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LCQ6: Airlines crew fatigue cases

     Following is a question by the Hon Lee Cheuk-yan and a written reply by the Secretary for Transport and Housing, Professor Anthony Cheung Bing-leung, in the Legislative Council today (February 17):


     It has been reported that Cathay Pacific Airways (CX) received in 2014 nearly 1 100 reports of fatigue in aircrew (FIA), representing a rise of 38% as compared to those received in 2013.  Moreover, it is learnt that in one of the recently reported cases, both of the two pilots of a freighter were alleged to have dozed off briefly while flying the freighter into anchorage in July last year, which could have turned into a disaster.  In this connection, will the Government inform this Council:

(1) whether the Civil Aviation Department (CAD) knows the occurrence of FIA cases; if CAD does, whether it has investigated into those cases; if CAD has, of the outcome;

(2) whether CAD knows the total number of FIA reports received by the airlines in Hong Kong last year; if CAD does, of the number of such reports, and whether CAD has taken follow up actions with the airlines concerned with a view to reducing the occurrence of FIA cases; if CAD has, of the details of the actions taken; if not, the reasons for that;

(3) whether CAD regularly monitors the flight hours of pilots and the impacts of pilot fatigue on the safety of passengers and aircrew; if CAD does, of the details of the relevant work;

(4) of the justifications for CAD's stipulating the standby duty requirement in the Flight Standards CAD 371 (the Avoidance of Fatigue in Aircrew) that if an aircrew member is called out from standby for a flight duty period (FDP) with a report time after the end of the scheduled standby duty, then the maximum time limit between the start of the scheduled standby duty and the end of FDP shall be 23 hours (the 23-hour rule); whether CAD, in the light of a recent scientific research finding that 17 hours of wakefulness is equivalent to 0.05 per cent of blood alcohol content, will review the 23-hour rule with a view to reducing the hours of wakefulness of aircrew and avoid the occurrence of FIA; and

(5) whether any CAD officer attended any of the meetings of the Fatigue Risk Management System Committee, which was established by CX in 2011, held in the past five years; if so, of the number of those meetings attended by them; whether CAD has any plan to require all airlines in Hong Kong to set up similar committees for monitoring and managing FIA?



     The International Civil Aviation Organization (ICAO) has promulgated very stringent standards on aviation safety.  In compliance with the ICAO requirements, the Civil Aviation Department (CAD) maintains close and regular inspections of airline operators, including flight inspections and operational records inspections, to ensure the airworthiness and safety of the flight operations.  In addition, CAD also monitors regular reporting from airline operators.

     According to the requirements of ICAO and international practice, fatigue cases, like other occurrences, are identified and handled by at least two levels of risk management activities, namely those with low or no safety implications that are outside the scope of the Mandatory Occurrence Report (MOR) Scheme (Note 1) and those that are required to be reported to CAD by airline operators.  For the former type, such fatigue-related cases are reported and investigated internally by airline operators who do not have to submit reports to CAD.  For the latter, these fatigue-related cases are reported to CAD under the MOR Scheme.  They can be of different risk levels, ranging from those entailing suggestions for improving the airline's fatigue avoidance measures, such as rostering practices, to reports on personal or subjective fatigue events.

     As regards the 1 100 reports of fatigue in aircrew mentioned in the preamble of the Hon Lee Cheuk-yan's question, according to the statistics provided by the airline operator concerned, the average risk of the aforementioned cases was rather low.  Only 29 cases or about 2.6 per cent of them were reported to CAD under the MOR Scheme and have all been investigated by the airline operator concerned as well as reviewed, discussed and agreed by both the airline operator and CAD at the regular MOR review meetings.

     As regards the particular fatigue report involving two pilots mentioned in the same preamble, CAD had followed up with the airline operator in accordance with the established procedures.  According to the investigation report submitted by the airline operator to CAD under the MOR Scheme in September 2015, the "pilot monitoring" (i.e. First Officer in this case) of the flight concerned had prompted the "pilot flying" (i.e. Captain in this case) to set up the aircraft for the approach to the airport in accordance with the standard operating procedures.  The aircraft subsequently landed safely.  Both the airline operator and CAD had found no evidence to support the allegation that both pilots had fallen asleep in any phase of the flight.  The airline operator had subsequently proposed follow-up actions including better management of flight roster and ways to improve pilots' ability to manage fatigue.

     My reply to the specific parts of the Hon Lee Cheuk-yan's question is as follows.

