Edited transcript of interview of Drew Dawson, Director, Centre for Sleep Research, University of South Australia, by Frederic Zalac, CBC News, for the documentary "Dead Tired", March 24, 2010.
Frederic Zalac: SO FIRST I’D LIKE TO KNOW, WHAT PROMPTED YOU TO LOOK INTO PILOT FATIGUE?
Drew Dawson: I think we’d had some very interesting discussions with the regulator in Australia; we had some very interesting conversations with the pilots and the operators and I think following the QF1 incident in Bangkok a couple of years ago where fatigue was identified as a clear factor in that particular incident, there was a decision that we need to look at fatigue – how tired the pilots are and what the implications of that are for decision making on the flight deck.
FZ: SO, WAS THAT THE GOAL OF YOUR STUDY?
DD: I think the goal of the study, based on discussions with all the parties, was that they didn’t want to do yet another study showing that tired pilots make mistakes; I mean, I think that’s reasonably well-established. What we wanted to look at in those particular studies was how tired are pilots and most importantly how tired is too tired – that is, being tired is not a problem in and of itself unless you are unsafe, and we wanted to get a much more detailed understanding of how fatigue influences decision-making and most importantly the kind of predict-protective and adaptive behaviours that pilots were engaging in and to understand and see if we could systematically teach and train those as well as measuring the levels of fatigue.
FZ: WHAT DID YOU FIND OUT?
DD: I think we found out that, for the vast majority of pilots on the mast majority of occasions, they were getting sufficient sleep and we were getting few problems. I think what we also found out was, on some occasions, there were pilots operating aircrafts who had had very little sleep, but that wasn’t necessarily due to only poor scheduling by the airline; sometimes it was to do with what we politely refer to as non-work related factors: somebody had been up with a sick kid all night; somebody was operating a second business – there was a whole range of reasons that meant someone might end up in the workplace having not had sufficient sleep. So there was a combination of factors we had to work with and it was really important to understand, if you’re going to manage those low-frequency, high-risk situations, the traditional approach is based around prescriptive hours - flight and duty limitations could never really address those kind of problems.
FZ: SO IF IT WAS NOT SUFFICIENT, PEOPLE WOULD RESPECT IT AND SOME CASES I GUESS THEY WOULD – IT WAS ALL LEGAL WHAT THEY WERE DOING AND YOU SAW AT THE TIME?
DD: I think if you look at the QF1 incident in Bangkok that Qantas had, they had a pilot who had management responsibilities and had been working during the day then gone off to fly at night. Now, under the flight and duty time regulations, he was completely legal. On the other hand, you say well, where does work start and where does work finish? Is it stick time, so to speak, or if a pilot’s actually working at work during the day then chooses to fly all night, how do we actually manage those situations? And I think when you work in this area, you realize it’s actually quite complex: the solutions are not simple and straightforward and you need to have a much more nuanced understanding of the issues if you’re actually going to manage the risks associated with fatigue.
FZ: SO BEFORE WE GO ONTO TO THAT PART, I WOULD LIKE TO KNOW - WHAT KIND OF RISK ARE WE LOOKING AT?
DD: Well, we saw small numbers of pilots who had very low levels of sleep – less than four hours sometimes – in the night preceding a flight, and we know from the data we collected in our simulation studies that once the amount of sleep gets down below five hours, we see a doubling of the rate at which errors are made, and we see significant consequences on how those errors are managed – that is whether they lead to an unsafe state for the aeroplane in the simulator. So I think there is no doubt that where people aren’t getting enough sleep, it’s a problem. The question is, if you are to control that, you have two options: the first option is that you can give people flight and duty time regulations that are so tight that they always have enough time to sleep and what we learned from our studies is that even when people were given two weeks off, which should normally – is more than sufficient amount of time to get some sleep, sometimes they travelled in order to fly long distances. We know for example with some of the American airlines, you may well have pilots living in the south of France flying to work to commence in New York. Now, they’re legal and I think what people are starting to realize is you can never come up with a set of rules that covered every possible consequence that was sufficient to allow an airline to operate safely and economically. So I think what people are starting to look at is, do we have ways that we can actually manage flexible operations and in a sense permit people to operate in ways that are safe and clearly remove people from working when they demonstrably unsafe. But you could have a limitation of a two-hour flight that’s not going to stop somebody from being up all night with a sick child. So you have to have a system whereby you manage both work-related causes of fatigue and non-work related causes of fatigue.
FZ: AND THAT’S THE PROCESS THAT YOU’VE OUTLINED. YOU’VE DONE A LOT OF STUDIES ON THE EFFECTS OF FATIGUE ON PILOTS. CAN YOU GIVE US AN ANALOGY FOR WHAT THAT WOULD MEAN (THAT LACK OF SLEEP) ON THE PILOT. I THINK YOU DID SOMETHING THAT’S RELATED WITH ALCOHOL.
