Flight Safety Pty Ltd
May 2010
Safety Alert
News from Flight Safety Pty Ltd
In This Issue
Audit Findings - Fatigue
Stress and fatigue on the increase
FAA told to address fatigue
Award for fatigue research
FRMS case study
Fatigue Risk Management Forum
Global Helicopter Flight Data
Non-Towered Airports
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Dear Colleage,

This month's topic is fatigue, especially pilot fatigue, and how to address it. We discuss the Audit Findings relating to fatigue and have included some case studies of the problem, but also some  valuable research and solutions involving Fatigue Risk Management Systems (FRMS).

In other news, there is a new Global Helicopter Flight Data  Monitoring (HFDM) Steering Group in the process of being formed, and some tips on the use of Non-Towered airports from NASA's Aviation Safety Reporting System - a USA perspective.


Colin Weir

Colin Weir, Managing Director
Flight Safety Pty Ltd
Audit Finding Analyses - Flight & Duty Time

Finding 4 - Fatigue 

National regulatory systems define the parameters for flight & duty times; in turn the AOC holder is responsible for rostering aircrew within these defined parameters.  Hypothetically the final line of defense is the crew member who is usually given a documented (Flight Operations Manual) right of refusal if he or she considers themselves to be too fatigued to fly.

The 'right of refusal' is the selected audit finding topic for this Newsletter, as global audit processes have revealed an insidious and potentially catastrophic double-bind situation that we are all aware of but powerless to control.

It relates to some organisations' tacit or otherwise expectation that aircrew will not decline a flight even if fatigued, due to commercial pressures often linked to financial stress - this in turn compromises the aircrew member, as all too often their job is in jeopardy.

It is common knowledge that aircrew can be fatigued beyond safe limits even though they are within statutory flight & duty time limits.

The solution to this problem is complex as it is dependent upon a combination of regulatory requirements, with integrity and self-discipline as critical core components.

An established 'Confidential Reporting System' is an important factor in solving this global problem.

Further Reading:

CASA FRMS Project >>

Transport Canada FRMS Toolbox >>
Stress and fatigue in aviation on the increase says Turkish researcher

Dr Ellen Rosskam
Dr Ellen Rosskam
Increasing demands, precarious work and a lack of financial security have made civil aviation workers more vulnerable to stress and fatigue.

That was the message put forward recently by a researcher looking into stress and fatigue as part of an International Transport Federation (ITF)  study. Speaking at a public meeting in Istanbul, Turkey, on 29 April hosted by the Turkish ITF-affiliated aviation union Hava-Is, Dr Ellen Rosskam, lead researcher on the ITF global stress and fatigue study, addressed pilots, cabin crew, ground staff, as well as airline representatives.

Rosskam explained why civil aviation workers, airlines and civil aviation authorities should be concerned about increased stress and fatigue levels and outlined responses received from ITF civil aviation affiliates during her research. She said:

"According to almost 90 per cent of aviation workers, jobs are getting more and more demanding. And an increase in precarious work means more job stress. Those had been coupled with decreases in social and economic security."

Read full article >>
FAA Told to Address Crew Fatigue in Aviation
Friday June 13, 2008

Go Jet After the crew of a commercial aircraft apparently went to sleep at the wheel and flew right over their destination airport, the National Transportation Safety Board (NTSB) has recommended that the Federal Aviation Administration (FAA) take steps to "address"  the effects of human fatigue in commercial aviation.

The NTSB urged the FAA to adopt regulations requiring airlines to establish fatigue management systems designed to increase the sleep time and quality of aircrews between flights, improve crew alertness, mitigate performance errors, and prevent incidents and accidents.

In making their recommendation, the Board cited four fatigue-related incidents occurring since 2004, one resulting in the deaths of both pilots and 11 passengers.

Perhaps the most bizarre incident took place on Feb. 13, 2008, when Go! flight 1002, operated by Mesa Airlines flew beyond its destination airport, General Lyman Field, Hilo, Hawaii. For over 18 minutes air traffic controllers at General Lyman Field tried without response to contact the Go! crew, as the plane continued over Maui, the big island of Hawaii and continued flying southeast over the Pacific Ocean. After flying 26 miles beyond the airport, the crew responded and returned to land at General Lyman Field. There were no injuries, probably just a lot of embarrassment and extensive discussion with the FAA.

"Addressing this safety related measure is long overdue," said NTSB Chairman Mark V. Rosenker in a press release. "We must and can correct this serious concern." Let's all hope Chairman Rosenker is correct.

