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Exclusive: SFO near miss might have triggered ‘greatest aviation disaster in history’

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Exclusive: SFO near miss might have triggered ‘greatest aviation disaster in history’

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Old Oct 14, 2018, 6:18 pm
  #1021  
 
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Originally Posted by canadiancow
But the fact is that he made the decision to fly.

What was the economic incentive to say yes?
He got paid for the flight, or the pairing. However, there was risk in that decision. As a professional, he should weigh the risk/reward. In this case, he may have discounted the risk. Now he is paying the price. Thankfully, he isn't paying the price with lives.
I wish I knew the answer to solve this. I just know that it isn't as simple as charging passengers a premium to pay crews for pairings that they don't attend.
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Old Oct 14, 2018, 8:56 pm
  #1022  
 
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Originally Posted by YEG_SE4Life
He went to bed. His kids woke him up early.

I find it comical to relate the amount of pay to the professionalism. I wonder what exact number you think it would take to give him "incentive" to go to bed.
I have spoken to many folks who have flown on reserve. For the most part, they actually take it very seriously. However, life does happen. They get to decide, when they get the call, whether they are fit to go.
I wonder, how much are you prepared to pay, as a passenger, to look after a reserve employee? Will you pay for their child care? Will you pay their full wage, and keep them in a hotel room? Will you guarantee that, while they are in their hotel room there will be no noises or other distractions, while they try to sleep during the day?
Life just isn't as simple as your make belief world.
Honestly, I do not think this is a relevant question. When you purchase an airline ticket there is no add-on for "more stringent crew fatigue standards +$50.00". This is not something that the market allows passengers to decide and discriminate based on price. The airline and regulators make the call, the costs are passed on and we buy the tickets believing that all reasonable measures are being taken to ensure our safety. If I decide to fly WestJet for $200 instead of AC for $250, I do that believing that while seat pitch and cabin amenities may vary, both airlines are held to the same regulatory standards.

So respectfully, don't put this on the passenger. That isn't and has never been our call to make. If a building collapses, nobody says "how much are you willing to pay for rent in a building that is properly engineered and constructed not to fail catastrophically?" We have every right to expect that every option on the market meets that minimum standard. If that isn't the case, then regulators have failed.

edited to add:

Based on your subsequent post I see that I've misinterpreted your point and I think we actually arguing in the same direction - that this isn't simply a matter of money. The pilots involved in all likelihood started their work day with the good faith belief that they were fit to operate this flight.
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Last edited by eigenvector; Oct 14, 2018 at 9:07 pm
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Old Oct 14, 2018, 8:58 pm
  #1023  
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Originally Posted by eigenvector
Honestly, I do not think this is a relevant question. When you purchase an airline ticket there is no add-on for "more stringent crew fatigue standards +$50.00". This is not something that the market allows passengers to decide and discriminate based on price. The airline and regulators make the call, the costs are passed on and we buy the tickets believing that all reasonable measures are being taken to ensure our safety. If I decide to fly WestJet for $200 instead of AC for $250, I do that believing that while seat pitch and cabin amenities may vary, both airlines are held to the same regulatory standards.

So respectfully, don't put this on the passenger. That isn't and has never been our call to make. If a building collapses, nobody says "how much are you willing to pay for rent in a building that is properly engineered and constructed not to fail catastrophically?" We have every right to expect that every option on the market meets that minimum standard. If that isn't the case, then regulators have failed.
I think @YEG_SE4Life was being rhetorical, but I could be wrong.
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Old Oct 14, 2018, 9:38 pm
  #1024  
 
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Originally Posted by eigenvector
The pilots involved in all likelihood started their work day with the good faith belief that they were fit to operate this flight.
I have no idea if it is technically possible, but assuming it is, it would probably be a good idea to do a fatigue level test before allowing a pilot to fly an assignment. Somewhat akin to performing a sobriety test before allowing someone to drive professionally.
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Old Oct 16, 2018, 12:31 am
  #1025  
 
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Originally Posted by Jagboi
I have no idea if it is technically possible, but assuming it is, it would probably be a good idea to do a fatigue level test before allowing a pilot to fly an assignment. Somewhat akin to performing a sobriety test before allowing someone to drive professionally.
Technically possible, perhaps. Possible in the eyes of the pilots' union? Most likely not. I can't envision the employer pushing too hard for this either, given the logistical and cost implications of proving fitness-for-duty. Such a concept would erode trust on both sides, and best of luck to the designers of an effective fatigue test.
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Old Oct 16, 2018, 1:24 am
  #1026  
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Originally Posted by eigenvector
When you purchase an airline ticket there is no add-on for "more stringent crew fatigue standards +$50.00".