Q: Yeah, probably ten years or some ago we did some studies looking at the effects of fatigue on hand-eye coordination and decision making, and we showed once people had been awake for 18-20 hours, starting at 8 o’clock in the morning, then their performance was impaired to about the same level as somewhere between 0.05 and 0.07 blood alcohol concentration and that after they’d been awake 24-hours straight, that is around 6 or 7 o’clock in the morning, their impairment was equivalent to a 0.1 blood alcohol concentration. And I think this kind of signalled to people that the comparative of risk associated with fatigue is potentially quite high, and while it would be completely unacceptable for a pilot to be in the work place with a blood alcohol concentration of 0.05 or 0.1 percent, it’s not uncommon to see pilots operating aeroplanes with the same level of impairment, but due to a different cause, and that raises some very important safety questions. If it’s not okay to be impaired due alcohol, why is it okay to have the same level of impairment due to fatigue?
FZ: SO IS IT BECAUSE PILOTS DON’T WANT TO ADMIT TO THAT?
DD: I think it’s a cultural thing and there are enormous pressures on people to operate in commercially profitable ways and I think sometimes it is very difficult to admit you are not fit for duty. I think particularly in command and control-style organizations and particularly those that have strong traditions coming out of military um perspectives, it’s very hard to say, “I’m not fit for duty,” and if that’s going to stop an aeroplane with 400 passengers and cost of thousands of dollars to relocate and reposition, people are going to be very reluctant sometimes to put their hand up when there’s no way they could actually be caught. And for the vast majority of occasions, the decision to operate fatigued doesn’t lead to a negative outcome, so in many cases people are reinforced continually for doing the wrong thing. If the wrong thing does happen, people don’t generally survive to learn the lesson.
FZ: NOW LET’S TALK ABOUT THE REGULATION OF FLIGHT TIMES THAT DO EXIST. WE’VE GOT, IN CANADA, A LIMITATION OF 14 HOURS FOR DUTY, WHICH DOESN’T TAKE INTO ACCOUNT THE TIME OF DAY WHEN YOU START AND ALL THAT. WHAT DO YOU THINK OF THAT? ESPECIALLY SINCE EUROPE HAS DIFFERENT MODELS WHERE DEPENDING ON IF YOU START AT 2 AM., YOU CAN’T NECESSARILY HAVE THE SAME LENGTH OF DAY.
DD: Look, I think there’s a long history of developing flight and duty limitations. But I think whether it be aviation, road transport, or lots of other industries, the origins of that process are primarily through labour law – they’re industrial processes and they’ve been based on a negotiation between employees and employers. And those decisions on what’s acceptable or not have been primarily driven through industrial relations – labour law – negotiation and haven’t necessarily been influenced by the science. If you look at most of the negotiations around what are acceptable hours and not, you’ll typically see a regulator, a union, and management involved in that decision-making process; it’s only been in the last decade we’ve seen significant input from the researchers. But even though we’ve had that input from the researchers in the last couple of decades, in many cases decisions on what makes an acceptable schedule aren’t only based on fatigue, so the quality of life; the amount of time you get to stay away; what are referred to in Canada as onerous pairings, can be onerous for reasons other than fatigue. And in many organizations we’ve seen fatigue is an acceptable cost in order to get a quality of life outcome in a schedule or roster people are working. So it’s a very complex political and sociocultural phenomenon around hours of work and flight and duty time limitations in aviation. We shouldn’t ignore those complexities in trying to understand why people make what look like good fatigue decisions not necessarily good quality of life decisions.
FZ: NOW WHAT DO YOU THINK OF OUR REGULATIONS? ARE THEY DATED? WHAT’S YOUR TAKE?
DD: Well, I think the notion of prescriptive flight and duty-time limitations, and they way they’ve actually been operationalized in most developed countries, probably haven’t kept up with the latest research and science, so we know for example, time of day factors are absolutely critical in determining people’s level of alertness or fatigue, and we know very few of the regulations around the world actually embed any principles around either time of day or body clock issues related to crossing time zones. And the reason for this is that it’s complicated and it’s hard and very difficult to develop rule sets that can manage that complexity in simple and straightforward ways.
FZ: SOME PEOPLE ARE SAYING, WE’RE STUCK IN THE ‘40S IN TERMS OF REGULATION. WHAT DO YOU THINK? DO YOU AGREE WITH THAT?
DD: Maybe ‘50s.
DD: Look, I think if you look at the changes in how flight and duty times have been regulated in the last two decades, the changes have been miniscule – that is, they’ve been very, very minor changes. Yet if you look at the risk profile of the industry, the nature of the cockpit, the way technology has adapted and the distances that planes are flying, all of those are incredibly powerful influences on the level of fatigue and the likelihood of error. Yet the changes in flight and duty-time limitations have been relatively trivial compared to those massive changes. It would not be unreasonable to kind of stop, sit back and go, “If we were to approach this from an evidence-based perspective, how would we do it? And start from a zero-budgeting approach” so it’s if we’re going to build a regulatory system now based on what we know, we would probably come up with something entirely different than what’s currently being done.
FZ: NOW THE 14-HOUR FLIGHT HOUR LIMITATION IN CANADA LIKE I WAS SAYING, THIS IS LIKE THIS FLAT LINE IF YOU LOOK AT A GRAPH OF THE TIME OF THE DAY. WHAT DO YOU THINK OF THAT? IS THAT INAPPROPRIATE KNOWING WHAT WE KNOW NOW WITH SCIENCE?
