When things don’t run smoothly

CHIRP received 362 reports during the last 12 months, that’s 50% of our pre-COVID reporting rate. This is not surprising, considering aviation didn’t get going again until October 2021 when the traffic light international restrictions were reviewed and countries on the ‘red list’ were much reduced.

Since 1st June 2021, CHIRP has received 245 cabin crew confidential reports. The majority of these concerns were also reported internally, either via their senior crew member, the captain or a report form. 79 reporters didn’t report their concerns internally, and the majority of those were were related to fatigue. If you believe that you are suffering from the effects of fatigue, you must report this internally, as we often say, reporting internally helps an operator identify and mitigate a safety concern that could be occurring. Please refer Cabin Crew FEEDBACK Edition 75  for more discussion on fatigue.

Cabin crew recruitment is in full swing by numerous operators either due to many colleagues leaving the Industry as a result of the pandemic or redundancies. However, staffing is not just a concern within the cabin crew community but in many ground-based roles in aviation too. From the very start of a passenger’s journey, they are experiencing the effects of an industry generally understaffed — buses to the terminals are experiencing delays, as are security and customs and by the time a passenger is greeted at the aircraft door their experience has most likely not been as smooth as it once may have been. Although CHIRP have not seen an increase in passenger management related reports, we understand that some operators have.

As cabin crew, your duty up until boarding may also have not been as smooth as pre-covid either, you may have experienced delays getting to the crew room or getting through security, delays with cleaners and caterers, missing ground staff, pressure to board, and this is all before a potential slot delay on push back.

In the face of such delays and frustrations, it’s important to adhere to safety SOPs to ensure that all crew perform all tasks in a consistent and safe manner; they are designed to protect everyone onboard. Even if you feel under pressure because of time or your workload, every crew member has a responsibility to make sure that all their safety checks are completed in accordance with your Operations Manual and in a timely manner. This isn’t just the case for pre-boarding but also during the flight and post flight. Don’t rush or ignore your checks, safety must always come first.

A lack of resource is typical of a hazard hole in the Swiss Cheese Model by James Reason and safety reporting is as vital as ever. Reporting safety concerns internally should always be the first report that you make, this allows your operator to be aware of the challenges you are facing, to react by investigating or use your reports as data to interrogate trends. CHIRP stands ready to assist as best we can those who do not feel able to do so.

Near Miss reporting is also very important too — concerns about safety-related incidents that ‘nearly happened’ and might not meet the threshold for formal reporting elsewhere. Any crew member can report to CHIRP, regardless of your rank or position and length of service.

In 1993 Gordon Dupont developed a Human Factors concept he called ‘The Dirty Dozen’, these twelve elements influence people to make mistakes.

• Lack of Resources
• Complacency
• Lack of Knowledge
• Distractions
• Lack of Teamwork
• Fatigue
• Pressure
• Lack of Assertiveness
• Stress
• Lack of Awareness
• Norms
• Lack of Communication

When you read the reports included within this edition, see if you can identify which of the 12 elements above are applicable to each CHIRP report.

A lack of communication on board can lead to a misunderstanding, not just for the crew but also for the passengers. In the majority of the reports that were recently discussed at the CHIRP Cabin Crew Advisory Board, many of the issues raised could have been resolved on the day if effective communication had taken place between the crew. Effective communication between colleagues is vital for the safe and smooth running of every sector.

Here at CHIRP we very much value your inputs and comments, positive or otherwise. We recognise that there is always room for improvement, and we want to ensure that we are giving you valuable content to support and enhance safety. Please do get in touch at mail@chirp.co.uk and let us know what you think about this edition, or anything else (that’s safety related).

