NPRM will result in substantial incre ases in flight cancellations. As discussed above, the FAA calculated the scheduli ng costs of this rule by running the pertinent data through the Cygnus crew scheduling o ptimization model. The Cygnus model did not indicate that there would be an increase in can cellations as a result of the changes imposed by this rule. This is because certificate holders will be able to use their existing staff members to cover the scheduled flights. It was argued by commenters that by excluding the c ost of schedule buffering required by multiple provisions of the NPRM, the FAA has omitte d the major source of cost to the industry. There are a few major changes related to crew sched uling made in the final rule from NPRM, which significantly reduced the cost to the i ndustry. The pertinent changes from the NPRM are: (1) a flight extension for unexpected cir cumstances that arise after takeoff, and (2)9

the removal of the requirement that “circumstances beyond the control of the certificate holder” have to be present in order to utilize the 2-hour F DP extension for certain unforeseen operational circumstances. Using the crew pairing optimizer to simulate operation schedule, costs that attributable to the final rule were estimated to th e full extent, including the cost of schedule buffering. The commenters further stated that the FAA has omit ted the cost estimation attributable to the provision of “three consecutive nights” (sec tion 117.27, NPRM), which is more likely to impact cargo carriers partly because they have a su bstantial concentration of operation during the night time period and flight crew that are accustom ed to night time operations. As an initial matter, the FAA notes that, based on the cost-benefit analysis, all-cargo operations are not required to operate under part 1 17. However, based on industry comments the FAA has mitigated the burden to cargo operators who may choose to operate under part 117 by reducing (to two hours) the length of “mid-duty res t” that is necessary to schedule five consecutive nighttime FDPs. Moreover, UPS and FedEx stated in their comments that they currently provide their flightcrew members with a m id-duty breaks that are, on average, two hours long. Because the final rule permits five co nsecutive nights with two-hour breaks, the impact of the consecutive-night provision on all-ca rgo operators such as UPS and FedEx will be minimal. The commenters also argued that, under the FAA’s c ost-benefit methodology, there is no benefit to limiting duty time below 15 hours.
The FAA agrees the risk of accident prevalence in the 15 th hour block and beyond is much greater than that associated with duty times s hort of the 15 th hour block. To evaluate this proposition, the FAA computed ratios of accidents t o exposure duty hours (dividing accidents in10

a sequence of flight hour blocks by pilot exposure duty hours), which substantiated the conclusion that accident risk steeply increases in the 15 th hour block and beyond. However, the FAA has also determined that FDPs of less than 15 h ours can lead to unacceptably high accident risk. For example, the statistic evidence indicate s that the ratios of accidents to block hour rises in a fast rate in the 13 th to 14 th hour block range. Therefore, the regulation of fl ight duty time being limited under the 15 th hour block is necessary and beneficial.
Allied Pilots Association (APA) generally supported the NPRM but stated that the FAA overestimated computer programming cost, fatigue tr aining costs due to overstated training pay and rest facility installation costs. In addition, APA commented that the FAA underestimated the schedule optimization factor and the agility of air carriers when motivated to achieve efficiency.
The computer programing cost is a very small compon ent of airline operation cost. Since the computer programming cost was estimated based o n the market pricing, it was adjusted slightly lower or at about the same level as the FA A gained more accurate market data than that used for NPRM through its software providers. Over all, the operation cost in the final rule was revised and turned out to be lower than that of NPR M. Fatigue training costs was revised to be lower than that of NPRM because of the changes made to the proposed fatigue training requirements by the final rule. The revised rest f acility installation cost was also lower than that of NPRM. APA’s comment on the overestimation of t he NPRM cost was based on the assumption that long-term optimization will occur a t much faster rate than implicit in the cost analysis, which would result in more savings in the long run than that in the short run. The FAA agrees that long-term optimization of air carriers could be greater than expected. The FAA believes that the crew scheduling optimizer program provides a better estimate to the final rule.11

Therefore, the FAA believes that the final rule cos t estimates incorporating crew scheduling optimization model accurately reflect the complianc e costs. ATA's Oliver Wyman analysis on September 14, 2011 , “Estimated Job Loss Resulting from Flightcrew Member Duty and Rest Requirements” attached to the ATA petition on Flight, Duty and Rest asserted that the proposed rule would cause nearly 17,000 U.S. airline jobs, which would result in total job losses to the economy of 398,000 jobs. The FAA believes that ATA’s analysis of the jobs i mpact from the proposed Flight, Rest and Duty rule is inaccurate. ATA’s jobs impact ana lysis is based on its estimate, derived from its analysis of the NPRM, that this rule will cost $19.6 billion over a 10-year period. However, many of the major provisions of the final rule have been significantly altered from the NPRM, and, as discussed elsewhere, the FAA estimates thatthe final rule will cost approximately $390 million over 10 years. This $390 million cost is s ignificantly smaller than the $19.6 billion cost on which ATA based its job impact analysis. CrewPa iring’s analysis of the final rule results in no change in pilot employment. Therefore, the FAA d oes not agree with ATA’s job impact findings. With regard to the accidents that were used to calc ulate the benefits for this rule, some commenters stated that the ATI 2/16/95 flight (RT2) was a part 91 ferry flight, and that the issues leading to that flight’s accident have been address ed by other rulemakings. Consequently, the commenters assert, this flight would not be permitt ed under current rules. This comment refers to an accident involving ATI in Kansas City during a nighttime Part 91 engine-out ferry flight in a 4-engine DC-8. Pri or to takeoff, the Flight Engineer (FE) had improperly determined the minimum control speed on the ground (VMCG), which produced a value that was 9 knots too low. On the first takeo ff attempt, the pilot applied power too soon to12

the “asymmetrical engine” (the serviceable engine o n the side with the failed engine) and was unable to maintain directional control during the t akeoff roll. He rejected the takeoff and, in preparation for a second takeoff, the pilot agreed to have the FE advance the throttle on the next takeoff attempt. This conflicted with the prescrib ed procedure. At 3,215 feet into the takeoff roll, the DC-8 start ed to veer to the left. At 3.806 feet, the aircraft rotated with a tail strike but the tail re mained in contact with the runway for another 820 feet. At 5,250 feet, the aircraft became airborne and climbed to 100 feet, then sank and crashed. All 3 crew members were killed. NTSB focused on 2 core issues. First, NTSB found t hat the crew was flying after a shortened rest break, since rest periods were not r equired for ferry flights. According to the report, the crew was fatigued from lack of rest and lack of sleep, and from disrupted circadian rhythms. Second, NTSB found that the crew did not have adequate, realistic training in techniques or procedures for a 3-engine takeoff. N TSB added that the crew did not adequately understand 3-engine takeoff, and did not adequately understand the significance of VMCG. In response to an NTSB recommendation related to tr aining crews for a 3-engine takeoff ((A-95-39), FAA issued a Flight Standards Informati on Bulletin (FSIB). The FSIB directed FAA principal operations inspectors to inform their respective operators to take additional measures to ensure: (1) that aircraft manual requir ements for engine-out ferry flights are clear; (2) that crew training segments are clearly outline d for engine-out operations; and (3) that operators use only crews specifically trained and c ertified for engine-out operations. This has become FAA policy and NTSB found the action accepta ble and closed the recommendation. Consequently, the comment is appropriate to the deg ree that it addresses the issue of training, which is not part of the proposed rule. However, FAA believes that this flight also13

illustrates the role and risks associated with fati gue, which the FSIB noted above did not address. With or without training in 3-engine takeoffs, NTSB ’s findings on fatigue in this accident remain pertinent to this rulemaking.



## Benefit/Cost Summary
We have analyzed the benefits and the costs associa ted with the requirements contained in this final rule and our estimates are summarized in table 1. The FAA has made significant changes to the final rule since the NPRM. The trai ning requirement has been substantially reduced because the FAA has determined that pilots are already receiving the requisite training as part of the statutorily required Fatigue Risk Ma nagement Plans. The FAA also has removed all-cargo operations from the applicability section of the new part 117 because their compliance costs significantly exceed the quantified societal benefits. 3 All-cargo carriers may choose to comply with the new part 117 but are not required t o do so. Since the carrier would decide voluntarily to comply with the new requirements, th ose costs are not attributed to the costs of this rule. The costs associated with the rest faci lities occur in the two years after the rule is published. The other costs of the rule and the ben efits are then estimated over the next ten years. We provide a range of estimates for our quantitativ e benefits. Our base case estimate is $376 million ($247 million present value at 7% and $311 million at 3%) and our high case estimate is $716 million ($470 million present valu e at 7% and $593 million at 3%). The total

3 The projected cost for all-cargo operations is $30 6 million ($214 million present value at 7% and $25 2 million at 3%). The projected benefit of avoiding one fatal a ll-cargo accident ranges between $20.35 million and $32.55 million, depending on the number of crewmembers on board the aircraft.14

estimated cost of the final rule is $390 million ($ 297 million present value at 7% and $338 million at 3%). Table 1: Summary of Benefits and Costs Total Benefits over 10 Years

Estimate Nominal

(millions) PV at 7%

(millions) PV at 3%

(millions) Base $ 376 $ 247 $ 311 High $ 716 $ 470 $ 593

Total Costs over 10 Years
Component Nominal

(millions) PV at 7%

(millions) PV at 3%

(millions) Flight Operations $236 $157 $191 Rest Facilities $138 $129 $134 Training $16 $11 $13 Total $390 $297 $33815



## Benefit Analysis
This rule is intended to address the problem of fat igued pilots flying in Part 121 commercial service. The nature and extent of the pr oblem is such that the NTSB continues to list pilot fatigue as one of the Most Wanted Transportat ion Safety Improvements. The NTSB recommendations are based on accident investigation s and the NTSB safety study on airline safety. The requirements contained in this final ru le address both NTSB recommendations and existing public law. This benefit estimate first e xamines the nature of fatigue, followed by its causes and how it relates to transportation. Second , we summarize some recent findings on fatigue and occupational performance. Next, we look at the magnitude of crew fatigue in Part 121 passenger operations by briefly examining fatig ue reports in the context of this final rule. We then re-analyze the likely effectiveness of the requirements contained in this final rule and the potential to decrease these types of accidents in the future. We project a likely number of preventable events that will occur in absence of th is final rule. Finally, we estimate the benefits that will be derived from preventing such events. We provide a base case estimate, and a high case estimate, in addition to a threshold/break eve n analysis. 

### The Nature of Fatigue Most fatigue studies agree that, “fatigue refers to a subjective desire to rest and an aversion to further work, coupled with an objective decrease in performance.” 4

4 Jones, et al., “Working hours regulations and fati gue in transportation: A comparative analysis,” **Safety Science** , Vol. 43, 2005.16

Fatigue is characterized by:

• “increasingly frequent lapses in performance,

• general cognitive slowing, including a lowering of optimum performance,

• memory problems,

• time on task decrements, and

• an increasing inability to maintain the vigilance r equired to perform the tasks required.” 5 Fatigue has been described as “a nonspecific sympt om because it can be indicative of many causes or conditions including physiological s tates such as sleep deprivation....[s]ome describe fatigue in terms of physiological data or ‘objective’ observations of...decrements in work or performance....or time-related deterioration in the ability to perform certain mental tasks.” 6 While physiological criteria related to fatigue c an be readily measureable, subjective feelings of fatigue are not directly observable, an d in some instances individuals who are exhibiting diminished performance levels also feel confident in their ability to focus and perform assigned tasks.


### Causes of Fatigue A number of factors increase the risk of fatigue. T hese include:

• Time of day is very important, because the body fol lows a rhythm over an approximately 24 hour period, often referred to as a circadian cy cle

5 Jones, et al., “Working hours regulations and fati gue in transportation: A comparative analysis,” **Safety Science** , Vol. 43, 2005. 6 Torres-Harding, Susan and Leonard A. Jason, “What is Fatigue? History and Epidemiology,” **Fatigue as a Window to the Brain**  , edited by John DeLuca. The MIT Press, 3-18, 2007

.17 • The amount of recent sleep that a person has receiv ed also affects the level of fatigue

risk; most people need an average of eight hours of sleep per 24 hour period.

• The number of continuous hours awake also increases fatigue risk, and for most individuals, once the number of continuous hours aw ake exceeds 17, fatigue risk increases significantly.

• Sleep debt, the difference between the amount of sl eep needed to be fully rested and actual sleep, also contributes to fatigue. Sleep d ebt accumulates over time, and fatigue risk is higher if sleep debt exceeds eight hours

• Work load and time on task can also affect fatigue risk. If work intensity is high and/or there is a long continuous period of time on task, the risk of fatigue increases.


### Fatigue and Transportation The nature of work in the transportation sector mak es that sector especially susceptible to risks to performance, vigilance and response to haz ards that are associated with fatigue. Workdays of those responsible for the safety of tra nsportation operations can be characterized by long work periods, often at nighttime or early morn ing hours. Because transportation workers must sometimes rest or sleep away from home, condit ions for rest and sleep quality are also important. Analysts have examined the links between the specif ic features of work in the transportation industry, including commercial aviat ion, and the general features of human physiology and fatigue for decades. For commercial aviation, it has been nearly two decades since the first citation of fatigue as a probable c ause for a major aviation accident. This accident, the crash of American International Airways flight 808 at Guantanamo Naval Air Station, Cuba, on August 18, 1993, was investigated by the Nationa l Transportation Safety Board. Probable18

causes of the accident identified by the NTSB inclu ded “the impaired judgment, decision making, and flying abilities of the captain and fli ghtcrew due to the effects of fatigue...” As part of the investigation of that accident, NASA researchers and contractors performed an analysis of the links between aviation risks and th e effects of fatigue on human vigilance and performance. This research was reported as part of the NTSB report on the Guantanamo Bay accident 7 and later revised for inclusion in an NTSB report on U.S. Department of Transportation efforts to address fatigue issues in Transportation

. 8 This NTSB research and literature summary provides a thorough and well-documented review of these issues. In the 1999 restatement of the research results in the context of addressing fatigue issues in transportation general ly, the following summary is provided: Fatigue, sleep loss and circadian disruption create d by transportation operations can degrade performance, alertness and safety. An extensive sc ientific literature exists that provides important physiological information about the human operator, which can be used to guide operations and policy. For example, there are huma n physiological requirements for sleep, predictable effects of sleep loss on performance an d alertness and patterns for recovery from sleep loss. Additionally, the circadian clock is a powerful modulator of human performance and alertness, and in transportation operations, it can be disrupted by night work, time zone changes, and day/night duty shifts. Scientific examination of these physiological considerations has

7 Rosekind, et.al.,”Appendix E: Analysis of Crew Fat igue Factors,” Aircraft Accident Report: Uncontroll ed collision with Terrain, American International Airways flight 808, Douglas DC-8-61, N814CK, U.S. Naval Air Stati on, Guantanamo Bay,Cuba, August 18, 1993. Washington D .C., NTSB Report AAR-94/04, pp. 133-144. http://humanfactors.arc.nasa.gov/zteam/PDF_pubs/G_Bay/Guantanam oBay.pdf 8 Rosekind, et.al., “Appendix C: Summary of Sleep an d Circadian Rhythms,” **Evaluation of U.S. Department of Transportation Efforts in the 1990s to Address Oper**  **ator Fatigue.** Washington D.C. NTSB Safety Report NTSB/SR99/01, May 1999, pp.67-81. http://www3.ntsb.gov/publictn/1999/sr9901.pdf19

documented a direct relationship to errors, acciden ts and safety. This scientific information can provide important input to policy and regulatory co nsiderations.


