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|
Attributes | |
ACN | 548973 |
Time | |
Date | 200205 |
Day | Mon |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | airport : zzz.airport |
State Reference | US |
Environment | |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | tower : lfmn.tower |
Operator | common carrier : air carrier |
Make Model Name | B757 Undifferentiated or Other Model |
Operating Under FAR Part | Part 121 |
Flight Phase | ground : taxi |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp |
Experience | flight time last 90 days : 140 flight time total : 13500 flight time type : 4500 |
ASRS Report | 548973 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Events | |
Anomaly | other anomaly other |
Independent Detector | other flight crewa |
Resolutory Action | none taken : anomaly accepted |
Supplementary | |
Problem Areas | Flight Crew Human Performance Environmental Factor Company |
Primary Problem | Company |
Narrative:
The final day of pairing is constructed in a way that leaves the flight crew no alternative to flying in a severely fatigued state. By being forced to fly in this condition, the margin of safety on flight from ZZZ1 to ZZZ2 cannot help but be compromised. The final day of the pairing is legal by both contractual and FAA standards. However, the important questions to ask are: should it be? And, is there any compelling reason to have the pairing built in this manner to begin with? In my opinion, the answer to both questions is no! Because the pairing checks in prior to XF00 on the final day, the crew can be scheduled to fly 13 hours 30 mins and actually fly 16 hours. This pairing is scheduled for XA35. If this pairing checked in just 20 mins later, the crew could only be scheduled for 12 hours and the pairing would be illegal. From a practical standpoint, most any conscientious crew would attempt to get a long nap in the afternoon before check-in. Because they have to cut their nap 20 mins short, they can now be scheduled for an additional 1 hour 30 mins of duty and be on duty an additional 2 hours 30 mins in case of WX or delays. Note also that a complete body clock shift from daytime to nighttime flying occurs in this 24 hour period making any type of effective nap nearly impossible anyway. Also, look at the implications upon arrival in ZZZ2. The crew is technically legal until XX40. Our actual experience on this flight was as bad as or worse than you might expect. Upon arrival in ZZZ, our airplane is cleaned, catered and towed to a remote parking area for the overnight. This makes it unsuitable for the pilots to nap on during our 3 hour 29 min situation time. ZZZ1 has no crew rest area with any type of couch or recliner so there is no opportunity for any type of rest in this situation. Ironically if the situation was slightly over 1 hour longer, the company would have to provide a hotel room where we could take a quick nap and grab a shower before the redeye segment. Our airplane was then 1 hour late inbound from ZZZ2. Operations told us this is the norm for this flight and I'm confident an audit of its arrival times would bear that out. Our forecast for the flight showed 2 potential areas of thunderstorms to circumnav en route. Arrival forecast was IMC with extensive fog and local thunderstorms over much of the northeast requiring us to use ZZZ3 as our alternate. An additional line of thunderstorms lay between ZZZ2 and ZZZ3 complicating a divert if necessary. Our dispatcher had put on less than 30 mins of effective hold fuel and when I called him to request more, he told me I could have as much as I wanted because he was busy with a medical emergency and didn't have time to look at it. As you can see, not a pretty picture for a crew already operating in a back side of the clock, sleep deprived state. Fortunately, although we did get a minor rerte for WX, the flight was, for the most part, uneventful and the WX on arrival was well above minimums. It was indeed fortunate because on descent and approach my personal performance was marginal at best. I was the monitoring pilot and my first officer was flying. I only had 1 brief episode where I caught myself nearly falling asleep but my monitoring skills deteriorated to nearly nothing. I found myself fixating repeatedly and had to force myself repeatedly to try and confirm what tasks I had completed and verify that everything was getting done. Worse yet, on approach, due to the marginal visibility and an irregular cloud deck, I developed a case of vertigo and had to spend considerable time and discipline just scanning the instruments to reassure myself that we were wings level and right side up. I believe the reason we were safely able to complete the flight is that we were lucky that nothing went wrong and the WX was better than forecast. Consider the possibility of holding, missing an approach and then diverting to ZZZ3 and the situation would have been even worse. Ironically the company's position would have been that we were still legal to gas up and return to ZZZ2. I would have had no choice but to shut the trip down in ZZZ3 for fatigue but would have facedpotential disciplinary action from the company because of it. Most fortunate of all was that I had one of the more capable and conscientious first officer's that I have flown with in the past yr. We both knew that we were flying impaired and we took it seriously and tried to compensate as best we could. Lastly, did the pairing need to be built this way? ZZZ1 has multiple departures to both ZZZ2 and ZZZ4 daily. This has been the case for a long time and it has never been necessary to resort to this unacceptable sequence of flts. There are a myriad of ways crews can fly in and out in a productive and cost effective manner. It would be only a guess on my part but I think it was put together like this because on paper it looks like a productive trip for commuters with its late check-in and early return. Obviously no reason is acceptable for compromising the safety of our passenger, aircraft and crew. Even if this pairing was put together by the computer there should have been some human oversight to consider the real world human factors issues with this pairing. There also needs to be a way of changing a pairing such as this after the bid packet is printed. If a pairing is deemed unsafe, it can't be allowed to be flown for an entire month just because it's already on the lines of time.
