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Ep 33 – Fatigue and Incapacitation

Podcast | March 28, 2023

New fatigue rules are here, and it can be a complex issue. How do you know if you are fatigued? How do you know if a crewmember is fatigued? How do you ask someone if they are fatigued? Some airlines have had robust fatigue rules for a while so much of the data available comes from airlines. Airline pilots might fly more hours and perhaps more days but, in my experience, fatigue can happen to you on your first day of work. Do a self-check and keep doing them.

In August of 2016, an Airbus 320 being operated by Wizz Air Hungary on a scheduled passenger flight from Barcelona to Riga was in cruise over northern Italy when the Captain’s cognitive condition began to deteriorate. He assigned all flight tasks to the First Officer and remained in the cockpit. When his condition deteriorated further, another First Officer travelling as one of the 182 passengers was brought up to the flight deck to assist. The captain was eventually removed from his seat and the two First Officers landed the aircraft at the destination. Having a third pilot was obviously helpful to this crew.

The 35-year-old Captain, who had joined Wizz Air as a direct entry Captain, had initially acted as the Pilot Flying on the flight. He had over 8,000 hours flying experience on all aircraft types. The First Officer was of similar age but had much less experience on the Airbus and in general.

So what happened to the captain?

During the preflight briefing the captain’s health was discussed but it was not reported why it came up in the briefing. He said he was fit to fly. Operationally the first flight was delayed and there was pressure to get back to Riga before the airport closed for the night. There was also stormy weather in the forecast.

The first flight went smoothly but the turnaround was full of issues with ground personnel and the flight plan had to be refiled. During taxi out for the second departure the captain’s health problems became visible to the other crew members and when asked he said he was tense but fit to fly.

The return flight started out fine but then, “the Captain’s health problems worsened, which, as he said, manifested in a tense mood, intense heartbeat, and mood swings”. Then he “began to complain of sickness and panic attacks”. An emergency landing in Milan was discussed but dismissed, the Captain then gave over control of the aircraft to the FO and had a 30 minute rest. Even after the rest, the captain was no longer able to continue operating as a crew member. This is when the other FO joined the flight deck and assumed operational duties from the jump seat. The captain did eventually remove himself from the captain seat at the top of descent.

The two FOs broadcast PAN PAN message to ATC and the rest of the flight was completed twenty minutes ahead of the airport closing time. On the ground medical people examined the captain but did not transport him to a hospital.

The captain was further examined later and was found to be suffering from “fatigue due to long lasting stress”. The captain said he had had several stressful events occur in his life and that he felt physical and mental exhaustion. The events in his life were “multiple changes of base airport, an adverse change in his private life, several bird strike incidents in the previous months and a flight with a malfunctioning weather radar in stormy weather a few weeks earlier”. He had also previously missed the Riga airport closing time and had to divert to an alternate airport.

What was Wizz Air doing to manage fatigue in general?

About a year prior to the event, Wizz Air had begun to establish a department to manage fatigue, however the department and the program were not complete.

The investigation found that the department intended to:

raise awareness of fatigue through training and regular communication with flight crew, management, and crew rostering personnel,
to quote ‘gather information on exhaustion or imminent danger of exhaustion among flight crew’,
to assess and evaluate the extent and evolution of the risk arising from exhaustion,
They planned to develop proposals to reduce risks associated with fatigue, AND
follow up and monitor the fatigue plan.

These sound like realistic and achievable goals. How were they doing?

The Investigation was completed 4½ years after the event had occurred, and at that time the computerised flight crew rostering output was still being checked manually against a piece of paper hard copy of fatigue rules. This is a very difficult task considering Wizz air had a few thousand pilots in 2019.

It’s also interesting to note that a Wizz Air chief executive said in 2022 quote ‘“We are all fatigued but sometimes it is required to take the extra mile.” Could be taken out of context but there was a lot of backlash as a result.

So how do Wizz Air flight crews feel about fatigue and how it’s managed?

Hard to know completely but they had some obstacles to overcome as an employee group. The number of fatigue reports was increasing but limited data was available regarding how the company dealt with these reports. The captain must have felt some pressure to complete the trip, which is not uncommon.

Flight crews and operators know that fatigue and its affects are a threat to aviation safety but how do you and the company defend against it?

