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Safety Recommendation Details

Safety Recommendation A-97-071
Details
Synopsis: On 5/11/96, about 1415 eastern daylight time, a McDonnell Douglas DC-9-32 crashed into the everglades swamp shortly after takeoff from Miami International Airport, Miami Florida, the airplane, N904VJ, was operated by ValuJet Airlines, Inc., as ValuJet flight 592. Both pilots, the three flight attendants, and all 105 passengers were killed. Before the accident, the flightcrew reported to air traffic control that it was experiencing smoke in the cabin and cockpit. Visual meteorological conditions existed in the Miami area at the time of the takeoff. The destination of the flight was Hartsfield International Airport, Atlanta, Georgia. Flight 592 was on an instrument flight rules flight plan.
Recommendation: TO THE FEDERAL AVIATION ADMINISTRATION: 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. (A-97-71 is superseded by safety recommendaiton A-13-01)
Original recommendation transmittal letter: PDF
Overall Status: Closed - Unacceptable Action/Superseded
Mode: Aviation
Location: Miami, FL, United States
Is Reiterated: No
Is Hazmat: No
Is NPRM: No
Accident #: DCA96MA054
Accident Reports: In-Flight Fire and Impact With Terrain Valujet Airlines Flight 592 DC-9-32, N904VJ
Report #: AAR-97-06
Accident Date: 5/11/1996
Issue Date: 9/9/1997
Date Closed: 1/29/2013
Addressee(s) and Addressee Status: FAA (Closed - Unacceptable Action/Superseded)
Keyword(s): Fatigue,

Safety Recommendation History
From: NTSB
To: FAA
Date: 1/29/2013
Response: -From the aircraft accident report Loss of Control, Sundance Helicopters, Inc. Eurocopter AS350-B2, N37SH, Near Las Vegas, Nevada, December 7, 2011, report adopted on January 29, 2013: 3.2.1.2 Lack of Maintenance Personnel Duty-Time Limitations The NTSB has had longstanding concerns about the effects of fatigue on maintenance personnel. On September 9, 1997, as a result of the May 11, 1996, accident in which a McDonnell Douglas DC-9-32 operated by ValuJet Airlines, Inc., as ValuJet flight 592 crashed into the Everglades swamp shortly after takeoff from Miami International Airport, Miami, Florida, the NTSB issued Safety Recommendation A-97-71, which asked the FAA to do the following: 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. (A-97-071) The NTSB notes that on November 17, 1997, in response to Safety Recommendation A-97-71, the FAA stated that its data suggested that night shift and/or mixing of day/night work schedules affect performance more than an extended length of duty time but that no current definitive studies were available to evaluate these parameters as comparative measurements. The FAA stated that it was going to expand its human factors research program to include studies regarding duty length and shift scheduling and that at the conclusion of this research, it would implement appropriate policy or regulatory change. The NTSB notes that in the 15 years since the issuance of Safety Recommendation A-97-71, the FAA has conducted additional research regarding the effects of duty length and shift scheduling as factors contributing to fatigue. Fatigue has been linked to a decrease in cognitive performance, including reduced attention (for example, overlooked and/or misplaced sequential task elements, preoccupation with single tasks, and breakdowns in systematic scanning ability) and diminished memory (for example, inaccurately recalling operational events, forgetting peripheral tasks, and reverting to “old” habits). However, the FAA has not taken any regulatory actions in these areas. As a result, on October 7, 2009, the NTSB classified Safety Recommendation A-97-71 “Open?Unacceptable Response” pending the issuance of duty-time requirements. Because the Sundance inspector’s fatigue was caused, in part, by extended duty time, the NTSB continues to believe that establishing duty-time limitations is a key strategy to reducing the risk of fatigue-related errors in aviation maintenance. The NTSB notes that an even more robust base of scientific knowledge and industry best practices exists on which to formulate such rules than existed when Safety Recommendation A-97-71 was issued. As a result, the NTSB concludes that sufficient scientific research on fatigue and knowledge of industry practices currently exists from which to establish duty-time limitations for maintenance personnel that would help reduce the risk of fatigue-related errors in aviation maintenance. Therefore, the NTSB recommends that the FAA establish duty-time regulations for maintenance personnel working under 14 CFR Parts 121, 135, 145, and 91 Subpart K that take into consideration factors such as start time, workload, shift changes, circadian rhythms, adequate rest time, and other factors shown by recent research, scientific evidence, and current industry experience to affect maintenance crew alertness. (A-13-01) Because of the FAA’s inactivity, the NTSB classifies Safety Recommendation A-97-71 CLOSED—UNACCEPTABLE ACTION/ SUPERSEDED and classifies Safety Recommendation A-13-01 “Open?Unacceptable Response.”

