Pilot Fatigue
The Wall Street Journal published a piece in last Saturday's edition, called "Pilot-Fatigue Test Lands JetBlue In Hot Water", describing how U.S. carrier JetBlue Airways tested pilot fatigue in an illicit experiment a year and a half ago, unbeknownst to passengers. The airline recruited pilots to spend more time at the controls than the strict eight hour limit set by the FAA. The Wall Street Journal quoted David Stempler, president of Air Travelers Association, an advocacy group for travelers who said, "passengers would be shocked that this was going on."
Would they? 439 million people flew on scheduled domestic and international flights on U.S. airlines during the first seven months of 2006, according to a Bureau of Transportation Statistics press release in October, 2006. But public demand for information about airline safety seems tepid and the issue is barely covered by the media. Individuals don't seem to know or care how fatigue leading to pilot error translates to a personal fatality risk. Or perhaps they know full well and choose to accept the risk.
In the Wall Street Journal's rundown of the JetBlue story, the airline worked with Mark Rosekind, an alertness researcher and ubiquitous airline consultant whose company markets a product called "Alertness Metrics Technology (AMT)" --an actigraph and personal digital assistant (PDA). A group of volunteer JetBlue pilots flew ten or more hours a day and the devices helped the pilots record their 24-hr sleep/wake patterns and physiological information.
According to the article, word got out that JetBlue was scheduling pilots on longer shifts. The pilots union complained to the Federal Aviation Administration ( FAA). If the FAA allowed JetBlue to flout the rules, than arguably union affiliated airlines would be compelled to compete with JetBlue's cost saving measures.
Pilot fatigue is influenced by a host of factors, including age, fitness, and individual physiology. One pilot error can and has caused hundreds of deaths. Current FAA regulations impose an eight-hour limit for a pilot's flight time during a 24-hour period, and the pilot must have eight continuous hours of rest in the preceding 24-hour. They limit continuous duty to 16 hours. Pilots increasingly report that they fly longer hours with shorter breaks, that scheduling is chaotic and asynchronous, and that flight delays cause longer work days. Studies indicate the extent of the problem:
"in a 4-year study of regional airlines that ended in 1998, 88 percent of the crew members indicated fatigue was a common occurrence, and 92 percent reported fatigue as a moderate-to-serious safety issue".
The FAA rules have not been changed significantly since the 1940's. During one House of Representatives hearing on pilot fatigue Vernon S. Ellingstad, Director of Research and Engineering, National Transportation Safety Board complained:
"the Department of Transportation has spent over 20 million taxpayer dollars to research operator fatigue, but little has been done to apply the knowledge gained from this research."
The FAA readily points out that it was forced to drop changes it proposed in 1995 because of years of disagreement, complaints, congressional hearings and lawsuits among invested parties.
JetBlue - In Hot Water?
In the meantime, the FAA is not enforcing the rules effectively. JetBlue seems to have designed its own regulatory guidance by increasing pilot flying times during this experiment. The Wall Street Journal account seems incomplete if not spurious. "It has been nearly 18 months since [JetBlue's] novel experiment", they say.
However, on January 24, 2006, 9 months ago, the Washington Post wrote about JetBlue's plan. The story, "Poor Behavior, Fatigue Led to '04 Plane Crash; Proper Procedures Not Followed", focused on the crash of a corporate jet in 2004 that investigators attributed to fatigue¹. In the last couple of paragraphs it talked about JetBlue's pilot scheduling. Duane Woerth, president of the Air Line Pilots Association, claimed that even as investigators found fatigue fatal in that crash, JetBlue was trying to get around the eight-hour limit on pilots' flying hours:
'"I am most concerned -- no, paranoid -- about the pressure for profits and productivity that JetBlue and others are trying to get even more hours in a single duty day,' Woerth said. He claimed that JetBlue, whose pilots are not union members, was trying to get around the eight-hour limit on pilots' flying hours."
In response, the JetBlue spokesperson, according to the paper, "said the airline received a temporary exemption in May allowing some of its pilots to fly more than the limit as part of a study on pilot fatigue", and that the airline was not trying to 'squeeze the most out of crew time for the carrier.'
Last Saturday's paper said that JetBlue claimed it got the OK for the experiment from the regional New York office and that FAA headquarters had no idea the experiment was being carried out. But on Janary 21, 2006, three days before the Washington Post report, JetBlue wrote its own press release about the experiment. That press release, "JetBlue Plans Innovative Alertness Management Safety Program.", which has since been removed from the airline's site, didn't mention the FAA regulations or that its pilots were flying longer hours then the FAA allowed. But it did announce the experiment and describe aspects of it, albeit sugarcoated with marketing:
"This program will help us reduce risks associated with fatigue," said Dave Barger, JetBlue's President and COO. "Safety has always been our top priority and, with our collaboration with Alertness Solutions, we will be able to make the safe skies even safer."
