Tag Archives: fatigue

UPS 1354, Birmingham Runway 18, August 14, 2013: Is FAA Policy vs Procedures Inconsistency Causing A Severe Safety Risk in Commercial Aviation? “Is the Tail Wagging the Dog ?”

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In the last 40 years the US FAA has spent hundreds of billions of taxpayer dollars engineering safety into the nation’s commercial aviation infrastructure. This policy at the FAA has led to great success in achieving an astonishing low commercial aviation mishap rate in the US.  Moreover it has provided an example for Western Europe, Pacrim Asia and the rest of the world to match in building and outfitting highly standardized, major international commercial all-weather airports. Birmingham International Airport in Birmingham, Alabama is one of these airports.

But on the early morning hours of August 14, 2013 at Birmingham International, all of the latest and greatest in hundreds of billions of dollars of technology and engineering was put aside, so that an airfield electrician could change out a few dozen fifteen dollar light bulbs.  When UPS 1354 arrived at Birmingham in the cloudy, dark soup of early morning, the pilots’ heads were swimming in night time induced fatigue.  All that they hoped for was that the local FAA area Air Traffic Control approach controller would vector them onto the final approach course for the amazingly technical all weather runway. They hoped to couple up their fantastically sophisticated jet’s autoflight system to the airfield’s highly accurate electronic glide slope and precision path localizer. They planned to comply with FAA all weather approach procedures and bring their huge  jumbo jet down to the runway along an approach path well clear of trees, mountains and towers. They hoped to land on a well light, precision marked, sharply cut grooved and crowned runway.

But instead, someone at Birmingham, we don’t know who yet, made a decision to invoke a local procedure, a procedure that did not support the most sophisticated FAA instrument approach procedures nor the FAA policy of providing the latest and greatest engineering and technology to commercial flight crew landing huge jumbo jets at Birmingham Airport.

Someone at Birmingham took it upon themselves to take all of this engineering and technology out of service, to shut down all of these highly sophisticated procedures and do so for a considerable amount of time. They did so knowing full well that UPS 1354 would be scheduled to arrive at just this time and in fact was arriving in the area as scheduled. They also knew that the weather at the field held low lying clouds. Additionally, they knew full well that the runway that they would offer UPS 1354 on which to land held only antiquated technology dating back to the dawn of commercial aviation, literally into the 1930’s. Finally, they knew that the descent path for the approach to that runway was directly over hilly and irregular terrain north of the airport, an area unsuited for the installation of any ATC approach modern technology and engineering.

Who was it locally at Birmingham that approved such a procedure that clearly was inconsistent with official FAA all weather commercial operations policy and procedure, and especially so for a cloudy runway at night in the mountains, all while a fully instrumented and safely engineered runway was available and would be consistent  with current FAA safety policy? Where is that procedure written down?

Additionally, how did this conflict between local procedure and FAA policy and procedure for all weather commercial operations come to exist at Birmingham? For that matter how did it come to exist at any international FAA airport? Why didn’t someone either in Birmingham FAA Air Traffic Control Office or the Washington FAA Headquarters Air Traffic Control Directorate or the Commercial Air Safety Directorate question this apparent policy versus procedures inconsistency? Was this an FAA managerial snafu or in fact is this a widespread FAA organizational inconsistency and thus a severe commercial aviation safety hazard?

Was not a very similar commercial aviation safety policy versus all weather procedures conflict involved in the Asiana crash in San Francisco just a few months earlier? In that case, instead of an electrician changing out light bulbs, the airfield’s multi billion dollar engineering and technology instrument approach system was set aside so that bull dozers could move dirt around to build a taxiway.

How is it that such inconsistencies exist at FAA? Is this a case of the tail wagging the dog? How is it that the maintenance of light bulbs and airfield construction take precedence over the safe operation of commercial flight? Who at the Washington FAA Headquarters Safety Policy Directorate and the Air Traffic Control Directorate is supposed to be ensuring that local airfield FAA managers are employing procedures that are supportive and consistent with the FAA safety policy? Why are US taxpayers spending hundreds of billions of dollars on commercial airfield infrastructure and operational safety only to have that safety compromised by maintenance and construction and local procedures?

Are we really expecting our international jumbo jet flight crew members to make up for this FAA policy vs procedures failure, at 4am in the morning, in the dark, in the clouds and in the mountains by resorting to 1930’s technology and procedures? Really?

How many more similar commercial airline crashes must occur before the FAA is able to determine that they have policy vs procedures safety inconsistency?