AC HQ:

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Old Oct 16, 2018, 1:27 am
  #1027  
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Originally Posted by Jagboi
I have no idea if it is technically possible, but assuming it is, it would probably be a good idea to do a fatigue level test before allowing a pilot to fly an assignment. Somewhat akin to performing a sobriety test before allowing someone to drive professionally.
A pilot could start a flight completely sober, but become impaired during the flight... just by drinking on the plane.

Fatigue happens automatically without any action by the pilot.
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Old Oct 16, 2018, 4:37 am
  #1028  
 
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Originally Posted by yulred


1. Not punishing for claiming fatigue, and incentivizing potentially risky behaviour are two separate issues. That said, there's really no reason for AC to rely on a reserve pilot who had been flying until midnight the night before. Barring, of course, the non-availability of other reserve pilots, which shouldn't be an issue if the pool isn't too shallow.

2. Do I have knowledge of AC's policies? Only to the extent that they're covered in AC's submission and the report. But then again, like many here, I've also had a front row seat to AC's cost-cutting/profit maximization approach. I find it interesting it that when it comes to nickel and dining, AC literally states that it does so to align with "prevailing North American industry practices". Odd that they don't align with those very standards on this particular safety related issue. Any idea why?

3. Where did I say US pilots are never fatigued? I am willing to say that US FAA rules aimed at tackling the issue are more stringent than Canadian regs, which lowers the likelihood significantly. You tried to attribute their misalignment to fatigue, but there is nothing to suggest they were fatigued. There is plenty to suggest that the AC pilots were fatigued. Worth noting that the NTSB has asked TC to fix its regs. Did they have reasonable grounds to do so? Either you view them as a credible authority in this issue, or you don't.

4. If his kids kept him up, he shouldn't have gone in. Just as he wouldn't have if he was still feeling the effects of an evening of drinking. Thats where the consequences need to be made clear before hand. Regardless of AC management, it doesn't say much for the professional judgment of these pilots, or how it's being assessed.

5. All the jurisdictions covered are listed on the right side of the graph. Check it out instead of asking speculative questions, and you'll find out.
My only point is that the fatigue, in this particular case, appears to be as a direct result of something beyond the employer's control. To take this example and run it up the flag pole to show the world how our regulations aren't tough enough is wrong. I don't know of any jurisdiction that would prevent it.

Personally, I don't know if more stringent is always better. I am sure there is a point where major change will give minor gain. I am not debating whether Canadian regs are too lenient or not.

In addition, whether I agree or disagree with anyone on a particular subject, is not a statement of how credible I think they are.

Your premise appears to be that, if we tell folks what their punishment would be, before hand, that will absolutely alter their behavior. If that were true, wouldn't we just need one empty jail, and a threat of jail time, to prevent any laws from being broken? Humans do things. They take risks. They make bad decisions. They make mistakes. They normalize deviations. That is why safety programs are focusing on human behaviors. To my knowledge, nobody has solved that one, where human action is required.
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Old Oct 16, 2018, 3:17 pm
  #1029  
 
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Originally Posted by YEG_SE4Life
My only point is that the fatigue, in this particular case, appears to be as a direct result of something beyond the employer's control. To take this example and run it up the flag pole to show the world how our regulations aren't tough enough is wrong. I don't know of any jurisdiction that would prevent it.

Personally, I don't know if more stringent is always better. I am sure there is a point where major change will give minor gain. I am not debating whether Canadian regs are too lenient or not.

In addition, whether I agree or disagree with anyone on a particular subject, is not a statement of how credible I think they are.

Your premise appears to be that, if we tell folks what their punishment would be, before hand, that will absolutely alter their behavior. If that were true, wouldn't we just need one empty jail, and a threat of jail time, to prevent any laws from being broken? Humans do things. They take risks. They make bad decisions. They make mistakes. They normalize deviations. That is why safety programs are focusing on human behaviors. To my knowledge, nobody has solved that one, where human action is required.
- If you have read the report, you will have seen recommendation 13: "Current Canadian regulations do not, in some circumstances, allow for sufficient rest for reserve pilots, which can result in these pilots flying in a fatigued state during their window of circadian low."

It's clear that airlines and regulatory authorities have a degree of control in this situation. Which they did not use. Hence the NTSB's subsequent recommendation to TC: "Revise current regulations to address the potential for fatigue for pilots on reserve duty who are called to operate evening flights that would extend into the pilots’ window of circadian low. (A-18-29)". Note that AC could have done this unilaterally. According to its own submission, it did not.