On January 24, 2006, the FAA also put out a press report. Taken in context with JetBlue's press release and the Washington Post report, its hard not to see the FAA's press release as a response to JetBlue's announcement, the pilots union reaction to the airline's press release, and the fact that the news had dribbled out to the press -- although the Washington Post was the only paper to report the story. The FAA press release noted that its rules "have evolved along with advances in commercial air travel". It seemed to speak directly to the JetBlue experiment:
"The FAA is confident that, overall, the airline industry complies with the FAA's current rules....The current rules are fundamentally sound but the FAA remains open to any new research or data on fatigue that would assist the agency with developing a new proposal."
In summary, the information the Washington Post reported January 24, 2006, was available in a JetBlue press release January 21st. The FAA said on January 24th that they were open to new research. But, the Wall Street Journal article last Saturday reports that when FAA headquarters found out about JetBlue's experiment they were incensed. They were "red-faced", and a "high-ranking FAA policy maker" said "'We don't allow experiments with passengers on board, period.'" But if they only found out about the experiment in January, and were surprised, why did they say at the time they were "open to any new research on fatigue"? Is JetBlue really in "hot water"? The Wall Street Journal reports:
"...the FAA reprimanded JetBlue, ordered it to clarify procedures as well as flight manuals and Mr. Ballough personally chastised management. But the agency closed its investigation without imposing any monetary fines on the carrier, adding that it was not 'an effort to squeeze the most out of crew time for the carrier'. Since then, FAA officials say headquarters has ordered closer scrutiny by inspectors of all JetBlue. But the agency closed its investigation without imposing any monetary fines on the carrier. " [emphasis ours]
If the FAA was so incensed why didn't they fine JetBlue? Why did their January press release note that they welcomed research? Why are they welcoming research when according to all parties, they don't act on the abundance of research that exists? There are several possibilities.
When Airlines are Nimble and the FAA is Not
The airline industry responds rapidly to the expanding and changing market by outsourcing maintenance, flying fuller flights, establishing low-cost carriers, and cutting costs wherever feasible. However an audit of the FAA's oversight of the changing industry by the U.S. Department of Transportation inspector general in June, 2005, indicated that the agency can't keep up with the rapid changes.
Five major airlines studied in the audit "retired 664 aircraft, stored 166, closed 42 maintenance facilities, cut 9,920 pilot jobs and 12,873 mechanic jobs", in a couple of years after 9-11. Yet FAA could not adjust its operations to the changing profile of the industry, in part because of personnel shortages. Much of the report focused on the agency's failure to properly oversee maintenance operations². The audit also noted that there were more incidents and accidents when airlines were in bankruptcy and because of "prolonged psychological stress and fatigue that pilots had experienced as a result of major pay cuts and flying extra hours to make up for the loss of pay". The audit recommended that the FAA increase its vigilance commensurate with the gravity of these circumstances and adjust its inspection regime for better oversight of the rapidly expanding low-cost carriers, JetBlue and others.
While the results of excessive fatigue can be catastrophic, public and legislative attention focuses elsewhere unless there is a fatal accident. At a congressional hearing following the crash of an American Airlines flight, when attention to the problem piqued, a US Department of Transportation official expressed his frustration:
"The Safety Board's first aviation recommendation related to human fatigue was issued in May 1972, more than a quarter of a century ago, and it asked the FAA to revise FAR 135 to provide adequate flight and duty time limitations. Twenty-seven years later, we are still examining the issue of fatigue, this time in the accident involving American Airlines Flight 1420 that crashed on landing on June 1st in Little Rock, killing 13 people...
It's a complicated problem and the solution is not straight-forward. But in a bureaucratic agency like the FAA this lack of pressure can lead to dangerous complacency in the public, regulators and legislators.
Flouting the FAA -- Or Not?
The Wall Street Journal article noted that JetBlue "says it never intended to mislead anyone at the FAA, and the JetBlue spokeswoman chalked the situation up to 'a miscommunication.'" However the same sort of miscommunication happened with American Airlines several years ago.
