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ATFB 148

The risks of rostering

It’s not just flight duties, the overall scheduling of simulators, training and standby duties sometimes doesn’t take account of crews’ effective rhythms

Rostering and duty lengths have been the stand-out issues reported to CHIRP over the last few months, many of which reflecting what appears to be a mis-match between schedule requirements and resource availability. The inevitable outcome being that crews appear to be being rostered increasingly tight duty periods that risk becoming unsustainable. And it’s not just flight duties themselves, the overall rostering of simulators, training and standby duties sometimes doesn’t take account of crews’ effective circadian rhythm and acclimatisation. Scheduling brutal rosters with earlies followed by lates then earlies again is effectively causing the same effect as time zone and ‘WOCL’ transitions and should be recognised as such.

Although rostered duties may well fall within the published flight time limitations (FTL), some scheduling can be extremely disruptive to rest/sleep and contrary to rostering guidelines (for example, extremely early morning positioning for ground training within other duties can be highly disruptive and fatigue inducing). Company responses of ‘it’s legal’ need to be framed within ‘it’s safe/sensible’ and reflect the fact that current FTL regulations are permissive rather than being restrictive. ‘Legal’ is not the same as ‘safe’ – it’s ‘legal’ to drive at 60mph down a winding country road but rarely ‘safe/sensible’ to do so – and FTL maximums, imperfect as they are, should only be approached in extremis and in a carefully managed manner.

The nature of many of these reports mean that it’s impossible for us to disidentify them sufficiently such that specific circumstances are removed whilst maintaining their meaning and impact. As a result, often we can only generically engage with the operators because, much as we would wish that the tenets of Open Reporting and Just Culture are upheld, some crews fear that some management appear to be less than enlightened in this respect and infer their displeasure and potential consequences for crews. But that is why we have a confidential reporting process and, although we err on the side of caution with respect to contacting operators, CHIRP regularly passes on disidentified processed and anonymised intelligence to the CAA who then factor that into routine and ad hoc oversight activities focused on issues raised. Notwithstanding, we encourage reporters to continue to report through company reporting systems where they feel able so that data is directly collected and processed within their FRMS and which might then highlight trends and issues that cause changes to be made – without such reporting and data, little will change.

Commander’s Discretion gets another airing in this issue, and we’re aware that the CAA is also focusing on this in light of a number of reports from us and their own analysis of MORs; they recently sent an open letter to all operators reflecting on the fact that “… the use of Commander’s Discretion (‘CD’) is being inconsistently interpreted by industry stakeholders, leading to inappropriate application (or the perception of inappropriate application) of CD.” On an associated theme, controller rest is also a topic of concern, but from 2 opposing angles. Some controllers are concerned that they are being pressured to operate beyond the rules for duty versus breaks, whilst the other angle is the seeming incoherence of flight crews having to employ Commander’s Discretion when faced with temporary ATC closures at regional airports because controllers are having a mandated break and there’s no other controller to replace them. Just as for Commander’s Discretion, the circumstances pertaining at the time are crucial, and it should be recognised that controllers can exceed their duty times but each exceedance must be formally reported. Accepting that there is a risk of direct pressure being applied by in situ senior managers, perhaps it’s time to look at defining some form of ‘Controller Discretion’ that, subject to a controller’s personal decision on their ability to do so versus traffic density, workload etc, allows for minor extensions of duty to facilitate continued operations without the penalty of a formal report? Overall, it seems that fatigue management is not well developed in some ATCU safety systems and so there’s probably also a need for better awareness of the effects of fatigue on controllers in general.

Finally, we’re rapidly approaching winter in the UK and Europe and so the extra considerations of cold weather operations also have to be factored into the post-COVID-19 ‘new normal’ for many. Many crews will be used to operating into colder climates throughout the year, but the extra pressures of returning to a UK environment that may not be so well rehearsed in cold weather operations as in previous times bears consideration. Some third-party service providers may well still be recruiting and training new staff to aviation who may not have extensive experience of cold weather operations (last winter was fairly mild) and so extra vigilance will be required if there is a cold snap where runway clearance, apron operations and de-icing crews may not be on top of their game. The prospect of operating with potentially fatigued crews who are new to cold weather operations in dark, miserable weather conditions adds another level of complexity to the calculation for all those involved, be they flight crew, cabin crew, engineers, controllers or ground-handling staff. There’s lots of scope for errors and mistakes to mount up as we cope with cumulative pressures that, in themselves, would otherwise be easily handled individually.

The bottom-line? CHIRP provides a vital safety net as another route to promote change when the normal channels of reporting aren’t delivering results, you don’t feel able to report through company systems, or for collecting reports with safety concerns that did not meet the threshold for normal reporting and might otherwise have gone unwritten. We rely on you to report Human Factors related aviation safety concerns to us so that we can both help in their resolution and highlight relevant issues to others. Reporting is easy by using either our website portal or our App (scan the appropriate QR code shown or search for ‘CHIRP Aviation’ – avoiding the birdsong apps that may come up). In our reporting portal you’ll be presented with a series of fields to complete, of which you fill in as much as you feel is relevant – not every field is mandatory, but the more information you can give us the better. Although you’ll need to enter your email address to get access to the portal, none of your details are shared outside CHIRP, and we have our own independent secure database and IT systems to ensure confidentiality.

