"On August 18, 1993 at 1656 eastern daylight time, a Douglas DC-8-61 freighter, registered to American International Airways, Inc., operating as AIA flight 808, collided with level terrain approximately 1/4 mile from the approach end of runway 10, after the captain lost control of the airplane while approaching the Leeward Point Airfield at the U.S. Naval Air Station, Guantanamo Bay, Cuba. The airplane was destroyed by impact forces and postaccident fire, and the three flight crewmembers sustained serious injuries. Visual meteorological conditions prevailed, and an instrument flight rules plan had been filed. The flight was conducted under 14 Code of Federal Regulations, Part 121, Supplemental Air Carriers, as an international, nonscheduled, military contract flight."
"The National Transportation Safety Board (NTSB) conducted a review of this accident and determined that the probable causes of the accident were the impaired judgment, decision-making, and flying abilities of the captain and flightcrew due to the effects of fatigue. The Board also identified additional factors contributing to the cause were the inadequacy of the flight and duty time regulations applied to 14 CFR, Part 121, Supplemental Air Carrier, international operations, and the circumstances that resulted in the extended flight/duty hours and fatigue of the flightcrew members." (NTSB, 1994)
The Fatigue Countermeasures Group, at the request of the NTSB, provided analysis of the pertinent sleep/duty factors preceding this accident, and provided input to the Board which proved decisive in their probable cause determination. The combined effects of cumulative sleep loss, an extended period of continuous wakefulness, and circadian factors were determined to have significantly affected the performance capabilities of the flightcrew.
This represents the first time that the NTSB has cited fatigue as the probable cause in a major aviation accident. NTSB recommendations included, "expedite the review and upgrade of Flight/Duty Time Limitations of the Federal Aviation Regulations to ensure that they incorporate the results of the latest research on fatigue and sleep issues;" and "include, as part of pilot training, a program to educate pilots about the detrimental effects of fatigue, and strategies for avoiding fatigue and countering its effects."
GuantanamoBay.pdf (6.5 MB for the full report)
GB-factual.info.pdf (2.7 MB)
GB-analysis.pdf (1.4 MB)
GB_concl-app.pdf (2.0 MB)