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Pilot Error and Pilot Fatigue Essay

There are airline passengers whose knuckles will turn white upon take-off and they will grip their seats tight when the plane is about to land. Experts would like to assure frequent flyers that there is nothing to fear because the accident rate is negligible and that it is very safe to use airplanes as a means of transportation. Still accidents do occur from something as mild as flying past an intended landing site to something as serious as crash landing on rough terrain, killing people on board.

With the rapid technological changes experienced in the 20th century there must be an explanation why severe accidents still occur in the aviation industry. A closer examination will reveal that most accidents are related to pilot error and pilot fatigue. There is therefore a need to develop fatigue-management systems that will reduce the incidence of accidents and incidents due to pilot error and pilot fatigue. Pilot Error It is not hard to imagine the difficulty experienced by the Wright brothers when it came to the technological challenge of trying to levitate an object that is heavier than air.

There was a need for technological breakthroughs. Their first few attempts to fly an airplane failed. Even when they succeeded in flying the first airplane able to carry a human passenger, there was still the general concern regarding air safety to contend with. So many things require improvement. Clearly the Wright brothers as well the numerous innovators who followed their footsteps had to deal with the need to upgrade fuselage and engine design. This obstacle has to be hurdled before airplanes can be used commercially.

But during the Second World War mankind saw the radical changes in airplane design and construction that made it possible for many countries to become part of the global airline industry. With positive changes in aircraft technology, there was also a noticeable improvement in air safety. But as technology was on the rise many airline safety experts began to observe, “The primary cause of aviation accidents has clearly shifted from mechanical failure to human error. In spite of the overall improving trend in aviation safety, the rate at which the human element is failing has not gone down” (Kern, 2001).

Ironically the more complex the aircraft the more difficult it is for the pilot to manage the same. Pilot Fatigue It will be explained later that even if aviation technology continues to improve the human body is the limiting factor that will cause the whole system to breakdown even if technology is available to increase the workload of airline pilots. Former FAA Administrator Robert Sturgell once told the audience of a fatigue forum that, “While fatigue may not have been called out by name, it’s been … lurking in many of the accidents we’ve faced over the years” (Werfelman, 2008).

Sturgell added, “Even with an outstanding safety record, we’re not where we need to be when it comes to understanding and dealing with fatigue” (Werfelman, 2008). The pronouncements made by the former FAA administrator must be taken seriously even if accident rates are very low. Sturgell’s conclusions can be partially understood using the premise that pilot fatigue is very difficult to observe and analyze. According to one expert, pilot fatigue, “… must be inferred from a variety of factors such as the time an accident occurred and the pilot’s 72-hour history …

In addition, other issues such as work tempo, experience, and flight duration may also come into play, all of which make any determination of pilot fatigue an inexact science at best” (Wiegman, 2003). A metal fatigue in the fuselage of the airplane can be studies using highly-sophisticated equipment but human factors could only be studied using inferences and other inexact sciences. This does not mean that the study of pilot error and pilot fatigue was left to guesswork. There are numerous studies geared towards understanding this phenomenon.

It is common knowledge that there are periods of sleepiness and low motivation especially during predawn and midafternoon (Miller, 2001). But to this general idea modern aviators and operators can add the more sophisticated information regarding the human circadian and circasemidian rhythms that actually cause a two-peak daily pattern in accidents and incidents (Miller, 2001). This simply means that there are two periods in a 24-hour cycle when men and women are sluggish and slow to respond. These are the times when humans are supposed to be taking a nap or in deep slumber.

In a study conducted in a Swedish gas company where workers performance was monitored over a 20-year period, it was discovered that majority of the errors were made between 1 A. M. and 2 A. M. (Miller, 2001) A much smaller peak in errors occurred during the afternoon hours between 1 and 3 P. M. (Miller, 2001). Even a non-scientist can confirm these conclusions. It is common knowledge that during these time periods it is best to take a break from work, and during nighttime it is best to be in bed resting rather than moving about doing complex tasks.

There are other studies made that will corroborate these results. For instance in a research focused on vehicle crashes it was discovered that a high percentage of vehicular accidents where there is no mechanical failure and no alcohol or substance-related causal factors occurred between midnight and 6 A. M. and also between 1 and 4 P. M. (Miller, 2001). These results could no longer be attributed to chance and that there is a growing evidence that there is something in the biological make-up of a man or a woman that make them susceptible to sleep and sluggishness during these time periods. Aviation Accidents

The best way to illustrate the impact of the daily two-peak pattern of errors is to examine the numerous accidents related to pilot error during time periods when he or she was supposed to be resting and not doing highly complicated tasks. The first accident that will be analyzed is the one that occurred in runway 02 at the Springfiled-Branson regional airport at Kansas City, Missouri. The pilot was on his last flight leg for the evening and he was cleared for an instrument landing system (ILS) approach (Miller, 2001 ) The aircraft was not able to reach its final destination and crashed about a mile short of the runway.

