Up all night
Sometimes we all need to sleep
Came across this article on the BBC website which outlines a superficially worrying incident where a civilian pilot on an Air New Zealand flight dozed off a couple of times.
Air New Zealand pilot ‘fell asleep’ during flight
As it happens, there wasn’t a problem and the flight deck was fully manned at the time. A couple of things stand out for me though.
The first is the culture of the airline. Not only did the pilot feel free to report the incident, and therefore pass on the learning to other pilots in the airline; but the airline recognises the importance of not necessarily disciplining personnel who are involved in potential or actual safety incidents. This ‘open’, ‘no blame’ or ‘just’ culture (pick your own flavour) is an indication of a Learning Organisation, i.e. one that is keen to improve operational safety by addressing incidents and near misses before they become accidents or fatalities. Good for them.
But did they go far enough? By keeping the learning ‘in house’ (it needed a freedom of information request to gain access) the chance for other airlines (or even other industries) to learn from the experience is lost. Regular readers will know of my advocacy of confidential industry-wide reporting systems like the UK based CHIRP. Maybe the airlines need a worldwide implementation to improve safety across the globe.
Still, it’s a welcome and refreshing change to see a ‘no blame’ culture in action.
I did say there were a couple of points I wanted to address from this report, and the second is about the recognition of fatigue and its symptoms and causes. At the root of this incident seems to be inappropriate sleep hygiene. The pilot was disturbed by faulty air conditioning on three occasions during the night. On top of the time zone changes that he was presumably also coping with. To quote Human Factors for Pilots* “the body will sleep when it needs to, even in the most unlikely places”. Unfortunately in this case the ‘unlikely place’ was the flight deck.
All commercial pilots are exposed to a lot of issues with fatigue and sleepiness. Long haul pilots have to cope with time zone changes, desynchronisation and resynchronisation of circadian and other body rhythms, and sometimes inappropriate or unplanned rostering. Not dissimilar to issues faced by workers working shifts in the process industries. Every pilot has to pass his or her exams, which includes a section on sleep and fatigue. The causes and symptoms should be familiar to pilots and they can take appropriate precautions (though this obviously didn’t happen in this case).
Our operators and technicians seldom receive this level of training and support, yet it is equally important. If the person feeling the symptoms of fatigue can’t recognise them or feel free to speak up then we are all at risk. It is worth considering some training and coaching in this area, and considering what you would do as an organisation if someone were to report fatigue problems. Who would he report them to and what would they do about it? What would you do if a technician came to you and said that he didn’t feel capable of doing a safety critical task because his young child had been ill and he had no sleep during the previous day or night? The first hint of ‘blame’ is likely to drive the issue back underground, where I suspect it has been since shift work began. Maybe those first line managers, shift supervisors, shift managers or similar need some guidance and help managing fatigue in their teams?
Some organisations are starting to offer this level of support, and others may eventually be forced to do so. In the US, the Codes of Federal Regulations governing the transportation of hazardous materials by pipelines are already mandating this type of coaching in symptom recognition and demanding that organisations have a system and policy in place to address the issue. Where they lead, the rest of the world may eventually follow. I certainly hope so, as this is an important topic for the process industries and needs to be confronted openly and honestly.
As always, what do you think?
PS regular readers will recall my fondness for Air New Zealand’s humorous safety videos. Here’s the latest.
*A nice handbook with some good stuff applicable to a lot of environments and professions outside the aviation industries. It’s doubly good because it once got me an unexpected upgrade. I was sat down the back of the plane on a flight from London to Budapest happily engrossed in the book when about half an hour into the flight I was approached by the cabin crew offering me a seat in business class. It was only after accepting that I realised that they assumed I was an airline pilot and were offering me a professional courtesy common in the airline business. Good job I had the ‘dead tree’ version and not the Kindle copy!
Image credit: The Ridge Resorts via flickr