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Safety Recommendation Details

Safety Recommendation A-13-001
Details
Synopsis: On December 7, 2011, about 1630 Pacific standard time, a Sundance Helicopters, Inc., Eurocopter AS350-B2 helicopter, N37SH, operating as a “Twilight tour” sightseeing trip, crashed in mountainous terrain about 14 miles east of Las Vegas, Nevada. The pilot and four passengers were killed, and the helicopter was destroyed by impact forces and postimpact fire. The helicopter was registered to and operated by Sundance as a scheduled air tour flight under the provisions of 14 Code of Federal Regulations (CFR) Part 135. Visual meteorological conditions with good visibility and dusk light prevailed at the time of the accident, and the flight operated under visual flight rules. The helicopter originated from Las Vegas McCarran International Airport, Las Vegas, Nevada, about 1621 with an intended route of flight to the Hoover Dam area and return to the airport. The helicopter was not equipped, and was not required to be equipped, with any on-board recording devices. The accident occurred when the helicopter unexpectedly climbed about 600 feet, turned about 90° to the left, and then descended about 800 feet, entered a left turn, and descended at a rate of at least 2,500 feet per minute to impact. During examination of the wreckage, the main rotor fore/aft servo, one of the three hydraulic servos that provide inputs to the main rotor, was found with its flight control input rod not connected. The bolt, washer, self-locking nut, and split pin (sometimes referred to as a “cotter pin” or “cotter key”) that normally secure the input rod to the main rotor fore/aft servo were not found. The investigation revealed that the hardware was improperly secured during maintenance that had been conducted the day before the accident. The nut became loose (likely because it was degraded)1 and, without the split pin, the nut separated from the bolt, the bolt disconnected, and the input rod separated from the linkage while the helicopter was in flight, at which point the helicopter became uncontrollable and crashed. The NTSB determines that the probable cause of this accident was Sundance Helicopters’ inadequate maintenance of the helicopter, including (1) the improper reuse of a degraded self-locking nut, (2) the improper or lack of installation of a split pin, and (3) inadequate postmaintenance inspections, which resulted in the in-flight separation of the servo control input rod from the fore/aft servo and rendered the helicopter uncontrollable. Contributing to the improper or lack of installation of the split pin was the mechanic’s fatigue and the lack of clearly delineated maintenance task steps to follow. Contributing to the inadequate postmaintenance inspection was the inspector’s fatigue and the lack of clearly delineated inspection steps to follow.
Recommendation: TO THE FEDERAL AVIATION ADMINISTRATION: Establish duty-time regulations for maintenance personnel working under 14 Code of Federal Regulations Parts 121, 135, 145, and 91 Subpart K that take into consideration factors such as start time, workload, shift changes, circadian rhythms, adequate rest time, and other factors shown by recent research, scientific evidence, and current industry experience to affect maintenance crew alertness. (Supersedes Safety Recommendation A-97-71 and A-13-01)
Original recommendation transmittal letter: PDF
Overall Status: Closed - Unacceptable Action
Mode: Aviation
Location: Las Vegas, NV, United States
Is Reiterated: No
Is Hazmat: No
Is NPRM: No
Accident #: DCA12MA020
Accident Reports: Loss of Control Sundance Helicopters, Inc. Eurocopter AS350-B2, N37SH
Report #: AAR-13-01
Accident Date: 12/7/2011
Issue Date: 3/1/2013
Date Closed: 4/27/2018
Addressee(s) and Addressee Status: FAA (Closed - Unacceptable Action)
Keyword(s): Fatigue

Safety Recommendation History
From: NTSB
To: FAA
Date: 4/27/2018
Response: You reiterated that you do not believe there is enough data to justify establishing duty-time regulations for maintenance personnel. In the 20 years since we issued our first recommendation on this safety issue, you have researched the effects of duty length and shift scheduling on fatigue and found that fatigue is linked to decreased cognitive performance, including reduced attention and diminished memory; however, you have not taken any regulatory actions in these areas. Instead, you have insisted that a nonregulatory approach would produce quicker and more effective results. We have repeatedly requested data demonstrating that your efforts to date have reduced fatigue among aviation maintenance crews, and you have not responded to our requests. Although we believe that your efforts to develop training materials and programs on this issue are commendable, we have told you that these actions alone would not satisfy this recommendation. The time is long overdue for you to issue duty-time regulations for maintenance personnel that take into consideration factors such as start time, workload, shift changes, circadian rhythms, adequate rest time, and data shown by research, scientific evidence, and current industry experience to affect maintenance crew alertness. A tired maintenance employee suffers from the same performance decrements as a tired pilot, and the alertness of both is crucial to safe aircraft operations. However, because you indicated that your actions on this recommendation are complete, Safety Recommendation A-13 1 is classified CLOSED--UNACCEPTABLE ACTION.