### Recent Findings on Fatigue and Occupational Perform ance Fatigue is prevalent in the U.S. workforce, with ne arly 38 percent of workers in a study reporting fatigue during a two-week period. 9 The National Sleep Foundation conducted a poll in 2008, which found that 29 percent have fallen asleep or b ecome very sleepy while at work and two percent did not go to work due to sleepiness or a s leep problem. 10 Numerous studies have found that fatigue can significantly reduce productivity. A review of published studies on shift work and productivity found a large decrease in efficien cy during the night shift, with the low occurring at 3:00AM. On average, the authors found that productivity was five percent lower at night. 11 A large scale study was conducted at 40 companies a nd institutions in the Netherlands to investigate the relationship between fatigue and fu ture sickness absence. The presence of fatigue was measured using self-reported symptoms, with emp loyers providing absence data. The study controlled for numerous socio demographic and work characteristics. The investigators found that higher levels of fatigue were statistically si gnificant predictors of both short-term and longterm sickness absence. 12

9 Ricci, et al., “Fatigue in the U.S. workforce: prev alence, and implications for lost productive work t ime,” **Occup Environ Med**  , Vol. 49(1): 1-10, 2007. 10 National Sleep Foundation, “2008 Sleep in America Poll: Summary of Findings.” 11 Folkard and Tucker, “Shift work, safety and produc tivity,” **Occupational Medicine** , Vol. 53, 2003. 12 Janssen, et al., “Fatigue as a predictor of sickne ss absence: results from the Maastricht cohort stud y on fatigue at work,” **Occup Environ Med** , 2003, 60(Suppl I): i71-i76.20 A study was conducted to estimate fatigue prevalenc e and associated health-related lost

productive time (LPT) in U.S. workers. The investi gators found that workers with fatigue were much more likely to report health-related LPT, with a cost of $136.4 billion annually. This amount exceeded health-related LPT reported by work ers without fatigue by $101.0 billion. A study compared the rate of errors made by medical residents working in the ICU on 80 hour weeks versus those on 63 hour weeks. The residents with the shorter work week schedule experienced half the rate of attention failures. T he residents with the longer work week schedule made serious medical errors (those causing or havin g the potential to cause harm to a patient) at a rate 22 percent higher than the residents with th e shorter work week schedule. 13 The railroad industry is at a relatively high risk of fatigue, due to typical 24 hour per day operations. A number of railroads have implemented fatigue countermeasures, which generally reduced absenteeism. For instance, after implement ation of fatigue countermeasures for CANALERT, absenteeism decreased from 8.1 to 3.2 per cent. After fatigue countermeasures were implemented for the Conrail-Buffalo-Toledo IMP AC project, a statistically significant increase in attendance from 95.21 percent to 98.06 percent was observed. 14 This data demonstrates the potential for fatigue issues, whic h we will now examine within the specific requirements of this final rule.

13 Board on Health Sciences Policy, “Sleep Disorders and Sleep Deprivation: An Unmet Public Health Probl em,” **The National Academies Press**  , 2006. 14 Sherry, “Fatigue Countermeasures in the Railroad I ndustry: Past and Current Developments,” **Association of American Railroads**  , 2000.21



### ASRS One can observe fatigue in aviation by examining th e Aviation Safety Reporting System (ASRS). The ASRS collects, analyzes, and responds to voluntarily submitted aviation safety incident reports in order to lessen the likelihood of aviation accidents. It is part of a continuing effort by government, industry, and individuals to maintain and improve aviation safety by collecting voluntarily submitted aviation safety in cident/situation reports from pilots, controllers, and others . The data in the ASRS is used to:

• Identify deficiencies and discrepancies in the Nati onal Aviation System (NAS) so that these can be remedied by appropriate authorities.

• Support policy formulation and planning for, and im provements to, the NAS.

• Strengthen the foundation of aviation human factors safety research. This is particularly important since it is generally conceded that over two-thirds of all aviation accidents and incidents have their roots in human performance err ors. ASRS assures confidentiality and data cannot be tra ced back to individual operators. So although we cannot claim the rule could prevent spe cific ASRS events, it is a useful tool in evaluating and validating the presence of fatigue i n Part 121 operations. We performed a query for Part 121 ASRS for Fatigue 15 . Since June of 2009, there were a total of 256 re ports where fatigue was cited as a factor. We have neither cul led the data nor edited any of the data that was reported to ASRS. The top seven results are listed in Table 2.

15 We believe that this is a very conservative assump tion because other human factors can reveal fatigue , such as confusion and communications breakdown.22 Table 2: ASRS Part 121 Fatigue Reports

Result Total Relative % General None Reported / Taken (No action was taken as a result of the fatigue issue reported) 68 26.6%
General Work Refused (Fatigue caused a worker to re fuse an assignment) 21 8.2% General Maintenance Action (Typically a fatigue eve nt related to a maintenance issue—not related to this final rule). 14 5.5% Flight Crew Became Reoriented (Confusion related to some type of malfunction.) 10 3.9% Flight Crew Took Evasive Action (Crew took action t o avoid an accident or incident) 8 3.1%
Air Traffic Control Issued New Clearance (Substitut e clearance given to get back on track) 5 2.0%

Flight Crew Executed Go Around / Missed Approach 5 2.0% One captain on an international flight described an onerous flight sequence in the Pacific he believed to be unsafe due to cumulative and predict able fatigue: “This report concerns a trans-Pacific flight assign ment including back to back all night pairings (body clock), two un-augmented inter-Asia segments and 36 hours of flight time. We started the sequence with a 12.7 hour actual flight, single augmented with an hour plus delay on the front end. When we arrived we cabbed to downtown fo r an additional 1.5 hours on the body before rest. The first internal Asia leg is all nig ht, un-augmented. The return leg is daylight-but all night body time-followed by another 1.5 hour ca b ride downtown. The [opportunities for] rest were insufficient to maintain any alertness pa rticularly on the last leg. Both the First Officer and I experienced periods of unintended sle ep while at the controls. No amount of coffee or mental discipline was sufficient to stay awake!!! This is unsafe and made more unsafe by requiring: 1. Over 12 hours single augmented on the first leg. 2. Two un-augmented legs on the back side of the clock with long preflight awak e hours. 3. Over 8 extra hours of "duty time" in CABS!!! Rework this trip before someone gets hur t. No one in the cockpit for the last 623

hours was at their peak to respond to irregular sit uations. We weren't even able to stay awake the whole time in the seat”. Even if no anomalies occur during a flight, a fatig ued crew may be poorer problem solvers than well-rested crews as noted in the rese arch cited above, and thus add a degree of risk to the system. In addition, taking evasive action a nd missed approaches because of fatigue are serious safety events indicating substantial risk m anifesting in the current system. 

### Effectiveness It is usually the case that multiple factors can be identified as causes of specific accidents, and it is seldom the case that a specific rule is 1 00 percent effective at addressing a variety of accident causal factors. In particular, fatigue is rarely a primary or sole cause of an accident, and therefore this final rule will not likely prevent a ll future fatigue related accidents. For this fina l regulatory evaluation, we have established a modifi ed effectiveness ratio to categorize accidents for which fatigue may be a contributing causal fact or. This number represents the likelihood the requirements contained in this final rule would hav e prevented an accident from occurring. It is applied in the calculation of the number of forecas ted fatigue accidents, if no action was taken to address the fatigue problem in Part 121 operations. In its analysis of the effectiveness of the final r ule, the FAA reviewed accidents that could have been prevented or could have been influe nced by the requirements contained in this final rule. The effectiveness analysis works by as sessing the likely capability of the requirements contained in the final rule to have pr evented those accidents. As part of this analysis, the Office of Accident Investigation revi ewed the accident reports from NTSB and foreign investigative authorities on all accidents where the NTSB cited fatigue or fatigue was thought to be either a cause or factor. This was d one in order to assess the likelihood that the24

provisions of the final rule would have averted tho se accidents (including positioning flights operating under Part 91). A consistent definition was applied to the 20-year history as the requirements of the rule apply to all Part 121 operations. As such, we revie wed the accident history for all operations that would currently operate under Part 121. The final analysis will take into account NTSB findings, FAA’s independent assessment, and comment s to the docket. Some accidents reviewed scored “zero” because fatigue could not be establis hed as a significant factor or because the final rule would not prevent such an event had the requir ements been in place today. These accidents were removed from our effectiveness analysis and fo recast. Because this final rule does not mandate compliance with Part 117 for all-cargo oper ations, we also removed them from our final analysis. Anticipated costs and benefits for these operations, were the rule to apply on a mandatory basis, are provided in footnotes to the r elevant discussions in this document. Each accident was then re-evaluated by conducting a scoring process similar to that conducted by the Commercial Aviation Safety Team (C AST), a well-documented and well understood procedure, similar to the NPRM. The FAA Office of Accident Investigation used the NTSB recommendations along with narratives, probabl e cause, contributing factors and other pertinent data to score the accidents. When these accidents were not well defined in the probable cause or contributing factors statements of the NTS B reports, Accident Investigation used a Joint Implementation Monitoring Data Analysis Team (JIMDA T)-like method. The JIMDAT-type scoring system is from 0 to 5, and the score is bas ed on the likelihood that a proposed action would have mitigated that accident. The level and percentage of effectiveness criteria are detailed in Table 3.25 Table 3: JIMDAT-Type Scoring System

5 90% effectiveness. The proposed requirement dire ctly addresses the NTSB causal factors and would very likely prevent the accident in the f uture. 4 75% effectiveness. The proposed requirement direct ly addresses the majority of the NTSB causal factors and would probably prevent or i s likely to reduce the risk of the respective accident, given the circumstances that p revailed. 3 50 % effectiveness. The proposed requirement direc tly addresses one of several NTSB causal factors and is likely to reduce the risk of the respective accident, given the circumstances that prevailed. 2 35% effectiveness. The proposed requirement genera lly addresses the NTSB causal factors and is likely reduce the risk of the respec tive accident, given the circumstances that prevailed. 1 15% effectiveness. The proposed requirement is l ikely to have reduced the risk of the respective accident, given the circumstances that p revailed. 0 0% effectiveness. The proposed requirement would not reduce the risk of this type of accident in the future.
FAA applied this methodology to each pilot fatigue accident to reach an overall effectiveness ratio for the requirements contained in this final rule. The qualitative assessments ranged from zero (0) to low (1), moderate (3), high (4) and very high (5). The qualitative assessments then were converted to quantitative eff ectiveness scores as follows: zero; 15%; 35%; 50%; 75%; and 90%. For this analysis, the FAA presents the quantified benefits and effectiveness analysis for a 10-year period that parallels the cost analysis. A lthough we only forecast ten years of benefits, we have included a twenty year history of accidents , as these are the circumstances and events which have led to this final rulemaking. Table 4 su mmarizes the past twenty years of pilot fatigue accidents. The appendices contain a summary of each accident and the corresponding effectiveness analyses.26 Table 4: 20 Year Accident History

Date Location Service Carrier A/C On Bd Ftl Ser Damage Scenario Score

07/02/1994 Charlotte, NC 121 Pax US Air MD-82 57 37 16 Dest LOC on Approach; Icing 0.15
02/16/1995 Kansas City,

MO Ferry ATI DC-8-63 3 3 0 Dest LOC in RTO; Engine Out 0.9
12/20/1995 Cali,

Colombia 121 Pax American B757 164 160 4 Dest CFIT High 0.35 08/25/1996 JFK, NY 121 Pax TWA L1011 262 0 0 Sub Tail Strike Landing 0.35 01/22/1999 Hyannis, MA Positioning Colgan Air (Part 91) BE-1900 4 0 0 Dest Hard Landing (BETA) 0.15 05/08/1999 JFK, NY 121 Pax American Eagle SF34 30 0 1 Sub RE Landing 0.5
06/01/1999 Little Rock,

AR 121 Pax American MD-82 145 11 45 Dest RE Landing 0. 15

10/19/2004 Kirksville,

MO 121 Pax Corporate Airlines as American Connexion BAE-32 15 13 2 Dest CFIT Low on Approach 0.75

08/27/2006 Lexington,

KY 121 Pax Comair as Delta Connection CRJ-200 50 49 1 Dest Wrong Runway T/O 0.35

02/18/2007 Cleveland,

OH 121 Pax Shuttle America as Delta Connection ERJ-170 74 0 0 Sub RE Landing 0.5

04/12/2007 Traverse City,

MI 121 Pax Pinnacle as NW Express CRJ-200 52 0 0 Sub RE Landing 0.9 06/20/2007 Laramie, WY 121 Pax Great Lakes BE-1900 11 0 0 Sub LOC Bounced Landing 0.15 02/12/2009 Buffalo 121 Pax Colgan Air DHC-8- Q400 49 50 0 Dest LOC In Flight; RE Landing 0.5 Average 52.5%



### Quantitative Benefits James Reason characterizes major accidents and cata strophic system failures as the consequences of multiple, smaller failures that lea d up to the actual accident. It is a “Swiss27

cheese” model of human error 16 and also a sequential theory of accident causation . Reason’s model describes four levels of human failure, each one influencing the next. O rganizational influences lead to instances of unsafe supervision which in turn lead to preconditions for unsafe

acts and ultimately the unsafe acts of operators . The unsafe acts of operators are where most accident investigations are focused. It is a useful framework to illustrate how analyses of major accidents and catastrophic systems failures tend to reveal multiple, smaller failures leading up to the actual accident. The chances of the exact same circumstances happening again and causing the “same accident” are virtually nil but the possi bility of preventing a similar set of circumstances is real. This sequential “Swiss cheese” formulation is a ver y appropriate tool for characterizing the circumstances leading up to accidents. The nat ure of fatigue is such that actions, reactions and the thought processes of fatigued crews are mor e susceptible to the types of cascading errors of judgment described in the Reason model of catast rophic failure. The requirements contained in this final rule will decrease pilot fatigue and therefore the accompanying accidents that are associated with fatigue. While it is very difficultto accurately attribute all past accidents to one or more causes indisputably, we have developed the average effectiveness measure to apply to the estimates and recognize that there are addition al uncertainties with preventing a future fatigue related event. First, we examine an accide nt that occurred on October 19, 2004:

At about 1937 central daylight time, Corporate Airl ines a BAE Systems BAE-J3201, struck trees on final approach and crashed short of runway 36 at Kirksville Regional Airport, in

16 Reason, 199028

Kirksville, Missouri. The captain, first officer, a nd 11 of the 13 passengers were fatally injured, and 2 passengers received serious injuries. The airplane was destroyed by impact and a postimpact fire. 17
Re search and accident history indic ate that fatigue can ca u se pilot s to make ri sky, impul s ive decisions, to become fixated on one aspect of a s itua tion, and to react s lo w ly to warnings or signs that an approach s hould be discontinued. Fatigue especially affects decision making , and research shows t hat people w ho are fatigued be co me le ss able to consider options and are more likel y to become fixated on a course of action or a de s ired outcome. A fatigued pilot might fail to discontinue a flawed approach or might make a risky de c i sion to continue a dangerous approach. The fatigued crew reported for duty at 0514. The ac cident was near end of 6th sector on a 'demanding' day. Crew had been on duty 14.5 hours a nd the PIC is said to have slept poorly night before. The captain was observed resting on a sma ll couch in the company crew room ; however , the quality of rest the captain obtained during this time could not be determined. Company pilot s
state d that the crew room was a noi sy meeting area that was not ide a l for sleeping. Additionally, the pilots' high workload during thei r long d ay ma y have in creased their fatigue. The acc iden t occurred during the s ixth flight s egment of the day while the pilots were

