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FEEDBACK

ATFB 155

Safety Culture

CHIRP reporting themes

My first six months as Air Transport (AT) and Advanced Air Mobility (AAM) programme manager in CHIRP’s aviation team has been both enlightening and professionally rewarding. Having previously been a member of the Air Transport Advisory Board (ATAB) I was very familiar with how CHIRP’s advisory boards dealt with the human factors based reports presented to them for discussion, but now that I’ve taken on the newly created AT/AAM PM role, I have more insight into the reports as they arrive into CHIRP, and importantly, I’m able to have direct contact with the individuals who report in to us with their concerns. Reporters’ motivations for submitting confidential reports to CHIRP vary greatly, as you’d expect, but a few common themes involving safety culture are appearing from my first six months in the job. I thought I’d share some of these with you having been given this opportunity to write my first editorial for Air Transport FEEDBACK. But before I do, I wanted to set the scene regarding what I believe is meant by the term ‘safety culture’ in aviation, as the concept is very pertinent to the subject of Air Safety Reporting (ASR) in general, and confidential reporting in particular.

Safety, in its broadest sense, represents the priority given by an organisation, at every level of operation, to keep employees and customers free from harm. Culture, as it relates to humans working within socio-technical systems, refers to the prevalent attitudes, behaviours, and beliefs that exist amongst a majority working within the organisation. Culture, in a nutshell, determines what is deemed acceptable behaviour within an organisation. Therefore, when a genuine safety culture is said to exist in an organisation, it will reflect a commitment by senior leadership, and all others in the organisation, to prioritise safety and to continuously learn and make improvements based on events that occur and the personal experiences of employees. The organisation promotes and values those attitudes, behaviours, and beliefs that facilitate safe outcomes, and always above other considerations, such as those associated with short term financial or operational pressures. Positive safety culture includes clearly defined safety responsibilities and accountabilities, effective teamwork to achieve a common set of well understood safety goals, open and honest reporting of hazards and near misses, errors, mistakes, incidents and accidents, and finally, a feeling of trust throughout the organisation that safety really is, yes, let’s go ahead and say it
 “the number one priority”. An easily said strap line, and one that is arguably overused, but is in fact a very high bar to reach, particularly in the cut and thrust world of 21st century commercial aviation!

Here at CHIRP we often receive reports that highlight what can happen when an employees personal experience of their organisation’s safety culture is at odds with what is said on the company’s SMS intranet site, or on notice board posters in Flight Ops, and therefore falls short of the ideal. A recent confidential CHIRP report stated that there was a perceived “punitive culture’’ prevalent at an airline and the reason that the reporter felt compelled to write to CHIRP was because they feared retribution and actions against them if they submitted an internal ASR.  Another report into CHIRP stated that the employee had submitted an ASR but had still not received an acknowledgment from the safety team, let alone a detailed reply. Sometimes, CHIRP is told, the reply to an ASR is simply that the report “is now closed’’.  It is worth remembering that an effective safety culture can only exist when all employees feel able to report without fear of a negative outcome.  The concept of Just Culture attempts to capture how this is done, which as James Reason identified, is when an organisation has a “just and fair approach” to errors and mistakes as and when they are identified. But this only works both ways; SMS require employees to submit internal reports to identify hazards and risks, but in return, the leadership must be genuinely willing to hear from employees, even when staff believe management have made errors and mistakes, for example in the interpretation of CAA regulations for Flight Time Limitations and setting rosters that will, based on FRMS reports and ASR reports from employees, result in fatigue.

CHIRP receives reports from individuals who believe that their organisation is playing a sort of game with the regulations, setting schedules and rosters for example that are, by the letter of the regulation, arguably “legal’’ but in the opinion of reporters are not conducive to safe operations when a busy flying roster is considered. Fatiguing rosters, and based on reports received latterly, insufficient or interrupted rest periods, are currently two of the most common reporting subject areas for CHIRP aviation. A worrying aspect that I have noted is that many reporters don’t believe that the safety culture prevalent at their airline encourages them to submit FRMS reports or more generally ASRs about their personal experiences of fatigue. And the very last recourse open to crews, calling in unfit due to fatigue, is viewed by many of the reports we receive at CHIRP as a punishable event in reality. This type of personal experience will determine how the reporters perceive overall safety culture in the organisation, something that is hard to change in a short space of time. CHIRP will always speak up for reporters who feel unable to submit ASRs, backed up with our ability to engage directly with the airlines themselves, but at all times ensuring the confidentiality of the reporter is preserved.

William Dean, Air Transport (AT) & Airborne Air Mobility (AAM) Programme Manager

For all CHIRP Aviation Team, see CHIRP bios.

