ATFB 143

You report it, we help sort it

Reporting can sometimes be an issue, which is why CHIRP aims to bring concerns into the open through its independent, confidential process.

This year is the 40th anniversary of the CHIRP aviation programme and so perhaps a good opportunity to reflect on what it’s all about and how it’s been going. Although commercial air transport accident rates are extremely low, they have remained relatively constant over the past few decades and a major challenge for the air transport industry has been to develop and promote effective processes to identify key causal factors that in some circumstances might lead to an accident, before the accident occurs. Reports fall into two broad categories; those indicative of an undesirable trend, and those detailing discrete safety-related events, occurrences or issues. As part of this, since its inception, CHIRP’s role has been to improve the quality of feedback from the professional groups involved in air transport operations not just through the reporting of incidents but also the reporting of things that nearly happened (but were averted or didn’t develop into a reportable incident) in order to provide additional important information related to contributory causal factors.

Importantly, although mandatory reporting systems make an essential contribution to the feedback process, for many reasons they are less successful in gaining information on human factors related aspects due to individuals’ concerns about the personal implications of submitting reports that may be critical of their companies or superiors. Confidential human factors reporting systems were introduced to address this. It is important to understand that the confidentiality part applies to the identity of the reporter not the information; whenever possible the latter is disseminated as widely as possible, but in a disidentified manner so that the reporter cannot be recognized, and only with the reporter’s consent.

A confidential reporting system permits individuals who are working within the aviation system to report safety-related matters that they might not report through other ‘open’ systems.  Reporting directly to an organisation such as CHIRP that is totally independent of the operational management and regulatory agencies allows reporters to describe the issue in their own words and ensures that reports are received without being filtered in any way. More importantly, the confidential process permits the non-attributable reporting of deficiencies and discrepancies that may result from, or cause, human errors without exposing the reporter or other individuals within the system to critical judgement or the attachment of blame. On the other side of the coin, for companies and organisations, confidential reports provide a source of non-attributable safety information to safety management and regulatory agencies that otherwise would probably not be available. This type of information often provides organisations with early warning precursor alerts of potential problems, or substantiates other sources of information.

Within this, our mission at CHIRP – the ‘what’ – is to help improve aviation and maritime safety and build a Just Culture by managing an independent and influential programme for the confidential reporting of human factors-related safety issues. Our desired strategic outcomes – the ‘why’ – are:

  • better leadership, awareness and attitude towards safety issues;
  • improve safety culture by changing behaviours, so that practices, processes and procedures are as safe as they can be; and
  • that safety outcomes identified in CHIRP reports are adopted by regulators, managers and individuals.

With regard to Just Culture, nobody comes to work intending to fail: mistakes & errors are part of the human condition.  However, sometimes people should have known better (unprofessional), could have known better (training), or may have intentionally broken the rules with good or bad intentions.  These aspects all need to be taken into account when reviewing people’s actions in any incident or event. CHIRP’s four key principles of operation are:

  • VOLUNTARY – Voluntarily submission of reports concerning events related to safety for the purpose of system alerting, understanding and learning.
  • CONFIDENTIAL – Protection of identity through disidentification of persons, companies, and any other identifying information.
  • INDEPENDENT – Trusted, unbiased dissemination of safety information and advice.
  • JUST CULTURE – Non-judgemental safety net for reporting occurrences that might not otherwise be reported.

With the widespread introduction of additional safety processes such as company ‘open’ reporting schemes, Flight Operations Data Monitoring programmes and Line Operations Safety Audits, it might be questioned whether there is a continuing need for an independent confidential reporting system when other avenues are apparently more readily available. However, the evidence from mature confidential systems is that reporters prefer to raise some safety-related issues on a confidential basis; this is demonstrated by the fact that despite the increased availability of alternative reporting methods, the number of confidential reports submitted per annum has remained essentially the same or increased over the past ten years (the 2 years of COVID-19 hiatus in aviation activities excepted). The key is that an integrated approach is essential to ensure that human performance and environmental information are appropriately and fairly coupled with technical/operational data because although data/event logging provides insights into human actions and ‘what happened’ it does not inform as to ‘why’ an event occurred, any pertaining external influences and distractions, or an individual’s capabilities and remaining capacity at the time.

A few words of caution though, the reports that CHIRP receives represent a fairly small statistical sample and so we should be careful about reading too much into them. Also, CHIRP obviously receives reports that are generally critical of things that have gone wrong and so there is a bias towards negativity that might not reflect the majority experience.

