The Number of Sectors and Other Risk Factors Related to Fatigue Among Shorthaul Commercial Pilots in Indonesia

Background: Fatigue could impair cognitive function in pilots which may lead to accidents in short-haul flight. Theaim of this study was to identify the risk factors related to fatigue among short-haul commercial pilots in Indonesia.Methods: A cross-sectional study with purposive sampling was conducted among Boeing 737 seriestyped-rating pilots taking medical examination at the Civil Aviation Medical Center, Jakarta from May5-26, 2014. Fatigue was measured with Self-Reporting Questionnaire, Fatigue Severity Scale (FSS). Datawere collected using anonymous self-reporting questionnaire on demographics, workload, sleep restriction(Epworth Sleepiness Scale-ESS), personal factors, and managerial support. Linear regression was used toidentify dominant risk factors related to fatigue.Results: During data collection, 785 pilots were taking medical examination, 382 pilots were willing toparticipate, and 239 pilots met the criteria. The FSS mean was 4.66 ± 1.202. The number of sectors in 24hours, flight times of unplanned flights in 30 days, and sleep restriction were dominant factors of fatigue.Each additional sector increased FSS by 0.371 points [regression coefficient (β) = 0.371; P = 0.000].Furthermore, each additional ESS, increased FSS by 0.043 points (β = 0.043; P = 0.008), while eachadditional unplanned flights increased FSS by 0.033 points (β = 0.033; P = 0.000).Conclusions: Additional number of sectors in 24 hours, additional unplanned flight times within 30 days,and sleep restriction increased the risk of fatigue among short-haul commercial pilots in Indonesia. (HealthScience Journal of Indonesia 2015;6:69-75)

Fatigue could impair cognitive function in pilots, including judgment, memory, concentration, selective attention and decision making. These factors have been known as contributory factors to aircraft accidents and incidents. 1 The National Aeronautics and Space Administration (NASA) Aviation Safety Reporting System indicated that 21% of reported aviation incidents were fatigue related. 2 The causes of pilot fatigue are primarily related to sleep loss for both long-haul and short-haul flights. Night flights and jet lag are the most important factors that generated fatigue in long-haul flights. 3 While other studies revealed that fatigue in short-haul operation was caused by the number of sectors, 3,4 more than one unplanned flights in a month, 2,5 cumulative duty time in the preceding week, 3 and sleep restriction. 5 Repeated mild sleep restriction without sufficient opportunity for recuperation, could cause cumulative fatigue and lead to great risk for aviation safety. 6 Indonesia is an archipelago nation and short-haul domestic flights between cities or small islands play an important role. High domestic passenger rate and tense competition among airlines in Indonesia 7 pushed airline management to a culture of short-haul pilots flying more sectors, flying unplanned flights during rest periods and cumulatively flying close to legal maximum of flight and duty time limitations, as was clarified by 30% of subjects during preliminary study. This condition may adversely affect the safety of short-haul flights in Indonesia The aim of this study was to identify the dominant risk factors related to fatigue among short-haul commercial pilots in Indonesia.

