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Danny Cheng/ 鄭永安Safety Investigators,
Aviation Safety Council(ASC)2018 FRMS Forum
Fatigue Investigation Experience Sharing
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Outline
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Potential Causes of Fatigue Introduction of the ASC Fatigue Investigation Guide Integrated Fatigue Factors Investigation Diagram Fatigue Issues Related to GE222 CFIT Accident
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Potential Causes of Fatigue
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What is
the state of tiredness that is associated with long hours ofwork, prolonged periods without sleep, or the requirementto work at times that are’ out of synch’ with the body’sbiological or circadian rhythms.(Dr. William Dement)
an increased level of sleepiness associated with impaired cognitiveand/or physical functioning that may, as a consequence, result in anelevated risk of error or accident. (Transport Canada, 2008)
a subjective feeling of tiredness that makes concentrationon a task difficult.(Dr. John A. Caldwell)
a state of impairment that can include physical and/or mentalelement, associated with lower alertness and reducedperformance.(Melanie Todd)
an experience of physical or mental weariness that resultsin reduced alertness. (Transport Canada, 2007)
Fatigue
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ICAO Fatigue Definition
Consequences
Symptoms
Causes
Fatigue in aviation has been defined byICAO (Doc 9966, 2011):
A physiological state of reduced mental orphysical performance capability
resulting from sleep loss or extendedwakefulness, circadian phase, or workload(mental and/ or physical activity)
that can impair a crew member’s alertnessand ability to safely operate an aircraft orperform safety related duties.
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Existed Fatigue Investigation Guides Appendix I. Evaluating the Contribution of Fatigue to Safety
Events, Second edition, ICAO Doc 9966 (2016)
Guide to Investigating Sleep-Related Fatigue, Second Edition, TSBCanada (2014) Sleep & fatigue knowledge
Method for investigating fatigue
Fatigue data collection and analysis tools
Methodology For Investigating Operator Fatigue in a transportationaccident, NTSB (2006)
Fatigue CheckCard for Mishap Investigation, AFRL (2004)
A Guide for Investigation for Fatigue, TSB Canada (2002)
Fatigue Investigation Checklist, ATSB (2001)
Causes of Fatigue
ICAO Doc 9966 TSB, 2014 ASC
Sleep-related fatigue Physical fatigueMental fatigue
Sleep-relatedfatigue
Sleep-relatedfatigue
Physical fatigueMental fatigue
Sleep quality factors O O O
Sleep quantity factors O O O
Continuous wakefulness O O O
Circadian factors O O OSleep disorder O O O
Workload (mental/physical ) O X O
Psychological conditions,
Illness, medicine or drug effects
X O O7
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Poorly managed psychological conditions, medical condition, Illness, medicine or drug effects
Poor sleep quality and quantity at night
Feel sleepy in the day time or excessive daytime sleepiness
depression, anxiety and other conditions involving stress not treated or properly
managed;
Diabetes, obesity, pain, cold, allergy, etc. not treated or properly managed
Side effects of medications for cold,
allergy, nasal congestion, etc;
Nicotine, Caffeine
High fatigue level on duty
Causes of Fatigue
ICAO TSB, Canada ASC
Sleep-related fatigue Physical fatigueMental fatigue
Sleep-relatedfatigue
Sleep-relatedfatigue
Physical fatigueMental fatigue
Sleep quality factors O O O
Sleep quantity factors O O O
Continuous wakefulness O O O
Circadian factors O O OSleep disorder O O O
Workload (mental/physical ) O X O
Psychological conditions,
Illness, medicine or drug effects
X O O9
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Introduction of the ASC FatigueInvestigation Guide
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Fatigue Investigation
Fatigue is a major human factors hazard because it affectsmost aspects of a crewmember’s ability to do their job.
ICAO Doc 9966 indicates that:
How to conclude fatigue was a probable cause or riskfactor led to the occurrence?
To study fatiguebio-mathematical
models, their applications and
limitations forinvestigation
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How to Develop ASC Fatigue Investigation Guide
Previous investigation experience
Learn from trainingcourses related to
fatigue investigation, management
or human factors
To study the existed fatigue investigation
guides which has developed by
other organizations
Consult with aviation medical
examiners & universityprofessors who are proficient in fatigue
management
Refer to fatiguerelated research papers& fatigue management
manuals
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(6)Use of FatigueBio-mathematical
Models
A Guide to Human Fatigue Investigation
and Risk Analysis
(3)FatigueInvestigation
Process
(1)Fatigue and Sleep related Knowledge
(2)Fatigue Management Information
(5)Fatigue DataAnalysis
(4)Fatigue DataCollection
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(1)Fatigue and Sleep related Knowledge
FatigueDefinition
Types ofFatigue
Causes ofFatigue
FatigueSymptoms
Sleep Architecture
SleepInertia
MicroSleep
SleepDisorders
Continuous Wakefulness Circadian
Rhythm Effect Medicine
Effects Illness,Psychological
conditions
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(2)Fatigue Management Information
Fatigue risk
assurance
Fatiguemitigation
Fatigueprevention
Minimize scheduling risks for fatigue: lack of predictability, frequent changes, backward
rotation, inadequate recovery time, excessive overtime;
Use of fatigue modelto identify fatigue risk;
Adequate fatigue training;Work rotation & opportunity
for breaks available
Tools provided to employees recognizing
fatigue;Means for employees to report fatigue and
take appropriate steps to mitigate;
Fatigue countermeasures available &permitted.