17 The NTSB evaluated fatigue as a possible factor in this accident and looked at the various circumstan ces present the day of the accident that might have contributed to the pilots’ fatigue. The pilots’ available res t time (from about 2100 to 0400) did not correspond favorably wi th either pilots’ reported usual sleeping hours, re sulting in much earlier than normal times to go to sleep and a waken. Additionally, the early wakeup call times w ould have been challenging to both pilots because the human b ody is normally physiologically primed to sleep bet ween 0300 and 0500.29

performing a non-precision approach in lo w cei lings and reduced visibility. The pilot deficiencies observed in this accident are co nsi ste nt with fatigue imp a irment. Similarly, although the fir st officer 's junior stat us wi th the co mpan y ma y have been an
i ss ue in hi s failure to cha llenge the captain during the approach, he may also have been suffering from fatigue; his failure to mon i tor and react to the captain's deviat i ons from non-precision approach procedures was consistent with the degrading effects (slowed reactions and/or tunne l vision) of fat i gue. The Safety Board concluded that , on the basis of the l ess than optimal overnight rest time available , the early reporting time for duty , the length of the duty day , the number of flight legs , the demanding conditions (non-prec i sion instrument approaches flown manually in conditions of
l ow ceilings and reduced v i sib i lities) encountered during the long duty day (an d the two previous day s), it i s likely that fatigue contr i buted to the pilots ' degraded performance and decisionmaking. Another fatigue related accident occurred in Traver se City, Michigan on April 12, 2007. The accident occurred well after midnight at the en d of a demanding day during which the pilots had flown 8.35 hours, made five landings, had been on duty more than 14 hours, and been awake more than 16 hours. During the accident flight, the CVR recorded numerous yawns and comments that indicate that the pilots were fatigue d. Additionally, the captain made references to being tired at 2332:12, 2341:53, and 0018:43, and t he first officer stated, “jeez, I’m tired” at 0020:41. Additionally, the pilots’ high workload (f lying in inclement weather conditions, and in the captain’s case, providing operating experience for the first officer) during their long day likely increased their fatigue. The aircraft ran o ff the departure end of the runway during snowy30

conditions. Although there were no injuries among t he 49 passengers, the aircraft was substantially damaged. As we observe a clear accident history and the acco mpanying science dealing with fatigue, it is apparent that fatigue threatens avia tion safety by increasing the risk of pilot error that could lead to an accident. Fatigue is charact erized by a general lack of alertness and degradation in mental and physical performance. Fa tigue manifests in the aviation context not only when pilots fall asleep in the cockpit while c ruising, but perhaps more importantly, when they are insufficiently alert during take-off and l anding. Each flight segment that is flown by a flightcrew member includes a takeoff and a landing, which are the most task and safety-intensive parts of the flight. A flightcrew member whose fli ght duty period (FDP) consists of a single flight segment only has to perform one takeoff and landing, while a flightcrew member whose FDP consists of six flight segments will have to pe rform six sets of takeoffs and landings. Because takeoffs and landings are extremely task-in tensive, it logically follows that a flightcrew member who has performed six sets of takeoffs and l andings will be more fatigued than the flightcrew member who has performed only one takeof f and landing. Reported fatigue-related events have included procedural errors, unstable ap proaches, lining up with the wrong runway, and landing without clearances. As such, a fatigue d crew is dangerous no matter what “type” or segment of operation is examined and the requiremen ts in this final rule will eliminate the distinctions between various operations. As we have shown, in an airplane accident, there is a series of errors (both causes and factors) that contribute to an accident. Accident scenarios can vary greatly depending on phase of flight, the type of operation, phase of flight a nd size of the airplane. While pilot fatigue can occur during any stage of flight, takeoff and landi ng are especially critical times for the crew to31

exhibit good judgment and sound decision making. T he airplane is close to the ground and there is little room for error during these particular ph ases of flight. The FAA provides a range of benefit estimates. The base case estimate only looks at the historical events as an exact mirror for the future . The high case estimate assumes that regional carriers will begin flying larger planes. We under stand that future accidents, will not be identical to historical accidents but our approach provides a conservative look at the benefits of this rule based on a snapshot of the past. Here the FAA provides a quantitative benefit estim ate of historical-based accidents (base case), and a high case of expected benefits from fu ture averted accidents once this rule is promulgated. Generally our benefit analysis begins using past history as an important reference from which to begin the benefit analysis. We belie ve the base case benefit estimate, which is based solely on the outcome of past accidents, may be low because today passenger load factors and aircraft size are already greater than they wer e in the past decade. On the other hand, we also note that this estimate may not fully take int o account changes in regulatory requirements that postdate those accidents and that may mitigate the projected risk. As such, our base case estimate represents a snapshot of risk. Airplane accidents are somewhat random both in term s of airplane size and the number of people on board. For these reasons, projections of future fatalities may be based on future risk exposure, and our projections are typically based o n expected distributions around the mean. Our typical scenario incorporates increasing airpla ne size, expected load factors, and a breakeven analysis. However, our evaluation of the historica l accidents showed a disproportionate risk among smaller, regional carriers. Accordingly, as we discuss below, the FAA has decided to base its high case estimate on preventing an accide nt in a regional jet airplane.32 In response to comments, we have reduced the analys is period from the 20 years

provided in the proposed regulatory analysis to 10 years here. We received comments disputing the use of a 20 year time frame for accidents stati ng the accident rate has declined over time. While noting the wide range of operations over the last 20 years, we shortened the accident history to the last ten years. A reduction in the length of the sample period introduces other problems, most importantly with less time there are fewer observations. Observations are important, as the nature of aviation accidents is t hat while they are rare events, very often these accidents result in severe, high consequences. The FAA Office of Accident Investigation assessed t he effectiveness of this rule to prevent the 6 fatigue-related accidents which occurred on passenger-carrying aircraft in a recent ten year period. This office used the Commercial A viation Safety Team (CAST) methodology to assign a value to how effective the rule will be atpreventing each accident. On average, we expect this rule would have been 52.5 percent effec tive in preventing the types of accidents had it been in effect over the last 10 years.



### Base Case Estimate The base case estimate only looks at the historical events as a specific reference point. In this estimate the exact number of fatalities for ea ch past event is multiplied by the relative rule effectiveness score to obtain the historical number of deaths that would have been averted with the requirements contained in this final rule, had this rule been in effect at the time. The base case estimate supposes roughly six deaths will be a verted annually. Multiplying six annual averted deaths by the $6.2 million value of statist ical life equals $37 million annually. In addition, had the requirements been in place at the time of these historical accidents, $2 million in hull damage for each accident would have been av erted, which equals $6 million for ten years33

or $0.6 million annually. When summed over the ten year period of analysis, the base case estimate is $376 million ($247 million present valu e at 7% and $311 million present value at 3%).


### High Case Estimate Because airplane accidents are relatively rare they are not necessarily representative of actual risk, especially with regard to airplane siz e and the number of people on-board. In addition, future conditions will be different than they were when the accident occurred. Thus, the base case represents a snapshot of the risk tha t fatigue introduces in the overall operating environment. It considers neither the forecasted i ncrease in load factors nor the larger aircraft types. The future preventable events that this rul e addresses will not exactly mirror the past events because the airplane types, utilization, and seating capacity have changed. To quantify the expected benefits in the high case scenario, we narrowed the analysis to three of the six historic accidents which were cata strophic (all on board died). In this case the expected number of preventable catastrophic acciden ts equals the three accidents multiplied by the 52.5 percent effectiveness rate. Thus over a t en-year time period the expected number of preventable accidents is 1.575. Using the Poisson distribution there is roughly a 20 percent chance for no accident; however, there is also a 50 percent probability of two or more accidents. While the 20 year accident history has a broader ra nge of catastrophic accidents, in the shorter ten year historical period all the three ca tastrophic accidents were on regional airplanes. We recognize that as regional airplanes are smaller than the ‘typical’ passenger jet, assuming all future accidents would be on a regional jet underst ates the relative risk across the fleet of aircraft affected by this rule. It does, however, representhistorical accidents and may be somewhat34

representative actual future risk, since the mainli ne carriers typically have collective bargaining agreements that are already largely reflective of t he requirements of this rule. 18 The average size airplane in the forecast period is a B737/A320 with an expected number of passengers and crew of 123 given a forecasted 14 2 seat airplane and a load factor of 83 percent. 19 Even though there was a (relatively large) B757 passenger airplane accident in the 20 year history, if one looks at the past 10 years as truly representative of risk, the preventable accident would likely be on a regional airplane. For the high case the FAA backed away from a benefi t outcome based on mean fleet, flight hours, and occupant numbers because ultimate ly we were persuaded there was information which could not be ignored by the three regional pa ssenger accidents occurring without a mainline passenger accident. For this reason, we s elected an 88 seat regional jet (like an ERJ175) to be the representative airplane for the high case. This size airplane is also consistent with the fact that regional operators are expected to fl y somewhat larger airplanes in the future. The expected benefit from this high case follows a simple methodology for estimating and then valuing the expected number of occupants i n a prevented accident. With a total of 0.3 accidents per year over the ten year period multipl ied by the 52.5 percent effectiveness rate, the analysis assumes 0.1575 average accidents per year. The estimated occupant value for each averted accident equals the average number of seats (88) multiplied by the load factor of 77% plus 4 crew members for a total of 72 averted fatal ities. Each of these prevented fatalities is

18 It is unusual that collective bargaining agreement s would closely mirror regulatory requirements. Ho wever, flight and duty limitations are unique because they address both safety considerations, which are regu latory in nature, and lifestyle considerations, which are pro perly addressed in collective bargaining agreements . Because of the impact of collective bargaining agreements on t he number of hours that pilots work, those agreemen ts were considered by the FAA in calculating both the costs and benefits of this rule. 19 Table 6, FAA Aerospace Forecasts Fiscal Years 201135

multiplied by a $6.2 million value of statistical l ife. The expected value of a preventable accident equals the sum of the averted fatalities a t $446.4 million added to the value of the airplane hull loss ($8.15 million replacement value ), for a prevented accident benefit of $454.6
million. 20 Over a ten year period the value of preventing th e expected 1.575 accidents equals approximately $716 million ($470 million present va lue at 7% and $593 million present value at 3%).



### Benefit Summary The new requirements in this final rule will elimin ate the current rest and duty distinctions between domestic, flag and supplementa l operations as the requirements apply universally to all Part 121 certificate holders con ducting passenger operations. The sleep science, while still evolving and subject to individual incl inations, is clear in a few important respects: most people need eight hours of sleep to function e ffectively, most people find it more difficult to sleep during the day than during the night, resu lting in greater fatigue if working at night; the longer one has been awake and the longer one spends on task, the greater the likelihood of fatigue; and fatigue leads to an increased risk of making a mistake. The requirements contained in this final rule and the accompanying analysis ar e designed reduce the factors that lead to fatigue in most individuals and for all flight crew

. The actual benefits of the final rule will depend u pon the type and size of accident that the rule averts. Because we recognize the potentia l variability in the quantified benefits of this

20 In contrast, the value of an averted all-cargo fat al accident would range between $20.35 million (los s of hull and 2 crewmembers) and $32.55 million (loss of hull and 4 crewmembers).36

final rule, we provide a base case estimate, and a high case estimate. We also note that preventing a single catastrophic accident in a 10-y ear period with 61 people on board would cause this rule to be cost beneficial. Our base ca se estimate is $376 million ($247 million present value at 7% and $311 million at 3%) and our high case estimate is $716 million ($470 million present value at 7% and $593 million at 3%)

.37



## Cost Analysis
The cost of the final rule to Part 121 passenger ai r carriers can be categorized into three main cost components: flight operations, training, and rest facilities. Flight operations cost consists of three main sub-components: crew schedul ing cost, computer programming of crew management systems cost, and cost saving associated with the need for fewer reserve flightcrew members. Training cost consists of two main sub-co mponents: dispatchers and management fatigue training cost, and curriculum development c ost. Rest facilities cost consists of four main sub-components: engineering cost, installation cost , aircraft downtime cost, and increased fuel usage cost. The final rule costs were calculated u sing industry-provided data whenever possible, along with expert analysis. The total estimated cost of the final rule is $390 million for the ten year period from 2013 to 2022. The present value is $297 million and $33 8 million using a seven percent and a three percent discount rate, respectively. The 2013 effe ctive date of the final rule allows two years for carriers to become compliant with the final rule. The FAA classified costs into three main components and estimated the accompanying costs. D ata was obtained from various industry sources; the sources of the data used in cost estim ation are explained in each section. Table 6 identifies the three main cost components. Flight operations cost accounts for approximately53 percent of the total present value cost of the rule . Rest facilities account for approximately 43 percent of the total present value cost of the rule . Roughly four percent of the costs contained in this analysis are attributable to training. Each o f the main cost components are explained indepth in the following sections of this document.38 Table 6: Cost Summary Cost Component Nominal Cost (millions) PV at 7%

(millions) PV at 3%

(millions) Flight Operations $236 $157 $191 Rest Facilities $138 $129 $134 Training $16 $11 $13 Total $390 $297 $338



### Flight Operations Cost The flight operations cost component of the final rule is composed of three subcomponents: crew scheduling costs, crew management system computer programming costs, and cost savings of reduced reserves due to reducing fa tigue. Table 7 provides a summary of the three sub-components of the flight operations cost. The derivations of sub-component costs are explained in-depth in the following sections of the document. 21

21 Operators might be able to reduce their flight oper ations costs by developing and implementing a fatig ue risk management system (FRMS). The FAA is not imposing an FRMS program requirement on Part 121 carriers, b ut does allow carriers the FRMS option. Carriers might develop an FRMS program as an alternative to the f inal rule flightcrew member duty and rest requirements when t he crew scheduling cost savings equal or exceed the costs of the FRMS program. Carriers might do this for ultra -long flights, which have flight times over 16 hour s. FRMS is optional and would only be implemented by an operat or if their compliance costs could be reduced as FR MS only provides cost relief. We did not estimate this pot ential savings as we do not know how many operators would use FRMS and the cost of FRMS has a wide range.39 Table 7: Summary of Flight Operations Costs Flight Operations Cost Sub-Component Nominal Cost (millions) PV Cost

(millions) Crew Scheduling $ 440 $ 289 Computer Programming $ 8 $ 7 Reducing Fatigue Saving ($ 211) ($ 138) Total Flight Operations $ 236 $ 157 Note: Numbers may not sum to total due to rounding- off error. 

### Crew Scheduling

Overview Numerous commenters objected to FAA’s assumptions r egarding the 25 percent costsavings resulting from long-term scheduling optimiz ation in the NPRM. To address these concerns, the FAA estimated the scheduling complian ce costs using a commercial crew scheduling program. The final rule’s impact on cre w scheduling costs was evaluated using Cygnus, a pairing and bid line optimizer developed by CrewPairings, Inc. 22 . Part 121 passenger air carriers provided actual crew schedule data to the FAA for assistance in the cost analysis of the Flightcrew Member Duty and Rest Requirements Ru lemaking. Each carrier provided data for one or more “cases”. A case is defined as a ca rrier fleet, which usually consists of one aircraft type. In some of the cases, the carrier s chedules multiple aircraft types using the same pool of flightcrew members; the methodology in this regulatory impact analysis mirrors actual carrier practice.

22 Cygnus has been used by more than 30 major airline s worldwide over the past 40 years.40 In total, carriers provided data for eight cases. We believe these are representative of the

Part 121 air transportation industry. Mainline pas senger carriers were represented with two short-haul, narrow-body aircraft cases and two long -haul, wide-body aircraft cases. Regional passenger carriers were represented with two cases. 23 Cargo carriers were represented with one short-haul, narrow-body aircraft case and one long- haul, wide-body aircraft case. In addition to the eight cases based on actual carr ier fleets, a synthetic supplemental carrier case was created because no supplemental ca rriers provided crew schedule data. Creation of the synthetic supplemental carrier involved modi fication of the cargo wide-body case. The flight schedules and crew bases of the cargo wide-b ody case were retained because cargo carriers consist of the major share of supplemental carriers . The cargo carrier collective bargaining agreement (CBA) rules were replaced with those refl ecting a representative supplemental carrier CBA. The representative supplemental carrier CBA r eflected rules from a number of actual supplemental carrier CBAs. These changes reflect t he impacts of this final rule on actual supplemental passenger carriers operating wide-body aircraft with route structures similar to the cargo carrier wide-body aircraft case. The crew schedule data consisted of one scheduling period (month) per case. The specific periods varied by carrier, based on data a vailability. The data included full bid line and pairing information for each flightcrew member, and included both lineholder and reserve flightcrew members.

