AF447, what about Fatigue ?

[DirectCF]

The following is in French.

http://www.lepoint.fr/societe/crash-du-rio-paris-la-fatigue-des-pilotes-a-ete-cachee-15-03-2013-1640312_23.php (Could fatigue be one of the reasons of the AF447 crash ?)

Basically, it states that the Captain mentions : "I didn't have enough sleep last night. One hour, that was not enough" at 1:04 am.

Not a sound from the flight deck crew for the first 23 minutes of the recording on the CVR, with a bit of music even played before filling the ETOPS duties.

We know that around 80% of the accidents in aviation have a Human Error factor, but how many of them are actually linked to Fatigue ... ?:eek:

[BOAC]

That is NOT fatigue! Fatigue is quite different. Disturbed sleep one night = just simply 'tired'.

[toffeez]

I posted a long time ago that I was surprised the report didn't go into what they got up to in Rio. It can't be irrelevant. Maybe they went to bed early with a mug of hot chocolate. However one of them brought his wife along. Maybe they were all out on the town without drinking.

Ok, one doesn't get that info from th CVR, but it's not so difficult to find out.

[DirectCF]

That is NOT fatigue! Fatigue is quite different. Disturbed sleep one night = just simply 'tired'.

Thank you for this valuable input.

Who talks about one single night ? I thought long haul crew had disturbed circadian rythms, jet lags, and sometimes bad sleeps in hotels ?

Does this make an appropriate cocktail to start talking about fatigue ? :ugh:

[HEATHROW DIRECTOR]

They ought to try being a hospital doctor, then they could talk about fatigue.

[wheelie my boeing]

Bit of a silly comment Heathrow Director. To suggest that fatigue is not apparent in long haul operations is quite simply lack of knowledge. It most definitely is apparent, just as it may be with hospital doctors.

Fatigue may have been an issue in AF447, as tiredness could be too. If it was looked into they probably wouldn't like the answer, hence they won't look into it.

:8

[BOAC]

Exactly, HD.

DirectCF - your post referred to 'one night', hence my comment. Who talks about one single night ? - you did. Yes, crew do have all those things, but they are part of life and normally make you 'tired'. Crews are also expected to be 'tired', possibly very tired after a long or extended duty. It is expected. We all have disturbed hotel nights, hotel fire alarms, and other disturbances - some self-inflicted. Handling these is a part of life. What should the Captain have done if he did not consider himself fit to operate?

Also I cannot believe that an AF crews' roster would lead to serious 'fatigue'?

[averow]

Finally something I can post intelligently about ! Yes we doctors do suffer from fatigue both acute and chronic. The key is managing ones routines and practices to minimize mistakes: follow checklists, acquire good habits while in training and never be afraid to ask for help from colleagues when fatigued.

The "hero doctor syndrome" has been summarily shot down as a poor way to manage stress.:ok:

These routines were all acquired from our aviation colleagues! A lot of the mindset is similar, and the hard won lessons still apply. Our training has gradually become more humanized (hours are less) and patient safety has gone up accordingly.

[Lonewolf_50]

If it was looked into they probably wouldn't like the answer, hence they won't look into it.
Perhaps, but also the problem is nailing down solid and usable evidence given that all crew are dead. If I retire to my hotel room with the missus, or some gal I met, or someone I am having an affair with, how many chances does an investigator have to know if I slept, or if I spent hours in bedroom sports?

What if I had the telly on and got engrossed in a movie?

How does the investigator show that, rather than speculate?

[rivalino]

Fatigue doesn't cause a pilot to hold back on the stick when the A/C is
calling STALL at you. If the F/Os had been taught to fly rather than
operate this would never have happened. This is a product of minimum
cost training. I recently said to a F/O that his speed was getting slow,
his reply, THE AUTOTRUST IS IN, my reply I HAVE CONTROL. Shortly we will be having the MPL boys and girls coming through heaven help us.

[wheelie my boeing]

Agreed Lonewolf.