DD: Well, the answer to that is; it depends: it’s 14 hours doing what; how many sectors; what time of day; what are the conditions one’s flying under – it’s a very complicated question based on our knowledge to date to answer that. What I think is important to reflect on is the fact that the assumption under that approach is that at 13 hours and 59 minutes I’m perfectly fit to fly and at 14 hours and one minute I’m perfectly unfit to fly. That doesn’t reflect any biological reality that the research can explain to us.
FZ: NOW THAT’S THE APPROACH THAT’S BEEN TAKEN UP TO NOW ON FLIGHT DUTY LIMITATION, AND - I THINK YOU WERE ALLUDING TO COMMUTING ISSUES, FOR INSTANCE, EARLIER WHEN YOU WERE SAYING THAT…IS THAT SOMETHING THAT IN YOUR VIEW IS A PROBLEM IN THE INDUSTRY AND SHOULD BE TAKEN INTO ACCOUNT?
DD: Well, whether it’s a problem or not, I can’t say because I don’t have data to answer that question, but I can say it’s a factor that an organization needs to take a look at in terms of their own internal risk assessment about it’s a problem. So if you have people commuting long distances, how does that actually impact on their subsequent performance and how are you going to manage the risks associated with that? Flight and duty time limitations don’t typically focus on those kind of extraneous factors. I think it’s H.L. Mencken who said, “For every complex problem there is a simple solution and it’s usually wrong,” and I think flight and duty times are a classic example of that kind of wicked problem.
FZ: SHOULD WE JUST GET RID OF THEM OR SHOULD THEY STAY THERE AS A BASE?
DD: I don’t think you can get rid of regulation. I think it would be very difficult to just say we’re just going to let people look after it themselves on the ‘trust me’ principle. And I think the economic pressures and the individual predilection of pilots would be such that we wouldn’t necessarily get the safest outcome. I think there needs to be regulation, but the regulation can assume different shapes in terms of what we’ve traditionally seen as far as flight and duty time limitations.
FZ: WHAT DO YOU MEAN?
DD: Well, I think good safety management systems theory – and I make an important distinction between well-implemented and poorly-implemented safety management systems approaches – I think they could be approached, or they could be applied to fatigue management very effectively and we’re starting to see some initiatives around the world where people are starting to say, “There’s a better way of doing this other than traditional flight and duty-time limitations. Let’s try them out and see how they go, and see whether they produce flexible, safe outcomes.”
FZ: YOU DID STUDIES AND CANADA. WHAT WAS YOUR INVOLVEMENT WITH TRANSPORT CANADA?
DD: Well, we worked on some projects in terms of providing resources for organizations looking at implementing a safety management systems approach – there was in effect a toolkit provided to operators that would enable them to look at their operation, assess the level of risk and then set appropriate controls for managing that risk in as flexible a way as possible. My understanding is that the uptake on that approach has been relatively low to date.
FZ: IN WHAT SENSE?
DD: I don’t believe many organizations have approved fatigue risk management systems based on SMS approaches developed by Transport Canada actually up and operating.
FZ: SO JUST TO AVOID THE MESS, YOU’RE SAYING THAT THE SELF-ASSESSMENT APPROACH THAT YOU PROPOSED IS NOT BEING IMPLEMENTED?
DD: I don’t think a self-assessment approach was ever suggested; it was to take a safety management systems approach, which was in effect to say to the organization, “You prove to us you’re going to manage fatigue appropriately; we want to see that you’ve assessed the risk accurately based on what your pilots or maintenance engineers do in your operation on a day-to-day basis and we want to be confident you’ve put in appropriate and adequate controls to manage that risk.” Now, in very practical terms that’s been very challenging for a lot of organizations. I think aviation has a long history of prescriptive, rule-based regulation and I think a lot of organizations, when they look at a safety management systems approach, are a bit overwhelmed by it. And I think in many cases around the world, not only have the operators been overwhelmed by it, but I think the regulators have been overwhelmed about how to implement it in the most effective way.
FZ: SO WHEN YOU WERE CONTACTED BY TRANSPORT CANADA. DO YOU REMEMBER THE CONTEXT - WHY THEY CAME UP TO YOU AND SAID WE NEED TO DO SOMETHING? WHAT WAS THE REASON THEY DECIDED TO ACT?
DD: Well, I think it was within a broader safety management systems initiative and I think they wanted to see was it possible to develop an approach to managing fatigue consistent with a safety management systems perspective. As many organizations around the world have moved to this different approach, I think there has been sometimes a kind of a contradiction between prescriptive rules and safety management systems approach. I think they were looking at what happened in Australia and New Zealand with their regulators who have, maybe a little further at the time, to a safety management systems approach to fatigue and said, “Well, maybe we should put our toes in the water and try it here.”
FZ: WHAT YOU’VE PROPOSED – I SAID SELF-REGULATION AND YOU SAID NO, IT’S NOT THAT. CAN YOU TELL US, BASICALLY IN LAYMAN’S TERMS, WHAT IT IS FOR FATIGUE YOU’RE PROPOSING?
