Times up for Pel_air MkII
Courtesy Ben Cook, via Oz Aviation... Rolleyes


Pel-Air revisited – The ditching of Australian aviation governance Part 1
April 14, 2018 by Ben Cook 1 Comment

[Image: ao2009072_fig15.jpg]

Think about the reason you’re reading this article. I suspect, like myself, your passion for all things aviation began at a young age. Perhaps it was influenced by a family member already working in the industry, or it seemed part of your genetic makeup – something flowing in your veins.

For me it began when I was very young. I spent hours daydreaming, staring into the sky to watch aircraft fly past. I watched endless movies about aviation, space and action heroes, especially Superman, and ran around the backyard with my arms out pretending I could fly.

My first opportunity to experience the true thrill and exhilaration of flying began in a glider in my early teens. My sense of comfort in the sky became immediately apparent. It became difficult to explain to others why having the horizon appear at unusual angles felt so good!

The key players in this article, Dom and Karen, also followed their dreams to live a life where they could describe their careers as a passion. What’s better than waking up and thinking, “I get paid to do this”? It’s the ultimate motivation when work and life blend into a passion, leading to positive releases of the brain’s feel-good chemicals.

In Dom’s case, a flight in a Tiger Moth at 13 was life-changing – a defining moment where he knew aviation was his chosen career path and not just a hobby. He put in the hard yards, saving money for flying lessons and taking jobs that many would reject; all for the love of building hours to eventually become the captain of a small business jet.

For Karen, her journey started a little later. At the age of 27, already married and with three children, she decided to become a registered nurse. Full-time study for three years took passion and perseverance, but Karen was driven by her years of watching other family members experience congenital heart conditions. Her specialisation in cardio-thoracic, intensive care and pre-hospital trauma nursing led her to an aviation workplace, where she cared for critically ill patients.

Both Dom and Karen were fortunate to have good health, great family and friends, and a passion flowing through their veins – for which they were also getting paid.

For many, aviation can be all-consuming, making you feel complete, satisfied, energised and alive. Yet the joys of aviation can turn to nightmares as the skies around you can change so quickly. For Dom and Karen, this began on the night of November 17 2009 – all-consuming stress, physical and emotional pain, and sleepless nights have been part of their lives for almost a decade since their Pel-Air Westwind II ditched into the ocean off Norfolk Island.
Sadly, the two organisations whose core role is to ensure the Australian aviation industry upholds adequate professional standards and gains positive lessons from these types of accidents, are also at the heart of their nightmare.

It is important to note that this article is by no means a reflection of the present organisations or their senior leaders, but I believe both the Civil Aviation Safety Authority (CASA) and the Australian Transport Safety Bureau (ATSB) still have a hard road ahead to rebuild trust within the aviation industry.

Short notice aeromedical evacuation – is this flying at its best?

It’s Tuesday morning and another beautiful late spring day in Sydney. Dom is up a little earlier than normal at 5.30am. Later in the morning he receives a call from his company regarding a possible patient medical evacuation that will require a long night flight to Apia, the capital and largest city of Samoa, a small island about 4,300km north-east of Sydney. Later, Karen and the other crew members (a flight doctor and first officer) are also notified of the planned flight.

For Karen, having been awake since 6.30am, it was a short notice request to cover for another nurse who was unable to make the flight. Given the lack of formal regulations and applied fatigue management practices for the flight doctors and nurses employed within the air ambulance sector, it was not uncommon to work extended periods with limited sleep.
These types of aviation operations are on the top of the list of challenging and exciting roles. Highly-motivated crews are saving lives and flying demanding missions all over the world. The work can be tough for sometimes modest pay, but it meets an intrinsic need to make a difference for the benefit of the community.

Typically, these operations contain all the human factors elements that can degrade normal performance: stress and time pressure (short-notice planning, sick patients needing help quickly); fatigue (lots of late nights and early mornings); distractions (dealing with multiple stakeholders); egos; a reliance on accurate and timely communication; complacency; and most importantly, a high trust relationship and reliance on a broad collective team (the crew, operations support, refuellers, air traffic controllers, meteorological forecasters, the aviation regulator and so on).

The crew spend most of the day waiting for confirmation the flight is happening, including planning to ensure they deliver the necessary response and critical care to protect the life of the patient. At the aircraft that night, the team looks forward to another flight – they’ve done this many times before. While the long night flights and disrupted sleep are a down side, they know when it gets busy their adrenaline will mask their tiredness (and sometimes boredom) and help them deliver the performance required to get the job done.

[Image: IAI-1124-Pel-Air-VH-AJG-Sydney-12-6-2006...chison.jpg]A Pel-Air Westwind II at Sydney Airport. (Grahame Hutchison)

They like the jet, a Westwind, registration VH-NGA, which performs well at high altitude and gets them where they need to be nearly as quickly as the larger jets used by the airlines. What the crew is less aware of is the impact of inadequate company training, standards and regulatory oversight regarding crew resource and fatigue risk management. These are the processes for teaching teams how to better support each other’s roles, to monitor for errors, to cross-check each other, to manage fatigue and have a genuine understanding of the impact of lack of sleep on decision-making. They are also unaware of what will be some lapses in the standards for fuel management and broken communication, including critical weather updates.

Just like the air crash investigation television shows, there are many systemic (organisational) and regulatory deficiencies that are all about to line up – sometimes referred to as the Swiss cheese model – and set this crew up for failure. It’s also going to test their ability to perform under extreme pressure, particularly at the critical moment between life and death.

The Swiss cheese moments

The flight departs Sydney late that night and it’s a long flight requiring a refuel at Norfolk Island. Just like a few times before, the weather forecast for Norfolk Island is far worse than the actual weather they experience on arrival. On the ground you could see the stars, the night looked quite clear, yet the automatic weather reporting system was suggesting the weather should have been much worse.

When asked about this the local aerodrome support person at Norfolk Island mentioned the automatic system often overstates how bad the weather is. Little do they know this has the potential to set up expectation bias: a false sense of security based on past experiences or norms.

Once refuelled the crew departs Norfolk Island around 2.45am (local time) for Apia. All aboard are looking forward to a bed in a hotel room before the return flight the next night.
The captain, like many of the company pilots, has a history of making conservative decisions, including carrying extra fuel, as flights to remote islands such as these leave little margin for error should there be a need to find another airport to land.

While this approach to carrying extra fuel is appropriate, the company policy refers to other, more complicated, fuel calculations for helping to determine when to divert to other airfields.
For many pilots, these calculations are not a normal part of what they’ve been shown to do – an example where policy exists for the sake of policy. Ever wonder about the possible adverse influence of other more senior pilots in shaping the workplace culture and norms?
Is what you actually do, even when you know it’s different to what is stated in the company policy, what everyone does?

It’s likely you too have experienced this; an initial feeling of discomfort with not wanting to be a lone voice that asks a difficult question. Instead, you accept the workplace practice to fit in with the group.

Although the weather forecast doesn’t require it, on this evening Dom has planned an alternate aerodrome in addition to Apia as part of the flightplan – again another conservative decision. They’ve now flown all night and land around 7am local time. It doesn’t take long to put the aircraft to bed and head to the hotel for some well-earned sleep.

Yet, as sometimes happens, there is a delay with hotel check-in and the already tired crew have to wait a little longer before they get their room keys. The recovery sleep and down time cannot come quickly enough and the delays at check-in are frustrating. It would be easy for the crew to lose it but understanding that fatigue and long nights are linked to being more irritable helps keep the relationship with the check-in staff professional.

Every minute is a minute of lost recovery time, so critical to manage the performance of medical evacuation flights, with the potential to push the body closer to a danger zone, where decision-making is severely diminished. The ongoing delay is time lost for sleep and every hour is moving the body closer to a circadian cycle that makes it harder to get to sleep.
After finally getting the keys to his room, Dom takes a quick shower to raise his body temperature (for some, the normal sleep cycle is made easier when the body is cooling back down and the shower helps recreate this natural process).

Dom’s room is not ideal. Poor curtains mean a fair amount of daylight is streaming into the room. He’s also fighting his normal body clock, which right now, regardless of the extended hours awake, is working against him when it comes to getting good quality sleep during the day. At best, the sleep at this time of day won’t be great.

Now Dom’s mind is working a bit too hard and thinking too much about the real need for sleep and this anxiety is making it even harder to get to sleep. Trying to relax the mind, counting slowly, slowing down the breathing rate, eventually the eyes slowly close and Dom drifts off to sleep.

But just to make matters worse, once eventually asleep housekeeping enter his room twice, waking him momentarily; yet another unnecessary and avoidable disturbance.

Awake, wide awake, Dom wonders what time it is. It’s only 11am. He knows he needs more sleep. He decides to get up and make a couple of calls to home to try to stay relaxed, sure he can get some more sleep later. He manages a little more sleep before getting up around 2.30pm to start the planning for the return flight (Apia–Norfolk Island–Sydney–Melbourne). He can’t get an internet connection and tries to call operations back home to help with the planning but there is no answer. He eventually does the best he can over the telephone to get some weather and to submit a flightplan. It’s not ideal but he has enough to get started and can get further updates once airborne.

Dom is making a number of these decisions at a critical time: the afternoon window of circadian low (WOCL) – a fancy name for that time later in the afternoon where your body experiences a natural degradation in performance. It’s a typical time when you may struggle to stay awake during an afternoon presentation and it’s also a good time to take a nap. At this time, Dom also makes a decision that is not consistent with his normal thought processes: he only fills up the main fuel tanks but not the tip tanks.

[Image: IMG0182.jpg]The Westwind’s captain made a decision that was not consistent with his normal thought processes: he only filled up the main fuel tanks but not the tip tanks. (AA archive)

The crew conducts a combined brief, loads the patient and her husband into the aircraft and departs for Norfolk Island. Karen and the flight doctor have not had the luxury of any further sleep (other than the three to four hours they managed to get in the aircraft on the flight over) as they’ve been busy all day getting the patient ready for the medical evacuation.

There remains another layer of Swiss cheese that further exacerbates the upcoming problems for this crew: some critical weather information was either passed incorrectly or not at all.

This, combined with the relaxed and inconsistent company-wide approach to fuel planning, means a number of critical decision gates have been missed, exacerbated by lax regulatory oversight.

Many factors have now combined to set this crew on a doomed path and one that will expose them to outcomes they will carry with them for the rest of their lives.

