Definition
The interaction of people with tasks, technology, environment, teams, and organizations; fatigue is a physiological state that can reduce alertness and performance.
Why it matters
Safety outcomes rarely reflect a single error; they emerge from conditions that support or erode detection, decisions, coordination, and recovery.
Questions that turn reading into a defensible review
A strong review separates the event description, possible precursors, recorded evidence, approved criteria, and the final safety decision.
What exactly is being examined?
The interaction of people with tasks, technology, environment, teams, and organizations; fatigue is a physiological state that can reduce alertness and performance.
Which conditions could build the exposure?
Sleep loss, circadian disruption, and workload; Expectation or continuation bias.
What evidence would strengthen the picture?
Schedule and fatigue-risk context where lawful Decision points, callouts, workload, and mode transitions
What must remain authoritative?
Current approved aircraft data, operator procedures, investigation findings, and the source document’s own scope control any operational conclusion.
Timeline, aircraft state, relationships, and recurrence
Vertical speed, Calibrated airspeed, Engine thrust, Autopilot status can contribute to a synchronized event picture when their mappings, units, sampling, and flight-phase logic are validated.
Cause, intent, compliance, and technical disposition
An FDM alert or pattern is not by itself a causal finding, judgement of individual performance, regulatory conclusion, or aircraft maintenance and airworthiness determination.
Reports, approved criteria, context, and authoritative evidence
Combine the recorded picture with applicable procedures, crew and operational reports, weather or airport information, technical evidence, and the linked official publications and investigation sources.
Performance-shaping conditions
Task, team, technology, environment, and organization influence what people can perceive and do.
Common causes and precursors
- →
Sleep loss, circadian disruption, and workload
- →
Expectation or continuation bias
- →
Ambiguous interfaces, roles, or communication
Operational risks
- R1
Reduced monitoring
- R2
Delayed decisions
- R3
Procedural drift and weak recovery
Guidance themes
These are cross-source themes for orientation. Apply only the current, approved material for the aircraft and operation.
- Manage fatigue through the approved system
- Design strong cross-checks and calls
- Investigate conditions, not blame labels
Safety actions to consider
Use confidential reporting and LOSA/FDM insights
Improve interface and procedure design
Test controls in realistic scenarios
Parameters that help explain the event
A useful event picture comes from signal relationships—not a single exceedance or a generic threshold.
Vertical speed
It helps describe energy management, approach stability, flare development, and the severity context of a touchdown.
Open parameter guide ↗ktCalibrated airspeed
Speed relative to the applicable target and configuration is central to energy management, approach stability, runway performance, and stall margin.
Open parameter guide ↗% / ratio / aircraft-specificEngine thrust
Thrust is a primary part of energy control and is essential for understanding approach corrections, takeoff, go-around, and engine malfunctions.
Open parameter guide ↗discrete / modeAutopilot status
Mode transitions can explain changes in path, speed protection, pilot expectation, workload, and manual-control readiness.
Open parameter guide ↗Recommended monitoring questions
Schedule and fatigue-risk context where lawful
Decision points, callouts, workload, and mode transitions
Cases that add context
ASIP provides a concise learning index. The investigation authority report remains the definitive source.
Editor-reviewed starting points
These records include a deeper ASIP editorial review. Continue to the full evidence index below for direct matches and broader manufacturer, regulator, and investigation reading.
Safety Management Manual (Doc 9859), Fourth Edition
ICAO's fourth-edition manual explains how safety data, risk management, assurance, culture, and governance work together in State and service-provider safety management.
Official sourceGo-Around Decision-Making and Execution Project — Final Report
The Flight Safety Foundation project examines go-around policy compliance, decision biases, operational pressures, and the risks that also need to be managed during go-around execution.
Official sourceTitle or indexed metadata explicitly matches this topic.
Related collection material for adjacent systems, phases, and defenses.
Manufacturer, regulator, investigation, and safety-organization sources.
Where the reading comes from
33 source records
Official links · no copied report files33 source records match the current evidence filters.
Annual Safety Review 2025
EASA's review uses occurrence and accident information to describe performance across aviation domains and to support the European safety-risk-management process.