Original NASA ASRS Text
Title: ACR PIC EXPRESSES CONCERN WITH FATIGUE ISSUES RESULTING FROM COMPUTER GENERATED FLIGHT SEQUENCES.
Narrative: THE FINAL DAY OF PAIRING IS CONSTRUCTED IN A WAY THAT LEAVES THE FLC NO ALTERNATIVE TO FLYING IN A SEVERELY FATIGUED STATE. BY BEING FORCED TO FLY IN THIS CONDITION, THE MARGIN OF SAFETY ON FLT FROM ZZZ1 TO ZZZ2 CANNOT HELP BUT BE COMPROMISED. THE FINAL DAY OF THE PAIRING IS LEGAL BY BOTH CONTRACTUAL AND FAA STANDARDS. HOWEVER, THE IMPORTANT QUESTIONS TO ASK ARE: SHOULD IT BE? AND, IS THERE ANY COMPELLING REASON TO HAVE THE PAIRING BUILT IN THIS MANNER TO BEGIN WITH? IN MY OPINION, THE ANSWER TO BOTH QUESTIONS IS NO! BECAUSE THE PAIRING CHKS IN PRIOR TO XF00 ON THE FINAL DAY, THE CREW CAN BE SCHEDULED TO FLY 13 HRS 30 MINS AND ACTUALLY FLY 16 HRS. THIS PAIRING IS SCHEDULED FOR XA35. IF THIS PAIRING CHKED IN JUST 20 MINS LATER, THE CREW COULD ONLY BE SCHEDULED FOR 12 HRS AND THE PAIRING WOULD BE ILLEGAL. FROM A PRACTICAL STANDPOINT, MOST ANY CONSCIENTIOUS CREW WOULD ATTEMPT TO GET A LONG NAP IN THE AFTERNOON BEFORE CHK-IN. BECAUSE THEY HAVE TO CUT THEIR NAP 20 MINS SHORT, THEY CAN NOW BE SCHEDULED FOR AN ADDITIONAL 1 HR 30 MINS OF DUTY AND BE ON DUTY AN ADDITIONAL 2 HRS 30 MINS IN CASE OF WX OR DELAYS. NOTE ALSO THAT A COMPLETE BODY CLOCK SHIFT FROM DAYTIME TO NIGHTTIME FLYING OCCURS IN THIS 24 HR PERIOD MAKING ANY TYPE OF EFFECTIVE NAP NEARLY IMPOSSIBLE ANYWAY. ALSO, LOOK AT THE IMPLICATIONS UPON ARR IN ZZZ2. THE CREW IS TECHNICALLY LEGAL UNTIL XX40. OUR ACTUAL EXPERIENCE ON THIS FLT WAS AS BAD AS OR WORSE THAN YOU MIGHT EXPECT. UPON ARR IN ZZZ, OUR AIRPLANE IS CLEANED, CATERED AND TOWED TO A REMOTE PARKING AREA FOR THE OVERNIGHT. THIS MAKES IT UNSUITABLE FOR THE PLTS TO NAP ON DURING OUR 3 HR 29 MIN SIT TIME. ZZZ1 HAS NO CREW REST AREA WITH ANY TYPE OF COUCH OR RECLINER SO THERE IS NO OPPORTUNITY FOR ANY TYPE OF REST IN THIS SIT. IRONICALLY IF THE SIT WAS SLIGHTLY OVER 1 HR LONGER, THE COMPANY WOULD HAVE TO PROVIDE A HOTEL ROOM WHERE WE COULD TAKE A QUICK NAP AND GRAB A SHOWER BEFORE THE REDEYE SEGMENT. OUR AIRPLANE WAS THEN 1 HR LATE INBOUND FROM ZZZ2. OPS TOLD US THIS IS THE NORM FOR THIS FLT AND I'M CONFIDENT AN AUDIT OF ITS ARR TIMES WOULD BEAR THAT OUT. OUR FORECAST FOR THE FLT SHOWED 2 POTENTIAL AREAS OF TSTMS TO CIRCUMNAV ENRTE. ARR FORECAST WAS IMC WITH EXTENSIVE FOG AND LCL TSTMS OVER MUCH OF THE NE REQUIRING US TO USE ZZZ3 AS OUR ALTERNATE. AN ADDITIONAL LINE OF TSTMS LAY BTWN ZZZ2 AND ZZZ3 COMPLICATING A DIVERT IF NECESSARY. OUR DISPATCHER HAD PUT ON LESS THAN 30 MINS OF EFFECTIVE HOLD FUEL AND WHEN I CALLED HIM TO REQUEST MORE, HE TOLD ME I COULD HAVE AS MUCH AS I WANTED BECAUSE HE WAS BUSY WITH A MEDICAL EMER AND DIDN'T HAVE TIME TO LOOK AT IT. AS YOU CAN SEE, NOT A PRETTY PICTURE FOR A CREW ALREADY OPERATING IN A BACK SIDE