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04 November 2007

To Sleep, Perchance to Dream: How a Recent NASA Controversy Helped to Publicize the Case of the Sleeping Pilots

The previous post discussed a recent decision by NASA management to withhold the results of a safety survey of 24,000 pilots. While that study, part of the $11.3 million National Aviation Operations Monitoring Service (NAOMS) program has received plenty of recent media attention, it is completely different from the long running Aviation Safety Reporting System (ASRS). In place since 1976, the ASRS collects, analyzes, and responds to voluntarily submitted aviation safety incident reports in order to lessen the likelihood of aviation accidents. These reports can be from pilots, air traffic controllers, flight attendants, maintenance technicians and others. Unlike NAOMS, which until last month NASA had planned to keep from the public, information from the ASRS database has long been widely available to the public.

ASRS relies on voluntary reports, primarily from the people who may have committed a violation of FAA regulations. For pilots and others involved in the aviation industry, a key benefit of reporting a violation is that there will be no civil penalties or suspension of an FAA-issued certificate if the violation was inadvertent, did not involve criminal activity, was reported within 10 days of the event. There may be sanctions for the person reporting if the event involved an accident, discloses a lack of qualification or competence, or if the person reporting has had an FAA violation or been subject to an FAA enforcement action in the previous five years.

On the 31st of last month, NASA chief Michael Griffin testified in a hearing called by the House Science and Technology Committee of the U.S. Congress ( that the plan to keep NAOMS data from the public was a mistake and that the report would be released. The value of publicly releasing aviation safety data was illustrated in the hearing when a 2004 event from the ASRS database was discussed. During that event, the two pilots on a late night flight from Baltimore to Denver both fell asleep, with the captain being awakened by frantic calls from air traffic control. Fortunately, the crew was able to land without further incident.

As frightening and potentially dangerous as this event was, it would have been far more damaging to the level of airline safety had there been no outlet like ASRS to get this kind of information out in the open. NASA was concerned that releasing the NAOMS data would have made the public hesitant about flying. That ASRS event mentioned in the hearing certainly got plenty of coverage, but in none of that coverage was there any reports about passengers canceling reservations and avoiding airports. NASA’s administrator Griffin publicly admitted that it was a mistake to have this kind of attitude about the public. We should all hope that these lessons are followed by the rest of NASA.

Accessing ASRS Data
If you want to look at this report of the sleeping pilots, just head on over to the ASRS web site at There you can read about the organization and search the database for events of interest. The March 2004 sleeping pilot event has the event number 611329. While the report does not mention a specific airline, the only U.S. airlines flying the type of aircraft involved (Airbus A319) were United and Frontier. An edited version of the captain's narrative of the event is included below:

Had been doing four months of stand-up's. Late report, fly to DFW airport, arrive and go to motel and rest approx eight hours, fly back to Denver. For the month of March, had a schedule change to 'red eyes,' which consists of leaving Denver, fly to Baltimore and one hr turn-back to Denver. No rest, just straight 7 hour 55 minute flight to Baltimore and back. On this particular day after two previous red eyes, this being third red eye in a row, last 45 minutes of flight, I fell asleep and so did the first officer. Missed all calls from air traffic control (ATC) to meet crossing restrictions at (a particular waypoint about 60 miles southeast of Denver) of 19,000 feet altitude and 250 knots airspeed. Instead, we crossed (the waypoint) at 35,000 feet and Mach 0.82. I woke up, why I don't know, and heard frantic calls from air traffic control approximately five miles inside of (the waypoint). I answered ATC and abided by all instructions to get down. Finished all checklists and landed in Denver with no further incidents. Was not told to call ATC, but did file report with company. Attribute incident to pilot fatigue, and hopefully company is in process of changing these trip pairings.

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