BOAC: It seems to me that modern rostering in certain airlines (not necessarly AF as I don't know about it there) is so "efficient" that fatigue is eventually a certainty. I'm not suggesting that pilots are fatigued all the time, but they almost definitely are some of the time. I'm not sure how many people would have the balls to go fatigued when many would be very concerned about the repercussions of doing so from management. If a pilot thinks (or knows) he is fatigued how easy is it for him to say downroute in a hotel in the middle of nowhere "Sorry guys but I can't operate at the moment I'm just not up to it". What will management say to that? Nothing? What is the pilot supposed to think management will do? Harsh reality would suggest in many companies going fatigued on more than one occassion could be a very career limiting move. Many guys in the right hand seat would be concerned it would go on their "file" - to the extent that they wouldn't go right hand seat to left.
To top it of their attitude will generally be "It'll be alright if I can just get back home"... This may be an error of theirs but it shouldn't be ignored.

Major carriers are already planning crews to the legal limits - limits which were created as a LIMIT not as a target. I personally don't think it's fair to place the responsibility solely on the pilots shoulders. It is the rostering which creates the issue (unless self inflicted!).

When you state that you cannot believe AF crews rosters would lead to serious fatigue can I ask whether you believe that because they operate for AF or is it because they are airline crews and therefore couldn't possibly be fatigued?


Rivalino:
"Fatigue doesn't cause a pilot to hold back on the stick when the A/C is
calling STALL at you."
Erm, what was the Colgan accident all about then? What did the Captain do when they received the stall warning? Was he seriously fatigued or was he poorly trained also?

[Agnostique75]

For the sake of clarity, and for those not familiar with the workings of the French judicial system, the investigation into AF 447 is a two-pronged affair. The BEA, the French equivalent of the NTSB, has issued a technical report on the causes of the crash –not apportioning blame etc…-. In parallel, the French police, working under the supervision of three judges, completed its own enquiry, which will serve as the basis for any legal decisions in this case.
It is the later enquiry that the article in magazine “Le Point” is referring to. While the BEA claims that it did not want to “infringe on the personal lives” of the flight crew, the French police appears to have been considerably less shy in that regard. Beyond the Captain’s remark concerning his state of fatigue, the atmosphere in the cockpit described as “lacking in energy”, the fact that the crew listened to music, the judicial enquiry has taken a closer look into the crew’s activities during their stay in Rio de Janeiro.
While their findings largely corroborate the BEA’s as to the technical aspects of the crash, we can expect a number of disturbing facts to emerge in relation to the crew’s stay in Rio and their level of readiness / preparation for the ill-fated flight. While the full judicial report is not yet published, some elements, such as the presence of some of the flight crew’s partners / spouses, have attracted the attention of the police. We can reasonably assume that more details will emerge in the coming weeks.

[BOAC]

wheelie - I have no disagreement with your post. As I said, however, I do NOT think an AF roster would induce 'fatigue'.

People often talk about 'fatigue' when they mean dog-tired. I have said this many times before - the two conditions are quite different which is why they are specified and treated differently in Ops Manuals.

I had my fill of varying duty start times over 20 years of airline flying, a succession of earlies on the trot, into afternoon through night operations, disturbed rest (voluntary and involuntary:)) but I don't think I was EVER 'fatigued'

To clarify, here is one take on the symptoms of Chronic Fatigue:

Primary Symptoms

As the name chronic fatigue syndrome suggests, fatigue is one part of this illness. With CFS, however, the fatigue is accompanied by other symptoms. In addition, the fatigue is not the kind you might feel after a particularly busy day or week, after a sleepless night, or after a single stressful event. It's a severe, incapacitating fatigue that isn't improved by bed rest and that is often worsened by physical activity or mental exertion. It's an all-encompassing fatigue that can dramatically reduce a person's activity level and stamina.

People with CFS function at a significantly lower level of activity than they were capable of before they became ill. The illness results in a substantial reduction in work-related, personal, social, and educational activities.

