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blues deville

NTSB report on Air Canada at SFO

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 "Gotta have someone to sue, even when a human error was made in a challenging environment."

 

Gotta disagree.

If human error may be causal in a crash, but remains hidden because the industry prefers to keep its institutional shortcoming from the public view, is the public good being served?

The NTSB produces reports that don't assign blame, they only make recommendations. When it comes to implementing those recommendations we're well aware that the regulator may, or may not implement any of them for their own often misguided, but 'secret' reasons.

I don't know if you see it JO, but one of the industry's biggest weaknesses is a feature of this incident and a ticking time bomb that's prevalent throughout the business. Imho, it is an issue that must exposed and examined in the light of day if the true objective of all investigations, 'prevention' is to be realized. 

So, if not for lawyers digging, how would the general public ever know if the regulator is representing them, or the selfish interests of industry?

The fiasco updating duty time regulations stands out as a great Canadian example of regulator intransigence in the face of need and it too is at issue in this event.

 

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A reasonable comment well-stated, Defcon.

I had recent occasion to speak to a retired orthopaedic surgeon about the frequency of problems secondary to arthroscopic surgery. He held up his hand commenting; " These are all fingers but they are not all the same."

That is true about every occupation and self-regulation of the professions will only last as long as those professions in fact regulate.

Back to pilots....for discussion purposes only, assume a failure to conform to the reasonable standard of care expected of a commercial pilot. If damage results, that pilot is liable in negligence. That pilot may not stand alone. Perhaps the atc was contributorily negligent; maybe the employer's training program was inadequate; maybe the federal regulations to lax....the list goes on. The fact remains that if loss was sustained, it must be recovered from those whose fault or neglect contributed to the loss.

I readily understand the concept of promoting full disclosure ( candour) so as to generate improvement in safety. People are urged to self-report drug and alcohol abuse and in return, the employer undertakes to not use that information to punish the employee. Is there  a limit on that " bargain"? Yes. Imperial Oil had such a program. An employee self-reported substance abuse. He was removed from his " safety-sensitive" job and sued. He lost. The necessity of protecting the public from the risk outweighed the individual's rights deriving from his " bargain".

It certainly would not be necessary to broadcast the personal details of the SFO pilots involved in this incident but I do believe the public had a right to access the information through channels reasonably easy to navigate.

And let me emphasize...I think everyone should be able to reasonably access information about the " negligent acts" of their lawyer; doctor; teacher; .....any self-regulating occupation that expects members of the public to believe in their competence simply because they are licensed.

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I don't think any pilot has a problem with the incident being fully investigated and a comprehensive report being made public.  The problem I have is with the names being made public in this case were there was no loss.  (that includes the names of the pilots in the other aircraft)  Certainly came very close and, yes, would have been a major accident but it didn't happen and there's no lawsuit to be filed and no public need being served by publishing the names.  

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NTSB faults pilots for SFO incident. Not the first time viewing this SFO airport video but as mentioned in the report I just noticed the second a/c in line turning on their lights as the A320 approached the UAL 787. May have helped with the crew's decision to go-around.

As a courtesy I usually turn off any lights pointing in the direction of a landing aircraft but try to leave something to show our position such as an opposite side turn-off light as the logo lights and beacon are sometimes out of view. Wing inspection lights can also be effective.

https://www.google.ca/amp/s/www.cbc.ca/amp/1.4838586

https://www.google.ca/amp/s/beta.ctvnews.ca/content/ctvnews/en/national/business/2018/9/25/1_4108110.html

78433B43-8115-4FD8-B2BB-23258BAFF372.png

Edited by blues deville

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Maybe the prod from the NTSB will make the astronaut politician “wake up” when it comes to fatigue in Canada. 

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If the rumours I hear are true, it’d be pretty difficult when his own staff can’t even agree on what the changes should look like. 

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On 9/26/2018 at 12:31 PM, Ex 9A Guy said:

Maybe the prod from the NTSB will make the astronaut politician “wake up” when it comes to fatigue in Canada. 

Yes...and they mention the mess of NOTAMS that appear on flight plans. Relevant ones (runway closures, taxiway closures and nav aid outages) should be brought to the forefront. The States at least highlight these in their ATIS’s.

Edited by Critter
Added thought

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Interesting take by an MIT student:

https://www.theglobeandmail.com/opinion/article-ottawa-must-diverge-from-its-wrong-path-to-air-safety/

"Opinion

Ottawa must diverge from its wrong path to air safety

 
Ashley Nunes
Special to The Globe and Mail
Published 2 days agoUpdated 2 days ago

Ashley Nunes studies regulatory policy at MIT’s Center for Transportation & Logistics

Blame Canada – or perhaps more appropriately, two Canadian pilots.

[see more at link source]

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The danger of our modern 'fake news' times is that BS gets more air time than fact and we have ample proof that lies work if you tell them often enough.

This individual has absolutely no idea what they are playing with.  I am certain that the first time they actually encounter a situation caused by the fatigue they can't understand, they will have zero ability to understand what is going on.  All that they will be certain of is that they are right and everyone else is wrong and the situation is so unfair to them. 

Just keep whistling past the graveyard Ashley.  A lot of our friends are buried there, so we can't afford your luxurious level of ignorance.

Rant over.

Vs

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One of the biggest causes of fatigue is commuting whether it’s driving or flying and nobody wants to admit it. The other is red eye flying and a 24 hour layover for the return.  Of course in my humble opinion. I shortened my commute to 35 minutes by road years ago.

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The long layover for redeyes is actually new and supposed to be a mitigator, but I agree, trying to sleep twice in one day is bad.

Commuting is not so black and white.  If you're commuting transcon (or trans-oceanic as some have tried), then that's clearly an issue.  If it's within the triangle YXU-YYZ-YOW-YUL or YVR-YYC-YEG then really, I'm not so sure. 