From: FAA
To: NTSB
Date: 1/11/2018
Response: -From Daniel K. Elwell, Acting Administrator: The Federal Aviation Administration (FAA) understands and agrees with the Board that factors such as start time, workload, shift changes, circadian rhythms, and adequate rest time are crucial to safety in the aviation maintenance environment. As stated in previous letters, the FAA has done a tremendous amount of research and work in the field of human factors and personnel fatigue in aviation maintenance since the issuance of Safety Recommendation A-97-71, and subsequently A-13-01. However. we continue to believe there is not enough significant data or justification to proceed with formal rulemaking efforts. Since our last response and to further address the Board's recommendation, the FAA is providing additional research and data to support that our education and training initiatives related to fatigue among aviation maintenance personnel address this recommendation. On April 11, 2017. we published Advisory Circular (AC) I 20-72A. Maintenance Human Factors Training. This AC provides many sources of in formation to develop, implement, reinforce. And assess aircraft maintenance human factors (MxHF) training, and a lengthy list of resources for data, analysis, studies, programs, etc. These resources provide descriptions of references and training materials to ensure that the reader can assemble a MxHF training program matched to the applicable needs of their specific organization. The bibliographic information in these sources are critical to the value of this AC as it brings together a detailed listing of information sources that help the reader prepare for and deliver up-to-date MxHF training. It also provides an abundant collection of references and resources that have been fielded throughout the aviation industry worldwide for a certificate holder. air agency. or operator to tailor their programs based on their specific needs in several areas including s tart time, workload, shirt changes, circadian rhythms, adequate rest time, and fatigue and awareness training. This AC addresses all aspects of maintenance training-specific design, development, delivery, and evaluation. Additionally, the AC makes recommendations for human factors training content so that it meets European Aviation Safety Agency foreign part I 45 requirements. This AC is available at the following Web site: https://www.faa.gov/documentLibrary/media/ Advisory_ Circular/ AC_ I 20-72A.pdf. On December 2, 2016, the FAA published AC 120- 1I 5, Maintainer Fatigue Risk Management (MFRM). This AC provides maintenance organizations and the individual maintainer with the information necessary to detect fatigue symptoms, identify fatigue hazards, assess the associated safety and health risks, and implement fatigue countermeasures. AC 120-1 15 also provides information to determine acceptable approaches/tools for mitigating fatigue-related risks and to create science-based practices for managing fatigue risks. The AC states that Fatigue Risk Management should be part of a Safety Management Systems (SMS), which is a structured management system to control risk in operations. It is also an integrated network of people and other resources performing activities that accomplish the safety mission and reach safety goals in an aviation environment. This AC is available at the following Web site: https://www.faa.gov/documentLibrary/media/ Advisory_ Circular/ AC_ I 20-72A.pdf. The FAA contends that establishing rulemaking for operators to address the factors identified by the Board would target only a few of many safely risk management and human factors personnel management issues. However. SMS provides a comprehensive approach for identifying hazards and managing risks that extends beyond regulatory compliance. We researched data from numerous areas to support our position that the 17 AA ·s education and training initiative, related to fatigue among aviation maintenance personnel. is effective. Based on this research. We believe SMS programs. combined with continuous oversight education and interaction with the operators of these programs, as well as ongoing certificate management activities. are a more appropriate approach to address this safety recommendation. We maintain that an effective SMS minimizes the need for additional fatigue-specific regulations. The FAA also believes 14 CFR pa11 5, Safety Management Systems, addresses this recommendation. Specifically. the FAA highlights§§ 5.1. 5.3, 5.5, 5.5 1. and 5.55. In general, this rule requires each air carrier operating under part 121 to develop and implement a SMS to improve the safety or its aviation-related activities. SMS stresses not only compliance with technical standards but also increased emphasis on the overall safety performance of the organization. Additionally, FAA Order 8900. L Flight Standards Information Management System (FSIMS), addresses training and oversight related to fatigue among aviation maintenance personnel. FSIMS. volume 17. chapters I through 3 provide instructions for Principle Inspectors on how to review SMS Implementation plans and for the continuous surveillance of SMS programs. FSIMS, volume 3, chapter 24, section 2, provides guidance for the evaluation, acceptance, and, in certain scenarios, approval of human factors training programs. Inspectors may also use this guidance for acceptance of human factors training programs for both the Aviation Maintenance Technician awards and Inspection Authorization renewals. The FAA is dedicated to the continued efforts in the area of personnel fatigue in aviation maintenance. Based on the actions identified above, I believe the FAA has effectively addressed recommendation A-13-01 and consider our actions complete. We plan no further action.