From: NTSB
To: FAA
Date: 11/15/2010
Response: Notation 8257: The National Transportation Safety Board (NTSB) has reviewed the Federal Aviation Administration's (FAA) Notice of Proposed Rulemaking (NPRM) titled "14 CFR Parts 117 and 121: Flightcrew Member Duty and Rest Requirements," which was published at 75 Federal Register 55852 on September 14, 2010. The notice proposes to amend 14 Code of Federal Regulations (CFR) Part 121 and establish 14 CFR Part 117 to create a single set of flight time limitations, duty period limits, and rest requirements for pilots in Part 121 operations. According to the NPRM, the rulemaking recognizes the similarities between the types of operations conducted under Part 121 and the universality of factors that lead to human fatigue. In addition, the rulemaking acknowledges the need to consider fatigue-inducing factors such as time of day, length of duty day, workload, whether an individual is acclimated to a new time zone, and the likelihood of being able to sleep under different circumstances. The rulemaking aims to ensure that pilots have an opportunity to obtain sufficient rest to perform their duties, with an objective of improving aviation safety. The NPRM acknowledges that the FAA is proposing to limit this rulemaking to Part 121 certificate holders and flight crew members who work for them and address fatigue on an incremental basis. Further, the NPRM explicitly identifies two specific NTSB recommendations regarding pilot fatigue in its background statement, Safety Recommendations A-06-10 and A-95-113. The NTSB strongly supports most aspects of the proposed rule while also acknowledging a variety of important issues that remain to be addressed. Since 1990, the safety issue of reducing accidents caused by human fatigue has been on the NTSB's Most Wanted List of Transportation Safety Improvements. Over the last 20 years, the NTSB has investigated many air carrier accidents involving fatigued flight crews, including the American International Airways flight 808 accident in Guantanamo Bay, Cuba; the American Airlines flight 1420 accident in Little Rock, Arkansas; the Corporate Airlines flight 5966 accident in Kirksville, Missouri; and, most recently, the Colgan Air flight 3407 accident in Buffalo, New York. NTSB recommendations issued over the same period of time in an effort to counteract the threat of human fatigue to passenger and crew safety promote, among other measures, scientifically based hours of service, eliminating tail-end Part 91 (for example, training or ferry) flights, developing guidance on fatigue risk management systems (FRMS), and addressing the challenges of obtaining adequate rest when associated with pilot commuting. The proposed revisions to Part 121 and creation of Part 117 address many of these areas. As noted in the NPRM, the FAA drew from available data on sleep and fatigue science to provide a foundation for the proposed rule. In addition, the FAA reviewed international standards and drew from the experienced guidance of industry, including representatives from operators and labor who comprised the aviation rulemaking committee (ARC), as well as scientific advisors for this NPRM. The NTSB commends the FAA for its efforts to develop this critically important rule using a broadly inclusive, scientifically based approach. We expect that these efforts will yield the expedited adoption of a final rule that meets the needs of both the individual pilot and the industry in effectively mitigating fatigue hazards to improve safety. Implementation of the proposed revisions will represent a significant improvement in the regulations to prevent flight crew fatigue in Part 121 operations. The NTSB's specific comments on several areas of the NPRM follow. Consideration of Factors Affecting Alertness and Consolidation of Part 121 The NPRM takes into consideration length of duty day, starting time, workload, and time-zone changes. These factors have been shown by sleep and fatigue research to affect alertness, both alone and in combination with other factors. As a result, the proposal is a significant improvement over current regulations, which do not address the criticality of these factors as they relate to the development of fatigue. If adopted, the proposed rule would likely meet the intent of Safety Recommendation A-06-l0, which is currently on the NTSB's Most Wanted List of Transportation Safety Improvements. The rule does not specifically address NTSB Safety Recommendation A-09-64, which calls for the need to address unique issues affecting the development of fatigue in short-haul operations through specific research into this area.2 Based on the ARC input, the proposed rule does shorten flight duty periods and maximum flight time based on the number of flight segments that exceed four in I day, which should help to mitigate fatigue in these operations. However, as acknowledged in the NPRM, there is little data directly addressing short-haul operations, and, as recommended in Safety Recommendation A-09-64, research into factors affecting the development of fatigue in these operations (especially in the context of the proposed rule) would be beneficial. By removing the former distinctions under Part 121 between domestic, flag carriers, supplemental, and operations conducted under Part 91 (including tail-end ferry flights), the NPRM acknowledges that the human fatigue factors are the same across these operations and science cannot support the notion of allowing longer duty hours for certain subgroups. Additionally, the proposed rule addresses the NTSB's longstanding concern of eliminating tail-end ferry flights in Part 121 operations. Adoption of this element of the proposed rule would likely meet the intent of Safety Recommendation A-95-113, which is currently on the NTSB's Most Wanted List of Transportation Safety Improvements. Maximum Flight Time and Rest Period Expansion The NPRM proposes to increase the maximum flight time from 8 to 10 hours and acknowledges that research in this area does not provide a definitive conclusion about the effect this would have on fatigue.3 The NTSB considers it important that the 10-hour flight times are only allowed for flight duty period start times between 0700-1259, which should ensure that flight crews do not accumulate this extended flight time during the circadian low. In addition, the reduction of the flight duty period as the number of flight segments exceeds four should help to mitigate risk associated with the increased workload that this part of the NPRM proposes. However, the NTSB urges the FAA to proceed cautiously on the expansion of flight time to 10 hours and collect data on this proposed change so that any adverse consequences are identified and mitigated. In addition, the NTSB suggests that the FAA look to other modal administrations in the Department of Transportation to help assess the effect of this change on safety. The NTSB is encouraged that, as defined in the proposed rule, a rest period begins once the flight crew arrives at the actual location of the rest facility (such as a hotel). This should help to ensure that crewmembers can allocate additional time to actual sleep during the defined rest period. Although the NPRM did not clearly define when the rest period would end, the FAA provided clarifying guidance to the rulemaking docket stating that the "rest opportunity commences when the flightcrew member reaches the hotel or suitable accommodation and ends when he or she checks out. The NPRM also states that the required rest period would be extended to 9 hours, and the clarifying guidance states that the 9-hour rest opportunity should allow for an actual 8-hour sleep opportunity. However, the associated draft advisory circular (AC) on fitness for duty states that, "it is unrealistic to assume that a 9-hour rest period will yield 9 or even 8 hours of sleep when you take into consideration time lost in checking in at a hotel, eating, and preparing to resume duty at the conclusion of the sleep opportunity." The NTSB concurs with this observation6 and notes that the final rule should be consistent with the guidance contained in the draft AC. Therefore, the NTSB strongly encourages an increase in the duration of the required rest period to accommodate an opportunity for 8 hours of sleep. Joint Responsibility for Fatigue Mitigation and Fatigue Education The NPRM states clearly that effective fatigue mitigation in aviation requires individual responsibility at the pilot level and corporate responsibility at the air carrier level. The NTSB agrees and, based on findings from accident investigations and the reality of the aviation system, recognizes that effective actions and coordination among pilots, airlines, and regulators must occur to effectively address fatigue issues. Furthermore, the NPRM would enable a flight crewmember to self-report as too fatigued to continue working an assigned flight duty period and prohibit the certificate holder from allowing the flight crewmember to continue. The NTSB supports this element of the proposed rule, which, if adopted, would likely satisfy the intent of Safety Recommendations A-08-19 and A-08-20 for Part 121 operations. The NPRM addresses commuting as a fitness for duty issue, and the associated guidance material contains information about responsible commuting. Although the NTSB agrees in part with this perspective and believes that education and training can help, it also is steadfast in its belief that the concept of joint responsibility applies equally to commuting. If implemented, the NPRM's treatment of commuting-related fatigue risks would not meet the intent of Safety Recommendation A-10-16, because this recommendation advocates going beyond guidance to helping an individual commuting pilot obtain adequate rest; Safety Recommendation A-10-16 also addresses the need for operators to identify pilots who commute, use scheduling practices to minimize fatigue in commuting pilots, and develop or identify rest facilities for commuting pilots. While the NTSB acknowledges the difficulty in identifying a regulatory solution for commuting hazards at the individual level, steps can be taken at the company level without undue regulatory burden and that would be consistent with the level of company action called for in other areas of the NPRM. The NTSB strongly encourages the FAA to ensure that the final rule's treatment of commuting incorporates company level responsibilities reflected in Safety Recommendation A-10-16, including the identification of pilots with challenging commutes and provision of mitigating measures. The NPRM also proposes requiring a fatigue education and training program for all flight crewmembers, employees involved in the operational control and scheduling of flight crewmembers, and personnel having management oversight of these areas. The NTSB strongly supports this concept and believes it to be consistent with earlier NTSB recommendations advocating the need for fatigue education among flight crewmembers.9 In addition, this concept is among the foundational elements of an effective FRMS. The NTSB notes that the required course content addresses a broad range of fatigue causation factors, countermeasures, and mitigation strategies and is encouraged that the draft AC on fatigue training supporting this NPRM contains a discussion about medically based sleep disorders, such as obstructive sleep apnea, that can affect a crewmember's ability to receive adequate sleep. However, the NPRM does not sufficiently address identifying and treating medically based sleep disorders such as obstructive sleep apnea, and the NTSB encourages the FAA to consider Safety Recommendations A-09-61 through -63 in the guidance associated with this NPRM. Additionally, the NTSB believes that training conducted under this proposed rule should also consider personal strategies that have been scientifically demonstrated to be effective for maintaining alertness and performance on the flight deck (for example, strategic napping) and that the draft AC supporting this training should also be modified to address specific methods that crews can use to maintain alertness on the flight deck. Fatigue Risk Management Systems and Data Collection The NTSB is encouraged by the proposed rule's recognition of FRMS as a way for both operators and the FAA to make informed decisions about operator-specific exemptions to the rule to address unique operational challenges. NTSB safety recommendations on FRMS, which are on the NTSB's Most Wanted List of Transportation Safety Improvements, have asked for the development of FRMS guidance for operators, as well as a methodology for the FAA to evaluate the effectiveness of these systems. The NPRM references the development of AC 120-103, "Fatigue Risk Management Systems for Aviation Safety," which is intended to help operators develop and implement FRMS and is largely consistent with the intent of Safety Recommendation A-08-44. However, because the NPRM states that operators would only be required to implement an FRMS when they are seeking exemptions to the rules, the NTSB is concerned that the FAA's proposed implementation of FRMS is too narrow. Operators not seeking exemptions could benefit from the synergistic advantages of fatigue risk mitigation provided by an FRMS closely coupled with effective flight and duty time regulations, and, as noted in AC 120-103, there may also be economic benefits to implementing these systems. As recommended in Safety Recommendation A-08-45, the FAA should continue to pursue the development and use of a methodology to continually assess the effectiveness of FRMS. Independent of the concept of FRMS, the proposed rule requires operators to provide regular submissions of schedule data and maintain data on fitness-for-duty reporting. The NTSB notes that collection and analysis of these data will be critical to ensuring that the proposed rule has the intended effect and will allow both the industry and the FAA to identify the need for adjustments. Moreover, the continual assessment of system operation in this manner is an integral component of current data-driven feedback approaches to safety management, such as safety management systems (SMS) and FRMS. If the proposed rule becomes final, both the industry and the FAA must commit to more than rote data collection and ensure that these data are thoroughly evaluated to ensure that any unforeseen fatigue hazards are identified, understood, and corrected. Summary Observations The NTSB's review of the NPRM suggests that, if adopted, the proposed rule will provide substantial benefits towards reducing the hazards associated with flight crew fatigue in Part 121 operations. As noted previously, the FAA chose to limit the scope of the NPRM, and therefore it does not specifically address Part 135 and Part 91 subpart K (fractional ownership) operations, which the NTSB has cited in related safety recommendations, or other safety critical personnel involved in air carrier operations. However, the NPRM does state that a proposal to address Part 135 operations may be forthcoming after the final rule for Part 121 is adopted. Although these areas are outside the scope of the current NPRM, the methodology the FAA used to develop the current NPRM should serve as a strong foundation for swiftly initiating regulatory efforts to address these other areas of concern, including NTSB recommendations pertaining to other safety critical personnel. The NTSB believes that time is of the essence to finalize the rule for Part 121 operations based on this NPRM. The record of accidents clearly shows that fatigue has caused, contributed to, or been identified as a safety issue in multiple accidents involving Part 121 operators. Many of these accidents have occurred since the FAA's last attempt in 1995 to enact rulemaking that would have addressed flight time and duty time issues-an effort that was eventually terminated with no change to the regulations. We are hopeful that, with stakeholder support, the legacy of the current inclusive and scientifically based rulemaking effort will be far more positive and sustained, as the traveling public, crewmembers, and air carriers must not continue to endure the significant human loss of life and financial costs resulting from continued accidents involving fatigue. The NTSB appreciates the opportunity to comment on this NPRM.