Ditching a business jet into the ocean

“What’s happening, did the captain just say we’re going to ditch the aircraft?”
“Could this really be happening?”

“Just a few hours ago I remember a blue sky and light breeze standing on the tarmac at Apia, deeply satisfied that we were about to get a sick patient to a medical centre.”

These are the random thoughts facing the crew. Yet right now, the pilots are solely focused on landing a small jet onto the ocean.

Other thoughts will flood later: “Why didn’t I do some further checks of the fuel? Where did this weather come from – the forecast looked good when we left? What did I miss? How could this happen?”

From a human performance perspective, it would be ideal to still be under the influence of the parasympathetic nervous system (PNS), which for most parts of this flight has been responsible for sitting back, comfortable, warm, sometimes bored, but mostly helping keep the body in a relaxed state (storing energy) as the aircraft cruises towards Norfolk Island.
Right now, it’s the sympathetic nervous system (SNS), commonly known as a ‘fight or flight’ response, that is in charge. Luckily at this stage, with little to no conscious knowledge, Dom is largely unaware that his body’s stress drugs (epinephrine and norepinephrine) have been released. They’ve increased his heart rate. His bronchial tubes within his lungs and his heart vessels have dilated, allowing more oxygen to flow around the body and tensing his muscles. He’s having to consciously keep himself relaxed and to not tense up too much to ensure his fine motor skills still allow him to fly the aircraft accurately onto the water.

This is the difference between getting it right and wrong, it’s a life and death scenario. He’s delivering this performance under extreme pressure, and courtesy of all his years of training, he’s able to fly the aircraft rather than freeze up, which could result in an aircraft stall and an uncontrolled crash into the water with almost no chance of survival for those on board.

With about three-and-a-half hours of broken sleep, Dom should be experiencing a response similar to combat veterans, such as stress diarrhoea or loss of fine motor control. Yet he’s doing a remarkable job under very difficult circumstances.

[Image: Pelair-pic-7.jpg]File image of a Westwind night flight. (AA archive)

No time for other random thoughts. It’s dark, it’s cool and Dom has no sense of the temperature – he is only focused on landing a business jet onto the ocean.

Concentrating, time feels like it has slowed down, and Dom can clearly hear the first officer calling the altitude to the water. Dom thinks, “I’ve got to get this right; make power adjustments to keep the airspeed steady; quickly scan between attitude indicator, the airspeed indicator and the vertical speed indicator to fly a controlled approach.”

It’s now 9.25pm. The aircraft is around 440ft above the water and the first officer instructs the passengers to brace. An automated aircraft system continues to announce, “too low terrain”, and this is just another distraction that luckily does not impact the performance of this team.

Below 400ft the aircraft is established in a stable descent and airspeed, a pretty impressive outcome under such trying conditions. The first officer calls out 200ft and the same automated system announces, “terrain ahead, pull up”.

During all of this, the first officer recognises the gear needs to be raised (the aircraft is now about 115ft above the water) and calls for “gear up”, which in addition to ongoing annunciation of “terrain ahead, pull up” also activates a gear warning horn.

Think about it: the constant noise and distractions, a dark night, trying to hold a constant rate of descent and airspeed, flying an approach onto an ocean and keeping it together – at this moment it’s certainly an example of human performance at its finest, not perfect by any means but definitely a good standard of performance when confronted with so many stressors.

Furthermore, Dom is performing a task he’s never practised or been adequately trained for, a novel task under extreme pressure, which with consideration to the aviation environment is about as risky as it gets. For many this stress would cause fixation and loss of fine motor skills. Yet Dom has airspeed almost constant, at a constant rate of descent, 80ft to go (descent stabilised at 360ft per minute, airspeed 108kt); 50ft to go (airspeed 103kt and decreasing); the first officer calling out the final descent heights, 40ft, 30ft, 10ft …
BANG… bang… bang. Three impacts as a business jet skips across the water.

Landing on water at such speeds is like landing on concrete, but somehow the aircraft is still right side up. The fuselage separates into two sections soon after coming to a stop, with the tail section afloat.

Surreally, there is no more engine noise and it’s relatively quiet. The primary sound is water flowing very quickly into the aircraft. Fight and flight drugs are still pumping through the bodies of the crew.

And for the patient – at one stage happily on her way to a medical facility – strapped on a bed, unable to release herself, in an aircraft sitting on the ocean and flooding with water; her stress and panic is likely unbearable.

Right now, in a small aircraft cabin quickly filling with water, with a sick patient strapped to the medical bed, Karen, briefly knocked unconscious, has opened her eyes with water already half way up her shins. She feels no pain (due to her own release of fight and flight chemicals), allowing her to immediately collect her thoughts and respond with the flight doctor to get the patient and her husband out of the aircraft. The severe impact has torn muscles and nerves that will result in lifelong damage and severe pain for Karen.

Dom has already reacted instinctively and exited the rear door, which has been partially damaged by the impact and is also flooding with water. The first officer, initially knocked unconscious, has also quickly recovered and is the last to leave the aircraft.

Six people are now out of the aircraft, all huddled together and a few miles off the coast of Norfolk Island. As time goes on, the fight and flight chemicals will start to wear off, but for now it’s a state of ‘high performance’ and shock, so no one has a real sense of the cold, nor fear. Reality will set in not long after the rescue boat picks them out of the water.

A lucky rescue

Even during the high pressure ditching with less than 600ft above the water, the first officer passed critical information to an aerodrome support person on Norfolk Island stating: “We’re going to proceed with the ditching”.

This aerodrome operator contacted the Norfolk Island emergency services coordinator (ESC) to advise him of the situation, who then called out the other members of the airport rescue and firefighting services, including coordination to contact the owners of two fishing charter vessels that could be used for a search.

One of the firefighters responding to the call-out elected to travel via some cliffs west of the airport. He stopped his vehicle to check the sea to the west of the island, believing that it was possible the aircraft had ditched there. He recalled looking out to sea and seeing what he thought was an occasional and intermittent glow of light (which was from Dom’s torch).

 After looking for a few minutes, he was convinced the light was real and at about 10.20pm he phoned the observation through to the ESC.

This initial information was critical and helped deliver a quick response. At about 10.50pm, after about one hour and 25 minutes in the water, the aircraft’s five evacuees were located and assisted on board the search vessel.

Interestingly, Norfolk Island locals had recently completed emergency response scenario training, further enabling them to respond quickly and efficiently.

The real nightmare begins

[Image: IMG0372.jpg]File image of VH-NGA taxiing to depart Sydney Airport. (AA archive)

So where were you on Thursday 19 November 2009 when the news broke across the country that an Australian aircraft had ditched into the ocean off Norfolk Island? You may have been very interested in the story, or this article may be the first you’ve heard about this tragic accident.

When was the last time you were confronted with extreme levels of stress that have the capacity to cause emotional instability and loss of fine motor skills? In this case, Dom had to make small and fine inputs to aircraft controls (one- or two-degree changes in pitch) and power. He had to almost subconsciously control the fine line between muscle tension that could cause paralysis and a complete loss of control.

Unless you’re a human performance subject matter expert, it’s important to be careful about making too many assumptions. I know personally, having flown aircraft to Norfolk Island many times, that my first thoughts were very critical of the organisation and the pilots.

Luckily, I’ve been well-trained as both an investigator and as a human factors practitioner to recognise these initial thoughts were not helpful.

Like thousands of aviation professionals within corporate culture, Dom was doing the best he could aligned to the normal practices, and positive reinforcement, of more senior pilots around him. Certainly, Dom accepts he could and should have done some things differently.

Unfortunately, CASA and the ATSB pointed the finger too heavily at the aircraft captain. It’s his passion for aviation and strong perseverance that has kept Dom going since the accident.

Through any post-accident process, it’s vital that ATSB investigators and CASA auditors use self-awareness – to seek other evidence to support initial assumptions, be aware of biases, and be cautious about the influence of strong-minded personalities.

The combination of bias and strong egos can adversely influence an aviation accident investigation, ultimately leading to breakdowns in communication, assumptions, inadequate collection of critical investigation evidence and, in the worst case, a re-write of a preliminary investigation to align with possible political agendas (this will never be proven).

This only makes the suffering worse for survivors and destroys the careers of seasoned and competent ATSB investigators.

For many of us, we assume that CASA and the ATSB are the key players to make sense of the why in these types of accidents – that they will search for the root causes to ensure the broader aviation community can genuinely learn some lessons to prevent reoccurrence. Yet it appears this wasn’t the case for those aboard that medical evacuation flight in 2009.
Most importantly, getting to the cause of what happened and implementing processes to address these is vital for the crew, the passengers, and their families and friends, to get some closure.

A taste of things to come

No surprises but there is talk of a future movie based on this scenario. If you thought the movie Sully (the story about the ditching on the Hudson River) was interesting, some of that content was not factual but rather Hollywood hype.

Our local version has the trademarks of a great documentary, including extracts such as the following made by the Transport Safety Board of Canada after completing an independent review of the ATSB:
  • lapses in the application of the ATSB methodology with respect to the collection of factual information;
  • errors and flawed analysis stemming from the poor application of existing processes were not mitigated;
  • an early misunderstanding of the responsibilities of CASA and the ATSB in the investigation was never resolved;
  • this misunderstanding persisted throughout the investigation, and as a result, only two ATSB interviews were conducted with managers and pilots of the aircraft operator.
And the list goes on.

So why should you trust my interpretation of the events in a series of upcoming articles?

First and foremost, I have one strong belief: we all need a better balance around organisational issues and pilot culpability to genuinely learn some lessons from this accident. If nothing else, the survivors deserve a more balanced understanding as to what caused this accident.

In the most tragic of circumstances, the patient, suffering heavily from post-traumatic stress disorder and fighting for basic medical compensation, lost her will to fight and lost her life to an overdose in February 2015.

Dom and Karen are continuing to battle with a basic need to feel the system has learnt lessons from the tragedy. Just a glimmer of hope will help them get on with their lives and to feel the real story is known.

[Image: IMG0167.jpg]The medical retrieval interior of Pel-Air Westwind II VH-NGA. (AA archive)

At the time of the accident I was CASA’s human factors manager and I have a good appreciation of the processes that occurred post-accident. I was actively involved with the CASA special audit of the operator. I’ve read volumes of correspondence – accidents and independent review reports from cover to cover – and where necessary, to help manage my own bias and prejudice from a human factors perspective, I’ve had certain material independently reviewed by a former head of a human performance aviation accident investigation division, recognised as one of the best in the world.

