Ouch: Both Pilots Of Ethiopian Airlines 737 Fall Asleep, Miss Approach

Ouch: Both Pilots Of Ethiopian Airlines 737 Fall Asleep, Miss Approach

49

An Ethiopian Airlines flight earlier this week was a bit longer than usual. The reason? Both pilots were sound asleep, and didn’t wake up until the autopilot disengaged, and a loud alarm went off.

Ethiopian Boeing 737 overshoots Addis Ababa Airport

The Aviation Herald reports on an incident that happened on Monday, August 15, 2022, on Ethiopian Airlines flight ET343 from Khartoum, Sudan (KRT), to Addis Ababa, Ethiopia (ADD). The flight was operated by a roughly 12 year old Boeing 737-800 with the registration code ET-AOB.

The relatively short 620-mile flight was blocked at 1hr50min, and was scheduled to depart Khartoum at 3:30AM and arrive in Addis Ababa at 6:20AM (with a one hour time change).

The flight departed as planned, and climbed all the way up to 37,000 feet. There was only one problem — the plane stayed at 37,000 feet even when it reached Addis Ababa Airport, because both pilots fell asleep. How do we know?

  • Air traffic controllers attempted to reach the pilots multiple times, without response
  • The plane continued on the approach course for runway 25L that was entered into the flight management computer (FMC); that means the plane made the correct approach, it just didn’t descend at all (since altitude adjustments have to be programmed separately)
  • After overflying runway 25L at 37,000 feet (the runway is at an altitude of ~7,600 feet, so they were 29,000+ feet too high), the autopilot disconnected, and clearly that alarm woke up the pilots

After the pilots woke up, they ended up performing another approach, and touched down on runway 25L around 25 minutes later. Below you can see a visualization of the approach, with the purple line being the initial approach (at 37,000 feet), and then the turquoise line being the second approach (where the plane actually landed).

An Ethiopian Airlines Boeing 737 overshot Addis Ababa Airport

It’s my understanding that both pilots have been suspended, pending the results of an investigation.

My take on this Ethiopian Airlines incident

First of all, unfortunately both pilots falling asleep probably happens more often than you’d expect (we’re talking on flights without relief crews). We hear about these incidents every so often, and those are just the ones that are reported. Think of all the times both pilots doze off without anyone noticing.

In many cases airlines even allow “controlled rest,” where one pilot can doze off at the controls for a limited period of time. Of course that concept relies on the other pilot being able to stay awake.

What makes this situation noteworthy is for just how long both pilots were asleep, as they missed their approach for 20+ minutes. They weren’t woken up until the autopilot disengaged as they were over the runway (except way too high), and an alarm went off. It’s kind of terrifying to wake up to the sounds of the autopilot disengaging, no?

Pilot fatigue is a huge issue across the industry, and I think it’s easy enough to see the factors that contributed to that here. Presumably the pilots were doing an overnight turn to Khartoum, so you can imagine why they’d be tired at this point in the morning.

Then there are Ethiopian Airlines specific factors. While the airline has become a huge success story for African aviation, unfortunately the airline doesn’t have a great reputation with pilots or with its overall safety culture (just check out the discussions on pilot forum PPRuNe).

There are plenty of reports of pilots flying well over 100 hours per month, and on top of that pilots work on a system of “X days on, X days off” (often 20 days on and then 10 days off), so they do a lot of flying in short periods of time. That obviously contributes to fatigue as well.

Bottom line

An Ethiopian Airlines Boeing 737 overshot Addis Ababa Airport earlier this week, after both pilots fell asleep. The pilots didn’t respond to air traffic controllers, and only woke up when the autopilot disengaged as they were over the runway at Addis Ababa Airport (only 29,000+ feet too high).

Fortunately the plane landed safely, but this sure is a scary incident. Sometimes it’s better that we don’t know what’s happening on the other side of the cockpit door…

What do you make of this Ethiopian Airlines pilot story?

Conversations (49)
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  1. iamhere Guest

    Your comment about Ethiopian Airlines safety - Well it can't be that unsafe if it is part of the Star Alliance. Also, many of the larger up and coming airlines do hire foreign pilots and flight crew and for training as they do not have enough qualified staff.

  2. koggerj Guest

    3rd worlders aren't as capable as their American counterparts. Just look at the max crashes as examples. when Us pilots were put in the sim they could easily handle the trim runaway emergency.