From: NTSB
To: FAA
Date: 3/27/2017
Response: In a March 2, 2017, e-mail between FAA and NTSB staff, we learned that, based on your review of Advisory Circular (AC) 120-72, “Maintenance Resource Management Training,” you intend to rename the AC “Maintenance Human Factors Training” and not “Maintenance Fatigue Risk Management,” as indicated in your letter. We note that you also intend to revise its contents to include guidance for operators on start time, workload, shift changes, circadian rhythms, adequate rest time, fatigue, and awareness training for maintenance personnel. We are aware, however, that, on December 2, 2016, you published AC 120-115 “Maintainer Fatigue Risk Management,” which describes the basic concepts of human fatigue and how it relates to safety for aviation maintenance organizations and individual maintainers. Although we are encouraged by your plan to provide additional guidance, we would like to know how the guidance will be allocated between the two ACs to ensure that relevant fatigue information for maintenance personnel is not scattered across multiple sources that could impede its usefulness. We also note that you continue to research and analyze data that support your belief that your education and training initiative related to fatigue among aviation maintenance personnel has produced measurable results. We look forward to reviewing this information, which may form the basis for 2 an acceptable alternate response to this recommendation. For now, however, we continue to believe that regulations are needed that consider factors such as start time, workload, shift changes, circadian rhythms, and adequate rest time. Accordingly, pending action that satisfies Safety Recommendation A-13-1, it remains classified OPEN--UNACCEPTABLE RESPONSE.

From: FAA
To: NTSB
Date: 12/23/2016
Response: -From Michael P. Huerta, Administrator: The Federal Aviation Administration (FAA) continues to research data from numerous areas that could support our position that the FAA's education and training initiative related to fatigue among aviation maintenance personnel is effective. We expect to have this information available to the Board in our next update. Although we understand the Board's position that such factors as start time. workload, shift changes, circadian rhythms, and adequate rest time are crucial to safety in the aviation maintenance environment, we continue to believe at this time there is not enough significant data or justification to proceed with formal rulemaking efforts. The FAA contends that rulemaking action for operators to address these specific components (start time. workload. shift changes circadian rhythms. and adequate rest time) targets only a few of the many safety risk management (SRM) and human factors personnel management issues. A safety management system (SMS) is built by structuring safety n1anagement around four components: safety policy, SRM, safety assurance (SA). and safety promotion. An operator's SMS program (required for part 121) utilizes SRM/SA processes, human factors training programs, and the FAA’s acceptance of the implemented and ongoing programs. These programs. combined with the continuous oversight and interaction with the operators of these programs as part of the certificate management responsibilities. are a more appropriate approach. There are manageable SRM components, and the FAA believes they are best pursued through education of personnel via human factors training programs and through an effective SMS program. Start time. workload. shift changes. circadian rhythms. and adequate rest time are all moving targets and can change depending on many variables. such as the operator's type of operation, changes in operations, seasonal considerations, etc. Integration and application of SMS provides a comprehensive approach in identifying hazards and managing risks that extends beyond regulatory compliance. An effective SMS minimizes the need for additional fatigue-specific regulations. We reviewed Advisory Circular (AC) 120-72, Maintenance Resource Management Training and are currently revising and renaming it Maintenance Fatigue Risk Management. We will verify that factors such as start/duty time, workload. shift changes, circadian rhythms, adequate rest time, fatigue. and awareness training are addressed for maintenance personnel. The AC will specifically address fatigue risk management (FRM) as part of an effective SMS program providing a comprehensive approach in identifying hazards and managing risks that extend beyond regulatory compliance related to worker fatigue. Requirements of an effective FRM/SMS minimize the need for additional fatigue-specific regulations. The document is currently in formal coordination and we anticipate publication prior to June 2017. I will keep the Board informed of the FAA’s progress on this recommendation and wi II provide an update by September 30, 2017.