Steve Forward, Director Aviation

In Memorium

CHIRP is sad to hear that Chris Morris, an Air Transport Advisory Board member since October 2017, sadly passed away this summer. The CHIRP team would like to offer Chris’s family our deepest and most sincere condolences.

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  • ATC833

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    Rest-period tasks
    Rest-period tasks

    Initial Report

    With the removal of SRATCOH [as a result of the introduction of CAP670 Part D], I feel that the issue of additional tasks taken on during breaks is not well regulated. Our unit has introduced their own rule stating that “ATCOs may undertake additional tasks during their breaks, including meetings, if such tasks do not cause mental or physical fatigue”. Due to chronic staff shortage (which is unlikely to improve in the near future) there is virtually no facility time available so this modification appears to have been introduced to allow administrative tasks to be completed despite the lack of staffing. Until a task or meeting has been completed how will an ATCO know whether it has caused mental fatigue? Also by this point you will be scheduled to recommence providing live operational duty. If you then declare yourself as fatigued, it is likely that an operational position will have to close. At a small airport such as ours this can lead to a full closure of the airport and this can cause you to feel obligated to continue working. I feel this modification has been introduced for the sole benefit of the management and to the detriment of the operational staff.

    My major concern caused by the introduction of this rule is the ability of our management to try and cover the shortfall in our staffing by making those of us left carry out all the required administrative tasks while “on duty” but within our breaks from the operational position. Our management say there isn’t a problem because the instruction only says “MAY carry out additional tasks IF they don’t cause mental or physical fatigue” but you won’t know if you feel fatigued until after the meeting/administrative task and that will be just as you are about to resume live operational duties.

    CHIRP Comment

    UK CAP670 Section D is largely silent on what may or may not be done during breaks other than to give broad guidance on what should constitute a ‘Break’ in itself as in Para D27 below.

    CAP670 Part D Para D27: “Breaks shall include all measures necessary to ensure that controllers will not be suffering, to any extent as a consequence of their duties, mental or physical fatigue whilst exercising the privileges of their licence. Such measures are expected to include a certain detachment from the operation, e.g. rest areas, some of which shall afford the individual ‘quiet space’ and facilities for adequate refreshment.”

    Part of the problem is that administrative staff who had previously dealt with many of these tasks are often now no longer employed at many units due to resource constraints and so increased burden and pressure is falling on controllers to manage and conduct additional administrative activities in addition to their core workflow. As a result, there are undoubtedly additional tasks that need to be done by controllers but they should not necessarily be expected to do so during breaks. Moreover, extraneous tasks that are not required for regulatory purposes should be shed, and ANSPs should review the remaining administrative/ancillary tasks that they are expecting controllers to do during breaks to evaluate the risk/benefits so that everyone is clear as to their likely demand. These risks/benefits and safety justifications should be transparently stated and continually reviewed as part of the unit’s change management process so that controller activities and fatigue levels are appropriately monitored.

    CHIRP has previously reported on similar concerns about additional tasks that might cause a conflict with SRATCOH in July 2020’s AT FEEDBACK Ed 135, Report 13 where we stated:

    “Whilst SRATCOH provides guidance on duty hours, the critical factor is whether controllers are actually feeling fatigued. Any mandated non-control duty counts towards the ten hours SRATCOH limit, but some meetings are considered voluntary and therefore do not technically affect SRATCOH. Irrespective, it is essential that an ATCO removes themselves from duty and report instances of fatigue whenever they occur. That being said, it is more prudent to prevent the situation in the first place, and use the guidance provided under SRATCOH to help avoid known situations where fatigue can become an issue. If extra duties are to be carried out in addition to a full operational shift, then it would be better to do these extra duties after the operational part of the shift, rather than before – some units reduce the finish time for afternoon/evening shifts if meetings are conducted in the morning, and allow the option of attendance or not for afternoon meetings if morning shifts have been carried out. Ultimately, an ATCO is fully within their rights to refuse to attend any meeting prior to a full ATC shift.”

    The CAA commented in Ed 135 that completing additional tasks such as this was voluntary and so it was up to controllers to either accept them or decline. That is easy to say in theory no doubt, but somewhat harder to do in practice at small units where resources are constrained and some additional tasks simply have to be done to ensure the smooth operation of the unit.

  • CC6337 (AT)

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    Flight Deck Rest
    Flight Deck Rest

    Initial Report

    I [Cabin Crew] called the flight deck to make my routine check via interphone, there was no answer, this is concerning. One FO was in flight crew rest, leaving an FO and Captain in the flight deck. I proceeded to enter the usual code into the flight deck door keypad, initially there was no answer, after a good 10 seconds I was allowed entry and asked to be quiet as the FO was in-seat napping. The flight crew had not made the crew aware that both FO’s we’re napping at the same time.

    CHIRP Comment

    Cabin Crew Advisory Board (CCAB): The pilot in command  should have informed the senior cabin crew member of the intention of the flight crew member to take controlled rest, frequent contact should be established between the non-resting flight crew member and the cabin crew.