DD: Yeah, the prescriptive systems are based on a very simple principle where there is a set of rules then the regulator’s role is to find people who are breaking the rules and punish them. A safety management systems approach reverses the burden of proof and says “We accept no rule set will enable every organization to perfectly operate as safely and effectively as possible. You show us how you intend to manage the risk and we will look at that and see if it’s reasonable and if we think that you’ve got a reasonable plan for doing it, we’ll allow you to do it and monitor and evaluate it.” But it is accepting the fact there is different approaches to different organizations in different parts of the industry and it is not unreasonable for certain organizations to put in place flexible, safe, operating rules. There is also a realization that some organizations lack the safety infrastructure or developmental sophistication to actually do it and those organizations probably shouldn’t be allowed to do a safety management systems approach.
FZ: CONCRETELY FOR PILOTS, WHAT DOES THAT MEAN? UP TO NOW INSPECTORS WOULD GO AND CHECK THE NUMBER OF HOURS PUT IN – THE NUMBER OF HOURS THEY WERE OFF. THAT’S THE LIMITATION THEY HAD. NOW, YOU’RE PROPOSING SOMETHING DIFFERENT. FOR THE PILOTS AND THE COMPANY, WHAT WOULD HAPPEN?
DD: I think what we’re proposing is a two-stage process: one is that the organization has a primary responsibility to ensure that the hours a pilot is scheduled to work and actually works do provide an adequate opportunity to rest and recover and there are a number of software packages and models out there that would take into account time zones and time of day; they’re not perfect, but they certainly do a lot better at estimating the likely risk than we can with compliance to a rule set. But the second part of the equation is that even though I provide people with an adequate opportunity to rest and recover, they don’t necessarily convert that time into sufficient sleep. What we learned from our studies in aviation and many other industries is hours of work and flight and duty times aren’t a very good predictor of the level of fatigue that an individual will experience. On the other hand, if we measure the actual amount of sleep that they’re getting, that turns out to be a very powerful predictor, not just of fatigue, but of safety performance. So what we’re advocating is a two-step process: one of which the organization is responsible for managing the sleep opportunity, but over and above that, where the pilot or any other individual is responsible for managing their time away from work. And that they have clear guidelines on what constitutes a sufficient amount of sleep to operate safely and in the event they haven’t got sufficient sleep, there is a clear, demonstrable process in the organization for putting your hand up and managing that situation.
FZ: THAT’S IN AN IDEAL WORLD. WE’VE HEARD FROM MANY PEOPLE IN THE INDUSTRY THAT ARE SAYING THAT, ESPECIALLY IN SMALLER AIRLINES, THE REALITY IS THE PILOTS OFTEN FEEL THEY CAN’T SAY THEY ARE FATIGUED, FEEL CONCERNED THEY’RE GOING TO LOSE THEIR JOB, NOT GET THE FLIGHTS THEY HOPE TO GET – THINGS LIKE THAT. THAT’S THE REALITY. THIS SEEMS TO BE A NICE PROPOSITION BUILT ON A DREAM.
DD: No, and what I would suggest is there are many organizations out there who don’t deserve to have a flexible safety management systems approach and should not be given them. On the other hand, where an organization can show that they can do it right, then I think it’s good to align economic benefits with safety benefits. So I think it’s probably quite reasonable to say if the burden of proof is over to you as an operator, you have to prove to the regulator and to the community that you can do it safely, but if the pressures and culture in your organization are such that you can’t do it, neither should you be allowed to.
FZ: WHAT IF A COMPANY SAYS WE’RE READY TO GO IN THIS WAY AND ALL THAT. THEY TAKE THE OPPORTUNITY TO JUST GO AROUND AND HIDE WHATEVER PROBLEMS THEY HAVE BECAUSE THEY DON’T NECESSARILY HAVE TO REPORT THEM – THEY’RE SUPPOSED TO TAKE CARE OF THAT INTERNALLY. SO WHAT WOULD BE THE INCENTIVE FOR A COMPANY THAT IS BASICALLY DRIVEN BY PROFIT TO ADMIT TO THE REGULATOR THAT THERE’S MAJOR PROBLEMS?
DD: Well, I think that is a misunderstanding of a safety management systems approach. Safety management systems approach doesn’t hand over all responsibility to the operator; what it is, is it’s your responsibility to prove to us that you’re doing the right thing. You can’t have a safety management systems approach that doesn’t have effective, external oversight and it’s probably true that in many jurisdictions around the world we have seen a flight to safety management systems models without a corresponding oversight from regulators in ways that would give the community peace and comfort at night.
FZ: HOW IMPORTANT IS THAT OVERSIGHT?
DD: I don’t think you can consider a safety management system independent of the regulatory oversight: It’s an absolutely critical and essential element. And my view would be a badly managed safety management approach would be worse than what we’ve got at the moment.
FZ: AND IF WE GO BACK TO THE SLEEP ISSUE – FAITGUE ISSUE, HOW IMPORTANT IS IT TO HAVE CONTROLS - WHAT KIND OF CONTROLS AND HOW IMPORTANT ARE THOSE?