The fatigue of CFS is accompanied by characteristic illness symptoms lasting at least 6 months. These symptoms include:


increased malaise (extreme exhaustion and sickness) following physical activity or mental exertion
problems with sleep
difficulties with memory and concentration
persistent muscle pain
joint pain (without redness or swelling)
headache
tender lymph nodes in the neck or armpit
sore throat

Other Symptoms

The symptoms listed above are the symptoms used to diagnose CFS. However, many CFS patients and patients in general may experience other symptoms, including:


brain fog (feeling like you're in a mental fog)
difficulty maintaining an upright position, dizziness, balance problems or fainting
allergies or sensitivities to foods, odors, chemicals, medications, or noise
irritable bowel
chills and night sweats
visual disturbances (sensitivity to light, blurring, eye pain)
depression or mood problems (irritability, mood swings, anxiety, panic attacks)

Which is why you MUST NOT operate if you are suffering from fatigue.

So, if the AF Captain had these symptoms, then yes he was probably fatigued, but should have been off the roster.

Incidentally, I wonder if his 'tiredness' caused him to take his bunk rest when he did, which most of us consider to be ill-advised.

I am intrigued by Agnostique75's post..............................................

[Lookleft]

CFS is a very different catagory to the fatigue that pilots experience. I agree with you that a lot of what pilots experience is tiredness. The problem with fatigue as it applies to pilots is you are not allowed to anticipate that a duty will be fatiguing even if you know from experience that it will be. So you start a duty tired but at the other end (e.g. BOC over multiple days you will start showing signs of


difficulties with memory and concentration
brain fog (feeling like you're in a mental fog)
visual disturbances (sensitivity to light, blurring, eye pain)
These are the symptoms of fatigue that controlled rest is supposed to alleviate.
Whether the AF447 pilots had this and it had a major impact on the sequence of events is unlikely IMHO. As has been mentioned, holding the side stick back despite the warnings has more to do with training and deskilling of pilots than fatigue issues.

[Sober Lark]

Is it truth or rumour that the Captain on AF447 said he had only one hour of sleep the night before the flight?

[toffeez]

The article in Le Point says the official Judicial Report (not the BEA one) includes the following, taken "word for word" from the CVR.

"Cette nuit, j'ai pas assez dormi. Une heure ..."

[FLEXPWR]

The captain was not at the controls during the full course of this tragic event. Tired or not, he was not the one fyling the plane at that moment.
Could have been a different outcome if he did, I cannot imagine a 10,000+ hours captain pulling to the stop during a stall for 4 minutes, especially starting fom this altitude. Even whitout sleep.

The fact remains that high altitude flying serioulsy lacks training, wether from APTL training or in company training. I have met with many AF pilots who say no such technical course was ever given at the time. Dunno about now.

[BOAC]

Looking rationally at '1 hr sleep' it should not be a big problem - not good, no, but manageable. Bear in mind said Captain could be slipping on his silkies about 3 hrs after take-off and taking bunk 'rest' from then on, so a reasonable chance to re-charge the batteries - and 3 crew, of course. Every now and then a few of us will have pre-flight rest like his, and manage it.

[avt]

It's interesting how little sleep deprivation creates a notable loss in performance, though.

From Anne-Marie Feyer's editorial in the British Medical Journal, Volume 322, 7 April 2001, pp. 808-809 "Fatigue: time to recognise and deal with an old
problem":

"We recently compared the effects of sleep deprivation and alcohol intoxication and found that after 17-19 hours without sleep, starting from waking at about 0600 hours, individuals’ performance was equivalent to or worse than at 0.05% blood alcohol concentration. In other words, commonly experienced levels of sleep deprivation—one extended day for a well rested individual—had a profound effect on performance. At around 2230-2430, well before reaching the circadian trough in alertness, performance levels were low enough to be considered incompatible with safe driving in many countries."

The specific research quoted in the article came from:

Williamson AM, Feyer A-M. Moderate sleep deprivation produces impairments in cognitive and motor performance equivalent to legally prescribed levels of alcohol intoxication. Occup Environ Med 2000;57:649-55.

[FLEXPWR]

Lost in translation?

In french, "je suis fatigue" means I am tired. There is no direct translation for the english word "fatigue", maybe a description of a long term exhaustion in a specific environment.

Stop fiddling wether this is fatigue or not fatigue, the document original design is in french... and in french, you can get fatigue from a single night out or get fatigue from jet lag, poor rostering, etc. Same word, different meanings.

The captain says he got fatigue due to very short sleep, it seems to be what it says on the tin, lack of sleep.

