[Peetwo]

Vortex sleepy pilot investigation completed -   

Remember this? 

Ironsider follow up to snoozing pilot incident - 

via the Oz today:

Pilot fell asleep at wheel
ROBYN IRONSIDE
Two investigations are under way into a freight flight that overflew its destination because the pilot was asleep

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Freight pilot’s 40 winks propels two safety investigations

Two investigations are under way into a freight flight that overflew its destination by almost 50km because the pilot was asleep.

The Civil Aviation Safety Authority is investigating the fatigu­e management practices of flight operator Vortex Air.

The Australian Transport Safety Bureau is also investigat­ing the incident, which it classified as “pilot incapacitation”.

The flight left Devonport in Tasmania at 6.20am on November 8, to make the 250km trip to King Island. It was the first flight of the day for the Piper PA-31-350 Navajo Chieftain, which can carry up to 700kg of freight.

The Australian understands the pilot reported for duty despite having had little or no sleep the prev­ious night due to a personal crisis. He was the only person on board and, according to the ATSB investigation summary, fell asleep during the cruise part of the one-hour flight.

It’s thought a radio call may have woken him after the aircraft overflew King Island Airport by 46km. The Piper landed safely just after 7.20am, then went on to do six further flights that day.

The ATSB investigation was launched in response to “addit­ion­al information” received by the bureau in the past week but a spokesman was unable to provide any further details.

As part of the investigation, the pilot would be interviewed and operational procedures reviewed, the ATSB summary said.

A CASA spokesman said its investigation would focus on the fatigue risk-management practices of Vortex Air to ensure it met Australian standards.

Vortex managing director Colin Tucker refused to comment yesterday on the incident.

Devonport Airport general manager Dave Race said Vortex Air was a reputable and safe operator that conducted regular flights, carrying freight and passengers to King Island, which boasts three golf courses.

King Island Council Mayor David Munday also described Vortex as a “professional” airline.

Research undertaken by the ATSB on pilot incapacitation incide­nts in Australia between 2010 and 2014 found they were rare in the general aviation sector.

There are only two reported cases of pilots falling asleep on the job. In one case, the pilot of a Cessna 210 Centurion awoke to find he had entered controlled airspace twice without clearance while flying from Port Macquarie on the NSW mid-north coast to Bankstown in Sydney. In the second, a passenger awoke the pilot of a Gippsland GA-8 who nodded off doing locust spotting over farmland in Ardlethan, NSW.

This today from the ATSB:

Acute fatigue leads to pilot incapacitation

A pilot was experiencing acute levels of fatigue before falling asleep during an early morning freight flight from Devonport to King Island, an ATSB investigation has confirmed.



The Piper PA-31-350 aircraft had reached top of descent into King Island when the pilot, who was the only person on board, started to feel tired and quickly fell asleep. After several unsuccessful attempts by ATC and other pilots in the area to contact the pilot, he awoke and advised ATC operations were normal and that he was turning back to King Island.

While on autopilot the aircraft had overflown the island by approximately 78 km to the north-west.

The aircraft landed without further incident. However, after talking with the operator, the pilot then flew from King Island to Moorabbin to complete his shift.

The ATSB found that the pilot had been awake for about 24 hours and had been unable to sleep during a scheduled rest period before the incident flight. Analysis confirmed the pilot’s fatigue was at a level known to effect performance, while further analysis showed that even if the pilot had been able to sleep during his rest period he still would have been fatigued to a level known to affect performance.

In addition, the pilot had not modified his sleep pattern in preparation for the planned night shift, contributing to his fatigue.

The ATSB found that the pilot had been awake for about 24 hours and had been unable to sleep during a scheduled rest period before the incident flight.

“This investigation highlights the need for pilots to assess their level of fatigue before and during their flight,” said ATSB Executive Director, Transport Safety, Mr Nat Nagy.

“Before commencing night operations pilots are encouraged to modify their usual sleep routines to ensure they are adequately rested.”
The ATSB also calls on operators to consider the risks of allowing a pilot to continue operating directly after a fatigue-related incident without corrective management.