23 Most regional carriers operate code-share flights for a number of mainline partners; crew scheduling is usually performed separately for each mainline partner. Th is analysis was conducted using the same process as the actual carrier, so each regional carrier case represents a sub-fleet.41 The use of a pairing and bid line optimizer enabled the FAA to more accurately model

the impacts of the final rule on industry crew sche duling costs than was possible during NPRM cost analysis. The pairing and bid line optimizer h as been used worldwide by all types of airlines for their own crew scheduling needs and addresses t he optimizer and scheduling limitations in the NPRM cost analysis. Due to this extensive real -world experience, results for these eight cases can be expected to accurately portray the imp acts of the final rule on crew scheduling costs for the cases studied, without making assumptions a bout potential optimization by carriers.
Crew Scheduling Analysis Accurately analyzing the final rule’s impact on cre w scheduling costs for the eight cases required isolating the final rule’s impact from the impacts of various contractual, management, and discretionary crew scheduling practices. The p airing and bid line optimizer was first calibrated to ensure that it was capable of creatin g crew schedules identical to the crew schedules provided by the carriers. After calibration, exist ing federal regulations relevant to flightcrew member scheduling were removed from the optimizer a nd replaced with the final rule requirement. Changes in crew scheduling cost could then be attributed solely to the final rule. The first step in optimizer calibration was receivi ng and formatting the input data from carriers for use in the optimizer. The input data included flight schedules, aircraft flow information, production pairings, regulations, and the carrier’s rule set (contractual, management, and discretionary rules) from the carri ers’ crew management systems. Carrier rule sets included parameters for crew bases, maximum/mi nimum flight time, rest time, duty time, and ground time to allow aircraft changes. The bid lines and pairings that were received directly from the carriers in this first step are referred t o as the “production solution.” Since no modifications were made to the production solution by the FAA or the optimizer, the production42

solution accurately represents the current crew sch eduling environment, including all regulatory, contractual, management, and discretionary rules. Once the production solution was established, the b id lines and pairings were set aside. The optimizer was run using only the flight schedul es, aircraft flow information, federal aviation regulations and the carrier’s rule set. The optimi zer then created its own bid lines and pairings, which are referred to as the “Baseline solution.” The Baseline solution was compared to the production solution using a number of metrics, such as the amount of credit hours, duty periods, hotel room nights required, distribution of time am ong crew bases, number of aircraft swaps, etc. Once the Baseline solution was identical or virtual ly identical to the production solution, the optimizer was deemed calibrated for each of the cas es. Calibration of the optimizer verified that the opti mizer could accurately reproduce the crew scheduling process at each of the carriers. T he Baseline solution could be substituted for the production solution at each carrier with no cha nge in crew scheduling cost. To determine the impact of the final rule, the regu lations in the Baseline solution were replaced with the final rule. All provisions of th e final rule were implemented in this analysis, including maximum flight time, maximum flight duty time, minimum rest time, and cumulative limits. All other, non-regulatory rules from the B aseline solution were retained. Using these inputs, the optimizer created bid lines and pairing s referred to as the “final rule solution.” Since the only difference between the Baseline solu tion and the final rule solution was the substitution of the final rule for the existing regulations, the change in cost between the solutions is solely attributable to the final rule. Eight industry groups were created for the final rule cost analysis. Three cargo groups were droppe d from final rule cost estimates. The two short-haul passenger cases were combined for the pa ssenger narrow-body group. The two long-43

haul passenger cases were combined for the passenge r wide-body group. The two short-haul passenger and two long-haul passenger cases were co mbined for the passenger integrated group. The two regional cases were combined for the region al group. The synthetic supplemental case was renamed the supplemental group. Table 8 lists the number of flightcrew members per industry group used in the crew pairing analysis, i n the determination of the compliance cost for the final rule. Table 8: Flightcrew Members per Industry Group Industry Group Flightcrew Members Passenger Integrated 4,173 Passenger Narrow-body 2,622 Passenger Wide-body 1,551 Regional 540 Supplemental 806

For each industry group, the change in cost between the Baseline and final rule solutions was divided by the number of flightcrew members in the Baseline solution to determine the monthly final rule crew scheduling cost per flightc rew member for that group. The final rule crew scheduling cost is valued by summing the chang e in credit hour cost, per diem cost, and hotel cost from the Baseline solution to the final rule solution. The annual final rule crew scheduling cost per flightcrew member was calculate d by multiplying the monthly cost by 12. Table 9 presents the monthly and annual final rule cost per flightcrew member for each group.44 Table 9: Final Rule Crew Scheduling Cost per Flight crew Member
Industry Group Final Rule Monthly Cost per Flightcrew Member Final Rule Annual

Cost per Flightcrew Member Passenger Integrated $22 $264 Passenger Narrow-body $98 $1,176 Passenger Wide-body -$107 -$1,284 Regional $84 $1,008 Supplemental $1,261 $15,133

The final rule crew scheduling cost per flightcrew member in Table 9 includes crew salary, per diem, and hotel costs. Crew salary is calculated by multiplying the change in credit hours from the Baseline solution to the final rule solution by the estimated average credit hour cost per flightcrew member. Estimated average cred it hour cost per flightcrew member was calculated using Bureau of Transportation Statistic s Form 41 data 24 and other industry data. Item 51230, Pilots and Copilots, from Schedule P-5. 2 was used to determine the total flightcrew cost by carrier and by aircraft type. B lock hours by carrier and by aircraft type were taken from the AirHoursRamp item in the Air Carrier Summary Data, T2: U.S. Air Carrier Traffic and Capacity Statistics by Aircraft Type re port. Total flightcrew cost data and aircraft block hour data were both summed for each of the fi ve industry groups. The industry group sum of total flightcrew cost was divided by the industr y group sum of aircraft block hours for each of the five industry groups. These calculations resul ted in the average total flightcrew cost per aircraft block hour.

24 Data is from 1Q 2010 through 3Q2010, the most rece nt data available as of April 2011.45 To determine the average cost per block hour for an individual flightcrew member, it was

necessary to divide the average total flightcrew co st per aircraft block hour by the average number of flightcrew members per flight. The avera ge number of flightcrew members per flight was estimated using data provided to the FAA by a n umber of carriers. Several steps were necessary to convert from the av erage cost per block hour per flightcrew member to the average credit hour cost p er flightcrew member. First, estimated credit hours per flightcrew member per month by industry g roup were derived from analysis of AIR Inc. Salary Survey data. The AIR Inc. Salary Surve y provided estimated credit hours per flightcrew member per month for 29 carriers. Each of these carriers was assigned to one of the industry groups. Weighted average estimated credithours were calculated using carrier block hour data from Schedule T2: U.S. Air Carrier Traffi c and Capacity Statistics by Aircraft Type carrier block hours from the Air Carrier Summary Da ta database. Next, actual crew scheduling data provided by a number of carriers to the FAA wa s analyzed to determine the average flightcrew member number of block hours per month f or each of the industry groups. Dividing the average flightcrew member block hours per month by the average flightcrew member credit hours per month resulted in a ratio of block hours per month to credit hours per month, for each of the industry groups. The average cost per block hour per flightcrew member was multiplied by the ratio of block hours per month to credit hou rs per month to result in the average credit hour cost per flightcrew member for each of the ind ustry groups. The approach to calculating the average credit hour cost per flightcrew member presented in Table 10 addresses NPRM comments made by several commenters. Commenters stated that46

the salary data used in the NPRM RIA “does not appr oximate current, real world flight crew unit
costs...” 25 ATA suggested that the FAA use DOT Form 41 data f or calculation of crew salary costs. The approach to crew salary costs presented in Table 10 responds to this comment by using the most recent 2010 DOT Form 41 data availab le as of April 2011 for the calculation of average credit hour costs per flightcrew member. T his approach does not include payroll taxes because these represent a transfer cost. This appr oach also does not include pension and benefit costs, because these costs will not be affected by the marginal change in credit hours attributable to the final rule. Table 10: Average Flightcrew Member Cost per Credit Hour

Industry Group Average

Flightcrew Cost per Block Hour Average

Flightcrew Members per Flight Average

Flightcrew Member Cost per Block Hour Weighted

Average Estimated Credit Hrs/Month Average

Flightcrew Member Block Hrs/Month Ratio of

Credit Hrs/Month to Block Hrs/Month Average

Credit Hour Cost per Flightcrew Member Passenger Integrated $481 2.24 $214 78 59 0.76 $163 Passenger Narrow-body $417 2.00 $209 82 60 0.73 $153 Passenger Wide-body $629 2.67 $236 60 59 0.98 $231 Regional $179 2.00 $89 82 48 0.59 $53 Supplemental $712 2.16 $329 71 44 0.61 $201

Table 10 summarizes the steps used to calculate the average monthly credit cost per flightcrew member. First, the number of flightcrew members in the Baseline solution of each case was summarized by industry group. Next, the c hange in credit hours from the Baseline solution to the final rule solution was calculated. The result was multiplied by the average

25 Comments of the Air Transport Association of Ameri ca, Inc. in the matter of Notice of Proposed Rulema king for Flightcrew Member Duty and Rest Requirements, Docke t No. FAA-2009-1093, November 15, 2010.47

flightcrew member cost per credit hour 26 to calculate the final rule credit hour cost. The final rule credit hour cost per flightcrew member was nec essary to have for extrapolation of the crew scheduling cost to the industry; this was calculate d by dividing the final rule credit hour cost by the number of flightcrew members in the Baseline so lution and is shown in Table 11. Table 11: Average Monthly Credit Hour Cost per Flig htcrew Member Calculation

Industry Group Baseline Solution Flightcrew Members Change in

Credit Hours from Baseline Solution to Final Rule Solution Average

Flightcrew Member Cost per Credit Hour Final Rule

Credit Hour Cost Final Rule

Credit Hour Cost per Flightcrew Member Passenger Integrated 4,173 723 N/A $29,854 $7Passenger Narrowbody 2,622 1,758 $153 $268,664 $102Passenger Widebody 1,551 -1,035 $231 -$238,809 -$154 Regional 540 94 $53 $4,953 $9 Supplemental 806 4,642 $201 $930,922 $1,155
Note: The passenger integrated group is the combine d passenger narrow-body and passenger wide-body gro ups.

Per-diem costs were calculated by multiplying the c hange in time away from base (TAFB) from the Baseline solution to the final rule solution by the appropriate per diem rate. Because flightcrew members at some carriers receive different per diem rates based on whether TAFB is domestic or international, the pairings sum mary in each of the solutions provided domestic and international TAFB separately. The pe r diem rates used in this analysis were a weighted average of carriers reporting per diem rat es in the 2006-07 AIR, Inc. Salary Survey. The data was categorized by operator type (freight, passenger, and regional) since per diem rates

26 Average flightcrew member cost per credit hour cal culation is shown in Table 10.48

do not differ by aircraft type operated. Weighted averages were calculated using T2: U.S. Air Carrier Traffic and Capacity Statistics by Aircraft Type carrier block hours from the Air Carrier Summary Data database. Table 12 shows the weighted average hourly per diem rates by operator type used in this analysis.

Table 12: Hourly Per Diem Rates by Operator Type
Operator Type Weighted Average Domestic Per Diem Rate Weighted Average International Per Diem Rate Passenger $1.94 $2.28 Regional $1.60 $1.99 Supplemental $2.06 $2.28

Table 13 summarizes the steps used to calculate the average monthly domestic per diem cost per flightcrew member. First, the number of f lightcrew members in the Baseline solution of each case was summarized by industry group. Next, the change in domestic TAFB hours from the Baseline solution to the final rule solution wa s calculated. The result was multiplied by the weighted average domestic per diem rate to calculat e the final rule domestic per diem cost. The final rule domestic per diem cost per flightcrew me mber was necessary to have for extrapolation of the crew scheduling cost to the industry; this w as calculated by dividing the final rule domestic per diem cost by the number of flightcrew members in the Baseline solution.49

Table 13: Average Monthly Domestic Per Diem Cost pe r Flightcrew Member Calculation

Industry Group Baseline

Solution Flightcrew Members Change in

Domestic TAFB Hours from Baseline Solution to Final Rule Solution Weighted

Average Domestic Per Diem Rate per Hour Final Rule

Domestic Per Diem Cost Final Rule

Domestic Per Diem Cost per Flightcrew Member Passenger Integrated 4,173 7,488 $1.94 $14,557 $3 Passenger Narrow-body 2,622 3,625 $1.94 $7,048 $3 Passenger Wide-body 1,551 3,863 $1.94 $7,510 $5 Regional 540 9,960 $1.60 $15,972 $30 Supplemental 806 3,159 $2.06 $6,509 $8

Table 14 summarizes the steps used to calculate the average monthly international per diem cost per flightcrew member. First, the number of flightcrew members in the Baseline solution of each case was summarized by industry gr oup. Next, the change in international TAFB hours from the Baseline solution to the final rule solution was calculated. The result was multiplied by the weighted average international pe r diem rate to calculate the final rule international per diem cost. The final rule intern ational per diem cost per flightcrew member was necessary to have for extrapolation of the crew scheduling cost to the industry; this was calculated by dividing the final rule international per diem cost by the number of flightcrew members in the Baseline solution.50 Table 14: Average Monthly International Per Diem Co st per Flightcrew Member Calculation

Industry Group Baseline Solution Flightcrew Members Change in

International TAFB Hours from Baseline Solution to Final Rule Solution Weighted

Average International Per Diem Rate per Hour Final Rule

International Per Diem Cost Final Rule

International Per Diem Cost per Flightcrew Member Passenger Integrated 4,173 6,637 $2.28 $15,120 $4 Passenger Narrow-body 2,622 1,030 $2.28 $2,346 $1Passenger Widebody 1,551 5,607 $2.28 $12,774 $8 Regional 540 -16 $1.99 -$31 $0 Supplemental 806 9,759 $2.28 $22,270 $28

The final rule domestic per diem cost per flightcre w member column from Table 13 and the final rule international per diem cost per flig htcrew member column from Table 14 were summed to calculate the final rule per diem cost pe r flightcrew member. The results are shown in Table 15. Table 15: Average Monthly Per Diem Cost per Flightc rew Member

Industry Group Final Rule Domestic Per Diem Cost per Flightcrew Member Final Rule

International Per Diem Cost per Flightcrew Member Final Rule Per

Diem Cost per Flightcrew Member Passenger Integrated $3 $4 $7 Passenger Narrow-body $3 $1 $4 Passenger Wide-body $5 $8 $13 Regional $30 $0 $30 Supplemental $8 $28 $36

Hotel costs were calculated by multiplying the chan ge in required hotel room nights from the Baseline solution to the final rule solution by the average hotel room cost. The hotel room51

costs used in this analysis were included in data p rovided to the FAA and differ by carrier. Table 16 summarizes the final rule monthly hotel cost per flightcrew member by industry group. Table 16: Cost Components of Monthly Final Rule Cos t per Flightcrew Member

Industry Group Final Rule Monthly Credit Cost per Flightcrew Member Final Rule

Monthly Per Diem Cost per Flightcrew Member Final Rule

Monthly Hotel Cost per Flightcrew Member Final Rule

Monthly Cost per Flightcrew Member
Passenger Integrated $7 $7 $8 $22 Passenger Narrow-body $102 $4 -$8 $98 Passenger Wide-body -$154 $13 $34 -$107 Regional $9 $30 $46 $84 Supplemental $1,155 $36 $70 $1,261

Extrapolation of Crew Scheduling Analysis All Part 121 passenger air carriers in the U.S. air transport industry were categorized into one of the five industry groups based on how closel y the carrier resembled one of the five industry groups. A number of metrics such as opera ting authority, aircraft fleet, aircraft utilization, markets served, collective bargaining agreements, etc. were examined to determine which of the five industry groups each carrier mostclosely resembled. Table 17 lists the number of air carriers in each group and the number of fli ghtcrew members in each group.52 Table 17: Final Rule Cost Analysis Industry Groups Industry Group Part 121 Carriers Flightcrew Members
Passenger Integrated 7 36,013 Passenger Narrow-body 16 12,128 Passenger Wide-body 1 150 Regional 40 20,668 Supplemental 3 1,267 Total 67 70,226 Source: Adapted from FAA VIS, December 2010

The number of flightcrew members presented in Table 17 reflects the number of flightcrew members listed on each Part 121 carrier’ s operating certificate in the FAA’s Vital Information Subsystem (VIS) as of December 2010. T he total industry final rule cost would be overstated if extrapolation was based on the number of VIS flightcrew members because not all of these flightcrew members are lineholders. Each carrier employs a significant number of reserve flightcrew members. The FAA estimated thatreserves comprise 15 percent of flightcrew members for the average Part 121 passenger air carr ier based on APA published information 27

. Thus, the extrapolation of the crew scheduling anal ysis to the Part 121 passenger air transportation industry used the number of flightcr ew members (lineholders) shown in Table 18 to determine the final rule crew scheduling cost.