The top-15 key issues reported to CHIRP by Flight Crew over the last 12 months have seen Company Policies and Culture; Duties and Rosters; Commercial/ Management Pressures; and Management Relations well to the fore. Concerns have focused on FTL/FDP limits being regularly approached; rosters containing successive long-haul duties with minimum rest at destinations or after return to the UK; reduced resources (crew availability); pressures to operate to time schedules despite the additional constraints of COVID procedures; late rosters; and many reports of crews who feel fatigued but do not feel they can report as such due to fear of consequences. Increased efficiency is a laudable notion that has obvious managerial attraction in keeping down costs as some airlines struggle to survive and remain viable in the immediate post-COVID economic circumstances but there’s a trade-off: as James Reason identified in his ‘Safety Space’ concept, at some point, reducing costs too far can have a negative impact on safety and this needs to be at the forefront of any change management risk assessment – as the old saw goes, ‘if you think safety is expensive, try having an accident…’

All of which has echoes from the past and indicates a continued need for confidential reporting so that regulators and senior management remain attuned to concerns and feedback from those at the coal-face. CHIRP will continue to engage with the CAA and organisations where it can to ensure that your concerns are aired in a confidential, independent and impartial manner. The first option should always be to use the formal ASR/MOR/VOR reporting systems where you feel able to because this will hopefully gain the quickest and most complete response to any concerns. But CHIRP stands ready to assist as best we can those who do not feel able to do so or wish to report concerns about things that ‘nearly happened’ and might not meet the threshold for formal reporting elsewhere.

Steve Forward, Director Aviation

  • FC5090

    Crews operating into UK extremely fatigued #1
    Crews operating into UK extremely fatigued #1

    Abridged (see also FC5093)

    This report is to raise awareness of the practises of a foreign operator which contravene the spirit of the FTLs, and to raise a grave concern with regards to [Airline] flight deck crews operating into UK airports and through UK airspace. We have been continuously assigned rosters with block hours exceeding 130hrs per month based on a modified FTL that the company has been unilaterally changing to their convenience. For [Airline] it is now not only possible, but commonplace, to do a 23hr FDP which is not possibly viable or doable. Those FDPs were originally for COVID support freight ops but now have been extended to 15 destinations on our network. The passengers in the back are oblivious to the exhausted pilots and what we have to endure at the threat of being fired.

    [Airline] insist that you log only half or two thirds of the flight time on augmented sectors for you to remain below the 1000hrs legal limit while your actual flight time might be in the 1300/1500hrs range. The almost universally agreed flight time limit of 900hrs a year has been imposed for a reason after civil aviation authorities have collated data and studies; [Airline] does not respect nor believe in that universally agreed limitation.

    Understandably, a lot of [pilots] are very hesitant to come forward and submit reports because they are afraid of retaliation and probably termination. Unfortunately this company subsists on a culture of fear, contrary to their stated ‘open door’ policy and make-believe transparency efforts. We are overworked, overstretched and overstressed, all under a semblance of legality.  We also have been told ‘unofficially’ by people in management (who still care about their pilot colleagues, and are under the same threat of termination themselves) to report sick instead of going through the FRMS fatigue reporting system because the company would look back at our operational history to find an excuse to retaliate and probably find cause to terminate your employment.

    I attach [ACN Aircrew Notice]. The ACN illustrates a lot of the wrongdoings going on in terms of logging of hours and the breaches of safety that have been now institutionalised here at [Airline]. On page 3 of the ACN, in the ‘general notes for pilots’ section, it clearly states that for 4 crews operating a flight (as for example a flight to the United States) the relief crew logs total time minus 1:30 minus Crew A rest period, and on the way back the same crew logs total time minus Crew B rest period, which amounts to 50% of the total block time. This is illustrated in the rosters I have submitted. In view of this, we can fly (in all actuality!) 200 block hours in 28 days with the company getting away with it as we technically are allowed to log only 100 (50%). This goes against all laws and regulations and is a blatant disregard for the 100 hour in 28 days rule which is clearly stated in [NAA] duty periods regulations.

    Company Comment (abridged)

    The core point raised in your letter relates to FTL. In this regard, we operate in full accordance with the ‘Flight and Duty Time Limitations and Rest Requirements’ approved by our regulator and are satisfactorily meeting its periodic regulatory oversight reviews.

