by Bill Monan

One 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.

Contributing Factors

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.

• "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 over-eagerness 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, one chagrined flight crew was informed that they had exited the aircraft with an engine still running at the gate.

General aviation pilots are not immune to the homeitis disease. As one rueful G/A pilot reported: "My ground speed dropped off...I had a choice of either landing to refuel or to continue. I decided to press on. At 4 miles out, the engine went to idle. At 2-1/2 miles out, the engine stopped."

GetHomeItis is a disease that can also afflict a pilot who is fresh and rested, but we're willing to bet that fatigue both occasions and compounds the problem.

Complacency

Perhaps the most welcome sight in aviation is the familiar home airport coming into view on the horizon, especially after a long, hard series of downline flights. However, the subtle slide into psychological letdown, (frequently cited in last-flight-of-the-day narratives), can lead to error, embarrassment or hazard. Noted one reporter: "Having the field in sight and being very familiar with local area, I came off the gauges and busted my altitude." Another reporter in reflection of his deviation noted: "I was complacent about checking the approach plate and in flying our normal procedures." A captain who strayed off the route was apologetic: "Since it was the last leg home, I put away my charts. Next time I'll leave them out."

Cockpit Management

The omission of cross-checking and crew concept monitoring duties was a common factor in last-flight-of-the-trip circumstances. "We were relaxed," admitted one reporter. "We were too relaxed," insisted another [emphasis added]. Common errors include selection of wrong VOR and ILS frequencies, radials, and DME distances; incorrect comprehension and readback of clearances; and misinterpreted runway assignments. Pilots psychological let-down in vigilance and cross-checking were frequently cited: "Not paying attention to what the captain was doing...," "not monitoring theF/O's actions...," "the crew let down their guard...lost backup monitoring...."

Looking for Solutions

Awareness of the potential for each of us to be a victim of fatigue, complacency, and GetHomeItis is the first step in the cure of the disease.

Combatting Fatigue

Fatigue is insidious. Without realizing its progressive impact upon alertness and attentiveness, tired pilots drift toward passivity, inertia and lethargy. In an increasingly competitive industry, air carrier pilots often cite scheduling as the major contributor to fatigue. There is little advice the author can give airline flight crews except to eat well and get as much rest as possible. General aviation pilots often have more control over their schedules and should plan for adequate rest periods.

Professionalism

By definition, complacency is not recognized as a problem in the cockpit while the flight is in progress. Complacency as a factor in flight crew error is identified only in post-incident reflection. None of us is immune to the condition of complacency. Working hard to maintain a professional attitude at all times will go a long way in providing a degree of immunity from the affliction. (By the way, you don't have to be a fly-for-hire pilot to strive for professionalism; even the newest student pilot needs to develop a professional attitude.)

Cockpit Management

Maintain proper cockpit and flight crew monitoring, and observe duty priorities. Projecting thoughts forward to post-arrival details distracts pilots from the tasks at hand.

It Ain't Over 'Til...

"The last leg of the flight should be flown in the same way as the first flight of the day," stated one reporter, "or else it might be the last flight in the pilot's career."