Re: Human Factors and Accident reduction/mitigation

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

Owen DeLong wrote:
> On Nov 6, 2009, at 12:04 PM, JC Dill wrote:
>
> > 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.
>
> As a point of information, I _AM_ a commercial pilot.

There are commercial pilots who fly for a living, and there are those 
who have the certification but who don't fly for a living.  Do you 
regularly fly for a commercial airline where your schedule is determined 
by the airline's needs, part 135 or part 121 rules, union rules, etc. 
with no ability to modify your work schedule to allow for adequate rest?
> > 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.
> Flying in such a state of exhaustion is, whether you like it or not, a 
> form of pilot error.
There is no other effective option.  Almost all the commuter airline 
schedules have these short overnights, and it's impossible for most 
pilots to avoid being scheduled to fly them.  If you bid for these 
schedules you are expected to fly them.  You can't just decide at 11:30 
pm that you need more than 5 hour's rest and that you won't be getting 
up at 4:30 am to get to the airport by your 6:00 am report time, or 
decide when your alarm wakes you at 4:30 that you are too tired and are 
going to get another 2 hours sleep, or decide at 7 pm that you are too 
exhausted from flying this schedule for 2 days and are not going to fly 
your last leg.  If you do this *even once* you will get in very hot 
water with the company and if you do it repeatedly you will ultimately 
lose your job.  They aren't going to change the schedule because it's 
"legal" under part 135.
> A pilot who chooses to fly on such a schedule is making an error in 
> judgment. Sure, there are
> all kinds of pressures and employment issues that need to be resolved 
> to reduce and eliminate
> that pressure,

Right now there is no way to avoid putting your job in jeopardy by 
refusing to fly these unsafe schedules. 

> and, I support the idea of updating the crew duty time regulations 
> with that
> in mind.
>
> That does not change the fact that FAR 91.3 still applies:

The airlines don't care.  They draw up these unsafe schedules and expect 
pilots to magically be capable of flying them safely.  If there's an 
accident it goes down as pilot error, but if you try to claim exhaustion 
and refuse to fly citing 91.3 on a repeated basis you WILL be fired.  
Catch 22.

Sounds a lot like working in IT with clueless management, doesn't it?

> > 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?
> Sure, this happens, but, it's not the only thing that happens.
>
> > 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.
> That's very true.  I wasn't advocating that we should emulate 
> aviation, so much as I was attempting
> to point out that if you want to reduce accidents/incidents, there is 
> a proven model for doing so
> and that it comes at a cost.
Agreed.
> Today, we actually seem, and in my opinion, rightly so, to prefer
> to live with the existing situation.  However, given that is the 
> choice we are making, we should
> realize that is the choice we have made and accept the tradeoffs or 
> make a different choice.

Fast(big/powerful), cheap, good - pick any two.   :-)

jc