Fatigue investigationcapacity & implement;
Fatigue voluntary reporting system;Fatigue survey;
Fatigue related SPImonitoring.
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Investigating Fatigue ABC
STEP 1
STEP 2
STEP 3
Determine the operator’s level of fatigue or exist causes of fatigue
(Test for Existence)
Determine whether the operator had fatigue symptoms and contributed to unsafe acts of
the occurrence events (Test for Influence)
Examine fatigue management in the organization
(3)FatigueInvestigation
Process
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(4)Fatigue DataCollection
Collection Form & QuestionnaireOptimal Sleep-Wake Pattern Actual Sleep-Wake History
Subjective Fatigue EvaluationMedical & Psychological History
Fatigue Management practices
(5)Fatigue DataAnalysis
Evaluation Table & Reference Guide
Level of FatigueFatigue Symptom & Influence
Fatigue Management Assessment
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(6)Use of FatigueBio-mathematical
Models ICAO definesfatigue bio-mathematical model as:
a computer program designed to predict aspects of a schedule thatmight generate an increased fatigue risk for the average person,based on scientific understanding of the factors contributing tofatigue.
Australian CASA Bio-mathematical Fatigue Models Guidance, 2014 The Boeing Alertness Model (BAM) The Circadian Alertness Simulator (CAS) The Fatigue Assessment Tool by Inter Dynamics (FAID) The Fatigue Risk Index (FRI) The System for Aircrew Fatigue Evaluation (SAFE) The Sleep, Activity and Task Effectiveness Model and associated Fatigue Avoidance Scheduling
Tool (SAFTE-FAST): The Sleep Wake Predictor (SWP)
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System for Aircrew Fatigue Evaluation (SAFE)
FRMSc, UK
Features LimitO Actual sleep period X Sleep quality
O 2~4 Crew composition X Single pilot operations
O Nu. of sectors (workload factor) X Nu. of sectors applicable to helicopter pilot
O Sleep inertia considered --O In-flight rest considered --
Pilot’s fatigue level when the occurrence happened based onpilot’s actual sleep period three nights at least prior to theoccurrence, (only for reference)
Identify high fatigue risk duties in the fleet pilot’s rosters
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Integrated Fatigue FactorsInvestigation Diagram
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Acute/chronic sleep disruption;
Continuous wakefulness;Circadian rhythm effect;
Sleep disorders;Psychological conditions, illness or medicine effects;
Workload
EmotionalCognitivePhysical
Integrated Fatigue Factors Investigation Diagram
Fatiguelevel
Fatiguesymptoms
Unsafeact
Unsafeevent Occurrence
Fatigue management regulation, guideline,
and surveillances
Scheduling
Manpowermanagement
Fatigueprevention
FatiguemitigationFatigue
riskassurance
Operationaldemand
Trainingdemand
Company Operations & Fatigue Management
CAA Oversight
Duty preparation & use of fatigue countermeasuresEmployee Fatigue Countermeasures
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Collect manpower, operational & training demand related data, and examine their impact on scheduling
FatigueRisk of
SchedulingHighLow
Effectivefatigue
managementmeasures Manpower
Operational & training
demand>
Optimal aircraft/ pilot ratioOptimal caption/FO ratio
Number of captions and FOsNumber of aircrafts
Actual caption/FO ratio
Operational flights trendTraining flights/course trend
Average fleet flight time trendPilot’s max daily sectors trend
Flight number
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Fatigue Issues Related to GE222CFIT Accident
TransAsia Airways GE222 CFIT Accident During Final Approach
Background information• 23 July 2014• ATR72-500• Schedule passenger flight• KHH to MZG, Penghu islands• Normal flight time 30 minutes• 54 passenger• 2 flight crew/ 2 cabin crew
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Flight information• 1320 reported for flight duty• 3rd flight of the day• Took off at 1745• 1h45’ delay due to weather• Crashed in the final approach at 1906
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MATMO Typhoon hit Taiwan and Penghu
General weather conditions• Intermittently thunderstorms;• Intermittently heavy rain
showers;
Take-off, holding and approach
• At 1745, took off from KHH
• At 1811, started to holding
• In the holding pattern of the MZG airport, at 1829, reducingwind 210/ 5~11kt, visibility 800m still, requested 02 ILSapproach, tail wind landing
• Waiting for military approval
• At 1842, reported visibility from 800 up to 1,600m
• At 1845, requested 20 VOR approach, and then ATC issuedradar vector and guided GE222 to perform VOR 20 approach
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MZG single RWY 02/20• RWY 02 ILS, 800m limit• RWY 20 VOR, 1600m limitRWY 20 in use
18:59.0018:30.00
18:40.00 19:07.00
Airport Surveillance Video
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• At 1905:12, when GE222 passing through 450ft, Cap. stated:“300”, and then selected altitude was reset to 300ft.