  • ILAHFFT –

    10 Lessons I Learnt the Hard Way

    A recent article by Captain Jop Dingemans, an experienced Helicopter Emergency Medical Services (HEMS) pilot, who posted an on-line article on the website – PILOTS WHO ASK WHY – entitled “10 Lessons I Learned the Hard Way from 7 Years as a HEMS pilot”. The article applies equally well, in most parts, to all types of flying, including commercial fixed wing aviation. We have provided the list below with a short precis of each lesson, but please visit the website to get the benefit of the full version; it is well worth a read.

    • Your worst flight could come out of nowhere
      • Pilots are very used to routine. Routines are good, SOPs are there for a reason, but what if routines or SOPs don’t quite fit or get interrupted?
      • It probably won’t be just one thing that will catch you out. More likely a combination of factors that merge into an ugly monster trying to ruin your day.
    • Weather can be your biggest enemy if you let it
      • Bad weather does not cause accidents – bad decisions in bad weather do. All pretty basic stuff, and not an issue if we can accurately predict what the weather will be at time X and place Y. The problem is a weather forecast is nothing more than just that, a forecast – not a crystal ball.
    • Fatigue creeps up on you
      • I’ve lost count of the number of times my first officer and I have had to correct each other’s actions after a long night. It’s those moments that make me so happy to be involved in a multi-pilot environment: you have each other’s backs when you both need it. We humans are pretty bad at assessing how fatigued we are. It’s like asking a drunk person to accurately state their blood alcohol level.
    • The landing site has more threats than the rest of the flight combined
      • Taking off from an airport and cruising along to the overhead have less risk than the approach phase. Don’t just take my word for it; the EASA data on this consistently shows the approach phase of HEMS to have the most risk. As the job becomes more ‘routine’ and ‘normal’, normalisation of risk comes in.
    • Emotional intelligence matters way more than you think
      • Both pilots and management have a tendency to think that being a good pilot means: flying a great ILS approach, flying on the numbers, knowing everything there is the know about the aircraft and any other technical skill imaginable.
      • But the longer I am in this job, the more I realise that me and the rest of the crew would rather fly with someone with great emotional intelligence who’s a little rusty on the controls than someone who’s not great to work with but can fly the best ILS you’ve ever seen. It’s more important to understand how other people work and think than trying to be a ‘great’ pilot.
    • Life is nuanced, and so is aviation
      • Safe vs unsafe, good vs bad, acceptable vs unacceptable: my personal / natural way of looking at things can be quite black and white. Not as effective or helpful as I thought when I entered the industry! People, life, and aviation are nuanced and usually complex, trying to fit it all into two brackets didn’t get me very far – because it doesn’t work. Judgement and risk management are everything.
    • Your aircraft will eventually let you down
      • After weeks, months and years of no engine failure, you might take that Take-off Decision Point or Landing Decision Point (or V1 for our fixed wing friends) less seriously than someone who has had to deal with it in the heat of the moment. I’ve had a few moments where I’ve been reminded that no matter how great your engineering department is, the aircraft will eventually let you down when you desperately need it not to.
      • Thinking the ‘what ifs?’ isn’t neurotic; train yourself to have a healthy dose of vigilance.
    • You can’t please everyone, and you shouldn’t try
      • There’s pressure from pretty much every angle to deliver. I’ve definitely stepped into the trap in the past and overthought decisions, not because they weren’t safe, but because I didn’t want to let people down. The turning point came when I realised that every time you say “yes” to please someone, you’re gambling with the one thing you’re responsible for: safety.
      • You’re not hired to be agreeable. You’re hired to make the right call, even when it disappoints someone, whether that’s your boss or your crew members.
    • Trust – but verify
      • You can’t have an aviation industry without trust. You trust your crew, your maintenance team, your dispatchers, your medics. Most of the time, that trust is completely reasonable and earned. But over the years, I’ve learnt a critical addition: trust – but verify.
    • The job changes you
      • I used to fly with an exceptionally experienced (and now retired) HEMS pilot. Anytime he saw people panicking or getting worked up, he’d walk in and jokingly ask: “Is anyone dying, is anyone pregnant? If not, let’s all calm down.” You start this job thinking it’s all about skill, airmanship, decision-making and precision. In some ways it is. What they don’t tell you beforehand though, is that HEMS changes you – slowly and quietly.
      • You see people on the worst day of their lives. You land in places no one else would go. You see things you can’t un-see. Some of it stays with you, but also a lot of stuff bothers you less and less as you grow more experienced.

    CHIRP thought: this article could be a fitting “springboard’’ to receive comments from our Air Transport readers – what are your 10 lessons, learned the hard way and from your personal experiences in commercial AT aviation? If 10 is too many, how about your top 5? We’d love to hear from you!

  • ATC866

    –

    ATC rushed landing
    ATC rushed landing

    Initial Report

    Report summary: [Location] NOTAM indicated airfield was closing for 35 minutes (11.00-11.35) to observe ATC break. Vectors given for runway [number] with low cloud base and marginal conditions. [The situation] was made worse by being told aircraft needed to land by 10.50, [10 minutes earlier than the NOTAM-stated closure time]. Calculated 10.48 so [timing] was ok. During landing, a significant tailwind was experienced, just within aircraft limits but not ideal for an [AT aircraft type] on a short runway. Notified ATC when landed and this was simply put down to changing wind direction. Would have been better to have been vectored for reciprocal runway 08, but this, I assume would have taken longer to vector and [therefore] would have been closer to the closure time.

