Confidential Human Factors

Incident Reporting Programme

Submit Report

The Charity

Aviation

Maritime

The Charity

Aviation

Maritime

Submit Report

FEEDBACK

CCFB 83

Report it, to sort it.

In July 2001, the CHIRP (Confidential Human Factors Incident Reporting Programme) cabin crew programme was launched. Among the initial reports received was one titled ‘Pressure to Operate’, alongside others such as ‘Long Duty Day’, ‘Sickness in Cabin Crew’, and ‘Intimidation by Management’. Twenty-three years later, has anything changed in aviation?

We are human, and the challenges faced by cabin crew persist; shift working, eating at irregular times, resting in unfamiliar hotel rooms etc. remain; as humans we are susceptible to things such as stress, fatigue, pressure, and distraction — just four of the most recognised twelve elements that contribute to human errors and can act as precursors to accidents or incidents.

So what can we do to help ourselves and being human? How can we prevent the holes in James Reason’s Swiss Cheese Model from lining up?  We can submit safety-related reports! Report your concerns, whether it’s something that has happened or may happen report it, CHIRPs motto is ‘You report it, we help sort it’ but that also goes for reporting internally to your company. How can an operator know of a potential safety concern if no-one is telling them about it? Absence management programmes, temporary contracts, probation periods, and pay deductions are often cited as reasons why cabin crew members hesitate to report their safety concerns as well as illness and/or fatigue. Without reporting safety concerns, mishaps, and near-misses, nothing is likely to change. Operators rely on safety reports for their safety management systems (SMS) to function effectively, it lets them know what is happening out on the line, just as they need fatigue reports to identify roster stability and if certain routes are contributing to crew fatigue.

Remember, any crew member can report a safety concern internally (or to CHIRP); it is not restricted to just senior cabin crew and pilots.  Some SMS don’t send a response to a report, which is not unusual, but this does not mean your concerns are being ignored or that nothing will change.  A decline in reports could signal to your operator that a safety concern has been resolved. If you are still concerned, report it.  If you don’t feel able to, we are here for you and are ready to receive your report.

Maintaining a just culture of reporting is crucial for ongoing safety improvements. Encouraging open communication and addressing the root causes—such as fatigue, stress, and the reluctance to report illness — will lead to a safer, healthier working environment for everyone onboard.

Stay safe,

Jennifer Curran

 

  • CC6468

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    On-time departure pressures put on SCCMs
    On-time departure pressures put on SCCMs

    Initial Report

    Boarded the aircraft following the company’s SOP to ensure we departed on time. Caterers were still loading, we were unable to start boarding due to the safety implications of trolleys and canisters blocking emergency exits. During our SEP/Security checks, one crew member immediately informed me that a forward stowage was faulty and they couldn’t complete their security check. I asked for an engineer to attend to fix the stowage. The engineer arrived very early on and fixed the issue enabling my crew member to conduct their security check. We started boarding which was slow at first due to boarding lots of PRM pax and the flight being nearly full.

    Once I checked into my hotel after a long duty day I was greeted by an email from the office asking me to explain why we had a 4-minute delay which had been attributed to cabin crew. Followed by another email requesting for me to call into the office again to explain why I had 2 delays attributed to the cabin crew.  Both were due to safety issues and I spent lots of my rest period trying to find out why this flight had a delay put down to the cabin crew, it transpired that it was because I had asked for engineering support. This practice can potentially cause SCCM to cut corners and think twice about asking for engineering support. Please note this is added to our files and could have detrimental consequences to SCCMs moving forward.

    CHIRP Comment

    CHIRP was advised that some of the points in the company comment have only recently been included in the internal communications, these changes may have been as a result of internal reporting.

    It is commercially important that operators monitor timings, this reporter’s concerns however are related to the communication between the reporter and the company. Whatever your safety concerns are please report them to your operator, without reports and the data gathered from these reports other internal teams cannot make the appropriate/required changes/improvements. The more information you can include in your report the better, if a report doesn’t contain any information then contact from the management team is usually to establish delay codes. As stated in the company comment above there are no punitive actions associated with the follow up.