Source: About.com >>
Clemson professor receives national award for research on pilot fatigue

Professor Scott Shappell A Clemson University professor's work to identify fatigue and other human factors that lead to airplane accidents has earned him the top award from the Aerospace Human Factors Association.

Scott Shappell, an industrial engineering professor, has received the 2010 Henry L. Taylor Founder's Award for outstanding contributions in the field of aerospace human factors.

"Scott Shappell is a well-known human-factors professional who has made significant contributions to the field," the association wrote in presenting the award. "In addition to his early work on fatigue and shift work, he is probably best known for his research in the areas of human error, human-factors safety-management systems and fatigue effects on performance."

Shappell is co-developer of two important tools, the Human Factors Analysis and Classification System (HFACS) and Human Factors Intervention Matrix, that are used to identify and prevent human factors associated with accidents in high-risk industries such as aviation, mining, rail, energy and medicine.

Read full Press Release >>
FRMS case study - easyJet

easyJet FRMS was covered in the November-December 2008 - Issue No. 65 of Flight Safety Australia Magazine.

Ben Cook, CASA's human factors manager, examines the importance of fatigue risk management systems (FRMS), and looks at a best-practice implementation of FRMS by the UK-based easyJet.

Download the Managing Fatigue article (PDF) >>

Visit the Flight Safety Australia Nov Dec 08 archive >>
Airlines launch fatigue risk management forum

Fatigue A group of airlines working with UK research company Qinetiq has set up a fatigue risk management forum to help the industry share best practice in controlling the dangers of pilot, cabin crew and engineer fatigue.

The International Civil Aviation Organisation has already ruled that fatigue risk management systems (FRMS) should become standard in the industry - over and above flight time limitations - and the European Aviation Safety Agency is preparing to mandate FRMS as a part of every airline's safety management system (SMS).

At Qinetiq's main base in Farnborough, UK, delegates from 52 organisations all over the world met to agree arrangements for launching the Fatigue and Risk Management Forum. On 8 May they unanimously voted the organisation into existence. The main airline players involved in setting up the forum are Air New Zealand, EasyJet, Delta Air Lines and Virgin Atlantic, but many more carriers sent representatives, as did regulators from Australia, Europe, New Zealand and the UK.

Forum members have agreed to meet again in a year, (May 2010) by which time the website should have assumed its basic shape.

Read full article at Flight Global >>
Global Helicopter Flight Data Monitoring Steering Group Formed

Helicopter Data VANCOUVER, Canada (30 April 2010)   Driven by a desire to increase helicopter safety by promoting best practice and cooperation in the design, support and operation of Helicopter Flight  Data Monitoring (HFDM), a new organization has formed to bring all aspects of the industry together   the Global Helicopter Flight Data Monitoring Steering Group. The Global HFDM Steering Group was formed following the CHC Safety & Quality Summit held in Vancouver, Canada at the end of March.

Bringing together more than 70 people representing 48  organisations from across the globe, the Steering Group seeks to make HFDM as accessible as  possible to all operators both large and small, by sharing information with the intent of making  HFDM easy for operators to implement. The wide adoption of HFDM has been recognized as a key initiative by the International Helicopter Safety Team, formed in 2005 with a vision of reducing the  rate of civil helicopter accidents by 80% within 10 years.

The Global HFDM Steering Group will publish information on its website at www.HFDM.org which is expected to be ready in the near future; it will also be linked to the IHST website www.IHST.org, which will host information in the interim.

Read full press release at IHST.org >>
Safe Operations at Non-Towered Airports

Sedona Non-Towered Airport
Sedona Non-Towered Airport
The key to communicating at an airport without an operating Control Tower is selection of the correct common frequency for airport advisories while operating to or from the airport. CTAF, which stands for Common Traffic Advisory Frequency, is designated for this purpose.

Use of the correct CTAF, combined with visual alertness and application of recommended operating practices, will enhance safety of flight during non-Towered operations.

April's Callback focuses on ASRS non-Towered airport incidents that emphasize the following themes:
  • Communication - Monitoring CTAF and use of the radio to report position and intentions.
  • Traffic Mix - Being aware that straight-in IFR traffic to a non-Towered field may conflict with patterns for VFR traffic, especially in reduced visibility conditions (broken or overcast ceilings, haze, etc.).
  • Avoidance - Practicing see-and-avoid procedures and visually checking the final approach course before takeoff or landing.
  • Frequency - Use of the correct CTAF and current charts and flight information.
Read NASA's April Callback >>