    CAA Comment

    Although the Scheme for Regulation of Air Traffic Controllers’ Hours (SRATCOH), previously in Part D of CAP670, is no longer included as a requirement (following publication of ORS 9 Decision 6), it is still available as guidance, and most ANSPs use it. The purpose of SRATCOH is to ensure, so far as is reasonably possible, that controller fatigue does not endanger aircraft and thereby to assist controllers and ANSPs to provide a safe and effective service. The adjustment in regulations allows ANSPs to develop bespoke fatigue risk management systems if they wish. We would expect that any fatigue risk management system would (like SRATCOH did/does) allow for discretionary extension of duties (when a controller is not fatigued) similar to the discretion applied to flight crews. However, current FRM systems in ATC have historically been perceived as somewhat ‘rigid’, with an unjustified assumption that the CAA will take licensing action as a result of each and every any fatigue risk management breach. In reality the CAA reviews every breach report but will only take action where breaches are systemic or excessively repetitive, or where there is an indication that a controller may have continued to provide services whilst fatigued. The CAA recognises that that there will sometimes be circumstances when (for example) extending a duty is a sensible and pragmatic decision provided the controller does not feel fatigued. Example situations include facilitating a landing aircraft that would otherwise need to be diverted, or that was operating on a medical evacuation / organ transfer flight. Provided the event is reported with a clear explanation for the breach and includes reasonable and safe decision making, then the CAA will be sympathetic; licencing action is highly unlikely. Ultimately, it is the responsibility of each individual ATCO not to control when fatigued, but there is always scope for being flexible and adaptable when it is sensible to do so.

    CHIRP Comment

    This report highlights a number of human factors-based issues. Firstly, it serves as a reminder that captains shouldn’t feel obliged to accept an unsuitable runway, no matter what the circumstances. The captain is responsible for the safety of the aircraft, and it is always advisable to question ATC instructions that are either out of limits or marginally safe. The reporter was clearly uncomfortable with the alternative runway given and seemed to feel pressurised into accepting it. It might have been better in this situation, when there was a more ‘into wind’ option, to have pressed the controller for this option. Albeit that it is human nature to ‘show willing’ and accept instructions as given, especially when there is perceived pressure i.e. the notification that the aircraft needed to land 10 minutes before the NOTAM’d airfield closing time. Although the full details behind this incident aren’t known, it is possible that the controller was working both tower and ground and would need to get the aircraft on stand before their mandatory rest period began. There is sympathy for controllers trying to juggle lots of variables and remain within limits; it is also possible that the controller wasn’t aware of the full implications of the runway offered. Given that the incident occurred some time ago, it hasn’t been possible to gain more information than that presented by the reporter, however, it seems likely that the airfield was closing for a 35-minute break to facilitate a Fatigue Risk Management (FRM) requirement. It was on basis of this assumption that CHIRP consulted the CAA for a view of the application of FRM in Air Traffic Control (above).

  • ENG 771

    –

    Fatigue in engineering
    Fatigue in engineering

    Initial Report

    Although fatigue is frequently cited in reports concerning flight crews, I have never encountered an engineer who has formally reported fatigue. Yet, every night shift worker has likely experienced drowsiness or even momentarily fallen asleep while driving home after a shift. Engineers are all too familiar with the foggy mental state and diminished agility that arise when faced with first wave callouts at the end of a night shift. Despite this, we feel compelled to “crack on,” as the principles of human factors do not seem to apply to us in the same way they do to crews. A significant proportion of aircraft maintenance is deliberately scheduled during the early hours of the morning—the time when human performance is most affected by fatigue—simply to maximise aircraft availability for revenue-generating operations. This is not a new practice, but the increasing trend towards shorter turnarounds, often unattended by engineers, has only exacerbated the issue. Maintenance is being concentrated during the small window of time when engineers are at the lowest point in their circadian rhythm. As an industry, we have long ignored human factors, relying instead on processes and procedures to prevent accidents, while neglecting the reality of fatigue for engineers.

    Airline Comment

    [Airline’s] Engineering & Maintenance (E&M) department actively promotes and builds on the Safety Culture that is the backbone of the airline’s Integrated Management System by cultivating an atmosphere where people can have confidence to report concerns without fear of reprisal, punishment, or blame, and trust that such concerns will be adequately and fairly assessed, by raising awareness and disseminating information, and by learning from mistakes, making necessary changes and adapting to changing demands.