Still, it does not preclude that fatigue -as known to english speaking professionals- could have been there as well.

Flex

[Notsoalert]

It is. We have a definition now for fatigue in aviation from ICAO and it bundles together long and short term effects. Let's use it.

[BOAC]

Notso - I have looked briefly through all 150 pages of the FRMS pdf and my first thought is that companies will just 'file and forget'.

Amusingly the 'new' ICAO definition of 'fatigue' has departed from the medical definition and now equates to the third 4 sector early start short-haul day...................or even the end of a long two-sector day-I

"Crewmember fatigue can be defined as:

A physiological state of reduced mental or
physical performance capability resulting from
sleep loss or extended wakefulness, circadian
phase, or workload (mental and/or physical
activity) that can impair a crew member’s
alertness and ability to safely operate an aircraft or
perform safety related duties."

Hmm! Should keep the 'Fatigue Manager' busy:)

[Mr Angry from Purley]

BOAC
Spot on
Flexpwr its called sleepyness well thats what i'm told by the experts, we tend to bundle it into fatigue, if i get a bad nights sleep tonight i may suffer from sleepyness. Very unlikely fatigue with the French Union and social rules protecting them unless it goes into that area where no one likes to go - self management of rest

How long were the crew in Rio, 24hr slip or more?.

Departure was 1900 local time, French time probably in the WOCL.

The transcripts suggested the FO coming in from his bunk rest was tired, sleep inertia?. Cpt would have had it for sure.
We'll never know
RIP

[Agnostique75]

How long were the crew in Rio, 24hr slip or more?

According to the final BEA report, published July 2012, « L’enquête n’a pas permis d’établir avec exactitude l’activité des membres d’équipage de conduite pendant l’escale à Rio de Janeiro où l’équipage était arrivé trois jours plus tôt. Il n’a pas été possible d’obtenir des données relatives à leurs sommeils pendant cette escale ».

Translated into the lesser Shakespearian language, this would amount to a 72h layover. Citing respect “for the crew’s privacy”, the BEA has chosen not to detail those three days, merely commenting that “It was not possible to obtain data relative to their sleeping patterns during this layover”. This choice raised a number of questions when the BEA released their report in July 2012.

As stated previously, under the French system, the investigation into AF 447 is a two-pronged affair. The BEA, the French equivalent of the NTSB, issued its technical report on the causes of the crash –not apportioning blame etc…-. In parallel, the French police, working under the supervision of three judges, completed its own criminal enquiry, which will serve as the basis for any legal decisions in this case.

It is the later enquiry that the article in magazine “Le Point” (http://www.lepoint.fr/societe/crash-du-rio-paris-la-fatigue-des-pilotes-a-ete-cachee-15-03-2013-1640312_23.php) is referring to. While the BEA claims that it did not want to “infringe on the personal lives” of the flight crew, the French police appears to have been considerably less shy in that regard and, working with / through their Brazilian counterparts, they appear to have collected testimony from a variety of witnesses. While translation issues have hampered the swift transmission of the full judiciary investigation to the victims’ lawyers, it is most likely that the contents of this report will be “leaked” in preparation for the trial.

A.

[G-CPTN]

Plane crash pilot in which three Irish doctors died 'had only had one hour's sleep' - Independent.ie (http://www.independent.ie/world-news/americas/plane-crash-pilot-in-which-three-irish-doctors-died-had-only-had-one-hours-sleep-29148358.html)

[BOAC]

Hmm - if there was a Mrs Captain, I bet she is enthralled to know from the Irish Indie that his 'lack of sleep' with Veronique may well have assisted the crash.

Now - 1 minute to get back to the cockpit 'shock/horror' - I call that pretty smart. Disentangle from Veronique, replace trowies etc and report. Going some!