In my opinion, the US National Transportation Safety Board needs to investigate this safety inconsistency, this very severe FAA commercial aviation safety hazard, this severe risk to the US taxpaying public and make a recommendation for corrective action to the FAA before the next similar commercial aviation mishap occurs. In my opinion, they should do so quickly.

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The Injury of Pilot Fatigue: Is Fatigue a Stress or a Strain ?

Early morning sun rising through clouds.

Early morning sun rising through clouds.

Fatigue: Is It a Stress or a Strain, that is, an injury? Is fatigue an injury to the human body from which we need time to recover? Or is fatigue just being tired or over tired, a stress for which a good night’s sleep is the common remedy?

That is the question: is fatigue just a stress on the body and mind and as such something from which the body and mind can bounce back without any damage? Or is fatigue rather something more insidious and injurious than just a stress? Is it possible that fatigue is actually a strain, that is to say,  an injury, damage to the body and mind? If fatigue is an injury to the body and mind, an overstress resulting in a strain, does the body and mind need time to heal back to health from this injury? Is the time of a “good night’s sleep enough time to heal from this injury?

Does repeated stress lead to more damaging strain? Can the road to recovery from the strain of fatigue to the body and mind be a lot longer than just one good night’s sleep? Is the body and mind being damaged beyond the ability to recover in a day or a weeken

Human beings who has spent many nights and days working multiple shift hours far in excess of any reasonable eight or ten hour schedule can be over tired, falling asleep at the switch as the saying goes from fatigue. Yet they are there trying to do a good job, a necessary job and trying to have a life outside of work at the same time. The one thing that has not been discussed is does recovery from fatigue take much more time than just one good night’s sleep. If so, why? Is a person somehow injured in my mind and body to the extent that they need to heal? If so, where was the injury, how can a person feel it and how can they measure it? How much time is needed for full physiological recovery of body and mind? Is sacrificing the health of body and mind for a job well understood? If so, are people being separately compensated for both the work done and the sacrificing of the health of body and mind?

There are two issues to working at night and working extended hours repeatedly, the issue of compensation for the work and compensation for the hours past any reasonable shift.

But there are often more questions about fatigue than answers.  What is the pineal gland anyway and how does it work? Does the brain need oxygen and sugar to function? Why does worry have the same affect as caffeine? Why is a hot shower so refreshing when tired? Why do kids fall asleep when tired wherever they sit down? Why do older folks struggle often with sleep?  Why do flight crew often feel so tired on weekends that they just want to relax and do nothing stressful, just recover and hope for restful sleep? How and why does fatigue knock your brain out like a light switch turning off, even when you are not lying down in bed? How does it know to do that? What else do we not know about fatigue?

So, in my curiosity I harkened back to my university days studying metallurgy. We studied the physical relationship between stress and strain on a metal sample and on samples of wood, plastic, ceramics and other material. Stress is the force that is applied to the metal sample and strain is the amount of deformation that occurred to the sample piece as a result of the stress.

As students we found was that for the most part, metals deform elastically under lower levels of stress and essentially return to their original shape, size and strength. This means that the stress is bourne by the material and it springs back into its original being.

In physiology terms, we might say that one all-nighter isn’t so bad; just get a good night’s sleep and you will bounce back, good as new and be ready to go just fine. Probably all true, especially so for lab studies of human being subjects.

Now back to the metal samples. As we continued to add stress to the metal samples, somewhere down the line we got strain that is no longer elastic. The sample no longer bounces back. The sample now begins to deform. It is still strong and has some of its original strength, but it has become bent, stretched and weakened.  The stress that was put on the sample past the elastic strain point damaged the sample. It is deformed plasticaly, that is, it will no longer spring back into it’s original size, shape and strength. It is deformed into a new shape. It is still one piece, but deformed. It will not now nor ever go back into its original shape. Moreover, if the stress is continually applied, not only does the strain result in a deformation in size, shape and strength, the sample will eventually break, fail and just come apart, often with a very loud bang.

Now, back to the human physiology story. Again does the human body and mind react in a similar manner, that is to say, that the body and mind can take some stress, some sleeplessness, and bounce back elastically with just a good night’s sleep. But what happens to the human body and mind when the stress of sleeplessness is applied continuously and applied over the ability to take this stress undamaged?

Can the stress eventually cause a strain, that is, damage to the body and mind, damage that one good night’s sleep is insufficient in time and regenerative power to cause or allow a recovery? Can we over stress the body and mind with fatigue? Can fatigue be damage that affects the body and mind such that it is injured and needs time to recover from the injury? Is fatigue more than a stress? Can fatigue cause a strain or injury?

