The NTSB’s 2016 Most Wanted list of transportation safety improvements makes it clear to me how many of the recommendations come back to individual accountability and responsibility, especially the importance of keeping up-to-date with the latest safety information and taking responsibility for one’s own decisions. This is true for every level of aviation, from GA to the largest airlines, repair stations and manufacturers. It is especially true for general aviation because there is no corporate structure to share responsibility for, say, training or scheduling. For GA pilots and mechanics–including pilots and mechanics at small corporate operations–it’s really all up to you to seek out the education you need to operate safely and to hold yourselves personally responsible.
Some recommendations show up on the top-ten list year after year. That’s OK; sometimes the problems are difficult to deal with. But that doesn’t mean we don’t keep trying. Seven of the NTSB’s 10 recommendations this year are applicable to aviation and can be implemented, at least to some extent, by aircraft owners and individual pilots. The recommendations are:
- Reduce fatigue-related accidents
- Disconnect from deadly distractions
- Require medical fitness for duty
- Strengthen occupant protection
- Prevent loss of control in flight in general aviation
- End substance impairment in transportation and
- Enhance use of recorders to improve transportation safety
Several of the recommendations cross occupational lines and are as applicable to mechanics, air traffic controllers and dispatchers as they are to pilots, even if the NTSB doesn’t specifically call out all those occupations. The two most insidious issues have the broadest applicability across aviation: fatigue and unintentional substance impairment.
Personal Accountability for Fatigue Management
Although the Board does not officially rank the importance of its recommendations, I don’t think it’s happenstance that fatigue is number one on the list. Not only does it affect safety across transportation modes and across occupations, but it is also one of the most difficult issues to deal with in our 24/7 world. Add to that the research finding that fatigue masks fatigue; as the NTSB points out, “Fatigue actually impairs our ability to judge just how fatigued we really are.” While the focus of this recommendation is on vehicle operators, the need to stay awake, alert and attentive is critical across safety disciplines. The Board notes, “Human fatigue is both a symptom of poor sleep and health management and an enabler of other impairments, such as poor judgment and decision making, slowed reaction times and loss of situational awareness and control. Fatigue degrades a person’s ability to stay awake, alert and attentive to the demands of controlling their vehicle safely.”
While the NTSB recommends additional research, “sleep experts say most adults need between seven and nine hours of sleep each night for optimum performance, health and safety.” While many factors can influence fatigue–including environmental factors such as temperature, noise, light and even vibration–individuals can at least focus on getting enough sleep each day. And they can read up on fatigue and fatigue management. This might involve making tough decisions about how we spend our free time, but they are decisions that are ultimately critical to our own safety and the safety of others.
The NTSB cites the 2013 UPS crash in Birmingham, Ala., as support for the importance of this recommendation. In its accident report, the NTSB highlights the issue of personal accountability for off-duty time management, as well as fatigue awareness: “Review of the first officer’s use of her off-duty time indicated that she was likely experiencing fatigue, primarily as a result of improper off-duty time management. Even though the first officer was aware that she was very tired, she did not call in and report that she was fatigued, contrary to the UPS fatigue policy.” The first officer apparently used her time off to visit a friend instead of sleeping. Although the NTSB’s example is an air carrier flight, GA pilots would do well to add fatigue to their preflight checklist: at a minimum did they get seven to nine hours of sleep the night before?
Maintenance workers can affect aviation safety (and their own) just as much when they work fatigued. Hangars and ramps are dangerous places, even more so when you’re working tired. A recent UK accident investigation highlighted the impact of fatigue in a catastrophic engine failure on a British Airways Airbus A319 on takeoff from London Heathrow Airport. In this accident, the precipitating factor was that the engine fan cowl doors detached on takeoff because they had not been properly closed and latched after routine overnight maintenance. The A319 was substantially damaged and the crew had to make an emergency landing. The accident report details not only the obvious failures to comply with maintenance manual procedures but also less obvious contributing factors that left the cowling doors unlatched, including the mechanics’ schedules and likely effects of fatigue.
Responsibility for Learning About Side Effects of Legal Drugs
The NTSB’s research of drug use among pilots killed in crashes found “the prevalence of potentially impairing drugs increased from an average of 11 percent of fatally injured accident pilots during the period from 1990 to 1997 to an average of 23 percent of accident pilots during the period between 2008 and 2012. During the same time frame, positive marijuana results increased to 3 percent from 1.6 percent. But the most commonly found impairing substance in fatal crashes was diphenhydramine, a sedating antihistamine found in over-the-counter medications.”
As more states legalize marijuana, pilots–and others performing safety-critical functions–need to remember that it remains a prohibited substance in aviation. But aviation workers need to be cautious about any medications they take. For prescription drugs, pilots need to specifically ask their doctors about any effects on flying. Mechanics and others need to ask about effects on handling machinery. With non-prescription drugs, it’s important to read the label for the presence of diphenhydramine, which can cause sleepiness. When planning for a flight, adding medications to your checklist might be a start. And while the NTSB doesn’t specifically mention mechanics and other aviation workers, drugs for common ailments such as allergies or colds can affect the work that they do.
These are just two areas of the NTSB’s Most Wanted list of transportation safety improvements. But every day, aviation workers make decisions that can affect their own lives and the lives of others. Aviation safety hinges on continuing education and responsible decision-making, and nowhere is that responsibility more personal than in general aviation.