From: NTSB
To: FAA
Date: 11/2/2015
Response: Regarding this recommendation and Safety Recommendation A-97-71, we are aware that the FAA has long believed that duty-time regulations for maintenance personnel are not appropriate, and that guidance and training you developed would effectively address these recommendations. Although we have commended the FAA for its sponsorship of research on fatigue in maintenance personnel and for the training materials and programs the agency has developed, we have repeatedly stated that these actions alone would not satisfy the recommendation. Our review of the research leads us to believe that such factors as start time, workload, shift changes, circadian rhythms, and adequate rest time are crucial to safety in the aviation maintenance environment and, therefore, appropriate for regulation. In our August 13, 2013, letter, we asked that you provide data supporting your position that the FAA’s efforts regarding limiting human fatigue in aviation maintenance personnel have produced measurable results. We note that you are currently researching and analyzing data that supports your position?that the education and training initiative related to fatigue among aviation maintenance personnel has done so. We look forward to reviewing this information when it becomes available. Although the information you are collecting may form the basis for an acceptable alternate response to this recommendation, we continue to believe that regulations that consider factors such as start time, workload, shift changes, circadian rhythms, and adequate rest time are needed. Accordingly, pending FAA action that satisfies Safety Recommendation A-13-1, it remains classified OPEN—UNACCEPTABLE RESPONSE.

From: FAA
To: NTSB
Date: 9/2/2015
Response: -From Michael P. Huerta, Administrator: As previously stated, the Federal Aviation Administration (FAA) has done a tremendous amount of research and work in the field of human factors and personnel fatigue in aviation maintenance since the issuance of Safety Recommendation A-97-7 1, and subsequently A-13-01. The FAA has completed several studies and accomplishments on the maintenance fatigue issue, including the release of the Operator's Manual: Human Factors in Aviation Maintenance, 2nd Edition (September 2014). This manual is available at the following Web site: https://www.faa.gov/about/initiatives/maintenance_hf/library/documents/medialhuman_factors_maintenance/hf_ops manual_2014.pdf. Although we understand the Board's position that factors such as start time, workload, shift changes, circadian rhythms, and adequate rest time are crucial to safety in the aviation maintenance environment, we continue to believe there is not enough significant data or justification to proceed with formal rulemaking efforts at this time. ln its last letter, the Board requested the FAA provide data supporting the FAA's position or showing that the FAA's efforts have produced measurable results. We are currently researching and analyzing data from numerous areas that support our position that the FAA's education and training initiative, related to fatigue among aviation maintenance personnel, have produced measureable results. We are also reviewing Advisory Circular 120-72, Maintenance Resource Management Training, to verify that factors such as start and duty time, workload, shift changes, circadian rhythms, adequate rest time, and fatigue and awareness training are addressed for maintenance personnel. Upon completion of our analysis we will provide the Board with data demonstrating that our efforts to date have reduced fatigue among aviation maintenance crews or produced measurable results. I will keep the Board informed of the FAA's progress on this safety recommendation and provide an update by July 2016.