     

  • CC6572

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    Operated a flight with 6 crew, the minimum is 8
    Operated a flight with 6 crew, the minimum is 8

    Initial Report

    We had an incident where two crew members were not fit for flight two hours before check out in AAA.

    We thought we would need to stay or not be able to operate the flight back as we were 8 cabin crew reduced to 6. The manual said it was a minimum of 7 cabin crew on the aircraft that we flew back on. It also mentioned about it being 50 pax per crew member. We had around 230 passengers.

    We got told that it had been approved by the UK CAA to fly back with this amount of crew.

    We had check out delayed and flight delayed by around two hours while this was being decided.

    The flight went okay but safety wise this didn’t feel that great. If anything were to go wrong there was a lot less of us to evacuate or deal with emergency/medical situations.

    CHIRP Comment

    The operator’s manual (OM) should contain a process for reducing the crew complement in certain situations and these dispensations are all about managing risk. The flight reported operated in accordance with the regulations and if the OM stated so, may have been reduced further by one more crew member (230 passengers to 5 crew).

    After an event such as this, a Mandatory Occurrence Report (MOR) must be completed by the flight crew to advise the CAA of the event.

    ‘Unforeseen’ allows an operator to return an aeroplane to a base from a layover/turnaround destination (where a replacement cabin crew member is not available) this is for unforeseen circumstances only and not for ‘planned’ or a known eventuality where-by the operator has time to position a replacement crew member.

    ORO.CC.205 Reduction of the number of cabin crew members during ground operations and in unforeseen circumstances


    (b) By way of derogation from point (a), the minimum number of cabin crew members may be reduced in either of the following cases:

    (1)  during normal ground operations not involving refuelling or defuelling when the aircraft is at its parking station;


    (3)  at least one cabin crew member is required for every 50, or fraction of 50, passengers present on the same deck of the aircraft;


    For the full regulations please click on this link ORO.CC.205 Reduction of the number of cabin crew members during ground operations and in unforeseen circumstances (caa.co.uk)

  • FC5332(C)

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    Fitness to fly
    Fitness to fly

    Initial Report

    As a Commander, in recent months I have had to offload crew members on 3 occasions due to being unfit to fly, both pilots and cabin crew. On all occasions it was due to cold symptoms, which whilst weren’t that obvious at report time, manifested themselves throughout the subsequent sectors leading to an offload part way through the day.

    There are 3 issues I feel need addressing; Commanders responsibility for crew members fitness to fly. Assessing a crew members fitness is subjective, as a cold can vary in severity and can be hidden well during the briefing. Asking the crew member if they are ft will inevitably lead to a ‘yes’ – and as captains are not doctors it is difficult to make a judgement. We need clear guidance from the Company that the Commander’s decision will be final and non-punitive to both parties.

    1. Perceived pressures from the Company. While the Company says it has a sickness policy and crew will be paid, cabin crew in particular will not receive any extra remuneration for the duty if they are sick – and this was quoted to me as a reason for not calling sick for the duty as ‘they didn’t have many hours that month as it was and couldn’t afford it’. There is also the threat of an interrogation from management depending on the individuals sickness record. The Commander is then under considerable pressure and may have to argue with a crew who may consider themselves ft even when they are clearly not – but as before this is subjective.
    2. Inadequate education of crew on the risks of flying while unfit. In the case of the pilot offload, he was unaware that flying with blocked ears could have serious consequences when it comes to burst eardrums etc. I feel that time should be spent during initial training/induction establishing the company culture re sickness and how various ailments that might be mild on the ground can be very different in the air.
    3. The Company often stays quiet on such matters as they obviously don’t want to ‘encourage’ sickness, but I have seen a definite trend of crew reporting when unfit and offloads during the duty, which creates additional problems.

    CHIRP Comment

    CHIRP Cabin Crew Advisory Board Comment –

    If you are feeling unwell, please consider; Am I fit to do my job for the whole duty? What’s the impact of me operating when I’m not fit to do so? What effect will flying have on my health, since it could exacerbate an existing illness? Don’t expect your SCCM or Captain to make the decision for you, if you are offloaded the duty will depending on your operator probably still be classed as an absence. As the reporter states ‘Captains are not doctors’, it is a personal assessment to evaluate whether or not you are ‘fit’ to operate as cabin crew.