    Air Transport Advisory Board (ATAB): CHIRP has received a number of reports in the past from cabin crew regarding the procedure and practice of flight crew Controlled Rest, and it’s one of those areas where reminders about what the process should be are useful. Controlled Rest is sometimes referred to as ‘in-seat-napping’ and is used by most UK operators. It is the process where the flight crew can be ‘off task’, including taking short periods of sleep, whilst temporarily being relieved of operational duties in accordance with company prescribed ‘controlled rest’ procedures. UK regulations GM1 CAT.OP.MPA.210 ‘Crew members at stations’ describes the overall rules for conducting Controlled Rest, which is limited to 45mins per individual at any one time, with a maximum of 30mins asleep so that they don’t enter deep sleep/sleep inertia. Under Controlled Rest, one member of the flight crew should always be awake at all times and, although flight crew can sequentially take controlled rest, there should be 20mins between such periods to ensure that the crew member who has come out of rest is fully alert and briefed before the other one enters rest. Controlled Rest should only be used during periods of reduced cockpit workload i.e. during cruise, and has been proved to increase alertness levels during other critical stages of flight such as the approach and landing. Some of the longer-range aircraft have designated rest areas for the flight crew to use but these should only be used when there are more than two flight crew rostered to operate the flight.

    The need for flight crew to inform cabin crew that they are undertaking Controlled Rest is a fundamental requirement both to ensure that such periods are not interrupted by the cabin crew but also for safety reasons so that the cabin crew can ensure that both operating flight crew have not inadvertently fallen asleep. The flight crew must tell the cabin crew how long they will be conducting Controlled Rest for, and the plan for regular contact intervals (e.g. every 30mins) to ensure that communications between the cabin crew and flight crew are maintained. In support of this, there should be procedures stated in the company’s OM-B for how controlled rest will be managed. When conducting contact at the prescribed interval, cabin crew should understand that an immediate response may not be possible if the awake flight crew member is busy with other tasks such as communicating with ATC or carrying out critical flight activities that delay them responding.

  • FC5246

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    Simulator unfit for training
    Simulator unfit for training

    Initial Report

    Today has finally made me submit a report due to the inoperative A/C in the simulator. It could not be controlled and went as low as 13°C which is against health and safety guidelines for working indoors. We resorted to wearing jackets, hats and scarves to complete the training, which is not acceptable. This has been flagged to training management who appear to be ignoring the problem with one even telling me he could lend me his hat if needed (not funny and shows the disdain held for the trainers). This is on top of numerous faults being carried in the simulators which have not been working for months and I can’t believe it is considered as acceptable to use them for training let alone testing. We are all very good at adapting in order to complete the task but it just seems we are not being heard and nothing is getting done which will ultimately impact the quality of the training.

    CHIRP Comment

    Environmental temperature is something that should not be compromised because it not only has wider health and safety implications but can also lead to cognitive decline as temperatures reduce. Noting the airline’s comments about instructor responsibilities and empowerment, CHIRP is heartened that they will re-emphasise these during instructor recurrent training but the issue remains that in the incident described it appears that the third-party simulator operator had not responded to fault reports in the past. Whilst less than desirable, and subject to MEL requirements for specific training activities, we suggest that instructors faced with similar conditions should stop the training detail until MEL requirements are met; that will soon get the attention of both the airline and the third-party operator when the airline subsequently asks questions.

  • ENG729

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    Part M/145 organisation resources
    Part M/145 organisation resources

    Initial Report

    All areas of engineering at [Location] are at breaking point. There is simply not enough staff employed to conduct the work to a satisfactory standard. CAMO has recently reported that unsecured access panel reports are increasing exponentially. It is only a matter of time before another [Registration] incident (or worse) occurs.

    So many staff are leaving or have already left! To [Alternative Operator] mainly but there are other places recruiting and paying more. Morale is really low and ADDs are through the roof because there’s no spares. Our lineside vending machine has been broken for months. Not enough vans, etc, but we’re told by senior management that everything is fine, that the rate of attrition is no more or less than anywhere else. It’s worse than I’ve ever experienced in my time at [Operator]. We’re managing to keep going because of overtime but I feel sorry for the [Engineering Section A] staff, they’re really struggling, especially the [Aircraft Type] Engineers. The news that [Engineering Section B] are closing and they and the [Terminal A] staff are moving to [Terminal B] just means that more qualified people will be leaving. They’re in [Engineering Section A] because that’s what they prefer to do, apparently 4 of them immediately said they were leaving. And management won’t talk about pay.

    CHIRP Comment

    This report is one of several in relation to this operator, some of which are still in progress. A number of these have been passed straight to the CAA to add to their records of safety issues. It should also be appreciated that CHIRP has received a number of similar reports in relation to various other operators with exactly the same post-COVID safety concerns.

    Although the remit of CHIRP means that we cannot enter into any discussions about remuneration or industrial relations, manning levels; the number of carried-forward defects; and insufficient ground vehicles are of course safety issues and so this report was passed to the CAA with the reporter’s consent. We note the CAA’s comments about increased oversight of this operator as a result of reporting, and it is vitally important to continue reporting such problems internally so that trends and patterns can not only be identified by the company but also so that the CAA, your employer’s customers and their National Aviation Authorities can become aware of issues when and if they request a review of Internal Reports. Resolution of these issues will be a long-term prospect but at least the company and regulator are aware of the issues and hopefully applying suitable mitigations (the operator has reduced its flying as one mitigation). When submitting an Internal Report, it is important to differentiate between industrial relations, safety and human factors issues. CHIRP is of course ready and able to investigate your Human Factors reports and forward safety concerns to the CAA so that they can either become whistle-blower reports or at least be recorded for trends and statistical purposes.