From: NTSB
To: FAA
Date: 10/7/2009
Response: The FAA last wrote to the NTSB concerning this recommendation on October 2, 2000. At that time, the FAA indicated that it had conducted research and issued a report on fatigue among aviation maintenance personnel but that further research was needed. The scope of the research needed to be expanded to include conditions that accelerate the onset of fatigue, decrease job performance, and increase human error. Based on the research it completed at that time, the FAA concluded that fatigue was an issue with maintenance crews. The FAA planned to begin the next phase of its research program in August 2000 and anticipated completion of that phase in December 2003. On April 24, 2001, the NTSB replied that, although the FAA’s research on fatigue among aviation maintenance personnel was valuable, Safety Recommendation A-97-71 did not request such a research program. We believed that the current state of scientific knowledge was sufficient to provide a basis for and justify the development of regulations to establish duty-time limitations for aviation maintenance personnel. Because scientific knowledge supported that human fatigue is an issue for aviation maintenance personnel, a fact confirmed by the FAA’s own research, the NTSB indicated that the FAA should not wait for completion of additional research to develop regulations to limit duty time among aviation maintenance personnel. Pending development and issuance of those regulations, Safety Recommendation A-97-71 remained classified "Open -- Acceptable Response." At the Safety NTSB’s annual review of its Most Wanted List on November 15, 2005, it was noted that the FAA had not taken action, nor communicated with the NTSB on this issue since October 2000. However, in the Department of Transportation’s (DOT’s) 2005 annual report to the Congress regarding DOT’s responses to recommendations on the NTSB’s Most Wanted List, the DOT indicated that, because of the extreme complexity of the issue of fatigue and duty time, the FAA did not believe that regulatory activity in this area was appropriate. Rather, the FAA stated its belief that education and training better addressed the intent of the recommendation. The DOT reported to the Congress that the FAA had initiated and was pursuing a number of activities related to education and training about the issues of fatigue management in aircraft maintenance personnel. As a result, at the November 15, 2005, meeting, the NTSB classified Safety Recommendation A 97 71 Open Unacceptable Response. On April 18, 2006, the NTSB sent a letter to the FAA indicating that the NTSB disagreed that regulatory action was not appropriate; the NTSB also disagreed that the FAA’s education and training activities related to this issue could meet the intent of the recommendation. On February 22, 2007, the NTSB again wrote to the FAA, indicating that no written correspondence had been received since October 2, 2000, regarding the FAA’s response to Safety Recommendation A 97 71. The NTSB restated its disagreement with the FAA that (1) regulatory action was not appropriate and (2) the FAA’s current education and training activities related to this issue could achieve the intent of the safety recommendation. The NTSB asked the FAA whether it would consider establishing duty-time limitations for personnel who perform maintenance on air carrier aircraft, as recommended. In its current letter, the FAA continues to maintain that increased awareness, as well as education and training in fatigue management and maintenance resource management, constitutes the best approach for addressing the recommendation. The FAA maintains that this approach will produce quicker and more effective results than rulemaking. The FAA described a number of activities it is conducting to educate and train the aviation community on fatigue management for aircraft maintenance personnel. Among the enclosures that the FAA provided was the FAA’s Human Factors Guide for Aviation Maintenance. This guide contains a chapter on fatigue and fitness for duty and another chapter on shift work and scheduling. The NTSB found this guide potentially useful and believes that an FAA inspector might use the guide in evaluating a carrier’s fatigue management program for its maintenance operation. However, the FAA has no mechanism to require such a program or to ensure that the program’s contents comply with best practices. The FAA provided the curriculum for a course, titled Maintenance Resource Management for Aviation Safety Inspectors. Among the 22 objectives for this class are 4 that specifically address fatigue, including defining and identifying sources of stress and fatigue, symptoms of stress and fatigue, and actions to alleviate and manage stress and fatigue. The NTSB acknowledges that the FAA has developed a number of educational activities regarding human factors in aviation maintenance, including the issue of fatigue. The NTSB is encouraged by these activities and urges the FAA to continue and expand these efforts. However, as stated in our letters of April 18, 2006, and February 22, 2007, the NTSB continues to disagree with the FAA’s position that (1) regulatory action is not appropriate and (2) the FAA’s current education and training activities related to this issue can achieve the intent of this safety recommendation. On June 12, 2008, the NTSB issued Safety Recommendations A-08-44 and -45, which asked the FAA to develop guidance on fatigue management systems. In the letter transmitting Safety Recommendations A-08-44 and -45, the NTSB stated that, although a fatigue management system is needed and valuable, it is not a replacement for regulated duty-time limits. In sum, the FAA appears to be developing guidance and encouraging operators to develop fatigue management plans for maintenance personnel. Although the NTSB encourages this valuable and commendable activity it is not an acceptable alternative to the recommended action of establishing duty-time limitations. Although the FAA has consistently indicated that it does not plan to establish such limits; the NTSB is aware that you as the new Administrator have publicly committed to review all aspects of FAA regulations that address fatigue. We hope that you will concur with the need for the recommended regulations. Pending such regulations, Safety Recommendation A-97-71 remains classified OPEN -- UNACCEPTABLE RESPONSE. The NTSB appreciates that the FAA considers itself to be a data-driven organization, particularly with respect to oversight activities. If the FAA has any data demonstrating that its fatigue management efforts have achieved the same effect as a time and duty regulation, and the FAA submits such data to the NTSB, we will consider reclassifying the recommendation.