So what’s coming in future articles? I’m going to explore the many human factors involved in this accident. I’ll review elements such as egos, trust, expectation bias, professionalism, fatigue, inconsistencies within the systemic investigation report, culture and its influence on behaviour. These insights from a real scenario provide lessons for each of us, and ways for all of us to better manage human factors.

To reiterate, I’ve worked for both the present CASA Director and the Commissioner of the ATSB and I have the utmost respect and faith in their professional standing to return both CASA and the ATSB back to where they need to be – with the trust and confidence expected by the Australian aviation community and the travelling public. My review in these articles is focused on the culture and processes prior to their appointments.

Until next month, safe flying and enjoy those positive feel-good chemicals you get to release every time you head to the skies.

This feature article first appeared in the April 2018 issue of Australian Aviation.



Comment from Capt Mulloy:

William Mulloy says
April 15, 2018 at 1:21 am
Wow ! Gripping article . I am from Canada and am now retired after 40 years of flying . I think back of how lucky I am to have survived through my career . My last 30 years were for the most part influenced by a good safety culture oversite from Transport Canada at the airline I flew for but I can say this ; my first 10 years of bush flying ; charter flights & medevac flights where there was very little oversite from either your management or higher ups & I was virtually on my own and doing everything myself ( most of that time single pilot ) on aircraft like Mitsubishi MU-2 & piper PA-31 it is a wonder I managed to keep an unblemished track record . I know that I was extremely lucky because I can tell you this : I scared the hell out of myself more than once & I put myself there but I sometimes think if ther was a bit more oversite in my small company I wouldn’t have exposed myself to several of the questionable situations that I ended up in . Anyway thank you for reading my letter as I have nothing but compassion for those pilots & pax in your article . I really feel for those pilots because I know they set out with the best of intentions in that westwind & other factors helped put them where they ended up . I hope to see the film if it is ever produced. Thank you from Captain W Mulloy CRJ-900 .




Excellent stuff Ben, choccy frog is on it's way and I am definitely looking forward to Part II -  Wink


MTF...P2  Cool
Reply
Ben Cook has written a highly descriptive story with some interesting analysis.
But with respect there might be other judgements that go right to the most critical element of cause. Quote:-

“exacerbates the upcoming problems for this crew: some critical weather information was either passed incorrectly or not at all.”

This surely is the question; and if “not at all” or “incorrectly” is true then surely it is very difficult to see that any appreciable blame should fall on the shoulders of the crew. Reading other analysis by PAIN contributors at the AuntyPru website, with time lines, it seems that if certain weather reports had been passed to the crew then they would have had reason, and sufficient fuel, for a diversion to an alternate airport.
This is the impression that is given, please correct if wrong.
Thus a failure to communicate critical weather information did not “exacerbate the upcoming problems” because to that point there was no problem(s).
In which case it then might also follow to give less weight to sleep deprivation as a factor of cause, though obvious enough that proper procedures seemed to be lacking and corrective action was called for.

The above is a comment submitted to the Australian Flying website but further points, hopefully to be taken as respectful criticism, here in addition.

In common with some other writings about the ditching its notable that the individuals named are not accorded with their full names or formal titles. They should be, along with some discussion regarding the role of the co-pilot.

In regard to Ben Cook’s question: “When was the last time you were confronted with extreme levels of stress that have the capacity to cause emotional instability and loss of fine motor skills?

I could say last year putting a C150 with engine trouble after takeoff into a wet paddock. Would that do? Or talking to the local ag pilot with three forced landings to his credit, one with a double mag failure, I expect he would know. Perhaps Ben Cook has a similar experience that he could share with us, nothing like the real thing to add to academic expertise. And for sure there’s plenty of pro pilots to compare notes with, Ben could check with the Mildura “fog landing” pilots.

Lastly I have to take issue with Ben’s statement as follows:-
“Unless you’re a human performance subject matter expert, it’s important to be careful about making too many assumptions.”
Reading this literally one can take it to mean that an expert is entitled to make too many assumptions, presumably with impunity.

The whole sorry saga of the botched investigations, with the suspected wink and nod between CASA and the then newly independent ATSB, has been muddied with assumptions and obfuscation. Government Industries, headquartered in Can’tberra.
Reply
Ben Cook and the Choc Frog award.

The Ben Cook article published in the  Australian Aviation magazine is of great value in that it casts a wider net over the inherent contributing factors, the systematic failures and the lack of ‘real’ safety related oversight from the CASA, rather than safe, minimum compliance with ‘the law’.

Ben is a respected, acknowledged expert in his field of endeavour, the article reflects that expertise – from his point of view.

BC – "For many of us, we assume that CASA and the ATSB are the key players to make sense of the why in these types of accidents – that they will search for the root causes to ensure the broader aviation community can genuinely learn some lessons to prevent reoccurrence. Yet it appears this wasn’t the case for those aboard that medical evacuation flight in 2009.”

Your opinion depends of course on how ‘thorough’ and meticulous your own analysis of the incident has been and where and when the seeds of this accident were sown. For PAIN those seeds were sown with the Lockhart River tragedy. The abominable behaviour of both CASA and the ATSB before, during, after and since that event leaves much to be desired – from an operational safety point of view. The ATSB fall from excellence began with Lockhart. Many believe their ‘spirit’ was broken from then, routed, repressed and regressing to the pathetic ‘milk and water’ PR guff they provide today. The Pel-Air v1 and Pel-Air v2 reports stand testament to their shameful degeneration. ATSB should have drawn many of the same conclusions as Cook, the reports provided fail, dismally, to do so.

For some as yet unidentified reason, Dolan and McCormick embarked on a very risky journey, never expecting for one moment, that it would blow up to a Senate inquiry; well it did that and more. Had Cook and ‘operational’ expert opinion been sought in the beginning then a report of real safety value could have been produced and the disgrace which followed the Senate Inquiry could have been avoided – alas. But I digress.

Sandy raises some valid questions; the most obvious being why the amended weather forecasts were never received. That, in a nutshell is the final gaping hole in that famous Reason cheese. However, the Cook article tracks the chain of events back to Samoa; which is a reasonable starting place, but is it the right starting place?

I, for one, don’t believe it is. From an operational point of view one must dig a little deeper. For one small example of the many operational malfunctions which the CASA ‘experts’ failed, over a number of years to identify and correct, consider CFIT analysis. CFIT is a globally acknowledged killer; much hard work and expertise has been employed to reduce the risk. The Flight Safety foundation even provided a simple, highly effective tool, which, if used draws an operating crew to realise that their risk is elevated. When you run the analysis for the Norfolk flight, it clearly demonstrates an increased risk level of a CFIT event. Had the company procedures specified a ‘low’ and ‘high’ risk score and made it a requirement that a ‘high’ risk score demanded additional operational support - such as flight following or operational assistance on stand by; then, perhaps James may have been given a heads up on the changing weather conditions. There are many operational risk mitigation tools available to an operating company – beginning with clearly defined SOP which reflect realistic operational safeguards. Simple things like fuel planning requirements – how to; a fuel plan and ‘howgozit’ log, with CP and PNR calculations computed pre departure – amended as an where required to reflect actual operational conditions. Again, I wander.

Ben’s excellent article defines many of the background links in a long chain, very well. Certainly the ultimate ‘gotcha’ was the missing weather forecasts – but this accident began many, many moons ago.

I say the real investigation is yet to be done – ATSB and CASA have may questions to answer, the principal one being ‘what the hell were you playing at; and why? That’s before we take a long hard look at the facts of the Pel-Air audit and the speedy return to ‘normal’ operations. A close look at the ATSB second report is also on the cards; there are some questions there which demand satisfactory answers. Gods alone know how we are to get these questions asked and answered, with O’Sofullame at the helm of the Senate committee. No matter, we shall try.

Sandy – “The whole sorry saga of the botched investigations, with the suspected wink and nod between CASA and the then newly independent ATSB, has been muddied with assumptions and obfuscation.” Amen to that.

Nicely done Ben, second the Choc Frog nomination and look forward to the next.

Toot toot.
Reply
THE GOBBLEDOCK COMES CLEAN.......

At great risk to myself I’m going to put my arse on the line here. I’m not going to reveal how or why I know this, just that it is fact; for many within the CAsA circus the Pel Air accident did not come as a surprise. By that I mean; ‘a moderate sized aircraft on an Australian AOC running out of fuel in that region’. CAsA knew that there were operators pushing the envelope and flying sectors on the smell of an oily rag. The risk was high and Fort Fumble knew it.

They also knew of similar shenanigans taking place between PNG and Australia. One particular B727 operator comes to mind but I won’t identify them. Running aircraft to Oz with barely fumes in the tanks. And I’m not talking about back in the 1970’s.

Fortunately for CAsA they use (or used to use) a wonderfully fucking useless system called TRIM to bury data, surveillance and inspection and audit reports, risk data and all sorts of information. Once it goes in there it’s never to be seen again. Handy for covering your ass in times of need. CAsA are a disgrace. A bloated bureaucratic juggernaut that has been built around CYA of the employees at the coalface up to the Minister. Just like the ATO and any other Government organisation they have the money, power and protection to do what they want, when they want and as they want. Their absolute power makes the Mafia look like a bunch of Kansas City faggots.....

Tick Tock
Reply
Ben Cook Part II & III - PelAir revisited.

[Image: PelAir-PT-II.jpg]


The ditching of Australian aviation governance - Part 2

Quote:..When was the last time you did something that, in hindsight, you thought was foolish, stupid, not consistent with your normal behaviour, and possibly something that made you feel a little embarrassed about afterwards?

One of my experiences (a little over 20 years ago, but it only feels like yesterday) that left me feeling this way involved a big night out as part of a weekend flyaway that could have cost me, and my aviator mates, our careers.

Our mix of personalities, a not-so healthy combination of egos, and some environmental factors (alcohol) led to some very poor decision making. The outcome: one of the guys was going to drive a hire car off a long pier into the ocean!

The only reason this didn’t happen is the person who signed for the hire car was too worried they would be held accountable, so he wrestled the keys away from a very disgruntled pilot who was about to earn a pooled $500 from the other members of the
group. And we had a grand vision of waiting for the media with a beautiful sunrise and national stardom greeting us all.

