Human Factors and Accident reduction/mitigation

Owen DeLong owen at delong.com
Sat Nov 7 12:04:34 CST 2009


On Nov 6, 2009, at 12:04 PM, JC Dill wrote:

> Owen DeLong wrote:
>>
>> We could learn a lot about this from Aviation.  Nowhere in human  
>> history has
>> more research, care, training, and discipline been applied to  
>> accident prevention,
>> mitigation, and analysis as in aviation.  A few examples:
>>
>>    NTSB investigations of EVERY US aircraft accident and published  
>> findings.
>
> Ask any commercial pilot (and especially a commercial commuter  
> flight pilot) what they think of NTSB investigations when the pilot  
> had a "bad schedule" that doesn't allow enough time for adequate  
> sleep.  They will point out that lack of sleep can't be determined  
> in an autopsy.

As a point of information, I _AM_ a commercial pilot.

> The NTSB routinely puts an accident down to "pilot error" even when  
> pilots who regularly fly those routes and shifts are convinced that  
> exhaustion (lack of sleep, long working days) was clearly involved.   
> And for even worse news - the smaller the plane the more complicated  
> it is to fly and the LESS rest the pilots receive in their overnight  
> stays because commuter airlines are covered under part 135 while  
> major airlines are covered under part 121.  My ex flew turbo-prop  
> planes for American Eagle (American Airlines commuter flights).  It  
> was common to have the pilot get off duty near 10 pm and be requited  
> to report back at 6 am.  That's just 8 hours for rest.  The "rest  
> period" starts with a wait for a shuttle to the hotel, then the  
> drive to the hotel (often 15 minutes or more from the airport) then  
> check-in - it can add up to 30-45 minutes before the pilot is  
> actually inside a hotel room.  These overnight stays are in smaller  
> towns like Santa Rosa, Fresno, Bakersfield, etc.  Usually the pilots  
> are put up at hotels that don't have a restaurant open this late,  
> and no neighboring restaurants (even fast food) so the pilot doesn't  
> get dinner.  (There is no time for dinner in the flight schedule -  
> they get at most 20 minutes of free time between arrival and take- 
> off - enough time to get a bio-break and hit a vending machine but  
> not enough time to actually get a meal.)  Take a shower, get to bed  
> at about 11:30.  Set the alarm for 4:45 am and catch the shuttle  
> back to the airport at 5:15 to get there before the 6:00 reporting  
> time.  In that "8 hour" rest period you get less than 6 hours of  
> sleep - if you can fall asleep easily in a strange hotel.
>
Flying in such a state of exhaustion is, whether you like it or not, a  
form of pilot error.

A pilot who chooses to fly on such a schedule is making an error in  
judgment. Sure, there are
all kinds of pressures and employment issues that need to be resolved  
to reduce and eliminate
that pressure, and, I support the idea of updating the crew duty time  
regulations with that
in mind.

That does not change the fact that FAR 91.3 still applies:

Sec. 91.3

Responsibility and authority of the pilot in command.

(a) The pilot in command of an aircraft is directly responsible for,  
and is the final authority as to, the operation of that aircraft.
(b) In an in-flight emergency requiring immediate action, the pilot in  
command may deviate from any rule of this part to the extent required  
to meet that emergency.
(c) Each pilot in command who deviates from a rule under paragraph (b)  
of this section shall, upon the request of the Administrator, send a  
written report of that deviation to the Administrator.

A failure to declare him/herself to be incapable of safely completing  
the flight is a failure to meet
the requirements of 91.3(a).

> Commuter route pilots have been fighting to get regulations changed  
> to require longer overnight periods, and especially to get the  
> required rest period changed to "behind the door" so that the  
> airlines can't include the commute time to/from the airport in the  
> "rest" period.  This would force the airlines to select hotels  
> closer to the airport or else allow longer overnight layovers -  
> either way the pilots would get adequate rest.  See:
>
> http://asrs.arc.nasa.gov/publications/directline/dl5_one.htm
>
And that would be a good change.

In part, that change is supported by the number of times that the NTSB  
has made statments
such as:

We find the probable cause of the accident was pilot error. We believe  
that fatigue was likely
a factor in the accident.

> The NTSB does a great job with mechanical issues and with training  
> issues, but they totally miss the boat when it comes to regulating  
> adequate rest periods in the airline schedules.

No, you miss the boat on the relationship between the stakeholders.

The NTSB has repeatedly commented on the need for better regulations  
and better studies
of crew duty time requirements and fatigue as a factor in accidents  
and incidents.

However, the NTSB CANNOT change regulations. They investigate  
accidents and make
recommendations to the regulatory agencies. The FAA needs to be the  
one to change the
regulations.  The FAA has not done a particularly good job in  
addressing this topic, where
they have done a better job in improving mechanical and training  
issues and have been
more likely to follow up on NTSB recommendations in these areas.  In  
part, that is the
result of reduced pushback on the FAA in these areas from industry.  
After all, Boeing does
NOT want to publicly say "We think that this mechanical factor the  
NTSB just determined
as the cause of 400 fatalities isn't really an issue and the FAA  
should not issue an AD
to make us correct it."

On the other hand, it's much harder for the kind of public feedback  
loop that exists in
the above statement to apply to crew fatigue issues.

In any case, this has drifted well off the NANOG topic, and, I would  
be happy to discuss
the NTSB, FAA, etc. with you off-list if you wish.

> To bring this back to NANOG territory, how many times have you or  
> one of your network admins made a mistake when working with  
> inadequate sleep - due to extra early start hours (needless 8 am  
> meetings), or working long/late hours, or being called to work in  
> the middle of the night?
>
Sure, this happens, but, it's not the only thing that happens.

> Finally, having lived with a commercial aviation pilot for 5 years  
> and having worked with network types for much longer, I can say that  
> while there is some overlap between pilots and IT techs, there are  
> also a LOT of people who go into computers (programming, network and  
> system administration) who are totally unsuitable for the regimented  
> environment required for commercial aviation - people who HATE  
> following a lot of rules and regulations and fixed schedules.  If  
> you tried to impose FAA-type rules and regulations and airline  
> schedules on an IT organization, you would have a revolt on your  
> hands.  Tread carefully when you consider to emulating Aviation.
>
That's very true.  I wasn't advocating that we should emulate  
aviation, so much as I was attempting
to point out that if you want to reduce accidents/incidents, there is  
a proven model for doing so
and that it comes at a cost. Today, we actually seem, and in my  
opinion, rightly so, to prefer
to live with the existing situation.  However, given that is the  
choice we are making, we should
realize that is the choice we have made and accept the tradeoffs or  
make a different choice.

Owen




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