From: FAA
To: NTSB
Date: 12/11/2008
Response: Letter Mail Controlled 12/23/2008 5:07:44 PM MC# 2080750: - From Robert A. Sturgell, Acting Administrator: 12/11/08 The Federal Aviation Administration continues to take part in an overall systems approach regarding fatigue in aviation operations. We seek to educate the industry on the reality of fatigue and ways to effectively mitigate its dangers. We have completed several studies and have made several accomplishments on the maintenance fatigue issue. The following is a list of these items: Studies: Published a final report on the Study of Fatigue Factors Affecting Human Performance in Aviation Maintenance. A copy of this report was provided to the Board in October 2000; and Published a final report entitled, “Evaluation of Aviation Maintenance Working Environments, Fatigue, and Maintenance ErrordAccidents in April 2000. A copy of this report was provided to the Board in October 2000. Accomplishments: Completed new guidance manual entitled, Operators Manual for Human Factors in Aviation Maintenance, in September 2005, where 20 percent of this industry/FAA guidance material is dedicated to fatigue. We have enclosed a copy of this manual for the Board‘s information (Enclosure 1); Hired a Chief Scientist and Technical Advisor for Human Factors in Aircraft Maintenance Systems and an aviation safety inspector as a maintenance human factors subject matter expert. Collectively, they provide human factors lectures at industry workshops, renewals, symposiums, and conferences to educate the aviation community further on many maintenance human factors issues, including fatigue, on a continuing basis; and Co-sponsored three Aviation Maintenance Human Factors International Symposiums with the Air Transport Association of America which included presentations on fatigue. The first was held September 6-7, 2006, the second September 5-6, 2007, and the third September 3-4, 2008. We have enclosed the brochures, biographies, agenda and CDs of presentations and educational materials for the Board‘s information (Enclosures 2, 3, and 4). Studies consistently support an approach to this safety issue based on increased awareness and education and training in fatigue management and maintenance resource management. We believe that this approach will produce quicker and more effective results than rulemaking. Consequently, the FAA conducted several actions to educate and train the aviation community on fatigue management in aircraft maintenance personnel. The following is a partial list of these actions: Issued Advisory Circular (AC) 120-72, Maintenance Resource Management (MRM) Training, on September 28, 2000, which includes a prototype MRM computer-based training (CBT) course for industry; Developed and distributed MRM CBT to industry, academia: and regulatory authorities worldwide on over 10,000 CD ROMs. We have enclosed a copy of the CD for the Board’s information (Enclosure 5); Developed MRM curriculum and course, Maintenance Resource Management for Aviation Safety Inspectors. The FAA provides this course to aviation safety inspectors and, to date, approximately 1,000 inspectors have attended the class. An entire section of the course has been dedicated to stress and fatigue. We have enclosed a copy of the course objectives for the Board’s information (Enclosure 6); Sponsored several international conferences on aircraft maintenance human factors that included management of fatigue for aircraft maintenance personnel. We have enclosed a sample presentation from one of these conferences (Enclosure 7); Addressed fatigue, shift work, and scheduling for aircraft maintenance personnel in the FAA Human Factors Guide for Aviation Maintenance. We have enclosed a copy of chapters 4 and 7 of the guide for the Board’s information (Enclosure 8); Made available some of the studies, training, and recommendations on maintenance personnel fatigue on the FAA Human Factors Web sites at http://hfskyway.faa.gov and www.hfskyway.com. We have enclosed copies of three reports that use some of these studies, for the Board’s information (Enclosures 9, 10, and 11); and Sponsored the first Aviation Fatigue Management Symposium from June 17 through 19, 2008. This symposium brought together 325 experts from industry, government, and academia to share the most current information on fatigue and discuss possible fatigue management strategies and best practices. The participants looked at issues affecting flight and cabin crews, air traffic controllers, technicians, mechanics, dispatchers, and ramp workers. The conference attendees generally agreed that fatigue mitigation must be based on scientific principles developed through enhanced data collection. I believe these activities have effectively addressed this safety recommendation. However, the FAA is reviewing the results of the fatigue symposium to determine the most appropriate next step to continue to address fatigue issues in aviation, broadly, and aviation maintenance, in particular.

