PPRuNe Forums - View Single Post - AAIB investigation into serious fatigue-related incident near Birmingham, UK, 2004
Old 31st May 2007, 09:04
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shoey1976
 
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further quote re fatigue

Just to quote the key bits, in my opinion, from that AAIB report

Analysis
Investigation of this incident has focussed on trying to determine why the co-pilot mistakenly selected the flap lever when attempting to raise the gear. In doing so several significant areas were identified which may have been contributory.

a Fatigue
The co-pilot commented that he had had a particularlybusy roster during the month leading up to the incident, flying 87 hours 50 minutes in the previous 28 days. The legal absolute maximum number of flying hours quoted in CAP 371 over the same period is 100 hours. In the same period he had been rostered nine days off, two of which were single days off. In all but one case these days off were preceded by duty periods finishing between 2035 hrs and 2110 hrs (local) and all were followed by duty periods starting between 0600 hrs and 0925 hrs (local). He stated that the week leading up to the incident had been particularly busy with six duty periods, half of which involved early starts.
Whilst his roster conformed to the required legal limitations the co-pilot believed that it had left him generally fatigued. This, in his opinion, was the major cause of the incident and he stated that he had failed to recognise in himself "a level of fatigue that would facilitate such an error".

and yet, in the Conclusions and Safety Recommendations section, there is no mention of fatigue.
I'm intrigued to know why not - is it just because the crew were within legal FTLs, and it's not the AAIB's role to criticise CAP371?
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