Later investigation revealed that there was an error in his altimeter settings making the aircraft fly lower than where it was supposed to be. An interview made concerning the accident yielded the information that the pilot was observed to be very tired and fatigued before the flight (Miller, 2001). The more revealing information was that the accident occurred at 4:36 A. M. In another example of pilot error linked to pilot fatigue, a Bombardier CL-600 en route to Honolulu to Hilo, Hawaii flew past the intended destination (Welferman, 2008).

Air traffic control tried in vain to contact the flight crew. The airplane operated by Mesa Airlines, flew 48 kilometers past Hilo, Hawaii. Then all of a sudden the crew was able to contact air traffic control and safely landed the plane. Later investigation revealed that both pilots fell asleep at the same time. Preliminary investigation also revealed that both pilots were on the third day of a very physically demanding schedule (Welferman, 2008). It was also discovered that one of the pilots was suffering from sleep apnea making it very hard for him to get quality sleep.

In another accident involving one of the planes operated by Shuttle America the Delta Connection Embraer ERJ-170 ran off the end of a runway at Cleveland Hopkins International Airport (Welferman, 2008). The plane was substantially damaged and the investigation revealed that the pilot, “…had been suffering from intermittent insomnia during the months preceding the accident” and that he did not remove himself form duty because he was afraid that he would have been fired if he reported his problem (Welferman, 2008).

The fear of reprisal must be noted as the main reason why pilots will not initiate a fatigue-management protocol. Their weakness can be perceived as a flaw that will cost them their jobs. It is now made clear that long flights and a continuous work schedule that does not permit adequate rests will result in pilot fatigue that will greatly affect his or her performance. There is enough evidence to prove that after working long hours the negative consequences of such behavior will become evident during between midnight and 6 A. M. where the human body is at its lowest point and craving for sleep and rest.

Therefore, airline operators must be mindful regarding how they create flight schedules and distribute workloads among their pilots. Impact of Technology The rapid development of technology in the 20th century benefited the aviation industry. This is especially true in the advent of highly advanced electronics and computers. This paved the way for the upgrading of the cockpit that led one commentator to remark that there is now more risks involve in flying a commercial airline as compared to flying an aircraft created a few decades earlier.

As a result the impact of technology when it comes to pilot fatigue is not always positive. While automation and high-tech gadgets made flying very easy in the 21st century, the same advancements in technology makes it hard for pilots to stay awake especially during ultra-long flights. On the other side of the coin technological advancements in aviation makes it doubly hard for pilots to manage the cockpit and the numerous devices that require focused attention.

This led many to remark, “Aviation designers were beginning to see that technology was reaching a point where the man-machine mix would require greater attention” (Kern, 2001). The degree of concentration required to monitor these systems is greater in modern aircraft as compared to older models where everything is manually operated and that will only require the pilot to focus on a few levers and gauges. Based on the aforementioned discussion, there are two ways to link technology, pilot fatigue and pilot error: 1. The inadvertent effect of automation to pilot error and pilot fatigue.

2. Technology can be used to monitor pilot error and pilot fatigue. There is a correlation between these factors and will be expounded in the following pages. First of all there is a need to understand the evolution of technology not only in the creation of faster and bigger airplanes but also in the technology that would make it easier to fly one. Since the modern age of aviation began the quest to build bigger and better planes was not limited to the engine or fuselage of the aircraft but also the technology that would make it easier for pilots to control the huge aircraft.

With the advent of advanced electronics, the cockpit is no longer a cocoon filled with simple levers and gauges it is now an area filled with complicated computer systems that require the utmost attention of the pilot. While technology is a useful tool to improve efficiency there were inadvertent effects of cutting-edge technology to the performance of pilots. These can be described as increasing the impact of fatigue due to the need to monitor complex systems as well as the boredom generated from using fully automated systems.

According to one source, “Automation has gotten to the point where there is often little or nothing for the modern flight crew to do other than to monitor the computerized systems” (Kern, 2001). This can be likened to someone driving on the freeway with cruise control, there is nothing left to do and therefore increase the probability that the driver will fall asleep at the wheel. But there is also another side to technology because it can also be used to prevent pilot error.

