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Old 29th Dec 2023, 09:05
  #663 (permalink)  
NoelEvans
 
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Almost nothing said about possible fatigue in that report, other than "Previous rest period" -- "​As per CAAN requirements" and a fleeting reference to a "SHELL model" for Human Factors.


The hours flown in the previous 7 days, 30 days, 3 months and 12 months are all given, but nothing about the work patterns for those hours, especially over the week and month before the crash. It will all no doubt be "As per CAAN requirements", but do those 'requirements' make sense in those circumstances? A training captain training a new captain means both of them sitting in seats that they are not 'every day' familiar with. The cumulative fatigue of that can be significant. How many sectors had they flown that week? Were they all early starts? That was their third sector that day, what time did they start that day? That was a very short sector with obviously very high workloads and the two previous sectors were very similar, had they all been like that in the preceding few days?


The report says: "The CVR transcript captured a flight deck environment rich with discussion on the appropriate way to fly a visual approach into the new Pokhara Airport. Both pilots were experiencing high workload, distractions to the external environment, and may have impacted on effective CRM within the cockpit. This may have lead them to not follow the checklist properly in critical phases of flight. The crew were most probably distracted due to excessive conversation in cockpit because the flight was first for the PF and the PM was occupied with providing instructions and was not focused on the PM duties." Yes, it was a training flight!! You teach by talking!!!


There is not enough information given about the fatigue possibilities as a contribution to this crash, other than a fleeting comment that some computer model does not consider that to be a factor: "A 72-hour history of both crewmembers indicated that fatigue ... [was] not a factor prior to the accident. Both pilots were reported to have eaten routine foods, went to bed, and rose at routine hours.". From personal experience in very similar circumstances, I feel that fatigue is a very, very valid factor in this crash and the report does not look into that aspect in anywhere enough detail.
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