METHODS
This cross-sectional among the population of active pilots working for commercial airlines was conducted under Civil Aviation Safety Regulation (CASR) part 121 in Indonesia. Subjects were selected by purposive sampling from commercials pilots taking medical examinations at the Civil Aviation Medical Center in Jakarta from May 5 -26, 2014.
The inclusion criteria were active commercials pilots holding an Airline Transport Pilot License (ATPL) or Commercial Pilot License (CPL) type license, operating in short-haul flights of less than 2 hours flight time per sector, and having a Boeing 737 series type rating. The exclusion criteria were subjects taking hypnotics or stimulants.
Subjects who were willing to participate signed an informed consent letter. They were asked to fill a selfreporting questionnaire regarding demographics, workload, sleep restriction, managerial support, personal factors at home, behavior, and overall fatigue experience in the last week.
Fatigue was measured using Fatigue Severity Scale (FSS) that consisted of 9 questions relating to fatigue and its impact on functioning and behavioral aspects in the past week. The FSS questions were: (1) my motivation is lower when I am fatigued; (2) exercise brings on my fatigue; (3) I am easily fatigued; (4) fatigue interferes with my physical functioning; (5) fatigue causes frequent problem for me; (6) my fatigue prevents sustained physical functioning; (7) fatigue interferes with carrying out certain duties and responsibilities; (8) fatigue is among my most disabling symptoms; and (9) fatigue interferes with my work, family, or social life. Subjects answered the questions on a scale of "1" indicating agrees to and "7" indicating disagrees to. Mean FSS score was used as a continuous measure of fatigue scale. 5 While the number of sectors was any flight which has a take-off and landing at different airports which are not less than 50 nautical miles apart in the last 24 consecutive hours. 8 The risk factors were frequency and flight time of unplanned flights, flight duty time in the last 24 hours, sleep restriction, managerial support, personal factors at home, and health behaviors. Flight time was divided into the last 24 hours and into 7 days.
Unplanned flight was considered as flight duty, performed by the pilot, which was not in their schedule or during their day-off, in the last 30 consecutive days. This variable was divided into frequency and flight time of unplanned flight.
Flight time was considered as total elapsed time from the moment the aircraft first moved under its own power for takeoff, until the time it comes to rest at the end of the flight. This variable was divided into flight time in the last 24 hours and into 7 days.
Flight duty time was total elapsed period from the time a pilot report for duty to the time he completed all official duties in the last 24 hours. 8 Sleep restriction was measured by the Epworth Sleepiness Scale (ESS) that has 8 questions relating to how likely the subjects were to doze off or fall asleep in the following situations: (1) sitting and reading; (2) watching television; (3) sitting inactive in a public place (e.g. theatre, meeting); (4) as a passenger in a car for an hour without break; (5) lying down in the afternoon when circumstances permit; (6) sitting and talking to someone; (7) sitting quietly after a lunch without alcohol; (8) driving a car, while stopping for a few minutes in traffic. Subjects answered the questions on a scale of 0 = would never doze; 1 = slight chance; 2 = moderate chance; 3 = high chance. The value of each scale was summed and used as a continuous measure of ESS. 9 Managerial support was measured using the Whitehall organizational justice that has 6 question relating to the subjects' situation at the company they worked for, which were: (1) do you get sufficient information from line management (your superior)?; (2) do you get consistent information from line management (your superior)?; (3) how often do you get help and support from your colleagues?; (4) how often are your colleagues willing to listen to your work related problems?; (5) how often do you get help and support from your immediate superior?; (6) how often is your immediate supervisor willing to listen to your problems? Subjects answered the questions on a scale of 1 = never; 2 = seldom; 3 = sometimes; 4 = often. Managerial support was scaled as ordinal measure. 5 Personal factors at home were measured by the Home Stress Checklist that has 4 questions relating to the stress situation that the subjects experienced at home every day. The question and choices of answer were: (1) how is your role at home? as the main source of family income/ as a father or mother/ as a husband/wife/ as a financial support to other family members/ as a payer or pay various bill/ as a gardener/ as home decorator/ as a household repairmen (answer can be more than one); (2) which are the physical factors at household/neighborhood that you feel can annoy you? neighborhood noise/ the narrow house/ homes that's not well organized/ leaks and physical damage in other household/ dense neighborhood/ neighborhoods prone to flooding/ unsafe neighborhood (answer can be more than one); (3) how do you describe your tension at home: low (a bit of dispute, can be openly discussed) or moderate (there is some tension, but can be tolerable) or severe/high; (4) when you are at home, how often do you have the opportunity to yourself and do activity that's relaxing? The answers were either every day, rarely, or several times a week. For questions number 1 and 2, "low" was if the subject answered 0 -2, "moderate" if the subject answered 3-5, and "high" if the subject answered ≥6. For question number 3, "low" was if the subject stated their tension at home as a bit of dispute, can be openly discussed; "moderate" if the subject stated there is some tension but was tolerable, and "severe/high" if the subject felt the tension at home was severe/high. Personal factor at home was in ordinal scale. 10 Health behavior was considered as the frequency of drinking alcohol per week, frequency of drinking coffee per day, duration of smoking (months), number of cigarettes per day, and frequency of sport activities per week. 11,12 Ethical clearance was granted from the Research Ethical Commission of Faculty of Medicine Universitas Indonesia and data collection was approved by the Head of the Civil Aviation Medical Center.
Linear regression was used to identify dominant risk factors related to fatigue 13 , and computed using Stata released 9.

RESULTS
In the 16-day data collection period, there were 785 pilots taking medical examination and 382 were willing to participate. None of the subjects were excluded because of taking stimulants or hypnotics. Pilots who were excluded were 81 long-haul flight pilots, 43 Airbus 320 type-rated pilots, and 19 Avions de Transport Regional (ATR) type-rated pilots. Finally, there were 239 pilots with Boeing 737 series type-rated short-haul commercial pilots. Table 1 showed that no subject reached the maximum (9) for FSS. The average FSS was mid-scale (4.66) between the least and the maximum and the average number of sectors was 3.58 in the last 24 hours. There were subjects with a sleep period of 4 hours, but the average sleep period was 6.83 hours, while average ESS was 8. Flight time in the last 7 days, sleep and wakefulness periods slightly fluctuated (coefficient of variations was less than 20%), while frequency and flight time of unplanned flights fluctuated widely. Furthermore, the highest variation among subjects was for the duration of smoking at 98.6%. Table 2 showed that age, physical factors at home, opportunity to do relaxing activities, and role at home did not have any effect on fatigue. The number of sectors in the last 24 hours, frequency and unplanned flight time in the last 30 days, flight time in the last 24 consecutive hours and 7 consecutive days, flight duty time in the last 24 hours, ESS, and tension at home were more likely to increase the risk of FSS.