It all sounds stupid in hindsight but it’s the power of personalities, eroded decision-making (via alcohol consumption) and an unnecessary acceptance of risk, which could have
resulted in permanently changed careers – or injury.

Yet this was a turning point for me to better understand the myriad of human factors that can quickly take us away from being the best we can be...

&..

[Image: PelAir-PT-III.jpg]

Lessons from the Pel-Air ditching - Part 3

Quote:...Last issue we highlighted the significant impact fatigue can have on crews. In the case of Pel-Air Westwind ditching, the aircraft captain, having obtained only 3–3½ hours of average quality sleep, displayed a fixation on a simple plan to land. He and the remainder of the crew were too impaired to recognise growing evidence that the plan was not working. The flight nurse and doctor received minimal to no sleep during the day of the accident as they were too busy caring for the patient.

Even worse, the accident itself occurred on a remote island around 9.40pm, yet the crew were meant to be continuing from Norfolk Island to Sydney and then to Melbourne; well outside the acceptable limits of any mature fatigue risk management system (FRMS). This information has gained little attention even though it’s a clear example of failed company
processes and regulatory oversight.

The impact of elevated levels of fatigue is that people do not realise their level of impairment. They press on ‘lethargic and indifferent’ with a simple plan. This can occur in large organisations to even the most experienced crews...



MTF...P2  Cool


Ps Part IV to come in the next edition of AA magazine... Wink
Reply
(06-16-2018, 11:46 AM)Peetwo Wrote: Ben Cook Part II & III - PelAir revisited.

[Image: PelAir-PT-II.jpg]


The ditching of Australian aviation governance - Part 2

Quote:..When was the last time you did something that, in hindsight, you thought was foolish, stupid, not consistent with your normal behaviour, and possibly something that made you feel a little embarrassed about afterwards?

One of my experiences (a little over 20 years ago, but it only feels like yesterday) that left me feeling this way involved a big night out as part of a weekend flyaway that could have cost me, and my aviator mates, our careers.

Our mix of personalities, a not-so healthy combination of egos, and some environmental factors (alcohol) led to some very poor decision making. The outcome: one of the guys was going to drive a hire car off a long pier into the ocean!

The only reason this didn’t happen is the person who signed for the hire car was too worried they would be held accountable, so he wrestled the keys away from a very disgruntled pilot who was about to earn a pooled $500 from the other members of the
group. And we had a grand vision of waiting for the media with a beautiful sunrise and national stardom greeting us all.

It all sounds stupid in hindsight but it’s the power of personalities, eroded decision-making (via alcohol consumption) and an unnecessary acceptance of risk, which could have
resulted in permanently changed careers – or injury.

Yet this was a turning point for me to better understand the myriad of human factors that can quickly take us away from being the best we can be...

&..

[Image: PelAir-PT-III.jpg]

Lessons from the Pel-Air ditching - Part 3

Quote:...Last issue we highlighted the significant impact fatigue can have on crews. In the case of Pel-Air Westwind ditching, the aircraft captain, having obtained only 3–3½ hours of average quality sleep, displayed a fixation on a simple plan to land. He and the remainder of the crew were too impaired to recognise growing evidence that the plan was not working. The flight nurse and doctor received minimal to no sleep during the day of the accident as they were too busy caring for the patient.

Even worse, the accident itself occurred on a remote island around 9.40pm, yet the crew were meant to be continuing from Norfolk Island to Sydney and then to Melbourne; well outside the acceptable limits of any mature fatigue risk management system (FRMS). This information has gained little attention even though it’s a clear example of failed company
processes and regulatory oversight.

The impact of elevated levels of fatigue is that people do not realise their level of impairment. They press on ‘lethargic and indifferent’ with a simple plan. This can occur in large organisations to even the most experienced crews...

Ben Cook & AA magazine initiative on fatigue: 

Quote:LEARN MORE ABOUT FATIGUE
written by Australianaviation.Com.Au May 11, 2018

In support of human factors expert Ben Cook’s feature article in the June issue of Australian Aviation, we have made available the following supporting documents:
  • Fatigue investigation checklist: a simple checklist, as collectively developed by several civil and military organisations to provide enhanced guidance to determine whether fatigue contributed to the incident or accident. Download here
  • Fatigue risk management chart: a list of some of the many factors that should be considered in determining whether fatigue risk is unacceptable. The chart is particularly good for personnel to better understand the main factors that influence fatigue. Download here
  • A guide to a good night’s sleep: some extracts from a definitive book, A complete guide to a good night’s sleep, written by Dr Carmel Harrington, one of our local leaders in sleep science. The extracts provide practical insights from over 20 years of applied sleep science. Download here


MTF...P2  Wink
Reply
(06-17-2018, 09:25 AM)Peetwo Wrote:
(06-16-2018, 11:46 AM)Peetwo Wrote: Ben Cook Part II & III - PelAir revisited.

[Image: PelAir-PT-II.jpg]


The ditching of Australian aviation governance - Part 2

Quote:..When was the last time you did something that, in hindsight, you thought was foolish, stupid, not consistent with your normal behaviour, and possibly something that made you feel a little embarrassed about afterwards?

One of my experiences (a little over 20 years ago, but it only feels like yesterday) that left me feeling this way involved a big night out as part of a weekend flyaway that could have cost me, and my aviator mates, our careers.

Our mix of personalities, a not-so healthy combination of egos, and some environmental factors (alcohol) led to some very poor decision making. The outcome: one of the guys was going to drive a hire car off a long pier into the ocean!

The only reason this didn’t happen is the person who signed for the hire car was too worried they would be held accountable, so he wrestled the keys away from a very disgruntled pilot who was about to earn a pooled $500 from the other members of the
group. And we had a grand vision of waiting for the media with a beautiful sunrise and national stardom greeting us all.

It all sounds stupid in hindsight but it’s the power of personalities, eroded decision-making (via alcohol consumption) and an unnecessary acceptance of risk, which could have
resulted in permanently changed careers – or injury.

Yet this was a turning point for me to better understand the myriad of human factors that can quickly take us away from being the best we can be...

&..

[Image: PelAir-PT-III.jpg]

Lessons from the Pel-Air ditching - Part 3

Quote:...Last issue we highlighted the significant impact fatigue can have on crews. In the case of Pel-Air Westwind ditching, the aircraft captain, having obtained only 3–3½ hours of average quality sleep, displayed a fixation on a simple plan to land. He and the remainder of the crew were too impaired to recognise growing evidence that the plan was not working. The flight nurse and doctor received minimal to no sleep during the day of the accident as they were too busy caring for the patient.

Even worse, the accident itself occurred on a remote island around 9.40pm, yet the crew were meant to be continuing from Norfolk Island to Sydney and then to Melbourne; well outside the acceptable limits of any mature fatigue risk management system (FRMS). This information has gained little attention even though it’s a clear example of failed company
processes and regulatory oversight.

The impact of elevated levels of fatigue is that people do not realise their level of impairment. They press on ‘lethargic and indifferent’ with a simple plan. This can occur in large organisations to even the most experienced crews...

Ben Cook & AA magazine initiative on fatigue: 

Quote:LEARN MORE ABOUT FATIGUE
written by Australianaviation.Com.Au May 11, 2018

In support of human factors expert Ben Cook’s feature article in the June issue of Australian Aviation, we have made available the following supporting documents:
  • Fatigue investigation checklist: a simple checklist, as collectively developed by several civil and military organisations to provide enhanced guidance to determine whether fatigue contributed to the incident or accident. Download here
  • Fatigue risk management chart: a list of some of the many factors that should be considered in determining whether fatigue risk is unacceptable. The chart is particularly good for personnel to better understand the main factors that influence fatigue. Download here
  • A guide to a good night’s sleep: some extracts from a definitive book, A complete guide to a good night’s sleep, written by Dr Carmel Harrington, one of our local leaders in sleep science. The extracts provide practical insights from over 20 years of applied sleep science. Download here

Noted point of interest from this week's SBG: Minister for Reality – Really?


Quote:P2 comment - Read the Ben Cook PelAir Part 2 article here: The ditching of Australian aviation governance - Part 2

Quote: Wrote:»» CASA’s procedures and guidance for scoping an audit included several important aspects, but it did not formally include the nature of the operator’s activities, the inherent threats or hazards associated with those activities, and the risk controls that were important for managing those threats or hazards.
»» Consistent with widely agreed safety science principles, CASA’s approach to conducting surveillance of large charter and air ambulance operators had placed significant emphasis on systems-based audits. However, its implementation of this approach resulted in minimal emphasis on evaluating the conduct of line operations (or ‘process in practice’).

Although there are pragmatic difficulties with interviewing line personnel and conducting product surveillance of some types of operations, such methods are necessary to ensure there is a balanced approach to surveillance, particularly until CASA can be confident that operators have mature safety management systems (SMSs) in place. [If CASA surveillance is too shallow how do more senior personnel (chief pilot, standards managers, check and training pilots) know whether their own practices are adequate and
aligned with best practice?]

Ultimately, inadequate regulatory oversight also contributed heavily to a false sense of security within Pel‑Air. How devastating it must have been post accident to have CASA inspectorate staff suddenly find so many systemic issues that had not been picked up during previous CASA surveillance.

Now watch again the '$89 million bucket' video (below). Anyone else get the impression there was no love lost between the former DAS McComic and BC [Image: huh.gif]






 MTF...P2  Cool
Reply
Dear BO - 'Tell them nothing to see here, move along' - L&Ks DPM McNobody 

I note that today there was tabled in the RRAT Budget Estimates Additional Info section a letter from the invisible miniscule responsible for aviation safety. This letter informed the now neutered Senate RRAT committee, addressed to the Chair Barry (I'm not conflicted) O'Obfuscation, that there was no safety issues surrounding the relay of aviation weather forecasts to operational aircrew in Australia and the surrounding regional FIRs -  Confused

Quote:The Hon Michael McCormack MP, Minister for Infrastructure and Transport - Correspondence to the committee regarding the provision of weather information to flight crews. - 31 May 2018
PDF 2431KB


[Image: Dear-bazza-1.jpg]

[Image: Dear-bazza-2.jpg]

[Image: Dear-bazza-3.jpg]

Notice the 'ATSB' or 'CASA' advises - in other words the miniscule has absolutely NFI what he is putting his moniker to; but basically there is nothing to be worried about, 'nothing to see' and the political elite can continue to bury their heads in the sand while the Dept, CASA, the ATSB and Airservices Australia continue to maintain the MOAS bollocks over the Aussie travelling public -  Dodgy 

[Image: mil2.jpg]

Three strikes.