The CHIRP Aviation Programme also provides a facility for confidential reporting of Bullying, Harassment, Discrimination and Victimisation (BHDV) where there is an identifiable safety-related concern.  CHIRP has no specific expertise or resources to investigate BHDV reports.  CHIRP’s role is to aggregate data to build a picture of the prevalence of BHDV in the aviation sector.  See our BHDV page on the CHIRP website for further information.  CHIRP’s role in reporting Bullying, Harassment, Discrimination and Victimisation (BHDV)

Reports

CC5862 - Lightning Strike

Initial Report

The aircraft was hit by lightning prior to landing at [Airport] on the outbound flight (the aircraft was struck 6 times), we were delayed on the ground due to engineer checks of the potential damage to the aircraft, this caused a delay. The engineers advised physical check was necessary using a ‘cherry picker’ vehicle to investigate several marks on the aircraft exterior caused by the direct strike. Operations pushed for the aircraft to leave due to the flight deck FTL and magically the engineers no longer needed to check visually and the flight departed.

Many crew felt unsafe and were not confident to fly as the checks weren’t completed to a ‘satisfactory standard’ as we were rushed to meet OTP rather than safety. The whole purpose of the delay was to wait for the vehicle for a detailed inspection but after almost 2 hours awaiting (with no success as several aircraft had been struck) it was decided without the physical inspection that the vehicle was no longer required. If this was the case then why did we need to wait for the 2 hours to begin with?

Customers reaction was generally ‘good’ however a few customers asked for reassurance if the aircraft was safe and ‘where they could find the life jackets. Personally, if I wasn’t under pressure around the security of my job, I would have refused to operate this evening on the grounds that I don’t feel the engineers were ‘allowed’ to make a thorough diagnosis due to the pressures of the company operations department.

CHIRP Comment

The Operator was contacted with the reporter’s permission. The Operator responded with very comprehensive details, backed by evidence and their planned corrective and preventative actions.

Their investigation did not establish any evidence of the staff in their contracted engineering organisation (a different operator) of being pressured to release the aircraft without carrying out the required inspections. They were prepared to admit however, that one contracted Engineer involved, whilst working in accordance with the Aircraft Maintenance Manual (AMM), incorrectly assumed that he could defer his phase 1 inspection because a phase 2 inspection would be required.

An inspection after a lightning strike is split into two phases, as are many other inspections (Heavy/High Energy Landing or Bird Ingestion into an engine, for example) The theory being that if you do not find anything beyond a certain limit on the Phase 1 inspection, you do not have to carry out Phase 2 and the aircraft can continue in service for a set number of cycles (Landings) until more comprehensive inspections take place. This report has great merit and it was received by the operator in an open and professional manner leading to improvements in inspection standards and a review of required ground equipment.

This report highlights the need for effective communication onboard the aircraft. In this instance, had the flight crew explained to the cabin crew why the checks were no longer required then the cabin crew might not have felt ‘unsafe to fly’, the cabin crew in turn would have been able to have explained this to the passengers that were concerned. Communication works both ways, if you are onboard and you don’t understand why a decision has been made, then ask the question. Had effective communication taken place on the day then this report probably wouldn’t have been submitted.

CC5881 - Minimum Rest Requirements

Initial Report

Delayed arrival into AAA, long journey to crew hotel meaning down route rest falling way below required 10 hour ‘Key to Key’.

Crewing phoned to advise of arrival time at hotel so pick up could be adjusted accordingly.  Initially told we had achieved 12 hours ‘chocks to chocks’ so not an issue.

Next person insisted the term “key to key’ is defined as arrival at hotel until commencement of next FDP.

comments

Operators Comment

CAA Comment

CHIRP Comment

As you can imagine, this is not the only report that CHIRP have received of this nature. As minimum rest is often the new norm it is important that all crew are familiar with their minimum rest requirements, especially as it’s not unusual for an individual to have a different FDP from the rest of the crew due to being called out from stand-by, please ask your colleagues if you are unsure. Rest should be counted from when the crew arrive at the hotel and this is how the regulation should be read as. However, if there was a delay at the check-in desk, the commander could advise the Ops team that their rest needs to be amended and the next day’s report should be delayed accordingly.