DISCUSSION
In interpreting this study, firstly the small number of subjects willing to participate must be considered. The low participation was probably because pilots felt uncomfortable if the exceeded flight time was discovered by the DGCA and affect their certification process. Secondly, fatigue was measured in subjective concept (FSS). Nevertheless, FSS is a widely used self-reporting questionnaire relating to subjects' fatigue and its impact on functioning and behavioral aspects in the past week. FSS has good reliability and validity with Cronbach α= 0.85. 5.14 Furthermore, there were some factors effecting fatigue which were not measured in this study, for example the circadian rhythm, vibration, noise, and automation. 15,16 Short-haul pilots often had unplanned flights, early starts and late finishes, which can result in sleep restriction and disrupt circadian rhythm. This effect was minimized by using ESS to subjectively determine the subjects' sleepiness scale. ESS has been used in many research, recommended by the Fatigue Risk Management System (FRMS) of the International Civil Aviation Organization (ICAO) and has good reliability and validity with Cronbach α = 0.77-0.88. 9 In addition, this study was only directed to Boeing 737 type-rated short haul commercial pilots and therefore the effect of vibration and automation were expected to be similar among subjects.
The average FSS (4.66±1.202) was almost the same as the British Airline Pilots Association (BALPA) pilots in United Kingdom (UK), Germany, French and Italy which was 4.7±1.0. 5 The number of sectors was the highest factor to significantly increase fatigue, which increased FSS by 0.371 for every additional sector in the last 24 hours. These results were consistent with a study by Powell in New Zealand that stated each additional sector was equivalent to an increase of 0.38 on the 7-point Samn-Perelli fatigue scale. 4 Bourgeois-Bougrine in France also found that each additional sector was equivalent to an increase of 0.48 on the visual analog scale of fatigue. 3 Take-offs and landings are critical phase of flight that requires high concentration and intense conversation between pilots and Air Traffic Controller (ATC). 2,4 Thus several repeated sectors in a short haul operation can cause cumulative fatigue that will impair a pilot's cognitive function leading to accidents or incidents. 17 Other These results were not consistent with the study by Bourgeois-Bougrine in France which revealed that each additional flight time in 4 days was significantly correlated with higher visual analog scale of fatigue. 3 Powell in New Zealand also revealed that each additional flight duty time was significantly correlated with higher Samn-Perelli fatigue scale. 4 The explanation for this dissimilarity was probably the different characteristic and measurement of fatigue, and although some subjects may fly the same flight time or flight duty time, each subjects flew different numbers of sectors. That is probably why the number of sector was the highest factor to significantly increase fatigue.
Personal factors at home and managerial support were not dominant factors of fatigue. These results were not consistent with Deros in Malaysia which revealed that fatigue in Malaysian pilots was due to trouble sleeping because of personal worries. 18 While Steptoe revealed that subjects with low perception of organizational justice were less likely to have lowered fatigue scale. 5 These differences were explained by Yuliana who studied the same population in 2013. It was stated that pilots were highly intellectual and rational people who had the ability to use coping strategy such as comfort in religion that will decrease distress level as much as 51%. 10 But this requires further study to investigate the effects of distress and coping strategy on fatigue.
This study revealed that fatigue was a multi-factorial physiologic condition that was caused by an imbalance between workload and recovery sleep. Fatigue could impair a pilot's cognitive function to safely operate an aircraft. Therefore, it is important for pilots to get enough rest-period, understand their fatigue level before considering a flight duty especially unplanned flights, assemble a good Crew Resource Management (CRM), and notably manage safety culture and safety report for every flight duty (pilots must be free to express their concern and share their thoughts of every flight safety related conditions).
As a member ICAO, Indonesia strives to implement FRMS to our regulations. This study was conducted as the first step of FRMS implementation, to gather data and information of fatigue in short-haul operation. 9 Further studies are suggested to establish the presence of fatigue in different operations and organize a cooperative arrangement between The Ministry of Transportation Republic of Indonesia, every operating airline in Indonesia, as well as airport operator to work in harmony for adopting every step of FRMS as amended by the ICAO.
In conclusion, additional number of sectors in 24 hours, additional unplanned flight times within 30 days, and sleep restriction increased the risk of fatigue among short-haul commercial pilots in Indonesia.