AF447, what about Fatigue ?
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AF447, what about Fatigue ?
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
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 ... ?
http://www.lepoint.fr/societe/crash-du-rio-paris-la-fatigue-des-pilotes-a-ete-cachee-15-03-2013-1640312_23.php
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 ... ?
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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.
Ok, one doesn't get that info from th CVR, but it's not so difficult to find out.
Last edited by toffeez; 15th Mar 2013 at 10:45.
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That is NOT fatigue! Fatigue is quite different. Disturbed sleep one night = just simply 'tired'.
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 ?
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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.
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.
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Exactly, HD.
DirectCF - your post referred to 'one night', hence my comment.
- 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'?
DirectCF - your post referred to 'one night', hence my comment.
Who talks about one single night ?
Also I cannot believe that an AF crews' roster would lead to serious 'fatigue'?
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doctors Fatigue
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.
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.
The "hero doctor syndrome" has been summarily shot down as a poor way to manage stress.
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.
If it was looked into they probably wouldn't like the answer, hence they won't look into it.
What if I had the telly on and got engrossed in a movie?
How does the investigator show that, rather than speculate?
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.
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.
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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?
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?
Last edited by wheelie my boeing; 15th Mar 2013 at 11:45.
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BEA report / Criminal enquiry
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.
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.
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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:
The symptoms listed above are the symptoms used to diagnose CFS. However, many CFS patients and patients in general may experience other symptoms, including:
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..............................................
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
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)
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..............................................
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
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.
- difficulties with memory and concentration
- brain fog (feeling like you're in a mental fog)
- visual disturbances (sensitivity to light, blurring, eye pain)
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.
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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 ..."
"Cette nuit, j'ai pas assez dormi. Une heure ..."
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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.
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.
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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.
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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.
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.
Last edited by avt; 18th Mar 2013 at 15:07. Reason: typo in first paragraph
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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
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
Last edited by FLEXPWR; 17th Mar 2013 at 09:05.