Ab-initio FATIGUE-INDUCED INCIDENTS

Summary:

Post here any incidents that you have experienced where fatigue may have been a contributory factor, and help out fellow pilots with theirs.

How sometimes we get really fatigued.

JDPerezgonzalez 23 Oct 2008 00:27

[In behalf of Rnadom, originally posted on 22 Oct 2008.]

I remember when we were in semester two, and towards the end we had to do night flying. Of all the semesters so far in […the school…], most of us would say the first year was the most hectic, with tests on average of once a week, flying to do, self study and our personal lives to juggle, most of us have our hands full. A few other students have their part time jobs after 8-5 in school and it doesnt help but it's their means of providing for themselves.

When we had night flying, usually we would also have that on our study week if the weather was good. This means that we have to stay from 8-5pm, and wait until sun sets or Evening Civil Twilight as we call it, which would be… 7 or 8pm when daylight saving is on. By the time we preflight and get ready for takeoff, it could be 8.30pm. This means that we could have already spent 12 hours in school even before flying an aircraft. It does take its toll. But that's ok because we are dieing to fly and learn and we persevere.

Things take a turn for the worse, however if we have a flight scheduled the next day! Personally I myself, and know a few others, have been scheduled for 9pm night flights, and also scheduled the next morning at 8am for flying too. This throws the IMSAFE model out of the window because we simply do not have enough rest. Typically, if a student gets airborne for night flight at 9pm, he or she would have landed by 10.30pm. By the time covers go on, and all the admin work is done, it could be 10.45pm or 11pm. After a short debrief the student goes home and takes a shower, has "dinner" and it could be past midnight already, having to reach the airport to preflight 30 minutes before a 8am flight means waking up at around 6.30 if the person owns a car and can afford to leave the house late.

- Rnadom.

Last edited on 23 Oct 2008 00:28 by JDPerezgonzalez Show more

Fatigue in Flight

JDPerezgonzalez 23 Oct 2008 01:37

[In behalf of hash86, originally posted on 20 Oct 2008]

Back in May i was due to get my night rating.
I had classes from 0800-1200, a navigation flight (2.5hours) at 1330, arrived back at nearly 4pm, and had a night flight at 1730 (one hour) and my NF check at 1900.
By the end of the night I was totally exhausted and then had to drive the 45minutes home.
I managed to get my rating, but I dont think it was the best idea to do so much in one day.

Unapproved touch and go

JDPerezgonzalez 23 Oct 2008 22:36

[In behalf of Anonymous user, originally posted on 21 Oct 2008]

On the flight of my CPL handling solo, I was coming from the south from doing my second Maximum Rate of turn exercise. I did about ten max rate and couple of other things. At the same time I was fasting (No water & food) for a full day started from 0430am to 0620 pm, and my flight was from 1030 am-1200 pm. I knew that we shouldn't fly while we had nothing inside our stomach. But its just a compulsary for me to fast in that month (Ramadhan). And I already experience the same thing last year flying while fasting. Of course my performance on that flight was not as good as usual. Especially while we pulling G's. On the first 30 mnts it was fine and I didn't feel any difference on my body. However, on the completion of my practice when I was joined for circuit I felt that I am loosing concentration i.e. my situational awareness is reduced. ATC told me to make city arrival and hold overhead the city. then, on my 2nm final, there was an ATR just about to take off at 25, ATC told me ''continue approach and make a full stop due turbulance''. Then i continue final and touch down on the runway, however, i didn't make a full stop landing, I move my throttle to full power and took off again. At that time the turbulance just hit my aircraft straight away. ATC then called me and said that it was unapproved T & Go and told me 'watchout for the turbulance'. I realized that i was wrong and in that situation the aircraft was too close to the ground abaout 35ft.
I think i've learned smthing from that. Therefore situational awareness for pilot is very essential. And also The IAMSAFE mneumonic is important prior every flight including Eating.

Re: Unapproved touch and go

Anonymous (guest) 01 Feb 2009 02:32

Sometimes clearances given by Air Traffic Control (ATC) can be very confusing for pilots, especially after a long tiring sortie. I have heard many cases when pilots get confused with whether they have been issued with a ‘touch and go’ clearance, a ‘stop and go’ clearance, or a ‘full stop’ clearance. There were a couple of instances when pilots either took off without a clearance, or did not stop on the runway as instructed. When a landing clearance is given, pilots should make sure that they fully understand the instructions. Always ask or reconfirm if in doubt. It is advisable to ‘verbalise’ the landing clearance instructions doing the finals checks. This can act as a reminder as to what the instructions were. Takeoff and landings are the two phases of flight where most accidents occur. Therefore, never relax upon landing.

Changing sleeping habit...

