Technologies 2020, 8, 40; doi:10.3390/technologies8030040 www.mdpi.com/journal/technologies
The Requirements for New Tools for Use by Pilots
and the Aviation Industry to Manage Risks
Pertaining to Work-Related Stress (WRS)
and Wellbeing, and the Ensuing Impact
on Performance and Safety
Joan Cahill 1,*, Paul Cullen 1, Sohaib Anwer 2, Keith Gaynor 3 and Simon Wilson 4
1 School of Psychology, Trinity College Dublin, Dublin 2, Ireland; CULLENP4@tcd.ie
2 School of Mathematics & Statistics, University College Dublin, Co., Dublin 4, Ireland;
3 School of Psychology, University College Dublin, Co., Dublin 4, Ireland; firstname.lastname@example.org
4 School of Computer Science & Statistics, Trinity College Dublin, Dublin 2, Ireland; SWILSON@tcd.ie
* Correspondence: email@example.com
Received: 12 May 2020; Accepted: 29 June 2020; Published: 6 July 2020
Abstract: Work is part of our wellbeing and a key driver of a person’s health. Pilots need to be fit
for duty and aware of risks that compromise their health/wellbeing. Recent studies suggest that
work-related stress (WRS) impacts on pilot health and wellbeing, performance, and flight safety.
This paper reports on the advancement of new tools for pilots and airlines to support the
management of WRS and wellbeing. This follows from five phases of stakeholder evaluation
research and analysis. Existing pre-flight checklists should be extended to enable the crew to
evaluate their health and wellbeing. New checklists might be developed for use by pilots while off
duty supporting an assessment of (1) their biopsychosocial health status and (2) how they are
coping. This involves the advancement of phone apps with different wellness functions. Pending
pilot consent, data captured in these tools might be shared in a de-identified format with the pilot’s
airline. Existing airline safety management systems (SMS) and flight rostering/planning systems
might be augmented to make use of this data from an operational and risk/safety management
perspective. Fatigue risk management systems (and by implication airline rostering/flight planning
systems) need to be extended to consider the relationship between fatigue risk and the other
dimensions of a pilot’s wellbeing. Further, pending permission, pilot data might be shared with
airline employee assistance program (EAP) personnel and aeromedical examiners. In addition, new
training formats should be devised to support pilot coping skills. The proposed tools can support
the management of WRS and wellbeing. In turn, this will support performance and safety. The pilot
specific tools will enable the practice of healthy behaviors, which in turn strengthens a pilot’s
resistance to stress. Healthy work relates to the creation of positive wellbeing within workplaces
and workforces and has significant societal implications. Pilots face many occupational hazards that
are part of their jobs. Pilots, the aviation industry, and society should recognize and support the
many activities that contribute to positive wellbeing for pilots. Social justice is a basic premise for
quality of employment and quality of life.
Keywords: mobile technologies; behavior change; healthy behavior; work-related stress (WRS);
health monitoring; pilot wellbeing; pilot mental health; stress coping; self-management of health;
flight safety; resilience; privacy; COVID
Technologies 2020, 8, 40 2 of 51
1.1. Introduction to the Problem
As suggested in the ‘triple bottom line’ accounting framework, human activity (including work)
should not compromise the long-term balance between the economic, environmental, and social
pillars [1–3]. Further, as defined by the tripartite labor collaboration  and ‘responsible work’
concepts, work should be designed to benefit all stakeholders. This includes employers, employees,
and society. This follows from the argument that social justice is a basic premise for quality of
employment and quality of life and associated concepts such as ‘corporate social responsibility’
(CSR), ‘decent work’  and tripartism .
Commercial aviation is a 24/7 business. Pilots’ anti-social working hours and continuously
changing schedules present barriers to maintaining ‘healthy lifestyle’ routines and accessing help if
needed. The airline industry and public expectations (flight scheduling and ticket prices) have
changed dramatically in the last 15 years. The effects of these changes on the health and well-being
of pilots, along with pilot performance and flight safety, is only recently being understood and
Like other remote and shift workers, pilots experience many physical, emotional, and
environmental stressors . Recent research indicates that given the demands of the job (i.e., anti-
social work hours, disturbed sleeping patterns/fatigue, etc.) and nature of the work (i.e., sedentary
work, with little or physical activity, mix of high and low stress periods, isolation), pilots are
potentially more at risk for developing mental health issues .
