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A constructive and responsible response to incapacitation (https://skybrary.aero/accidents-and-incidents/a320-en-route-northern-italy-2016)
Summary:
On 15 August 2016, the cognitive condition of an aircraft Captain deteriorated en-route to Riga and he assigned all flight tasks to the First Officer. When his condition deteriorated further, an off duty company First Officer travelling as a passenger was invited to occupy the flight deck supernumerary crew seat to assist. Once descent had commenced, the Captain and assisting First Officer swapped seats and the flight was thereafter completed without any further significant event. The Investigation concluded that the Captain’s serious physical and mental exhaustion had been the result of the combined effect of chronic fatigue and stress.
Acesse o link do título para ver o texto completo.
Chamo a atenção para trechos (excertos) da abordagem do caso.
Antecedentes relatados pelo 'Captain"
"A specialist examination of the Captain which was performed “abroad” after the event found that he was suffering from “fatigue due to long-lasting stress”. The Captain himself reported that “several stressful events” in the period prior to the investigated flight had “contributed to his physical and mental exhaustion”. He identified these events as “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 also mentioned “an emotionally charged conflict in the previous month” which arose after he had to divert to an alternate airport after missing the closing time of Riga Airport. He considered that his condition was aggravated by events on the day of the occurrence “in particular the risk of a late arrival at Riga, which had previously been a very unpleasant experience” on a day when the usual destination alternate, Vilnius, would not have been available meaning that any diversion would have been a much longer one to Helsinki."
Ver também
Wizz Air and Pilot Fatigue
It was noted that almost a year prior to the investigated event, the airline had begun to establish a department to “manage the risk arising from fatigue of flight crews” but that this establishment was still incomplete. It was noted that the main responsibilities of this new department were intended to be:
raising awareness of the subject through training and regular information for flight crew, their managers and crew rostering personnel,
gathering information on exhaustion or imminent danger of exhaustion among flight crew,
assessing and evaluating the extent and evolution of the risk arising from exhaustion,
developing proposals to reduce these risks,
following up and monitoring the implementation and impact of the proposals adopted.
[...]"
"Organisational Culture
The Investigation noted that “the fatigue-related organisational culture of flight crews is contradictory and difficult to quantify”. It was also observed that whilst it is well known that flight crew fatigue poses a threat to aviation safety, “the assessment of the risk it entails for a crew member and its meaning is not a simple task (since) on the one hand, it may conflict with the image perceived by the person of his/her own physical condition and endurance and on the other (induce) anxiety about the real or perceived danger of reprisal from the airline” which may mitigate against the open admission of fatigue. "
E, o que me parece pior, A CONCLUSÃO:
"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 formally identified:
The Captain had not properly assessed his physical and mental condition.
The other member(s) of a flight crew have no means to override a Captain’s decision on his own physical and/or mental condition until he/she becomes incapacitated.
The Final Report was finalised on 24 March 2021 and subsequently published in both English translation and in the definitive Hungarian language version. No Safety Recommendations were made.
BREVE COMENTÁRIO PARA ESTIMULAR REFLEXÕES.
Se " a causa" (sic!) é resultado do efeito combinado de fadiga crônica e estresse, não seria o caso de incluir na análise uma exploração sobre as origens dessas duas condições? Inclusive considerando aspectos como vivências apontadas como antecedentes em falas do comandante? (vide acima)
Os fatores contributivos destacados definem como responsabilidade individual do comandante o reconhecimento de sua condição física e mental. Será correto concluir/agir como se o Departamento encarregado da gestão de riscos relacionados à fadiga não tivesse mesmo nada a ver nesse momento? (raciocínio similar poderia ser usado para discutir aspectos da conclusão relacionada ao papel dos outros membros da equipe)
Enfim embora a conclusão se dê em área como a da aviação, em que avanços do conhecimento costumam ser mais rapidamente incorporados nas práticas de SST parece importante questionar:
Considerando que as origens da fadiga crônica e do estresse do comandante são desconsideradas no relato é possível supor que persistem intocadas e seus efeitos potenciais continuarão afetando o sistema?
Será que a resposta adotada é mesmo construtiva
O conclui com links de sugestões de leituras complementares sobre o tema
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