Fatigue in air ambulance accident

This week at ISS we’ve been talking about a positive development in the area of fatigue management – and that is a shift in culture towards trust and honesty. In July, a report was released on a 2017 Air Ambulance accident in Alaska in which fatigue was a factor. We think the contents of the report represent a really positive shift, Dr Adam Fletcher says, “the fact that the pilots were so open during the interview about when they realised fatigue was setting in, is honestly cause for celebration because it’s a very recent shift that pilots trust that they are not going to be personally made liable.”

On 21 October 2017, at c0530 Local Time, Beechcraft King Air 200 N363JH, operated on a Part 135 Air Ambulance flight by Bering Air, was damaged in an unintentional gear-up landing at the Ted Stevens Anchorage International Airport (ANC), Alaska. The pilot, two flight medics and medevac patient were uninjured.

During a post-accident interview, the pilot stated that he, “… felt real good flying the airplane from Nome to Anchorage. Just the fatigue started to set in when I was coming in the outer ring of the Class C airspace into Anchorage.” He added, “I feel like my judgment was impaired at the end of the flight.”

The pilot accepted responsibility for the accident and, to his credit, reflectively identified five mitigating factors:

  1. Long duty period (13 hours). I felt clear and alert at the beginning of the flight, however my alertness began to diminish at the beginning of the arrival phase of the flight.
  2. I failed to manage my rest accordingly.
  3. I failed to manage the cockpit accordingly. Had I selected flaps beyond approach flaps I would have received a gear handle light and a warning horn.
  4. I failed to check for the 3 gear down and locked lights.
  5. I am feeling very comfortable in the BE20 [KA200]; however, I allowed for complacency to set in.


When I spoke to Adam, he saw the response to this accident as a really positive shift in the industry, “five years ago, they would have been genuinely worried about losing their license or getting sued, and so they would have just shielded that they were falling asleep or having fatigue issues… The pilot is to really be commended for being brave enough to be honest about the fact that fatigue crept in. We basically need more trust in these investigative processes and systems so that we can learn from events and hopefully not repeat them,” he said.

One gap we did recognise was the need for comprehensive fatigue management training for these pilots. We offer a variety of comprehensive and cost-effective training options, including our flagship Advanced Fatigue Management Course and our Aviation focused 1-Hour Fatigue Management Awareness Course, and we encourage you to get in touch with us to learn more about these and our other solutions.

If you want to learn more about the accident and report click here:


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