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Number
339
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March
2008
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P.O. Box 189, Moffett Field, CA 94035-0189 |
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Number
339
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March
2008
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P.O. Box 189, Moffett Field, CA 94035-0189 |
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'I'M SAFE' Incidents from ASRs
Section 8-1-1 of the Aeronautical Information Manual (AIM) offers a personal “fitness for flight” checklist that can apply to all aviation personnel who want to evaluate themselves before performing flight-related duties. This checklist can easily be committed to memory: I’MSAFE. The I’MSAFE checklist presents a short list of operator impairments that can contribute to incidents and accidents:
A pilot, flight attendant, maintenance technician, dispatcher, or air traffic controller can use the I’MSAFE checklist as a memory aid to detect any of these conditions, and if one or more conditions are recognized, to employ appropriate mitigation strategies. Let’s take a closer look at some of these categories of impairment, using incident reports submitted to ASRS.
Illness 
The safest advice is not to fly while suffering from any illness. Even a minor illness may seriously degrade performance of duties vital to safe flight, as well as produce distracting symptoms that may impair mental functioning. In a report to ASRS, a B757 Captain described his concern about a flight attendant flying with laryngitis.
While checking in with gate agent, she...laughed saying that we would not be able to hear the purser because she had a terrible case of laryngitis. When I attempted to brief the flight attendants, it was painfully obvious that she had almost no voice at all! I asked her if she would be able to perform her duties and ‘bark’ her commands if an evacuation were necessary. She replied that she would do her best...She relayed to me that she really did not want to call in sick because of the sick leave policy. She stated that she did not really feel that bad, but she was also worried about her voice and ability to give commands during an evacuation if necessary....
I nor any of the rest of the crew appreciated being exposed to her virus! I also wonder what the health/safety authorities...would think about a flight attendant serving meals/drinks with a contagious condition? I was tempted to ask her to pull herself from the flight, but at such short notice, I knew that we would be greatly delayed, if not canceled. I advised her that if she wished to continue, that she must grab a megaphone immediately if the need for any emergency condition developed. She felt comfortable with this and even ‘keyed up’ the megaphone to see if she could be heard properly.
Another air carrier Captain echoed the concern over crew members who fly while ill.
During the flight, it became readily apparent after we departed that the First Officer was recovering from an illness. As he used the radio to communicate with ATC, he coughed uncontrollably. It was at this point that I realized that he should have taken some time off via the sick list to recover more fully...This...placed me in an uncomfortable situation, as I do not have the expertise to diagnose a person’s illness. I contemplated diverting the flight due to his state, but elected not to after determining it was safe to continue....
Stress
Stress from the pressures of everyday living can impair human performance, often in very subtle ways. A PA38 pilot who had been under unusual stress had a near collision with another aircraft during takeoff roll at a small uncontrolled airport.
[Cherokee], piloted by the author, taxied out with 1 person on board for a photo survey flight. A normal call was made for back-taxi on Runway 1 because airport has no taxiways. A successful back-taxi was completed to the run-up area at the takeoff end of Runway 1...Run-up was completed and call made for takeoff...A call for takeoff included the alert that the [Cherokee] would be circling off the departure end of Runway 1 for the purpose of shooting pictures...The takeoff roll was started. After an acceleration to approximately 25 knots...the [Tomahawk] appeared directly overhead on a landing approach. The [Cherokee]...immediately aborted the takeoff and called ‘aborted takeoff’ on the radio. The [Tomahawk] did a normal touch-and-go on Runway 1 and departed the pattern. The [Cherokee] returned to the starting point on Runway 1 for another takeoff run, but also asked the [Tomahawk] pilot if he had made normal calls in the traffic pattern.. He responded that he had ...Upon further inspection, the [Cherokee] pilot (the author) discovered that, during the taxi-out, the radio volume had been turned down in order to hear something that was said by the passenger about the coming survey flight, but it had not been restored to normal volume...As the pilot of [the Cherokee], I believe that my inattention was the cause of this near-miss. Because of financial concerns and my current situation of training for a substantial career change, I have been under more than the usual stress during the past several weeks...a psychological factor which could have had the effect of reducing my alertness in the airplane. I have grounded myself until my career change is settled.
Maintaining awareness of stressful situations, and exercising extra diligence in the performance of duties, may prevent unwanted events from occurring. Here is more from an aviation maintenance report to ASRS.
The inbound air carrier experienced a slat problem channel #2. Our...technician requested my assistance in deferring the problem per MEL. We pulled up MEL and both agreed that our problem matched MEL 27-XXX and performed test as prescribed, which resulted in pulling and collaring circuit breakers. On arrival of flight at ZZZ1, crew experienced channel 2 flaps (circuit breaker out). Item changed to MEL 27-XXY...I have since reviewed MEL and determined that in fact we did use wrong MEL. I feel that stress might have been determining factor, as both the...technician and myself had been working outbound aircraft which were having unusual problems, and we were shorthanded and working against the clock.
Alcohol
The FARs prohibit pilots from performing crew member duties within 8 hours after drinking any alcoholic beverage or while under the influence of alcohol. The AIM suggests an excellent rule is to allow at least 12 to 24 hours between “bottle and throttle,” depending on the amount of alcoholic beverage consumed.
A B757 First Officer was faced with a “bottle to throttle’ dilemma due to an unknown schedule change at a foreign location.
Fatigue
Fatigue is an important human performance consideration within the transportation industry. It can be a significant hazard to flight safety, as it may not be recognized or detected until a serious error has occurred. As one indicator of the pervasiveness of this problem, almost 6,000 ASRS Database reports directly reference fatigue issues.
For a BE400 corporate flight crew, fatigue (and nutrition) issues complicated what should have been a routine flight.
| Editor’s Note: The ASRS Database Online (DBOL) provides a report set of Air Carrier (FAR 121) Fatigue Incidents that can be downloaded at http://asrs.arc.nasa.gov/search/reportsets.html. Twenty-three other report sets of interest to the aviation community can be accessed at this web address. |
| ASRS Alerts Issued in January 2008 | |
|---|---|
| Subject
of Alert |
No. of Alerts |
| Aircraft or aircraft equipment |
13 |
| Airport facility or procedure |
8 |
| ATC procedure or equipment |
7 |
Company policy |
2 |
| TOTAL |
30 |
| January 2008 Report Intake |
|
|---|---|
| Air Carrier/Air Taxi Pilots | 3,353 |
| General Aviation Pilots | 820 |
| Controllers | 46 |
| Cabin/Mechanics/Military/Other | 259 |
| TOTAL | 4,478 |