Re: Human Factors and Accident reduction/mitigation

[JC Dill <jcdill.lists () gmail com>]

Owen DeLong wrote:
> We could learn a lot about this from Aviation.  Nowhere in human 
> history has
> more research, care, training, and discipline been applied to accident 
> prevention,
> mitigation, and analysis as in aviation.  A few examples:
>
>     NTSB investigations of EVERY US aircraft accident and published 
> findings. 

Ask any commercial pilot (and especially a commercial commuter flight 
pilot) what they think of NTSB investigations when the pilot had a "bad 
schedule" that doesn't allow enough time for adequate sleep.  They will 
point out that lack of sleep can't be determined in an autopsy. 

The NTSB routinely puts an accident down to "pilot error" even when 
pilots who regularly fly those routes and shifts are convinced that 
exhaustion (lack of sleep, long working days) was clearly involved.  And 
for even worse news - the smaller the plane the more complicated it is 
to fly and the LESS rest the pilots receive in their overnight stays 
because commuter airlines are covered under part 135 while major 
airlines are covered under part 121.  My ex flew turbo-prop planes for 
American Eagle (American Airlines commuter flights).  It was common to 
have the pilot get off duty near 10 pm and be requited to report back at 
6 am.  That's just 8 hours for rest.  The "rest period" starts with a 
wait for a shuttle to the hotel, then the drive to the hotel (often 15 
minutes or more from the airport) then check-in - it can add up to 30-45 
minutes before the pilot is actually inside a hotel room.  These 
overnight stays are in smaller towns like Santa Rosa, Fresno, 
Bakersfield, etc.  Usually the pilots are put up at hotels that don't 
have a restaurant open this late, and no neighboring restaurants (even 
fast food) so the pilot doesn't get dinner.  (There is no time for 
dinner in the flight schedule - they get at most 20 minutes of free time 
between arrival and take-off - enough time to get a bio-break and hit a 
vending machine but not enough time to actually get a meal.)  Take a 
shower, get to bed at about 11:30.  Set the alarm for 4:45 am and catch 
the shuttle back to the airport at 5:15 to get there before the 6:00 
reporting time.  In that "8 hour" rest period you get less than 6 hours 
of sleep - if you can fall asleep easily in a strange hotel.

Commuter route pilots have been fighting to get regulations changed to 
require longer overnight periods, and especially to get the required 
rest period changed to "behind the door" so that the airlines can't 
include the commute time to/from the airport in the "rest" period.  This 
would force the airlines to select hotels closer to the airport or else 
allow longer overnight layovers - either way the pilots would get 
adequate rest.  See:

http://asrs.arc.nasa.gov/publications/directline/dl5_one.htm

The NTSB does a great job with mechanical issues and with training 
issues, but they totally miss the boat when it comes to regulating 
adequate rest periods in the airline schedules. 

To bring this back to NANOG territory, how many times have you or one of 
your network admins made a mistake when working with inadequate sleep - 
due to extra early start hours (needless 8 am meetings), or working 
long/late hours, or being called to work in the middle of the night?

Finally, having lived with a commercial aviation pilot for 5 years and 
having worked with network types for much longer, I can say that while 
there is some overlap between pilots and IT techs, there are also a LOT 
of people who go into computers (programming, network and system 
administration) who are totally unsuitable for the regimented 
environment required for commercial aviation - people who HATE following 
a lot of rules and regulations and fixed schedules.  If you tried to 
impose FAA-type rules and regulations and airline schedules on an IT 
organization, you would have a revolt on your hands.  Tread carefully 
when you consider to emulating Aviation.

jc