From: NTSB
To: FAA
Date: 2/22/2007
Response: The Safety Board wrote to the FAA on April 18, 2006, requesting an update on FAA activities undertaken in response to this recommendation; the last written update from the FAA regarding this recommendation is dated October 2, 2000. In its letter, the Board noted that, in the Department of Transportation’s (DOT) annual reports to Congress on progress the DOT is making in response to recommendations on the Most Wanted list, the DOT had indicated that regulatory action in this area is not appropriate because of the extreme complexity of the issue of fatigue and duty time. The DOT had further reported to Congress that the FAA had initiated and was pursuing a number of activities related to education and training in the issue of fatigue management in aircraft maintenance personnel. In its letter, the Safety Board stated that it disagreed with the FAA’s position (1) that regulatory action is not appropriate and (2) that the FAA’s current education and training activities related to this issue can achieve the intent of this safety recommendation. The Safety Board reviewed Advisory Circular (AC) 120-72, Maintenance Resource Management (MRM) Training, which, based on the DOT report to Congress, seems to be the primary focus of the FAA’s education and training initiatives related to fatigue among aviation maintenance crews. We 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. AC 120-72 contains little guidance as to how an employer should design a program to ensure that maintenance crews are not fatigued. Safety Recommendation A-97-71, now more than 9 years old, is currently classified OPEN -- UNACCEPTABLE RESPONSE. So that we may fully evaluate the FAA’s activities in response to this recommendation, we ask that the agency inform us as to whether it has produced 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.