Following the crash of an American Airlines flight in Little Rock, Arkansas that investigators blamed on fatigue, the FAA issued a warning to all airlines that it would increase enforcement of crew rest rules. American Airlines asked for an extension of the December, 1999 extension, as did most major airlines, according to a story in the Dallas Morning News -- "Pilots feel pushed despite rest rules". (May 12, 2002)
The FAA did not grant American Airlines extension request and followed up, as it warned it would, with an audit of the airlines practices. It found 825 infractions of the rest rules between December 1999 and May 2000. However when the FAA cited the airline for not complying with the rest rules, not hiring extra pilots to cover shifts, and ignoring the FAA's request, a spokesperson for American Airlines said "The [FAA's] Southwest Region knew what we were doing."
Because of the ambiguity of the deal struck between the local office and American Airlines, the company wasn't fined, despite ample evidence of each of the 825 infractions, admissions from the pilots, and no evidence of any agreement between the airline and the regional office. The FAA ended up citing the airline for 38 violations which occurred in two weeks following the FAA's audit. It fined the airline $285,000 for violations of crew rest rules.
As reported by the Dallas Morning News, "had the FAA chosen to fine American the maximum amount, those violations could have cost the airline more than $9 million." Even after being fined American Airlines continued its practices by suggesting that pilots lower their altitude on flights from Dallas to Honolulu in order to the shorten flights. However the plan rarely worked, so airline crews continued to fly long days in violation of the FAA rules. (New York Times, August, 2001)
At the time of the bungled American Airlines audit, the FAA also audited Delta Airlines' pilot rest practices. Delta didn't have records of rest in its computers and, according to the same news Dallas Morning News report "Delta was unwilling or unable to provide historical detail", therefore it wasn't cited by the FAA.
Fatal Errors-- Cost Benefit Analysis
Fatigue errors can be deadly, but major airplane crashes are fairly rare. In a congressional hearing on pilot rest requirements, the issue of cost-benefit analysis was broached by one Congressman:
Representative Defazio: [Oregon] How do we calculate benefit in preventing one crash which kills 1 or 200 people; what is that worth? What value are we currently putting on life? You always have a value. I am just curious what it is today.Margaret Gilligan (Deputy Associate Administrator for Regulation and Certification of the Federal Aviation Administration): I believe the number that is still used by the Department is on the order of $2.7 million. There are econometric models that we apply for that analysis....
As a multi-billion dollar operation, the airline industry needs to adapt business practices that benefit the bottom line. But if JetBlue can fly pilots for longer hours and call it "research", don't all airlines need to do the same in order to remain competitive? As long as the perception remains that it's safe to fly, it appears that disobeying the FAA, even chalking up 825 infractions in six months, doesn't carry significant consequences. While American Airlines doesn't seem like the best bet, according to fatality statistics at Airsafe.com, the airline, for whatever reason, seems to attract a disproportionate number of terrorist threats, probably not due to fatigue.
While its easy to say, after an airline accident, that the passengers would have probably not minded being a little late, passengers often don't necessarily prioritize the same way when their delayed to their important 9:00 meeting in Manhattan. Catastrophe is still rare in aviation, even though the risks are continuous and growing. So when passengers don't question the issue of pilot fatigue they explicitly or implicitly agree to share the economic cost-benefit with the airlines. They either intuitively comprehend and accept the risks, or they don't know the risks therefore don't complain.
The FAA seems to know and understand the risks. It also has the technological knowledge to make the changes, even as, oddly, it calls for research. The question is, does the agency fail to change because the public pressure isn't high enough? Because management practices are so disfunctional that it can't? Or is the FAA so feeble or beholden to the airlines that it repeatedly allows companies to dictate which rules they follow and which ones they ignore, fails to fine airlines for infractions, and bows to pressure when it does initiate change?
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¹ According to the post crash analysis, the Corporate Airlines Flight 5966 (which connected with American Airlines) met its demise as the two person flight team were "joking and cursing at one another" at the end of their 14 hour day, while "ignor[ing] guidance about when and at what speed to descend the plane". The National Transportation Safety Board Report (NTSB), which carried out the analysis and listened to the tapes before the crash, recommended that the FAA update its pilot work-rest rules.
² The agency didn't have enough inspectors, and failed to complete an average of 26% (United 42%, Delta 40%, American 27%, Northwest (18%), US Airways 15%) of its inspections of five major carriers. In "identified risk areas", the inspectors failed to complete on average 55% of the inspections, and rarely inspected maintenance operations at night (1-3% of the total inspections).
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Acronym Required wrote Crash Tests For Dummies", also about the airline industry. We periodically cover other US government agencies such as FEMA and the FDA.
