November 1, 2014 - 1:19am
It’s difficult for me–and perhaps many of you who have worked late night shifts, as well–to read the NTSB’s preliminary report of the UPS Airbus A300 that crashed in the early morning hours of August 14 last year just short of the runway in Birmingham, Ala., and not think of our own experiences working midnight shifts. Both the pilot and copilot were killed and the aircraft was destroyed. This accident, like any aircraft accident–especially one with fatalities–is disturbing to those of us who have spent our lives in aviation, but particularly so when the circumstances of the crew hit uncomfortably close to home.
In this case, the Board shines a bright–if not harsh–light on the personal decisions many of us midnight-shift workers make all too frequently: to use the hours we should be sleeping to take care of personal or family matters. For these crewmembers, fatigue might have contributed to the accident that took their lives. In other cases, fatigue has led to mechanics and other airport workers making mistakes that can cause or be contributing factors in aircraft accidents or can be factors in their own injuries or even death on the ground.
In its investigation of the UPS crash, the NTSB found the probable cause of the accident was the flight crew’s “continuation of an unstabilized approach and their failure to monitor the aircraft’s altitude,” which ultimately caused the airplane to crash into terrain. But it found contributing factors that included “the captain’s performance deficiencies likely due to factors including fatigue…and…the first officer’s fatigue due to acute sleep loss resulting from her ineffective off-duty time management and circadian factors.”
The NTSB report highlights the issue of personal accountability for off-duty time management, as well as fatigue awareness. In the preliminary accident report, the NTSBstates: “review of the first officer’s use of her off-duty time indicated that she was likely experiencing fatigue, primarily due to improper off-duty time management. Even though the first officer was aware that she was very tired, she did not call in and report that she was fatigued, contrary to the UPS fatigue policy.” The first officer apparently used her time off to visit a friend instead of sleeping.
Support at All Levels
This is an all-too-familiar scenario for shift workers, especially those working midnights. I worked midnights for many years and I know how life frequently intrudes on hours you should be sleeping, especially with family obligations that occur during those daylight hours that are supposed to be your sleep time. All manner of family events–from school plays to weddings–are scheduled for the 9-to-5 world. Even catching up with friends is difficult to do if you work midnights. Of course, much less was known scientifically about the impacts of fatigue back when I was turning wrenches. But we all knew no sleep left us drowsy, irritable and susceptible to mistakes. The one advantage we had in those days as mechanics was that our staffing was not as barebones as it is today. If you were exhausted, you could take a nap and your coworkers would cover for you. We all did that for each other. But it’s not that easy today with reduced staffing and cameras everywhere. Of course, it’s always been harder for two-person pilot crews to get a quick nap in once they started a flight, especially on a short hop from Louisville, Ky., as was the case in the UPS crash.
While the NTSB highlights personal accountability in its report, it also recognizes the importance of supporting pilots in thinking about fatigue and includes recommendations on this issue to the FAA, the airline and the pilot’s union, the Independent Pilots Association. It recommended that the FAA ensure that air carriers with overnight operations “brief the threat of fatigue before each departure, particularly those occurring during the window of circadian low” which is typically between 2 a.m. and 6 a.m.
The Board’s recommendations to UPS and the pilots union include working together to counsel pilots who call in fatigued “to understand why the fatigue call was made and how to prevent it” in the future. It also called on the company and union to conduct an independent review of the “fatigue event reporting system to determine its effectiveness as a nonpunitive mechanism to identify” and address fatigue.
The latter recommendation is particularly significant. While I believe that personal accountability and responsibility are the cornerstones of air safety, I also know from my years of work as a mechanic for a number of air carriers (including cargo companies) and my years on the NTSB that corporate cultures have a definite impact on safety. Some cultures have a positive impact, encouraging a proactive safety approach, and then there are those cultures that are at best indifferent and at worst exhibit a callous disregard for safety.
When I first read the Board’s finding that the copilot could have called in fatigued “and been immediately removed from duty until she felt fit to fly again,” I wondered if she really could have or if she would have hesitated for fear that it would have a negative effect on her career. Does UPS have a culture that truly supports crewmembers calling in fatigued or is there subtle or not-so-subtle pressure to stick to a schedule and not report problems like fatigue? I have no personal knowledge of UPS’s safety culture and my comments are not directed at them, but I’ve seen many airline cultures where it would be frowned upon for a copilot to call in sick or tired, or sick and tired. In addition, as a woman in a predominantly male culture, the copilot might have faced additional pressures not to call in. For these reasons, I hope UPS and the IPA jointly pursue an independent review of the fatigue call-in system and adopt any safety recommendations that come out of it.
John Goglia - AINonline