Pilots need to be fit for duty and aware of risks that compromise their health/wellbeing,
performance, and flight safety. Pilot wellbeing influences the nature and quality of their relationships
with others, thereby influencing the wellbeing of those around them. This spans a pilot’s family,
friends, and work colleagues (including their fellow co-pilot while on duty). Further, pilot wellbeing
impacts on human performance (i.e., awareness, decision making, and concentration) both inside and
outside work. Importantly, how pilots perform as aviation professionals impacts on flight safety .
Since the Germanwings 9525 accident in 2015, the question of pilot mental health and managing
mental health issues amongst pilots has been gaining increased attention. In 2019, the European
Aviation Safety Agency (EASA) introduced new rules pertaining to the management and assessment
of pilot mental health . Specifically, the rules follow from the EASA-led Germanwings Task Force
on the accident of the Germanwings Flight 9525 and the related safety recommendations issued by
the Bureau d’Enquêtes et d’Analyses pour la Sécurité de l’Aviation Civile (BEA) . The new
regulations pertain to three key areas: psychological evaluation of pilots before they start the job,
access to peer support, and random substance abuse testing . European airlines will be required to
demonstrate compliance with these rules by July 2020 . To support the implementation of the new
rules, EASA has prepared draft guidance material (so-called Acceptable Means of Compliance and
Guidance Material—AMC/GM) . Many in the industry feel that these recommendations do not
go far enough. In the effort to prevent another Germanwings tragedy, there has been insufficient
attention on the promotion of positive wellbeing and coping . Arguably, a more holistic and
preventative approach to promoting positive wellbeing [7,11], along with peer support services [13–
15], is required.
Recent research investigating the use of stress coping behaviors in pilots found that nearly 60%
of the pilots were using coping mechanisms to manage work-related stress (WRS) and its impact on
wellbeing [7,8,16]. The use of certain coping mechanisms such as sleep management and taking
physical exercise were found to be associated with lower depression severity levels . This research
points to the need to develop tools to better manage WRS, wellbeing, and the home-work interface.
Further, it indicates that a new definition of safety behavior for pilots is required, managing the
home/work interface and fostering resilience.
More recently, the EASA and aviation groups such as the Royal Aeronautical Society (RAeS)
and the Flight Safety Foundation (FSF) have advocated for the practice of healthy behaviors to
promote positive wellbeing, while also preventing ill health, spanning all three pillars of wellbeing
Technologies 2020, 8, 40 3 of 51
. Through the Together4Safety safety promotion initiative, led by the EASA, stakeholders have
been collaborating to promote a common safety agenda that is mindful of the diverse stakeholder
goals, needs, and challenges .
The recent COVID-19 outbreak has put increased stress on pilots and airlines. The airline
industry has experienced a decrease in capacity of roughly 60–80% at major carriers . Many pilots
have lost their jobs and/or are on extended leave, which presents some new challenges . Now,
more than ever, there is a need to advance tools to support pilot coping and resilience. Pilots will
need to be ‘cleared for take-off’ on returning to work . This will require self-awareness,
acceptance, and developing new routines and behaviors that enable and foster resilience.
This paper reports on a new tool framework and associated tools concepts supporting the
management of wellbeing and WRS issues for pilots at different levels (i.e., pilots, airline and aviation
industry, and society). Specifically, it focuses on the requirements for new checklists and digital tools
for use by pilots both in and outside work and how these might relate to tools used by other
stakeholders (for example, airline staff involved in flight planning, crew rostering and safety/risk
assessment, and aeromedical examiners), linking to wider operational and safety management
processes. This research follows from several phases of human factors research, involving deep
participation with pilots and industry stakeholders. This research has been structured into five parts.
Aspects of the first two parts of this research have been reported in earlier papers. This includes a
subset of the pilot wellbeing behavior model (i.e., preliminary lived experience model and impact
scenarios) [7,8] and the high-level requirements for new tools supporting pilot wellbeing
management at both pilot and airline levels . Accordingly, this paper reports on the outcomes of
the latter three parts (i.e., parts 3, 4, and 5). First, the theoretical background to this study is presented.
Following this, an overview of pilot wellbeing, coping strategies, airline approaches to
performance/safety management, existing tools, and the COVID-19 context is presented. The
methodological framework for this study along with the research methodology is then outlined. This
is followed by an overview of research results. This includes results in terms of problem framing, the
pilot wellbeing behavior model, sources of WRS associated with COVID, the three operational
scenarios defined by the Flight Safety Foundation (FSF), the proposed tool framework (hereafter
referred to as tool 1, 2, 3, 4, and 5), the specific requirements and prototype concepts associated with
Tool 1 and 2, and issues pertaining to data protection and pilot safeguards. The results are then
discussed and some conclusions drawn.