[Lonewolf_50]

A few things that annoyed me about this story in the Irish paper ...
THE captain of an Air France plane which crashed into the sea with the loss of all 228 people on board had only slept one hour the previous night after a romantic jaunt in Brazil with his girlfriend. A damning report also found that his co-pilots appeared dangerously tired.
To whom? Which report? (I did not find an English version of Le Point, so I may be missing the obvious here)
Three young Irish doctors, Jane Deasy (27) from Dublin, Aisling Butler (26) from Co Tipperary and Eithne Walls (28) from Co Down were killed when AF447 plunged into the Atlantic Ocean as it travelled from Rio de Janeiro in Brazil to Paris in June 2009.
I guess the other 225 people are chopped liver. Thanks. :p
The close friends had studied medicine together in Trinity College and remained friends after graduating in 2007.
RIP, lads.
The revelations may help shed light on why the pilots took what air accident investigators describe as "inappropriate" action when the Airbus 330 flew into turbulence during a tropical thunderstorm. Co-pilots Pierre-Cedric Bonin, 32, and David Robert, 37, were unable to bring the plane under control as it rolled from side to side.
Not quite, Boyo. Maybe read the whole thing. Get a pilot to help you understand it. It's called "background" and it's handy for a journo.
Black box recorders showed that Captain Marc Dubois, 58, had been asleep when the trouble started and took more than a minute to return to the cockpit when they alerted him.
Seems an OK time if he had fallen asleep, given that their whole task once he left were to fly straight and level, with one planned climb when conditions permitted, and course changes by flight planned route ... Not too much to ask, eh?
But a report commissioned by French magistrates investigating the crash said the captain had been recorded as grumbling shortly after take off: "I didn't sleep enough last night. One hour is not enough."
Quote out of context, but more or less what other sources have ... though the pause is omitted.
Le Figaro also published a previously unseen email sent by a friend of Captain Dubois' after the crash showing that he had taken Veronique Gaignard, his girlfriend, who was an off-duty flight attendant, to Rio. "I can tell you that he was happy because he told me that he was leaving (for Rio) with Veronique and he was so happy that she was there and accompanying him," the mail reads. Le Figaro said Captain Dubois and Ms Gaignard had driven to see friends an hour from Rio and flown by helicopter over the bay during the weekend.
Gee, here's a surprise. A Frenchman, pilot, has a mistress, stew, and flies for a major airline. Who would have thunk it? Maybe the Missus already suspected ...
When he reached the cockpit after being roused, Captain Dubois used words that suggested he was not fully awake, according to French press reports.
Those words about no sleep were not when he was getting back to the cockpit after Robert's call. The words quoted are taken a bit out of context.
"Go down," he told a co-pilot. " No go up. You go up. It's not possible."
This journo mixes Robert's comments with Dubois' comments. Journo used a bit of license there. Or lied.

Much deleted, but to show how at variance with the record this journo's assertions are ... this trans is rough from our own poster spagiola, but it gets the gist of the flow PF = Bonib PNF = Robert CAP = Dubois
2 h 10 min 06
PF: J’ai les commandes = I have the controls
2 h 10 min 11
PNF: Qu’est ce que c’est que ça ? = What's that
2 h 10 min 49
PNF: (…) il est où euh ? Uh, where is he?
2 h 11 min 06
PNF: (…) il vient ou pas Is he coming or not
2 h 11 min 43
CAP: Eh qu’est-ce que vous (faites) ? = Hey what are you doing?

Well look at that. First words when he got back to the cockpit were actually "Hey, what are you doing?"

PNF: Qu’est-ce qui se passe ? Je ne sais pas je sais pas ce qui se passe ~
What's happening? I don't know I don't know what's happening
2 h 11 min 52
CAP Alors tiens prends prends ça ~ So here take take that
2 h 11 min 58
CAP: D’accord ~ OK
2 h 12 min 15 to 2 h 12 min 19
CAP: Là je sais pas là ça descends ~ I don't know we're going down
CAP: Les ailes à plat ... l’horizon l’horizon de secours ~ Wings level ... the horizon the backup horizon
2 h 12 min 27
PNF: Tu montes ... Tu descends descends descends descends ~You're going up ... you're going down go down go down go down
2 h 12 min 30
PF: Je suis en train de descendre là ? = Am I going down?
PNF: Descends = Go down
2 h 12 min 32
CAP: Non tu montes là No you're going up, there
2 h 12 min 42

The Captain has been in the cockpit for just under a minute and if the court find fault, it may be in the speed of his triage/assessment of just what the hell it is his two copilots are/were doing, per his opening question?