• At 1905:26, Cap. stated: “200”, and then selected altitude wasreset to 200ft.
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Final approach
MDA=330ft
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South west wind (250 at 18kts, gust 28kts)
1905:51MAPt
1906:11 FO: go around
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At 1906:11, both pilots called “go around” at 72. Two secondslater, the aircraft hit the trees.
And then GE222 sustained significant damage and consequentlycollided with a residential area..
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• Due to the high impact forces and post-impact fire, the aircraftwas totally destroyed.
• All 4 crew members and 44 passengers sustained fatal injuries.
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InsufficientKey Safety
Manpower &Training
IneffectiveSafety
Management
PoorSMS
Implement
Failed to follow
SOP & lostSA
CFITAccident
Poor FleetSafety Culture
IneffectiveCAA
Oversight
captain’sperformance
degraded by fatigue
PoorFatigue RiskManagement
Fleet Expanding
Changing ofA/C Type
Pilot Shortage
Effects of Operational
Growth
Weather, CRM,
overconfident
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Conclusion: the captain’s performance was probablydegraded by fatigue at the time of the occurrence but thatthe first officer’s performance was not adversely affectedby fatigue.
Fatigue Analysis
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Fatigue Symptoms Examination Physical
Cognitive
Emotional
The captain stated he was very tired and his yawning was detected by the CVR.
Displayed lapses of attention, decreased vigilance,and memory errors during the occurrence flight: lapses in radio communications with ATC; incorrect VOR approach course selection; incorrect recall of ATC wind information; incorrect autopilot mode selections
Displayed a willingness to take risks: intentionally descended below the MDA; Not immediately perform go-around
after passing the MAPt without runway insight
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Causes of Fatigue Examination
Acute/chronic sleep disruption;
Continuous wakefulness
Circadian Rhythm effect
Sleep disorders;Psychological
conditions, illness or
medicine effects
unable to be assessed because specific information about the captain’s wake/sleep cycles in the days
before the occurrence were not available.
the occurrence flight was not at a time that corresponded with a normal individual’s
circadian low
The captain’s medical records and toxicology report did not indicate that he was adversely
affected by any medication or physical health problem.
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Workload
Causes of Fatigue Examination
.
The last 3-month increasing workload might be a cause of the captain’s fatigue:
Captain’s cumulative flight time of the last 90-daysprior to the occurrence significantly increased andwas the highest since 2013.
Considering his age was over 60 years old, it mightbe hard for captain to adapt himself to high flighttime
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Early reportingtime prior to 6Am
Flight duty periodover 10 hrs
Consecutive 6-8flight sectors
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7% 4%
11%
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Fatigue Management in TNA . Limited in Fatigue Management
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Follow the flight and rest regulation to flight crew scheduling. Allow crew to proactively report to related departments while
he/she cannot conduct a flight duty due to fatigue or sick, whichwas described in the flight operations manual.
. High Risk Decision-making by the Top Manager
.
When the introduction of the 3rd ATR72-600 in 2014, topmanager decided not to phase out the 3rd ATR-500 in order toincrease flight numbers. The issues of ATR pilots shortage andflight time increased were raised to the manger by staff.
However, top manger decision remained unchanged because theflight time still remained within the regulation limitation.
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Safety Recommendations to TNA
. Rectify the human resources deficits in the flight operations
division and the safety and security office, including of crewshortage.
. Implement an effective safety management process, such as a
data-driven fatigue risk management system (FRMS), tomanage the flight safety risks associated with crew fatigue.
. Provide flight crew with adequate fatigue management
education and training, including the provision of effectivestrategies to manage fatigue and performance during operations.
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Safety Recommendations to CAA
. Develop detailed guidance for operators to implement effective
fatigue risk management processes and training.
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Thanks for your listening