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The Human Factor: A Perfect Storm of Fatigue

By Jay Hopkins / Published: Apr 13, 2011
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(April 2011) AFTER WRITING THREE articles on the subject of fatigue I figured I had pretty much covered that topic. Then I started receiving e-mails and phone calls from Flying readers, more than I have ever received before. It is obvious that fatigue is a critical issue for many people.

Paul Reeves described his own battle with micro naps that developed into micro sleep intrusions in which he was “still awake but under severely degraded motor function and a zombielike cognitive state — eyes open, brain off.” He said that he could not tell when this occurred, and could hear everything in real time, but he had dreamlike experiences that were close to hallucinations. Paul stopped driving and lost his medical for eight years while he got help with this problem. He pleaded with other pilots with sleep disorders to seek help, because he has “no doubt if I had continued on my own, you would not be reading this letter.”

Dr. L.C. Carmichael, who works at a sleep disorder center, echoed that plea, saying that studies indicate “there is a sizable number of pilots with a sleep disorder. One should not duck and run at the thought of being a member of that group as there are a number of successful strategies available for many sleep problems and one has only to seek the advice of a sleep physician.”

The most compelling and eye-opening responses came from air traffic controllers. It turns out that many air traffic facilities use a rotating shift, with controllers working evening, afternoon, morning and night rotations in the span of one week. While this allows an 80-hour break between work periods, one retired controller said that “it certainly took a toll on my body and had me working fatigued on many occasions.” He said it was “hard to get a good night’s rest when your shift starts just eight hours after the last one ended.”

Another controller said, “This schedule is exhausting because it is very hard to adjust sleeping times and get a solid eight hours of sleep. Even the weekends are not restful because you are trying to transition back to staying up late for the first late shift when you resume your workweek. Sometimes you get unscheduled overtime which could be any shift, and that can really throw your schedule off.” He said the fatigue makes it hard for him to concentrate and do the job properly.

I had always wondered about accident reports that described a controller with very little traffic or other workload making critical mistakes or even watching an airplane enter severe weather without providing any warning to the pilot. Working the night shift is difficult enough, but the first night on the night shift is the worst. On controllers’ rotating shift schedules, they are changing shifts throughout the week and working one night shift after working that same morning. Research shows that is about the worst kind of schedule from the standpoint of causing fatigue. As one controller said, “You know you should do something, but you can’t force yourself to do it. It becomes hard to do your work.”

It seems like we have a “perfect storm” of fatigue in aviation — tired pilots working with tired controllers. The system of keeping an eye on each other breaks down when everyone involved is having a hard time keeping his or her eyes open. One example of this is the accident at Lexington, Kentucky, in August 2006, when a Comair regional jet crashed after attempting to take off on the wrong runway. This is a particularly interesting case because the pilots and the controller were all respected by their peers and the NTSB did not find any history of past performance issues. There also were no extraordinary circumstances that would have led anyone to be excessively fatigued. The captain had arrived in Lexington at 3:15 p.m. Saturday and had eaten dinner with his family before going to bed. The copilot had arrived at 1:40 a.m. Saturday but then had had no other duties the rest of the day.

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Captain Ray's picture

This was a tragic and unfortunate accident in so many ways. Airport design contributed to the confusion in the cockpit. However, the smart pilot always looks ahead at the chances of confusion and double and triple checks everything. One traditional place for rushing is Moysant airport in New Orleans. With a short taxi to the north/south and shorter runway I always prefered to stay put after pushing back (A-320), do all the required checklists and preparations and announcements before moving towards the runway. This allowed both pilots to have a heads out capability to minimize taxi/runway errors. This procedure would have saved this crew, passengers and plane.

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