  • FC5280 / FC5281 / FC5282

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    18hr awake ‘rule’
    18hr awake ‘rule’

    Initial Report

    FC5280 Report text: Recent communication from our Chief Pilot was aimed to ‘clarify’ the 18hr awake guidance we have in our manuals. This has been triggered by multiple pilots using this guidance to report as unable to perform a duty. The tone of this email is very clearly pressure being applied from above on pilots to operate the schedule they have very poorly designed from the outset. The biggest culprits are deep-night duties and our extended 2-sector duties which have the highest cancellation rates.

    Standbys are being rostered to start at 1400L where call-outs are being made for pilots to operate deep-night duties. These are typically scheduled to land back to base at 0500L to 0700L. The inference from the company by rostering like this is that the crew member should be adjusting their sleep periods to move towards these late duties in their own time on their own days off. A typical 3 days off would allow the circadian rhythm to only move about 4 hrs, which would still put a deep-night duty at the extreme end of the company’s own 18hr limit. A 1400L standby on day 1 after days off is fine but the expectation on the part of the company must be that a crew member can only operate a reasonable duty. A finish by 2am from this example would be reasonable as this could assume something like an 8am natural wake up as circadian rhythms predicate – a 7am finish is unreasonable.

    We have hundreds of new pilots in the company who are going to be very easily influenced by someone like the Chief Pilot and will now feel pressure to operate beyond what they should safely do. [Airline] seem to have forgotten their own responsibility to create safe rosters and put far too much onus on individual crew members.

    FC5281 Report text: [Airline] have recently picked up several night slots operating from 6-9pm and finishing 6-9am. Whilst if rostered this can be managed, a significant number of them are uncrewed on roster publication leading to Standby call outs. When on Home Standby, it is reasonable to be awake at 9am, regardless of the Standby start time. This subsequently leads to a period awake of roughly 24 hours and when quoting to crewing the 18hrs awake/reduction in FDP they’re extremely reluctant to change anything.

    We have recently had an email from our Chief Pilot applying lots of commercial pressure to be asleep until our Standby starts in order to complete these duties. Quite frankly I think it’s utterly ridiculous and stems from the company not adequately crewing the operation.

    FC5282 Report text: Our Chief Pilot issued an email reminder on the use of the 18hr awake rule when called from Standby. This is mainly related I believe to the overnight flights that [Airline] have been operating since last summer. These have proved difficult for the company to crew as they are effectively trying to operate package holiday flights while the organisation is setup to operate a scheduled service. This has resulted in them often being crewed by staff who have been called out from Standby duties that are not really aligned with the night flights.

    The latest email guidance from the company is that the 18hrs should only refer to the sum of the Standby period added to the FDP and that crew should be managing their rest appropriate to the Standby period. This seems to match the CAA guidance but surely it is madness to expect someone who has, for example, a 1415L Standby start embedded in a standard roster of lates (that might involve reporting early afternoon and off duty around midnight) to stay asleep until 1415L in case they get called to do a late duty?

    There are already plenty of stories doing the rounds of crews really struggling to operate safely when bringing a plane back into [Airport] in the middle of the morning rush and now we have some added commercial pressure to continue to operate when it’s not really sensible. Doesn’t look like a good recipe to me!

    CHIRP Comment

    The first key issue is whether being ‘awake’ is counted from the start of Standby or when actually awake. The guidance for 18hr maximum ‘awake’ calculation for time on standby plus FDP is somewhat vague in this respect and simply comments that the combination of standby and FDP should not lead to more than 18hrs awake time. The company email, says that they limit Home Standby to a maximum of 8hrs so their expectation is that there are at least 10hrs of FDP time available if someone were called at the end of the standby period and they were awake at the beginning of their Standby.  It is this awake time that is in contention given that people may well have been awake before their Standby starts depending on their previous roster/life activity. The human body cannot simply be switched on and off and so it is the impact of that pre-standby ‘awake’ time that needs to be considered but is not factored into regulations.

    This issue is akin to acclimatisation in circadian rhythm terms – the start of a standby period ought perhaps to be looked at in terms of effective time zone transitions from the previous duty so that an assessment of human performance can be made; that sounds complicated and involved but there may be ways of thinking of it in these terms to provide a firmer basis for rostering based on what might be expected of the human body. A table might be produced for those transitioning to standby from a previous rostered duty that reduces the ‘standby and FDP’ awake time allowed depending on the temporal relationship between the previous duty’s end and the Standby duty’s start.

    CHIRP considers that it is not unreasonable for companies to expect crews to condition themselves in terms of rest on days off before duties so that they effectively ‘acclimatise’ to the duty ahead, but there are limits as to what can be expected in normal day-to-day operations. To be fair to the company, the email does state that: “In the event that the crew member is insufficiently rested to complete the full advised FDP, the individual should explain this to the Crewing Officer who will consider whether there are other options available.” The bottom-line is that crews need to be sufficiently rested for the potential duty they might be asked to do and this might have to involve sleeping at odd hours during days off so that they are rested sufficiently to do the 18hr ‘standby plus FDP’ period (albeit the 18hr awake time is purely guidance).  If crews are not sufficiently rested when called from Standby then they are correct to report as fatigued and the company email highlights that: “In the event that the crew member states they are insufficiently rested to perform any FDP a Fatigue Report Form should be completed in the normal manner, within 72 hours of the conversation.”

