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by Bill Monan
O ne of the routine details frequently noted in pilots’ incident
reports submitted to the ASRS is the seemingly innocuous
statement, “This was the last leg of the flight.” Terminology in other
reports varies only slightly: “The last flight of the day,” “the final
leg,” and “the end of a long day.”
These air carrier, commuter, and corporate/general aviation pilots were involved in altitude
“busts,” heading/course deviations, missed crossing restrictions, active runway transgressions,
and other, less typical operational incidents.
What is there about the “last leg” that is fundamentally different from any other leg? Let’s take
a look at some of the factors involved in last-leg operations in the reports reviewed for this
article.
ContributingFactors
Fatigue
Reporters identified fatigue as an obvious
source of error. ASRS narratives included
statements such as “fighting bad weather all
day,” “multi-approaches to ILS minimums,”
and “delays” merged with “end of a long
thirteen hour duty day,” “the ninth and last leg
of a long day.” Such descriptions often prefaced
complaints such as “a little tired” and
“somewhat fatigued” to “work[ed] out,” and
“punchy,” and “mentally and physically
exhausted.” “After all,” contended one pilot,
“some inattention is to be expected at the end of
a long duty day.”
A good case can be made that fatigue contributed
to subsequent breakdowns in discipline
and procedure, and to attention problems.
Attention Problems
Loss of concentration was referenced in flight
crews explanations of last-leg errors such as
crossfeeds left ON, pressurization switches left
OFF, and misreading of systems gauges and
switches. Two flights departed without adequate
fuel on board. “I glanced at the fuel
gauges,” stated one first officer, “but what I
was looking at did not register.” The second,
and compounding error came about “when
both the captain and second officer looked at
the three fuel gauges, each reading 5,000
pounds, and came up with a total of 30,000.”
Forgetfulness plagued the pilots. A number of
flight crews “forgot” to call the tower for
landing clearances. “Just too many landings
for the day,” explained one reporter. Flight
crews neglected to reduce to 250 knots below
10,000 feet, to make crossing restrictions, to
tell the other pilot of the ATC re-clearance
and, on two occasions, “forgot to let down.”
Fatigue-induced loss of concentration and
breakdown in cockpit coordination is well
illustrated in the following narrative.
ASRS Directline 19
eg Syndrome continued…
Last
“Last leg of the flight. Driving along at flight
level 370, inbound to home, so I’m letting my
guard down a bit. The controller gives us a
clearance to descend, to cross 35 miles of
XYZ at 19,000… A little later, another
clearance, this time to cross 5 miles W[est] at
13,000. The controller added, ‘See if you can
make this one.’ What happened? We had
stayed at our cruise altitude. The captain
didn’t catch it and I missed it because I was
so darned tired I was letting him run the
store.”
Another flight crew failed to read the
checklist. “We advanced the throttles to
takeoff power. Upon hearing the [takeoff]
configuration warning horn, I glanced down
to verify the warning and was totally
surprised to see the flaps in the UP position.
I could hardly believe we had forgotten to
read the taxi checklist and to extend the
flaps!”
GetHomeItis
GetHomeItis is cockpit jargon for pilot anticipation
and eagerness to get finished with the
day’s work. ASRS analysts include
GETHOMEITIS as a diagnostic term when
reviewing reports that demonstrate an overeagerness
to get home. “I let my desire to get to
the airport overshadow good judgment,” stated
a commuter pilot who opted to land straight-in
at a non-tower airport without bothering to
call in on UNICOM. A near collision occurred.
An air carrier First Officer, reporting on a
runway transgression, stated that “The
Captain had homeitis. On our arrival at home
base, he was taxiing faster than normal to get
to the gate. Next time I’ll ask, ‘Where’s the
fire?’ ” In perhaps the ultimate embarrassment,
　
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