    1. jetjock64 Guest

      @Bender - Certitude based on ignorance is worth what you pay for it--just about nothing. Under your theory, we really don't need astronauts, deck officers on ocean liners, or any other kind of human intervention capability for automated systems. What about all those killed or maimed by the so-called Tesla autopilot? How would you like to be a passenger on a plane headed for a crash without a human on board to "save the day?"...

      @Bender - Certitude based on ignorance is worth what you pay for it--just about nothing. Under your theory, we really don't need astronauts, deck officers on ocean liners, or any other kind of human intervention capability for automated systems. What about all those killed or maimed by the so-called Tesla autopilot? How would you like to be a passenger on a plane headed for a crash without a human on board to "save the day?" You'd gladly be a guinea pig? Maybe you're re-thinking your theory at this point.

    2. jetjock64 Guest

      They knew it was coming.

  3. Azamaraal Diamond

    It is not a surprise that this happened to Ethiopian Airlines given their difficulty in hiring experienced pilots for their extensive network. Not surprising is that they were probably either overworked or did not manage sleep well.

    Without opening up a can or worms it is no surprise that pilot inexperience/ability was a factor in the Ethiopian 737 Max incident.

    1. Sean M. Diamond

      @Azamaraal - Your information is incorrect. The accident report did not cite either pilot experience or ability as a factor in the accident. To the contrary it specifically stated that the pilots "repeatedly performed all the procedures provided by Boeing to address the situation", but in vain.

    2. GS in PDX Guest

      Sean M. - perhaps you had better read up a bit more on Ethiopian and their pilot culture first. Sure, the accident report that was put out by their government doesn't lay fault with their government employed pilots - of course not, that would make them look bad. So, of course, full fault to Boeing and the aircraft, instead of any fault to pilot training. (I would presume to see the same thing with the...

      Sean M. - perhaps you had better read up a bit more on Ethiopian and their pilot culture first. Sure, the accident report that was put out by their government doesn't lay fault with their government employed pilots - of course not, that would make them look bad. So, of course, full fault to Boeing and the aircraft, instead of any fault to pilot training. (I would presume to see the same thing with the Lion air crash, although those pilots were not government employed since Lion is privately owned) It is quite interesting that several North American airlines were flying the Max successfully before the two very unfortunate crashes happened. Why would you expect that to be? #1 reason in pilot training.

    3. Azamaraal Guest

      Thanks GS

      Unofficial reports written by experienced pilots indicated inexperience and panic were involved. One pilot had 1000 hours on type approximately.

      In the Lion Air crash the aircraft experienced the same problem with the angle of attack indicator and the experienced pilot successfully handled the problem. Maintenance supposedly fixed the problem but the next pilot(s) could not correct procedure to save the craft.

      The Max 8 was flown safely for thousands of takeoffs and...

      Thanks GS

      Unofficial reports written by experienced pilots indicated inexperience and panic were involved. One pilot had 1000 hours on type approximately.

      In the Lion Air crash the aircraft experienced the same problem with the angle of attack indicator and the experienced pilot successfully handled the problem. Maintenance supposedly fixed the problem but the next pilot(s) could not correct procedure to save the craft.

      The Max 8 was flown safely for thousands of takeoffs and landings with experienced crew around the world. The problem was noted by some and I believe Boeing issued a notam on the issue before the crashes. Boeing should have done more for those new to the 737 but that is hindsight.

      The Max is now definitely the safest aircraft in the skies at this time.

  4. Lieflat19 Member

    how do i become a diamond member or OMAAT?

    1. Andrew Diamond

      Honestly, I have it and have no idea. I'm on the page every day and comment every day. That seemed to work, but perhaps Ben can explain the tiers.

    2. Ben Schlappig OMAAT

      @ Lieflat19 -- Thanks for the interest. It's all explained here:
      https://onemileatatime.com/insights/omaat-gold-diamond-status/

      :-)

  5. Andrew Diamond

    Oh boy. Taking an Ethiopian flight from Narita to Inchon in a few weeks. This should be fun.

  6. Robert D Guest

    It’s fascinating to me how some people can fall asleep sitting up. I struggle to fall asleep in my own bed.

  7. M C V Jose Guest

    The flight was in the WOCL- Window of Circadian Low and fatigue adds to the problems. Controlled Rest with another crew member ( can be cabin crew) in the cockpit when one of the pilots take 'the power nap' is the answer.

    1. foo blah Guest

      The correct answer is to remove humans from the cockpit. Automation is to the point where the human in the loop is redundant and also by far the biggest risk to safety.

    2. GS in PDX Guest

      Yes, and I am sure that all humans are going to trusts a bunch of robots at the controls. That will be the day!!

