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reporting system for the Aviation industry

Air Transport

Edition ATFB 155
July 2025

Safety Culture

William Dean
Air Transport Programme Manager

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 21^st 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.

Engineering Editorial

As the newest member of the CHIRP team, taking over from Phil Young who is enjoying his well-earned second retirement, let me start with a brief introduction. I began my aviation career in 1988 with British Airways Engineering, working in several technical and operational roles, mainly involved with the maintenance of Concorde and Boeing aircraft. After a very enjoyable and satisfying 18 years, I moved to Ground Handling, having the privilege of leading the BA Baggage operation at Heathrow Airport for the next nine years. In 2016 I left the world of aviation to work for organisations in the fields of baggage systems maintenance and public mass transport.

Having now returned to the world of aviation, albeit in a support role, I have seen several recent CHIRP reports relating to Engineering training. When I cast my mind back to my own experiences of Engineering training in the 1990s, it was largely a hands-on affair, relying heavily on physical components and printed documentation. All types of training were delivered in classrooms, by experienced engineers who had accumulated decades of practical wisdom. My practical training was with real aircraft, often in hangar environments, supported by a wealth of personal experience from those working alongside me.

Fast forward to 2025, and talking to my former colleagues, the developments in Engineering training appear dramatic. They tell me about the use of Virtual Reality (VR) and Augmented Reality (AR), how they can “walk through” an engine, identifying components and performing simulated maintenance tasks in a fully immersive VR environment. They have access to sophisticated maintenance simulators, whilst interactive multimedia modules have replaced the old textbooks and manuals, I became so familiar with. Computer-based training (CBT) platforms are commonplace, allowing for self-paced learning and continuous assessment.

These developments have undoubtedly brought a host of advantages. Complex procedures can be repeated countless times in virtual settings, trainees can make mistakes and learn from them in risk-free environments, and the use of CBT allows individuals to progress at their own pace whilst continuously monitoring their understanding.

However, it is crucial to acknowledge some of the potential disadvantages, as highlighted in some recent CHIRP reports. The potential over-reliance on CBT and other digital training platforms can reduce the opportunity to interact with colleagues, sharing experiences and mentoring that I certainly benefited from in my early days. Has the use of CBT been taken too far, being seen by some organisations as a more efficient and easier solution to delivering training, especially in some less technical fields such as safety, quality, human factors and compliance? Do these areas of training, in particular, benefit more from the sharing of experiences and lively discussions that in-person group facilitations offer, even if they are perceived as being less efficient than CBT modules by organisations? I am certainly thankful for the experienced colleagues who so willingly shared their knowledge, skills and stories during my early days in Engineering – and the lasting impact these interactions had on the rest of my career.

And talking of sharing experiences, I would like to finish by thanking Phil Young for his patience and perseverance in preparing me for this role. It was a pleasure working alongside him, albeit briefly, and I wish him a long and enjoyable second retirement.

Kuldeep Nothey, Engineering Programme Manager

Feedback on FEEDBACK

What do you think?  We’d love to get your views on the topics covered in FEEDBACK.  We don’t claim to have all the good ideas, and we may have missed something that relates to a report so please do contact us and give us your views. You never know, your thoughts might inspire the next editorial or perhaps give us more context for when we contact the companies.  Please send any comments to mail@chirp.co.uk for the attention of CHIRP Air Transport Programme Manager and we can start a conversation.

Comments on FEEDBACK

AT FEEDBACK 154 – Report ENG767

I read the subject report with interest as I’m currently engaged as a Maintenance Controller.

Firstly, could I politely recommend that that the CHIRP responses remain factual from the start, i.e. in this case ‘It is the responsibility of the commander in charge of the aircraft that there are no outstanding defects’; what goes after that is pure speculation, not backed up by facts or investigation. Firstly, was there actually a ‘Smoke’ event? Was it condensation? (The report indicated that the ‘smoke’ dissipated quickly in my experience this is humid air, steam, condensation – very common in hot and humid climates).

Secondly, the author of the response merely assumes all of the Human Factor Performance Influencing Factors (PIFs), without really knowing the facts… (There are many more PIF’s than 12….).

Furthermore, was the response of the Controller verified?