Anonymous (130.123.128.x) 31 Oct 2008 07:08

This was happened last year to me on my last PPL navigation flight before the PPL nav test. I was flying with one of the instructor. However it was a fasting month as well for me started from 04.30 to 06.00 depends on the time of the ECT(evening civil twilight). It wasn't a problem for me to not eat and drink for one day, because we get use to it since we were a child. However its just a matter of the sleepeing hours, because I have to get used to the new habit. Because of that, I have to sleep early at night(0800pm)and wake up early in the morning(0300am) to eat before the sunrise. My route was from PM-DV-NR-PM and my flight was at early in the morning at 0830am. However, as I woke up I feel a little bit tired with my body. I just then decided to continue the flight because the weather was so perfect, as you know that it is very hard to get good weather in NZ especially in Spring like today. Before take-off I request for dep via Mnwt Gorge, and the tower said change to OH control after take-off under his permission. Once I took-off I change to OH control straight away without telling PM tower before. It is not recommended procedure because you are still under control zone. However the instructor didn't realized as well that I was wrong. We then continue to fly to NR. In the middle of the flight I feel a little bit fatigue as my height holding was not accurate. The instructor then pull the throttle and simulate the aircraft for engine failure. I saw there was a lot of paddock and perfectly face into wind for force landing. However, I don't know why it took me like 2 minutes to choose the paddock and figure it out which way to land. At that time I lost about 800ft from the previous altitude. At the end I didn't make into the paddock and we had to go around. The intsrcutor give me a second chance and we made it, but it wasn't a good one for me. We then landed in palmy and had a debrief after that. Then ops called me and give me a letters from ATC about the departure procedure that I did in palmy. From that time I realized that it is not approved to change coms without permission from ATC. After the flight I slept straight away and realize that my performance is really affected by my sleeping hours.

Re: Ab-initio FATIGUE-INDUCED INCIDENTS

ALAMAKstress 07 Nov 2008 09:24

this was a flight which i should have taken full responsiblity of but had not. it was a night flight and i was really fatigue and caught up with all the work load that i decided to just do the flight and sign it off the wall chart so that i could just be done with it. night flying is known for all the dangers and flying in windy conditions would be harder than usual. but i thought that i would be able to do it and didnt bother much. it was windy but not that windy that i knew i would be able to handle it as usually during the day it would be alright. but once i was up there, the wind started picking up and my emotino started to kick in . instead of landing and going back so that i could do another flight i continued with it as i was too lazy to do it all over again. so i just kept on going. the landings were getting worse each time and i could have taken it as a sign but didnt. till my last landing that i skidded and made a terrible hard landing. the landing made my plane bounce thrice and yet i did not go around but made it land. i should have reported the landing but refused as i thought i would have gotten into a whole lot of trouble. so i kept my mouth shut but only my friends know and now u guys too….

The dangers of dehydration

JDPerezgonzalez 24 Nov 2008 00:51

[In behalf of Anonymous user, originally posted on 24 Nov 2008 under Incidents-General discussion]

I was having difficulty doing anything beyond simply flying the aircraft. Over the next 10 minutes, the situation deteriorated. I didn’t realise it at first, but my peripheral vision was reduced quite quickly, almost as if two curtains were being drawn on each side of my head until I could only see straight ahead in a very limited arc

I was suffering from dehydration on a cross-country flight from Christchurch to Nelson on a hot summer day. I felt very hot and sweating profusely. I consumed a bottle of water after the touchdown, i began to feel better after five minutes, and my peripheral vision returned, as did logical thinking.

All pilots need to be aware that it easy to become dehydrated while flying, and that dehydration will impair performance. It is important to carry sufficient water or other rehydration fluid in the cockpit and to drink regularly.

Re: The dangers of dehydration

*AvIaTrIx* 01 Feb 2009 02:58

Dehydration is the term given to a critical loss of water from the body. As a pilot, flying for long periods in hot summer temperatures or at high altitudes increases the susceptibility of dehydration since dry air at altitude tends to increase the rate of water loss from the body. Most pilots associate dehydration with thirst and assume an easy fix is just to drink any type of liquid. This is not always true. A pilot's dehydration condition can be caused by ‘a lack of water within the body cavity due to high body temperatures, a hot/dry aircraft environment, excess caffeine consumption, antihistamines, and not drinking appropriate fluids.’ Soft drinks, teas, and juice drinks do NOT constitute good water substitutes as they contain caffeine and sugars that absorbs more of the water content in the body. It is recommended that a supply of water be carried and used at frequent intervals on any long flight, whether thirsty or not. Wearing light- coloured, porous clothing and a hat will help provide protection from the sun. In addition, keep the cockpit well ventilated will also aid in dissipating excess heat.

The "F" Danger!