From: NTSB
To: FAA
Date: 8/13/2013
Response: The FAA’s letter reiterated much of the content of its December 2008 response to Safety Recommendation A-97-71, which was superseded by Safety Recommendation A-13-1. The FAA has long asserted that duty-time regulations for maintenance personnel are not appropriate, and that guidance and training developed by the FAA would effectively meet the intent of this recommendation. Although we have commended the FAA for its sponsorship of research on fatigue in maintenance personnel, and for the training materials and programs the agency has developed, we have repeatedly stated that these actions alone would not satisfy the recommendation. We continue to believe that the establishment of duty-time regulations for maintenance personnel is needed, and we believe that the findings from our investigation of the December 7, 2011, accident further support the need for the actions recommended. In its recent letter, the FAA states that “Studies consistently support an approach to this safety issue based on increased awareness, education, and training in fatigue management and maintenance resource management.” Our review of the research, including that sponsored by the FAA, leads us to believe that such factors as start time, workload, shift changes, circadian rhythms, and adequate rest time are crucial to safety in the aviation maintenance environment and, therefore, appropriate for regulation. The FAA maintains that its non regulatory approach will produce quicker and more effective results, but the FAA has provided no data demonstrating that its efforts to date have reduced fatigue among aviation maintenance crews or that its efforts satisfy the intent of this recommendation. Accordingly, we ask the FAA to provide the data supporting its position or showing that its efforts have produced measurable results. Pending our receipt of that information, Safety Recommendation A-13-1 remains classified OPEN—UNACCEPTABLE RESPONSE.

From: FAA
To: NTSB
Date: 5/21/2013
Response: -From Michael P. Huerta, Administrator: The Federal Aviation Administration (FAA) has accomplished a tremendous amount of research and work in the field of human factors and personnel fatigue in aviation maintenance since the issuance of Safety Recommendation A-97-71. As stated in our December 11,2008, letter in response to Recommendation A-97-71 , we published the following studies/reports related to maintenance fatigue: • A final report on the "Study of Fatigue factors Affecting Human Performance in Aviation Maintenance;" and • A final report entitled, "Evaluation of Aviation Maintenance Working Environments, Fatigue, and Maintenance Errors/Accidents." We provided copies of these reports to the Board in October 2000. Since that 2008 response, we also published a final report entitled, "Fatigue Risk Management in Aviation Maintenance: Current Best Practices and Potential Future Countermeasures" (dated June 2011 ). A copy of this report is available at the following Web site: https://primis.phmsa.dot.gov/crm/docs/FRMS_in_MX_OAM_TR_HobbsAversHiles.pdf. Additionally, we have made several accomplishments on maintenance fatigue. As noted in our December 2008 letter (in response to Recommendation A-97-71), we- • Completed a guidance manual entitled, "Operators Manual for Human factors in Aviation Maintenance," in September 2005, where 20 percent of this industry/FAA guidance material is dedicated to fatigue (previously provided to the Board); • Hired a Chief Scientist and Technical Advi.sor for Human Factors in Aircraft Maintenance, who provides human factors lectures at industry workshops, renewals, symposiums, and conferences to educate the aviation community further on many maintenance human factors issues, including fatigue, on a continuing basis; and • Co-sponsored several Aviation Maintenance Human Factors International Symposiums with the Air Transport Association of America, which included presentations on fatigue. Studies consistently support an approach to this safety issue based on increased awareness, education, and training in fatigue management and maintenance resource management. We maintain that this approach will produce quicker and more effective results than rulemaking. Consequently, FAA conducted several actions to educate and train the aviation community on fatigue management in aircraft maintenance personnel. We highlighted some of our actions in the December 2008 letter to the Board (in response to Recommendation A-97 -71 ). The FAA continues to support research and development (R&D) efforts in this specific area, headed by the Civil Aerospace Medical Institute. Industry subject matter experts participate in workgroups to support these R&D efforts. Air carriers, manufacturers, labor and academia are represented in the workgroups. The groups, along with the R&D efforts, have been actively involved in many projects dealing with fatigue risk management in aviation maintenance, such as: • Hosting a multi-disciplinary workgroup to develop practical science-based recommendations for fatigue risk management in aviation maintenance; • Hosting an industry workshop entitled "AVS Maintenance Fatigue Leaders Workshop, Aviation Maintenance Fatigue: From Science to Workplace Reality"; • Developing and distributing Fatigue Countermeasure Training (computer based training and lecture) to more than 9,000 aviation maintenance technicians and general aviation pilots; • Developing an automated Fatigue Risk Assessment Tool for personalized assessment and accident investigation; • Developing an objective fatigue risk assessment form that can be used in incidents and accidents to assess whether fatigue was a contributing factor, which industry leaders have adopted; • Developing an automated return on investment tool for human factor interventions to evaluate and market decisions to improve quality and safety; • Publishing in October 2005 an Operator's handbook for fatigue risk management in aviation maintenance operations; and • Participating in the MITRE Aviation Fatigue Symposium to develop practical, science-based solutions for problems relating to aviation fatigue. We have made significant efforts to address the intent of this recommendation, based on the activities highlighted above, and I find that there is not enough significant data or justification to proceed with formal rulemaking efforts at this time. Therefore, the FAA plans no further action in direct response to Recommendation A-13-1.