There are many factors at play here:

How do you determine if you are fatigued, as a crew member?
If you decide you are fatigued, this may portray as a sense of weakness to others in your mind, or in minds of others as well. Many operators and employees have a ‘get-it-done’ attitude which is good to some extent, but this can get in the way of the safest possible operation if taken to the limit.
The company may not be well situated to deal with fatigue at remote locations or even their home base and this could enter into the crew member’s decision making.
Can you be fatigued on day one of a trip? The short answer is yes. Days and days of lots of flying are not a requirement. However, a crew member is responsible to use all available strategies to show up to work rested and ready for duty. For many reasons, this may not be possible.
Has the company ever taken a harsh stance against those who report being fatigued? If management portrays an attitude that is counter reporting, this can create a reluctance to report.

Fatigue reporting should be confidential to help quash external factors in the mind of a crewmember deciding whether to report fatigue or not. The crewmember should take the training provided and make decisions without external influence, which is easier to say than do. The company should provide fatigue training, provide a way to receive fatigue reports and deal with those reports in accordance with regulations.

Another factor is the authority gradient. In the case of the Wizz Air occurrence, the captain was adamant on two separate occasions that he was fit to fly. This is a difficult situation for a First Officer and a Flight Attendant to be in. As a crew member, what do you do if you believe a superior crew member is dangerously fatigued?

The investigation found that in the time leading up to the occurrence flight “the life of the Captain had contained a number of events which increased his fatigue to a level exceeding the usual and was also fairly demanding for him mentally”.

These events caused irregular sleep patterns and insufficient rest. The captain acknowledged the lack rest but that’s where he thought it ended. He did not believe that he was compromised or unable to complete his duties. He believed he was fit to fly at the beginning of the duty period when his condition was discussed and in fact he could have been. What the report said is that the captain could have been fit to fly at the briefing. That makes this scenario even more difficult.

The captain may have been fit to fly at the beginning of the duty period. It’s hard for him to know and even harder for the First Officer to say he is not. The investigation said “in this case, the Captain was far from incapacitated at the time of the departure”. This means that at the time of departure even if the First Officer felt that the Captain was unfit, there was no way to intervene. In fact, the Captain deflected the issue multiple times when asked about fatigue. To his credit, once he agreed that he was unfit, the investigation found he did everything he could to ensure the crew had what they needed to complete the flight safely.

This may seem to be a complex issue because it is. So how do we, as an industry, defend against fatigue? One part of the answer is culture. I can hear the groan out there. We hear this in the Safety Management System world, and it is also important in the fatigue management world. Rules and regulations can’t cover all possible scenarios and operator’s perform different types of missions in different environments therefore the company must look at their own operation and develop a fatigue management system that fits their employees. People makes decisions all day in aircraft and on the hangar floor so they must feel free to decide that they are fatigued.

The cause of the Serious Incident was determined as the Captain’s serious physical and mental exhaustion which had been the result of the combined effect of chronic fatigue and stress.

Two contributory factors were also identified:

The Captain had not properly assessed his physical and mental condition.
The other members of a flight crew had no means to override the Captain’s decision on his own physical or mental condition until he became incapacitated.

The final report was released on 24 March 2021 and no safety recommendations were made. I’ll leave a link to the report in the notes.

In The News: Making Clean Jet Fuel out of Carbon Dioxide Emissions

Ok let’s switch gears for a moment. In the news is a part of the podcast where I talk about other things in aviation.

Researchers at the U.S. Department of Energy’s National Renewable Energy Laboratory, with help from the Massachusetts Institute of Technology and Washington State University,

have released a report saying that they have developed a process that will use previously unused parts of feedstock for the production of sustainable aviation fuel.

Plant matter makes biofuels and within plant matter are many cells. Part of a cell wall is lignin and lignin is a difficult substance to break down chemically. What’s interesting about lignin is that it carries a high percentage of oxygen content when converted to an oil substance. When creating SAF from feedstock, the oxygen content must be less than a half percent which is not the case in lignin. So, this group of researchers said that they have developed a process to extract the excess oxygen from lignin so that it may be used to create what they called jet fuel blend stock. The research is called ‘Continuous Hydro-de-oxygenation of Lignin to Jet Range Aromatic Hydrocarbons.’

More importantly is that current SAF must be blended with some conventional jet fuel due to the need for aromatics.

Aromatics are hydrocarbons such as benzene which when combusted, generate soot and particulate matter that can be harmful to the environment. This sounds like we don’t want them in our fuel but aromatics also provide for the proper swelling of rubber type seals in an engine which prevent fuel leakage and the threat of fire.

And guess where lots of aromatics can be found? You guessed it, lignin. This new process could result in 100% SAF where no conventional fuel is required at all.

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