Technology such as computer databases can be used to monitor and gather data that in turn can be utilized later to analyze and prevent pilot error. Computer databases can collect, organize, and retrieve data for investigators. A careful analysis of the information will reveal a pattern that the investigators will be able to link to the accident. A human brain is a complex organ that can be trained to do complex computations but only a computer can record voluminous data that seems to be of no relevance at the moment and yet will prove to be very useful later on.

The computer cannot do the analysis but it can help retrieve the data accurately when needed. Reducing Incidence of Accidents Sturgell summed up what needs to be done in terms of dealing with pilot error and pilot fatigue when he made the assertion that operators need to establish fatigue management systems and to develop steps that will continually assess their ability to, “… improve sleep and alertness, mitigate performance errors and prevent accidents and incidents” (Werfelman, 2008). The U. S.

National Transportation Safety Board (NTSB) defines fatigue management systems as, “…incorporating various fatigue-management strategies including scheduling practices, attendance policies, education, medical screening and treatment, ‘personal responsibility during non-work periods’, task/workload issues, rest environments, commuting policies, and/or napping policies” (Wefelman, 2008). This is a long list of things to accomplish and it has to start with a clear understanding of pilot fatigue and what can be done to create a system that will give advance warnings to operators and flight crews.

There is indeed a definite need to develop fatigue management systems but this is easier said than done. The first major roadblock is the nature of the problem itself. Pilot fatigue is very difficult to quantify and therefore extremely difficult to measure. A system can be put in place where the computer can alert the pilot if there is a mechanical problem within the engine of the plane but what kind of system can be installed that will alert the crew that the captain is about to doze off? What exacerbate the problem are the limited resources allotted by operators to solve the problem.

According to one study when it comes to the investigation concerning the engineering aspect of the accident there are numerous technical experts that can lend their skills and experience in analyzing what went wrong but there will only be a few human factors professionals who can be expected to give their expert opinion regarding the cause of the accident. This led one investigator to exclaim, “What makes matter worse is that unlike the tangible and quantifiable evidence surrounding mechanical failures, the evidence and causes of human error are generally qualitative and elusive” (Wiegman, 2003).

Increasing the number of human factors expert will not solve the problem because one has to be not only knowledgeable about a one aspect of aviation engineering but also with regards to human behavior etc. Aside from the above-mentioned concerns there is a need to contend with the culture existing in the workplace. How can pilot fatigue be reported and analyzed without the fear of reprisals from the management? In one example an operator was able to establish a system that was able to encourage workers to monitor pilot fatigue with, “…a just safety culture and non-punitive safety reporting” (Werfelman, 2008) was used in one airline company.

This is very much needed as seen in the aforementioned case where the pilot did not inform management of his problems with insomnia. Due to his fear of losing his job, he created an incident where people were about to lose their lives. Aside from dealing with the fatigue factor and the creation of systems that will mitigate pilot error due to fatigue, there is also a need to improve the way computer systems are currently used in the cockpit. Charles Billings an aviation human factors expert who works for the FAA, “…

points to the dangers of over-automation without addressing the potential consequences” (Kern, 2001). One example given by Billings was the Korean Airlines Flight 007 which ventured far into Russian airspace as the result of pilot error due to improper inputs into the flight system (Kern, 2001) In this case there is a clear need for a back-up system where another flight crew is given the capability to countercheck the inputs made by the other pilot. There is a need to review the over-reliance on automation because the results can be deadly.

The aforementioned Korean Airlines Flight 007 was shot down by a Russian fighter jet (Kern, 2001). The tragic accident should be a wake-up call for aircraft builders to find a way for automated systems to truly improve the efficiency of pilots and not to magnify their errors. This is because in an automated system, a slight error is amplified due to the reliance of the computer on the data given earlier. A human brain does not work that way, a human pilot is able to see the whole picture. In the Korean Airlines tragedy the computer is oblivious to the idea of politics and ideology.

As long as the data encoded into the computer was accepted by the system it will continue to lead the airplane towards those coordinates irregardless if it means flying over enemy territory. In this regard safety experts recommend the overhaul of policies concerning flight scheduling etc. Using the information gleaned from the study of human circadian and circasemidian rhythms, operators must take a closer look at the flight legs that are most vulnerable to drowsiness and inattention (Miller, 2001).

A system must be put in place where the flight crew will be trained to work together and develop skills necessary to combat lethargy and drowsiness. Pilots must double-check the work of other pilots during these periods where they are vulnerable to the impact of their bio-rhythms. Conclusion Fear of flying is common around the world. There are many men and women who would rather go to the dentist and subject themselves to a painful medical operation such as a root canal rather than fly over long distances.