DD: Well, I think if I look at some of the organizations we’ve been working with in the aviation sector, they have moved very significantly in their ability to manage their culture and to assign some primacy to pilots in their ability in actually putting their hand up if they are feeling unsafe to listen to that and say, “We will listen to you.” On the other hand, if you consistently put your hand up and haven’t had sufficient sleep to be safe despite being provided an adequate opportunity, then there’s a performance management issue – why is that happening; what is the problem? And that’s not acceptable in the long run. On the other hand, someone can be up with a sick child all night and that’s going to happen and we should acknowledge that and build systems that anticipate the kind of problems that happen in the real world on a regular basis.
FZ: I’M THINKING OF THE SITUATION OF COMMUTING. AGAIN, I WAS SHOCKED TO HEAR SOME PILOTS ARE LIVING IN VANCOUVER AND STARTING THEIR DAY IN MONTREAL, SO THERE’S A FIVE-HOUR FLIGHT THERE IN-BETWEEN. HOW WOULD A PILOT LIKE THAT IN THE SYSTEM YOU’VE PROPOSED, WHERE HE’S MAKING THE DECISION TO WORK OUT OF MONTREAL BECAUSE HE’S PAID $40,000 MORE AS A CAPTAIN THEN AS A CO-PILOT, AS HE WOULD BE IN VANCOUVER – HE’S MAKING THAT CHOICE FOR HIMSELF. HE KNOWS HE’S RESPONSIBLE FOR BEING UP MUCH EARLIER THAN HE WOULD NORMALLY BE, AND HE GOES THROUGH THIS ASSESSMENT, “AM I FATIGUED? YES,” WILL HE WILLINGLY ADMIT TO THAT WHEN IT GOES AGAINST – HE’S GOT TO BE RESPONSIBLE FOR THAT. I MEAN, I’M TRYING TO SEE HOW A SYSTEM LIKE THAT CAN ACTUALLY WORK WHEN THERE’S INTERESTS THAT GO IN THE OTHER DIRECTION.
DD: Well, I’d come back to the first point, which is that a pilot, if for whatever reason is choosing to commute as part of their work pattern, that has to be included in the initial analysis of are we providing this person an adequate opportunity to rest and recover. So what that may mean in practical terms is that instead of saying your hours or work or your flight times are from 6 o’clock until midnight and it’s only a six-hour shift, but there’s actually a five-hour commute there, then we need to say, “No, your hours of work actually start from the time you leave home, and not from the time you sign on,” and I think there are really good examples from around the world where those factors are being embedded in the risk assessment those organizations are doing. Where it goes wrong at the moment is that there is no requirement from a regulatory perspective to include those factors automatically in the risk assessment; there are ways it can be done and it would not be unreasonable for regulators to come along and say, in determining whether you’re providing people with an adequate opportunity to rest and recover, you need to take into account commute times – where the person is located – activities involved that preclude the opportunity to sleep, but don’t necessarily involve you flying. And I think it’s perfectly reasonable to expect organizations to take those factors into account.
FZ: BUT THERE SHOULD BE REGULATIONS ACCORDING TO YOU, TO FORCE AIRLINES TO DO THAT.
Q: OR ELSE THEY PROBABLY WON’T DO IT WITHOUT THE MONEY.
DD: Well, nobody will do anything they don’t want to unless they’re made to, and even though you know there is a very small risk of 1 in, you know, 500,000 or something there will be an accident, if you push it on the day, that can be a hard decision to make because there’s going to be a hundred to two hundred passengers that will be forced to stay over night – you’re going to have to reposition the plane and the short-term cost of that can be very high. So I think it’s important people are able to set the framework for managing fatigue, but not in the context of the day-to-day operations of what someone has to do there. I think, for example, if somebody has had insufficient sleep, organizations (and many of the organizations we work with now do this), they will say, “You need to put up your hand and we need to collect that data on an aggregate basis across the organization, and if we see lots of occasions with people putting up their hand, we’ve got a problem and we need to go back and look at what we’re doing even though it might look like we’re compliant with the rules for whatever reason it is, people aren’t getting sufficient sleep.” And I think it’s this dual focus on sleep opportunity and the amount of sleep that is obtained that provided organizations the capacity to manage this much better and much more flexibly.
FZ: IS THAT ALL AT WORK FOR TRANSPORT CANADA?
FZ: IT’S ON THE WEBSITE?
Q: WHAT’S IT USED FOR NOW?
DD: Well that’s a Transport Canada issue. I think they are trying to say to people there is an opportunity to look at this differently; whether there is active encouragement of people to pursue that path; whether there is an appetite by the community and the operators to go down that path, is obviously questionable because we’re not seeing a huge number of people go down that. I think it’s important to understand why people are not doing it: whether they see it as too expensive, whether they see it as too ambiguous – we know from our experience in Australia that putting up a safety case and developing that for a small to medium company can be quite expensive and if you don’t have any clear indication it’s actually going to be signed off on or approved, that can be a big risk for a small organization without a lot of resources to put into it. We also know that the smaller and medium ends of the business also don’t have the professional expertise to put those safety cases together. Well, I think there is a clear argument for building a set of templates or toolkits or in a sense standardized models that would enable organizations to go down that path with a greater ability to know whether they are actually going to get approved or not in advance. But I also think there’s an important point: just because you get your safety management system approach to fatigue approved, the regulator has a moral responsibility to be in there and make sure that it wasn’t just there for six months and then it continues to operate and work as originally specified and I think those ambiguities have been very challenging for regulators and the industry.