    The corollary question from all of this is, “Are days off really days free from duty if people are expected to condition themselves for subsequent ‘work days’ given that this might involve serious disruption to their ‘day off’?” but that is part and parcel of being a professional pilot to some extent.

    Associated regulations:

    CS FTL.1.225 Standby

    (b) Standby other than airport standby:

    …

    (2) The operator’s standby procedures are designed to ensure that the combination of standby and FDP do not lead to more than 18 hours awake time;

    GM1 CS FTL.1.225 (b)(2) Standby

    AWAKE TIME

    Scientific research shows that continuous awake in excess of 18 hours can reduce the alertness and should be avoided.

    CAP1265 EASA FTL Q&A

    How do you apply CS FTL.1.225 (b)(2)? What is the definition of “awake time”?

    CS FTL.1.225 (b)(2)

    …

    EASA have not provided a definition of “awake time”. A straight forward mathematical answer is not possible. There is no expectation on the operator to verify how long a crew member has been awake.

    However, the operator has to design its standby procedures in a way that the duty in combination with the FDP will manage this limitation. The operator can only manage what it has control of (the standby and FDP). The operator’s procedures need to demonstrate how the awake time is managed. It is reasonable for the operator to expect a crew member to manage rest and nap opportunities in pre- duty rest periods and while on standby to enable them to carry out an FDP. The expectation is on the design of the procedure.

  • FC5275

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    Disruptive PAX
    Disruptive PAX

    Initial Report

    I am deeply concerned about the lack of action being taken regarding disruptive passenger behaviour, fuelled by excessive alcohol consumption and drug use affecting flights to a well-known party destination in the Balearic Islands. My cabin crew are constantly having to deal with passengers who are either unable or unwilling to comply with safety instructions, or who are abusive and disruptive during the flight. While the company have made it clear that the crew are empowered to cease the sale of alcohol on board if necessary, this is totally ineffective if the majority of passengers are already intoxicated when they board the aircraft, or deceptively consume their own duty free purchases after take-off.

    I have operated flights in the past where there has been so much disruption in the cabin that, had an emergency situation arisen, I very much doubt that the cabin crew would have been able to a) successfully brief the passengers for an emergency landing or b) obtain any kind of compliance or meaningful action in the event of an evacuation. Sadly, I think it’s only a matter of time before an incident occurs on one of these flights and the lack of sobriety by the majority of the passengers will be the direct cause of either injury or death.

    Article 242 of the ANO states that nobody must enter an aircraft while drunk or be drunk in any part of an aircraft. This is extremely difficult for the gate staff to implement if a large percentage of passengers who are boarding are intoxicated. There have been numerous attempts in the past to reduce these kinds of incidents; police presence at the departure gate, pre-flight communication to passengers regarding the potential consequences of disruptive behaviour on a commercial flight etc, most of which have done very little to improve the situation. The CAA, in conjunction with retail outlets, pubs and bars need to implement a system whereby the sale of alcohol can either be limited or withheld from customers travelling on certain routes.

    CHIRP Comment

    Disruptive passengers are a particular problem at the moment and are recognised as such by the industry and regulator; this matter has also been discussed by the CHIRP Cabin Crew Advisory Board (CCAB) who have published associated comments in Cabin Crew FEEDBACK Edition 81 offering practical advice about de-escalation but CHIRP agrees that more should be done to deny boarding of potentially disruptive passengers in the first place. We note that the first reading of the ‘Aviation Banning Orders (Disruptive Passengers)’ Bill recently occurred in Parliament (24th May 2023) and this is intended to give some legal basis for action. However, the second reading in Parliament is not due until 24th November 2023 and so, although a welcome initiative, this is not expected to provide any productive resolution this year.

    Part of the problem is that responsibilities for action are not clear: ground staff often just want to get rid of the problem by getting passengers onto the aircraft; airport bars and pubs want to maximise profits; and cabin crew are then often left to deal with the problem. As the commander of the aircraft, captains have a responsibility to support overtly and visibly (when practical) their cabin crew in the handling of disruptive passengers, and airlines could also usefully collaborate with an exclusion list such that problem passengers identified by one airline are banned from all airlines.

    Within Annex 17 ‘Aviation Security’, ICAO defines a disruptive passenger as: “A passenger who fails to respect the rules of conduct at an airport or on board an aircraft or to follow the instructions of the airport staff or crew members and thereby disturbs the good order and discipline at an airport or on board the aircraft.” ICAO also defines a hierarchy of 4 levels of disruptive behaviour as below, and the Skybrary article ‘Unruly Passengers’ provides useful further material.  Legal action in respect of Level 3 and 4 is probably fairly straight-forward, but Level 1 and 2 transgressions are harder to deal with legally, and the threshold for when a Level 2 transgression becomes illegal under the Offences Against a Person Act 1861 is sometimes hard to determine. In regulatory terms, once the associated Aviation Banning Orders Bill mentioned above has passed through Parliament and become law, the acceptable level of evidence for legal action and bans should be clearer and more could probably be done in defining how to deal with such incidents, the powers of gate staff / cabin crew and the permitted levels of intoxication of passengers.

