The ideas for articles frequently come from comments made by you, my readers. While most of you don’t post comments online, a number email me, some call me and quite a few talk to me when you bump into me at an aviation event, at an airport or even on airplanes. I can’t count the number of times crewmembers have stopped to say something about a recent AIN article or even just that they read my articles. And I appreciate all of you who take the time to talk to me, but the ones I find most flattering, I admit, are the ones who say they turn to Torqued first when their copy of AIN arrives.
This article grew out of a number of comments that were made in response to my November Torqued about personal accountability for time management. That article stemmed from the NTSB’s report on the Aug. 14, 2013 UPS A300 that crashed just short of the runway in Birmingham, Ala. The report determined that a contributing factor was “the first officer’s fatigue due to acute sleep loss resulting from her ineffective off-duty time management.” It also found that although the first officer knew she was tired, she didn’t call and report her fatigue under UPS’s fatigue policy.
Having worked as a mechanic for many years on the midnight shift, I thought the NTSB’s focus on personal accountability for time management was important. In the end, we all have choices we need to make. And while many of you agreed with the critical importance of personal safety choices, those who spoke with me privately felt that the NTSB had stopped short of getting to the bottom of organizational factors that might have affected the copilot’s failure to report her fatigue.
NTSB Review of Fatigue Management
Although the NTSB’s report recommends that UPS and the pilots’ union conduct an independent review of the “fatigue event reporting system to determine its effectiveness as a nonpunitive mechanism to identify” and address fatigue, most of the commenters I spoke with felt that the Board should have probed that issue and not left it to third parties. On reflection, I think these commenters have a point: an NTSB review would be for the public benefit and could arguably come from an airing of whether the corporate culture at the airline encouraged a pilot to report fatigue or whether directly or indirectly, however subtly, it discouraged pilots from reporting fatigue. I have no personal knowledge of UPS’s culture and I don’t know whether UPS’s fatigue policy is normally effective. With fatigue such an important issue across modes of transportation the effectiveness of corporate policies to report fatigue should have been investigated by the NTSB.
The results of an NTSB investigation of UPS’s corporate culture could have led to specific recommendations for improving or supporting pilot decision-making regarding fatigue instead of the more general recommendation that the company and union study the effectiveness of current policies and procedures. While this is certainly a great effort for UPS and its pilot union to undertake, it’s unlikely to result in a report that will benefit other carriers and the public in general. Of course, I am well aware of budgetary constraints at the NTSB, but I think the issue of fatigue and calling out the decisions of a copilot on her time-management warranted, as commenters have expressed, a review of the culture at UPS to see whether there would have been any cultural obstacles to reporting fatigue.
In retrospect, I agree with the commenters who suggested that the NTSB should have looked at whether organizational factors at UPS could have affected the copilot’s decision not to report her fatigue. In the absence of an NTSB review of that issue, it would be helpful if UPS not only followed the NTSB’s recommendation to perform an independent review of the effectiveness of its fatigue reporting policy with its pilots union but also at least shared with the NTSB, other airlines and unions any recommendations that come out of that review. It’s likely that other airlines could benefit from a UPS review.
Apart from this particular accident–where the NTSB report states that the difference in FAR crew rest requirements for cargo flights was not an issue–the NTSB should consider an independent review of the FAA’s decision to allow different rest requirements for passenger and cargo flight crews. As many of you may recall, Part 121 operators were initially going to be held to the same rest requirements and the FAA’s notice of proposed rulemaking did not differentiate between the two types of operation. At some point that changed and it’s never been clear to me why, other than intense lobbying from cargo airlines.
What the UPS accident makes clear is that fatigue affects the safety of not only those in the air but also those on the ground. Fortuitously in this accident, the airplane crashed away from populated areas and no one on the ground was killed. That might not always be the case, and the public deserves an independent analysis of whether a distinction between passenger and cargo operations is warranted in the interests of safety.