FZ: WHAT DO YOU THINK OF THE NEW ZEALAND APPROACH TO REDUCING PILOT FATIGUE?
DD: Well I think Air New Zealand have spent a good 10 years working on new approaches to this, and I think what they’re doing is as good or better than what’s happening in most of the rest of the world. Is it perfect? No. Are they working on improving it? Yes. And I think there’s been a lot of effort and energy expended on trying to approach this and most importantly, moving towards an evidence-based approach. Now the evidence may not be perfect and we can all argue about that amongst ourselves as scientists and researchers, but I think where a particular city pairing or operation is brought into question because of people, you know, reporting they’re feeling fatigued, there’s a process of going in, quantifying and measuring the sleep – the amount of time people are spending flying – all of those activities and then looking at that in a sense that is informed by evidence. That’s a really new approach and I think that’s a really good approach. It isn’t an approach that’s being used elsewhere in other regulatory restrictions because in many cases it’s been a dialogue between pilots and regulators based on opinion, experience, and a whole range of factors that aren’t as evidence-based as
FZ: WHAT DO YOU MAKE OF WHAT’S GOING ON IN CANADA - THE LACK OF ACTION? SHOULD WE GET A WAKE-UP CALL ON THIS?
DD: Well, I think if you look around the world there was a lot of interest on fatigue in the late ‘90s and the early part of this decade and we’ve seen that slow down particularly in the last couple of years. I think there are a number of factors around that: I think in the last couple years the global financial crisis and the economic pressures on the airlines and the regulators to keep the airlines in business and stuff has been very important. I think if you take a longer-term perspective, we saw more enthusiasm for fatigue risk management systems right around the developed world and in the last couple of years we’ve seen initiatives come through IKO and at the international and global level. I think if you look in Australia and Canada at the moment, there is a sense that there are international regulations being put together and being discussed in this. It might be quite okay for us to sit back and see what comes out of those global discussions. I think based on those discussions to date everybody’s pretty clear what’s going to go ahead, but it’s always good to use what’s happening elsewhere as the reason for dropping the ball. I’m not sure Canada is the only place that’s dropping the ball on this; I think there are lots of cases in other jurisdictions where the initial enthusiasm has waned in the last couple of years.
FZ: BUT YOU’RE SAYING CANADA HAS DROPPED THE BALL ON THIS?
DD: Well, I think where they could have got from where they started could have been a lot further down the path, but I think as with many other jurisdictions, economic pressures, those international initiatives, can lead to complacency.
FZ: WHAT WILL IT TAKE TO ACTUALLY INITIATE CHANGE?
DD: Well, some of the major theorists in the area talk about complacency disruption events, so there’s nothing like a smoking hole in the ground to address attention. I think it’s James Reese who once also said, “People have spent billions of dollars preventing accidents that have already happened,” so I think there is a tendency in a lot of safety culture theory around the world to go, “Well, we will respond after the event,” and fatigue related accidents are difficult to prove, relatively low frequency, but high in consequence. And that’s always a difficult regulatory challenge.
FZ: YOUR POSITION OBVIOUSLY IS THAT WE SHOULD MOVE NOW, IS THAT IT?
DD: I think one of the important things to think about in this debate is that a lot of times people will put up new approaches; people will look at them and say “Well, there’s this problem. It’s flawed; it’s not perfect,” and I think we have to be careful, because the real question we should be asking is, “Is what is being proposed better than what we’re currently doing?” And I think there are resounding “Yes’s” to that question, however I think sometimes there is a tendency to use the imperfection of a potential new approach as a justification for inaction. And I think the old adage ‘Perfection is the enemy of better,’ applies very strongly to area of fatigue management in aviation.
FZ: WE TALKED ABOUT HOW HE (SERGE GAGNE) SURVIVED THE CRASH AND HE WAS THE CO-PILOT, AND HE WAS TELLING US YOU KIND OF FOCUS ON SOMETHING AND THEN YOU KIND OF FORGET ABOUT THE REST AND THEN “OH, BUT I FORGOT,” AND THEN YOU FOCUS ON SOMETHING ELSE – THAT’S HOW HE WAS DESCRIBING HOW HE FELT WHEN HE WAS THAT FATIGUED.
DD: Yeah, when people are tired they undergo an experience of what’s been referred to as attentional tunnelling, that is, you become very focused on a narrow range of issues and in short-term windows for the consequences for your actions. And that attentional tunnelling can lead to quite significant degradation of decision-making.
FZ: YOU LOSE THE BIG PICTURE IN A WAY.
DD: That’s true, and people become over-focused on irrelevant detail and forget the big ones. One of the ways this has classically been described is people shift their emphasis away from the important to the urgent, so you become focused on much more short-term, critical decisions – particularly those on which you can influence something.
FZ: SO, TELL US MORE ABOUT HOW PILOTS ARE TRYING TO AVOID THE BAD OUTCOMES FROM FATIGUE.
