Air Midwest Flight 5481 crashed on take-off killing 21 people. The NTSB concluded that the aircraft was tail heavy and the pilot was unable to keep the nose down because elevator travel was restricted due to improperly rigged flight control cables. The NTSB reported the maintenance work to the aircraft’s elevator system was performed on the midnight shift in the early morning hours.
Compounding the fatigue issues was the lengthy commute the employees made getting to the repair facility and long shifts that were routinely worked. Work had been performed on the elevator system and interviews with the mechanics indicated a number of shortcomings with maintenance procedures including lack of proper training, insufficient resources, and the possibility that fatigue affected the quality of the work performed.
Education and training alone are most likely not enough to deter mechanics from working while fatigued when many organizations push their mechanics to work 14- to 16-hour days. A combination of pressures including customer satisfaction, management pressure, time pressures, along with interruption of revenue associated with the loss of use of an aircraft, seem to win out and override good common sense as well as documented safety policy and procedures.
This begs the question and you may well be asking, what are effective countermeasures to not only cope with the problem, but reduce maintenance errors and enhance safety? Amazingly, they are simple but require commitment to a healthy lifestyle. Eating a balanced diet stabilizes energy levels and eliminates sugar “highs and crashes.” Don’t go to bed too hungry or too full, as this is definitely a sleep interruption and prevents deep solid rest. Use caffeine to increase alertness when you need it, but avoid it before bed, as its wakening effects can be long-lasting.
Exercise regularly, but not before bedtime as it increases energy levels. The “at-home” environment is a factor in allocating adequate undisturbed hours for sleep. This may take some coordination with family members and their respective schedules. Enhance your sleep environment with dark curtains, a quiet room; turn off the phone; and set the room temperature to 65 to 68 F.
Although a healthy lifestyle goes a long way toward personal fatigue management, it alone may not be enough. As maintenance tasks are self-paced rather than externally paced, fatigue management becomes a partnership between the employer and the employee. As an industry, a re-evaluation and recognition of the cultural norm in the aviation maintenance world that no workday is too long, and a lack of required rest periods is detrimental to safety is well in order. Workplace factors include working hours, staffing levels, and the availability of break periods.
Effective fatigue risk management requires a partnership between the employer and the employee, as each can contribute uniquely to solutions (Dawson, 2000; Fletcher, 2007; Transport Canada, 2007b, 2007c). It is unrealistic to aim for “zero fatigue” in all cases. An appropriate objective for fatigue risk management is to ensure that risks are as low as reasonably practical (Stewart & Holmes, 2008).
The maintenance environment presents opportunities to modify methods of task performance — having secondary inspections or operational and functional checks, and rescheduling the most safety-critical tasks, or those most susceptible to fatigue, at times when fatigue will have the least impact.
We would be foolish to think we can avoid the reduced mental functioning brought about by fatigue. For this reason, bringing awareness and focus to the problem becomes critical in mitigating it. Commitment from all levels in the organization is essential.
Ultimately, the quality of work rests with the individual maintenance technician, who by understanding the consequences of fatigue, is in the ultimate position to assure they are both well rested, and have access to strategies to deal with maintenance fatigue.
DeborahAnn Cavalcante earned her Master of Aeronautical Science, with a specialization in Safety Management from Embry-Riddle Aeronautical University in Daytona, FL, and her Bachelor of Science from VA Tech in Business and Risk Management.
Knowledge of fatigue hazards can become clouded by the necessity of meeting deadlines, fulfilling delivery promises, or pocketing some extra overtime wages.