From: NTSB
To: FAA
Date: 4/18/2006
Response: The Safety Board notes that the FAA has not provided the Board with any updates on actions being taken in response to this recommendation since October 2, 2000. However, the Board notes that in the Department of Transportation's (DOT) 2006 annual report to Congress on progress the DOT is making in response to recommendations on the Most Wanted List, the DOT indicated that because of the extreme complexity of the issue of fatigue and duty time, the FAA does not believe that regulatory activity in this area is appropriate. The DOT reported to Congress that the FAA has initiated and is pursuing a number of activities related to education and training in the issues of fatigue management in aircraft maintenance personnel. The Board disagrees with the FAA that regulatory action is not appropriate or that the FAA's current education and training activities related to this issue can achieve the intent of this safety recommendation. As a result, at the November 15, 2005, meeting, the Board classified Safety Recommendation A-97-71 OPEN -- UNACCEPTABLE RESPONSE.

From: FAA
To: NTSB
Date: 3/1/2006
Response: In its 3/1/2006 annual report to Congress, Regulatory Status of the National Transportation Safety Board's "Most Wanted" Recommendations to the Department of Transportation, the DOT wrote: FAA completed several studies on the maintenance fatigue issue. These studies include: Study of Fatigue Factors Affecting Human Performance in Aviation Maintenance; Evaluation of Aviation Maintenance Working Environment, Fatigue and Maintenance; Error Accidents; and Evaluation of Aviation Maintenance Working Environments, Fatigue, and Human Performance The findings indicated that the extreme complexity of the issue of fatigue and duty time did not present appropriate material for regulatory activity in this area. The findings did indicate that education and training in fatigue management were the most appropriate actions for the FAA to sponsor and foster. Consequently, the FAA conducted several actions to educate and train the aviation community on the issues of fatigue management in aircraft maintenance personnel. The following is a list of these actions: lssued Advisory Circular (AC) 120-72, Maintenance Resource Management (MRM) Training that includes a prototype MRM computer-based training (CBT) course for industry; Developed and distributed MRM CBT to industry, academia, and regulatory authorities worldwide on over 10,000 CD ROMs on maintenance human factors; Developed MRM curriculum and course, "Maintenance Resource Management for Aviation Safety Inspectors." This course is currently taught to aviation safety inspectors; Sponsored several international conferences on aircraft maintenance human factors that included management of fatigue for aircraft maintenance personnel; Fatigue, shift work, and scheduling for aircraft maintenance personnel issues were addressed in several chapters of the FAA Human Factors Guide for Aviation Maintenance; All studies, training, and recommendations on maintenance personnel fatigue available on the FAA Human Factors Website at http://hfskyway.faa.gov and Currently, FAA is working on another study "Effects of Fatigue, Vigilance, Environment on Inspectors Performing Fluorescent Penetrant and/or Magnetic Particle Inspections" to study the effects of fatigue environment on the vigilance decrement of inspectors performing Liquid Penetrant or Fluorescent Magnetic Particle Inspections as their primary work function.