Fear of heights can be one explanation for this problem but it is also possible that their knowledge of flight accidents made them paranoid and unable to trust statistics that pointed out the low incidence of accidents in the airline industry. Yet accidents do occur and there is no operator in this planet that can guarantee a 100% safe flight. In a closer examination of accidents and incidents that occur in recent years, it will be revealed that there is a correlation between pilot error, pilot fatigue, and highly-advanced technology.

At first it is hard to understand why technological breakthroughs in terms of aircraft design and aircraft equipment can lead to accidents. But the numerous studies conducted to analyze accidents in the aviation industry pointed out that pilot fatigue is the major cause of pilot error and that pilot error can be magnified in an environment that uses highly advanced computerized systems. According to one researcher, “In some ways, we are primitive beings who operate very demanding systems, the designs of which do not account for biology” (Miller, 2001).

Computers can work 24 hours a day but the human body requires sleep and rest. Pilot fatigue is caused by overwork. The pilot’s inability to say no to the pressures of a very demanding job will take its toll. This is exacerbated by the pressure coming from the need to perform as part of the requirements of promotion and job security. Thus, an airline pilot could not use the excuse of insomnia or the lack of sleep due to family problems in order to provide him or her, the much needed respite. This may cause the pilot his or her job.

The impact of globalization and increase in competition will force operators to schedule flights that would occur during the time period when the human body is at its most vulnerable to sleep and sluggishness. There is therefore a need for operators to fully understand the impact of the biorhythms of the human body. Just like what one expert said, humans thought that sleep can be controlled whereas evidence shows that the body follows a strict schedule. Even if it was the intention of the pilot to stay awake for 24 hours his or her body will not permit him to push it to the limit.

One way or another, the body will compensate for the lack of sleep and so there are cases where the pilots fell asleep while in flight. They were unaware that they were sleeping while a multi-million dollar equipment is flying unguided through the air. They place their passengers in serious risk and yet they are unwilling to report their problems to the management. It is at this point where operators must consider developing a fatigue-management systems that will not only focus on preventing pilot fatigue but also to encourage flight crews to report their problems concerning rest and sleeping patterns without fear of reprisals.

It is only through this system where they can truly gather and analyze data that will help them create an effective plan to mitigate the impact of pilot error and pilot fatigue. There is also a need to review the impact of automation when it comes to pilot error and pilot fatigue. On one hand automation makes their job easier and most importantly allows the pilot to fly their massive aircraft even through poor visibility. These computer systems allow them to land gigantic airplanes even if the weather outside makes it difficult for ordinary airplanes to negotiate.

But on the flip side automation leaves the actual flying to the machines and requires very little work from the pilots. It is at this point when an inactive mind can easily doze off without prior warning. While technology can have a downside it must also be pointed out that technology can also be used to combat the effects of pilot fatigue. A database can be established to gather data from flight schedules to the pilot’s workload. Data from previous accidents can also be encoded into these databases. The information gathered can be used to create a fatigue-management system that incorporates everything gleaned from the archived information.

Thus one can clearly see the irony that technology can both aid and hurt the pilot in his or her quest to improve flight safety. This leads the discussion back to the core issue which is awareness of the impact of the biorhythms of the human body. Flight crews must take the recommendations of various studies pointing to the great risk of working overtime and scheduling flights during the critical periods of the circadian and circasemidian cycle. It is better for operators to refrain scheduling flights between 1 A. M. to 4 A. M. where peak errors was consistently reported in numerous studies.

On the other hand it must also be acknowledged that due to globalization and intense competition in the global market it is impossible not to schedule flights during these time period. Therefore it is best to create a system that will increase the vigilance of the flight crews assigned during these critical periods. Aside from issuing a directive to be extra-careful during these times there must also be a protocol in place where flight crews will double-check each other’s work between midnight and 6 A. M. It is only through this practice where they can ensure that no one doing something that will jeopardize the whole flight.

This recommendation is highly applicable to the pilot and co-pilot. They must work in tandem, watching each others back so to speak during these critical periods when they are forced to fly past midnight. References Kern, A. (2001). Controlling Pilot Error. New York: McGraw-Hill. Miller, J. (2001). Controlling Pilot Error Series: Fatigue. New York: McGraw-Hill. Werfelman, L. (2008). The Science of Fatigue. AeroSafety World. Wiegmann, D. & S. A. Shappell. (2003). A Human Error Approach to Aviation Accident Analysis. Burlington, VT: Ashgate Publishing.


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