27 “The Reserve System – A Quality of Life Nightmare, ” page 16, Flightline, Allied Pilots Association, D ecember 2010/January 2011.53 Table 18: Reserve-Adjusted Flightcrew Members by In dustry Group Industry Group Flightcrew Members Adjusted for Reserves Passenger Integrated 30,611 Passenger Narrow-body 10,309 Passenger Wide-body 128 Regional 17,568 Supplemental 1,077 Total 59,692 Note: Numbers may not sum to total due to rounding- off error. The number of flightcrew members in each industry g roup shown in Table 18 was multiplied by the appropriate annual cost per flightcrew member ( Table 16) to extrapolate the estimated cost to the Part 121 passenger air transportation industry, as shown in the “Preliminary Annual Crew Scheduling Cost” column in Table 19. In 2010, ther e were eight Part 121 carriers that conducted both all-cargo and passenger operations. For those carriers, the number of passenger revenue departures as a share of total revenue departures i n 2010 as reported in Database T1: U.S. Air Carrier Traffic and Capacity Summary by Service Cla ss from the Bureau of Transportation Statistics was used as the share of crew scheduling costs attributable to the final rule. The “Final Annual Crew Scheduling Cost: Adjusted for Passenger Flights Only” column in Table 19 presents the annual, nominal crew scheduling costs by industry group.54 Table 19: Annual Crew Scheduling Costs

Industry Group Final Rule Annual Cost per Flightcrew Member ReserveAdjusted Flightcrew Members Preliminary

Annual Crew Scheduling Cost (millions) Final Annual Crew

Scheduling Cost Adjusted for Passenger Flights Only (millions) Passenger Integrated $264 30,611 $8 $8 Passenger Narrow-body $1,176 10,309 $12 $12 Passenger Wide-body* -$1,284 128 $0 $0 Regional $1,008 17,568 $18 $18 Supplemental $15,133 1,077 $16 $7 Total N/A 59,692 $54 $44 * Some flights that currently require four flightcr ew members could be completed with three flightcrewmembers under the final rule. Note: Numbers may not sum to total due to rounding- off error.

Table 20 presents the nominal and present value (atseven percent discount rate) crew scheduling cost for the entire passenger-carrying p ortion of the industry for each year of the ten year period of analysis 28 . Each table contains all crew scheduling cost com ponents, including crew salary, per diem, and hotel costs.

28 The projected cost for all-cargo operators associa ted with crew scheduling was $286 million over 10 y ears in nominal costs and $188 million in present value cos ts.55 Table 20: Ten Year Crew Scheduling Costs
Year Nominal

Cost (millions) PV Cost

(millions)
2014 $ 44 $ 38 2015 $ 44 $ 36 2016 $ 44 $ 34 2017 $ 44 $ 31 2018 $ 44 $ 29 2019 $ 44 $ 27 2020 $ 44 $ 26 2021 $ 44 $ 24 2022 $ 44 $ 22 2023 $ 44 $ 21 Total $ 440 $ 289 Note: Numbers may not sum to total due to rounding- off error

. Limitations of Crew Scheduling Analysis The FAA believes that carriers will be able to redu ce much of the cost shown in Table 20. Carriers will engage in additional network optimiza tion to reduce crew scheduling costs, which the FAA is unable to quantify at this point. In th e long run, this may involve re-timing flights, changing schedule frequency, and entering or leavin g markets. However, there may also be costs associated with these actions such as changes in aircraft utilization and revenue losses. At this time, the FAA has not estimated potential long -run optimization of crew scheduling costs. The final rule economic costs are best measured as society’s willingness to be compensated for consumption opportunities forgone a s a result of resources being diverted to the production of improved aviation safety. Because th ese opportunity costs are difficult to estimate, our estimates of crew scheduling costs reflect, for the most part, financial costs that will be56

incurred by affected air carriers. These financial costs are likely to overstate the economic costs of the proposed rule. A large part of estimated crew scheduling costs is increased compensation to flightcrew members for the additional time spent in avoiding p ilot fatigue. These compensation costs will reflect economic costs only if flightcrew wage rate s are accurate measures of the forgone value of goods and services that could otherwise be produ ced. However, it is likely that flightcrew members will be able to use some of the time spent avoiding fatigue in productive activities, including the production of leisure activities. Ou r cost estimates do not include offsets for the value of these activities. Increased per diem cost estimates do not include o ffsets that are likely to occur. For example, meals consumed on the road by flight crew members are substitutes for meals that would otherwise be consumed at home. Resource savi ngs (the value of labor and food used to produce meals at home in this example) are not refl ected in our cost estimates. Similarly, the costs associated with increased hotel expenses do n ot include offsets for at-home savings that will likely occur—e.g., reduced energy and water co nsumption and avoided cleaning costs.


### Computer Programming Carriers will incur computer programming costs as they will need to update their crew management systems and their schedule optimization systems with the constraints imposed by the final rule. A one-time cost will be incurred in 2013 as carrier s update their crew management systems. Crew management system update costs were estimated for each individual carrier, based on the number of flightcrew members listed on the carrier’s operating certificate.57 Carriers were assigned to one of three groups based on the number of flightcrew

members. Costs vary with size of carriers, estimat ed by the number of person-days and staff costs. Person-days required to perform the system u pdate were estimated about 400, 160 and 80 days for large (more than 1,000 flightcrew members) , average (250 to 1,000 flightcrew members) and small (less than 250 flightcrew member s) carriers, respectively. A daily professional staff cost was estimated approximately $625. Table 21 presents the nominal and present value of crew management system update cost s 29

.

Table 21: Crew Management System Update Costs

Year Flightcrew

Members Carriers Cost per Carrier Nominal

Cost (millions) PV Cost

(millions)

>1,000 16 $250,000 $ 4 $ 3 250-1,000 21 $100,000 $ 2 $ 2 2014 <250 30 $50,000 $ 2 $ 1 Total 67 $ 8 $ 7 Note: Numbers may not sum to total due to rounding- off error



### Cost Savings from Reducing Flightcrew Members Fatig ue The final rule is designed to reduce the risk of f atigued flightcrew members by limiting the maximum number of hours they are permitted to b e on duty, the number of hours they actually fly during duty periods, and by ensuring t hat they receive adequate rest periods before

29 The projected cost for all-cargo operations assoc iated with computer programming was $2 million in n ominal cost and $1 million in present value cost.58

reporting for duty. According to CDC, “chronic sle ep loss is an under-recognized public health problem that has a cumulative effect on physical an d mental health. Sleep loss and sleep disorders can reduce quality of life and productivi ty, increase use of health-care services, and result in injuries, illness, or deaths.” 30 It is expected that the final rule will result in better-rested flightcrew members, and reduce wage loss. The fina l rule will reduce flight crew member fatigue, thus reducing the use of sick time. When a flightcrew member is scheduled for duty and calls in sick or fatigued, the carrier must use a r eserve flightcrew member to complete the scheduled duty. The final rule will reduce the use of reserve flightcrew members to cover fatigue-induced sick call-ins by flight crew member s, which will reduce the flight operations cost associated with fatigue issues for carriers. While the precise share of current sick time attrib utable to fatigue is unknown, it is most likely greater than zero. Similarly, while the pre cise amount by which the final rule will reduce sick time is unknown, it is also most likely greate r than zero. Labor representatives have informed the FAA that the estimated sick time that is used due to fatigue is approximately five percent. In light of this information, the FAA ass umes, for the purposes of this analysis, that sick time accounts for five percent of total industry fl ightcrew member pay. Total industry flightcrew member pay was calculated by multiplying the averag e flightcrew member cost per credit hour from Table 10 by the estimated number of credit hou rs per month 31 and multiplied by 12 for each carrier to calculate total annual industry flightcr ew member pay.

30 CDC’s MMWR, Weekly, February 29, 2008 / 57(08);200-203. 31 Estimated number of credit hours per month by carr ier was taken from the 2006-07 U.S. Airlines/Corpor ate Salary Survey published in AIR Inc.59 In 2010, there were eight Part 121 carriers that co nducted both all-cargo and passenger

operations. For those carriers, the number of passe nger revenue departures as a share of total revenue departures in 2010 as reported in Database T1: U.S. Air Carrier Traffic and Capacity Summary by Service Class from the Bureau of Transpo rtation Statistics was used as the share of cost savings attributable to the final rule. The final rule is expected to reduce the use of sic k time by five percent. The nominal value of the cost savings is approximately $211 mil lion ($138 million present value) over the ten-year period of analysis. 32 Table 22 presents the annual cost savings.

32 The projected cost savings to all-cargo operators was estimated at $48 million nominal value over 10 years and $32 million in present value.60 Table 22: Reducing Flightcrew Members Fatigue Cost Savings
Year Nominal Cost

Savings (millions) PV Cost Savings

(millions)
2014 $ 21 $ 18 2015 $ 21 $ 17 2016 $ 21 $ 16 2017 $ 21 $ 15 2018 $ 21 $ 14 2019 $ 21 $ 13 2020 $ 21 $ 12 2021 $ 21 $ 11 2022 $ 21 $ 11 2023 $ 21 $ 10 Total $ 211 $ 138 Note: Numbers may not sum to total due to rounding- off error 

### Flight Operations Cost Summary The total flight operations cost is composed of the additional crew scheduling costs (flightcrew member salary, hotel, and per diem), pl us the computer programming costs, and less the cost savings from reducing flightcrew members f atigue. The net nominal value of the total flight operations cost for the period of analysis i s approximately $236 million, with a present value of $157 million 33 . Table 23 presents the annual nominal and presentvalue total flight operations cost.

33 The projected cost to all-cargo operators associat ed with flight operations is $240 million in nomina l cost over 10 years and $158 million in present value.61 Table 23: Total Flight Operations Cost
Year Nominal Cost

(millions) PV Cost

(millions)
2014 $ 30 $ 27 2015 $ 23 $ 19 2016 $ 23 $ 17 2017 $ 23 $ 16 2018 $ 23 $ 15 2019 $ 23 $ 14 2020 $ 23 $ 13 2021 $ 23 $ 12 2022 $ 23 $ 12 2023 $ 23 $ 11 Total $ 236 $ 157 Note: Numbers may not sum to total due to rounding- off error. 

### Rest Facilities The final rule establishes maximum flight-duty per iod limits for augmented operations that are dependent on the start time of the flight duty period, the number of flightcrew members assigned to the flight, and the class of rest facil ity installed on the aircraft. The final rule establishes detailed specifications for each of the three classes of rest facilities. Class 1 rest facilities are most conducive to reducing the risk of fatigue in augmented operations; accordingly, the maximum flight duty time permitted for augmented operations conducted with Class 1 rest facility-equipped aircraft is greater than the maximum flight duty time permitted for augmented operations conducted with either Class 2 or 3 rest facility-equipped aircraft. The definitions of the rest facilities are as follows:62 o A Class 1 rest facility is a bunk or other surface that allows for a flat sleeping position and is located separate from both the flig ht deck and passenger cabin in an area that is temperature-controlled, allows the crewmember to control light, and provides isolation from noise and disturbance.

o A Class 2 rest facility is a seat in an aircraft cabin that allows for a flat or near flat sleeping position; is separated from passengers by a minimum of a curtain to provide darkness and some sound mitigation; and is reasonably free from disturbance by passengers or crewmembers.

o A Class 3 rest facility is a seat in an aircraft ca bin or flight deck that reclines at least 40 degrees and provides leg and foot support. There are four sub-components of the rest facility cost component of the final rule. The first sub-component consists of the rest facility d esign and engineering costs. The second subcomponent consists of the cost resulting from the p hysical installation of the facilities on the affected aircraft. The third sub-component is the value of the aircraft downtime required to install the rest facilities. The final sub-compone nt is additional aircraft fuel consumption cost due to the weight of the rest facilities. The follo wing paragraphs discuss how the FAA estimated each of the rest facility cost sub-components, and Table 24 details the final cost of each of these sub-components. The total rest-facility cost is ap proximately $138 million ($129 million present
value 34 .)

34 We assumed costs of engineering, installation and downtime incur in two years prior to the compliance of the final rule and fuel cost incurs for a 10-year perio d.63 Table 24: Rest Facility Cost Overview Rest Facilities Cost Sub-Component Nominal Cost (millions) PV Cost

(millions) Engineering $ 12 $ 11.5 Installation $ 99 $ 96 Downtime $ 12 $ 11.5 Fuel $ 15 $ 10 Total Rest Facilities $ 138 $ 129



### Engineering During NPRM cost analysis, the FAA obtained detaile d cost estimates from two supplemental type certificate (STC) holders. For t his final regulatory evaluation we have delineated between engineering and kit/installation costs, as the engineering cost per operator would be a one-time, non-recurring cost for each ty pe (make and model) of aircraft. We continue using the data provided by the STC holders as the b asis for engineering and installation. The engineering costs are non-recurring, design costs. These consist of system, development, engineering, analysis, and certification costs. We conservatively use the engineering cost of $0.5 million per make/model as estimated by the STC hold ers. Accordingly, there will be roughly 24 different designs at $0.5 million per design (make/ model). The actual engineering cost will not be incurred until 2014, one year after the implemen tation of the rule (2013) because the final payment will not occur until successful demonstrati on of the STC on all of the aircraft. As such, the estimated engineering cost is approximately $12 million ($0.5 million x 24), or $11.5 million present value at 7% discount rate.64



### Installation Based upon public comments in response to the NPRM, the FAA has refined the estimate of the number of aircraft that will require rest fa cility installation. The FAA now estimates, based on data collected from FAA inspectors, that 223 air craft will need crew rest modifications to comply with the final rule. 35 This is an increase from the estimate of 104 airc raft in the NPRM cost analysis. However, it is lower than the estim ates of some NPRM commenters. The FAA believes that the final rule estimate of 223 aircra ft represents the worst case scenario because aircraft will be re-optimized based upon current co nfigurations. The FAA estimates that, any additional aircraft, beyond the approximate 223 air craft used in this analysis, will already have adequate rest facilities. Once the additional 223 a ircraft have rest facilities installed, each fleet will be re-optimized for the most efficient use. A s such, we conservatively assume all of these 223 aircraft will have a Class 1 facility installed for an upper-bound estimation. We continue to use the equipment and labor cost pro vided by an STC holder for our estimate of installation costs to the carriers. Th e kit and the installation for each of the individu al airplanes will cost roughly $350,000 and $95,000, r espectively. As such, the total cost of each installation will be roughly $445,000 ($350,000 + $ 95,000). When multiplied by the affected fleet of 223 aircraft, the total facility installat ion cost will be approximately $99 million ($445,000 x 223), or $96 million present value at 7 % discount rate.

35 All aircraft used in augmented operations by carri ers conducting both all-cargo and passenger operati ons are included in this analysis, since it is not possible to identify whether aircraft are used exclusively in all-cargo operations.65



### Downtime
Commenters indicated that an aircraft could be out of service for two weeks during rest facility installation. The FAA estimates the cost to Part 121 operators for this potential additional planned time out of service, or downtime, to install the rest facilities. STC designers have indicated that with proper planning, a modifie r can install rest facilities in two to four days. We conservatively use a four-day estimate for the c alculation of the downtime cost. The FAA conservatively assumes that if an aircraft was to b e out of service for any part of a day, that airplane would be out of service for the entire day

. For this analysis, the FAA uses the opportunity co st of capital to approximate the planned downtime cost to the operators. Using guidelines p rescribed by the Office of Management and Budget, the FAA uses seven percent as a proxy for a verage annual rate of return on capital. The FAA uses $69 million as the estimated market value of an aircraft 36 for downtime in this analysis. The yearly opportunity cost of capital per aircraft would be $4.83 million, roughly $13,233 per day. When multiplied by the affected f leet (223 aircraft) and the days out of service (4 days), the downtime cost for the fleet is $12 mi llion (223 x 4 x $13,233), or $10 million present value.