    The referenced Aircrew Notice (ACN) is not connected with FTL. That refers to the standardisation of procedures for Logbook hours, which is based upon the requirements as stipulated in [Regulator document], Aircraft Licensing; and its associated AMCs. This process too has met the scrutiny and standards of the [Regulator]. There has not been any recent change to these established processes.

    Fatigue Risk Management is part of our approved Safety Management System and addresses identified subjects that may require specific mitigation or attention. This is a dynamic process and operates in active consultation with industry subject matter experts.

    We also use the Boeing Alertness Model (BAM) for fatigue hazard identification as a supplement tool. This is used in the planning phase in order to support the crew rostering team in assigning duties to more than 17,000 aircrew. Flight crew fatigue levels are closely monitored by our FRMS and based thereupon, crew pairings i.e. rotations are reviewed on a monthly basis and most of our long haul operations are operated with an extra crew complement in addition to the minimum legal requirements.

    Based on the fatigue reports, we have made changes to our scheduling practices as required. This is a component of our ongoing fatigue mitigation as part of our Safety Management System. Engagements with industry subject matter experts with respect to fatigue surveys and comprehensive fatigue studies are part of our ongoing practices in this domain.

    Same as FC5093

    The essence of the issue is what portion of actual time in the aircraft is included in the airline’s FTL/FDP calculations? The airline’s ACN states that “Operating hours logged in [company flight time recording system] towards Flight Time Limitations (FTL) … are based on … the entire time Block Time minus the time spent resting in an approved rest area.” so any time resting in an approved rest area (i.e. not at the controls) appears not to be counted whereas the industry norm is that a rostered crew member is considered to be ‘operating’ if they carry out duties in an aircraft during a sector irrespective of their minute-by-minute actual activity in the aircraft. CHIRP sought clarification from the airline about FTL calculations but received only the statement above largely relating to the recording of logbook hours. Whilst logbook hours justifiably only take into account time spent at the controls, the whole portion of the flight time within a duty as an ‘Operating Crew Member’ should be used for the purposes of FTL calculations, including rest periods in flight.

    The regulation of foreign airlines lies beyond the UK CAA’s remit, but operations within UK airspace are conducted in accordance with protocols and responsibilities overseen by the Department for Transport (DfT), assisted by the CAA Air Safety Unit. Subsequent to receipt of this report and CHIRP’s engagement with DfT, they have established an International Risk Working Group to review and prioritise issues relating to foreign airlines operating in UK airspace and say that this specific issue will be progressed within that structure.

    Associated Regulations

    EASA Regulation (EU) 965/2012 Annex III Part-ORO ORO.FTL.105 Definitions (12) defines flight duty period (FDP) as: “a period that commences when a crew member is required to report for duty, which includes a sector or a series of sectors, and finishes when the aircraft finally comes to rest and the engines are shut down, at the end of the last sector on which the crew member acts as an operating crew member”.

    EASA GM1 ORO.FTL.105(17) Definitions defines ‘Operating Crew Member’ as: “A person on board an aircraft is either a crew member or a passenger. If a crew member is not a passenger on board an aircraft he/she should be considered as ‘carrying out duties’. The crew member remains an operating crew member during in-flight rest. In- flight rest counts in full as FDP, and for the purpose of ORO.FTL.210 [Flight Times and Duty Periods].

    EASA Regulation (EU) 965/2012 Annex III Part-ORO ORO.FTL.210 Flight Times and Duty Periods states that: “…(b)  The total flight time of the sectors on which an individual crew member is assigned as an operating crew member shall not exceed:

    (1)  100 hours of flight time in any 28 consecutive days;

    (2)  900 hours of flight time in any calendar year; and

    (3)  1000 hours of flight time in any 12 consecutive calendar months.

  • FC5093

    Crews operating into UK extremely fatigued #2
    Crews operating into UK extremely fatigued #2

    Abridged (see also FC5090)

    Pilots [at Airline] routinely fly over 1000hrs a year and fly up to 180 block hours a month. However, at the moment the flight time for 4-pilot augmented crew for a 13:30 hours flight is 07:30 for crew A and 06:00 for crew B. The latest change is that, in addition to time in ‘Inflight rest’ not counting, the time in the jump-seat during take-off and landing (1:30) also doesn’t count. Similar rules apply to 3-pilot crew.