From: NTSB
To: FAA
Date: 4/23/2013
Response: Notation 8486: On March 11, 2013, the US Chemical Safety and Hazard Investigation Board (CSB) published a request for public comment on a document released on its website titled “Draft Recommendations Evaluation for Public Comment: Fatigue Risk Management Systems (FRMS)” (CSB Evaluation). Subsequently, CSB staff invited the National Transportation Safety Board (NTSB) to share its experiences in investigating transportation accidents in which human fatigue was identified as a safety issue, and related NTSB safety recommendations. The NTSB is an independent federal agency charged with determining the probable cause of transportation accidents and issuing safety recommendations aimed at preventing future accidents. The NTSB has a long history of making recommendations to reduce fatigue and fatigue-related transportation accidents and, since its inception, has issued over 200 recommendations addressing fatigue in the aviation, highway, marine, railroad, and pipeline modes. We are pleased to share our experiences with the CSB. The CSB Evaluation comments on actions taken by the American Petroleum Institute (API) and the United Steelworkers International Union (USW) in response to Recommendation No. 2005-04-I-TX-7, issued by the CSB in 2005 to those organizations. The CSB recommendation was issued as a result of the March 23, 2005, Texas City, Texas, refinery explosion and fire. The portion of the CSB recommendation pertinent to this letter reads as follows: [D]evelop fatigue prevention guidelines for the refining and petrochemical industries that, at a minimum, limit hours and days of work and address shift work…. In April 2010, the API issued an American National Standards Institute-approved Recommended Practice titled Fatigue Risk Management Systems for Personnel in the Refining and Petrochemical Industries, First Edition (RP-755), and an accompanying technical report titled Fatigue Risk Management Systems for Personnel in the Refining and Petrochemical Industries, Scientific and Technical Guide to RP 755. The CSB Evaluation presents the results of a CSB staff review in which the CSB staff determined that RP-755 does not meet the intent of the CSB recommendation in several areas. The NTSB has reviewed RP-755 as well as the CSB Evaluation. With respect to human fatigue, the NTSB has specific experience with the following issues that are discussed in the CSB Evaluation: • The hours-of-service limits described in RP-755, which are more permissive than what is indicated by current scientific knowledge, and the suggestion that voluntary FRMS programs will compensate for the risk from excessive hours and days at work, and • The emphasis of RP-755 on voluntary efforts by industry and its lack of explicit requirements, especially with respect to elements of an effective fatigue management system. With respect to the hours-of-service limits, RP-755 describes “work sets” during normative conditions, which may include 12-hour day shifts or night shifts for 7 consecutive days, with the possibility of an additional “holdover period” beyond the duty day for training or safety meetings. The RP states that the “holdover period should not exceed 2 hours and, where possible, occur at the end of the day shift.” However, the use of the language “should” is not a requirement but is defined by the document as a “recommendation or that which is advised but not required in order to conform to the RP.” Therefore, a worker could, during a normal work set, work shifts of 14 hours or greater in a 24-hour period for several days. RP-755 also states that during planned or unplanned outages, workers may be called on to work 12-hour shifts for up to 14 consecutive days, with as little as 36 hours between 14-day, 12-hour work sets. Holdover periods of up to 2 hours are also allowed during outages. The RP also has provisions for extending work shifts up to 18 hours. In several of its accident investigations, the NTSB has recognized the relationship between long duty days and fatigue, both directly and through their effects on reduced sleep lengths during off-duty periods. For example, in the investigation of the October 2004 Corporate Airlines accident in Kirksville, Missouri, the NTSB determined that the probable cause of the accident was the pilots’ failure to follow established procedures and properly conduct an instrument approach at night, and that fatigue was one factor that contributed to the pilots’ degraded performance. The length of the pilots’ duty day (at the time of the accident, they had been on duty for 14 1/2 hours) was cited along with less-than-optimal overnight rest time, early reporting time for duty, the number of flight legs, and demanding flight conditions, as factors that resulted in the pilots’ fatigue. In the Kirksville report, the NTSB cited research showing that pilots who worked schedules that involved 13 or more hours of duty time had an accident rate that was several times higher than that of pilots working shorter schedules, and that airplane captains who had been awake for more than about 12 hours made significantly more errors than those who had been awake for less than 12 hours. As a result of the Kirksville investigation, the NTSB issued Safety Recommendation A-06-10 to the Federal Aviation Administration (FAA), which stated the following: A-06-10 Modify and simplify the flight crew hours-of-service regulations to take into consideration factors such as length of duty day, starting time, workload, and other factors shown by recent research, scientific evidence, and current industry experience to affect crew alertness. The NTSB reiterated Safety Recommendation