I've seen lots of cases where the commuter has come in, grabbed a nap or a shower at Goodlife and looks fresh as a daisy at check-in, compared to the frazzled partner rushing in late due to an accident on the 400, trouble parking and single train service at YYZ.  If on the other hand, you've planned to arrive on your flight at 0900 for an 0930 check-in, you need your head read.

Vs

 

 

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Not sure that I agree that commuting (whether by air, rail, or road) is necessarily a contributor to fatigue. If it is, then it is no more significant than the effect of a pilot who is up at 7 am to get kids off to school and then reports after dinner for a tranatlantic flight without a sleep period. I am not aware of any science based evaluation of commuting induced fatigue other than the obvious impact of consecutive awake hours. Common sense should prevail.

On the other hand, the impact of disrupted Circadian Rhythm on pilot fatigue levels is well documented and has in most regulatory jurisdictions resulted in science based flight and duty time limitations. A computer algorithm that generates pairings and pilot schedules is great for honouring scheduling restrictions contained in a pilot collective agreement but does nothing to factor in that body clocks and sleep patterns cannot be reset like a computer. I can recall being much more ‘fatigued’ during a 9.5 hour duty period that commenced at 0430 than a 14 hour duty period that commenced at 0800. And a 24-30 hour layover that inverts the wake/sleep pattern is an obvious contributor to fatigue.

it is an embarrassment to Canada that two successive Federal governments have slow walked the Flight and Duty Time file. Perhaps these politicians should come along for a pairing and find out what it feels like with the current rules?

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8 hours ago, Moon The Loon said:

Interesting take by an MIT student:

https://www.theglobeandmail.com/opinion/article-ottawa-must-diverge-from-its-wrong-path-to-air-safety/

"Opinion

Ottawa must diverge from its wrong path to air safety

 
Ashley Nunes
Special to The Globe and Mail
Published 2 days agoUpdated 2 days ago

Ashley Nunes studies regulatory policy at MIT’s Center for Transportation & Logistics

Blame Canada – or perhaps more appropriately, two Canadian pilots.

[see more at link source]

This smells like another paid for opinion piece by ATAC and others opposed to the proposed watered down Flight & Duty regs.  

Here is another of his "opinion pieces" 

WestJet's Labour Dispute

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2 hours ago, thor said:

One of the biggest causes of fatigue is commuting whether it’s driving or flying and nobody wants to admit it. 

No matter what the will a always be someone who would rather commute, but it certainly doesn't help being based on some of the most expensive cities in the planet (YVR, YYZ). Especially as effective pay goes down, while inflation goes up, taxes go up, pension costs more, utilities up, interest rates rise... free cash gets tight when average home price is over a million...

Companies need to pay to afford a life in the city you're based in...

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That's a good observation.  Permit me to extrapolate a bit.

So many of these cost cutting, over-negotiated or over-optimized fixes have looked good on isolated spreadsheets, yet always seem to converge on the line, either in the flight deck, cabin, maintenance or dispatch.  Companies want their crew within arm's reach of the airport at all times while paying them less per hour that most of their peers who live near them.  (Particularly new hires on reserve).

While it is ugly in all of these settings, from the perspective of the flight deck, the levels of distraction, fatigue, stress from the effects of a deteriorating schedule on home life and the expectation to also somehow interface with and satisfy passenger service issues can combine to create a life-threatening risk scenario. 

Was 759 such a case?  Do we really need to test this trajectory further?   I'll leave that answer to informed readers, one of which is not the aforementioned author of that reprehensible article.

Vs

Edited by Vsplat

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3 hours ago, Vsplat said:

The long layover for redeyes is actually new and supposed to be a mitigator, but I agree, trying to sleep twice in one day is bad.

Commuting is not so black and white.  If you're commuting transcon (or trans-oceanic as some have tried), then that's clearly an issue.  If it's within the triangle YXU-YYZ-YOW-YUL or YVR-YYC-YEG then really, I'm not so sure. 

I've seen lots of cases where the commuter has come in, grabbed a nap or a shower at Goodlife and looks fresh as a daisy at check-in, compared to the frazzled partner rushing in late due to an accident on the 400, trouble parking and single train service at YYZ.  If on the other hand, you've planned to arrive on your flight at 0900 for an 0930 check-in, you need your head read.

Vs

 

 

"looking" fres and not being fatigued are two different things.  I have seen drunk people look perfectly sober after a shower too but that doesnt make it so.  That freshen up shower may give you a boost but it is a short term boost followed by a crash (physical/mental not aircraft)

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The article's author does have a point. What the FAA has done is pretty loose in terms of science. A real scientific approach to fatigue management would mean giving up some elements of personal privacy. It would entail every pilot in the system wearing a bio-metric device that measures sleep patterns and heart rate and sends up red flags when anomalies occur. Such a system is in place in several jurisdictions (including the US) with carriers that are doing ULH flying. Subjecting oneself to those monitoring programs is a condition of employment. I've seen de-identified data from Delta's ULH monitoring program and the results were very impressive. The data on pre-flight rest, in-flight rest periods and rest during layovers is helping them to plan which crew members in a ULH crew are doing the landings by managing the in-flight bunk time. The effects of long distance commuting and poor sleep patterns stand out prominently in the data. They've even identified a couple of pilots who were suffering from an undiagnosed case of sleep apnea. 

So, if we really want fatigue management, are we willing to subject ourselves to that type of scientific approach? Are the operators?

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10 hours ago, Ex 9A Guy said:

This smells like another paid for opinion piece by ATAC and others opposed to the proposed watered down Flight & Duty regs.  

Here is another of his "opinion pieces" 

WestJet's Labour Dispute

That guy's a d-bag

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