- It is true that a pilot may not use his rest hours to get sufficient rest. That holds true for any type of impairment. Yet we regulate other types of impairment (alcohol/drugs). It helps ensure that the financial incentive to work does not result in pilots accepting too much risk. I think the lesson here is that we need to treat fatigue as seriously as other forms of impairment. Best we do it before someone loses their life.

- Comparing pilots to the general population does not make sense. Pilots go through a vetting process and are hired precisely because they are expected to behave in a certain way (ie - not take certain types of risks). If airlines have a pilot pool that is as risk-prone as a random sample of the general population, there's a problem with the hiring strategy.

- One may never solve an a potential outcome, but it is incumbent on us to reduce the likelihood of that outcome occurring (which is why we aren't a nation of bank robbers). A combination of adapting existing regulations to address issues associated with the circadian low, combined with company policies that offset any risk-inducing incentive to go to work while fatigued, would likely reduce certain outcomes to significantly lower levels.

- This incident did not occur in isolation. It occurred several years after a fatigued pilot on a YYZ-ZUR flight put people in hospital. That was the first blatant warning sign. Has it been addressed? Pilot fatigue is not a new issue at AC. According to AC pilots themselves.

- Can you provide a single reason for not adopting EU/US standards on safety, given how quickly AC adopts those standards when it comes to nickel and diming?

- One can keep trying to obfuscate but it seems to me that the issue here isn't about the degree to which risks can be reduced to US/EU/AUS levels, but whether doing so costs too much. Maybe that will change when lives are actually lost.


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Old Oct 16, 2018, 5:59 pm
  #1030  
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Originally Posted by Jagboi
I have no idea if it is technically possible, but assuming it is, it would probably be a good idea to do a fatigue level test before allowing a pilot to fly an assignment. Somewhat akin to performing a sobriety test before allowing someone to drive professionally.
As long as human beings are flying aircraft over long distances and across multiple time zones, fatigue will be an issue - irrespective of regulations that may be put in place. Ask anybody who has ever flown a transatlantic overnight flight in Y whether they are tired when they arrive. Not to mention turning around and going home 1-2 days later. Pilots aren't magic super-humans.

There are some interesting technologies in use in the mining and long distance trucking industry to actively monitor and warn of operator fatigue. they typically monitor either brainwave activity or eye movement. Here are some examples:
Fatigue Management | Drowsiness Detection System | Driver Fatigue Detection - | Optalert
SmartCap Technologies | Measure Alertness. Eliminate Fatigue
https://hexagonmining.com/solutions/...atigue-monitor

Incorporating such systems would proactively alert the pilot and their partner if fatigue is becoming an issue and information could be transmitted to the home office and/or ATC to be aware of the issue.

I suspect the industry is too afraid of what the results would show if they ever implemented such a system..
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Old Oct 17, 2018, 8:57 am
  #1031  
 
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Originally Posted by yulred
- Comparing pilots to the general population does not make sense. Pilots go through a vetting process and are hired precisely because they are expected to behave in a certain way (ie - not take certain types of risks). If airlines have a pilot pool that is as risk-prone as a random sample of the general population, there's a problem with the hiring strategy.
Comparing pilots to the general population is entirely sensible. The working world is full of folks working irregular hours while operating complex systems and holding responsibility for many lives.

The hiring process is not usually as you describe - at least not in North America. Some airlines have the luxury of recruiting suitable pilot cadets based upon aptitude and attitude, and training them from Hour One in a desired corporate culture. AC and other large airlines run their applicants through a verbal interview that superficially addresses suitability & behaviour, but in reality the new hires just have to meet an ever-lowering bar based largely upon previous experience, decent references and being able to 'play the game' during the interview itself. With demand for pilots beginning to exceed supply, I don't foresee meaningful improvements soon.
Originally Posted by The Lev
Incorporating such systems would proactively alert the pilot and their partner if fatigue is becoming an issue and information could be transmitted to the home office and/or ATC to be aware of the issue.
I don't want to be 'that guy' who points out problems without offering a solution, but this suggestion is laden with concerns on so many levels. The reliability of the detection software, the reaction of the employer who receives an alert, the tendency of the employee to trust the employer will react in a fair manner (see safety culture thread), privacy, CRM and liability issues all rear their heads.
And what would ATC do with such information, even supposing for a moment that they are an appropriate receiver of such data? More than likely, nod and think "huh you're not the only one running on too little sleep right now".
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Old Oct 17, 2018, 10:45 am
  #1032  
 
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Originally Posted by CZAMFlyer
Comparing pilots to the general population is entirely sensible. The working world is full of folks working irregular hours while operating complex systems and holding responsibility for many lives.