    The CAA stipulates in MED.A.020 Decrease in medical fitness: Cabin crew members shall not perform duties on an aircraft and, where applicable, shall not exercise the privileges of their cabin crew attestation when they are aware of any decrease in their medical fitness, to the extent that this condition might render them unable to discharge their safety duties and responsibilities.

    Sickness and absence days are routinely tracked (as is customary in all businesses) and operators will have various policies, which are detailed in your terms and conditions. Both cabin crew and flight crew can feel pressurised to operate when they are feeling unwell and CHIRP frequently receives reports related to sickness policies and this topic was also discussed in the editorial of CCFB edition 79. CHIRP has expressed and will continue to voice its concerns to the UK CAA regarding absence policies.

    CHIRP Air Transport Advisory Board Comment – 

    Although fitness to operate is a personal obligation, as the ultimate arbiter for the safety of the flight, CHIRP feels that captains clearly have an operational and moral responsibility as the final barrier not just for the safety of the operation but also to save people from themselves or deal with situations when they don’t realise they are unfit to operate – ultimately, peoples’ fitness to operate has relevance not only to the flight’s safety if they can’t conduct their duties but also for their personal safety and well-being. That being said, captains offloading crew members if they suspect they are unfit to fly must be done circumspectly given that captains are not specifically qualified to make such decisions for others. If someone is clearly not functioning well enough then that’s one thing, but if someone is just a bit ‘under the weather’ or has a minor ailment that they are happy to continue with but the captain is not, there is potential for all sorts of disputes about medical judgements. In this respect, it’s important that captains are supported by medical help and guidance. There are various third-party medical services that some airlines subscribe to depending on their chosen provider, and these are important sources of professional assistance in supporting the decisions made by captains so that they don’t have to shoulder the burden themselves when things may not be clear-cut. Aeromedical physiology is an element of pilot education and licencing so we’re genuinely surprised that a pilot would not know about the risks of flying with a cold. Cabin Crew are not licenced and their aeromedical training varies from company to company but, although they might perhaps not have the same level of knowledge, they should also be well aware of the risks of flying with colds etc. A minor snuffle might not be a significant risk, but operating with a heavy cold would of course not be a good idea. Ultimately, we acknowledge that there are huge financial and perceived adverse company policy pressures on crews to fly if they are unfit and so third-party oversight from captains is appropriate in applicable circumstances and must be supported by the companies.

     

  • CC6471

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    Pressure to depart from home base in discretion
    Pressure to depart from home base in discretion

    Initial Report

    Flight departing from base was delayed due to a technical issue. I was called from standby to join the crew. Extended delay and heat on aircraft meant that the food was no longer deemed safe for consumption for both crew and all passengers. Nobody wanted to inform passengers of this. The aircraft was reading 44 degrees Celsius in the cabin whilst the crew completed their security checks, we were delayed on the aircraft awaiting engineer sign off. The crew were hungry with no food and uncomfortable from having to stay in the heat. Flight Crew went into discretion and for some reason were adamant on the flight departing still.

    As I was called from standby I went into discretion first. Suddenly a new flight plan reduces the flight time by 30 minutes so we had more hours to work. None of the cabin crew were asked in a way or in a place where they felt safe and able to make an honest decision about working into discretion. It seemed like it was decided for us all to go into discretion. Passengers started boarding and halfway through boarding, the SCCM came round and asked crew members if they were happy to operate in discretion. We were all already in discretion and half the passengers had boarded so we all felt unable to say no we are not happy. We were tired and hungry with no access to food. The cabin was still quite hot too. Flight Crew didn’t ask cabin crew how they were feeling. There was no duty of care for the cabin crew. My boarding position was in the cabin, in front of passengers so I did not feel able to say I was not happy to operate into discretion (even though I was already in discretion at this point). While the SCCM asked me if I was happy to operate into discretion, she said “if you’re not, then you need to go and talk to the Captain”. No cabin crew felt able to say no. It did not feel like we had a choice to say no.