The subject of ‘smell events’ is a moot subject among maintenance engineers as we persistently find no valid reason for their submission, i.e. ‘brief whiff’, some crew ‘may’ have smelled something, often it’s attributed to de-icing and external issues.

Whilst we take smoke and smell events very seriously, they do obviously cause severe disruption, often causing a 36-hour AOG event. Unfortunately, it seems that some crews have used this to their advantage when disgruntled or in dispute with company policies. This trend could be seen when historic routes have been cancelled or curtailed.

CHIRP Response: The CHIRP Comment for ENG767 in the April 2025 issue of FEEDBACK serves as a useful reminder of the importance of the Tech Log as an essential communications tool with regards to recording the ‘fitness’ of the aircraft to operate.

With regards to the speculation about the root cause and potential seriousness of the notified ‘smell event’, CHIRP agrees that it’s not possible to be more certain of what the correct actions should have been in this specific event without further details. However, a more general discussion about such events, their frequency and potential seriousness is worthy of debate. In all such operational situations, there is the constant challenge of balancing commercial considerations against potential safety risks, and it is in such situations that organisations should rely on the knowledge, experience and judgement of all those involved – including Flight Crew and Maintenance Controllers. During our Engineering Programme Manager’s operational career, in such circumstances where there remained a level of uncertainty or a difference of views, his position had been to always err on the side of safety.

We hope that this report will also generate further discussion into the issue of ‘smell events’, just as you have done – namely their frequency, actions being taken to understand root causes and suggested ‘best practice’ responses.

AT FEEDBACK 149 & 153

The observations on Controlled Rest (Feedback 149 & 153) feed into a wider narrative: that the management of fatigue is a problem we can “science” our way out of. I have my doubts, and I am wary of the (former) editor’s call for more “definitive” regulation in this area, particularly his desire to see the CAA incorporate regulations on CR within their review of FTLs. I would argue that sleep science has not historically served aviation well and that by placing too much trust in a quantitative approach we kid ourselves that we have “fixed” a problem when in reality it is too complex, too personal and too unpredictable to be addressed in anything other than the most general terms.

Limitations on flight duties and roster patterns are, of course, essential but by attempting to present fatigue as a logical outcome that can be mitigated by adherence to a matrix of report times and time zones we are pretending to a level of agency that we simply don’t possess. The only metric that matters is how we, as crewmembers, are feeling on any given duty and therefore the most effective solutions are by nature ad hoc and flexible.

Indeed, the more rigidly we attempt to pin down sleep and rest behaviours, the more we imply that to feel tired is a failing on the part of the pilot concerned. This discourages accurate reporting. It also ignores the fundamental truth that sleep can be capricious and hard to come by no matter what the schedule – more so for some than for others. As a long and short haul pilot of many years, who struggles with sleep (and the two are probably not unrelated), I have come to accept that rest is not something that can be achieved just because it is available and whilst I cannot rely on CR either, I find it to be one of the few genuinely effective ways of keeping fatigue-related performance impairment at bay.

I understand the editor’s concern that CR has become a backdoor method for operators to have pilots tolerate longer, more punishing duties that would otherwise be flagged as unsustainable – and this is not acceptable – but CR itself is not the problem. An unpredictable threat, such as fatigue, requires an adaptable set of solutions, which is why, if more “definition” is felt to be required in this area, then it should still leave significant space for discretion by the operating crew. Left to others, any proposed regulation will likely focus on the potential pitfalls rather than the benefits, and risks being an exercise in the kind of false science that treats our fitness to operate as the output of an equation.

AT FEEDBACK 153

I am very impressed by the independent work CHIRP undertakes and the difficult line it walks between the reporter the industry and the regulator. It was very interesting to read the discussion on complex intercontinental rostering and your balanced response. However, the response does slightly contradict a previous comment by CHIRP which raised concerns with the underlying ‘sleep science’ and assumptions the modelling these rotations relies on. It would be interesting to consider the earlier CHIRP response in the context of a new operator finding its way and the learning of lessons that the industry should have already learned.

Report to CHIRP

Reporting to CHIRP is easy by using either our website portal or our App (scan the appropriate QR code shown or search for ‘CHIRP Aviation’ – ignoring 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.