Open official sourceSafety Management Manual (Doc 9859), Fourth Edition
ICAO's fourth-edition manual explains how safety data, risk management, assurance, culture, and governance work together in State and service-provider safety management.
Open official sourceGo-Around Decision-Making and Execution Project — Final Report
The Flight Safety Foundation project examines go-around policy compliance, decision biases, operational pressures, and the risks that also need to be managed during go-around execution.
Open official sourceSAFO 09014 — Concepts for Fatigue Countermeasures in Part 121 and 135 Short-Haul Operations
Official U.S. Federal Aviation Administration material indexed for human factors. Open the publisher source for the complete document, scope, and current status.
Open official sourceSAFO 06004 — Approach and landing accident reduction: Sterile cockpit, fatigue
Official U.S. Federal Aviation Administration material indexed for approach and landing and human factors. Open the publisher source for the complete document, scope, and current status.
Open official sourceNTSB Safety Alert SA-018 — Preventing Rote Callouts
Official U.S. National Transportation Safety Board material indexed for aviation safety. Open the publisher source for the complete document, scope, and current status.
Open official sourceNTSB Safety Alert SA-040 — Understanding Flight Experience
Official U.S. National Transportation Safety Board material indexed for aviation safety. Open the publisher source for the complete document, scope, and current status.
Open official sourcePreparing Flight Crews to Face Unexpected Events
Official Airbus Safety First material indexed for aviation safety. Open the publisher source for the complete document, scope, and current status.
Open official sourceSituation awareness and decision making
Official Airbus Safety First material indexed for human factors. Open the publisher source for the complete document, scope, and current status.
Open official sourceTraining Pilots for Resilience
Official Airbus Safety First material indexed for human factors. Open the publisher source for the complete document, scope, and current status.
Open official sourceSAFO 21004 — SAFO 21004, Air Traffic Control (ATC) Notification and Pilot Awareness When Conducting an Instrument Landing System (ILS) Autoland Procedure
Official U.S. Federal Aviation Administration material indexed for approach and landing and human factors. Open the publisher source for the complete document, scope, and current status.
Open official sourceSAFO 20014 — SAFO 20014, Boeing 737-8 and 737-9 Airplanes: Pilot Training and Flight Simulation Training Devices ( FSTD ) Updates
Official U.S. Federal Aviation Administration material indexed for human factors. Open the publisher source for the complete document, scope, and current status.
Open official sourceSAFO 18004 — SAFO 18004, Rotorcraft External Load Attaching Means and Quick Release Devices for Human External Cargo ( HEC )
Official U.S. Federal Aviation Administration material indexed for cabin and cargo and human factors. Open the publisher source for the complete document, scope, and current status.
Open official sourceSAFO 18013 — SAFO 18013, Updated Rotorcraft External Load Attaching Means and Quick Release Devices for Human External Cargo ( HEC )
Official U.S. Federal Aviation Administration material indexed for cabin and cargo and human factors. Open the publisher source for the complete document, scope, and current status.
Open official sourceSAFO 17001 — SAFO 17001, Pilot and Flightcrew Awareness of Class B Airspace Boundaries
Official U.S. Federal Aviation Administration material indexed for human factors. Open the publisher source for the complete document, scope, and current status.
Open official sourceSAFO 15004 — SAFO 15004, Scenario-Based Go-Around Training
Official U.S. Federal Aviation Administration material indexed for human factors. Open the publisher source for the complete document, scope, and current status.
Open official sourceSAFO 11010 — TCAS II Guidance and Training for Title 14 of the Code of Federal Regulations (14 CFR ) Part 135 and Part 125 Certificate Holders, Part 125 Letter of Deviation Authority ( LODA ) holders (125M), Part 91 Subpart K, (91K) Program Managers, Part 91 Operators and Part 142 Training Centers
Official U.S. Federal Aviation Administration material indexed for navigation and surveillance and human factors. Open the publisher source for the complete document, scope, and current status.
Open official sourceSAFO 10006 — In-Flight Icing Operations and Training Recommendations
Official U.S. Federal Aviation Administration material indexed for weather and human factors. Open the publisher source for the complete document, scope, and current status.
Open official sourceLessons learned
1Telling people to be more careful is a weak control
2Good systems make the safe action visible, credible, and achievable