From: NTSB
To: FAA
Date: 11/15/2005
Response: As part of its November 11, 2005 meeting addressing the Safety Board's Most Wanted List of safety improvements, the Board voted to reclassify this recommendation from "Open-Acceptable Response" to OPEN -- UNACCEPTABLE RESPONSE based on the FAA's indication that it does not intend to issue duty time limitations for aviation maintenance personnel.

From: FAA
To: NTSB
Date: 2/1/2005
Response: In its 2/1/2005 annual report to Congress, Regulatory Status of the National Transportation Safety Board's "Most Wanted" Recommendations to the Department of Transportation, the DOT wrote: FAA completed several studies on the maintenance fatigue issue. These studies include: Study of Fatigue Factors Affecting Human Performance in Aviation Maintenance; Evaluation of Aviation Maintenance Working Environment, Fatigue and Maintenance; ErrorsIAccidents; and Evaluation of Aviation Maintenance Working Environments, Fatigue, and Human Performance The findings indicated that the extreme complexity ofthe issue of fatigue and duty time did not present appropriate material for regulatory activity in this area. The findings did indicate that education and training in fatigue management were the most appropriate actions for the FAA to sponsor and foster. Consequently, the FAA conducted several actions to educate and train the aviation community on the issues of fatigue management in aircraft maintenance personnel. The following is a list of these actions: Issued Advisory Circdar (AC) 120-72, Maintenance Resource Management (MRM) Training that includes a prototype MRM computer-based training (CET) course for industry; Developed and distributed MRM CBT to industry, academia, and regulatory authorities worldwide on over 10,000 CD ROMs on maintenance human fzctors; Developed MRM curriculum and course, “Mainkxance Resource Management for Aviation Safety Inspectors.” This course is currently taught to aviation safety inspectors; Sponsored several international conferences on aircraft mainteiiance human factors that included management of fatigue for aircraft maintenance personnel; Fatigue, shift wor!i, and schedvling for aircraft maintenance persocnel issues were addressed in several chapters of the FAA Human Factors Guide for Aviation Maintenance; All studies, training, and recommen6ations on maintenanse personnel fatigue available on the FAA Human Factors Website at http://kfskvway.faa.ro;.; and Currently, FAA is working on acother study ‘‘Effects of Fatigue, Vigilance, Environment on Inspectors Performing Fluorescent Penetrant and/or Magnetic Particle Inspections” to study the effects of fatiguelenvironment on the vigilance decrexent of inspectors performing Liquid Penetrant or Fluorescent Magnetic Particle Inspectors 3s their primai-j work function.

From: NTSB
To: FAA
Date: 4/24/2001
Response: The FAA's research on fatigue among aviation maintenance personnel is valuable, and the Safety Board encourages the FAA to continue this activity. However, the Board notes that Safety Recommendation A-97-71 did not request that the FAA initiate a research program on this subject. The Board continues to believe that the current state of scientific knowledge on human fatigue in the aviation maintenance environment is sufficient to justify the development of and provide a scientific basis for regulations to establish duty-time limitations for aviation maintenance personnel. As with any technical issue that affects safety, future research may result in additional information that will warrant revisions and improvements to any regulations developed. However, because scientific knowledge supports that human fatigue is an issue for aviation maintenance personnel, as confirmed by the FAA's own research, the FAA should not wait until 2004 (when research is completed) to develop regulations to limit duty time among aviation maintenance personnel. Pending development and issuance of those regulations, Safety Recommendation A-97-71 remains classified OPEN -- ACCEPTABLE RESPONSE.