### Fuel Consumption Costs We have analyzed the costs associated with the desi gn and installation of Class 1 rest facilities. We assume the rest facilities will be installed in the most efficient manner possible, with no impact on passenger seats or the revenue th at they generate. As such, we do not estimate

36 November, 2010 The Airline Monitor. This number represents the appraised value of a 767 -300. p.3366

loss of revenue from a Class 1 rest facility, becau se as defined by the rule, the facilities will be located separate from both the flight deck and pass enger cabin, and will not necessarily require the removal of passenger seats. For example, a Clas s 1 rest facility can be located in aircraft belly or overhead area, neither of which requires t he removal of passenger seats. Although there will be no revenue impact, there will be an additio nal cost that will add to the aircraft operating costs due to the estimated additional impact of wei ght changes on each aircraft. Estimates for the additional incremental weight impact are used t o calculate the additional fuel consumption for the affected fleet. The estimated cost of fuel reflects the most recentforecast using data from the 2011 FAA Aerospace Forecast. We use the fuel consumption met hodology as derived from the FAA’s guidance, Economic Values for the FAA Investment an d Regulatory Decisions along with the estimated average fuel cost of approximately $2.85 per gallon. To calculate the additional annual cost of fuel per aircraft, we multiply the 3 00 additional pounds by the fuel consumption factor of .005 gallons per hour per pound (consiste nt with a two-engine, wide-body aircraft) and arrive at 1.5 gallons per hour per aircraft. This product is then multiplied by the average annual flight hours per aircraft of 2,380 37 and finally by the cost of fuel ($2.85) to arrive at the total annual estimated additional cost of fuel per aircra ft of $6,763. When multiplied by the affected annual fleet (223 aircraft), the annual incremental fuel consumption cost is approximately $1.5 million. When summed over the period of analysis, the total estimated cost for fuel is approximately $15 million (1.5 x 2,380 x 223 x $2.8 5 x 10) or $10 million present value.

37 DOT, Form 4167



### Fatigue Training In accordance with the Airline Safety and Federal Aviation Administration Extension Act of 2010, Section 212, each air carrier conducting oper ations under 14 CFR part 121 must have submitted a fatigue risk management plan (FRMP) to the Administrator for review and acceptance. A FRMP is an air carrier’s management plan outlining policies and procedures for reducing the risks of flightcrew member 1 fatigue and improving flightcrew member alertness. In this final rule the FAA kept the requirement for pi lots to receive fatigue training, but eliminated the incremental cost of compliance because the oper ators are already in compliance with FRMP. The final keeps the requirement for management and dispatchers to have fatigue training and the requirement for curriculum development and keeps th e costs for these requirements. Again, the FAA made this change as air carriers under 14 CFR p art 121 will be in compliance with the statutory pilot training requirement as part of the FRMP’s. This rule change reduces the nominal training cost requirement to $16 million.
The final rule requires that dispatchers and upper management having operational control over flightcrew members be given fatigue training. The number of dispatchers in the U.S. air transportation industry is equal to approximately t hree percent of the number of pilots. The number of management personnel (immediate superviso rs and schedulers) is estimated to be about nine percent of flightcrew members. Therefor e, the total number of dispatchers and management personnel required to receive fatigue tr aining is estimated to be approximately 12 percent of total flightcrew members.68 The estimated total cost of the proposed fatigue tr aining requirements for dispatchers and

management personnel over the ten year period from 2013 to 2022 is $16 million or $11 million in present value. In addition carriers will incur a one-time cost to develop fatigue training curriculum. According to industry standard, curriculum developm ent takes three hours for each hour of course required. Therefore, the time needed to deve lop the initial training curriculum will be fifteen hours and the time needed to develop the re current training curriculum will be six hours. The FAA assumes that the wage rate of the curriculu m developer is approximately $100 per hour. Each of the 67 Part 121 passenger air carrie rs will need to develop its own curriculum. The total cost of curriculum training is $140 thous and or $120 thousand in present value. Thus the training cost requirement for management and dispatchers plus curriculum development cost equals $16 million and $11 million in present value.



### Cost Analysis Summary The present value cost of the final rule to Part 12 1 passenger air carriers over the ten-year period of analysis is $390 million ($284 million pr esent value). Flight operations account for approximately 53 percent of the nominal total cost; crew scheduling cost is the largest subcomponent of flight operations cost. Rest faciliti es account for roughly 43 percent of the nominal total cost; rest facility installation is t he largest sub-component of rest facilities cost. Roughly 4 percent of the nominal cost of the final rule is attributable to training. All final rule cost components were calculated using industry-prov ided data whenever possible, along with expert analysis.69 Table 25: Cost Summary Cost Component Nominal Cost (millions) PV at 7%

(millions) PV at 3%

(millions) Flight Operations $236 $157 $191 Rest Facilities $138 $129 $134 Training $16 $11 $13 Total $390 $297 $338 Note: Numbers may not sum to total due to rounding- off error.


## Cost-Benefit Summary

The total estimated cost of the final rule over 10 years is $390 million ($297 million present value at 7% and $338 million at 3%). 38 We provide a range of estimates for our quantitative benefits over the same period. Our ba se case estimate is $376 million ($247 million present value at 7% and $311 million at 3%) and our high case estimate is $716 million ($470 million present value at 7% and $593 million at 3%) . We also note that preventing a single catastrophic accident in a 10-year period with 61 p eople on board would cause this rule to be cost beneficial.

38 The projected cost for all-cargo operations is $30 6 million ($214 million present value at 7% and $25 2 million at 3%). The projected benefit of avoiding one fatal a ll-cargo accident ranges between $20.35 million and $32.55 million, depending on the number of crewmembers on board the aircraft.70



## Accident Appendix

1. Accident DCA94MA065
Date : 7/2/1994 July 2, 1994 in Charlotte, NC A/C: MD-82, N954VJ Injuries: 37 Fatal, 16 Serious Accident Summary : Aircraft collided with trees and a private resid ence near the Charlotte/Douglas International Airport, Charlotte, North Carolina (CLT), shortly after the flightcrew executed a missed approach from the inst rument landing system (ILS) approach to
runway Probable Cause : Probable cause was determined to be the flightcr ew’s decision to continue an approach into severe convective activity that was c onducive to a microburst: 2) the flightcrew’s failure to recognize a windshear situation in a tim ely manner, 3) the flightcrew’s failure to establish and maintain the proper airplane attitude and thrust setting necessary to escape the windshear; and 4) the lack of real-time adverse wea ther and windshear hazard information dissemination from air traffic control, all of whic h led to an encounter with and failure to escape from a microburst-induced windshear that was produ ced by a rapidly developing thunderstorm located at the approach end of runway. Flight Crew/Fatigue Related Information: The captain was off duty for 3 days before the beginning of the accident trip. On the morning of J une 28, 1994, he flew with his National Guard squadron, which is based at Wright Patterson Air Fo rce Base Ohio, near his home. On the day of the accident he awoke about 0455 drove to the airpo rt in Dayton Ohio, and departed on a flight to Pittsturgh at around 0745. The reporting time fo r the trip that included the accident flight was 0945, and the departure time for LGA was at 1045. T he first officer flew a 4-day trip that ended71

around 0930 on July 2. On the day of the accident, he arose about 06 I5 and flew the leg to Pittsburgh that departed St. Louis at 0810. He arri ved in Pittsburgh at 0030. SCORE: 0.35 Fatigue could have affected FO's perfor mance (PF). PIC, who was off-duty preceding 3 days, was much less vulnerable to fatig ue, but he too had already had a long day. Accident occurred 14 hours into PIC’s day. He awoke at 0455, drove to Dayton from home, then flew to PIT to begin duty day. Accident occurred at1843, at end of third of 4 scheduled legs. His long day may have contributed to his failure to mak e 2 standard call-outs on approach at 1000 AGL & 100 AGL. As NTSB notes, failure to make these call-outs contributed to PIC’s loss of situational awareness, his directing FO to go-aroun d “to the right” instead of following runway heading as directed, & directing FO to “push down” after FO had initiated 15-degree nose-up & right banking turn. FO was more vulnerable to fatigue. His duty day end ed June 30 at 2230 at Blountsville, TN. NTSB report does not say when that duty day began, nor when FO awoke that day. At Blountville, he went to bed at 0130 & awoke at 0900 . His next duty day ended at STL at 2040 EDT. He went to bed at 2230 & awoke at 0615 on acci dent day. He then flew to PIT & began pairing with accident PIC. Like PIC, FO was nearly 14 hours into his day when accident occurred. He was PF on PIT-LGA leg & on accident le g from CAE. Fatigue could have contributed to incomplete pre-flight brief, failure to maintain sterile cockpit below 10,000 feet, approach briefing in which he omitted field elevati on, FAF altitude, DH, & MAP altitudes, all of which NTSB noted had contributed to lack of situati onal awareness by both pilots. Finally, all the above contributed to crew’s choice to initiate non-standard go-around. Other factors were important, including ATC performance, A/C's inadequ ate windshear algorithm, & abnormally72

severe windshear. In short, hard to justify a high score, but equally hard to argue that fatigue was irrelevant.

2. Accident DCA95MA020
Date : 2/16/1995 NTSB Identification: DCA95MA020, Air Transport Inte rnational February 16, 1995 in Kansas City, MO A/C: DC-8-63, N782AL Injuries: 3 Fatal Accident Summary : Aircraft was destroyed by ground impact and fire during attempted takeoff. Probable Cause : Probable cause was determined to be loss of direc tional control by pilot in command during the takeoff roll, flightcrews lack o f understanding of the three-engine takeoff procedures and their decision to modify these proce dures and the failure of the company to ensure that the flight crew had adequate experience , training and rest to conduct the non-routine flight Flight Crew/Fatigue Related Information: Safety board believes the captain and other crew members were experiencing fatigue at the time of th e accident. The captain’s performance in the accident reveals many areas of degradation in which fatigue is probably a factor. Accident report notes a demanding Delaware -Germany overnight round trip flight (6 time zones crossed) and a daytime rest period which caused disruptions in cir cadian rhythms. Additionally, the captains last rest period was repeatedly interrupted by the compa ny. Report also notes that since flight was non-revenue flight, it was under different duty rul es and the same flight, were it a revenue flight, would have been illegal given the rest periods the crew had.73

SCORE: 0.9 Fatigue was a significant problem in th is accident. With or without crew's inadequate training & knowledge of 3-engine T/O, NP RM would preclude this crew from this ferry trip. Also, all 3 crew performed poorly & all 3 likely were fatigued, per NTSB, & all 3 exhibited “performance degradation” symptomatic of fatigue (difficulties in setting proper priorities & continuation of T/O attempt despite di sagreement & confusion on important issues).

3. Date : 12/20/1995 NTSB Identification: DCA96RA020, American Airlines December 20, 1995 in Cali, Colombia A/C: B757-200, N651AA Injuries: 160 Fatal, 4 Serio us Accident Summary: Aircraft crashed 38 miles north of Cali, Columbia i nto mountainous terrain during a descent under instrument flight rules Probable Cause : Probable causes were determined to be the flight crew’s failure to adequately plan and execute the approach to runway 19 at SKCL and their inadequate use of automation; Failure of the flightcrew to discontinue the approa ch into Cali, despite numerous cues alerting them of the inadvisability of continuing the approa ch; The lack of situational awareness of the flightcrew regarding vertical navigation, proximity to terrain, and the relative location of critical radio aids; Failure of the flightcrew to revert to basic radio navigation at the time when the FMSassisted navigation became confusing and demanded a n excessive workload in a critical phase of the flight.

Flight Crew/Fatigue Related Information:74

At 2138 CFIT at 9000; peak at 9190. Night VOR/DME a pproach from MIA; 2 hrs late. PIC concerned to get cabin crew on ground to meet AAL r ules on cabin crew rest (for next day return flight). Cali in long N/S valley; high terrain west& east. Cleared to Cali VOR; readback "cleared direct," entered "direct;" way points go off displa y. Later cleared to interim Tulua VOR. Expecting “direct,” crew became unsure of location. CVR shows crew fumbled with charts & Tulua ID, but already past Tulua. When crew finally entered Tulua, A/C began turning back to Tulua; PIC overrode. Then ATC offered direct approa ch from north (was 01; now 19). Crew rushed to get down. Put in single-letter ID for ROS O, but Colombia has 2 navaids with singleletter "R." Per ICAO, software defaults to "R" with more traffic (well north at Romeo VOR-- Bogota); had to punch in all 4 letters for ROSO. Ag ain A/C began turning back. Crew now very confused & they knew it. FO (PF): "where are we?" P IC says go S/SE – now east of valley, 13 miles off course & below terrain between A/C & Cali . Now more confused; reading DME to ROMEO, thinking it was ROSO. Stepped down early, co nfigured to land as GPWS sounded. Pulled up but did not retract spoilers; slow climb (184 knots at impact). Hit east slope nose up, skidded over top & down west side. Both pilots, 6 F A & 152 pax fatal; 4 pax serious. CAUSE per Colombian CAA: 1. crew's failure to adequ ately plan & execute approach to runway 19 & inadequate use of automation; 2. Failure to di scontinue approach, despite numerous cues; 3. lack of situational awareness regarding vertical navigation, proximity to terrain, & relative location of critical radio aids; 4. Failure to reve rt to basic radio nav when FMS-nav became confusing & demanded excessive workload. Factors: 1 . crew's ongoing efforts to expedite approach & landing to avoid potential delays from e xceeding company duty time limits; 2. execution of GPWS escape maneuver with speed brakes deployed; 3. FMS logic that dropped all75

intermediate fixes from display(s) upon execution o f direct routing; 4. FMS-generated nav information that used different naming convention f rom that published in nav charts." SCORE: 0.35 Crew certainly would have been tired, d espite being first of their duty tour. PIC had been awake close to 17 hours & FO had been awak e at least 15 hours (14 & 17 hours are key thresholds in fatigue). Yet even if each had been o perating earlier in their day, they likely would not have sorted out confusion created by single-let ter identifier for Rozo & Romeo. Yet more rested crew may have avoided readback-hearback erro r related to “direct” with interim way points. Crew clearly knew they were very confused & that they were uncertain of their position in rugged terrain. More alert crew might have resp onded more appropriately, either by climbing above terrain to sort things out, or by reverting t o radio nav until they re-established their position, or may have recognized that over-ride of northbound turn had pushed them across ridge line, east of valley. Though crew certainly would b e tired, fatigue was less than a show-stopper. Key factors would have remained with or without ale rt crew: non-radar environment; confusion from multiple identifiers; self-induced pressure; u nexpected change to unfamiliar step-down approach at night in mountainous terrain; & signifi cantly delayed flight. The requirements might have led to avoiding confusion or to more appropria te response to confusion.