    Company Comment (abridged)

    The core point raised in your letter relates to FTL. In this regard, we operate in full accordance with the ‘Flight and Duty Time Limitations and Rest Requirements’ approved by our regulator and are satisfactorily meeting its periodic regulatory oversight reviews.

    The referenced Aircrew Notice (ACN) is not connected with FTL. That refers to the standardisation of procedures for Logbook hours, which is based upon the requirements as stipulated in [Regulator document], Aircraft Licensing; and its associated AMCs. This process too has met the scrutiny and standards of the [Regulator]. There has not been any recent change to these established processes.

    Fatigue Risk Management is part of our approved Safety Management System and addresses identified subjects that may require specific mitigation or attention. This is a dynamic process and operates in active consultation with industry subject matter experts.

    We also use the Boeing Alertness Model (BAM) for fatigue hazard identification as a supplement tool. This is used in the planning phase in order to support the crew rostering team in assigning duties to more than 17,000 aircrew. Flight crew fatigue levels are closely monitored by our FRMS and based thereupon, crew pairings i.e. rotations are reviewed on a monthly basis and most of our long haul operations are operated with an extra crew complement in addition to the minimum legal requirements.

    Based on the fatigue reports, we have made changes to our scheduling practices as required. This is a component of our ongoing fatigue mitigation as part of our Safety Management System. Engagements with industry subject matter experts with respect to fatigue surveys and comprehensive fatigue studies are part of our ongoing practices in this domain.

    Same comment as FC5090

    The essence of the issue is what portion of actual time in the aircraft is included in the airline’s FTL/FDP calculations? The airline’s ACN states that “Operating hours logged in [company flight time recording system] towards Flight Time Limitations (FTL) … are based on … the entire time Block Time minus the time spent resting in an approved rest area.” so any time resting in an approved rest area (i.e. not at the controls) appears not to be counted whereas the industry norm is that a rostered crew member is considered to be ‘operating’ if they carry out duties in an aircraft during a sector irrespective of their minute-by-minute actual activity in the aircraft. CHIRP sought clarification from the airline about FTL calculations but received only the statement above largely relating to the recording of logbook hours. Whilst logbook hours justifiably only take into account time spent at the controls, the whole portion of the flight time within a duty as an ‘Operating Crew Member’ should be used for the purposes of FTL calculations, including rest periods in flight.

    The regulation of foreign airlines lies beyond the UK CAA’s remit, but operations within UK airspace are conducted in accordance with protocols and responsibilities overseen by the Department for Transport (DfT), assisted by the CAA Air Safety Unit. Subsequent to receipt of this report and CHIRP’s engagement with DfT, they have established an International Risk Working Group to review and prioritise issues relating to foreign airlines operating in UK airspace and say that this specific issue will be progressed within that structure.

    Associated Regulations

    EASA Regulation (EU) 965/2012 Annex III Part-ORO ORO.FTL.105 Definitions (12) defines flight duty period (FDP) as: “a period that commences when a crew member is required to report for duty, which includes a sector or a series of sectors, and finishes when the aircraft finally comes to rest and the engines are shut down, at the end of the last sector on which the crew member acts as an operating crew member”.

    EASA GM1 ORO.FTL.105(17) Definitions defines ‘Operating Crew Member’ as: “A person on board an aircraft is either a crew member or a passenger. If a crew member is not a passenger on board an aircraft he/she should be considered as ‘carrying out duties’. The crew member remains an operating crew member during in-flight rest. In- flight rest counts in full as FDP, and for the purpose of ORO.FTL.210 [Flight Times and Duty Periods].

    EASA Regulation (EU) 965/2012 Annex III Part-ORO ORO.FTL.210 Flight Times and Duty Periods states that: “…(b)  The total flight time of the sectors on which an individual crew member is assigned as an operating crew member shall not exceed

    (1)  100 hours of flight time in any 28 consecutive days;

    (2)  900 hours of flight time in any calendar year; and

    (3)  1000 hours of flight time in any 12 consecutive calendar months.

  • FC5098

    Report Time
    Report Time

    Our airline has changed the report point to our crew room, which is after security and bag drop. This allows a reduced FDP so that they can operate [what were] 3-crew flights with 2 crew, by not including duties commensurate with operating the flight in the duty time. It is not unknown to take at least 1 hour to get to our crew room from the first duty. Can you please clarify if this exemption is allowed? This is further exacerbated by some flights now requiring a 2 hour report for COVID testing. Do the FDP tables take into account we need to allow at least an hour and a half from the car park to report for duty with this amendment? This means that we arrive at the car park 3½ hours before departure for what could be a 11 hour 2 crew duty.

