That fatigue is present in our daily live is known. Also, that it can be a contributing factor to incidents and accidents in aviation. However, how much the professionals, organisations and regulators know and do about it? Why is such complex? How proactive are organisations about Fatigue Risk Management?
If something I learned last week when I attended to the conference that the RAeS organised at Cranfield (Staying Alert: Managing Fatigue in Maintenace) is that Fatigue Management has three legs: the individual, the organisation and the regulator. I travelled to UK to maintain my currency as Aviation Maintenance Human Factors, but also because it was a unique occasion to learn from professionals and specialists sharing their knowledge, experience and advice about this topic. A great forum; I really congratulate the RAeS, and specially the Human Factors Group, to organise events like this.
In any case, and to be honest, I believe that many delegates as me were attending because the Fatigue Management is not regulated yet for Aviation Maintenance Organisations. And we wanted to know what is going on. And indeed, it has been some movement already. The FAA issued on December 2016 the Advisory Circular Nº 120-115 (Maintainer Fatigue Risk Management). Is not mandatory, but it is a good start to be introduced about the topic, understand how fatigue can be a safety hazard in aviation and how and why organisations should be implementing Fatigue Risk Management. Also, I recommend the FAA website Fatigue Risk Management as it is plenty of material.
During the day, we reviewed different accident reports were fatigue had been a contributing factor. For example, the loss of control in Nevada of an AS30B2 (N37SH) with a fatal end (the report can be found in the NTSB website: NTSB/AAR-13/01). It mentions how the performance of the mechanic and the inspector was degraded by fatigue, which contributed to the improper securing of the fore/aft servo connection hardware, the improper installation of the hydraulic belt, and the inadequate post maintenance inspection.
From the report, both the mechanic and the inspector did not have time to adjust to an earlier shift than normal, which lead experiencing fatigue. Also, the mechanic had an inadequate amount of sleep and the inspector had a long duty day.
These are cases were, between the multiple contributing factors, fatigue is present… again. So, in absence of a regulated time of duty for maintainers, what can organisations proactively do? Speakers from different aviation maintenance organisations shared some measures that have put already in place as:
- integrated Fatigue Risk Management in their Safety Management System
- deliver training about Fatigue Management to everyone in the maintenance organisation (integrate with Human Factors training)
- include Fatigue in risk assessments
- perform analysis of shift patterns
- issue working time policies that consider Fatigue Risk Management
- plan controlled breaks
- design facilities accordingly to facilitate rest
- fatigue reporting mechanisms
- reward schemes for good suggestions.
I left the event having learned how important is considering fatigue as a safety hazard and how important is raising the awareness of professionals and organisations as it is a shared responsibility being “fitness for duty”.