*AvIaTrIx* 05 Jan 2009 18:23

I am reporting this on behalf of an anonymous user, and obtained permission to do so.

In the IMSAFE Model, “F” for fatigue cannot be emphasised enough. Fatigue is a serious safety threat! Research has shown that the “the effects of fatigue are similar to moderate alcohol consumption” (ATSB, 2006). This incident occurred ten years ago when a pre Commercial Pilot Licence ab-initio pilot was doing his navigational training in a light aircraft:

This ab- initio pilot had just finished his semester’s final exam. He had no more than 5 hours of sleep a day for the past two weeks. He finished his last exam at 5pm in the afternoon, and went to a café to have dinner with his classmates for a little celebration. He got home at around about 8pm in the evening and checked the flying schedule, only to find that he has a solo navigation flight the next day at 9am! This means getting up by 7am and arriving at the flight school by 8am to get the planning done. He had not expected this. Since he had not flown for two weeks, he rushed around to get himself sorted and briefly revised his navigation procedures. By the time he went to bed it was already past midnight.

He got up the next day by 7am and was at the flight school by 8am. However, he was feeling a little fatigued. Thinking that the flight is only going to be two hours and a little fatigue probably will not affect the flight, he got himself ready and took off. The cloud base was not that high and after departure he climbed to an altitude of 3000ft and continued on his flight. After around one and a half hour, he was on his way back to base. He was cruising at 3000ft for 15 minutes already, in uncontrolled airspace with another 20 minutes to go. At that time, he was feeling very tired and a little dizzy. He was trying hard to keep his eyelids open. When he was ‘fully’ conscious again, he realised that his plane was at 1500ft and was still in a shallow descent! Somehow he dozed off and the aircraft descended 1500 ft during that time! This was an incident that he will never forget.

It was lucky that he had only dozed off for a short while, and recovered when the aircraft was still at altitude. However, this incident can, when without the luck, be potentially disastrous. Fatigue can seriously delay response and reaction times, impaired reasoning, reduced vigilance and impaired hand-eye coordination. Also, fatigue makes a pilot less vigilant and more willing to accept lower performance, and a pilot will begin to show signs of poor judgement. BUT the greatest single threat is being unaware that it is happening. Therefore, prevention is the key to stop this kind of situation from occurring. We as pilots should always ensure that we have enough sleep before conducting any flight, and never fly if we are already feeling fatigued before the flight. Maintaining a healthy eating and sleeping habit can also help pilots to maintain good physical and mental state. After all, sometimes there is only one chance in the air to get it right!

Re: The "F" Danger!

JDPerezgonzalez 07 Jan 2009 23:47

Know more about the IMSAFE model here.

Last edited on 08 Jan 2009 00:02 by JDPerezgonzalez Show more

Re: Ab-initio FATIGUE-INDUCED INCIDENTS

edmarlo 12 Jan 2009 09:07

This incident was related to me by an ab initio pilot that is currently undergoing training a rather prestigious flying club in Johor Bahru, Malaysia.

It was a solo nav that was suppose to take about 2.5 hours at approximately 8am in the morning. The pilot is a full
time national serviceman in the Singapore Police Force and does his flying part time on his off days. Being a fully operational police officer, he works shifts which can be rather physically demanding.

Just before this particular solo, he had already completed a 12 hour night shift from 6pm the day before to 6am, a mere 2 hours before this eventful flight. After a successful pre-flight inspection and completing his flight plan, he was clearance to taxi out and hold short of the active runway.

It was at this point where apparently his severe fatigue kicked in. He claimed that while waiting for clearance to line up, he unknowingly eased pressure off the brakes and was slowly rolling past his holding point. This runway incursion caused panic at the control tower due to the fact that another training aircraft was on long finals.

Finally a report and a thorough explanation follow through which resulted in a stern warning for the worn out pilot.

Key lesson here:

Be Responsible!

I personally feel there should be a clear-cut system to eliminate such hazardous attitudes that whisper to our minds things that out bodies cannot cope with. I feel that as a form of good and safe airmanship, all pilots should sign a formal declaration that they have fufilled all elements of IMSAFE.

Also I feel that especially for flight training institutions, they should be well informed on the other formal activities (esp career related) that part time pilots undertake.