    We encourage all personnel to report on any matter but especially those relating to safety concerns with human factors considerations. We promote the use of [Safety System] as the primary platform for incident reporting by engineers employed by [Airline] as well as those employed by contracted maintenance organisations. Human factors are a key consideration in E&M’s processes and procedures. All CAMO, Part 21 and Part 145 personnel receive human factors training every 2 years, regardless of their role, to ensure that staff are aware of the impact that their own actions, or lack thereof, can have on human performance. Our Safety investigators are trained to conduct root cause analyses that look beyond the surface level to be able to link any human factors related concerns with organisational influences, thanks to the use of targeted methodology such as HFACS, Five Why’s, SHELL model, Swiss Cheese. We have also recently launched an operational readiness cycle to evaluate the effectiveness of our fatigue risk management system within E&M.

    Since the implementation of SMS within Part 145, there has been even more emphasis on the matter of adequately identifying, assessing, and mitigating risks to our frontline operation and we recognise that most risks are intrinsically linked to the human performance limitations.  Our Safety Objectives, as displayed in our MOE, are mostly centred around fostering a safety-oriented mindset amongst maintenance personnel and thus promoting a safety culture where reporting is actively encouraged without fear of reprisal. More specifically, it is one of our Safety Objectives to ensure that all maintenance personnel receive annual recurrent training on human factors and fatigue management. The MOE goes a step further and addresses the consideration of human performance limitations in production planning as well as the monitoring of work accomplishment by management.

    CAA Comment

    Aviation Safety (Amendment) Regulation 2023 (SI 2023 No. 588) amended UK regulation (EU) No 1321/2014 introduces a Safety Management System (SMS) into Part 145. A SMS relies on a positive reporting culture to ensure its effectiveness. All Part 145 approved organisations should ensure that the reporting of safety concerns including fatigue is encouraged. As a certifying engineer, there is an obligation to ensure that you are fit for duty. The ANO includes overarching safety obligations that require all aviation personnel to act in a manner that does not endanger the safety of an aircraft or its occupants, which would naturally include being fit for duty. In practice, the CAA’s guidance and oversight, along with the SMS requirements under Regulation 1321/2014 (as amended), are the primary mechanisms for enforcing the fitness-for-duty standard for certifying staff.

    CHIRP Comment

    As detailed in the comprehensive CAA comment above, the recently amended regulation now includes human performance aspects for engineers as part of SMS requirements for Part 145 organisations operating in the UK. In addition, the Working Time Directive covers fatigue and tiredness for engineers and all those working in aviation. There is a significant difference between fatigue and tiredness. This distinction is well documented in aviation human factors publications such as Section A, Chapter 11 of CAP737 and SKYbrary’s article on Fatigue. In addition, the HSE article on fatigue offers valuable insights into its effects – especially for shift workers. Engineers should also be aware of the safety aspects of fatigue from their human factors training. The risk is greatest during the body’s natural circadian low, typically between 02:00 and 06:00, known as the Window of Circadian Low (WOCL), when alertness and cognitive function are at their lowest. Engineers often have to work during the WOCL and the very particular pressures that this brings should be a major consideration when rostering engineers for night duties over consecutive nights. In addition, frequent changes to rosters from days to nights are especially challenging. Where possible, individuals should be given enough days on a specific shift to acclimatise and then start performing at an optimal level. CHIRP appreciates that this is not always a practical solution, either for individuals or for maintenance organisations. Nonetheless, rosters should be carefully constructed to accommodate fatigue issues and, where sub-optimal rosters cannot be avoided, companies should have additional defences in place to allow for degradation in human performance.

    Fatigue during night shifts can significantly impair judgement, attention and motor skills which are critical faculties for safe aircraft maintenance. The situation is compounded if an engineer hasn’t taken the opportunity or been able to sleep, or sleep well, before the shift. Scientific evidence shows that being awake for 17 hours can impair performance to a level equivalent to a blood alcohol concentration (BAC) of 0.05%, and after 24 hours, the effect is similar to a BAC of 0.10%, well above most legal driving limits (Dawson & Reid, 1997). These levels of impairment can lead to missed inspections, incorrect torque settings, or overlooked safety-critical issues.

     

    Typical variation in human alertness across a 24-hour period, illustrating key circadian low points in the early morning and early afternoon.
    Adapted from SleepSpace, based on principles of circadian physiology. Source: www.sleepspace.com

    The key takeaway is that fatigue-related impairment can be as dangerous as alcohol intoxication yet is often underestimated or invisible in safety-critical work environments. CHIRP would like to challenge maintenance organisations to do more to consider the implications of fatigue in rostering and to highlight the importance of reporting fatigue as a contributory factor to any incidents, when considered relevant.