“Just as it is the pilot’s responsibility to use rest periods to get adequate sleep and to remove themselves from duty if they feel fatigued, it is also incumbent on operators to implement policies and create an organisational culture where flight crew can report fatigue and remove themselves from duty in a supportive environment,” Mr Nagy said.

Information on fatigue management is available from the Civil Aviation Safety Authority and ATSBwebsites.

Read the investigation report AO-2018-075: Pilot incapacitation involving Piper PA-31, VH-TWU, near King Island, Tasmania, on 8 November 2018

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& fm Ironsider, via the Oz:

Pilot who fell asleep at controls was allo



A Piper PA-31 Navajo aircraft. Aviation

• ROBYN IRONSIDE
  AVIATION WRITER
  @ironsider
  
• 2 HOURS AGO JUNE 25, 2019
  
• NO COMMENTS
  

A pilot who fell asleep while operating a cargo flight in Tasmania had been awake for 24-hours prior to the incident.
An Australian Transport Safety Bureau report into the incident, which occurred on November 8 last year, found the pilot was “acutely fatigued to a level affecting performance”.

Despite his lack of sleep, the pilot flew from Moorabbin in Victoria to Devonport, Tasmania, had a three-hour break, then headed off again to fly to King Island.

During the flight he nodded off, waking up to find he was almost 80km past his destination.

From 7.25am to 7.33am, air traffic control tried to contact the pilot without a response.

The ATSB report said at 7.33am a transmission was received from the pilot who advised that operations were normal.


An investigation has been launched into an incident in which a pilot fell asleep during a one-hour charter flight, resulting in the aircraft overflying its destination by 46km. The 6.21am Vortex Air flight from Devonport to King Island on November 8

He landed the Piper PA-31 at King Island at 7.55am and contacted his supervisor and air traffic control in Melbourne to discuss what happened. 

Despite the in-flight nap, the pilot was allowed to finish his shift, flying from King Island back to Moorabbin. 

The ATSB investigation found the pilot recalled not feeling fatigued before the morning flight which was his first after five days off.

During the three hour break at Devonport, the pilot said he rested but didn’t sleep.

“From the information reported by the pilot, it was determined that at the time of the occurrence, the pilot had been awake for about 24-hours,” said the report.

“Using the information obtained at interview and the pilot’s roster, fatigue analysis was conducted, which identified that the pilot was acutely fatigues to a level known to affect performance.”

The report took aim at operator, Vortex Air, pointing out that “despite knowing the circumstances of the incident, no measures were put in place to ensure the pilot was fit to continue the shift”.

“This resulted in the pilot continuing to fly the aircraft while still being fatigued to a level known to affect performance,” said the report.

Vortex Air managing director Colin Tucker said he spoke to the pilot on the ground that morning, and he assured him he was fine to fly.

He described the incident as a “tiny blip” that had caused considerable damage to the company despite its “exemplary safety record”.

“We’ve been flying for 15-years and it damages your brand. It’s a competitive air space we fly in,” Mr Tucker said.

He said the pilot was badly affected by publicity surrounding the incident but had returned to flying and was doing well.

“If you’ve been on leave for five days before a shift, there’s nothing as an organisation we could’ve done,” said Mr Tucker, adding the pilot was aware of his roster before he went on leave.

Changes had since been made to the rostering system to provide more notice for pilots but Mr Tucker said occasionally last minute changes were necessary.

Well this must be some kind of all time record for the Hooded Canary led ATSB i.e 7 months and 18 days to complete an aviation occurrence investigation?? - Yeah right...  

My cynical but best guess is that given there was apparently a regulator investigation run in parallel, that Fort Fumble are getting ready to drop the Big E-enforcement bomb on this Vortex mob and needed the Hooded Canary mob to be out of the picture...  

Q/What is it with all the YMMB connections (CASA Southern Region) of late? Hmm...I see some very big dots and dashes appearing before my eyes...  


MTF...P2