Carefully Assess Total Workload
There is a lot more to being a pilot than just flying the airplane. Pilots typically have ancillary duties that can take a considerable amount of time, and a chief pilot carries the full load of a manager in addition to any flight duties. Being on call means your time is not really your own, and a 24-hour operation has a deadly effect on sleep. The NMSP aviation-section managers had no problem with expecting the chief pilot, two full-time pilots and one part-time pilot to maintain 24-hour-a-day, seven-day-a-week operations with four aircraft. They also did not understand that the flight hours logged represented only the tip of the iceberg of the total duty times being worked, and they did not take into consideration the strain of being on call much of the time and working at all hours of the day and night. They expected the chief pilot to manage the flight department and maintain a full flight schedule, all while also functioning as a part-time public information officer.
Take Fatigue Seriously
The NMSP did have rules limiting pilot flight and duty time and stating that “a minimum of eight hours’ rest is required following any duty day that exceeds 12 hours prior to subsequent duty time.” However, it did not define “rest” or require a minimum rest period following less than 12 hours of duty. Thus this policy allowed the NMSP pilots, and especially the chief pilot, to develop what was likely a condition of chronic fatigue because they were on call and even performing work-related tasks during their “rest time.” The problem with chronic fatigue is that you get used to it and think you are performing well when, in reality, it will take only one unusually stressful event or tiring day to push you over the edge.
The FAA has finally realized that, if eight hours’ sleep is necessary for most people to be fully rested, eight hours between duty assignments is not nearly enough to allow eight hours of sleep. People need to unwind, eat and conduct personal business, and all that gets squeezed into “rest time,” often greatly reducing the amount of actual rest a person gets. The FAA has also decided to allow controllers to nap during their breaks, bringing their policy in line with years of fatigue research.
Develop an SOP
A standard operating procedure (SOP) contains predetermined successful solutions to many of the likely problems and pressures pilots can experience. Having an SOP to rely on can make it much easier to successfully respond to difficult situations, and to pressure from customers, management or internal missionitis. The NMSP had only a nine-page SOP, and as is often the case, it had many “unofficial practices.” Pilots would discuss how they would respond to various situations, but there was no overall consensus and no mandated policy to fall back on when tempted to push on.
Focus on Safety
While everyone wants to be safe, it is easy for safety to get pushed to the side during the rush of daily operations. The NTSB report noted that the NMSP did not have a safety officer or specific safety goals. There was also no protocol for risk assessment before launching a mission and during the mission, and no formal system for communicating safety-related information.