    There is no ‘standard’ reporting location within regulations because every airport and airline’s circumstances are different and so it is not possible to be prescriptive – reporting point and FDP authorisations form part of the CAA oversight of each airline’s operations manual. Although now somewhat overtaken by events as COVID-screening delays subside, we approached the CAA to see whether they were aware of any change in reporting point for this airline and airport and they engaged with the Company. Contrary to the reporter’s assertion, it appears that the reporting point for this airline has been the crew room for many years and has not changed. The Company responded to the CAA by saying that they added additional time within FDP calculations to account for any COVID-induced security delays in reaching the crew room, but it could be that this and the engagement that the Company were having with the airport to ensure that any actual delays were within the additional time factored into rosters may not have been widely appreciated.

  • FC5102

    Removal of TC Role
    Removal of TC Role

    [Airline] and [Ground Handling Company at Airport] withdrew the role of Turnaround Coordination (TC) in January 2021. This was not communicated to crews. It took place at a time of low levels of flying and low loads. TCs were also banned from boarding ac as a COVID mitigation. No safety control measure is visible. Local crews are using practical drift and local knowledge to overcome operational difficulties but short cuts of a safety nature are also happening. In one example a 1-tonne plus load was loaded in the wrong hold and only spotted by the crew. At the same time [Airline] has introduced further goal-conflict by cutting 5 minutes from its boarding time. Crews are under time pressure and now must be aware that all loading and ramp activities are not co-ordinated by a single person and many are carried out by staff recruited for less safety critical roles. Staff are unable to confirm who security-checks the holds and who is responsible. They are unaware of the LIRF [Loading Instruction Report Form – the loadsheet] or able to produce one despite having signed to say they have loaded the aircraft in accordance with it. Local management have dismissed concerns saying the trial is a success and any operational obstacles shall be overcome with further recruitment of front of house staff who are customer facing to carry out the former TC role. [Airline] are constantly piling more pressure on pilots to be the last and in many cases, only, line of defence whilst being in denial of the goal conflicts it creates with time pressures. The fact that any such changes are made whilst crews struggle with low levels of recency and high anxiety over external pressures shows a total lack of modern safety management.

    The BALPA company council (CC) have engaged [Airline] management direct on this matter and quoted ASRs that members have raised, especially the tonne of load in the wrong end of the aircraft. [Airline] have responded by saying they are now conducting an investigation. BALPA are also currently challenging other ramp related programmes in [Airline] that, when brought together with the above, personify the “lining up of the holes in the swiss cheese”. We have constantly fought fatigue battles at [Airline] over the pre-COVID years and now, whilst crews are at their most vulnerable in terms of recency and distraction, [Airline] introduces goal conflict between cabin/flight/ground ops teams by introducing boarding targets that are creating a rush-and-report-early culture as referenced by a recent survey of BALPA members. This latest programme is called “xxxx” and has whisked away another 5 minutes of pre boarding prep time for crews who are largely mitigating this with short cuts on safety checks and reporting early as the culture priorities on-time performance before safety, albeit subtly whilst stating safety is the number one priority (of course we all know stating such a thing does not make it so). This allows for less headcount on the ground which ties into the piece above where we have inadequately trained staff in low numbers under immense time pressure now being responsible for critical safety actions for which they feel under trained (load sheets), the effects of which we have and continue to see.

    We have seen no risk assessments for the removal of TC roles and have been told by local ramp staff to not expect to see them returned as local management have quoted how much this has saved.

    Whilst there are obvious cost savings to be made by reducing head-count, some roles are pivotal and their responsibilities must be ensured by other means if the post is deleted. It is not for CHIRP to comment in detail on individual situations such as this because we do not have the full facts, but it is worrying that those affected by the change were seemingly not aware of their extra responsibilities or how the associated threats to safety were otherwise being mitigated. The CAA are unable to share their detailed oversight outcomes with us as an external organisation, but their comment about change management and risk assessment hint that more could have been done in these respects; given the reporter’s comments about loading issues and training, we agree. If anything, as aviation recovers in this post-COVID context of constrained resources and new procedures, more supervision is required, not less, and the TC activity is an important ‘last-chance’ coordinating activity that must surely be safeguarded. Although it may well have been deemed appropriate to persist with the removal of the discrete TC role, we understand that it was subsequently recognised that this can only be sustained in future after the introduction of several unspecified safety recommendations/mitigations, all of which should have been identified beforehand as part of a robust change management review rather than post-implementation.

