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

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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

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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