4. NTSB Identification: NYC96FA174, TWA August 25, 1996 in JFK, NY A/C: L-1011, N31031 Injuries: None
Date : 8/25/1996 Accident Summary : Aircraft was substantially damaged when the tail struck the runway, while landing at John F. Kennedy International Airport, J amaica, New York (JFK).76

On arrival in JFK area, wx was 1⁄4-mile in fog, scatt ered at 200, & temp/dew of 66/66F. Crew expected 4R, but before reaching FAF, 4R went below minimum & ATC offered 4L (still above minimum). PIC accepted & FO (PF) transitioned to 4L . Inspection methods from Lockheed & adopted by TWA did not adequately specify how to ch eck slat drive system for slack. But crew failed to reset altimeter bug for new runw ay (100 feet higher than 4R). PIC also missed several required call-outs on approach & no charts for 4L were on board. When PF asked for charts, PIC said “just fly the approach.” A/C was slow & unstable throughout approach & when altimeter read 50 feet (in fact 150 feet), A/C bega n to flare. FO recognized they were high & pushed nose over. On landing, A/C had tail strike & substantial damage. Failure to reset altimeter & absence of charts were fundamental in this accide nt. Probable Cause : Probable cause was determined to be the failure o f the flight crew to complete the published checklist and to adequately cross-che ck the actions of each other, which resulted in their failure to detect that the leading edge slats had not extended and led to the aircraft's tail contacting the runway during the computer-driven, a uto-land flare for landing. Flight Crew/Fatigue Related Information: The captain reported that he had difficulty adjusti ng to disruptions in his sleeping schedule, and for this reason did not bid to fly international routes. According to his sleep schedule, he had been awake about 24 hours at the time of the accident and reported that he that he felt, ""awful, just ti red and exhausted."" The first officer said that th e captain attempted to rest during the cruise portion of the flight to JFK, with his head back in the seat, but that there were visiting crewmembers in t he cockpit and the captain might not have received good rest. In addition, the captain commen ted that he had not slept well in the hotel. The first officer reported that he had flown the LA S layover trip several times during July, and had learned the importance of good sleep for flying it. He reported that he had in excess of 1477

hours of rest in the scheduled 24 hours of off duty , which was split over two periods. At the time of the accident he had been awake for over 9 hours following a rest in excess of 5 1/2 hours. The flight engineer reported that she had not slept well in the hotel on the layover. Additionally, she reported that she felt rested when the accidenttrip began; however, at the time of the landing she was getting tired

SCORE: 0.35 Had crew been better rested, they may n ot have missed altimeter reset, may have recognized or acted upon unstable approach, or may have gone around, as required by company procedures when not stable at 500 feet. NPRM's trea tment of night operations may have affected this flight. Conversely, crews have made similar errors when well rested & flying at mid-day. FAA believes that avoidable fatigue contributed to crew’s failures on approach.

5. NTSB Identification: NYC99LA052, Colgan Air January 22, 1999 in Hyannis, MA A/C: BE-1900, N215CJ Injuries: None At 1719 (dusk), Beech 1900D by Colgan substantially damaged on landing at HYA. No injury to PIC, FO & 2 employees as pax on positioning flight from BOS to HYA in IMC. Started taxi at BOS at 1600. T/O & en route uneventful. But RVR at HYA went below minimum while en route. Wx was 100-foot ceiling in fog, with variabl e winds at 3 knots. On arrival at HYA, PIC performed 2 missed approache s. Before trying 3 rd approach, he advised tower & pax that this was last shot, or they return to BOS. On third approach, both PIC & FO visually acquired runway. FO said PIC lined up with centerline & requested flaps. FO said A/C “floated at 20 feet over runway at normal transitio n when I heard PIC taking power levers over78

flight idle gate by sound of engine/props.' This pl aced prop in 'BETA' range. A/C then started to sink, & PIC pulled back on control yoke. Main gear struck ground & fractured during +2.9G to uchdown, which occurred 2500 feet beyond approach end of 5,252 foot runway. Ran off right si de of runway, 4700 feet beyond approach end & stopped. To place throttles in BETA, it was neces sary to lift power levers over flight idle stop. Flight manual included warning: 'Do not lift power levers in flight.' On accident day, PIC reported for duty at 0535, wit h first departure from HYA at 0620. He returned to HYA at 0920, after 3 flights & 2:31 fli ght time. Then with different FO, PIC T/O for Boston at 1100. They flew 5 more flights for 3:53 f light hours, then returned to BOS at 1540. Probable CAUSE: PIC’s improper placement of power l evers in BETA position while in flight. Factors: fog & dusk conditions. SCORE: 0.15 Accident report summarizes only Captain 's flight day, not his preceding 72 hours. Clearly had a long day & difficulty getting into HY A did not help. Started taxi at BOS 12.5 hours into duty day for flight to HYA, so he needed to be on ground at HYA within half-hour to beat new NPRM max duty day. May have precuded this PIC from this flight (or not – close call). Also, though better rested PIC may have han dled flare better, others have pulled throttle & props into beta. Fatigue might help explain PIC’s d ecision to take 3 shots at landing below mimium,

6. NTSB Identification: NYC99FA110, American Eagle May 8, 1999 in JFK, NY A/C: SF34, N232AE Injuries: 1 Serious Accident NYC99FA11079

Accident Summary : Aircraft sustained substantial damage during land ing at John F. Kennedy International Airport (JFK) Probable Cause : Probable cause was determined to be the pilot-in- command's failure to perform a missed approach as required by his company proced ures. Factors were the pilot-in-command's improper in-flight decisions, the pilot-in-command' s failure to comply with FAA regulations and company procedures, inadequate crew coordination, a nd fatigue Flight Crew/Fatigue Related Information: On May 6, 1999, the captain went off duty about 2030, drove home, and was asleep about 2300. On Ma y 7, 1999, he awoke about 0700. He attempted to nap about 1200, but was unsuccessful. He reported for duty about 2200. The first officer was off duty on May 6, 1999. He departed L as Vegas, Nevada (commuting on a jumpseat) at 1230, and arrived at JFK about 1730. He ate, then rested in the pilot's crew room, but did not sleep. There was a 3 hour time differe nce between Las Vegas and JFK. The trip sequence scheduled the pilots to depart JFK at 2246 , arrive at BWI at 2359, on May 7, 1999; and depart BWI for JFK at 0610 on May 8, 1999. They we re provided with individual rooms at a local hotel, approximately 10 minutes from the airp ort. Due to a takeoff delay at JFK, the flightcrew did not arrive at BWI until 0025. They arrived at the hotel about 0100. The captain stated that he was asleep by 0130. He awoke at 044 5 for the scheduled 0530 van ide back to the airport. The first officer stated that he was asle ep between 0130 and 0200. He received a wakeup call at 0445. During post-accident interviews, b oth pilots stated that they were fatigued. At 0702, SF34 by American Eagle substantially damag ed on landing at JFK; 1 pax serious; no injury to 26 pax, FA & 2 pilots. En route from BWI uneventful. On arrival in NY area, crew completed checklists & briefings for runway 04 when ATC advised crew that RVR for 04 was 1,600. Crew needed 1800 so ATC cleared them to hold ing fix at 4,000. While flying toward80

holding fix, RVR increased. ATC offered crew ILS ap proach, but advised that they might be too high. PIC accepted clearance nevertheless. Controll er asked if crew could make approach from their position. PIC said yes & continued entire app roach with excessive altitude, airspeed, & rate of descent, while remaining above glide slope. This violated company procedures & FAR 91.175. Crew then failed to respond to 4 audible GP WS warnings. During approach, FO failed to make required callouts, including missed approach c allout. Landed 7,000 feet beyond approach end, at 157 knots, & overran. During interviews, both pilots said they were fatig ued. Crew was working continuous duty overnight schedule. Continuous duty overnights (CDO ) at American Eagle identifies trip sequence that is flown during late night hours, ext ending into early morning hours, with significant elapsed time period between one arrival & next departure. Since break between flights is not sufficient to qualify as free from d uty rest period, crew remains continuously on duty, though carrier may have provide hotel room fo r rest. On May 6, PIC went off duty at 2030, drove home, & was asleep at 2300. On May 7, he awoke at 0700. He tried to nap about noon but was unsucce ssful. He reported for duty at 2200. FO was off duty on May 6. He departed LAS (commuting on ju mpseat) at 0930 local time on May 7 (1230 EDT) & arrived at JFK at 1730. He ate then re sted in crew room, but did not sleep. Trip sequence scheduled crew to depart JFK at 2246, arri ve BWI at 2359, & then depart BWI for JFK at 0610 on 5/8. They were provided with individual rooms at hotel 10 minutes from airport. But, due to delays at JFK, crew did not arrive at BWI un til 0025. They arrived at hotel at 0100 & PIC was asleep by 0130. He awoke at 0445 for scheduled 0530 van ride back to airport. FO said he was asleep between 0130 and 0200. He received wake- up call at 0445. CAUSE: PIC's failure to perform missed approach as required by company procedures. Factors:81

PIC's improper in-flight decisions, failure to comp ly with FARs & company procedures, inadequate crew coordination, & fatigue. SCORE: 0.5 Crew likely was tired, & helps to explai n why crew did little right on or before the approach. Yet, the requirements would not reach the practice of “Continuous Duty Overnight, but it would have reached the FO’s continuous day s tarting with his commute. This would not have helped PI, but it might have ensured at least one alert crewmember.

7. NTSB Identification: DCA99MA060, American June 1, 1999 in Little Rock, AR A/C: MD-82, N215AA Injuries: 11 Fatal, 45 Serious Accident DCA99MA060 Accident Summary: Aircraft crashed after it overran the end of runway Flight Crew/Fatigue Related Information: The captain went to sleep about 2200 the night befo re the accident and slept until between 0700 and 0730. On nonflying days, he would typically go to sleep between 2130 and 2200, wake up about 0515, an d leave for work about 0600. On May 30, 1999, the first officer traveled from his home outs ide Los Angeles, California, to Chicago. The first officer indicated that he had been commuting from his home to the Chicago-O’Hare base for about 3 months and that, as a result, he was adjust ed to the central time zone. The first officer indicated that he was involved in routine activitie s while in the Chicago area. He went to bed between 2000 and 2200 the night before the accidentand woke up about 0730. The board found that at the time of the accident (2 350:44), the captain and the first officer had been continuously awake for at least 16 hours. Also the accident time was nearly 2 hours after the time that both pilots went to bed the night bef ore the accident and the captain’s routine82

bedtime (between 2130 and 2200), meaning their circ adian systems were not actively promoting alertness. The Safety Board concludes that the flig ht crew’s degraded performance was consistent with known effects of fatigue. CAUSE: failure to discontinue approach when severe thunderstorms & associated hazards to flight operations had moved into airport area, & cr ew's failure to ensure that spoilers had extended after touchdown. Factors: flight crew's (1 ) impaired performance resulting from fatigue & situational stress associated with intent to land under the circumstances, (2) continuation of approach when company's max crosswind component was exceeded, & (3) use of reverse thrust greater than 1.3 engine pressure ratio after landin g. SCORE: 0.15 FO was 5 months into 1-year probation & paired with Chief Pilot from ORD base. But FO later testified of good working relationship with PIC & said rank of Chief Pilot was no barrier. Accident occurred 14 hours into duty day & nearly 17 hours after awakening. Long day & disrupted flight into & from DFW. FO showed signs on CVR of recognizing that landing was not a good idea, but PIC focused on landing. Was th is fatigue or task fixation? Would more rest have made recently hired FO more willing to speak u p to PIC-Chief Pilot? Call-outs were made & SOPs indicate crew was engaged. Perhaps a less wo rn-out PIC would have considered diverting (or not), or may at least have responded to implied warnings from tower. Would have exceeded the requirements contained in this final r ule by 12 minutes at impact; may have changed sequence before T/O (had to be released by 2316 - - 2304 might have made a difference).

8. NTSB Identification: DCA05MA004, Corporate Airli nes as American Connection October 19, 2004 in Kirksville, MO83

A/C: BAE-32, N875JX Injuries: 13 fatal, 2 Serious Accident AAR0601 Accident Summary: Aircraft struck trees on final approach and crashe d short of runway. At 1937 on LOC/DME final at Kirksville in IMC, hit trees at 33 feet QFE on center line 1.3 NM out. WX: wind 020 at 6, visibility 4, mist & 300 ov ercast. On final, PIC (PF) maintained constant descent of 1200 FPM until impact (met company SOP b ut exceeded that recommended by FAA for descent below 1000 AGL). At MDA, PIC said 'I ca n see ground there' (as PF, he should have been on instruments). Continued through MDA & asked FO 'what do you think?' FO: 'I can't see (expletive).' Seconds later PIC said 'yeah, there i t is. Approach lights in sight' just as GPWS called “200” & FO announced 'in sight, continue'. ( Both looking out window; nobody on instruments). Never recognized low altitude until s eeing trees 2 seconds before impact. Wx complicated approach but crew never seemed too conc erned about wx. Flew approach in casual fashion & lack of professionalism: no sterile cockp it (casual conversation); non-standard phraseology; humming; etc. PIC known for sense of h umor & was said to 'emphasize fun in the cockpit'. Crew was fatigued: reported for duty at 0514. Accid ent was near end of 6th sector on 'demanding' day in IMC. Crew had been on duty 14.5 hours & PIC is said to have slept poorly night before. PIC commuted from home in NJ to STL & FO commuted from Ohio. Reported for duty at 1345 on 10/17 (2 days before accident). Fle w 3 flights in 8-hour duty day & arrived at over-night destination (Quincy) at 2125. On 10/18, departed Quincy at 1415 after more than 15 hours off. Flew 3 flights & 6:20 duty day. Arrived at over-night destination in Burlington at 1945. On 10/19, duty day began at 0514 after 9 hour s off. Departed BRL at 0544 to STL &84

arrived 0644. Next 2 flights cancelled due to wx. T /O for round-trip from STL-Kirksville (IRK) at 1236. Landed STL at 1745. Probable Cause: failure to follow procedures & improper non-precisi on instrument approach at night in IMC, including descent below MDA before ac quiring runway environment. Factors: non-standard callouts; unprofessional demeanor; & c rew fatigue. Probable cause was determined to be the pilots’ fai lure to follow established procedures and properly conduct a non-precision instrument approac h at night in IMC, including their descent below the minimum descent altitude (MDA) before req uired visual cues were available (which continued un moderated until the airplane struck th e trees) and their failure to adhere to the established division of duties between the flying a nd nonflying (monitoring) pilot Flight Crew/Fatigue Related Information: Captain reportedly did not sleep well the night bef ore the accident but did not report feeling tired. He w as later observed resting on a couch the morning of the accident. First officer reportedly d id not have any trouble sleeping the night before the accident and the day of the accident see med alert and happy. However, the flight crews rest time (2100-0400) did not correspond favorably with either ones sleeping patterns and at the time of the accident, they had been on duty 14.5 hrs and it had been 15 hrs since their last rest period. The board sugg ests that the pilot deficiencies observed could be consistent with fatigue impairment SCORE: 0.9 Accident flight T/O STL at 1842 for IRK on 6th flight of day after 6:14 flight time & 14.5-hour day already. Long, brutal day in IMC th at started with limited rest period. Crew was familiar with each other & with IRK. WX & PIC's est ablished practice of "fun in the cockpit" also were factors. Fatigue had to be a big player, though PIC's history of "fun in cockpit implies85

other issues. The requirements in this final rule would have precluded this crew from taking this flight.