    ICAO Hierarchy of Disruptive Behaviour

    Level 1 – Disruptive Behaviour (verbal)

    This can include: irrational or disorderly behaviour involving alcohol or drugs; abusive language; and defiant actions such as non-compliance with Crew Member commands.

    Level 2 – Physically Abusive Behaviour

    This can include: pushing; grabbing; hitting or kicking a cabin crew Member or another passenger; damage to aircraft equipment and systems; or damage to the personal effects of a Cabin Crew Member or another passenger.

    Level 3 – Life Threatening Behaviour (or display of a weapon)

    The involvement of a weapon in any passenger disturbance immediately increases the level of threat. A weapon is a means by which terrorists can rapidly achieve control of a large number of passengers and cabin crew by intimidation.

    The threat of a concealed weapon, the display of a weapon and the use of a weapon are all life threatening scenarios. When there is a threat of a concealed weapon cabin crew should attempt by peaceful means to confirm the existence of the weapon. When a passenger’s behaviour deliberately threatens life, with or without a weapon being displayed, then the cabin crew should assume that the action may escalate into an attempted hijack. Weapons include: guns; explosives; stun guns; knives, any item incorporating a sharp point or edge; and wires and cords etc.

    Level 4 – Attempted or Actual Breach of the Flight Crew Compartment

    The highest level of threat is an attempted or actual breach of the flight deck, whether intended, threatened or achieved. Hijackers may concentrate on violence or the threat of violence against cabin crew and passengers in order to gain access to the flight deck, rather than an initial attempt to breach the flight deck.

    Any threat or attempt to gain access to the flight deck has one purpose, to gain control of the flying of the aircraft, which may include the possibility of using the aircraft as a weapon.

  • FC5274

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    Financial incentives being paid to close doors on time
    Financial incentives being paid to close doors on time

    Initial Report

    At [Company] we have had a critical time path outlining where we should be and when, from arriving at security to arriving at the aircraft with the aim to be doors closed and Ready To Go (RTG) at Target Off-Blocks Time (TOBT) -5 minutes (RTG-5). Poor levels of on-time performance (OTP) can be attributed to many reasons: aircraft technical delays; only one gate staff being paid for to complete boarding; or cabin crew being expected to clean aircraft, including hoovering, prior to completing their safety critical tasks. In an effort to improve our OTP, management have offered financial incentives to both Flight and Cabin crew to meet RTG-5 targets. In my mind this just puts another hole in our Swiss cheese model that crew need to protect against. Our industry’s history is littered with incidents that have been caused by rushed departures or arrivals, and I fail to see any justification from a flight safety perspective to take this course of action.

    CHIRP Comment

    CHIRP is also concerned that such incentives could encourage unwanted/unsafe behaviours as people potentially try to cut corners in order to achieve the payment criteria.  We also note that, in some locations, ground handlers also receive incentives for achieving on-time or early departures and so the problem might be more endemic than it appears. The problem is akin to ‘press-on-itis’ in its potential for safety impact through people accepting poor, ill-considered or rushed outcomes by deviating from procedures. Whilst the concept of incentives is not unsafe in itself if enacted appropriately, their introduction needs to be done with appropriate mitigations in place to ensure that short-cuts are not made and safety is not compromised. CHIRP has passed on this report to the CAA who have agreed to review the matter in order to understand more specifically what is going on and, in the short term, they have increased their oversight of the company involved in order to review this and related concerns.

  • FC5277

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    Commander’s Discretion
    Commander’s Discretion

    Initial Report

    The Captain informed operations at the outstation that they would not be applying Commanders Discretion (CD) for the return 4th sector to homebase in accordance with the guidelines in our OM-A. Operations told the Captain to call the Duty Pilot to discuss the matter because Operations don’t deal with CD. As a courtesy, the Duty Pilot was contacted and they said that they had to complete a form for each Captain who doesn’t wish to exercise CD. A Captain should not normally have to provide reasons as to why CD is not exercised. Only the Captain can make the decision for CD, it’s considered exceptional, in unforeseen circumstances, and should be avoided in homebase with available standby crew; non-exercise of CD should be non-punitive as per guidelines in accordance with our OM-A. Nevertheless, the Captain was willing to explain his rationale briefly in not applying CD due to sustained TSRA at homebase and other issues heavily impacting the current FDP including an almost medical emergency with pax, multiple CTOTs, challenging non-precision approaches, and continuous CB avoidance in Southern Europe. What then ensued was that the Duty Pilot interrogated the Captain by suggesting hypothetical scenarios irrelevant to the current FDP.

    All possible direct and indirect negative insinuations from the company, including from the Duty Pilot and Operations, should be removed when Commanders decide not to exercise CD so that a non-punitive, Just Culture environment is ensured that supports the safety decisions made by the Commander.

    CHIRP Comment

    CHIRP has received many reports concerning Commander’s Discretion in the last few months, including alleged pressure to apply discretion so that the aircraft can return to homebase following delays; retrospective requests to complete discretion reports post-flight when it is discovered that a crew member exceeded their FDP; manipulation of flight schedule timings associated with use of discretion; pressure to use discretion to resolve disrupted schedules; and requests to use discretion when aircraft are delayed during turn-round or preparation for flight.