  • FC5117

    Fuel Tables
    Fuel Tables

    The company I work for has produced a quarterly fuel & carbon dashboard illustrating Captains’ fuel loading decisions based on a graduated position in relation to peers.  Those to the left of the fleet statistic chart have loaded extra fuel in addition to company SCF (Statistical Contingency Fuel) and those to the right have loaded minimal down to nothing extra on top of SCF.

    This rather blunt tool does not reflect a multitude of variables including the assessed airmanship risks of the day that may be deemed to fall outside of the SCF feed data. Much of fuel carriage assessment comes from years of experience, coupled with accurate modern data feeds such as SCF. Fuel carriage decisions include variable/extreme weather, unforeseen level or route deviations that when assessed fall outside of loaded contingency in terms of perceived risk, as well as a comprehensive knowledge of the company fuel policy. This has never been completely black or white and no doubt never will. Indeed, an excellent decision to carry extra fuel based on the crew’s judged risk which subsequently is not used will be shown as discretionary fuel “not required”, perversely moving the Captain to the left of the chart. In reality this is discretionary fuel simply “not used”. Whether it was “required” or not is down to the judgement the Commander utilising knowledge, experience, flight specific data and the full spectrum of the vagaries of the day ahead. The pilot’s arrowed position on the chart simply and crudely represents how much extra fuel was loaded in relation to peer comparison.

    Monitoring of SETO (single engine taxi out) & SETI (single engine taxi in) is however a useful area of data supplied, providing it does not encourage “competition”.  Pilots tend to be competitive in nature. Loading sensible fuel loads should be driven primarily on safe practice, followed by commercial awareness and further today, green credentials. Making this decision competitive in this fashion merely interferes with those safe priorities and indeed the focus ought to be equally on those on the right of the scale who think it’s “clever” to blindly rely on SCF data. The unwary will find themselves with low fuel states down a “blind alley”, being driven by an unintelligent and false sense of elitism, to immaturely please their positioning on the chart.

    Operating at a zero cost index or selecting speeds close to the best lift/drag ratio speeds to save fuel can place the aircraft in close proximity to VLS (Airbus) causing havoc with ATC & other traffic in close proximity (.72 cruise Mach by example is not practical or ideal). This lack of awareness and due consideration results in other carriers having to alter their trajectories which in turn will damage the collective carbon footprint by increasing collective fuel burn. Further to this if unforeseen turbulence or wake is encountered the safe margins as well as decision options are also compromised.

    Enough knowledge exists for all modern commercial pilots to be responsible regarding fuel usage. Intelligent safety orientated and commercial monitoring is no doubt prudent as well as showing responsible carbon footprint awareness. However, to make a competitive incentive to see whom can carry the least fuel can be viewed from a safety perspective as an irresponsible and reckless stance from an airline employer, albeit with good but misplaced motives at heart. Indeed, if a company chooses this behaviour then perhaps a “magnifying glass” ought to be directed at those carrying the least fuel to ensure safe practice.

    In summary, the importance of a decision regarding a safe quantity of fuel ought not be influenced by a position on a graph. If it does, then this leads to a question over the quality of Command selection, training and authority regarding safe fuel decisions.

    We’re grateful for the company’s extensive comments explaining the rationale behind the fuel graphs and their intention to enlighten captains as to fleet norms and encourage them to improve their individual environmental carbon footprint. Notwithstanding, it’s human nature to reflect on one’s own performance in relation to others, and some less experienced captains might conceivably perceive implied pressure or incentives to carry less additional fuel even if they felt they needed it in what was ultimately a safety-critical decision. It’s probably fair to say that some captains may habitually carry too much fuel but, equally, there are probably those who are at the other end of the scale and who habitually accept the bare minimum which could also be a cause for concern. Ultimately, the decision on fuel loads is dependent on many factors that are route and weather dependent and, if used in the intended manner, at least the company’s charts and fuel calculations offer a basis for decision-making on the day given that they take route factors into account by using a statistical norm for what additional fuel was required from the last 100 flights.