Human Factors Incident Reporting — Page 319, Lesson 512

I want to walk you through a new topic now — Human Factors Incident Reporting. This is a critical part of your training because it shows you real-world examples of how human performance limitations actually affect flight safety. We're going to look at three incident reports from the CHIRP system — that's the Confidential Human Factors Incident Reporting Programme, a voluntary reporting scheme where pilots and other aviation professionals can submit safety-related occurrences without fear of punishment. Let's start with CHIRP Report 6, which is about sleep and fatigue. The report describes an evening flight that left base delayed by about 45 minutes for what the reporter calls "some of the usual reasons" — the everyday operational delays we all experience. The flight was scheduled to wait in Greece for roughly three hours so that the aircraft would not arrive back before the end of the night curfew. That curfew is a noise restriction at many airports — you cannot land or take off during certain nighttime hours. So the crew had to time their departure from Greece so that they would be in the queue early enough to land as close as possible to their scheduled landing time of arrival. Now here's where the fatigue problem becomes critical. On first calling Gatwick approach — that's the approach control frequency for London Gatwick — the aircraft was told it was number 8 to land. The crew began gradually descending in the hold, the holding pattern, as other aircraft left the stack — the stack being the vertical sequence of aircraft holding at different altitudes, waiting for their turn to land. During the second hold, the aircraft descended on autopilot to FL 070 — that's Flight Level 070, meaning 7,000 feet on the standard pressure setting. The handling pilot — the pilot who was actually flying the aircraft — opened the throttles manually because there was no auto-throttle on this aircraft. He did this to maintain holding speed inbound to the fix — the geographical point in the holding pattern where you turn. And then, he woke up again almost two miles beyond the fix where he should have turned. The pilot fell asleep while hand-flying in the hold, and the aircraft continued straight past the turn point for nearly two miles before he regained consciousness. Now let's look at CHIRP Report 7, also about sleep and fatigue, and this one references Chapter 10 of the book. The reporter says: "The previous day I operated a flight of 13 hours 45 minutes duty, with 10 hours of flying. Arrived back at base at approximately 0815 local time having departed at 1810 the previous evening." So that's a night flight that ended the next morning. Then the reporter explains the local regulations: for flights departing between 6:00 am and 6:00 pm — daylight hours — the maximum duty period is 13 hours 45 minutes. For flights scheduled to depart between 6:00 pm and 6:00 am — nighttime — the maximum duty period is 12 hours. But here's the key manipulation: "By changing the departure to 1755 it thus becomes a DAYLIGHT flight!" — 1755 is 5:55 pm, just five minutes before the 6:00 pm cutoff. So by scheduling the departure at 1755 instead of 1800, the operator legally classified the flight as a daylight operation, allowing a duty period of 13 hours 45 minutes instead of the 12-hour limit that would apply to a night departure. The reporter is highlighting how the regulations can be exploited. Then the next night, the same pilot was rostered for a flight leaving base at 1:00 am with five hours of flight time, and the report says "Very little sleep dur" — it cuts off there, but the meaning is clear: very little sleep during the period between these two duties. That figure shows the CHIRP report form and the reporting process. But the key takeaway from these reports is that fatigue is not just a theoretical concept — it causes real operational errors like overshooting a holding fix by two miles, and it can be driven by regulatory loopholes that allow extended duty periods. These are the kinds of incidents that the CHIRP system exists to capture and share so that the entire aviation community can learn from them without naming individuals.