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Diffusing A Ticking Time bomb

This is the first of a two-part series that looks at fatigue in the aviation industry. Part one highlights both air and ground employees. Part two will focus on pilot fatigue.

An important consideration is the physiological and mental state of crew members whose bio-rhythms and bodily functions may or may not be aligned with local time.

In March 2010, the CBC TV program “Dead Tired” painted a fearful picture of air accidents allegedly caused by pilot fatigue. Scenes of U.S. pilots living in campers on waste grounds at Los Angeles International Airport, earning starvation wages and going to work “dead tired,” caused a public outcry. The CBC focused in part, on the February 2009 Colgan Airlines crash at Buffalo, N.Y., highlighting the fact that the co-pilot was fatigued due to a pre-flight commute to Newark, where she arrived 33 hours after waking in Seattle. However, the NTSB investigation report placed the blame on the (deceased) captain (who had commuted from Tampa). Board members could not agree on the extent to which pilot fatigue contributed to the crash but “recommended” airlines address the problem of pilots travelling many hours by air before takeoff and needing a place to sleep.

“Everyone wants to turn their head away from this commuting issue,” said NTSB chairwoman Deborah Hersman. “The pilots don’t want to talk about it; the airlines don’t want to talk about it.” Cold comfort for many – including pilots, bereaved families and the public, who might have been reassured by direction to the FAA as opposed to just recommendations to airlines. Furthermore, is it true that “pilots don’t want to talk about it”? They talked to the CBC; and to the press when they picketed the board meeting of Pinnacle Airlines Corp. in Minneapolis on May 21, 2009, just after the NTSB released its report on the Colgan crash. Pinnacle (a Delta connector) owns Colgan and was reported by pilots to be paying first officers about the same as dishwashers and construction labourers.

So what is happening in Canada? The CBC was critical of Transport Canada (TC), which unlike the U.K. and New Zealand for example, does not yet fully apply the 2009 amendment to ICAO Annex 6 by making CARs Flight Time Limitations, science-based. This includes consideration of the physiological and mental state of crew members whose bio-rhythms and bodily functions may or may not be aligned with local time. It also defines the Window of Circadian Low (WOCL) – the period between 02:00 hours and 05:59 hours, referenced to a crewmember’s acclimatized location. However, TC has established a new CARAC fatigue risk management working group which will address these issues.

While critical of some smaller airlines and the low salaries of many first officers, CBC did not highlight the fatigue management programs of the major Canadian airlines. CBC included the quote, “Paying passengers don’t care – they’ll scream bloody murder if fares go up 20 per cent.” This is key to the problem – the downward pressure on aviation employee costs comes from the travelling public as well as shareholders. Low salaries mean poor living conditions and stress which contribute to, and exacerbate fatigue – issues highlighted by Dr. Simon Bennett in the November 2009 Royal Aeronautical Society “Aerospace Professional.” Bennett, who describes pilots as “men and women who labour long and hard at the coalface of commercial aviation,” spoke of the “squalor” of the U.S. regional airline industry and said that the Colgan crash “demonstrates this is an industry in crisis.”

But fatigue affects all operational aviation workers. In 1990, the windshield of a British Airways BAC1-11 blew out (almost taking the Captain with it) and was largely blamed on maintenance engineer (AME) fatigue and human factors (HF) issues. Action followed and recent years have seen real progress on AME fatigue (e.g., Flight Safety Foundation, “Working to the Limit,” April 2008). The University of South Australia did groundbreaking work and was contracted by Transport Canada to produce the Fatigue Risk Management System (FRMS) and Toolkit for the Canadian Aviation Industry, published in 2007.

The crux of the issue
Fatigue is not just about feeling tired because of a hard days work, nor is merely limiting the length of the workday or flight duty the answer to the problem. Fatigue is about insufficient or poor quality sleep and the consequences arising. It is easy to forget that if you are deprived of sleep for long enough, you will die.

The Canadian Aviation Maintenance Council (CAMC) has taken a proactive approach to fatigue management, and program director Glenn Priestley affirms that regulatory aspects of fatigue management “is not an issue – what we care about is the employee.” Mike Doiron, CEO of Doiron Aviation Consulting is developing the CAMC training system, workshop and FRMS tool box. He thinks that Transport Canada (TC) is “backing away from heavy-handed regulation” and moving to a position of “this is what you should do, here are the guidelines and as a good corporate citizen you must analyze your responsibilities, risks, hazards and operational issues, and manage them proactively.”

In 2001, aided by NASA fatigue expert Dr. Mark Rosekind, NAV CANADA launched its Fatigue Management Program (FMP).

Priestley stresses, “we are not pre-empting CARAC (CARs Advisory Committee), because we already have the tools and a clear mandate to go forward, since CARs already require HF training for AMEs – and one of the human factors is fatigue. We are going ahead with our workshop, with the best people in Canada working on it, and know this is the right thing to do, because a non-fatigued worker is safer.”

“We are proud of how we support the aviation and aerospace workers,” continues Priestley. “HF training changed the way many AMEs dealt with hours of work and fatigue issues. The work culture has changed and CAMC believes that HF training has helped employers understand the importance of a reasonable work day to ensure employee effectiveness.”  

Doiron’s concerns about FRMS implementation include tracking and privacy issues, since operators can only be responsible for tracking the time that a person has been scheduled and worked, although an operator might be able to keep track of other employee duties – such as moonlighting for another employer. “The hours of sleep an employee has when off-duty, and the nature of that sleep,” he says, “is not directly any of my business as an operator. In any case, how reliable would the information be that an employee might give as to his/her off-duty time?”

“That,” says Priestley, “is why there are two sides to our project. It will put some onus on the employee – the off-duty lifestyle may have to be different from what it was 20 years ago.”

In October 2008, TC Advisory Circular SUR-001 expected that CAR 573 would be amended to require FRMS in all AMOs in 2009. This did not happen and the TC and regulatory situation will be reviewed in the next article.

A similar perspective
Like AMEs, air traffic controllers work irregular hours and in 1999, with the formation of the ATC fatigue working group of Transport Canada, NAV CANADA and CATCA, NAV CANADA was a leader in introducing a fatigue management policy. In 2001, aided by NASA fatigue expert Dr. Mark Rosekind (now a member of the U.S. NTSB), NAV CANADA launched its Fatigue Management Program (FMP). As Larry Lachance, assistant VP Operations and Procedures stresses, “Fatigue Management is one of 16 Corporate Safety Policies that are the core components of the Company’s Safety Management System. The FMP is fully integrated in NAV CANADA’s safety management policy, with fatigue management a joint responsibility between the Company and its employees; based on education, alertness strategies and scheduling practices.”

Finally, we must avoid the trap of a narrow focus on fatigue alone. Just as most accidents are the result of several contributing factors, the consequences of fatigue are exacerbated by other human factors. Being fatigued is dangerous; being fatigued and stressed and distracted and under pressure is a recipe for catastrophe.