A-06-10 in 2008 following its investigation of the April 2007 Pinnacle Airlines accident in Traverse City, Michigan. In that accident, the NTSB determined that the probable cause of the accident was the pilots’ poor decision-making as they prepared to land the airplane. The NTSB stated that “This poor decision-making likely reflected the effects of fatigue produced by a long, demanding duty day and, for the captain, the duties associated with check airman functions.” The pilots had been on duty for more than 14 hours at the time of the accident. The effectiveness of fatigue management is directly related to the availability of work schedules that allow a sufficient period of time between work shifts for the employee to obtain sufficient restorative sleep. The NTSB has investigated several accidents and serious incidents that provided clear and compelling evidence that air traffic controllers were sometimes operating in a state of fatigue because of their work schedules and poorly managed utilization of rest periods between shifts, and that fatigue had contributed to controller errors. Consequently, the NTSB issued Safety Recommendation A-07-30 to the FAA, which stated the following: A-07-30 Work with the National Air Traffic Controllers Association to reduce the potential for controller fatigue by revising controller work-scheduling policies and practices to provide rest periods that are long enough for controllers to obtain sufficient restorative sleep and by modifying shift rotations to minimize disrupted sleep patterns, accumulation of sleep debt, and decreased cognitive performance. The NTSB’s consideration of how long duty days affect fatigue and safety has not been limited to the aviation mode. Recently, in our investigation of the September 2010 collision of two freight trains near Two Harbors, Minnesota, the NTSB concluded that crew fatigue was a contributing factor in train crew errors that led to the collision. The train crewmembers who made the errors had been awake between 13 and 14 hours at the time of the accident, and the accident occurred during the final hour of a 12-hour shift. In its report, the NTSB cited a study showing that 12 hour work shifts have been associated with decrements in alertness and performance, compared to 8-hour shifts. Other studies of commercial drivers have found an exponential increase in crash risk with increasing driving times, especially for driving periods that extend beyond 8 or 9 hours. The NTSB has made numerous recommendations concerning hours of service across the transportation modes. A common theme of those NTSB recommendations has been an emphasis on establishing hours-of-service limits that are scientifically based, that set limits on hours of service, that provide predictable work and rest schedules, and that consider circadian rhythms and human sleep requirements. The second issue discussed in the CSB Evaluation with which the NTSB has experience concerns the lack of explicit requirements regarding essential elements of a fatigue management program. The CSB Evaluation remarks that The use of the word ‘should’ for most elements of a Fatigue Risk Management System (FRMS) in the RP means that they are optional, not required. In what is already a voluntary standard to begin with–employers can choose to conform to them, but they are not required by force of law to do so–‘should’ statements have very little force. The lack of required FRMS elements raises additional concerns because RP-755 states that its hours-of-service limits were “developed in the context of the existence of a comprehensive FRMS” and that “Consistently working at the limits shown is not sustainable and may lead to chronic sleep debt.” Hence, while RP-755 does not require the use of an FRMS, it does ostensibly allow operators to persistently schedule workers at the noted limits. The NTSB has recommended requiring the implementation of fatigue management programs. For example, as a result of its investigation of a June 2009 multivehicle accident near Miami, Oklahoma, in which a truck driver’s fatigue resulted in his failure to react to and avoid colliding with a slowing traffic queue, the NTSB emphasized the importance of comprehensive fatigue management programs. The report described the North American Fatigue Management Program (NAFMP), which is designed to address scheduling policies and practices, fatigue management training, sleep disorder screening and treatment, and fatigue monitoring technologies. In the report, the NTSB stated that “if the NAFMP guidelines remain voluntary—and are used by some carriers but ignored by others—this important safety tool might have only a limited effect in reducing fatigue-related highway accidents.” As a result of its investigation, the NTSB called on the Federal Motor Carrier Safety Administration to implement the following NTSB safety recommendation: H-10-9 Require all motor carriers to adopt a fatigue management program based on the North American Fatigue Management Program guidelines for the management of fatigue in a motor carrier operating environment. The NTSB has also made recommendations in the highway, railroad, and aviation modes to establish ongoing programs to evaluate, report on, and continuously improve fatigue management programs implemented by operators (NTSB Safety Recommendations H-08-14, R 12-007, A-06-11, and A-08-45). I hope that this information about the NTSB’s history of investigating fatigue-related accidents and the recommendations we have issued will be useful as the CSB moves forward with the evaluation of the API and USW responses to the fatigue-related CSB recommendation resulting from the Texas City investigation.