The answers to all of these questions is neither clear nor well known. But these questions need to be asked. Is fatigue more of a strain at some point than just a stress? Can we do injury to our bodies and minds by stressing them with fatigue to the point that they are damaged in some manner and no longer function well? Can this damage be such that one good night’s sleep is insufficient time in which to recover? Have we broken something that needs mending? Have we injured something in ourselves which needs recovery?

Is fatigue more of a strain than a stress?

 

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UPS Safety Program: Prevention or Mishap Investigation? What are the Financial Consequences of a Failed Safety Program?

Captain Paul Miller preparing for a coming storm.

Is UPS Airlines now joining the ranks of so many previously safe FAR Part 121 airlines whose safety program looks good on paper, but in the field is no longer functioning to prevent fatal mishaps?

Since 1982, UPS has run UPS Airlines free of fatal mishaps. In fact the few mishaps that have occurred in the operation by and large have not been attributed to flight crew error at all. This has been a substantially safe operation, most markedly from the pilots’ seat. In my opinion, this is a valid reflection of the training program and the safety program that have been working hand in hand successfully.

Now, however, in the space of 3 years, two fatal mishap events have occurred. The two events involved the deaths of four pilots. Additionally the events involved the total destruction of two jumbo jets fully laden with cargo and express packages have brought tragedy and disaster to the front door of this fairly large global shipping company. Has the airline safety program, a program that had been working so well, now failed to prevent two major financial disasters in three years? Are top UPS executives asking the question, “Does the safety program look good on paper but then fail to prevent aviation disasters and the accompanying hundreds of millions of dollars in financial losses?”

The airlines and the pilot union have just completed a three year process involving the GCAA (Dubai civil aviation authority) mishap investigation of the September 2010 fatal air tragedy of UPS Flight 6, a B747-400 freighter, that caught fire inside the cargo area and crashed after takeoff in Dubai, despite the heroic efforts of the crew. (See the article below concerning the report recently released on UPS 6 by GCAA.)

Now UPS once again is visited by tragedy and disaster in Birmingham, Alabama, with the crash of UPS 1354. By all early and outward reports this mishap appears to have been completely preventable. Many people may ask both, “Why and why now?”

Here is the most difficult questions of all for UPS Airlines and its Joint Safety Program with the FAA and its pilot union: Has the safety program been working to prevent mishaps from occurring? Has the Safety Program been serving the safety purpose? Or has the Joint Safety Program become a legal avenue to find blame for the tragedies and losses that are now occurring regularly, without really delineating concrete steps to prevent the mishap from recurring? Is the safety program now serving the legal purpose instead of the safety purpose?”

UPS, its pilot union and its FAA partners are now party to another massive NTSB investigation that will attempt to answer the safety question, “How did the UPS Flight 1354 tragedy at Birmingham’s airport happen and what can UPS, the FAA and its pilot union do jointly to prevent this mishap from occurring again?”

But then the line flight crew member may ask these questions: “Wasn’t the purpose of the Safety Program originally, to prevent this mishap from ever occurring in the first place? Why did that program not work, where was the failure and what can be done now to prevent another fatal mishap from occurring?”

So again the crew member may be wondering, “Has the Safety Program now shifted towards reacting to tragedy and disaster instead of preventing tragedy and disaster? What good is all this attention to the disasters, when at the end of the day two fellow crew members are once again dead?”

Airline operations had been safe between 1982 and 2010. Now losses are occurring. Where has the safety program failed, if in fact it has, and how does UPS return to safe operations?

Perhaps a safety forecast may be useful now in order to develop a new safety plan? Perhaps looking ahead to the safety hazards that the airline faces in the future will allow the airline safety department to create a safety plan to return the airline to mishap free operations.

Mishaps are terribly costly in both human terms and financial terms. The losses from these two mishaps at this time have most likely surpassed half a billion dollars. From a financial perspective alone, a safety forecast and a safety plan would be a wise strategy.

Winter Storm

Asiana 214, Fatigue and In-Flight Crew Meals: Postprandial somnolence, or getting sleepy after you eat.

The more factors I consider, the fewer seem likely until I consider the human factor of fatigue. Automation? He was flying a B747 prior, plenty of automation there. San Francisco? Not all that different from dozens of international airports in the Pac Rim. CRM? Things didn’t go bad until the last few miles. New captain, new instructor? Happens everyday at every airline. Cultural paralysis? What? These airlines fly safely all around the world daily. Airmanship? The guys have thousands of hours flying the heavy machinery. Sure, the B777 is different from a B747, but the pilot monitoring was a B777 instructor, trained and qualified.

