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Reduce Accidents and Incidents Caused by Human Fatigue in the Aviation Industry
Importance
The Safety Board has long been concerned about the effects of fatigue on persons performing critical functions in all transportation industries including flight crews, aviation mechanics, and air traffic controllers. In 1989, the Board issued three recommendations to the Secretary of Transportation calling for research, education, and revisions to existing regulations. These recommendations were added to the Board’s Most Wanted List in 1990, and the issue of fatigue has remained on the Most Wanted List since then. The Safety Board’s 1999 safety study of U.S. Department of Transportation efforts to address operator fatigue continued to show that this problem was widespread. Operating a vehicle without the operator’s having adequate rest, in any mode of transportation, presents an unnecessary risk to the traveling public.
Safety Board recommendations on the issue of human fatigue and hours-of-work policies have had a substantial effect on encouraging the modal agencies to conduct research and take actions towards understanding the complex problem of operator fatigue in transportation and how it can affect performance. However, the FAA has taken little if any action directly related to revising existing regulations and work scheduling practices.
Flight Crews
The FAA issued a notice of proposed rulemaking in December 1995 to update the flight and duty regulations for airline pilots; however, in the intervening 13 years, the regulations have not been revised. In recent years, the FAA has stated that it is developing a fatigue risk management system (FRMS) to provide an alternative to prescriptive limitations. Additionally, the FAA has supported the adoption of FRMS programs among certain air carriers for their ultra-long-range operations.
In June 2008, the FAA sponsored a symposium on fatigue management that provided an opportunity for subject matter experts to come together and discuss fatigue’s effects on flight crews, maintenance personnel, and air traffic controllers. The Safety Board believes that fatigue management plans may hold promise as an approach to dealing with fatigue in the aviation environment. However, the Board considers fatigue management plans to be a complement to, not a substitute for, regulations to prevent fatigue.
Maintenance Personnel
In 1999, the FAA issued a report, Study of Fatigue Factors Affecting Human Performance in Aviation Maintenance. The FAA expanded this study, completing the first phase of the expanded study and issuing a report in April 2000, titled Evaluation of Aviation Maintenance Working Environments, Fatigue, and Maintenance Errors/Accidents. The expanded study looked at multiple and combined environmental factors of temperature, noise, light, vibration, and sleep, which are known to accelerate fatigue onset, as well as the effects of lifestyle habits on fatigue and human performance. The study was designed to collect data in the aviation maintenance work environment on known factors that affect human fatigue and performance.
The FAA's findings suggest that fatigue is an issue in this work force. Data from “mini-logger monitors” that recorded data from the selected parameters of light, noise levels, and temperature; activity monitors that monitored physical activity, sleep, and sleep quality; and answers to background questions that employees were asked clearly indicate that sleep durations are inadequate to prevent fatigue. For most aviation maintenance technician specialties, 30-40 percent of respondents reported sleep durations of less than 6 hours, and 25 percent of respondents reported feeling fatigued or exhausted.
The data were intended for use in predicting situations that are conducive to fatigue, accidents, incidents, and errors. Data collection began in August 2000, and the expanded study was planned for completion in December 2003. However, an FAA Aviation Maintenance Human Factors Project Report from January 2004 stated that the research had not progressed, nor is any broad research effort or regulatory activity currently being conducted in this area.
The FAA has reported to Congress that, based on several studies completed on the maintenance fatigue issue, it believes that the extreme complexity of the issue of maintenance crew fatigue and duty time do not present appropriate material for regulatory activity, and that education and training in fatigue management are the most appropriate actions for the FAA to sponsor and foster. The FAA has consequently conducted education and training activities on fatigue management for aircraft maintenance personnel.
On April 18, 2006, the Safety Board informed the FAA that the Board disagrees with the FAA’s positions that regulatory action is not appropriate and that the FAA’s current education and training activities related to this issue can achieve the intent of this safety recommendation. On February 22, 2007, the Safety Board informed the FAA that it had reviewed Advisory Circular (AC) 120-72, “Maintenance Resource Management (MRM) Training,” which seemed to be the primary focus of the FAA’s education and training initiatives related to fatigue among aviation maintenance crews as reported to Congress. The Board found little in AC 120-72 that provides guidance on human fatigue in maintenance crews other than generalized warnings that attention to fatigue is important and should be considered in MRM Training. The AC contains little guidance as to how an employer should design a program to ensure that maintenance crews are not fatigued. The Board asked the FAA whether it has any additional guidance related to fatigue in aviation maintenance crews besides AC 120-72 and whether the FAA will consider establishing duty time limitations for personnel who perform maintenance on air carrier aircraft, as recommended. The FAA has not yet responded.
Air Traffic Controllers
On July 5, 2007, the FAA stated that it had convened a working group to develop shift rotation and scheduling guidelines and that the National Air Traffic Controllers Association (NATCA) would be invited to participate in the group. The FAA also stated that it would develop, within 12 months, and implement a fatigue awareness and countermeasures training program to be used by all FAA Air Traffic Organization operational service units. Since then, the FAA has assigned several of its professional research staff with expertise in human fatigue to study this issue and develop a set of recommendations that other concerned individuals and organizations, such as NATCA, can evaluate.