[Image: crisis.gif]


Irony is wasted on the stupid" | AuntyPru.com : Home of PAIN :
AuntyPru.com
Oscar Wilde once said “Irony is wasted on the stupid”. But the 'irony' of the present situation is too delicious to let it slide away, unnoticed.




MTF...P2  Dodgy

Bollocks.
Reply
Pass that bucket over P2- Ta!

The Australian Transport Safety Bureau (ATSB), the independent national safety investigator advises that while it has received reports of un forecast weather relating to wind-shear/turbulence, thunderstorms, and fog, there is insufficient data and evidence to support a position that there is currently an emerging safety risk and issue in this regard.

However:-

McNaughtman  “In addition to the range of regulatory requirements outlined above, BoM has also commenced implementation of the recommendations of the Review of Aviation Weather Services, which will establish two major aviation meteorological centres by the end of 2020 to improve national aviation weather services provided to the aviation industry.

McNaughtman – “I note that the research report does not recommend improvements be made to the manner in which Airservices disseminates weather reports to the aviation industry and how these matters are regulated. However, as indicated above, Airservices has advised that it has already taken steps to improve processes, including seeking to reinstate the alerting function of SPECI reports, following the findings of the ATSB in the Mildura Report.”

McNaughtman - Further, Airservices is implementing air traffic management system changes that will reinstate alerts to air traffic controllers where weather is deteriorating below the forecast at locations with automatic weather stations, facilitating the provision of this information to pilots. The changes are scheduled for commissioning in November 2018.

Nah; all’s well – nothing needed – but they’re going to plug the gaps anyway – WTD. Save BO the trouble of removing his fat head from the sand bucket, great stuff – ducking stellar.

Toot - retch – toot.
Reply
Question for the 'notice paper'?  Dodgy

Speaker: "Nothing to see here, HOWEVER?? - I think the 'Ayes' have it...(HOWEVER) ring the bells for 4 minutes..."  Big Grin

Serious QON -  Huh : Is miniscule McNaughtman conflicted on matters of aviation safety?  

DPM McNaughtman: ...The Australian Transport Safety Bureau (ATSB), the independent national safety investigator advises that while it has received reports of un forecast weather relating to wind-shear/turbulence, thunderstorms, and fog, there is insufficient data and evidence to support a position that there is currently an emerging safety risk and issue in this regard...

...I also sought the advice of our aviation safety agencies on other issues raised in your letter...

...the ATSB has advised that following on from its investigation, it provided information to CASA about the apparent lack of knowledge in the pilot community regarding which weather products were provided automatically and what needed to be requested. In response, CASA undertook national pilot seminars in 2017 to raise awareness of the process for requesting weather-related information...

...CASA advises that pilots operating to Lord Howe Island can rely on A WIS information broadcast from the two authorised BoM automatic weather stations (AWS) located near either end of the runway.

These weather services are commonly used throughout Australian airports by pilots for assessing the suitability of weather conditions...

...I am advised however that the ATSB Report extensively documents the weather inf01mation on the day, the reliability of weather forecasts, the information that was actually provided and information that should have been provided to the crew...

...However, as indicated above, Airservices has advised that it has already taken steps to
improve processes, including seeking to reinstate the alerting function of SPECI reports,
following the findings of the ATSB in the Mildura Report...


Reply letter from Sen Fawcett to McNaughtman, who was then Parliamentary Secretary to the Finance Minister "I'll be back" Cormann:  


[Image: DF-3.jpg]

However in typical ignorant 'all care and no responsibility' bliss, McNaughtman relied on the advice of the 30+ year Iron Ring spin-meister Dr A - who was acting in an unofficial/official capacity as Acting DAS for the former DAS Skidmark - see HERE or HERE.

Does this not suggest that miniscule McNaughtman would now be best advised not to be associated with any dealings or conflicted advice surrounding any aviation safety issues possibly connected to the PelAir cover-up debacle?

Perhaps in an attempt to get some distance, on this perceived COI, the miniscule would do well to illicit the assistance of the former committee member Sen Fawcett to help provide truly independent advice on the matters contained within the original correspondence from the RRAT committee?  

 Here is Sen Fawcett's original letter to Mathias Cormann:  



[Image: DF-1.jpg]
[Image: DF-2.jpg]

Rolleyes - Just saying -  Shy


MTF...P2  Cool

Ps For DPM McNaughtman: Here is a reminder of how your loyal minion HVH knew full well that he had a COI with the PelAir MKII reinvestigation:



Reply
Ben Cook's PelAir Part 2 on AA online: 


Quote:FATIGUE AND THE PEL-AIR WESTWIND DITCHING
written by Ben Cook June 24, 2018



[Image: ao2009072_tailsection_vh-nga.jpg]The tail of VH-NGA is winched to the surface so its cockpit and flight data recorders could be recovered as part of the ATSB’s reopened investigation into the ditching. (ATSB)

THE DITCHING OF AUSTRALIAN AVIATION GOVERNANCE PART 2
 
MTF...P2  Cool
Reply
Ben Cook PelAir revisited - Part IV:


Quote:IN THE BLINK OF AN EYE LID

Pel-Air revisited Part 4

WRITER: BEN COOK


[Image: Pelair-Westwind-VH-AJJ-CareFlight-3.jpg]

Continuing our review of the Pel-Air ditching, this issue we look into the complex influence of ego and power in determining the outcomes for those affected by the accident. Karen, the flight nurse on board that fateful night, discovered how various egos associated with the investigation process influenced and clouded proceedings, and made her life a living hell.

First, Karen provides her view of life after the accident, then we offer insights into the roles of governance bodies during the investigation. We also suggest red flags so you can recognise and respond to your own ego-driven decision-making for better performance.

The fragility of life: Karen’s world
There is a light breeze surrounding me as I soar gracefully over beautiful green fields. On my right I can see the coastline and a brilliant blue ocean, the sea looks calm and soft and I can hear the gentle tones of the sea as the waves roll onto the sand.

I’m in complete control. I have a sense of happiness, exhilaration, and calm, and am able to easily manoeuvre myself around the horizon. It’s as if I’m not in an aircraft – I’m flying, soaring like an eagle with a free-spirited energy I’ve not experienced for a long, long time. It’s like returning to a childhood holiday: warm, calm and relaxed. If only I could stay in this happy place, completely at peace, satisfied, carefree…

Now where am I? What is all this pain? I am closing my eyes in a desperate attempt to go back to that happy place. I cannot get back there; the pain is increasing, my body aches, yet I’m slowly regaining conscious thought.

It is dark, I am cold, scared and confused. It was a beautiful dream but now I’m back to reality, the constant pain is still there, it never (expletive) goes away and my life is now consumed by it. The same (expletive) process, fighting the system, constant anger, grief, frustration and yet another sleepless night.

Lying awake, I’m watching the clock count down to take me from now (it is 2am) to daylight, and I’m contemplating whether I can do this anymore. Can I keep up this fight? Is there any way I can go back to my dream and remove the pain? There are options but the consequences for my son and daughters would be lifelong. I have a sense of guilt for even thinking such thoughts. For goodness’ sake, I’ve spent a career caring for people – it is my fundamental purpose and destiny in life.

My name is Karen, and I’m the flight nurse who survived the Pel-Air ditching at Norfolk Island. I will never again be able to experience the joys associated with the freedom of flight.

My life changed in the blink of an eyelid. Literally overnight, almost nine years ago, life as I knew it changed forever. I no longer have the normal sense of purpose that comes with an exciting aviation job: the deep satisfaction of performing meaningful work that you care about, the camaraderie, friendships, the excitement of not knowing what you will be doing day-to-day, or which destination is next for a medical evacuation. I miss the laughter, the sense of purpose, and the workplace banter that is unique to air ambulance and aviation operations. For me, each day is now a struggle, a constant grey landscape where I no longer gain the deep satisfaction that I once had with life.

Quote:‘My life changed in the blink of an eyelid.’

As a single mum I worked harder than many, raising my three children while also completing university studies to shape a better life for my kids. Overnight, my income went from just over six figures to $37k. The struggles were huge: financial stress, three kids to take care of, seven operations, battling to make sense of the regulatory process, the accident investigation, and fighting through the courts. And on top of that, having to deal with insurance companies that took every step to make life as difficult as possible for the survivors.

Just like air crash investigators, it is ironic that I now use the words ‘if only I had known in hindsight’! Had I known there were inadequate safety regulations for air ambulance I would not have flown. I had no idea we were not protected by robust legislation, that it was acceptable for smaller operators to venture into complex, back of the clock, short-notice medical retrieval operations with limited oversight and company standards.

Those same companies paid the aircrew small wages in comparison to larger organisations, which inevitably meant the levels of experience were substantially lower and the turnover of crew high, resulting in more challenges when undertaking these more complex tasks.

And after all these years the facts get blurred and I get tired.

My journey has been horrific: trying to penetrate what feel like walls of deceit, erected by several people with very large egos. Again, it is ironic that air crash investigators often mention a need to understand your own bias, or that of a collective team, to make sure the investigation process is not adversely influenced. In my case, I feel egos have heavily influenced many processes to make life difficult; at times, unbearable.

I will never fly again, not because I’m scared of dying in a plane crash but because I’m scared that if I survived I could not bear to live through this hell again. The treatment has been nothing short of cruel and disgraceful, and sometimes I do not know how I have survived for this long.

But one thing I can tell you, I am the epitome of a strong, independent woman. And I will not give up this fight, not until the energy and the exorbitant amount of taxpayer resources (Senate enquiries, independent reviews, a second investigation, court cases, etc.) lead to enhancements to the Australian aviation system to prevent you and your loved ones from ever experiencing the same.

[Image: IMG0372.jpg]

Egos and failed governance

Ego can be described as a person’s sense of self-esteem. Everyone has an ego, it is a natural facet of our humanity. The way we invest our egos has major implications on the way we act, what we believe, and how we respond to adversity such as criticism, insults and failure.