  • FC5368

    –

    Airport standby duties
    Airport standby duties

    Initial Report

    I work for an operator that routinely uses airport standby duties at several bases. These are conducted as a whole crew in a separate, designated room, with reclining chairs. The room is supposed to be dark, quiet and comfortable, with the assumption that crew are ‘resting’ for any potential callout. The rostered duties start in the morning ranging from approximately 7-9am, and in the afternoon from 1-3pm. Both early and late duties are for a 6hr period. Crew are required to sit in silence, in their full uniform and react to any callout immediately, with the aim to be airborne within 1hr. By providing this kind of ‘rest facility’, the first 4hrs of the standby duty do not count towards the maximum allowed FDP in the event of any callout. This obviously allows great flexibility to the company, allowing them to allocate crew to an extremely long day, on the assumption that they have been ‘resting’ for the first 4hrs of standby.

    However, after conducting these duties for many years, I can say that only on a very few occasions have I seen crew properly resting. It is impossible to sleep when you are in a small room, in group of 6, staring at each other, in full uniform made of polyester. From an ASBY that reports at 1400Z, you can be called at 1955z and operate 2 sectors with a max FDP until 0500Z. How can that be safe and justified? We are expected to turn up for an ASBY duty fully rested in anticipation of a callout the minute we report, but then also be fully rested for a callout the minute it ends. How are we supposed to plan that rest? It is impossible to rest during the duty if you have reported, fully refreshed, prepared for a callout at the start.

    Rest is also prevented by the anxiety involved with being called to operate to an unfamiliar airport at minimum notice under commercial pressure. There are no company internal audits/surveys completed, asking crew about the quality of rest they achieve on airport standbys, or for an assessment of their alertness levels during the duty. If the company were serious about ensuring crew are fully rested for such potentially, horrendously long, duties they should:

    1) allow crew to rest in comfortable clothing

    2) provide dedicated individual hotel rooms

    Otherwise, they should remove the practice of not counting the first 4hrs of duty on the assumption that crew are resting, because it simply does not happen.

    CHIRP Comment

    CHIRP has sympathy with the reporter and thought that there were obvious risks in assuming that crews would be fully rested when the facilities provided might only meet the minimum regulatory requirements. ORO.FTL.225 simply states that operators should provide accommodation for airport standby, with no mention of the need to provide suitable accommodation for crew members to rest effectively without distractions nor interruptions. The CAA has confirmed that the subject of suitable accommodation, and the wording in regulations, will be included for consideration during the ongoing CAA FTL review. CHIRP understands that one of the aims  of the CAA review will be to provide guidance on whether, and when, ‘suitable accommodation’ is required for airport standby which will hopefully help organisations and crews to better understand not only the intent of the regulation but also guidance to organisations; as this report describes, some companies are discounting the first 4 hours of airport standby in the total FDP in the event of a call out, and when only providing shared accommodation space fitted with reclining seats. The reporter provides detailed information to back up the safety concerns, namely, poorly rested crews are not going to be able to perform at their best in case of a call out to an unfamiliar airport with little time to plan due to commercial pressures. CHIRP agrees with the reporter that direct feedback from the crews to management using questionnaires or other types of audit survey would be highly beneficial and allow the company to make continuous improvements to operating procedures, as well as to the appropriateness of the rest facilities provided.

  • FC5376

    –

    Commercial pressure
    Commercial pressure

    Initial Report

    This report contained two distinct topics under one title and was therefore considered by CHIRP as two separate issues: Sickness Reporting/Absence Management and Green Light Boarding.

    Report Text: It is my opinion that [UK Airline] is using fear to pressure staff (to work) when sick, and also to achieve certain targets (Green Light Boarding) within the operation. This is done with a carefully constructed sickness policy and for Green Light Boarding, by immediate contact via email when Green Light Boarding criteria are not met.

    Part 1 – Sickness reporting/absence management

    The sickness policy: If you have 3 absences or more in rolling 12 months you are subject to a “welfare meeting”. I have attended one of these meetings in the past. It consisted of questions about each absence. Why, did you see a doctor, did you take any medication etc. All information that the office already had on their records from the self-reporting form. At the end there was a question whether there was anything they could do for me regarding my welfare. However, when 95% of the meeting is asking questions about things they already know the answers to, it gives the feeling they are trying to catch you out, rather than having concerns about you. Further, we work in an environment where we are likely to have more absences than the general public. Reasons being, you cannot go home if a cold or other condition suddenly gets worse. You have to be sure, within reason, that you can go to work and safely finish your duty. Therefore, I think it is very possible that most will have 3 or more absences per year. The blanket policy of 3 absences triggers a “welfare meeting”. This means most crew will find themselves in a situation, where they know, calling in sick will mean a meeting to explain yourself. This generates pressure to go to work when you shouldn’t. I have flown with crew that admits during the duty that they should have stayed home, or they have come back to work too soon.