    CHIRP last commented on Commander’s Discretion in our April 2023 FEEDBACK Edition 146 where we highlighted the associated regulation (ORO.FTL.205 Flight Duty Period(f) and related AMC1 ORO.FTL.205(f)). As we said before, “The use of commander’s discretion is not a safety issue in itself provided it is managed properly. Importantly, it should not be used on a planned basis but is intended to be employed for those unplanned and unforeseen circumstances and delays that occur during a duty and which would take the crew beyond the normal FDP limit.” Moreover, and acknowledging that there have been plenty of resource and scheduling issues as companies still recover from the impacts of the COVID pandemic, the regulations are clear that the exercise of commander’s discretion should be considered exceptional and should be avoided at homebase and/or company hubs where standby or reserve crew members should be available (AMC1 ORO.FTL.205(f)(a)), and that operators shall implement a non-punitive process for the use of the discretion (ORO.FTL.205(f)(6)).

    Although the management of unforeseen circumstances during flight operations is a shared responsibility between operations management, flight and cabin crew, it is the Commander who exercises their overall responsibility for the safety of the flight as the final arbiter of any decisions: at his/her sole discretion, the Commander may extend the Flight Duty Period providing he/she considers that the safety of the flight will not be adversely affected by that extension. Whilst the Duty Pilot or Operations might offer suggestions and assistance in the decision, there is a fine line between this and applying direct or inferred pressure to use Commander’s Discretion, and we commend the reporter in the case above for standing up to such perceived pressure in the face of what seem to be significant weather and external safety influences.

    The pressures of contemporary operations and rosters mean that the use of Commander’s Discretion appears to be becoming more of a regular rather than exceptional event. Although easy to say when not facing the multitude of associated pressures and potential poor behaviours from the company system, commanders need to ensure that they comprehensively assess all of the relevant factors to ensure that the safety of the flight will not be adversely affected before deciding to use their discretionary privileges to resolve any unplanned or unforeseen circumstances. Supporting this, the CAA recently sent an open letter to all operators reflecting on the fact that “… the use of Commander’s Discretion (‘CD’) is being inconsistently interpreted by industry stakeholders, leading to inappropriate application (or the perception of inappropriate application) of CD.” Within this note they emphasised that “The operational consequences of the Commander considering it inappropriate to extend the crew duty period after report, including the possibility of a night-stop down-route, has to be accepted and no commercial pressure can be applied at any stage.”

  • FC5255

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    Cumulative fatigue
    Cumulative fatigue

    Initial Report

    I have been a Captain in this airline for many years and I am deeply concerned about the rising fatigue levels amongst my colleagues. This is coupled with a deafness and an attitude of denial by management, who seem unprepared to do anything to address it which may require a reduction in the flying programme and therefore loss of revenue. I have had several occasions during the previous year where I have taken in-seat rest during a long night flight home, opened my eyes during this period and found the First Officer fast asleep, or they have fallen asleep on me during a critical stage of flight. Many pilots are managing this by taking anything up to 3 hours ‘in seat napping’ which is far beyond what was ever envisaged or intended with ‘controlled recovery rest’, a practice to be used in extremis.

    What concerns me more is that, as a result of demonstrated unfairness of the handling of many pilot’s careers during the pandemic and their subsequent re-hiring, many of them are afraid to speak up or report fatigued for fear of not passing their command interview. The lack of feeling of security or trust is palpable. I feel that the understanding and respect for the challenges of our profession are virtually non-existent under the present management structure, and everything is geared towards working pilots into the ground and rolling the dice on safety.

    I submit many fatigue reports with honest reporting on the level of fatigue I do or do not experience on a flight, but those which I have scored most harshly, along with my colleagues, have never changed. I have submitted many reports on poor or inadequate hotel accommodation (another area which has been targeted for aggressive savings) and these are completely ignored, despite the obvious impact they have on fitness to operate home. Coupled with a morale that frankly I have never known to be worse in all the years I have been here, I am concerned that our management are just walking us into a serious incident or worse. Their bonus-focussed culture promotes denial of any issue that may point back to decisions they have made earlier. We have had a few eras of challenging morale in the past, largely caused by a similarly aggressive management approach which was resolved by a change of faces at the top. But I have never known it to be as bad as this, and the career vulnerability that many people now feel after the deliberate attack on seniority during the pandemic, means many are terrified of speaking up or voicing their concerns, or calling fatigued. This is the area that concerns me the most.

    CHIRP Comment

    This is one of those reports that we receive and which we cannot address with the company due to identifying aspects. Notwithstanding, we have shared the fuller report with the CAA and they have included it in their enhanced oversight activities. The CAA don’t share specific information with us due to commercial sensitivities but confirm that they are in regular contact with the company to ensure that they are operating safely and appropriately.