It is also worth noting that the ego largely stems from one’s personal experiences. For many people it is challenging to view issues or results rationally if their beliefs are clouded too deeply in their ego. One must always be open-minded to change and criticism. For some, this proves very difficult.

Looking back on the Pel-Air Norfolk Island ditching as the then human factors manager for the Civil Aviation Safety Authority (CASA), there are many memories that make it feel like it all happened yesterday.

At the time, at the very top of CASA there were very firm and clearly held views on the cause of the accident right from the start, even before the Australian Transport Safety Bureau (ATSB) had commenced its investigation.

One strongly held view was that the investigation process should focus primarily on the pilot, and why would anyone be wasting their time with other systemic findings, as in the end it is only the pilot who can decide whether he or she is fatigued and unable to conduct a flight.

That outlook contradicted the fatigue science and best practice available at the time. Fatigue is insidious, hence the crew themselves can lose the ability to self-assess. This is why it is so critical to have robust organisational and supervisory support mechanisms to further monitor pilot performance, particularly when conducting adhoc, aeromedical evacuation flights. And another view dismissed the importance of software to support crew flight planning.

Both those outlooks came from personal experience rather than an informed basis. They do not demonstrate an open mind seeking to understand how organisational culture effected this serious accident.

Within CASA there was also a culture of fear amongst middle and senior managers. This can have detrimental effects within any organisation, particularly when the communication flow is in one direction (down) and messages are changed when moving back up to ensure they meet the expectations of more senior personnel.

And making matters worse, an audit of CASA’s processes just prior to the accident by the International Civil Aviation Organization (ICAO) and/or the Federal Aviation Authority FAA) was critical of several internal CASA processes, including the quality of training of CASA staff.

In my mind this was potentially feeding the need to deflect any further adverse findings away from CASA back to the operator, and in this case, the aircraft captain. There was enough scrutiny of CASA’s own processes without the addition of an ATSB accident investigation report that had clear evidence within the CASA Pel‑Air Special Audit of systemic failures with CASA oversight. Yet, for the first investigation this information was not included or considered relevant by the then Commissioner of the ATSB.

The investigatory policy was robust, yet senior managers unwittingly contributed to a flawed investigatory process right from the start, and confusion reigned. Egos clearly led to failed governance, ultimately leading to the following findings by the Transport Safety Board of Canada after completing an independent review of the ATSB:

»» An early misunderstanding of the responsibilities of CASA and the ATSB in the investigation was never resolved…

»» …this misunderstanding persisted throughout the investigation, and as a result, only two ATSB interviews were conducted with managers and pilots of the aircraft operator…

»» ….errors and flawed analysis stemming from the poor application of existing processes were not mitigated…


Recognising ego and power

For Karen, the outcome of failed Australian aviation governance is a shattered life. Other more recent examples of the impact of ego and power have been seen through the ongoing banking sector royal commission, where the lives of many Australians have also been destroyed.

So, what can you and I do to protect ourselves?

Leveraging from the work of a long-time mentor of mine, Dr Tony Kern, the author of a number of aviation books, including Blue Threat: Why to Err is Inhuman and Going Pro: The Deliberate Practice of Professionalism, ego and power is identified as a known violation producing condition that requires careful consideration and management in the aviation industry.

If allowed to grow, it can become a belief that the violator has the skill and stature to do the job better outside the boundaries. It is particularly dangerous because it lives inside most high achievers.

Quote:‘Keep in mind that as individual human beings we are limited.’


Somewhere in our lives, most of us will admit that we have moments where we think we are smarter than the people who wrote the rules. This may or may not be true, but it is a dangerously irrelevant question when it comes to compliance.

Here are a few red flags from Tony’s work to warn us when our egos start to get in the way:

»» You find yourself being defensive about an idea or plan and taking it personally when someone disagrees with your ideas. This often leads to noncompliance to prove yourself and your idea can lead to mission accomplishment.

»» You routinely make a point of showcasing your brilliance, as in ‘those rules don’t apply here because…’

»» You view colleagues as rivals and are willing to bend the rules to ‘one up’ them.

»» You disagree with someone simply because you did not come up withthe idea first.

»» You prematurely criticise policiesor procedures that get in the way of your goals without considering their value.

Keep in mind that as individual human beings we are limited, and when we continually compare ourselves to others in an attempt at ego gratification, we often end up looking foolish and unprofessional by our wilful noncompliance.

And this process can start as you become more confident with experience. As an example, when you first learn about longer radio calls from air traffic control (ATC), hopefully the guidance has been to write the message down on a kneepad before reading the information back. You carefully and neatly write it down, pause to collect your thoughts and then read the information back clearly, but not too quickly, to ensure ATC also have the time to process (check) that you have received the correct information.

But, as you gain more experience and confidence there is the propensity to perform this process from memory with an urge to read the information back quickly, just to let ATC and others know that you are highly proficient. Wow, how did you remember all that information and read it back so quickly? You must be very good at what you do.

If you allow this to become your new habit pattern, then no surprises that somewhere down the track you will make an error. Perhaps you’ll be levelling off after takeoff at 3,000ft when in fact you were meant to level off at 2,000ft.

The most professional aviators instil good habit patterns. I admire the slight pause from operators at airfields in between making their readback to ATC because I know they are taking the time to write down and process the information more accurately than the over-confident quick talker, who is also the type that is known for taxiing the aircraft a little too fast.

Furthermore, keeping your ego calibrated – being able to acknowledge your flaws in both your personal and professional life – also builds trust.

High performance and self-awareness 
For any high performer you should always be open to change and improvement because the world is constantly changing. Investing your ego into beliefs to the point where you cannot change them in the face of evidence is one of the most foolish things you can do. It is critical to always keep yourself open-minded to new information and facts.

Take the time to consider the points above, particularly anytime you show signs of being defensive when receiving feedback from others. Similarly, if you start to blame the system (it was the fault of ATC, you did not brief me properly, it is not my fault) then you are entering a phase in your career that can be difficult to overcome.

High performers remain open to considering better ways of doing business; the process of seeking good habit patterns breeds a higher level of self-awareness. And good self-awareness, from my experience, is the most critical factor in understanding your own limitations and what you are truly capable of. With this you can consistently make better decisions to operate within your own personal boundaries of performance.

Working hard at improving self-awareness, always seeking to improve your personal habits and techniques while accepting feedback openly is positioning you to become a lifelong learner and a great leader, unencumbered by ego.

Next issue in our final article of this series, the focus will be on the importance of trust.
 
MTF with the fifth and final part in August...P2  Wink
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Ben Cook’s articles and Karen’s words need, must be, sent out as far and as wide as we can reach.

They are important.
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You blokes really don’t know anything hey? Bens writings are ok and all, but I prefer to follow Dr Jonathan Aleck. He works for CASA, spent time at ICAO and he has a PHD. He has spent more time travelling business class than any other CASA employee. He knows aviation.
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Fatigue - in another hemisphere.





While on the subject of fatigue and our still obstinate regulator's reluctance to embrace real science and human factors current day (21st vs 19th century) research/findings and practises on the subject, the following is an excellent BCA article that once again reveals the real insidious nature and safety risk of fatigue - Wink :


Quote:Flying Tired: Recovery From Sleep Loss Is Not So Simple
Jul 20, 2018
Patrick Veillette jumprsaway@aol.com Business & Commercial Aviation



Many of us as youngsters yearned to become pilots. We envisioned the “glamorous” jet-setting lifestyle with plenty of comely companionship on trips to exotic locations like Rio, Tahiti and Paris, feasting on the local cuisine and strolling along wide beaches and narrow cobblestone streets. Little did we know that the occupation would involve long duty days, early starts, multiple time zone changes, uncomfortable hours confined in a tight cockpit while breathing desert-dry air and forcing ourselves not to nod off.

John A. Caldwell, Ph.D., co-author of Fatigue in Aviation, is an internationally recognized scientist in the area of sleep deprivation and fatigue countermeasures. He asserts that “fatigue-related performance problems in aviation have been consistently underestimated and underappreciated” despite decades of research on pilots showing that insufficient sleep significantly degrades cognition, psychological mood “and fundamental piloting skills.”
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[Image: FLYINGTIRED_ImageSource-istockphoto.jpg]
Image Source: istockphoto


None of us are immune to the problems of fatigue. If you have found yourself or crewmates overlooking or misplacing sequential steps, becoming preoccupied with single tasks, having a greatly reduced audiovisual scan and being less aware of poor performance, then welcome to the brotherhood of the flying weary. Other notable warning signs of fatigue include being less likely to perform low-demand tasks, becoming more distracted and more irritable, and finally succumbing to a “don’t care” attitude.

The only way to recover from fatigue is to get adequate rest. Unfortunately, that’s often not an option. Dr. Curtis Graeber, who served as the human factors specialist for the Presidential Commission on the Space Shuttle Challenger Accident, joined [url=http://awin.aviationweek.com/OrganizationProfiles.aspx?orgId=19991]NASA Ames Research Center in 1981 as the principal investigator for a congressionally mandated study of fatigue and circadian rhythm factors in flight crews. The NASA research team found that the sleep deficit for a tour often begins before showing up for the first trip, especially if the report time involves an early wake-up. Under such frequent circumstances, the average pilot reports for duty on day No. 1 with a sleep deficit. Strike one.

If you feel that your sleep on the road is less restful that your sleep at home, you aren’t alone. NASA studies found that the average pilot sleeps an hour less per night during layovers than at home due to the significant increase in awakenings while in hotel rooms. Such sleep disruption is known to result in daytime sleepiness. That’s strike No. 2.

Let’s say you flew the “back side of the clock” and dragged your weary bones into the hotel room at 5 a.m. How many times has the chambermaid knocked on your door a few hours later loudly proclaiming, “Housekeeping,” despite the “Do Not Disturb” sign you hung on the exterior doorknob? And is it too much to ask hotels to put a “quiet close” device on guest room doors so that guests can’t slam them shut?

The quality of the sleep environment is an important contributor to rest and recovery, yet we pilots have no control over it and simply have to endure less-than-restful nights when on the road. That’s strike No. 3. But wait, there’s more to the fatigue problem.

