Confidential Human Factors
Incident Reporting Programme
The Charity
Aviation
Maritime
FC5355
Initial Report
This report relates to an incident where I feel there seems to be organisational drift at [Airline] in relation to crew informing the company that they may be fatigued or unfit for a duty. I feel on this occasion that commercial pressure was used to protect the operation in priority of safety. Having spoken to other pilots, it appears that this isnât a one-off, and many have had decisions relating to fatigue, fitness and FTLâs inappropriately questioned by crewing supervisors or management pilots.
CHIRP prĂ©cis to protect confidentiality: There had been an 18hr period between duties in the FOâs roster (a midnight finish followed by an 1830 report the next day). We all know that the 18-30hr gap is troublesome because itâs difficult to get 2 sleeps in and so itâs often the case that people report for the second duty having been unable to get an appropriately timed sleep to ensure theyâre fit to operate. To cut a long story short, the FO initially said that they would be OK to operate but then there was a series of unfortunate delays that meant they were pushed further into WOCL to the extent that they then didnât think theyâd be fit to operate the return sector. The Management Pilot became involved, had a conversation with the FO, and it was agreed that theyâd operate. Inevitably, the FO felt very tired during the flight, made many mistakes, and regretted agreeing to operate. The FO felt that there had been a certain amount of implied pressure from the Management Pilotâs involvement. To be clear, they stressed that the Management Pilot did not apply pressure per se, but their mere involvement in the issue meant that the FO felt that there was subconscious pressure that induced them to agree to operate.
Company Comment
Although they are not subject to a blanket restriction, we are always mindful of the difficulties with 18-30hr duty gaps because they are contextually dependent on previous duties and the crew memberâs circumstances at the time. There are algorithms within our rostering program that take this into account, along with the expected circadian cycle of the crew member. If a crew member reports that they need a fatigue absence either before or during a duty then they will be âfatigue offloadedâ at that point and hotel accommodation will be arranged if required.
The Management Pilot will likely have become involved in the situation because the Captain will have potentially reported that the flight may require a replacement FO or be cancelled down route. The Management Pilotâs intention will not have been to put pressure on the FO, and our crews should be reassured that they should not be concerned to make fatigue-offload requests because the company policy is to accommodate an offload rather than pressure crews to fly fatigued. It is regrettable that such pressure might be inferred from the Management Pilotâs involvement, but that was not the intention.
CHIRP Comment
Although the company comment is reassuring in as much as explaining the fatigue-offloading process and that individuals should not be concerned about fatigue-offload requests because â…the company policy is to accommodate an offload rather than pressure crews to fly fatiguedâ, the key issue was the influence of the Management Pilot on the reporterâs decision to operate when they felt they should not. The engagement by the Management Pilot in the matter was not unreasonable because the company would need to understand and make plans for any potential delays to the flight but, although likely well intentioned, engaging with the FO rather than the aircraft Captain had consequences. Perceived pressures on a potentially inexperienced FO by being contacted by a Management Pilot should not be underestimated and, although no such pressure might have been intended as a systemic outcome, this clearly influenced the reporter.