Runway Fatigue

CXWX (guest) 12 Jan 2009 12:15

I feel that this was a very bad display of airmanship. The pilot should have taken into account his physical state when deciding even to fly. Although IMSAFE is a good self analysis system, one must be disciplined enough to put it into practice. I agree that faitgue is a difficult physical state to determine; there are no medical measurements that can accurately determine fatigue. To make matters worse, one symptom of fatigue is a hightened sense of well being. Therefore, an individual may not know that he is being fatigued until it is too late. The pilot in this discussion should have decided not to fly that day. Should he have taken into account his previous days activities, he would have been aware of his physical state and may have decided to cancel the flight.

in response to your statement on a clearcut system, I have seen one, it takes into account every aspect of a pilot's state; his experience, is currency, his total amount of sleep within the previous 12 hours, his fammiliarity with the route ect.. the answers to the questions carry a grade point and the sum of these point will indicate the "airworthiness" of the pilot in the form of a colour. green yellow red. obliously a pilot in the red is not allowed to fly. this form is then signed by a witness and aproved by manager. This is to ensure that should the pilot be involved in an incident such as the one above, investigations prove that this was due to negligence and the data on the matrix was flase, appropriate legal action may be taken against the pilot. This seves as a deterrent for unprofessional behaviour.

Personally, I think that it is up to the individual to ensure that he is not a threat to himself and those around him.

Re: Runway Fatigue

JDPerezgonzalez 14 Jan 2009 02:59

Hi,

Do you have specific details on this color system and associated questionnaire? I could be a nice thing to put as a SOP or lesson.

Re: Runway Fatigue

edmarlo 15 Jan 2009 06:18

Just to add, i came across this risk management system called Fatigue Avoidance Scheduling Tool (F.A.S.T.) FAST works on date and location coordinates, specific individual's sleep habits, duty times, sleep time and quality. It will then project expected cognitive performance based on these variables. It will also accept the times and locations of all transmeridian travel (waypoints), and project and disruption of circadian rhythm.

It then plots a graph on what is called a mishap analysis to show effectiveness of performance and probability of a mishap. This system was apparently created by either the US Air Force or the US Navy to manage work-rest schedules for its officers and was further developed to use as an investigative/preventive tool for military aviation accidents.

Re: Runway Fatigue

JDPerezgonzalez 15 Jan 2009 23:03

Ok, I found a bit more information about the tool (FAST).

Risk Asessment Management System RAMS

CXWX (guest) 18 Jan 2009 04:45

I may try to get my hands on a copy of this system for you. it is called Risk assessment management system or RAMS and it is widely used in singapore in all factors of operations. From flights to construction to even delivery drivers..

Re: Risk Asessment Management System RAMS

CXWX (guest) 18 Jan 2009 04:47

Oh in addition, Rams is a tool used daily or before execution of a duty to determine whether to proceed or not.

Fasting impact in aviation.

M-4816 09 Sep 2010 07:50

My religion believe in fasting, of not to eat and drink from sunrise to sunset. I was aware of fasting could affect my performance, but sometimes feeling guilty of not obeying my religion is also an issue. According to I.M.S.A.F.E, fasting can affect pilot performance "E" on eating. The incident happen when i did my CPL training. The training was doing a maximum rate of turn, it is a maneuver that the pilot have to handle a 2 G's force sometimes 2,5 G's, depending on the speed and angle of bank of the aircraft.

During the mass brief the Eating part was very important, we can not afford to not eat if we are doing this maneuver. If we don't eat, it is very easy for us to get spatial disorientation, due to the high rate of turn. And also we could easily get black out due to lack of oxygen going through our brain. I was aware of this side effect of not eating before flying, but due to that feeling guilty of not doing what the religion told me it force me to differ from I.M.S.A.F.E.

I bring my friend along for the flight at that time and he was also the same level training as me, we both have our PPL. I did the sortie, the first, second and third maneuvers was not so well, i cannot maintain a constant altitude during the turn, i was suppose to maintain +/- 50 feet. I began to become frustrated and doing those maneuvers over and over again.

During the turn suddenly i feel a bit unwell, first i felt a really heavy headache, my vision becomes blur and becoming like a tunnel vision, and also short breath, maybe i was unconscious for a couple of second and i did not remember what happened, lucky i have my friend as a safety pilot so then he took over the control when i passed out. He told me we lose about 700 feet with rate of descent of 1000 feet, he said he was lucky enough to recognize with what happening to me at that time. Imagine if i was flying alone by myself i could probably crash the aircraft. However, we manage to land safely after that incident.

After i landed i did not tell anyone about this incident, i keep questioning myself on fasting when flying, it is not safe, but how can i not brake the religion rules and also not breaking the aviation safety rules as well..? so i go home and open my bible and try to find out the answer. It says that "fasting is a must, if we can do it, ie: we are not doing any activity that relates to flying, traveling in long distance, etc. however if we are flying as a pilot, we are allowed to not fasting, but we have to fast again some other time if we are not flying, ie: just doing normal activities". So now i know that whenever i fly, i never want to fast again. Having a good physical condition and fit for flying is always important for aviation safety, religion or believe can not be mix with it.

Last edited on 09 Sep 2010 07:52 by M-4816 Show more