On Nov 6, 2009, at 12:04 PM, JC Dill wrote:
Owen DeLong wrote:
We could learn a lot about this from Aviation. Nowhere in human
history has
more research, care, training, and discipline been applied to
accident prevention,
mitigation, and analysis as in aviation. A few examples:
NTSB investigations of EVERY US aircraft accident and published
findings.
Ask any commercial pilot (and especially a commercial commuter
flight pilot) what they think of NTSB investigations when the pilot
had a "bad schedule" that doesn't allow enough time for adequate
sleep. They will point out that lack of sleep can't be determined
in an autopsy.
As a point of information, I _AM_ a commercial pilot.
The NTSB routinely puts an accident down to "pilot error" even when
pilots who regularly fly those routes and shifts are convinced that
exhaustion (lack of sleep, long working days) was clearly involved.
And for even worse news - the smaller the plane the more complicated
it is to fly and the LESS rest the pilots receive in their overnight
stays because commuter airlines are covered under part 135 while
major airlines are covered under part 121. My ex flew turbo-prop
planes for American Eagle (American Airlines commuter flights). It
was common to have the pilot get off duty near 10 pm and be requited
to report back at 6 am. That's just 8 hours for rest. The "rest
period" starts with a wait for a shuttle to the hotel, then the
drive to the hotel (often 15 minutes or more from the airport) then
check-in - it can add up to 30-45 minutes before the pilot is
actually inside a hotel room. These overnight stays are in smaller
towns like Santa Rosa, Fresno, Bakersfield, etc. Usually the pilots
are put up at hotels that don't have a restaurant open this late,
and no neighboring restaurants (even fast food) so the pilot doesn't
get dinner. (There is no time for dinner in the flight schedule -
they get at most 20 minutes of free time between arrival and take-
off - enough time to get a bio-break and hit a vending machine but
not enough time to actually get a meal.) Take a shower, get to bed
at about 11:30. Set the alarm for 4:45 am and catch the shuttle
back to the airport at 5:15 to get there before the 6:00 reporting
time. In that "8 hour" rest period you get less than 6 hours of
sleep - if you can fall asleep easily in a strange hotel.
Flying in such a state of exhaustion is, whether you like it or not, a
form of pilot error.
A pilot who chooses to fly on such a schedule is making an error in
judgment. Sure, there are
all kinds of pressures and employment issues that need to be resolved
to reduce and eliminate
that pressure, and, I support the idea of updating the crew duty time
regulations with that
in mind.
That does not change the fact that FAR 91.3 still applies:
Sec. 91.3
Responsibility and authority of the pilot in command.
(a) The pilot in command of an aircraft is directly responsible for,
and is the final authority as to, the operation of that aircraft.
(b) In an in-flight emergency requiring immediate action, the pilot in
command may deviate from any rule of this part to the extent required
to meet that emergency.
(c) Each pilot in command who deviates from a rule under paragraph (b)
of this section shall, upon the request of the Administrator, send a
written report of that deviation to the Administrator.
A failure to declare him/herself to be incapable of safely completing
the flight is a failure to meet
the requirements of 91.3(a).
Commuter route pilots have been fighting to get regulations changed
to require longer overnight periods, and especially to get the
required rest period changed to "behind the door" so that the
airlines can't include the commute time to/from the airport in the
"rest" period. This would force the airlines to select hotels
closer to the airport or else allow longer overnight layovers -
either way the pilots would get adequate rest. See:
http://asrs.arc.nasa.gov/publications/directline/dl5_one.htm
And that would be a good change.
In part, that change is supported by the number of times that the NTSB
has made statments
such as:
We find the probable cause of the accident was pilot error. We believe
that fatigue was likely
a factor in the accident.
The NTSB does a great job with mechanical issues and with training
issues, but they totally miss the boat when it comes to regulating
adequate rest periods in the airline schedules.
No, you miss the boat on the relationship between the stakeholders.
The NTSB has repeatedly commented on the need for better regulations
and better studies
of crew duty time requirements and fatigue as a factor in accidents
and incidents.
However, the NTSB CANNOT change regulations. They investigate
accidents and make
recommendations to the regulatory agencies. The FAA needs to be the
one to change the
regulations. The FAA has not done a particularly good job in
addressing this topic, where
they have done a better job in improving mechanical and training
issues and have been
more likely to follow up on NTSB recommendations in these areas. In
part, that is the
result of reduced pushback on the FAA in these areas from industry.
After all, Boeing does
NOT want to publicly say "We think that this mechanical factor the
NTSB just determined
as the cause of 400 fatalities isn't really an issue and the FAA
should not issue an AD
to make us correct it."
On the other hand, it's much harder for the kind of public feedback
loop that exists in
the above statement to apply to crew fatigue issues.
In any case, this has drifted well off the NANOG topic, and, I would
be happy to discuss
the NTSB, FAA, etc. with you off-list if you wish.
To bring this back to NANOG territory, how many times have you or
one of your network admins made a mistake when working with
inadequate sleep - due to extra early start hours (needless 8 am
meetings), or working long/late hours, or being called to work in
the middle of the night?
Sure, this happens, but, it's not the only thing that happens.
Finally, having lived with a commercial aviation pilot for 5 years
and having worked with network types for much longer, I can say that
while there is some overlap between pilots and IT techs, there are
also a LOT of people who go into computers (programming, network and
system administration) who are totally unsuitable for the regimented
environment required for commercial aviation - people who HATE
following a lot of rules and regulations and fixed schedules. If
you tried to impose FAA-type rules and regulations and airline
schedules on an IT organization, you would have a revolt on your
hands. Tread carefully when you consider to emulating Aviation.
That's very true. I wasn't advocating that we should emulate
aviation, so much as I was attempting
to point out that if you want to reduce accidents/incidents, there is
a proven model for doing so
and that it comes at a cost. Today, we actually seem, and in my
opinion, rightly so, to prefer
to live with the existing situation. However, given that is the
choice we are making, we should
realize that is the choice we have made and accept the tradeoffs or
make a different choice.
Owen