From: FAA
To: NTSB
Date: 10/2/2000
Response: Letter Mail Controlled 10/04/2000 3:48:25 PM MC# 2001485 - From Jane F. Garvey, Administrator: The FAA has completed its initial review of personnel duty time fatigue in aviation maintenance and issued a report entitled "Study of Fatigue Factors Affecting Human Performance in Aviation Maintenance." I have enclosed a copy of the report for the Board's information. Based on the conclusions in the report, the scope of the research task has been expanded to include conditions that have been found to accelerate the onset of fatigue, decrease job performance, and increase human error. The FAA has completed the first phase of the expanded study and issued a report in April 2000 entitled "Evaluation of Aviation Maintenance Working Environments, Fatigue, and Maintenance Errors/Accidents." I have enclosed a copy for the Board's information. The expanded study looks 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 major objectives of the study included: · Determining the feasibility of collecting data at a task level on environmental parameters of noise, light, and temperature that affect the onset of fatigue. Additional data on personal lifestyle habits, including timing and duration of sleep, diet, and other parameters, were also collected in an effort to identify other fatigue factors. · Evaluating the durability of data collection devices within the rigors of the aviation maintenance workplace. Also, to profile the environment in which the aviation maintenance technicians work. · Determining whether there are differences in workplace environmental conditions between the various aviation maintenance specialties. · Identifying possible fatigue-producing problem areas and provide industry with an understanding of why these areas can be potential causes of reduced productivity and higher errors. Using the profile data to begin to develop a model that may predict conditions that would accelerate fatigue onset. The study approached data collection with the hypothesis that the various aviation maintenance specialties have different working environments or microenvironments. A microenvironment is a place like a fuselage on the ramp that exposes the aviation maintenance technician to different levels of noise, heat, cold, and lighting. These microenvironments may also change within a specialty and from shift to shift. Thus, understanding the environments for each aviation maintenance specialty across all shifts could help identify microenvironmental factors in each that could predict the onset of fatigue and, in turn, predict performance decrements in the form of accidents, injuries, and maintenance errors. The methodology consisted of three approaches--a background survey; mini-logger monitors that recorded data from the selected parameters of light, noise levels, and temperature; and activity monitors (actiwatches) that monitored physical activity, sleep, and sleep quality. Conclusions drawn from this study about aviation maintenance technicians are not to be extrapolated to the industry as a whole. Additional sites need to be studied before such conclusions can be made. The use of the mini-loggers, actiwatches, and the background survey tool provided a good study design and increased the reliability of the data. One of the main objectives of this pilot study of aviation maintenance technician working environments was to determine whether the data collection equipment could withstand the abuse it would receive in this environment. The pilot study adequately proved equipment reliability. This study also demonstrated the feasibility of collecting data in various aviation maintenance technician operational environments at the task level. This was an important issue due to the nature of the work. Aviation maintenance technicians often have to work in confined places, in elevated areas, and in areas that do not get direct lighting from overhead light sources. Understanding how these areas change the working environment may help explain possible differences in productivity, errors, incidents, and accidents. The FAA's findings suggest that fatigue is an issue in this work force. Data from the actiwatches and the background questions clearly indicate that sleep durations are inadequate to prevent fatigue. For most aviation maintenance technician specialties, sleep durations of less than 6 hours accounted for 30-40 percent, and 25 percent of respondents reported feeling fatigued or exhausted. The data collection of these factors and variables will model the data to predict situations that are conducive to fatigue, accidents, incidents, and errors. Data collection began in August 2000. Pending future budget resources, it is anticipated that the expanded study will be completed in December 2003. I will keep the Board informed of the FAA's progress on this safety recommendation.

From: NTSB
To: FAA
Date: 2/3/2000
Response: The Safety Board believes that the FAA's efforts to scientifically define the relationship between work conditions and fatigue have the potential to improve the quality of aviation maintenance work, which would enhance the overall safety of flying once duty time limits are determined and applied to aviation maintenance. Therefore, A-97-71 is classified OPEN – ACCEPTABLE RESPONSE, pending completion of the data collection, publication of the report, and the establishment of duty time limits for persons performing air carrier maintenance.

From: NTSB
To: FAA
Date: 7/23/1999
Response: Pending evaluation of the FAA's final action, the Safety Board classifies A-97-71 OPEN – ACCEPTABLE RESPONSE.

From: FAA
To: NTSB
Date: 6/17/1999
Response: Letter Mail Controlled 6/21/99 3:46:34 PM MC# 990670 - From Jane F. Garvey, Administrator: As part of the FAA's ongoing program to incorporate human factors into aviation maintenance, the FAA developed a "Human Factors Guide for Aviation Maintenance." This guide is the principal reference document used by the aviation industry and includes a chapter on personnel shift work and scheduling as it affects human performance. The data suggest that night shift and/or mixing of day/night work schedules affect performance more than an extended length of duty time; however, no current definitive studies are available to evaluate these parameters as comparative measurements. The FAA is completing its initial review of personnel fatigue in aviation maintenance and has developed a draft report. The scope of this research task has been expanded to include conditions that have been found to accelerate the onset of fatigue, decrease job performance, and increase human error. Data collection for these variables should begin in July 1999.

From: FAA
To: NTSB
Date: 11/17/1997
Response: Since 1988, the FAA has conducted research on aircraft maintenance human factors. As an outcome of the research program, the FAA published the "Human Factors Guide for Aviation Maintenance" in 1995. The guide is the principal reference used by the aviation industry and includes a chapter on personnel shift work and scheduling as they affect human performance. FAA data suggest that night shift and/or mixing of day/night work schedules affect performance more than an extended length of duty time; however, no current definitive studies are available to evaluate these parameters as comparative measurements. Consequently, the FAA will expand its human factors research program to include studies of duty time fatigue that will investigate factors regarding duty length and shift scheduling. The FAA also will work with Air Transport Association's (ATA) Human Factors Committee to develop joint guidelines/regulations for airline maintenance personnel duty time. At the conclusion of this research, the FAA will implement appropriate policy or regulatory change. I will keep the Board informed of the FAA's progress on this safety recommendation.

From: NTSB
To: FAA
Date:
Response: At the 1990 Board meeting addressing the NTSB’s Most Wanted List of Transportation Safety Improvements (MWL), the Board voted to place Safety Recommendations I-89-1 through I-89-3 and R-89-19 on the MWL under the issue category “Cross Modal Human Fatigue/ Hours-of-Work Policy.” Safety Recommendations H-95-1, A-94-194, A-95-113, A-97-71, A-99-45, I-99-1, H-99-19, R-91-45, R-91-47, R-91-48, R-96-20 through R-96-22, R-96-56, R-99-2, P-98-30, P-99-12, M-99-1, A-06-10, A-07-30, A-07-32, and A-08-44 were added to this category at later dates.