    The reporter’s heartfelt comments chime with other similar reports not just from this company but also others operating in the UK. Whilst recognising the problem of ‘fatigue-reporting fatigue’ wherein people stop reporting because they don’t feel listened to, we can only re-emphasise the need to continue reporting through the company systems where you feel able otherwise there is little prospect of changes being made without a weight of data to indicate trends and issues. Although the reporter comments that little changes as a result, it certainly won’t if no reports are made and, at some point, CAA scrutiny of company processes and statistics will come to bear. Perhaps the biggest concern in all of this is the perceived lack of trust between crews and management, which is the bedrock of Just Culture reporting. The pursuit of safety is a shared endeavour between management, crews and back-office staff at all levels; if these actors are not pulling together then safety can only suffer in the relentless drive for efficiency and productivity.

  • FC5256

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    Absence management
    Absence management

    Initial Report

    In the past few days I received a “memo” from the Flight Operations Base Manager informing me that the company had noticed a trend of repeated sickness absences on my part over the past 12 months. In the last 12 months I have been forced to be absent from work [ ] times, for a total of [ ] days of illness and always communicating it to the company at least 12 hours before duty: certainly not numbers outside the average and, in addition, all absences have been certified by an AME doctor.

    The worrying fact of the memo, however, was the somewhat threatening and prejudicial terminology used. [To paraphrase the company’s letter, they stated in no uncertain terms that the reporter was expected to report for duties. The company went on to threaten the reporter that they would be monitoring their attendance in future and expected to see an immediate improvement because their absences meant that others had to be called from Standby and this disrupted the company’s operations].

    I am a professional employee who is dedicated and passionate about the work I do and I believe to contribute positively and proactively to the success of the airline I work for. It is precisely for this reason that I believe that this type of communication constitutes a serious hazard to the safety of the company’s operations, placing unfair pressure on the crews and their professional judgment regarding their fitness to fly and a violation of the current Regulation (MED.A .020(a)(1)).

    CHIRP Comment

    There is a need for industry-wide protocols that reflect best-practice regarding absence management. The legal requirement for crews not to fly when unfit to do so remains paramount and companies must honour the fact that some more routine ailments for those on the ground can affect those who fly in a fundamentally different way due to physiological aeromedical issues. The CAA say that they acknowledge this and are working with the UK Flight Operations Liaison Group (FOLG) ‘fitness to fly’ and ‘fatigue’ sub groups to see if it is possible to construct common fundamental principles, policies and protocols that reflect best practice. Whilst this cannot address individual ailments and circumstances, which will always have specific ramifications, it is the way that companies administratively deal with sickness / absence management that is the issue so that crews do not feel pressured to operate when they are unfit to do so. Associated with this, the CAA are also looking at the issue of when long-term fatigue should be classified as long-term sickness so that any potential underlying medical concerns can be clinically diagnosed and treated.

  • FC5258

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    Call from standby
    Call from standby

    Initial Report

    I would like to seek advice regarding FTLs and standby duties. My first question is regarding early morning shifts. I set my alarm at night based on the flight I’m doing the following morning. Recently I have woken up to a change of duty and now rostered to operate an earlier flight which was changed as I was asleep. Sometimes this is 20/30 mins earlier than my original report. This immediately then makes me rush getting ready. Can you clarify if changing duties like this and giving crew earlier report times which they are not aware of until the wake up is legal? Secondly, regarding early standbys, often our employer will not call us but rather just send a text if we are required to operate. I then find myself having to wake up on my standby to check my iPad to see if I have any notifications. Whereas if they called, I could remain asleep and be woken up with my phone going off. Can you confirm if sending notifications are an acceptable method of being called off standby when it is assumed that the person will be asleep?

    CHIRP Comment

    With regard to changing report times during sleep periods, provided that the change is within a reasonable period then it’s very much down to the circumstances pertaining at the time. If the change is during the time that a person would reasonably be expected to be awake anyway (90mins prior to their original report for example) then the change is realistic (depending on the person’s individual FTL and previous duties etc) but companies should accept that the later they leave the change, or the later a person might realistically discover the change, will affect their ability to report in a timely manner, especially depending on what their commute situation might be. If you do not feel that you can report for the earlier duty in a reasonable state of preparedness then the duty should be declined as not being feasible.

    As for how changes are notified, it appears that there is no formal guidance for how crews should be called from Standby; when the regulations were devised, the assumption was probably that it would be a phone call but things have moved on since then with the introduction of other messaging means. Although a pre-warning notification of a duty by text/iPad/tablet is probably ok, it is not a realistic way of actually calling people from Standby if they are required for an early duty because it implies that crews will be awake and monitoring their device rather than being woken or alerted by a physical phone call that must be answered to acknowledged the call-out. If the duty was for later in the day and the crew member was not required to read the message until normal awake periods then that would also probably be viable, but clear guidance needs to be given as to what methods of notification will be made, and when crews are required to be monitoring messaging systems. Even so, text messages can be notoriously delayed in receipt, sometimes not arrive at all, and can be easily missed if the device is set to silent or in intermittent signal coverage so their use is fraught with problems compared to a physical call and acknowledgment by phone. If messages are used for call outs then unless ground-rules are set for when devices should be checked, crews could justifiably claim to be awake from the start of the standby period due to the need to monitor their devices and this is not a sensible use of time. Whilst it may be realistic if the standby period starts in normal awake hours, if the standby starts in the normal sleeping period then companies could be penalising themselves because crews could then invoke the 18-hr ‘rule’ for combined standby/FDP awake time.