  8. Bob Guest

    No support from me.
    I worked 7 years midnight shift and was pretty tired many times.
    I was a supervisor and I never fell asleep.
    It would have put my 9 man crew in danger and loss of a job and career.

  9. CT Dub Guest

    100 hours a month is strenuous?

    Newly licensed MDs (resident physicians) in the US used to routinely work 100+ hours per week during some portions of their residency. (And yes, I mean 100 hours/week, not 100 per month.)

    That wasn't a good idea. Current limits of 80 hours per week are much more reasonable for doctors taking care of patients.

    Look, the issue here is there should be backup safety systems in place to wake...

    100 hours a month is strenuous?

    Newly licensed MDs (resident physicians) in the US used to routinely work 100+ hours per week during some portions of their residency. (And yes, I mean 100 hours/week, not 100 per month.)

    That wasn't a good idea. Current limits of 80 hours per week are much more reasonable for doctors taking care of patients.

    Look, the issue here is there should be backup safety systems in place to wake up both pilots when they've fallen asleep.

    But the issue is not that they are overly exhausted. It's that their job is generally so routine and automated that they are bored and tired.

    1. jetjock64 Guest

      You may think it's so routine and automated, but the stress of being responsible for the lives of up to hundreds of people keeps you on your toes your whole time in the air (EXCEPT for those who don't properly plan their sleep-awake cycles and then wind up succumbing to their bodies' sleep need). You are, for every minute of the flight, forming a backup plan for ANYTHING that can possibly happen--especially any one of...

      You may think it's so routine and automated, but the stress of being responsible for the lives of up to hundreds of people keeps you on your toes your whole time in the air (EXCEPT for those who don't properly plan their sleep-awake cycles and then wind up succumbing to their bodies' sleep need). You are, for every minute of the flight, forming a backup plan for ANYTHING that can possibly happen--especially any one of dozens of possible, however remote, inflight emergencies or urgencies for which you practice, and some you don't. I would speculate, based on the cascade of stressors produced in your body on a say, 3- or 4-hour flight is probably the equivalent of seeing patients and writing up your reports in a 12-hour day. My daughter and her husband are both physicians, and so my "equivalency theory" is not totally unfounded.

    2. Bender Guest

      yes, your equivalency is unfounded. at most, it's a one to one. The real answer is to get humans out of the cockpit and automate the whole thing, as humans are always the biggest risk to safety. Yes of course a human saves the day once in a while, but most of the issues are caused by them. Until then, use the tech from self-driving cars that gives an alarm when the driver's attention is not on the road or they doze off.
      the ultimate solution is to #killAllTheHumans

    3. jetjock64 Guest

      @Bender - Certitude based on ignorance is worth what you pay for it--just about nothing. Under your theory, we really don't need astronauts, deck officers on ocean liners, or any other kind of human intervention capability for automated systems. What about all those killed or maimed by the so-called Tesla autopilot? How would you like to be a passenger on a plane headed for a crash without a human on board to "save the day?"...

      @Bender - Certitude based on ignorance is worth what you pay for it--just about nothing. Under your theory, we really don't need astronauts, deck officers on ocean liners, or any other kind of human intervention capability for automated systems. What about all those killed or maimed by the so-called Tesla autopilot? How would you like to be a passenger on a plane headed for a crash without a human on board to "save the day?" You'd gladly be a guinea pig? Maybe you're re-thinking your theory at this point.

    4. JohnHam Member

      100 hours per month is flight hours, not real world hours

  10. Geta chanie Guest

    It was only 1hr50min flight, the probability of pilots being fall a sleep is very low as it is relatively very short voyage. There must be something else for the situation happened.

    1. Lieflat19 Member

      i thought the exact same thing

    2. jetjock64 Guest

      You don't know how many legs they had already operated that day. A series of short-leg operations, especially where there are weather approaches, can can be orders of magnitue more stressful than any single flight of whaterver length. Or, maybe they just stayed up too late.

    3. Sean M. Diamond

      @jetjock74 - The information I have is that the crew reported at midnight for two sectors ADD-KRT-ADD with 0700 hrs scheduled signoff.

  11. Jerry Diamond

    Yes, these pilots shouldn't have been sleeping, but it really is amazing how safe commercial aviation is. If your bus/Uber/train driver falls asleep, you're not as likely to reach your destination as safely as you are on a plane.

  12. David Guest

    A cup of Tomoca coffee would have prevented that.