DD: Well, one of the most exciting things that we did that came out the research project on Qantas was, in our discussion with pilots, we realized there was actually a lot of subtle adaptive and protective behaviours they were engaging in, so, some of them were senior pilots who’d had a lot of time in the air and it was things like, “Well, when I’m really tired, I’ll let my co-pilot know I’ve had a tough night last night,” and what we noticed was in those situations, the co-pilot would be more vigilant and more likely to look for errors in their colleague. We saw for example that some of the pilots would say, “When I’m really tired, I will actually start my preparation for descent five or 10 minutes early just in case something goes wrong.” They were really clearly aware of the fact that under time pressure, fatigue really impairs decision making, so they were adapting to the fatigue by making sure there was plenty of time available for decision-making and then if things went wrong, they didn’t push themselves into a decision tunnel. We saw examples where people would say things like, “I typically make mistakes on calling altitudes and bearings when I’m tired, so hey, could you call those back to me so what you said and I thought I said are checked,” so we saw a lot of actual subtle mechanisms that were on the flight deck that prevented the errors from translating into negative consequences. I think that’s a really exciting part of the future of fatigue research, because we can start to look at what they are and most importantly, we can start to train and educate people to use those kind of adaptive and protective strategies, because sometimes you might be in the air and might not have been able to sleep in the rest facilities on a four-and-a-half day flight – we can’t put a new pilot in there. But what we could do is set up procedures and protocols and say if you didn’t manage to get any sleep on the flight and you are landing the plane, start the process earlier, anticipate the types of errors you would make, and get people to help you; introduce a whole set of check routines and mechanisms that minimize the chances of a fatigue-related error actually causing a negative consequence on a flight. That’s a really exciting and important area we should be looking for in the next little while.
FZ: JUST ONE LAST TIME ON THE QUESTION OF WHAT CANADA IS DOING OR NOT DOING. WHEN WE LOOK AT THERE’S BEEN ONE CHANGE IN THE REGULATION OVER THE LAST 30 YEARS MAYBE – IT WAS IN ’95 OR ’96 AROUND THAT TIME. THERE WERE TWO CHANGES: ONE WAS BASICALLY TO REDUCE THE DUTY HOURS FROM 15 TO 14, SO ONE HOUR LESS, AND THERE WAS A RULE THAT ALLOWED ACTUALLY FOR THREE PILOTS WHERE THAT WAS TAKEN AWAY. SO ONE IMPROVEMENT IN TERMS OF FATIGUE AND THE OTHER ONE WHERE WE TAKE AWAY A RESOURCE THAT COULD HELP PILOTS TO BE RELIEVED BY SOMEONE ELSE. AND NOW YOU’VE DONE YOUR STUDIES AND PROPOSED THINGS AND IT’S ON THE SHELF RIGHT NOW – IT’S NOT BEING USED. CANADA DOESN’T SEEM TO HAVE TAKEN THIS SERIOUSLY ENOUGH. WHAT DO YOU THINK?
DD: I’m not sure that it’s that they’ve not taken it seriously. I think it’s a very difficult problem to work through – something that is enormously conflicted by non-scientific factors. I think it’s industrial – I think it’s about quality of life; it’s about income and it’s about operational profitability, and I think when those forces are brought to bear often overwhelm what we know from the science and what would probably argue would be very sensible policy and strategy to put in place if it didn’t have the same consequences for operational profitability. I think the example you used before of putting three people on the flight deck and reducing it to two or in some cases in other jurisdictions we’ve seen increases in pilots – that doesn’t automatically improve or compromise safety. So for example, we have seen situations with ultra long-haul where we have a lot more pilots on the deck than we had in the past and that would certainly reduce risks related to fatigue, but as an offset we’ll see the situation where those pilots will actually have fewer take offs and landings and can only maintain currency by operating take offs and landings in simulators, so there’s a very complex interplay of one set of risks due to fatigue and offsets due to a range of other factors. The net overall safety to the organization is sometimes quite difficult to understand and analyze and I think in many cases people understand that at an implicit level and understand that sometimes the rules or the procedures and protocols put in place don’t actually make a lot of sense.
FZ: SHOULD WE JUST BE PAYING MORE FOR AIR TRAVEL, DO YOU THINK IN THE END?
FZ: I MEAN, IT’S A QUESTION…TO REDUCE THE RISK OF FATIGUE, IF IT’S GOING TO COST SOMETHING TO THE AIRLINES IN A WAY…I DON’T THINK YOUR SYSTEM IS GOING TO BE COST FREE FOR AIRLINES; IT’S GOING TO COST THEM MONEY SOMEWHERE. YOU SAID IT’S A COMPANY, SO…I’M JUST WONDERING, TO IMPROVE SAFETY REGARDING THINGS LIKE FATIGUE, IT’S GOING TO COST MORE FOR THE AIRLINES AND MAYBE IN THE END FOR THE PEOPLE THAT ARE FLYING.