(1)-(3) As part of its safety oversight regulatory activities, CAD maintains close surveillance of the duties and flying hours of the crew members of all airlines holding Air Operator's Certificates issued by CAD through regular operational records inspections.  In accordance with Article 54 of the Air Navigation (Hong Kong) Order 1995 (Cap. 448C), the operator of any aircraft registered in Hong Kong engaged on a flight for the purpose of public transport is required to establish a scheme for the regulation of flight times for every crew member (known as Flight Time Limitation Scheme), which must comply with the CAD guidance document (namely CAD 371 (2nd Edition)).  The scheme has to be approved by CAD and has to be made available to every crew member on the specific flight.  

     As mentioned above, according to the ICAO requirements and international practice, CAD requires all airline operators by the Air Navigation (Hong Kong) Order 1995 (Cap. 448C) to have two levels of fatigue reporting mechanism: (i) internal reporting and investigation mechanism under the Safety Management System (Note 2); and (ii) report filing to CAD under the MOR Scheme.  As regards the first level of reporting, airline operators are required to capture reports related to fatigue during flights and assess the risk level of the reports based on the severity and likelihood of the events.  For fatigue cases of higher risk level that fall within the scope of the MOR Scheme, they should be reported to CAD by airline operators as a MOR.  CAD attends airline operators' regular MOR review meetings for the follow-up of MOR cases and receives investigation reports submitted by airline operators.  CAD also regularly monitors airline operators' implementation of the rectification measures.

(4) The ICAO has not stipulated detailed rules in limiting the flight time for the avoidance of fatigue.  Other leading civil aviation authorities have not specified the limit of "Standby duty" together with "Flight Duty Period" (Note 3) either.  CAD, by making reference to the Australian regulation, introduced the "23-hour rule" in 2010 after consultation with airlines representatives, pilot and cabin crew unions and medical doctors with aviation medicine qualifications at its Flight Time Limitation Working Group meetings.  In gist, the rule states that the maximum time limit between the start of the scheduled "Standby duty" and the end of the "Flight Duty Period" shall be 23 hours.  Pilots could make use of the "Standby duty" period to take rest before being called out for duty.  That said, in view of the evolving international practice and scientific findings, CAD is already reviewing the "23-hour rule" and may consider if it is necessary to update the current arrangement, subject to the outcome of the review.

(5) To further mitigate the possible risk associated with crew fatigue, CAD encourages airline operators to set up their own Fatigue Risk Management System (FRMS), although this is not an ICAO mandatory requirement currently.  Having received fatigue reports from crew, the FRMS applies specific scientific modeling to identify potential hazards within rostering scheme, flight pattern and other operational areas, and mitigate the risks involved by preventive measures.  Under the FRMS, a Fatigue Risk Management Committee, comprising representatives of stakeholder groups including management, pilot representatives and medical doctors with aviation medicine qualifications, will be established.  The Committee will look into pertinent areas including: (i) risk management processes; (ii) safety assurance processes; and (iii) safety promotion processes.  Two Hong Kong-based airlines have set up such Committee in 2010 and 2012 respectively.  CAD will work with the other Hong Kong-based airlines to consider the feasibility of setting up their own FRMS.

     In the past, CAD, represented by an inspector and a medical doctor with aviation medicine qualifications, attended one FRMS meeting of a Hong Kong-based airline as observer.  It should be noted that proper management of fatigue in aircrew is the primary responsibility of individual airline operators.  CAD will continue to monitor the situation and consider attending FRMS meetings of local airlines when necessary.

Note 1: In accordance with Article 86 of the Air Navigation (Hong Kong) Order 1995 (Cap. 448C), the operator or the pilot in command of an aircraft operated by a Hong Kong holder of Air Operator's Certificates shall make a report to CAD of any incident related to such an aircraft or any defect in or malfunctioning of such an aircraft or any part or equipment of such an aircraft, being an incident, malfunctioning or defect endangering, or which if not corrected would endanger, the aircraft, its occupants, or any other person.

Note 2: According to Article 102 of the Air Navigation (Hong Kong) Order 1995 (Cap. 448C), a Safety Management System shall -  
(a) identify safety hazards and manage associated risks;
(b) ensure that remedial action necessary to maintain an acceptable level of safety is carried out;
(c) provide for continuous monitoring and regular assessment of the safety level achieved;
(d) aim to make continuous improvement to the overall level of safety; and
(e) be appropriate to the size, nature and complexity of the activities concerned and the safety hazards and risks related to such activities.

Note 3: In accordance with the CAD guidelines, CAD 371(2nd Edition), "Standby duty" means "a period during which an operator places constraints on a crew member who would otherwise be off duty".  "Flight Duty Period" means "any time during which a person operates in an aircraft as a member of its crew.  It starts when the crew member is required by an operator to report for a flight.  It finishes at on-chocks or engines off, or rotors stopped, on the final sector, or when a crew member last vacates a control seat and is free of all flight duty for the remainder of the flight, whichever is the earlier."

Ends/Wednesday, February 17, 2016
Issued at HKT 13:45


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