OF THE CLOCK, SLEEP DEPRIVED STATE. FORTUNATELY, ALTHOUGH WE DID GET A MINOR RERTE FOR WX, THE FLT WAS, FOR THE MOST PART, UNEVENTFUL AND THE WX ON ARR WAS WELL ABOVE MINIMUMS. IT WAS INDEED FORTUNATE BECAUSE ON DSCNT AND APCH MY PERSONAL PERFORMANCE WAS MARGINAL AT BEST. I WAS THE MONITORING PLT AND MY FO WAS FLYING. I ONLY HAD 1 BRIEF EPISODE WHERE I CAUGHT MYSELF NEARLY FALLING ASLEEP BUT MY MONITORING SKILLS DETERIORATED TO NEARLY NOTHING. I FOUND MYSELF FIXATING REPEATEDLY AND HAD TO FORCE MYSELF REPEATEDLY TO TRY AND CONFIRM WHAT TASKS I HAD COMPLETED AND VERIFY THAT EVERYTHING WAS GETTING DONE. WORSE YET, ON APCH, DUE TO THE MARGINAL VISIBILITY AND AN IRREGULAR CLOUD DECK, I DEVELOPED A CASE OF VERTIGO AND HAD TO SPEND CONSIDERABLE TIME AND DISCIPLINE JUST SCANNING THE INSTS TO REASSURE MYSELF THAT WE WERE WINGS LEVEL AND RIGHT SIDE UP. I BELIEVE THE REASON WE WERE SAFELY ABLE TO COMPLETE THE FLT IS THAT WE WERE LUCKY THAT NOTHING WENT WRONG AND THE WX WAS BETTER THAN FORECAST. CONSIDER THE POSSIBILITY OF HOLDING, MISSING AN APCH AND THEN DIVERTING TO ZZZ3 AND THE SIT WOULD HAVE BEEN EVEN WORSE. IRONICALLY THE COMPANY'S POS WOULD HAVE BEEN THAT WE WERE STILL LEGAL TO GAS UP AND RETURN TO ZZZ2. I WOULD HAVE HAD NO CHOICE BUT TO SHUT THE TRIP DOWN IN ZZZ3 FOR FATIGUE BUT WOULD HAVE FACEDPOTENTIAL DISCIPLINARY ACTION FROM THE COMPANY BECAUSE OF IT. MOST FORTUNATE OF ALL WAS THAT I HAD ONE OF THE MORE CAPABLE AND CONSCIENTIOUS FO'S THAT I HAVE FLOWN WITH IN THE PAST YR. WE BOTH KNEW THAT WE WERE FLYING IMPAIRED AND WE TOOK IT SERIOUSLY AND TRIED TO COMPENSATE AS BEST WE COULD. LASTLY, DID THE PAIRING NEED TO BE BUILT THIS WAY? ZZZ1 HAS MULTIPLE DEPS TO BOTH ZZZ2 AND ZZZ4 DAILY. THIS HAS BEEN THE CASE FOR A LONG TIME AND IT HAS NEVER BEEN NECESSARY TO RESORT TO THIS UNACCEPTABLE SEQUENCE OF FLTS. THERE ARE A MYRIAD OF WAYS CREWS CAN FLY IN AND OUT IN A PRODUCTIVE AND COST EFFECTIVE MANNER. IT WOULD BE ONLY A GUESS ON MY PART BUT I THINK IT WAS PUT TOGETHER LIKE THIS BECAUSE ON PAPER IT LOOKS LIKE A PRODUCTIVE TRIP FOR COMMUTERS WITH ITS LATE CHK-IN AND EARLY RETURN. OBVIOUSLY NO REASON IS ACCEPTABLE FOR COMPROMISING THE SAFETY OF OUR PAX, ACFT AND CREW. EVEN IF THIS PAIRING WAS PUT TOGETHER BY THE COMPUTER THERE SHOULD HAVE BEEN SOME HUMAN OVERSIGHT TO CONSIDER THE REAL WORLD HUMAN FACTORS ISSUES WITH THIS PAIRING. THERE ALSO NEEDS TO BE A WAY OF CHANGING A PAIRING SUCH AS THIS AFTER THE BID PACKET IS PRINTED. IF A PAIRING IS DEEMED UNSAFE, IT CAN'T BE ALLOWED TO BE FLOWN FOR AN ENTIRE MONTH JUST BECAUSE IT'S ALREADY ON THE LINES OF TIME.
Data retrieved from NASA's ASRS site as of July 2007 and automatically converted to unabbreviated mixed upper/lowercase text. This report is for informational purposes with no guarantee of accuracy. See NASA's ASRS site for official report.