9. NTSB Identification: DCA06MA064, Comair as August 27, 2006, Lexington, KY A/C: CRJ-200, N431CA Injuries: 49 Fatal, 1 Serious Accident AAR0705
Date : 8/27/2007 Accident Summary : Aircraft crashed during takeoff from Blue Grass A irport, Lexington, Kentucky. At 0607 Comair 5191 crashed on T/O from Blue Grass Airport (LEX) for ATL. A/C ran off end of Runway 26 & was destroyed by impact forces & pos t crash fire. T/O wrong runway; had been cleared to T/O on Runway 22. PIC, FA & all 47 pax f atal; FO serious. Threshold for 22 & 26 are close & common taxiway had construction near thresh olds, possibly inviting confusion in darkness after short taxi from nearby terminal. Als o, sole controller in tower turned away after clearing A/C for T/O (A/C was the only active A/C o n the airport). Runway 22 had minor construction work underway prec eding week with NOTAM for “some” lights out. Crew also appeared behind the curve ear ly: approached wrong RJ on ramp (corrected by ramp staff); called Toledo tower rather than LEX (corrected by tower); called wrong flight number (corrected by tower); & vocally ran through checklist on taxi so quickly NTSB had to slow CVR read-out to understand it. Crew then taxie d onto darkened, closed short runway (26). Initiated rolling T/O, further reducing chance to r ecognize wrong runway, crossed intersection with active runway, lighted 7,000-foot Runway 22, 5 00 feet from start of rolling T/O on 26,86

continued & rotated just as they ran out of pavemen t. Ran onto grass & nose lifted slightly (with main gear tracks deepening in grass) just as A/C st ruck perimeter fence, then rolled at high speed into trees & burned out. PIC, FA & 47 pax fatal; FO serious. CAUSE: crew's failure to use available cues & aids to identify A/C's location on airport surface during taxi & their failure to cross-check & verify that A/C was on correct runway before T/O. Factors: crew's non-pertinent conversation during taxi, which resulted in loss of positional awareness, & FAA's failure to require that all runway crossings be authorized onl y by specific ATC clearances. Probable Cause : Probable cause was determined to be s the flight crewmembers’ failure to use available cues and aids to identify the airplane’s location on the airport surface during taxi and their failure to cross-check and verify that the ai rplane was on the correct runway before takeoff Flight Crew/Fatigue Related Information: The captain and the first officer received more th an the minimum required rest periods during their respecti ve trips in the days before the accident, and their flight and duty times in the week and month b efore the accident would not have precluded them from obtaining adequate sleep. Also, both pilo ts had only been awake for about 2 hours at the time of the accident. Two factors in the pilot s’ schedules just before the accident could have been associated with the potential development of a fatigued state: acute sleep loss and circadian disruption - The captain and the first officer also awakened on the day of the accident at a time when they would normally be asleep.

Overall, The Safety Board concludes that, even thou gh the flight crewmembers made some errors during their preflight activities and the ta xi to the runway, there was insufficient evidence to determine whether fatigue affected their perform ance87

SCORE: 0.35 Fatigue likely was not an issue for PIC (PNF) but it may have affected FO’s performance (PF). FO began his duty tour on 8/25 atJFK. He drove that morning to FLL near his home for flight to JFK. Departed FLL at 0559 & arri ved JFK at 0832. NTB does not note when FO awoke, but it likely would have been around 0400 to reach his 0559 departure at FLL. His duty day then began with flight from JFK to ROC at 1305. Return flight to JFK T/O at 1600 but crew had to divert to BDL for fuel & did not land a t JFK until nearly 2000. Due to late arrival, crew was asked to reposition A/C to LEX. Departed g ate at 2130 but were not able to T/O until 2300; arrived at LEX at 0140. FO reached his hotel at 0210 on 8/26. By the time he got to bed, FO would have had nearly a 23-hour day. On 8/26, FO had day off. He told his wife that morning by phone that he had “slept in” & planned t o go to bed early that night. Phone records, hotel key cards, & credit card records indicate nor mal day of activity through at least 1830 on his rest day, when FO paid for meal in hotel restaurant(probably asleep no earlier than 2000). On 8/27 he & PIC reported for duty at 0515. FO likely had same wake-up call as PIC (0415). Though FO had free day before accident, 8/25 was 23 -hour day, with very late time to bed, followed on 8/27 by very early start to his day. D espite “sleeping in” on 8/26, FO would have been coping with sleep deficit. This could partly e xplain his confusion or inattention prior to departing gate. It also could have made him more vu lnerable to visual confusion caused by minor construction & related barriers, & his failure to r espond to visual cues of unlighted runway & crossing active runway that was fully lighted. Yet other factors also may explain these failures. For example, FO had flown into LEX 2 nights before when “lights were out all over the place.” That was at end of his 23-hour day; neither he nor that Captain apparently recognized that outages had been NOTAMed on 8/25. On morning of acc ident, runway end identifier lights were out of service. Closeness of 2 runway ends with sin gle taxiway also increases risk of wrong88

runway T/Os. Finally, with terminal close to runway ends, taxi time was short, increasing percentage of head-down time, at least for PNF. The requirements would have precluded FO from taking positioning flight & extending very lon g duty day on first day. This may have averted the entire scenario. 10. NTSB Identification: DCA07MA072, Shuttle Americ a February 18, 2007, Cleveland, OH A/C: ERJ-170, N862RW Injuries: None Accident AAR0801 Accident Summary : Aircraft overran the end of the runway during a l anding in snowy conditions and stuck an ILS antenna and fence, and the nose ge ar collapsed. Flight Crew/Fatigue Related Information: The day of the accident, the captain had been awake for all but about 1 hour of the previous 32 hours; he stated that his lack of sleep affected his ability to concentrate and process information to m ake decisions and, as a result, was not “at the best of [his] game.” The captain also reported thathe had insomnia, which began 9 months to 1 year before the accident and lasted for several day s at a time. From Feb 11-14 the first officer flew a total of 18hrs 27 mins. On Feb, he started a 3-day 6-leg trip and by the 18th, his total flight time was 11 hrs 50 mins. At the time of the accident, the first officer had been on duty about 9 hrs 15 mins with a total flight time of 5 h rs 30 mins. The first officer agreed to be the flying pilot because of the captain’s references to fatigue and lack of sleep the night before. A contributing factor to the accident was the pilot ’s fatigue which affected his ability to effectively plan and monitor the approach and landi ng. The Safety Board concludes that the captain was fatigued, which degraded his performanc e during the accident flight.89

CAUSE: failure to execute a missed approach when vi sual cues for runway were not distinct & identifiable. Factors: (1) crew's decision to desce nd to ILS DH instead of localizer (glideslope out) MDA; (2) FO's long landing on short, contamina ted runway & crew's failure to use reverse thrust & braking to max effectiveness; (3) PIC's fa tigue, which affected his ability to effectively plan for & monitor approach; & (4) carrier's failur e to administer attendance policy that permitted crew to call in as fatigued without fear of reprisals. SCORE: 0.5 A better rested PIC likely would have fl own this leg, & likely would have increased chances of going around. However, it but probably would not have changed confusion over glideslope & ILS DH versus localizer MDA. Either wa y, the requirements would have enabled PIC to opt out of flight. 11. NTSB Identification: DCA07FA037, Pinnacle as No rthwest Express April 12, 2007, Traverse City, MI A/C: CRJ-200, N8905F Injuries: None Accident AAR-0802
Date : 4/12/2007 Accident Summary : Aircraft ran off the departure end of the runway during snowy conditions. Probable Cause : Probably cause was determined to be the pilots’ d ecision to land at TVC without performing a landing distance assessment, w hich was required by company policy because of runway contamination initially reported by TVC ground operations personnel and continuing reports of deteriorating weather and run way conditions during the approach. This poor decision making likely reflected the effects o f fatigue produced by a long, demanding duty day, and, for the captain, the duties associated wi th check airman functions90

Flight Crew/Fatigue Related Information: The accident occurred well after midnight at the en d of a demanding day during which the pilots had flown 8 .35 hours, made five landings, been on duty more than 14 hours, and been awake more than 16 hou rs. During the accident flight, the CVR recorded numerous yawns and comments that indicate that the pilots were fatigued. Additionally, the captain made references to being tired at 2332: 12, 2341:53, and 0018:43, and the first officer stated, “jeez, I’m tired” at 0020:41. Additionally, the pilots’ high workload (flying in inclement weather conditions, and in the captain’s case, prov iding operating experience for the first officer) during their long day likely increased their fatigu e. SCORE: 0.9 Crew was clearly tired & had been on dut y 15 hours as of accident time & 12:44 hours at pushback; The requirements would have pr ecluded this crew from taking this flight.

12. NTSB Identification: DEN07LA101, Great Lakes Ai rlines June 20, 2007, Laramie, WY A/C: BE-1900D, N253GL Injuries: None Accident DEN07LA101
Date : 6/20/2007 Accident Summary : The airplane landed long, bounced, and touched do wn again. The captain tried to slow down and turn the airplane off the ru nway on to a taxiway at high speed. During the turn attempt, the airplane departed the runway and the airplane's right propeller struck the top of an electrical box that powered the runway approach lighting system.91

Probable Cause : Probable cause was determined to be The pilot's i mproper decision, his misjudgment of his speed and distance, and his fail ure to perform a go-around resulting in the airplane overrunning the runway and striking an ele ctrical box. Factors contributing to the accident were the failure of the crew to perform pr oper crew resource management, the first officer's failure to intervene before the accident occurred, and the electrical box. Flight Crew/Fatigue Related Information: Only mention of flight crew schedule is the crew wa s on the third day of a three-day trip, which had sta rted in Cortez, Colorado, that morning at 0520. The crew had flown from Cortez to Denver, Colorado, to Farmington, New, Mexico, back to Denver, then to Laramie, and then to Worland. SCORE: 0.15 Given number of days & segments flown, the accident occurred precisely at NPRM's proposed limit of 11-hour duty day. The req uirements might have made a difference.

13. NTSB Identification: DCA09MA027, Colgan Air as Continental Connection February 12, 2009, Clarence Center, NY A/C: DHC-8-400Q, N200WQ Injuries: 50 Fatal Accident DCA09MA027 Accident Summary : Aircraft crashed into residence 5 nautical miles northeast of the airport and was destroyed by impact and post-crash fires. At 2217 Dash 8-Q400 by Colgan Air as Continental Co nnection crashed on ILS approach to runway 23 at BUF 5 NM NE of airport in Clarence Cen ter. FO arrived EWR on red-eye from West Coast via MEM at 0623. First flight @ 1300 can celled. Accident flight delayed; T/O EWR at 2120. Newly upgraded PIC (110 hours in M/M); FO (PF) had 700 hours in type. Steady, nonpertinent chatter enroute & throughout approach. FO notes little knowledge of icing. Other pilots92

describe light-moderate rime icing b/ 6,500 & 3,500 but none at 2,300. Accident A/C was in icing 9 minutes. De-icing system was "on" (which in creases speed at which crews get low-speed cue, but does not affect actual stall speed). At 22:15:14 BUF Approach cleared flight for ILS app roach to runway 23 (acknowledged). At 22:16:02, engine power levers were reduced to fligh t idle & Approach instructed crew to contact Tower. Crew extended gear & auto flight system capt ured ILS 23 localizer. PIC then moved engine conditions levers forward to max RPM positio n as FO acknowledged instructions to Tower. At 22:16:28 FO moved flaps to 10°, & 2 secon ds later stick shaker activated (warning of impending stall) & autopilot disconnected, with ”di sconnect” horn sounding until impact. Stickpusher then activated (to correct actual stall ). Crew added power to 75% torque. At 2216:37, FO told PIC that she had put flaps up; air speed now 100 knots, & roll angle reached 105 degrees right wing down before A/C began to rol l back to left & stick pusher activated second time (about 2216:40). Roll angle then reache d 35 degrees left wing down before A/C began to roll again to right. FO then asked whether she should put gear up; PIC responded “gear up” with expletive. Pitch & roll had reached 25 deg rees nose down & 100 degrees right wing down, when A/C entered steep descent. Stick pusher activated third time (at 2216:50), followed by impact. All 4 crew & 45 pax fatal; 1 ground fat al. (Not an icing accident.) Both pilots likely were significantly fatigued. B oth pilots were based at EWR. PIC lived near Tampa & FO lived near Seattle. Neither had “cr ash pad” at EWR & both regularly used crew room to sleep. PIC tried to bid trips that ens ured some nights in hotels at out-stations. At EWR he usually slept in crew room. FO always sleptin crew room at EWR & was open about it.93

PIC, recently upgraded, commuted to EWR on 2/9 from TPA; arrived EWR at 2005 & spent night in crew room. Phone records & log-ins to crew tracking system indicate he got little sleep. Reported for duty at 0530 on 2/10, flew 3 flights & arrived at BUF at 1300& had hotel room. Left hotel at 0515 on 2/11 to report at 0615. Again flew 3 flights & returned to EWR at 1544; spent rest of day & night in crew room. Again, phon e, tracking system & contact with others indicate very little sleep. FO commuted to EWR from SEA. She awoke on 2/11/ at 0900, arrived at PDX at 1730 for FedEx flight to MEM; arrived MEM at 0230 EST (2230 PST); had about 90 minutes of sleep on flight. She then T/O MEM at 0418 & arrived EWR at 0 623, sleeping for “much of” 2-hour flight. At EWR, she spent day in crew room & napped, but ph one, tracking system & conversations show she got little sleep. On 2/12, crew was scheduled for 3 flights: EWR-ROC; ROC-EWR; & EWR-BUF. First 2 cancelled due to winds at EWR & ground delays. Disp atch estimated 1910 departure for accident flight. Multiple delays; pushed back at 1945 & fin ally T/O 2120 for BUF. FO noted multiple times that she was not feeling well & before T/O sa id she was “ready to be at hotel” at BUF.

CAUSE: Captain’s inappropriate response to activati on of stick shaker, which led to stall from which A/C did not recover. Factors: (1) crew’s fail ure to monitor airspeed in relation to rising position of low-speed cue, (2) crew’s failure to ad here to sterile cockpit procedures, (3) PIC’s failure to effectively manage flight, & (4) Colgan’ s inadequate procedures for airspeed selection & management during approaches in icing conditions. NOTE: NTSB Cited fatigue in findings, but not in causal statement because NTSB said it co uld not determine “the extent of their impairment & degree to which it contributed to perf ormance deficiencies.” But clearly suggests94

it did contribute. NOTE: NTSB was divided on the is sue, with some arguing that the overwhelming issue was skills-based: pulling up to 30 degrees, not pushing power up all the way even well into the stall, and thereby missing sever al opportunities to allow the aircraft to fly out of the stall. In short, debate is this: though the crew clearly was fatigued, would the outcome have been any different if the same crew were bette r rested? Flight Crew/Fatigue Related Information : On the day of the accident, the captain was sched uled to report to EWR at 1330. Because his duty period o n February 11, 2009, had ended about 1544, he had a 21-hour, 16-minute scheduled rest period b efore his report time. However, at 0310 on February 12, the captain logged into Colgan’s CrewT rac computer system. This activity would have meant that he had, at a minimum, a 5-hour oppo rtunity for sleep followed by another sleep opportunity of about 4 hours. During the 24 hours t hat preceded the accident, the first officer was reported to have slept 3.5 hours on flights and 5.5 hours in the crew room. At the time of the accident, the captain would have been awake for at least 15 hours if he had awakened about 0700 and for a longer period if he h ad awakened earlier. The accident occurred about the same time that the captain’s sleep opport unities during the previous days had begun and the time at which he normally went to sleep. Th e first officer had been awake for about 9 hours at the time of the accident, which was about 3 hours before her normal bedtime. The captain had experienced chronic sleep loss, and bot h he and the first officer had experienced interrupted and poor-quality sleep during the 24 ho urs before the accident The pilots’ failure to detect the impending onset o f the stick shaker and their improper response to the stick shaker could be consistent with the kn own effects of fatigue. The NTSB concludes that the pilots’ performance was likely impaired be cause of fatigue, but the extent of their95

impairment and the degree to which it contributed t o the performance deficiencies that occurred during the flight cannot be conclusively determined SCORE: 0.5 Accident had many issues, but fatigue cl early was one of them. Both pilots had to be exhausted when they initiated approach to BUF. P IC was completing 4th day since awakening on 2/ 9. He had opportunity for quality sleep only on night of 2/10, & that was cut short with departure from hotel at 0515 on 2/11. Both pilots e ssentially stayed up all night on 2/11, with no opportunities for deep sleep, then found themselves operating late-night flight after day-long cancellations & delays. At one level, any rule thatmight have diminished this crew's fatigue could have been a show-stopper with a high score. However, crew had other basic problems. PIC clearly was not well versed in stall recognitio n nor response to stall (never went to full power, which likely would have enabled the aircraftto fly out of the stall in at least 2 points during the sequence). Same lack of recognition & k nowledge appears true of FO; she raised flaps during a stall. Being well rested would not have provided this crew with any more skill than they already had, it would not necessarily hav e averted the chatter sustained throughout flight, nor would it necessarily have led crew to e nter proper ref speeds for conditions. BUT more rest may have at least kept them tuned in enou gh to monitor airspeed. That alone could have averted the entire scenario. However, too man y other fundamental issues to score above 50%.