Have you felt yourself getting even more tired during the progression of a tour? This, too, is commonplace since the lack of adequate rest accumulates. This “sleep debt” or “sleep deficit” is real and a real problem. Consider this: You have the dreaded 5:00 a.m. show on day No. 1 of a trip beginning at your home base at Van Nuys Airport (KVNY) in California for a nonstop to Chicago Midway Airport (KMDW), where you pick up additional passengers and continue to New Jersey’s Teterboro Airport (KTEB). Depending on your driving time to the FBO at Van Nuys, it’s quite possible you had to wake up at 3 or 3:30 a.m. Once at the New Jersey hotel, you might try to sleep around 7 p.m., but there’s the call home, shirt pressing, emails and such, and it’s more likely you’ll be lights out at 11 p.m., your normal sleep time. You’ve made it through the day with, maybe, 4 hr. of sleep. Any normal pilot would have felt groggy all day long.

The next morning, you’re bound for Toronto’s Pearson International Airport (CYYZ) with a departure time of 7 a.m. With the paperwork for the international trip you plan to be at the FBO no later than 5:30 a.m. local, which translates to a 4 a.m. wakeup. Will you drop immediately into deep restful sleep? Not likely.

According to Graeber, when sleep is attempted at a time abnormal to a person’s circadian rhythm, that person will have considerably more difficulty getting to sleep and, once successful, will usually awaken within a relatively short time. This is one of the key underlying problems for pilots that creates what is essentially a career-long battle with fatigue. Simply stated, humans get their normal recuperative rest when they go to sleep at their normal time, and wake up at their normal time. Doing otherwise substantially cuts down on the quality and quantity of sleep. We can’t simply “switch ourselves into deep sleep” just because the crew schedulers tell us this is our 10-hr. rest period. Let’s call this strike No. 4.

Then, when the alarm clock jolts you awake in Teterboro — which, by the way, is 1 a.m. on your California body clock — you can be forgiven for reconsidering your career choice. How much deep recuperative sleep did you manage to get? Clearly not enough. Perhaps it was 4 hr. of deep sleep, thus starting day No. 2 with an accumulated 8 hr. of sleep debt. That’s the equivalent of missing an entire night of sleep. Let’s designate the sleep debt issue as strike No. 5.

Changing time zones or operating on the back side of the clock imposes the additional burden of circadian desynchronization. Graeber’s research found that the circadian rhythm system is unable to adjust rapidly to sudden shifts. In effect, the system resists changes in its timing and stability and complete resynchronization of the body’s biological timing system can take several days.

Additionally, resynchronization occurs at a different rate depending on whether the body must adapt to a westbound or eastbound time zone changes. Medical specialists in the field of sleep medicine have determined that, depending on the number and direction of time zones crossed, it can take days for the circadian system to resynchronize. And recovery from eastbound flights is more difficult. The general rule of thumb is that adjustment to eastbound travel requires 1.5 days per time zone crossed. Yet, as pilots it is entirely possible to be in a different time zone each night of a trip. In short, we don’t get days to resynchronize. Circadian rhythm desynchronization is strike No. 6. Two batters down.

There are substantial differences in various people’s ability to adjust to repeated time-zone shifts. “Morning people,” introverts, the elderly and those with stable rhythms have slower rates of resynchronization than others. Furthermore, studies found that crew members over 45-50 years of age experience less total sleep and poorer quality sleep. If you’re in this age group, that’s strike No. 7.

The combination of poor sleep quality on the road as well as trying to sleep at times outside your body’s normal sleep time will worsen the sleep debt during the trip. It comes with the job. NASA research found that air crews tend to accumulate more sleep debt and thus become more fatigued as they progress through a trip.

Does working a pilot hard contribute to fatigue? Yes, it can, but if the pilot is operating during a normal “day” cycle and then has the opportunity to rest during a normal “night” cycle, the average aviator will be able to show up for flight duties the next day adequately rested.

I have asked pilot groups if they would rather work a hard 12-hr. day that begins at 7:30 a.m. or work an 8-hr. day that begins at 5 a.m., and they almost always choose the former. Why? The sleep loss associated with early morning report times is considerable. NASA research found that the timing of flight activities and not necessarily the length of the duty day or the number of segments flown appears to contribute more to fatigue.

You would not be alone if you dread the fatiguing effect of those early report times. (And admit it, how many of us set at least two alarm clocks for those early morning wake-up’s?) An early report time is strike No. 8.

The British Association of Airline Pilots, together with the University College London Psychobiology Group, carried out a survey of fatigue and well-being among British airline pilots. The study revealed that sleep problems are correlated with fatigue. As a consequence, fatigue can become self-perpetuating. It determined that “Pilots may eventually end up in the vicious circle of being too tired to adequately rest or sleep, which in turn will leave them even more exhausted.” (See the “How Bad Is the Problem?” sidebar.)

Dr. David Gozal, both a professor at the University of Chicago School of Medicine specializing in sleep disorders and a deputy editor of the journal Sleep and Frontiers in Neurology, found that recovery from sleep loss does not immediately restore all of the body’s systems. Neural and metabolic activity take much longer to recover. “Recovery is not so simple,” he found, adding, “If you accumulate debt, there will be compounded interest and an uphill battle to recover.”

Up to this point I have not touched on pilot duties in a typical day, the stresses involved, and the fatigue-inducing conditions under which we work. A 6 a.m. show in January for clients who enjoyed a weekend of skiing at a ski resort means you are likely walking out to an aircraft that has been cold-soaked to -20F on the ramp for maybe the last three days. Preflighting such an aircraft on a still-dark morning in the mountains can be breathtakingly unkind. Conversely, getting an aircraft ready for a post-maintenance inspection flight on an August afternoon with the ramp radiant temperature spiked at 120F will spike crew fatigue levels as well.

Let’s say your departure is from New York’s Westchester County Airport (KHPN) on a Friday afternoon with weather all around when your lead passenger shows up with an additional golf buddy for the trip to Bermuda. Suddenly, you have additional customs paperwork to file as well as new weight and balance to calculate that could cause a cascading set of changes on your loading and fuel. Naturally, the principal expects the engines to start turning as soon as he steps aboard and to be rolling within minutes, oblivious to the considerable stress imposed on the crew.

Entering New York airspace at that time and day along with foul weather guarantees a high workload environment for the departure with controllers issuing nonstop instructions as they try to keep the metal moving. You will not really catch your breath until climbing through FL 300.

The view from the flight deck at FL 410 on a clear day is one we would never trade, but the cockpit itself contributes to fatigue. Sitting confined in small seats for long hours induces lethargy, as well as our chances for developing deep vein thrombosis, or DVT. The dry, pressurized air is wicking away precious volumes of our body’s moisture, thus causing us to be in a chronic state of dehydration for most of our hours airborne. Glare, vibrations and noise all increase fatigue. How much does the combined effect of these add up? The anecdotal evidence suggests it is considerable. (See the “Cockpit Environment and Fatigue” sidebar.)

Despite the forging, most of us are Type A personalities who seek out challenges and enjoy the sense of doing a job well. So, as a group, we are not very good at stepping away from the plate and saying, “Coach, I need to sit this one out.”

In the words of Steven R. Hursh Ph.D., chief scientist of the Institutes for Behavior Resources, “There’s no breathalyzer for tired . . . but there should be.” Absent a practical real-time fatigue detector, he says most people underestimate just how tired they are and how impaired they are by that fatigue. 

Admonishments to “be more professional” or “show attention to detail” ignore the underlying pervasiveness of serious fatigue among line pilots. Professional aviators will continue to be warned to use their rest period productively, even though the scientific evidence is plentiful that the human body simply does not flip a switch at 6, 7 or 9 p.m. to begin deep recuperative sleep in preparation for a 3 a.m. report for duty the next day. It is the timing of sleep, not the amount of time awake or “in rest,” that is the critical factor controlling sleep quality.

The facts about fatigue are clear, and something to sleep on. 
   
Even though I might appear to be 'flogging a dead horse' Downunda; I note that the AA magazine last week refreshed the informative BC June article on 'understanding fatigue':   

Quote:
written by Ben Cook July 21, 2018
THE SIGNIFICANT IMPACT OF FATIGUE

Last issue we highlighted the significant impact fatigue can have on crews. In the case of the Pel-Air Westwind ditching, the aircraft captain, having obtained only 3–3½ hours of average quality sleep, displayed a fixation on a simple plan to land. He and the remainder of the crew were too impaired to recognise growing evidence that the plan was not working. The flight nurse and doctor received minimal to no sleep during the day of the accident as they were too busy caring for the patient.

Even worse, the accident itself occurred on a remote island around 9.40pm, yet the crew were meant to be continuing from Norfolk Island to Sydney and then to Melbourne. This was well outside the acceptable limits of any mature fatigue risk management system (FRMS). This information has gained little attention even though it’s a clear example of failed company processes and regulatory oversight.

The impact of elevated levels of fatigue is that people do not realise their level of impairment. They press on ‘lethargic and indifferent’ with a simple plan. This can occur in large organisations to even the most experienced crews.

[Image: Screen-Shot-2018-07-19-at-6.15.02-pm-e1531996697944.png]
Pel-Air Westwind VH-NGA at Sydney AirportPel-Air Westwind VH-NGA at Sydney Airport (Tim Bowrey)

THE INSIDIOUS NATURE OF FATIGUE

A clear wake-up call across international civil aviation was the 1993 crash of a DC-8-61 freighter while on approach to land at Guantanamo Bay, Cuba. It was one of the first accidents where fatigue was cited as the primary contributory factor. The US National Transportation Safety Board (NTSB) determined the probable causes of this accident were the impaired judgment, decision-making and flying abilities of the captain and flightcrew due to the effects of fatigue. Acute sleep loss contributed to degraded decision-making, visual and cognitive fixation, poor communication and slowed reaction times.

Leading up to the accident, the three crew members had each been continuously awake for 23½ hours (aircraft captain), 19 hours (first officer), and 21 hours (flight engineer).

The outcome being a loss of stabilised approach criteria and an uncontrolled in-flight collision with terrain. The aircraft captain who, like his copilot and flight engineer managed to survive this accident. They regained consciousness post-accident in “what felt like a crunched-up coke can, with wires and panels hanging all around them”. Luckily during the impact, the front part of the cockpit separated from the main fuselage and kept the crew away from the subsequent fireball that erupted as their four-engined jet transport crashed into the ground.

Earlier that day the crew knew they were going to be exposed to elevated fatigue risks and had planned to make a more conservative approach, rather than an approach that required visual guidance from a ground-based strobe light (that on the day was not working).