PF: En alti on a quoi là ? = In alti[tude] we're at what, here?
2 h 12 min 44
CAP: (…) C’est pas possible = It's not possible

At this point, was recovery possible, if immediately begun ?
(nose down, get AoA back, slow recovery to avoid restall ... only if any of the three understands "hey, we are stalled!" and so begins. )

Is this what the legal investigation is focused on?

2 h 12 min 45
PF: En alti on a quoi ? = In alti[tude] we're at what ?
2 h 12 min 45 to 2 h 13 min 04
PNF: Comment ça en altitude ? What do you mean in altitude?
PF: Ouais ouais ouais j’descends là non ?
yeah yeah yeah i'm going down here, no?
PNF: Là tu descends oui = You're going down here, yes

CAP: Hé tu ... tu es en… Mets mets les ailes horizontales = hey you ... you're in ... put put the wings level

CAP: Mets les ailes horizontales Put the wings level
2 h 12 min 59
CAP: Le palonnier = Rudder pedals
2 h 13 min 25
PF: Qu’est-ce qu’y… comment ça se fait qu’on continue à descendre à fond là? = What is... how come we're continuing to descend so fast?
2 h 13 min 38
CAP: Doucement avec le palonnier là = Easy with the rudder
2 h 13 min 39

He does not realize they are stalled, and at this point, recovery is probably no longer possible. (Depends ...)

PNF: Remonte remonte remonte remonte = Climb climb climb climb (literally, "remonte" is "climb back up")
2 h 13 min 40
PF: Mais je suis à fond à cabrer depuis tout à l’heure = But I'm nose up to the limit since earlier
CAP: Non non non ne remonte pas = No no no don't climb back up
PNF: Alors descends = Go down, then

Did this conversation have to do with raising or lowering nose?

2 h 13 min 45
PNF: Alors donne-moi les commandes à moi les commandes = So give the me controls. The controls to me.

PF: Vas-y tu as les commandes on est en TOGA toujours hein = Go on, you have the controls. We're still in TOGA, ok
2 h 14 min 05

CAP: Attention tu cabres là = Watch it, you're pitching up
PNF: Je cabre ? = I'm pitching up?
PF: Ben il faudrait on est à quatre mille pieds = Well, we should, we're at 4000 feet
2 h 14 min 18
CAP: Allez tire = Go on, pull

The pilots ignored normal procedures and raised, rather than lowered, the plane's nose when it lost lift or, in technical parlance, "stalled".
That was before he arrived in cockpit. The end game after Robert took controls was already hopeless in terms of time needed to recover versus rate of descent versus altitude.

Journo seems not to have read the BEA final report.
The terrifying result was a three-and-a-half minute plunge before hitting the ocean.
As most of the pax were probably asleep, only terryfiying for whomever
1. was awake and
2. was aware they were falling.
The French aviation safety authority, the BEA has already released a report which concurs with a 365-page judicial inquiry that the "captain had failed in his duties" and "prevented the co-pilot from reacting appropriately".
How can he say this? The two co pilots failed to keep the plane flying.

If the assertion is that once Captain Dubois got back into the cockpit he prevented those two from making it fly again ... how many seconds did he have from "arrival time" to "stall recovery commenced" before it was too late?

Based on the CVR, there was a window of opportunity for him to understand and then direct corrective action. As "stall" was apparently not understood by any of them, any corrective action that wasn't "recover from stall" would not be of any help.

The inverse of this, did something to PREVENT recovery, hinges upon first understanding that stall was his condition.

2:11:43 (What Are You Doing?) to impact? The amount of time to assess aircraft's state begin a recovery was (depending upon how much altitude you think it takes to unstall then pull out without restalling) about half a minute to a minute and a half -- before the ponit of no return?

Was his being just woken up the reason why he didn't recoginze the condition "stall" as he did his assessment of what was going on?

I'd be interested to see how that is proven, or not, in court.

Is there an English translation of the judicial inquiry?
French judges have launched a criminal inquiry into Air France and Airbus for alleged manslaughter.
Hadn't they begun this a few years ago?