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Fatigue Continues to Cause Accidents

Mon, Apr 21, 2008 — David Evans

Briefs

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Drowsy pilots, mechanics and air traffic controllers are involved in too many accidents, according to Member Steven Chealander of the National Transportation Safety Board (NTSB). Testifying 10 April 2008 before the Senate Commerce, Science and Transportation Aviation Subcommittee, he provided an excellent summary of the problem, but reflected the NTSB’s pallid position that only a “fatigue countermeasures training program” is needed for air traffic controllers, despite ever changing shift schedules that guarantee fatigue. Nonetheless, Chealander’s testimony reflects a good overview of the sleeplessness problem:

“The Safety Board has long been concerned about the issue of operator fatigue in transportation and has stressed its concerns in investigation reports issued throughout the 1970s and 1980s. In 1989, the Board issued three recommendations to the Secretary of Transportation calling for research, education, and revisions to existing regulations.

NTSB Member Steven Chealander

“These recommendations were added to the Board’s ‘Most Wanted’ list in 1990, and the issue of fatigue has remained on the ‘Most Wanted’ list since then. [In other words, the recommendations have not been acted upon for 18 years.] The Safety Board’s 1999 safety study of DOT [Department of Transportation] efforts to address operator fatigue continued to show that this problem was widespread. Operating a vehicle without the operator’s having adequate rest, in any mode of transportation, presents an unnecessary risk to the traveling public. The laws, rules, and regulations governing this aspect of transportation safety are archaic …

“Flight Crews

“In December 1995, the FAA [Federal Aviation Administration] issued an NPRM [Notice of Proposed Rulemaking] to update the flight and duty regulations for airline pilots; however, in the intervening 12 years, the regulations have not been revised. The FAA has attempted on three occasions to reach consensus with the industry on a proposed rule but has not succeeded.

“FAA’s ARAC [Aviation Rulemaking Advisory Council] upon reviewing Part 135 regulations has recently made some recommendations to simplify and improve the duty time regulations for flight crews covered by Part 135 [on demand and commuter operations]. The FAA recently advised the Safety Board that it is developing an NPRM that incorporates the ARAC’s recommendations; the NPRM will include a fatigue risk management system that provides an alternative to prescriptive limitations.

“The Safety Board recommended 14 years ago that the FAA close the loophole in the regulations regarding hours of duty for flight crews that allowed crews to be on duty flying for much longer periods of time than allowed under Part 121 [scheduled airlines] or Part 135. The 1995 NPRM proposed revisions that were responsive [to the Safety Board’s recommendations], however, those revisions resulted in considerable controversy and the FAA withdrew the NPRM. The Safety Board’s concern that flight crew fatigue is a significant aviation safety issue continues today, yet little or no action has been taken by the FAA and they have not indicated any firm plans to take the recommended action.

“Maintenance Personnel

“In 1999, the FAA issued a report entitled Study of Fatigue Factors Affecting Human Performance in Aviation Maintenance. The FAA completed the first phase of the expanded study and issued a report in April 2000 entitled Evaluation of Aviation Maintenance Working Environments, Fatigue, and Maintenance Errors/Accidents. The expanded study looked at multiple and combined environmental factors of temperature, noise, light, vibration, and sleep, which are known to accelerate fatigue onset, as well as the effects of lifestyle habits on fatigue and human performance … The data were intended for use in predicting situations that are conducive o fatigue, accidents, incidents and errors.

“The FAA’s findings suggest that fatigue is an issue in this work force. Data from ‘mini-logger monitors’ that recorded data from selected parameters of light, noise levels, and temperature; activity monitors that [captured] physical activity, sleep, and sleep quality; and he answers to background questions that employers were asked clearly indicate that sleep durations are inadequate … For most aviation maintenance … specialties, 30-40 percent of respondents reported sleep duration of less than 6 hours, and 25 percent of respondents reported feeling fatigued or exhausted.

“The FAA has consequently conducted education and training activities on fatigue management for aircraft maintenance personnel. The Safety Board reviewed Advisory Circular (AC) 120-72, ‘Maintenance Resource Management (MRM) Training,’ which seems to be the primary focus of the FAA’s education and training initiatives related to fatigue among aviation maintenance crews. We found little in AC 120-72 that provides guidance on human fatigue … other than generalized warnings that attention to fatigue is important and should be considered in MRM Training. …

“The Safety Board disagrees that regulating hours of service for aviation maintenance crews is not appropriate. In addition, the Board’s reviews of the FAA’s education activities related to reducing fatigue among maintenance crews shows them to be limited and of questionable value.

“Air Traffic Controllers

“In 2007, the Safety Board issued recommendations to the FAA and the National Air Traffic Controllers Association regarding air traffic controller fatigue. The Safety Board had investigated four incidents that provided clear and compelling evidence that controllers are sometimes operating in a state of fatigue because of their work schedules and poorly managed utilization of rest periods between shifts and that fatigue has contributed to controller errors. Controller fatigue decreases aviation safety [but] the FAA has been slow to change controller-scheduling practices.

“The FAA has convened a working group to develop shift rotation and scheduling guidelines [note the word ‘guidelines’ as opposed to ‘regulations’], and it is our understanding that last month the National Air Traffic Controllers Association (NATCA) provided information on fatigue and scheduling practices. … NATCA has informed the FAA and the Safety Board of … its commitment to developing workable scheduling practices that minimize controller impairment due to fatigue.

“Action Remaining

  • “Issue regulations [emphasis added] that establish scientifically based duty time limitations for air carrier maintenance personnel and flight crews. [Note: the NTSB appears to be ignoring contract maintenance facilities, where ever more airlines are outsourcing the maintenance of their airplanes.]

  • “Develop a fatigue awareness and countermeasures training program [emphasis added] for controllers and those who schedule them for duty.”

What’s of interest here is the failure to recommend regulations for air traffic controllers – people employed by the FAA and over which the agency has the most control (not to mention the potential to set the example for limiting fatigue).

The action remaining could well be limited to a single sentence:

“Issue regulations that establish scientifically based duty time limitations for flight crews, maintenance personnel [both these employed by air carriers and those who work in independent maintenance facilities] and air traffic controllers.”

The virtue of such a recommendation is simplicity and treating the work schedules of all personnel in safety-critical positions the same.


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