So why did they just stop flying, lose situational awareness, lose internal communications and CRM all at once? It seemed. like someone had whacked them in the head with a stick, like they ‘d had been incapacitated,  like they were barely conscious?

What is the one factor that would interrupt motor skills,cloud judgment and block action? Only one common factor comes to mind, the human factor of fatigue.

If culture was cause, then every flight operated by this culture would crash. But that is not what the facts tell us, since pilots from this culture operate hundreds of flights safely everyday, everyweek, everymonth, everyyear. Therefore logic tells us that culture is NOT THE CAUSE.

Since most commercial aviation mishaps are related to human factors, such as fatigue, which is highly incapacitating to all humans, regardless of culture, flight crew fatigue would be one of the first places to investigate in my opinion.

If we look at the many aircraft mishaps over the years, the demographics of flight crews involved cuts squarely across every cultural line. Any attempt to “culture-bait” this investigation in my mind is an attempt to divert us from the truth. And I personnaly do not like looking in the wrong direction for truth.

Let me ask any of you who are non-flight crew persons, how many of you who are office type persons spend 14-16 hours at your desk each day? Consider this hypothetical situation  because probably you have at least once spent 16 hours at your desk.
At the end of this theoretical 16 hr day, how good were your decisions, how clear was your judgment, how swift were your actions and how clear were your communications?

Fatigue can shut down the best parts of our brains. Why do we have such a hard time understanding that putting pilots in charge of a flight with 38 or more computer modes after a 14 hr day and 200+ peoples lives is not such a great idea?

And one further question, when did the crew eat their last meal before reassuming their duties on the flight deck? Did the after meal fatigue, the tendency for many of us to nod off as our digestive systems go to work, put the crew members into a food induced fatigue?

This is just my hunch, I have no facts to check this out.
Sometimes, when a crew grabs some rest, after they arise, they may eat a meal.
If after eating, they moved up to the flight deck and took over flight duties for the last 1 1/2 to 2 hrs, it is possible that the crew got hit with very human post meal drowsiness. Even with a few cups of strong coffee, many if not most people I flew with  were certainly affected.
I have never seen this addressed in any FAA reg, SOP or safety note. But it is certainly very common. I know of at least one B747 incident on record where the crew ate and fell asleep, the autopilot disconnected and the plane went out of control.
We will see, again this is  100% speculation.

I just ate my lunch. I think I will take a nap now.

 

Are “Passenger Lithium-ion Batteries” the same as “Cargo Lithium-ion Batteries?”

Captain Paul Miller preparing for a coming storm.

Captain Paul Miller preparing for a coming storm.

Recent passenger jet fires involving B787 Dreamliner have made news, but is it really new news? FAA and other regulators have dismissed the dangers of lithium-ion batteries when carried on cargo aircraft because. Why? Well, perhaps it is because fires on on cargo airline aircraft result in “no significant loss of life?” Isn’t this the legal reasoning offered by aviation officials when safety issues concerned cargo airline flights and not passenger airlines? That is right, cargo companies are called cargo airlines and operate under much the same rules as passenger carrying airlines.

But when a recent fatigue law was ruled not applicable to cargo airlines, thus cargo pilots, again by these same aviation officials, cargo pilots cried out, “Not fair to us!”

What they should have cried out should have been, “Not fair to the flying public!”

Yes, this ruling carved out an exemption from all sorts of safety rules for cargo airlines by aviation officials, from the same rules that will govern passenger carrying airlines. What I am arguing is this “carving out”process by aviation officials could well be seen as quite unfair to the flying public. How so you might ask?

Here are several examples. In 2006, lithium-ion batteries carried as cargo on a cargo airline caught fire in the air. A crew was hospitalized after they barely got the jet on the ground, that same aircraft finally being total destroyed by that fire.  The crew had to jump out of  cockpit windows to escape a burning smoke-filled aircraft.  Then again, four years later two cargo airline crews were not so lucky. In both of those cases in 2010 the fires were so quick moving and so intense, that despite their best efforts,  the crews of both aircraft perished in the fires while still in the air and then the cargo aircraft crashed.