CC5910 - High Levels of Fatigue within the Company

Initial Report

My operator is incredibly short of Cabin Crew. The number of crew that have reported fatigue has increased immensely. I have personally witnessed crew members in tears on duty due being so tired from the number of flights they have done. They had no fly on their roster as they had done so many hrs.

I have experienced multiple roster changes and increased workload both number of flights and on board. Minimum rest and delayed report to ensure the duty is legal is common and I have recently experienced this on my roster.

Lack of catering, face mask policy, disruptive passengers, the cabin baggage policy and slots all add to the level of fatigue. Most of which could be reduced with sufficient leadership however, this is lacking. I feel it could lead to serious safety events if the fatigue issue is allowed to continue into the summer months.

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Operator Comment

CAA Comment

CHIRP Comment

CHIRP has long since held the view that FTL maximums should be approached only infrequently and in a managed manner. Many cabin crew are feeling the daily pressures within aviation, as are many of our colleagues. Communicating with your operator and your colleagues is vital, if you believe that are suffering from the effects of fatigue, report it, if you have a safety concern, report it, if you’ve had a ‘near miss’ safety incident, report it. Without safety-related reports there is insufficient evidence for an operator (or the CAA) to see that ongoing safety concerns could be occurring.

FC5182(C) - Inexperienced cabin crew

Initial Report

Taxiing out for departure, SCCM called the flight deck and advised a pax had been physically sick in the cabin around row 16 and needed time to check on her wellbeing before departure.

The SCCM was attending to the passenger. Three cabin crew had limited experience and the 4th recently on line. A rear crew member called the crew member at the front and asked them to turn on the cabin lights (as the cabin was in darkness prior to departure at night). The forward crew member was unable to simply locate the cabin lights switch on the attendant panel. Unable to turn on the lights on meant the SCCM had to leave the ill passenger and return to the front galley to turn on the lights themself to then go back and assist the passenger.

My concern is new cabin crew are unable to locate simple – yet critical equipment and switches used daily and the experienced cabin crew (only the number one in this case) is doing all the work himself dealing with the passenger, communicating with the flight deck and managing the cabin environment.

This was a simple medical issue, however could very well have disastrous impact given the level of experience in the cabin that day.

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Operator Comment

CHIRP Comment

Cabin Crew Advisory Board Comment – 

All Cabin Crew receive initial training on how to use the cabin systems such as the forward attendant and the additional attendant panels. This information is also available in the Cabin Crew manuals. When new crew go on their aircraft visit as part of their initial training they would have been shown how to operate the lights at the attendant panels. Also, when the crew operated their first familiarisation flights, they would have had a checklist that probably included cabin lighting, amongst many other things to be covered on the day.

Once the crew member is then online, often the SOP is that the crew complete their checks, sit down, pass on their ‘secure’ to the senior and, once the senior has the ‘secure’ the senior will dim the cabin lights, for landing and take-off.

If you aren’t familiar with how to adjust the cabin lights please review this next time you are on the aircraft. The fleet structure of some operators can vary massively, crew can operate on different types and within those types there can be subtypes, even if the aircraft are all the same type, unless they are all the same vintage then the attendance panels can still vary from aircraft to aircraft. If you haven’t flown on type for a while, take the time to review the location of the cabin light controls and other panels etc that you might not regularly use next time you are onboard.

This report was discussed at both the CHIRP CC advisory board and the CHIRP AT advisory board, some members of the ATAB thought that there was scope for more formal familiarisation training to be in place to give cabin crew regular opportunities to operate all routinely used equipment and panels for this very situation where the SCCM maybe indisposed. Time is always pressing during flights we know, but more experienced crew can also help here by taking inexperienced crew members ‘under their wing’ when possible and refreshing their familiarity with panels and equipment.

An individual is personally responsible for ensuring that they are aware of the aircraft/type/config they are to operate on and, if necessary, refresh themselves via their SOPs/OM etc to avoid any possible confusion that may arise. Crew are onboard should an emergency arise and must be prepared for this to happen at any time. This is even more important for new crew, particularly with aircraft swaps etc that can happen on the day.