DD: Look, I think good safety is always going to cost more than bad safety, but you’ve got to ask yourself at the end of the day, what is the cost and yes, if my airfares cost me five per cent more, but would significantly reduce the number of deaths – if it’s me in that aeroplane with the tired pilot that ends up in the ground, then I’m going to think that’s a really good investment. The difficulty is the relative frequencies and that is the likelihood of dying in a fatigue related accident is very low, but the probability of paying an increased price on my fare happens every time I fly, and we know humans are really bad at judging the relative payoff of really low frequency, high consequence events, so we understand this from risk-theory perspective and the psychology of risk. The difficulty is is, in many organizations, the short-term pressures to increase profitability or income often overweigh the long-term interests of both employees and the organization.
FZ: DO YOU REMEMBER THE DAY YOU HEARD OF THE COLGAN AIR CRASH?
FZ: WHAT WENT THROUGH YOUR MIND WHEN YOU HEARD THAT?
DD: Well, I think one of the things that’s really interesting about that particular incident is that there were so many non-work related factors in terms of our current regulatory models that actually caused that or contributed to that event happening. And I think what it probably said to me is that the notion of a simple one-size-fits-all set of rules that would be able to anticipate and manage of those situations is well known impossible.
FZ: BECAUSE THERE’S NO WAY THE REGULATIONS COULD TAKE ALL OF THAT INTO ACCOUNT OR…?
DD: I think it’s very difficult to come up with a very complex set of rules that cover every situation and that are fair and equitable and actually produce safety. We can see a situation where we would start to mandate commute times and all those kind of things, but there will always be a situation where that rule doesn’t work or doesn’t operate or somebody can pervert the rule, that is they’ll rent an apartment and have that as the first address or as the second address etc., etc. So I think what we’re starting to realize and this happened since 1972 with an inquiry in the United Kingdom. What the inquiry had said in ’72 was that the rate at which technology is advancing and the rate at which organizations are increasing the complexity of their operations that the governments can never write all of the rules to cover all the contingencies or occasions and that at best we would be playing catch-up in many cases by the time the problem had emerged and we went through the process of changing the regulation, we may no longer have the problem. I think personally that there is a lot of truth in that statement and the idea that we can have these perfect rule sets of hundreds of thousands of pages that will cover every contingency probably will lead to some significant dis-economies associated with that regulatory complexity. On the other hand, as the inquiry said in 1972, ultimately the best judge of what constitutes the appropriate way to manage safety is at the organizational level, but with strong regulatory oversight and I think that is really important as we move forward into the next generation of air travel.
PRODUCER: RATHER THAN JUDGING THE PERFORMANCE, WHAT WOULD YOU ADVISE – WHAT WOULD YOU SAY TO CANADIAN REGULATORS, TO TRANSPORT CANADA NOW REGARDING THE RULES THAT GOVERN FATIGUE.WHAT SHOULD THEY DO?
DD: I think it’s a real challenge to develop a new, modern and flexible approach to managing fatigue-related risk in aviation, and I think sometimes you have to bite the bullet and go “This is going to be hard, but we need to push through with this.” I think it’s really important for the regulators to support industry – particularly the first few people that go down that pathway and to make sure the people who do get initial approval for these kinds of FRMS (Fatigue Risk Management System) approaches actually are well evaluated and monitored to make sure it does actually translate into improved safety.
PRODUCER: BUT THEY KEEP GIVING THIS EXPLANATION ABOUT THERE AREN’T ENOUGH STUDIES; WE NEED TO DO MORE STUDIES AND THERE ARE NO CANADIAN STUDIES. WE KNOW ABOUT THIS OTHER STUDY THAT WAS DONE WHERE THEY SAID, “LET’S GET RID OF SOME OF THE RECOMMENDATIONS, BUT KEEP THIS ONE AND DO MORE STUDIES. WHAT DO YOU MAKE OF THAT?
DD: I think you have to be really careful about that. I think we know a lot about fatigue and I also think we know a lot about how to manage it much, much better. Sometimes studies become a justification for inaction. Sometimes claiming that it was not done with our particular pilots or in our particular country or our circumstances becomes a justification for inaction. I think the general consensus is we know enough about fatigue now to do a lot better than we are currently doing.
FZ: RIGHT NOW?
DD: Right now.
FZ: SO WHAT KIND OF OVERSIGHT IS ACTUALLY BEING DONE IN AUSTRALIA AND NEW ZEALAND REGARDING FATIGUE WITH PILOTS?
DD: Well I think those organizations that have FRMS have two forms of oversight: the first is there has to be a system in place within the organization for order and compliance with what the organization itself claims to be doing, but we also have external oversight for that and that can be done through the regulators, but sometimes through independent third-parties as well. So we have been asked for example to come in and independently evaluate how FRMS is being implemented in an organization and whether there are opportunities for improvement; whether that organization is actually bona fide in a way that’s putting it into place or being disingenuous and using it to exploit as a form of de facto regulation, so I think quality, third-party oversight is absolutely critical – it needs to be done outside of the internal organizational politics, but it also needs to be done inside the organization as well and I don’t think you can have one or the other– that is, somebody has to watch the watchers.
FZ: YOU CAN’T LET THEM POLICE THEMSELVES?
DD: You would never put the rabbits in charge of the cabbage patch.