Once again however, aviation officials, in a show of unprecedented irony, ascribed the events to cargo airlines and therefore not a passenger airline issue. Strangely enough however, the one common thread in these three stories are the batteries, the lithium-ion batteries. In each case, the batteries carried as cargo caught fire in the air and then caused massive fires inside the airplanes.  Despite the three known fires investigated by aviation officials, despite warnings going back to 2006 that these lithium-ion batteries can be very unsafe to carry in the air, these same aviation officials approved the use of these same batteries on the B787 Dreamliner. Not only was the approval for carriage of the batteries, but the approval was to hook up the batteries to the aircraft electrical system as electrical power sources, meaning that on every flight of a B787, there would be large lithium-ion batteries aboard and connected.

Many people would ask why this was done and why it was allowed to be done? My guess, and it is only a guess is that most likely, battery manufacturing experts explained to some aviation official lawyers, that these are somehow different batteries and different battery applications than those involved in the three cargo aircraft destructive mishaps. On paper, on a slide presentation in front of a room of officials, that argument probably, and obviously,  played well.

But in the end, the question remains now in the front of the minds of the public and press, “Are ‘Passenger Airline Lithium-ion Batteries’ the same as ‘Cargo Airline Lithium-ion Batteries’?” The events surrounding recent B787 lithium-ion battery related fires seems to raise serious questions about that question.

Maybe time and science and engineering will show us that this gendre of lithium-ion batteries can be made safe for the skies. That would be preferable for the future of the battery industry and the airline industry. But for right now, the question seems to be that they are similar enough in their fire catching characteristics to make all us in safety quite concerned?

Maybe these same aviation official lawyers can reconsider whether cargo pilots are somehow less susceptible to fatigue than passenger pilots and rescind the cargo carve out of the most recent fatigue rulings.100_3985 For it is in this transgression of logic that B787 Dreamliners took to the skies with lithium-ion batteries that may be the same type of batteries that brought the first of three cargo airline aircraft to destruction more that six years ago.

US Passengers at Risk by FAA Fatigue Rule

Passengers on domestic US airlines are now at an increased risk of being  crashed into by sleepy cargo pilots. Lawyers at the FAA used case law, negligence reasoning and other historically based legal records to reach a regulatory milestone, aligning witIMG_0922_2h lawyers at   large US based package express and airborne freight haulers. The FAA pointed out that so far, when cargo pilots have had fatal crashes, they have only killed themselves. But is the regulation a millstone around the necks of cargo pilots? Industry safety experts say the risk to the passenger flying public is very real. Fatigue caused human errors can lead to massive passenger casualties. Take for instance one of the worst commercial aviation passenger disasters in history. 583 people were killed when two heavily laden B747s collided in Tenerife in 1977.   It is believed that some of the crew members who may have been on duty in excess of 15 hours, in my opinion, misunderstood ATC communications. The KLM captain was very near the end of his official duty day, but believed that if he could get airborne before the end of his duty day, that he could complete the flight to Amsterdam with his load of passengers. A good man, a man dedicated to his company, a man with a great record at the company as a captain, under the fatigue caused misconception that he had been cleared to take off, although he had not, began his takeoff roll, colliding just moments later with a Pan Am jet on a fog shrouded runway.

Now imagine hundreds of fatigued cargo pilots operating around the clock due to this FAA ruling. Imagine a sleepy cargo crew misunderstanding an ATC radio call and ramming 850,000 pounds of plane, cargo and fuel into your family in a passenger plane innocently waiting to takeoff, albeit by accident, while seated on a passenger jet, one tightly regulated by the FAA. One thing will be for sure. The lawyers from the FAA and the cargo industry will be saying, “We need to do something about this.”

So, we have a chance right now to “do something about this,” and we ought to do it before we witness another tragedy such as Tenerife. The FAA should let the law of the people speak for the people. After all, it is their safety that is really the first priority, is it not? Cargo carriers have prospered under FAA safety regulations, countering the claims by their lawyers that safety would cost them business losses. Check their financial records. Now check the FAA and NTSB accident records. In fact the records show that  many if not most of the cargo crashes were the result of fatigue and other human factors, and not safety regulations. The ruinous losses of these accidents is in the hundreds of millions of dollars. And these are fully  documented losses of property and lives, they are not suppositions, arguments or cases put together in a law office.

This other “study” of potential business losses due to safety regulations is purely speculative, oppositional and entirely hypothetical. There doesn’t appear to be a shred of real evidence in the entire argument. So, I think that it is time that we base our decisions of safety, of life and death on reality, on data, on facts and on history and not on the unsubstantiated claims of lawyers, accountants and other business professionals.100_3975