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The Case Of The Sleepy Air Canada Pilot

Old 04-17-2012, 04:38 PM
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From Associated Press:

TORONTO — A sleepy Air Canada pilot who mistakenly believed his jet was about to crash into a U.S. military plane forced a sudden dive that caused 16 injuries among passengers and crew on a transatlantic flight, a report says.
The Transportation Safety Board report released Monday describes the 46 seconds in which the plane dived and lurched back up during an overnight Air Canada flight from Toronto to Zurich in January 2011. Those hurt weren't wearing seat belts, the report said.
According to the report, the plane's first officer was napping during a rest period aimed at combating pilot fatigue when the captain's report on their position woke him.
At the same time, a U.S. Air Force plane was approaching about 300 yards (meters) below. That set off cockpit alerts, which the captain mentioned to the first officer.
The "confused and disoriented" co-pilot at first mistook the planet Venus for the approaching plane, the report said. When he did spot it, he thought it was coming straight at them. He overrode the autopilot by forcefully pressing on the control column, pushing the jet into a dive.
Fourteen passengers and two flight attendants among the mostly 103 sleeping people aboard slammed into parts of the plane, getting cuts and bruises.
The captain regained control as the U.S. military plane passed safely and returned the plane to its cruising altitude.
"This occurrence underscores the challenge of managing fatigue on the flight deck," Jon Lee, the investigator in charge, said in a statement.
Seven of the injured were treated in the hospital on arrival in Zurich three hours later.
The investigation found that the first officer, who had been asleep for about 75 minutes, was suffering "sleep inertia" magnified by fatigue.
The report said flight crews were not following standard procedures for "strategic napping," which is normally of 40 minutes duration. Pilots are supposed to have 15 minutes after a nap to awaken properly before taking control, according to safety protocols.
Capt. Paul Strachan, president of the Air Canada Pilots Association, said the incident shows Canada needs to mandate a third pilot for eastbound transatlantic flights instead of the in-flight rest periods.
"Canada's regulations are stark in their insensitivity to the science of fatigue," Strachan said.
Air Canada spokesman Peter Fitzpatrick said the company had already taken steps to address the fatigue issues. Pilots who feel they are too tired to fly have to report it, and a non-punitive system allows them to withdraw from assignments.
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Old 04-17-2012, 06:29 PM
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Sooo, is this saying that it is SOP at air canada for one pilot to take a nap on a night overwater flight as long as its less than 40 minutes? It's an actual procedure?
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Old 04-17-2012, 07:11 PM
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Who hasn't taken evasive for Venus at a strategic time?

One dark night in IMC over the CA coastal range, ZOA told me "Cessna XXX, when you break out, traffic will be at your 12 o'clock and 22 million miles, Venus." Apparently three aircraft had taken evasive before me.
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Old 04-17-2012, 10:30 PM
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Originally Posted by Tom a Hawk View Post
Sooo, is this saying that it is SOP at air canada for one pilot to take a nap on a night overwater flight as long as its less than 40 minutes? It's an actual procedure?
Not sure about SOP in the Great White North but elsewhere in the world it's an accepted procedure and known as "controlled rest". Down here, if you want a 40minute nap, you let the FA's know and they make sure not to disturb you until your time is up. The other guy puts all the straps on and wakes you up after your 40 mins. Also, you have to be awake no later than 20 mins before TOD.

The only time our guys tend to use it is on a red-eye or a late night transcon.
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Old 04-18-2012, 02:06 AM
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Originally Posted by jedinein View Post
Who hasn't taken evasive for Venus at a strategic time?

One dark night in IMC over the CA coastal range, ZOA told me "Cessna XXX, when you break out, traffic will be at your 12 o'clock and 22 million miles, Venus." Apparently three aircraft had taken evasive before me.
Same deal with Hale-Bopp comet a few years back. Similar readback/warning, but the controller added "traffic not a factor".

- stolen from the "On The Air" section of IFR magazine.
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Old 04-18-2012, 03:41 PM
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Originally Posted by Kenny View Post
Not sure about SOP in the Great White North but elsewhere in the world it's an accepted procedure and known as "controlled rest". Down here, if you want a 40minute nap, you let the FA's know and they make sure not to disturb you until your time is up. The other guy puts all the straps on and wakes you up after your 40 mins. Also, you have to be awake no later than 20 mins before TOD.

The only time our guys tend to use it is on a red-eye or a late night transcon.
Interesting, I just assumed that the only time you got rest was if you had a relief officer who came up and you went back to the bunk or first class or wherever.
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Old 04-18-2012, 07:35 PM
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Without giving away the details, an allied aircraft was lost in the first Gulf War, at night, because he thought Venus was a missile targetting his aircraft. He did a vertical defensive maneuver, and while fixated on the non-moving light, impacted the ground.
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Old 04-19-2012, 01:18 AM
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Originally Posted by UAL T38 Phlyer View Post
Without giving away the details, an allied aircraft was lost in the first Gulf War, at night, because he thought Venus was a missile targetting his aircraft. He did a vertical defensive maneuver, and while fixated on the non-moving light, impacted the ground.
Single seat? Very unfortunate.
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Old 04-19-2012, 05:07 AM
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Originally Posted by N9373M View Post
Single seat? Very unfortunate.
No, two.

I can vouch that it (Venus) was extremely bright during the war (in February, after the weather cleared-up). Most of us had not flown over such uninhabited areas at night. Our 'normal night sky' was where the light of cities washes-out the stars. During the war, I saw astronomical sights I didn't even know could be seen from an airplane. Many aircraft reported in mission-debriefs they had been illuminated by "Iraqi aircraft with searchlights," which were, in fact, merely Venus.

Ten years later, flying eastbound over the Pacific in the 747, I would see Venus ahead, just before dawn. Even though I was 99.99% certain it was Venus, atmospheric debris makes it seem to 'twinkle,' and I would see alternating red, green, and white...so that it appeared to be aircraft position lights or logo/recognition lights.

My point is that it isn't unreasonable this AirCan pilot could mistake Venus for an airplane, even with TCAS correlation. It's happened to many others.
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Old 04-19-2012, 07:51 AM
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Plenty of visual illusions night over water w/o horizon.

Heck, I've even maneuvered to avoid oncoming traffic that turned out to be a tower in the distance - 300' on a dark night w/NVGs can produce some interesting illusions as well.

This article seems to make it all about the sleep inertia, but in reality, it's a visual illusion. More susceptible with some sleep inertia? I don't know - maybe, possibly - but even wide awake and alert you're susceptible.
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