    During boarding, two passengers heavily under the influence had to be offloaded. Crew made the decision we did not want to travel with them as we had no food to sober them up and we didn’t want a situation on board. Police had to be called and their hold bags offloaded which caused further delay. The pressure from both Flight Crew and SCCM to operate into discretion was overwhelming. It felt like we were all being manipulated to operate well into discretion.

    CHIRP Comment

    On 24th August 2023, the UK CAA sent an open letter to all operators about Commander’s Discretion, the letter in full can be viewed here on the CHIRP website https://chirp.co.uk/hot-topic/commanders-discretion/

    Commander’s discretion may be used to modify the limits on the maximum daily FDP (basic or with extension due to in-flight rest), duty and rest periods in the case of unforeseen circumstances in flight operations beyond the operator’s control, which start at or after the reporting time regardless of being at base or not.

    UK Reg (EU) No.965/2012 AMC1 ORO.FTL.2059(f) comments on the “
shared responsibility of management, flight and cabin crew
” and that consideration should be taken of “individual conditions of affected crew members
”. Regulation does not state how the Captain should consult their crew or whether this should be conducted face-to-face, individually or as a whole crew. The reporter raises that they felt there was no duty of care from the Commander, onboard the aircraft we are a team, the flight crew at this point may have been very busy dealing with the technical issue and so it is appropriate that the SCCM was tasked with liaising with the crew. The reporter also states that they were consulted by the SCCM in front of the passengers, if possible, any questions of this nature should not be asked in front of the passengers for them to overhear. Although you may feel that there is pressure to operate,  you must speak up if you feel that you will not be able to perform the duties that are required of you for the duty.

    When you report for a duty, you should be mindful that there is often disruption and that you may end up operating to your max FDP on that day up to and including discretion. However, if you are feeling the effects of tiredness and are unable to complete your duty then you must communicate this to your SCCM and the Commander.

     

  • CC6577

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    Delayed Report Confusion.
    Delayed Report Confusion.

    Initial Report

    I feel like I’ve been coerced into operating today. My report was 1300z, but the flight was delayed.

    Crewing said they left me a voicemail at 1100Z, but I didn’t receive this. I later found out that my phone network was having nationwide issues (I’ve screenshotted the tweet as I don’t think crewing believed me). Crewing told me that they have made reasonable attempts to inform me of the delay so it’s on my shoulders.

    I rang them just after my report time to tell them I had just picked up Wi-Fi and been made aware of the delay, they then changed my report time to one hour later to protect my duty hours. I emailed them and had my original report time reinstated. When the rest of the crew arrived, the captain told me I would not be legal to fly home. Crewing told him that if I “refuse the duty”, and they await a standby, the flight would be further delayed and it was “on his head” (mine). I felt coerced into operating and deeply upset.

    On the return sector, the pilot told me he’d use the rest of the crew’s report time for my hours and I am no longer in discretion, disregarding my original report time which I arrived for.

    Captain told me I ought to be contactable 24 hours a day and crewing said they don’t need me to acknowledge a delay for them to have “done their bit”.

    Further to this, my roster app which ‘pings’ a delay had signed me out without my knowledge, so this line of communication didn’t happen either. The captain said I should have been contactable and I ought to ring crewing before every duty to ascertain if the flight is on time.

    I don’t feel I should be calling crewing on my rest time to check if flights are on time.

    CHIRP Comment

    It is disappointing that this reporter felt ‘coerced’ into operating and some of the comments made by their colleagues made are incorrect and inappropriate, generally cabin crew are not required to be ‘contactable 24 hours a day’.

    ORO.FTL.105 Definitions (23) ‘single day free of duty’ means, for the purpose of complying with the provisions of Council Directive 2000/79/EC, a time free of all duties and standby consisting of one day and two local nights, which is notified in advance. A rest period may be included as part of the single day free of duty;

    CS FTL.1.205 Flight duty period

     (d) Unforeseen circumstances in flight operations — delayed reporting

    1. The operator may delay the reporting time in the event of unforeseen circumstances
 Delayed reporting procedures establish a notification time allowing a crew member to remain in his/her suitable accommodation when the delayed reporting procedure is activated.

    When a crew member does not receive the notification and is therefore not in ‘his/her suitable accommodation when the delayed reporting procedure is activated’ then the report time used should be the original report time.