You report it, we’ll help sort it

Airport Security Special

CHIRP has recently received a number of concerning reports about security screening at UK airports. These reports come from across the industry – flight crew, engineers, cabin crew, and ground handlers alike. While the specific issues vary, some common themes have emerged:

• Inconsistent application of security measures
• Brusque or overbearing behaviour by security staff
• Lengthy waiting times
• Solid food items with a modicum of sauce being classified as ‘liquid’ and denied passage

So, what does this have to do with safety?

All our reporters highlight a troubling acceptance of poor treatment at airport security. Many now expect the worst and prepare themselves for the most stringent interpretation of the rules in an effort to ensure a smooth journey through screening. However, when treatment feels arbitrary or unreasonable, resisting the urge to react can be a significant mental challenge.

The effort required to stay calm – especially when you’re now going to be late for report or faced with inconsistency – can be considerable. Many crew report feeling anxious, frustrated and under pressure even before their duty day has begun. These stressors, though seemingly unrelated to flight operations, can significantly affect human performance and, ultimately, safety. For more on the effects of stress in aviation, see Skybrary’s article on stress and stress management.

To be clear, we are not advocating for security checks to be waived for crew or for standards to be lowered. Quite the opposite. Operating crew consistently express strong support for rigorous screening, recognising that it protects everyone – crew, passengers, and the wider public – by guarding against rogue elements. Crew also fully understand that they themselves are a potential hazard and that an aircraft in the wrong hands is a serious threat.

However, airports and airlines have a responsibility to ensure that security checks are conducted professionally and consistently. Otherwise, the knock-on effects on crew, who are humans not robots, can have unintended safety consequences. For example, one pilot reported being so wound up by their treatment through security, that they were still significantly distracted by it well into the flight. This a clear example of how pre-duty stress can affect operational focus.

What is CHIRP doing?

When CHIRP receives reports of security-related incidents that could impact flight safety, we raise them with the relevant airport and airline safety and security managers. Airports often resist change and argue that security regulations are being fully complied with, but with little regard for how the checks are conducted. There appears to be minimal concern for transparency, consistency, or the mental state of crew following these interactions. Worryingly, security staff often have little understanding of the safety-critical responsibilities crew members take on immediately after leaving the checkpoint.

Our advice for crew

While CHIRP continues to advocate on behalf of crew facing poor treatment at security, we also offer the following guidance for those dealing with this issue daily:

• Remain calm and professional. As hard as it may be, do not rise to provocation or complain during the screening process. Stay quiet, compliant and composed.
• Check in with yourself after screening. Recognising our own stress is notoriously difficult. If you feel angry, anxious, frustrated, or upset, try to pause and reset. Take a moment for yourself – find a quiet spot, have a coffee, do some breathing exercises, or whatever works for you. The military refers to this as getting back into the ‘mission bubble’. If your focus is disrupted, it’s your responsibility to restore your mindset before reporting for duty. It’s better to be late for report and fit to operate than to begin work mentally unprepared. Be sure to notify your company through the appropriate reporting system if this is the case.
• Stay calm in queues. If the problem is excessive queuing at security / lack of security checking resources, then provided you arrived at security by report time then try to relax; this is out of your control so don’t carry unnecessary guilt. Keep your head in the right place, ready to operate and calmly report once through and the extent of the delay is apparent.
• If you don’t feel confident reporting the issue internally, CHIRP is here for you. We offer a confidential, impartial and independent reporting option. Get in touch and we’ll support and advocate on your behalf.

Final Thoughts

Security checks are essential, but they should never have a detrimental effect on crew wellbeing, operational readiness, or aviation safety. You do not have to suffer in silence. Change can only happen by reporting the issues to the airlines and the other companies who employ the staff affected – in this context, it is the company’s themselves that have the power to influence change at airports rather than affected individuals.

CHIRP, what’s it all about?

Just a reminder that we’ve recently produced our latest short video (10mins) explaining what CHIRP does, voiced-over by 3 of our Advisory Board Chairs.  Why not click on this link to have a look and find out what we’re all about?

I Learnt About Human Factors From That

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!

Reports

ATC866 - 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.

Comments

CAA Comment

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

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.

Comments

Airline Comment

CAA Comment

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

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

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

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.

Comments

Airline Comment

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 - 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 - 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 - 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 - 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!

Comments

CAA Comment

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.