However, after receiving a request from air traffic control very late in the flight, when fatigue levels were excessive, they elected to change their original plan to a far more demanding visual approach that required steep manoeuvring to make the landing.This was all at the captain’s suggestion, “Just for the heck of it”. During the final minutes of the flight, the cockpit voice recorder (CVR) clearly highlights the negative effects of fatigue.

These include cognitive fixation (too focused on identifying a strobe light to the detriment of other cues), and pattering checklists by rote but not having the cognitive ability to recognise and act on other critical information such as airspeed control or verbal cues that the aircraft was well outside safe parameters.

COCKPIT VOICE RECORDING:

FE: Slow. Airspeed.

FO: Check the turn.

Capt: Where’s the strobe?

FE: Right over here.

Capt: Where?

FO: Right inside there, right inside there.

FE: You know, we’re not gettin’ our airspeed back there.

Capt: Where’s the strobe?

FO: Right down there.

Capt: I still don’t see it.

FE: [Expletive], we’re never goin’ to make this.

Capt: Where do you see a strobe light?

FO: Right over here.

Capt: Gear, gear down, spoilers armed.

FE: Gear down, three green, spoilers, flaps, checklist.

???: There you go, right there, lookin’ good.

Capt: Where’s the strobe?

FO: Do you think you’re gonna make this?

Capt: Yeah… if I can catch the strobe light.

FO: 500, you’re in good shape.

FE: Watch the, keep your airspeed up.

FO: 140.

 [sound of stall warning]

???: Don’t – stall warning.

Capt: I got it.

FO: Stall warning.

FE: Stall warning.

Capt: I got it, back off.

???: Max power!

???: There it goes, there it goes!

???: Oh no!

 [screams]

EXPERIENCED CREW

This crew were highly experienced (far more experienced than the Pel-Air crew), yet they too lost the ability to recognise what, in hindsight, look like obvious cues to us, that could have broken the error chain. The aircraft captain (Jim Chapo) had more than 20,000 hours flight time. He had served as a check pilot with a major commercial airline prior to commencing night cargo work. But, he received no specific training on the effects of fatigue, even though the night cargo work was quite different to the rosters he had experienced with the airline.

As part of an NTSB fatigue factors training course I attended,  I was fortunate to hear a presentation from Jim. He reported feeling “lethargic and indifferent” during the approach and, when he later reviewed the CVR, was surprised at how unresponsive he was to the concerns of others.  It was an emotionally moving presentation to listen to Jim so openly and honestly recount the horror of surviving an accident and the long-term trauma that followed. At the time, the crew were operating in accordance with the regulations and company procedures. It further highlights the true dangers of elevated levels of fatigue and the severe impairment to decision-making and cognitive processing.

Your challenge, in making sure you utilise human factors for high performance, particularly if you’ve made a transition from one type of operation to another – for example, ab-initio flying training to night freight operations – is to make sure you identify such gaps. True high performers don’t accept the status quo. They know their own limitations and they continue to respectfully seek the training and/or enhanced processes necessary to ensure they can maintain proficiency.

[Image: Screen-Shot-2018-07-19-at-6.11.50-pm-1024x657.png]

Miraculously the crew of the Guantanamo Bay DC-8 freighter crash survived. (NTSB)

PSYCHOPHYSIOLOGICAL INSOMNIA
One of the biggest challenges of fatigue is that certain conditions experienced by one person may have little to no impact on performance, yet another person under the same conditions can be severely impacted.

I’ve been fortunate over the years to gain some detailed operational experience in managing fatigue, including the use of specialist sleep watches to obtain real sleep data. This has involved the development of fatigue risk profiles, not as an academic research project, but rather for the management of a known hazard (fatigue) with the constraints of a safety management system (SMS).

So, look at the following real patterns of sleep, which are shared with consent. The first data column contains 10 consecutive days of sleep hours and minutes during a time when a student was completing a very demanding aviation training course on a high-performance aircraft. The second column contains 10 days of consecutive sleep data for the same person, though this time the person is performing an instructional role.


[Image: Screen-Shot-2018-07-19-at-6.05.47-pm-231x300.png]


FIT FOR DUTY?

What are your thoughts? Is this person fit for duty?

I hope you want to ask some further questions. As background, this person does not have a short sleep gene – they’re not one of the less than three per cent of the population that can perform well with much less sleep than most of us. In fact, when on holidays and relaxing (a good way to identify your normal sleep patterns) this person records seven–eight hours of sleep per night.

What’s your answer? Is this person fit for duty in any workplace, let alone within the cockpit of an aircraft? If you’re like most, including several sleep doctors, the answer is no.

LONG TERM HEALTH IMPACTS

Yet this person performed to a high standard throughout the duration of a particular training course. The bigger challenges were the longer-term impacts to the individual’s health and wellbeing.

I remember asking this person, when they were an instructor, their partner’s views on the impact to their sleep patterns. The response: “They just wanted their old partner back”.

It was at this point they sought specialist help from a sleep clinic to re-correct their sleep patterns, including techniques to manage the anxiety that was leading to poor sleep. While this person might be praised for their ability to perform well under such trying conditions, you need to be careful to not consider this as acceptable. The reality is disrupted sleep patterns like this over the longer-term lead to poor health outcomes. It’s also important to consider others that may not be able to perform like this, particularly if the additional stressors (such as a busy conversion course) are quite high and are actively contributing to additional anxiety and disrupted sleep. If, combined with a late night or very early morning simulator runs, you may be failing more than capable personnel at great cost.

HUMANS ARE COMPLEX YET WE SEEK SIMPLE SOLUTIONS

For most of us within our aviation organisations, life is pretty busy. We often seek simple solutions; it helps us tick off our task list and to move onto the next priority of the day. Only a fool dare tread in this space when dealing with human fatigue. For supervisors, you’re probably after a simple set of rules that not only define a broad limit for scheduling practices and fatigue management, but that can be used to make sure people conform to general work practices.

For example, if most of the team can handle a night shift in accordance with the rules yet one team member (we’ll call him Chris) cannot, what assumptions do you make? Have you ever heard phrases such as, “Chris is lazy”, or “Chris just doesn’t cut it in this workplace”? Chris may be more than competent to perform most tasks required to a high standard, it’s just that Chris’s individual biological differences result in a small part of the workplace routine not meeting his needs.

In mature organisations, these differences are understood and managed to align workplace practices to better support individual needs and to better understand the true complexity of fatigue. Yet so many organisations prefer the overly simplistic approach and along the way they lose good people like Chris, or even worse, they create a ‘them and us’ culture between workers and supervisors/managers.

The outcome is often catastrophic. After an accident, workers may state: “We knew that was going to happen, fatigue has been a problem for some time, why wouldn’t our managers listen to our concerns?”. In turn the managers respond: “We’ve got a fatigue risk management system and there’s nothing in there that suggests we had any problems”.

Simple tools applied to complex problems tend to erode confidence and trust in the fatigue management system and can decrease the open and honest exchange of information regarding the real problems.

SYSTEMATIC FAILINGS

As per the previous Pel-Air article, there were numerous systemic failings, and the following highlight typical findings that contribute to degraded levels of trust, which can ultimately lead to blind compliance of poor practices:

- Westwind pilots reported the rostering of their duty periods appeared to be heavily based on a fatigue score. They were never asked about their level of alertness or recent sleep when tasks were assigned, or during the progress of a trip.

- Some pilots indicated they were provided with insufficient information about the fatigue program and they did not understand how it produced its scores or why its scores seemed to be inconsistent with their perceptions of their own fatigue levels.

FATIGUE MODELLING TOOLS

For anyone experiencing similar outcomes, particularly if your company is over-reliant on a biomathematical model of fatigue (BMMF), then look at the following finding regarding limitations with simple tools and/or not validating such tools in close consultation to ensure the model matches the performance outcomes of the operational workforce:

The US Federal Railroad Administration (FRA 2010) compared a local Australian fatigue modelling tool with another BMMF model, the Fatigue Avoidance Scheduling Tool (FAST), which the FRA had previously validated for use in the rail industry. Based on this comparison, it concluded the local fatigue model scores between 70 and 80 can be associated with ‘extreme fatigue’. If there has been very little duty time in the previous seven days, the local fatigue model will underestimate the potential fatigue level associated with the next duty period, and at times this level of underestimation can be significant.

Yet many local operators continue to utilise scores between 70–80 under the watchful eye of the regulator. If you’re experiencing this type of FRMS then stand up as a human factors practitioner of high performance.  Make sure you utilise any reporting mechanisms available to ensure you don’t experience the same outcomes as the crew of the Pel-Air aircraft.

[Image: Screen-Shot-2018-07-19-at-6.12.03-pm-1024x647.png]

The primary cause of the DC-8 crash was crew fatigue. (NTSB)The primary cause of the DC-8 crash was crew fatigue. (NTSB)

WRAP UP

As humans we’re complex systems with our own unique biological needs. The combination of disrupted sleep, anxiety and/or fatigue (physiological degradation) remains one of the most significant contributors of degraded performance and increased errors, including eroded decision-making. A good starting point in any workplace is to better understand the multiple factors that can contribute to excessive fatigue. It is also critical in larger organisations to develop a high trust relationship where people are comfortable to report sleep and fatigue issues to ensure policy and process can be enhanced.

If you’re a smaller operator then the best you can do is to educate yourself on relevant fatigue factors and to make changes to your own habit patterns for enhanced outcomes.

FATIGUE CHECKLISTS

Given the importance of sleep and fatigue management, in consultation with a number of local human factors and sleep subject matter experts, Australian Aviation has made available the following support tools on our website:

- Fatigue investigation checklist: a simple checklist, as collectively developed by several civil and military organisations to provide enhanced guidance to determine whether fatigue contributed to the incident or accident. Download here

- Fatigue risk management chart: a list of some of the many factors that should be considered in determining whether fatigue risk is unacceptable. The chart is particularly good for personnel to better understand the main factors that influence fatigue. Download here

- A guide to a good night’s sleep: some extracts from a definitive book, A complete guide to a good night’s sleep, written by Dr Carmel Harrington, one of our local leaders in sleep science. The extracts provide practical insights from over 20 years of applied sleep science. Download here


This article first appeared in the June 2018 edition of Australian Aviation.
MTF...P2  Cool
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