The hiring process is not usually as you describe - at least not in North America. Some airlines have the luxury of recruiting suitable pilot cadets based upon aptitude and attitude, and training them from Hour One in a desired corporate culture. AC and other large airlines run their applicants through a verbal interview that superficially addresses suitability & behaviour, but in reality the new hires just have to meet an ever-lowering bar based largely upon previous experience, decent references and being able to 'play the game' during the interview itself. With demand for pilots beginning to exceed supply, I don't foresee meaningful improvements soon.

I don't want to be 'that guy' who points out problems without offering a solution, but this suggestion is laden with concerns on so many levels. The reliability of the detection software, the reaction of the employer who receives an alert, the tendency of the employee to trust the employer will react in a fair manner (see safety culture thread), privacy, CRM and liability issues all rear their heads.
And what would ATC do with such information, even supposing for a moment that they are an appropriate receiver of such data? More than likely, nod and think "huh you're not the only one running on too little sleep right now".
No, it's not. The incidence of certain types of behaviours in a professional cadre is typically significantly lower than in the general population. Put it this way: the incidence of criminal offences in the police force should be lower than in the general population. Or else, something is broken.

I dont know what standards AC pilots are assessed to, but I imagine they have to meet a certain standard and their behaviour is assessed regularly. If a risk-taking cowboy pilot with a license can just show up and get hired, there is a problem (regardless of the airline).

Its true that there is a pilot shortage that can complicate things, but I expect some airlines will do their best to recruit and retain the best. That said, I accept that others will cut corners to save a quick buck.
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Old Oct 17, 2018, 11:09 am
  #1033  
 
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Originally Posted by yulred
I dont know what standards AC pilots are assessed to, but I imagine they have to meet a certain standard and their behaviour is assessed regularly. If a risk-taking cowboy pilot with a license can just show up and get hired, there is a problem (regardless of the airline).
Well I have a good idea. And the only thing that is assessed is their flying prowess and adherence to SOPs, on the line and in regular simulator sessions. There is no more stringent "behaviour assessment' of Air Canada pilots than is given to the girl who lifted your fries out of the fryer at McDonalds. Come to think of it, she enjoys no special union protections, so she may be subjected - fairly or unfairly - to more rigorous assessments.

The notion of "risk-taking cowboys" is the opposite end of the spectrum, but I also know of at least a trio of such people at our nation's largest airline now inviting you to sit back, relax and enjoy your flight.

Originally Posted by yulred
Its true that there is a pilot shortage that can complicate things, but I expect some airlines will do their best to recruit and retain the best. That said, I accept that others will cut corners to save a quick buck.
I'm sure AC does their best to recruit and retain the best. However, it may not be to the idealistic standards some might expect.
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Old Oct 17, 2018, 2:07 pm
  #1034  
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Originally Posted by yulred
No, it's not. The incidence of certain types of behaviours in a professional cadre is typically significantly lower than in the general population. Put it this way: the incidence of criminal offences in the police force should be lower than in the general population. Or else, something is broken.
It may be BELIEVED to be lower. I'm not certain it is.

Countless times I've encountered and observed behavior unbecoming. The nature of my work allowed me to be just some unimportant anonymous background object. This often allowed for a "fly on the wall" vantage.
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Old Oct 17, 2018, 3:29 pm
  #1035  
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Originally Posted by CZAMFlyer
I don't want to be 'that guy' who points out problems without offering a solution, but this suggestion is laden with concerns on so many levels. The reliability of the detection software, the reaction of the employer who receives an alert, the tendency of the employee to trust the employer will react in a fair manner (see safety culture thread), privacy, CRM and liability issues all rear their heads.
And what would ATC do with such information, even supposing for a moment that they are an appropriate receiver of such data? More than likely, nod and think "huh you're not the only one running on too little sleep right now".
Your points are entirely valid, other than the reliability of the detection software.

I was perhaps insufficiently clear in my original post -- if such a system were ever implemented, I would see it being launched as something used in the cockpit only (i.e. no link back to HQ, etc.) Eventually if the system came to be accepted and valued by all stakeholders (pilots, airlines, regulators...) there might be a willingness to make it "connected" - but I certainly could not imagine doing that from the get-go.
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