    Part 2 – Green Light Boarding (GLB)

    GLB is a term used within the company to start boarding at or before a certain time. It has had a lot of focus, and it seems the company believe delayed boarding is the root cause of delay. In order to achieve GLB, it has for a while been linked to the cabin crew performance bonus. To start boarding the cabin needs to be ready and more importantly safety and security checks needs to be completed. To put these procedures under time pressure is not good practice. Recently, boarding automatically began starting at a certain time. That means, unless the crew actively tells the ground staff to hold the boarding, passengers will start coming up the steps at a given time. This adds more pressure on the cabin crew. It is escalated further by management contacting cabin crew directly, when GLB is not met, and sometimes before they have finished their duty. They are asked to explain why the target wasn’t met. When there is so much time pressure how is anyone meant to know why things are 2 or 5 minutes delayed. My experience lately is that some cabin managers are trying to cut corners in order to achieve the targets. We always have a briefing when the day starts. The whole crew gets a chance to greet each other and discuss what is expected of the day. It builds the team and is often a good chance to highlight any potential issues. On two occasions over the last few weeks, cabin managers have tried to skip the briefing with the entire crew. When I insist, they immediately mention concerns that we are meant to start boarding imminently. It is obvious to me the cabin crew are under pressure.

    CHIRP Comment

    Part 1 – Sickness reporting/absence management

    Airlines are required by law to have a sickness absence policy. How this policy is formulated, agreed and then promulgated differs from airline to airline. For example, some airlines had a restricted number of sickness days and after these have been ‘used up’ crew may feel compelled to report for work, even if unfit, e.g. with colds, headaches etc. The use by this particular airline of interviews, or so-called ‘welfare meetings’ as part of sickness policy, is, according to other CHIRP reports we have received, often regarded as a form of disciplinary process rather than a genuine concern for an individual’s welfare, particularly if the meeting is not handled well. Of course, if an individual crew member has concerns about their health and fitness, they should always get advice from an AME, whenever possible. In reality, this is easier said than done since accessing an AME at short notice is rarely straightforward. Successful application of sickness policy, however, results in a clear responsibility on both sides. Firstly, flight crew have a responsibility, in accordance with their licence, to turn up for work fit and able to carry out their duties unhindered by sickness or for other medical based reasons, and they should do so in the knowledge that they are protected by employment law. On the other side of the arrangement, for airlines, having a fair policy in place is only the beginning. Policies should be applied as sympathetically as possible, with an appreciation that reporting ‘unfit to fly’ can be a stressful experience for flight crew. Airlines should understand that the perception of the employee could differ from the intention of the policy. In the CAA’s experience, most airlines are genuinely concerned about an individual’s fitness to fly, as responsible employers; very few employees have been sacked owing to application of a sickness policy. Welfare interviews are a fair and reasonable way for airlines to monitor an individual’s situation and to best support them in returning to work or to make suitable provisions to arrange roster cover for potentially long absences. However, the conduct of these interviews should be tailored to the individual situation with care taken over questions asked; for example, asking the question “why are you sick?” will always be more effective than “why are you sick so often?” Overall, airlines have a responsibility to make sure that the reason for the interview is well understood, is conducted in line with the stated sickness policy, and will not be perceived as a form of disciplinary process or in any way put pressure on employees to fly when unfit.

    Part 2 – Green Light Boarding (GLB)

    CHIRP accepted that the reporter genuinely felt that they were being held responsible for the aircraft not being ready to board passengers on time when GLB was being used. The company had a responsibility to ensure that such policies were well understood by those who were affected by them. The report highlighted potential tensions and differing priorities between the parties involved in the boarding process. GLB is intended to move passengers forward as far as the jetty only, ready to board, with the understanding that, if nothing is heard to the contrary, then boarding would occur on time. Provided that a robust mechanism is in place to stop the automatic boarding if required, then the system is a reasonable efficiency measure for airlines to implement. Clearly, the onus is on cabin crew to ensure that the message is promptly transmitted if the aircraft isn’t ready for on-time boarding. Communication chains and methods of transmission mean that there will inevitably be occasions when the message might not be transmitted effectively to the boarding team. Airlines need to ensure that crews report internally using ASR on those occasions when the ‘stop’ system malfunctions, including details of specific problems encountered. Provided there is a healthy reporting culture at an airline, this conversation between policy makers and those implementing the policy should enable incremental improvements to the system. In fact, GLB can be a good example of collaborative decision making if handled correctly. CHIRP appreciates that the departure team at the airport are not members of the airline and often have financial incentives to ensure, whenever possible, aircraft depart on time, which can sometimes put them at odds with the crew who might be dealing with a technical or safety issue on board. As an alternative perspective, from a straw poll conducted by CHIRP amongst several experienced flight crew and cabin crew, generally the GLB system is working better than is indicated by the general tone of the report.

  • FC5389

    –

    Flight crew refuelling operations
    Flight crew refuelling operations

    Initial Report

    At many airports, aircrew are required to manually operate the fuel panel for refuelling operations. This procedure requires us to manually operate switches on the fuel panel, whilst on a ladder and with a headset plugged in to a headphone jack in order to be in communication with the other flight crew member on the flight deck. My concern is lack of training, as many of my colleagues have never been shown how to operate the fuel panel during training. I was only shown once by a line trainer 10 years ago and this was just how to operate switches, and there is no guidance in any of our manuals on how to operate and what to do in case of an emergency. Some companies even require special training to be on a ladder. I’d like this investigated in order to clarify whether or not this is actually safe, and if there are any recommendations that you could provide.