    Reporting concerns internally is crucial so that any issues may be fully investigated and addressed within the Safety Management System (SMS) and prevented from happening again.

     

  • CC6507

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    Briefing Down-route
    Briefing Down-route

    Initial Report

    Down-route the expectation has always been that we give a pre-flight brief on the bus.

    The company details in the operations manual a lengthy list of what is to be discussed with the crew prior to the inbound flight.

    I’ve written to the company and the union stating that the bus is not safe, I have highlighted that the bus is moving and the transport is up against time and we are officially on duty 1 hr before departure. Crew are spread out over a large bus, the lights can be turned off and pitch black, crew can’t be seen as they are all spread out and some wear ear pods and basically aren’t listening. The bus will not wait for me to give a brief and I should not be expected to stand, kneel on a seat or shout down a bus/coach to my crew to deliver an effective, safe briefing. If I was to fall the company would ask why was I not seated with my seat belt on if I was injured and I’m certainly not twisting my back or neck to turn around or shout down the length of a bus/coach.

    When I emailed the company, I explained my concerns about delivering the inbound briefing and where I’m expected to do it? Their reply was I could ask the crew to come down before report time! This is an absolute No! We were operating home on a different aircraft type so change of working positions and I should have been asking new SEP questions relevant to aircraft type.

    The point of all this is, there is no time allocated to conduct a briefing, my operator doesn’t want to change the report time because it will increase FDP eating into our 900 hrs and probably trigger additional costs to the company.

    CHIRP Comment

    An appropriate area and sufficient time should be allocated to brief the crew as required in the operators manual, if that time is not allocated, then the SSCM should conduct the briefing as required and be sure to document the incurred delay allowing the operator to investigate this specific instance. There may be occasions where the bus is an appropriate place to conduct a briefing and a suitable use of time. From a health and safety aspect crew should not be stood up or kneeling on seats on the bus to address the crew, they should be sat facing forwards and wearing a seatbelt if one is supplied.

    There is a review on UK FTLs (flight time limitations) currently taking place by the CAA, this review will include looking at the impact of things such as car parking locations, briefing times etc. have on FTLs, not just at base but down-route as well.

  • FC5322(C)

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    Operating pressures
    Operating pressures

    Initial Report

    As a Commander, I have been told by the cabin crew numerous times that they skip their meals until reaching daily sales target limit. If not reached, they are being called by the company or management to explain why they haven’t sold as much as planned.

    Constant fear is present among the crew as they think they will be fired. Same issue with the commander’s discretion. Most of the cabin crew will never report fatigue as they are scared for their job. One of the colleagues was called for a meeting after stating that she would not be able to continue her duty and threatened to be fired if it happens again. This is totally unacceptable, illegal and shows pure example of misuse of commander’s discretion.

    I, find this practice by my operator extremely unsafe. Safety should always be top priority, and not the profit. I don’t even want to imagine an incident or accident happening with my crew not feeling 100% ready because they didn’t eat as sales target had to be reached first.

    CHIRP Comment

    Cabin crew are on board primarily for safety and if you have not had your meal break, then you must speak up and inform the SCCM, the SCCM is responsible for managing the breaks on board and adapting the service if these breaks have not been achieved.

    ORO.FTL.240 Nutrition

    (a)  During the FDP there shall be the opportunity for a meal and drink in order to avoid any detriment to a crew member’s performance, especially when the FDP exceeds 6 hours.

    (b)  An operator shall specify in its operations manual how the crew member’s nutrition during FDP is ensured.

    The nourishment required from these breaks includes hydration, and not eating and/or drinking properly throughout the day will exacerbate the symptoms and feelings of tiredness, possibly leading to fatigue. One of the most common key-issue safety concerns that people report to CHIRP is ‘pressure’.  When targets are set, whether they are based on sales or Key Performance Indicators (KPIs), pressure can be felt to meet them, particularly when they are financially connected. Nevertheless, whether the pressure is real or perceived, the crew should not be skipping nourishing meal breaks.

    The reporter remarks that the crew ‘think they will be fired’, this practice, if true, goes against the principles of a just culture. All crew should feel empowered to report their safety concerns, be they the reason that they failed to meet a sales target or because they are fatigued.