Recently, the FAA and NATCA met for the first time to discuss the results of the FAA’s controller fatigue working group.
Actions Remaining
Issue regulations that establish scientifically based duty time limitations for air carrier maintenance personnel and flight crews. Revise controller work-scheduling policies and practices to provide adequate rest periods, modify controller shift rotations to minimize fatigue, and develop a fatigue awareness and countermeasures training program for controllers.
A-94-194 (FAA)
Issued November 30, 1994
Added to the Most Wanted List: 1995
Status: Open—Unacceptable Response
Revise the Federal Aviation Regulations contained in 14 CFR Part 135 to require that pilot flight time accumulated in all company flying conducted after revenue operations—such as training and check flights, ferry flights and repositioning flights—be included in the crewmember's total flight time accrued during revenue operations. (Source: Commuter Airline Safety, [NTSB/SS-94-02]).
A-95-113 (FAA)
Issued November 14, 1995
Added to the Most Wanted List: 1996
Status: Open—Unacceptable Response
Finalize the review of current flight and duty time regulations and revise the regulations, as necessary, within 1 year to ensure that flight and duty time limitations take into consideration research findings in fatigue and sleep issues. The new regulations should prohibit air carriers from assigning flight crews to flights conducted under 14 CFR Part 91 unless the flight crews meet the flight and duty time limitations of 14 CFR Part 121 or other appropriate regulations. (Source: Investigation of an Uncontrolled Collision with Terrain, Air Transport International, Douglas DC-8-63, N782AL, Kansas City International Airport, Kansas City, Missouri, February 16, 1995 [NTSB/AAR-95-06]).
A-97-71 (FAA)
Issued September 9, 1997
Added to the Most Wanted List: 1999
Status: Open—Unacceptable Response
Review the issue of personnel fatigue in aviation maintenance; then establish duty time limitations consistent with the current state of scientific knowledge for personnel who perform maintenance on air carrier aircraft. (Source: The Investigation of the In-flight Fire and Impact with Terrain, ValuJet Airlines Flight 592, DC-9-32, N904VJ, Everglades, near Miami, Florida, May 11, 1996 [NTSB/AAR-97-06]).
A-06-10 (FAA)
Issued February 7, 2006
Added to the Most Wanted List: 2006
Status: Open—Unacceptable Response
Modify and simplify the flight crew hours-of-service regulations to take into consideration factors such as length of duty day, starting time, workload, and other factors shown by recent research, scientific evidence, and current industry experience to affect crew alertness. (Source: Collision with Trees and Crash Short of the Runway, Corporate Airlines Flight 5966, BAE Systems BAE-J3201, N875JX, Kirksville, Missouri, October 19, 2004 [NTSB/AAR-06/01]).
A-07-30 (FAA)
Issued April 10, 2007
Added to the Most Wanted List: 2007
Status: Open—Acceptable Response
Work with the National Air Traffic Controllers Association to reduce the potential for controller fatigue by revising controller work-scheduling policies and practices to provide rest periods that are long enough for controllers to obtain sufficient restorative sleep and by modifying shift rotations to minimize disrupted sleep patterns, accumulation of sleep debt, and decreased cognitive performance. (Source: Recommendation letter to the FAA regarding four runway incursions and Attempted Takeoff from Wrong Runway, Comair Flight 5191, Bombardier CL-600-2B19, Lexington, Kentucky, August 27, 2006 [NTSB/AAR-07/05]), April 10, 2007.
A-07-31 (FAA)
Issued April 10, 2007
Added to the Most Wanted List: 2007
Status: Open—Acceptable Response
Develop a fatigue awareness and countermeasures training program for controllers and for personnel who are involved in the scheduling of controllers for operational duty that will address the incidence of fatigue in the controller workforce, causes of fatigue, effects of fatigue on controller performance and safety, and the importance of using personal strategies to minimize fatigue. This training should be provided in a format that promotes retention, and recurrent training should be provided at regular intervals. (Source: Recommendation letter to the FAA regarding four runway incursions and Attempted Takeoff from Wrong Runway, Comair Flight 5191, Bombardier CL-600-2B19, Lexington, Kentucky, August 27, 2006 [NTSB/AAR-07/05]), April 10, 2007.
A-07-32 (NATCA)
Issued April 10, 2007
Added to the Most Wanted List: 2007
Status: Open—Acceptable Response
Work with the Federal Aviation Administration to reduce the potential for controller fatigue by revising controller work-scheduling policies and practices to provide rest periods that are long enough for controllers to obtain sufficient restorative sleep and by modifying shift rotations to minimize disrupted sleep patterns, accumulation of sleep debt, and decreased cognitive performance. (Source: Recommendation letter to NATCA regarding four runway incursions and Attempted Takeoff from Wrong Runway, Comair Flight 5191, Bombardier CL-600-2B19, Lexington, Kentucky, August 27, 2006 [NTSB/AAR-07/05]), April 10, 2007.
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