    Airline Comment

    Refuelling procedures within [Airline] are fully approved by the [Regulatory Authorities] and the CAA. All flight crew are provided with comprehensive initial and recurrent training, which is contained with our Operations Manual (Crew Training Manual).

    The syllabus for this training is as follows:

    Refuelling Supervisor Training

    • Definitions
    • Roles and Responsibilities Flight Crew
    • Cabin Crew Special Refuelling Supervisory Responsibilities
    • Ground Crew Special Refuelling Supervisory Responsibilities
    • Responsibilities Refuelling Operator
    • Refuelling Supervisor Responsibilities
    • Refuelling Supervisor Responsibilities
    • Reporting requirements and procedures

    Operation of the Fuel Panel Switches  

    There are a limited number of cases where Flight Crew may be required to operate the fuelling panel; however, this restricted to the opening, closing and operation of the switching in the refuelling quantity panel only. Making any necessary nozzle connections to the fuel hydrant pit and the aircraft, operating the fuel vehicle will always be performed by the fuelling provider.

    All flight crew are provided with instructor-led classroom-based training on operation of the fuelling panel in order to facilitate the above.

    CHIRP Comment

    All AT pilots will be familiar with the general process for refuelling their aircraft type, as well as an awareness of the correct operation of appropriate switches in the cockpit. However, this isn’t the same as being properly trained on how to conduct safe refuelling operations, in practice, and when away from home base. The CAA’s view is that pilots should be trained on the refuelling process for their aircraft type, including talking through the process during line training as part of type-conversion. Subsequently, if pilots feel that they aren’t competent to take part in actual refuelling activities if and when asked to do so, then it’s important that they raise their concerns directly with management, who should then take steps to ensure that appropriate re-training and additional guidance is given. Reducing errors and mistakes, thereby minimising incidents and accidents, is in large part due to personnel being suitably qualified and trained and supported by relevant experience to maintain currency in standard procedures and be able to anticipate hazards as they develop during an operation.

  • FC5393

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    Sickness mobbing
    Sickness mobbing

    Initial Report

    I received a letter from my [airline] base manager, related to my days of sickness carried out in the last 12 months. Of note, for each day of sickness, I have always provided an approved medical certificate in accordance with our company and contract procedure. I have always provided a medical certificate on the first day of sickness to the company. Attached is part of a memo which I find evidence of “mobbing.” As a professional pilot, I will never put in danger my crew, my passengers, and my airplane by going to work unfit to fly, as mentioned on our Ops Manual.

    [NB For identification and confidentiality purposes, the actual letter provided to CHIRP cannot be reproduced in FEEDBACK; a summarised extract is provided below to indicate the type of language used.]

    “We recognise that flight crew will be absent from rostered duties from time to time and some absence is unavoidable. But, in your case, where repeated absence occurs, it impacts on the operational efficiency of our airline – we expect an immediate improvement in reporting for duty rates and reduction in sickness.”

    CHIRP Comment

    Having seen the original letter sent to the reporter from airline management, CHIRP firmly believes that it was a very poor example of formal communication from management to an employee. The wording would be upsetting and distressing to anyone receiving it, regardless of the circumstances and seniority of the employee. This report also raised a more general issue about safety culture at the airline whereby crew are being pressurised into flying owing to a fear of the consequences of not doing so. The report indicates an organisation that feels it is acceptable to write to employees in such a combative and threatening manner; especially concerning when the context is supposed to be welfare. CHIRP could see no mitigating reasons to send a letter with this tone and content. The reporter stated that they personally will continue to resist being pressured into reporting for work whilst sick. Not all crew members, particularly those at the start of their flying careers, may feel as able to stand up to such pressure from management.

    Please see CHIRP comments for FC5376 – Commercial Pressure, which also deals with another airline’s reported aggressive attitude to sickness which thus creates a pressure on crews to fly when unfit.

  • FC5394

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    Cleared to flight level below transition level
    Cleared to flight level below transition level

    Initial Report

    Published transition level by ATIS FL85. We were visual on approach to the airport. We were cleared to maintain FL50 by ATC. Once level, we were then re-cleared to an altitude of 4000’ on QNH 971. 1mb is about 30 ft so setting the local pressure setting resulted in the aircraft’s altitude being lower than the cleared altitude by a couple 100ft. The aircraft then climbed back up to the cleared altitude, exceeded it slightly then levelled off with no further issues. If the pressure setting was even lower this would cause further issues regarding clearance busts and potentially terrain clearance and MSAs. If the crew were in IMC this could become a dangerous situation with terrain. My other concern following this event is potentially having a wider issue with interpretation/understanding/SOPs of transition altitudes and levels. Having flown in other countries under other aviation authorities, this was always followed: When climbing, cleared to a flight level, set standard at the transition altitude. When descending, cleared to an altitude, set QNH at the transition level. The issue in this being non-standard is having aircraft potentially flying around on different altimeter settings below/above TA/TL.  I frequently observe crew when cleared to an altitude immediately setting QNH when above the TL and vice versa, setting standard when cleared to a level but below the transition altitude.