  13. Evan Guest

    I knew middle-of-the-night departures were common at extremely busy airports like DXB, but why does there need to be a 3:30 AM departure from Sudan to Ethiopia? I doubt it's a slot control or ATC issue. The much busier domestic US market manages to hum along without 3 AM departures. Pardon my ignorance, this is just interesting to me.

    1. Sean M. Diamond

      It arrives at 630am into Addis Ababa which gives connecting flight opportunities to over 40 destinations in the morning bank.

    2. JH Guest

      It's probably a general safety issue.

    3. Azamaraal Diamond

      It is temperature and altitude.

      Flights leave most countries at that latitude because the lower temperatures after midnight improve engine performance, increase air density and allow a more efficient flight with maximum payload not necessarily available in high temperatures in daytime.

    4. Sean M. Diamond

      It has absolutely nothing to do with that. Ethiopian flies multiple times a day between Addis and Khartoum with flights departing throughout the day including the afternoon heat peak.

  14. Eskimo Guest

    Can we remove humans yet?

    The most common cause of aviation incidents, human error.

    1. Brandon Biden Guest

      Reminds me of 80's movie War Games, when they take the humans out of the "loop" and it proves a mistake

    2. Eskimo Guest

      @Brandon Biden

      You also remind me of 80's movie Terminator, when Judgement days comes.
      It's a movie.

      @Dan77W

      You are missing the point entirely.
      Out of all those non combat crashes, how many attributed to mechanical issues, how many to airmanship (pilot error + computer error) In other words, if you replaced AI with human could it prevent the crash vice versa if you replace human with AI could it prevent the crash.

      That is what you should be looking for.

    3. JH Guest

      The US military has millions of hours of data to support the safe operating of autonomous aircraft.

    4. Dan77W Guest

      And hundreds of crashes not due to combat!

  15. Aaron Guest

    Remember Ethiopian 409?

    This was ruled pilot fatigue. All passengers died

  16. Zaki Rehman Guest

    People would be quick to blame Boeing if anything happens when this is the standard of pilots in Africa and South East Asia. As a proud Boeing shareholder I believe inadequate pilot training played a huge role in the MAX incidents. Funny how no hulls were lost in Europe, The USA or the Gulf where pilots are actually trained adequately.

    1. Sean M. Diamond

      Actually, my sources within Ethiopian advise me that the captain was an expatriate.

    2. JH Guest

      A poor safety culture is a poor safety culture irrespective of nationalities.

      But poor safety cultures are much more common in the developing world even if it is politically incorrect to point it out.

    3. Ksa63 Guest

      Expatriate from where? I hope not somewhere where pay to fly occurs.

    4. david Guest

      In the sense that Boeing was trying to get the MAX certified without additional training requirements I suppose you have a point. But that's on Boeing.

    5. JH Guest

      My customer was one of the two airlines that crashed a Max.

      They are great people but I wouldn't fly their airline because I saw their poor safety culture first hand.

      The public was gaslight by the media and Twitter to believe that Boeing was 100% at fault.

      Look at the so-called experts that this website uses as sources...Airlineflyer being one of the worst.

    6. Tilahun Girma Guest

      What about this? Stop biased reporting. Ethiopian is known for its safety!
      ***
      In April, pilots at Southwest Airlines and
      Delta Air Lines pressed airlines to address pilot fatigue amid climbing demand for travel and staffing shortages.

      "Fatigue, both acute and cumulative, has become Southwest Airlines' number-one safety threat," the Southwest Airlines Pilots Association, or SWAPA, told airline executives in a letter.

  17. SMR Guest

    This is a MAJOR issue worldwide, but more so here in the USA. Many airlines have pilots fly redeye turns. 2 flights through the WOCL. A true nightmare and a disaster waiting to happen. no augmented crews and no controlled rest.

  18. JayC Member

    I appreciate this article, as i didn't know that it's a thing for pilots to fall asleep being the wheel. Hopefully Ethiopian Airlines makes pilot friendly changes due to this incident and your article too.

Featured Comments Most helpful comments ( as chosen by the OMAAT community ).

The comments on this page have not been provided, reviewed, approved or otherwise endorsed by any advertiser, and it is not an advertiser's responsibility to ensure posts and/or questions are answered.

Sean M. Diamond

It arrives at 630am into Addis Ababa which gives connecting flight opportunities to over 40 destinations in the morning bank.

9
Sean M. Diamond

Actually, my sources within Ethiopian advise me that the captain was an expatriate.

7
TravelinWilly Diamond

They must have been tired.

4
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