Fatigue: The pilot’s common cold

Returning from a short tropical vacation, I barely napped on the transatlantic red-eye. It was the night before my third airplane instructional flight. During the ground lesson, I thought I was hiding my jetlag pretty well from my instructor. It turns out he saw through my ruse and blindsided me with one of his own.

My CFI told me to do a preflight inspection, which I did and then notified him that everything looked in order. We walked back out to the aircraft, where he led me to the tail and the exposed cables for the tail control surfaces. The inspection panel cover was gone.

“How the heck did I miss that?”

The CFI pulled the inspection panel cover from his pocket and told me to do another preflight. In my second check, I found a screwdriver lodged in next to the oil dipstick, a small pin pushed into the pitot tube, and a wad of gum stuck onto one of the flap extenders — all placed there on purpose by my instructor. That made four things I had overlooked. My fatigue had blinded me.

Fatigue is like the common cold. At some point, everyone succumbs.

For me, fatigue meant small inconsistencies that I had not trained myself to spot during the preflight had escaped me. None was inherently life-threatening. An absent panel of that size might only have meant a lot of noise in flight. Trying to take off with a pin in the pitot tube would have resulted in no airspeed indication, and I would have aborted. Again, not life-threatening.

Gum on the flap extender? In the worst-case scenario, it could have led to an asymmetrical flap condition. Not a plane killer. Even a screwdriver in the engine compartment most likely would not have brought down the airplane. All in all, the number of things I had failed to see had been embarrassing, yet instructional.

Persistent fatigue can present in the form of dulled senses, which in turn can create unintended hazards to others.

“We arrived at the gate and completed the shutdown checklist,” wrote one pilot in an Aviation Safety Reporting System report, commonly called a NASA report.

“After the passengers deplaned, the captain went into the terminal and I remained on board. I got up to talk to the purser for a couple minutes. Ground crew called and asked when we were going to shut down the #1 engine. I looked over, and to my amazement, it was still running! I can’t remember the last time I did something so moronic. I think fatigue caused me to miss this important item.”

Imagine how tired this pilot had to be to fail to hear or feel the motor turning. Now imagine if a ground crew member wearing hearing protection had walked into the “cone of death” in front of the running engine while servicing that jet.

Fatigue can also present as optical delusion. This same pilot went on to describe how both he and the captain thought they saw the engine master switch and fuel flow indicator in the off position. If fatigue is powerful enough to cause two people — ostensibly backing up each other — to view the same item mistakenly, imagine what it can do to you, the single pilot operator, without backup.

Forgetfulness is another way fatigue can rear its insidious head. This flight crew certainly discovered that: “After taking the runway for departure, I called for line-up items, which the first officer read off as being completed. When I advanced the throttles, we got a red master warning light and a three-beep takeoff trim warning. Not only had the first officer forgotten to put the trim in the green, he had forgotten to turn on the transponder and to preselect the assigned departure clearance frequency. Most importantly, I forgot to back him up.”

Part 121 airline rules are designed to help airline pilots avoid fatigue. They have duty day limits, minimum rest periods and maximum daily flight hour limits. Yet airline pilots fall victim to fatigue on a daily basis.

To a large extent, we GA pilots are left to fend for ourselves. That’s why the FAA established the IMSAFE checklist (Illness, Medication, Stress, Alcohol, Fatigue, Eating or Emotion). Based upon concepts of the military’s Operational Risk Management matrix, IMSAFE forces us to honestly self-assess. That, in turn, helps us say no to ourselves when we want to fly fatigued.

Despite the industry’s best intentions, the IMSAFE checklist is just that — a checklist. It is not ironclad. Nor is it legally enforceable. It is a set of guidelines intended to help us make a conscious choice.

If nothing else, the NASA reports I have cited here indicate that fatigue is not always obvious. Moreover, we cannot always decline a flight. Sometimes we have to launch.

In those instances, tricks my instructors taught me are useful. Something as simple as touching the knob, switch or panel you are about to move or inspect is helpful. Using tactile cues to back up visual ones adds another layer of safety. This works the same way a checklist backs up a flow.

Calling out items during a high workload flight regime is another way to battle fatigue. Research has proven that speaking a task aloud while doing it aids in recall during periods of distraction.

I encourage my students to “talk it out,” especially during solo flights. A solo flight is a high stress event fraught with anticipation, anxiety and agitation. Often my students have hardly slept the night before, or wound themselves up into such a state of excitement they are already fatigued well before they yell “Clear prop!”

It is an easy thing to spot the performance differences between those who talk it out and those who do not. At the airport, my students are readily identifiable as “the ones who talk to themselves.”

Odd as it may sound, talking aloud to yourself can actually be a great gauge of your own fatigue level. If you can’t articulate simple commands, then you are probably in a fatigued state.

This first officer discovered that skipping a meal resulted in misreading a Standard Instrument Departure procedure, which caused an altitude deviation.

“This was the second day of a grueling four-day trip with a captain who was new to me. We were on the second leg of a four-leg trip, and I forgot to eat between flights. I set us up for the Pitt 5 departure, then ‘as filed’ back to KIAD. I told the captain our initial altitude would be 5,000 feet, based on the SID’s textual description. He concurred without looking.

“We took off and proceeded on up to 5,000 feet. Upon handoff to Departure Control, I reported in: ‘Level 5,000.’ Departure Control then repeated three times, ‘Clearance gave you 5,000?’ Departure then suggested we re-read the Pitt 5 SID. Turns out I’d seen the procedure for turbojets and interpreted it to mean turboprops. I attribute the error to fatigue due to not eating anything for several hours prior to that flight.”

We don’t really know how big a problem fatigue is for GA pilots. What we do know is that most of us habitually sleep fewer than the optimal eight hours a night. We do know that most of us work too long and exercise too little. And we do know that most of us don’t eat that well.

Based upon what we do know, it is arguable that for most of us, fatigue is the new normal. If the best things we can take away from these fatigued NASA reporters are “see it and touch it,” “eat before flying“ and “talk out the task,” we have inoculated ourselves against the pilot’s common cold — fatigue.


  1. Dennis Reiley says

    Unless it’s life or death why would anyone fly when they know they’re fatigued? Are we now going to have to pass a psychological test to determine if a pilot is safe to be licensed to fly? Because I never want to be anywhere near that pilot when he’s airborne.

    • Jeffrey Madison says

      Dennis, you make an interesting point. My point in writing this piece is that many times, people are fatigued without even knowing it. In this rush rush, never turn off any gadgets, always stay connected world, most people operate in a low-level fatigue state.

  2. Mark Creighton says

    Thanks for this latest one Jeffrey. I’m beginning to look forward to your observations. Your “slice of life” examples keep it on a “yeah, that could be me” plane rather in the abstract. My greatest worry in a preflight is the constant interruptions from passengers, text and telephone and not doing it completely.

    • Jeffrey Madison says

      Great point, Mark. It never occurred to me before reading your comment, but now I’m going to extend the “sterile cockpit” concept of no extraneous chatter to the preflight inspection, too Mark you’re a genius!

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