    CHIRP Comment

    QNH as low as reported here is sometimes referred to as a ‘double low’. CHIRP believes it would be unusual for a controller to issue a flight level below the transition level owing to losing another level in the stack, but since extreme lows of pressure were relatively rare in UK airspace, such a procedure would not usually cause a problem, as was described in the report. There is an acknowledged discrepancy between the ICAO standard procedure and the one used in UK airspace relating to pressure settings and transition levels, which can be confusing for foreign crews. Not least because the controller cannot be certain if QNH has been set by flight crews. Future work is being considered to change the SOP to align the UK with ICAO for UK airspace. However, in a situation of uncertainty, as described in the report, the crew still had the opportunity to question ATC whether it was a FL or altitude instruction if they were unsure – it is always better to check than to assume in such situations. Finally, the last sentence of the report, although describing an apparent anomaly, is in fact the correct procedure in UK airspace.

    This report usefully highlights that not all procedures are not the same in UK as for ICAO, which can clearly cause confusion for non-UK trained/based crews.

  • FC5397

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    Taxi Provision
    Taxi Provision

    Initial Report

    Company subcontracts taxi requirements for positioning crew. I have had drivers fall asleep on me in the past. During the last positioning journey the driver missed the exit off the motorway but swerved over the chevrons almost hitting the barrier to make the exit. Needless to say, l did not continue the journey with that driver. [Airline] send taxis that are too small for the number of positioning crew and their bags. Some of the taxis are not clean. My major concern is that our HOTAC department have no oversight of the vehicle or the driver when they arrive at the pickup point. How do they ensure the drivers are fully rested? How do they ensure a minimum standard of driver? Finally, l believe that the company is compromising crew safety for cost, and it is a matter of time before someone is injured or killed.

    CHIRP Comment

    It wasn’t clear from the report whether the taxi was used before or after a duty, which is an important detail. Use of a taxi for transport to a duty period can be considered a flight safety issue since the journey might impact how the crew member was subsequently able to perform when on flying duties. For example, having an anxious crew member reporting for duty after being driven by a dangerous taxi driver could adversely affect their performance/decision making in flight. However, a taxi journey after a flight is arguably a matter of duty of care/ employer safety. Notwithstanding, a company always has a duty of care to their employees even when some of its functions and roles are subcontracted, such as taxi/transport provision. When functions are subcontracted, the airline still needs to ensure sufficient oversight to be able to assess performance of the contract but also, as this reporter emphasizes, that safety aspects are also being met.

  • FC5396

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    Ground duties in own time
    Ground duties in own time

    Initial Report

    [Airline] expect flight crew to collect and setup new EFBs in their own time contrary to Operations Manual guidance to allow sufficient time for personnel to perform ground-based duties. Collecting and setting up a new iPad for company use is a duty required by the company therefore should accrue duty time. [Airline] are ignoring requests for this by email and arguing the point with those who challenge it in person with operational managers on the day. If the EFB is required by the employer to be used by pilots, then collecting it and setting it up should be done in company time and accrue duty hours accordingly. [Airline] will try anything if they think they’ll get away with it!

    CAA Comment

    This is an industry wide issue. CAA Flight Ops Inspectors have been advised that duty time should be allocated for such tasks. Ultimately, if companies wished to realise the benefits of new technology, they must also consider the impact on individuals required to operate the devices.

    CHIRP Comment

    This is an issue that has been reported to CHIRP on numerous occasions. On the face of it, perhaps a somewhat trivial one, but the number of reports we have received indicates it has become a genuine concern for flight crew. Some airlines now deliver all their training via iPads, whilst others still provide a full face to-face training package to new joiners. Therefore, training delivery methods are not standardised across the industry. When an update to training procedures contained on electronic devices is required, some airlines may not want to pay for multiple licences, which then requires flight deck crew to come to operations to wipe and then reload their iPad. Setting up the device again from zero, so to speak, may take up to an hour to accomplish. Not counting such activities as duty doesn’t feel in the spirit of the FTL regulations. In contrast, there are some airlines that do allow crew to make a booking to come in for the procedure as part of their duty time. Finding efficiencies with the use of new technology should obviously be applauded, moreover, there are significant training enhancements to be gained with the innovative use of online training methods. On the economic side, the introduction of such technology was clearly intended to save training costs for organisations. Therefore, paying flight crew (as duty time) to attend to reboot, or collect devices, might be viewed by some airlines as counterproductive. There is a balance to be achieved, and airlines should appreciate that with new technology also come additional tasks, which need to be reasonably accommodated when considering what constitutes a duty.