From: NTSB
To: FAA
Date: 1/29/2013
Response: -From the aircraft accident report Loss of Control, Sundance Helicopters, Inc. Eurocopter AS350-B2, N37SH, Near Las Vegas, Nevada, December 7, 2011, report adopted on January 29, 2013: 3.2.1.2 Lack of Maintenance Personnel Duty-Time Limitations The NTSB has had longstanding concerns about the effects of fatigue on maintenance personnel. On September 9, 1997, as a result of the May 11, 1996, accident in which a McDonnell Douglas DC-9-32 operated by ValuJet Airlines, Inc., as ValuJet flight 592 crashed into the Everglades swamp shortly after takeoff from Miami International Airport, Miami, Florida, the NTSB issued Safety Recommendation A-97-71, which asked the FAA to do the following: Review the issue of personnel fatigue in aviation maintenance; then establish duty time limitations consistent with the current state of scientific knowledge for personnel who perform maintenance on air carrier aircraft. (A-97-071) The NTSB notes that on November 17, 1997, in response to Safety Recommendation A-97-71, the FAA stated that its data suggested that night shift and/or mixing of day/night work schedules affect performance more than an extended length of duty time but that no current definitive studies were available to evaluate these parameters as comparative measurements. The FAA stated that it was going to expand its human factors research program to include studies regarding duty length and shift scheduling and that at the conclusion of this research, it would implement appropriate policy or regulatory change. The NTSB notes that in the 15 years since the issuance of Safety Recommendation A-97-71, the FAA has conducted additional research regarding the effects of duty length and shift scheduling as factors contributing to fatigue. Fatigue has been linked to a decrease in cognitive performance, including reduced attention (for example, overlooked and/or misplaced sequential task elements, preoccupation with single tasks, and breakdowns in systematic scanning ability) and diminished memory (for example, inaccurately recalling operational events, forgetting peripheral tasks, and reverting to “old” habits). However, the FAA has not taken any regulatory actions in these areas. As a result, on October 7, 2009, the NTSB classified Safety Recommendation A-97-71 “Open?Unacceptable Response” pending the issuance of duty-time requirements. Because the Sundance inspector’s fatigue was caused, in part, by extended duty time, the NTSB continues to believe that establishing duty-time limitations is a key strategy to reducing the risk of fatigue-related errors in aviation maintenance. The NTSB notes that an even more robust base of scientific knowledge and industry best practices exists on which to formulate such rules than existed when Safety Recommendation A-97-71 was issued. As a result, the NTSB concludes that sufficient scientific research on fatigue and knowledge of industry practices currently exists from which to establish duty-time limitations for maintenance personnel that would help reduce the risk of fatigue-related errors in aviation maintenance. Therefore, the NTSB recommends that the FAA establish duty-time regulations for maintenance personnel working under 14 CFR Parts 121, 135, 145, and 91 Subpart K that take into consideration factors such as start time, workload, shift changes, circadian rhythms, adequate rest time, and other factors shown by recent research, scientific evidence, and current industry experience to affect maintenance crew alertness. (A-13-01) Because of the FAA’s inactivity, the NTSB classifies Safety Recommendation A-97-71 “Closed—Unacceptable Action/ Superseded” and classifies Safety Recommendation A-13-01 OPEN—UNACCEPTABLE RESPONSE.