1.2. Theoretical Background
As proposed in Engel’s ‘biopsychosocial’ model of health and wellbeing, a combination of
physical, psychological, and social factors (including working conditions) contribute to a person’s
health and wellbeing . Certain lifestyle factors have direct and well understood influences on each
of the three pillars of wellbeing as defined in the ‘biopsychosocial model’ . Physical health is very
much affected by diet, physical activity, and sleep. Our behavior, attitudes, stress management and
coping techniques have a profound impact on our mental health. Lastly, social health is very much
affected by our support networks including the quality of our relationships with family, friends, and
Some argue that the biopsychosocial model leads to eclecticism , while others argue that it
does not sufficiently deal with ‘complexity theory’ . More recently, the social aspect of Engel’s
model has been expanded to include ideas related to spirituality and the arts/culture and an
understanding of health as a dynamic system .
1.2.2. Stress and Work-Related Stress (WRS)
Stress is mental or emotional strain and tension resulting from adverse or demanding
circumstances, which creates physical and psychological/emotional imbalances within a person [25–
27]. Stressors refer to any activity, event, or other stimulus that causes stress. These can be internal
Technologies 2020, 8, 40 4 of 51
(cognitive or physical) or external (environmental) to the individual . Personal stressors include
issues or events outside the workplace, like family problems, health challenges, or financial issues,
that can contribute to stress. Although stress is a state and not an illness, prolonged or excessive stress
can lead to mental and physical health conditions .
1.2.3. Work-Related Stress (WRS)
Work-related stress (WRS) is the negative response people have to excessive pressures or other
types of demands placed on them at work. Typically, such demands do not fit the person’s
capabilities (i.e., knowledge and abilities) and challenges their ability to cope . WRS can be
worsened by personal stressors. As proposed in the ‘job strain model’, the highest stress and stress-
related health problems will occur for jobs with high demands and low decision latitude .
1.2.4. Stress Coping Styles and Strategies
The development of stress-coping skills and the routine practice of stress-coping strategies are
necessary for high stress occupations. Coping strategies involve behavioral and psychological efforts
that individuals use to overcome, accept, reduce, and/or minimize internal and external stressors .
People react differently when exposed to a stressor. The way in which a person appraises the
situation (i.e., the level of threat associated with the stressor and their ability to cope with it) impacts
on the type of stress experienced .
The literature distinguishes active and avoidant coping methods. Active methods are used to
alter the nature of the stressor and/or to change a person’s perception of it. Two types of active
strategies are distinguished. This includes problem-solving and emotion-focused methods. The type
of stressor and coping style of the individual has an influence on which of these two methods is used
. Avoidant strategies involve the practice of unhealthy behaviors (such as alcohol use or binge
eating) or various defense mechanisms (for example weeping or denial), without confronting the
actual stressors .
Therapeutic interventions focus on replacing avoidant and/or maladaptive coping behaviors
with active and/or adaptive coping behaviors . Typical strategies include physical exercise, the
practice of relaxation techniques, seeking social support and/or social participation, and engaging in
hobbies, creative/arts activities, and spiritual practices.
1.2.5. Mental Health
Mental health (MH) is part of our health and wellbeing. The World Health Organisation (WHO)
defines mental health as ‘a state of well-being in which every individual realizes his or her own
potential, can cope with the normal stresses of life, can work productively and fruitfully, and is able
to make a contribution to her or his community’ .
1.2.6. Management of Mental Health Problems
A variety of therapeutic frameworks and approaches have been proposed in relation to
managing mental ill health [36–38]. The National Institute for Health and Clinical Excellence (NICE)
recommends the ‘Stepped Care Model’ . Stepped care is a five-step system of delivering and
monitoring treatments for people with depression and anxiety disorders. The most effective and least
resource intensive treatment is first provided to the patient. Acritical component of this is the benefit
of in person/face to face support for those experiencing serious difficulties (i.e., beyond self-
1.2.7. Mental Wellbeing at Work
Mental wellbeing at work is determined by the interaction between the working environment,
the nature of the work, and the individual . Work has an important role in promoting
psychological wellbeing. However, it can also have negative effects on mental wellbeing, leading to
Technologies 2020, 8, 40 5 of 51
1.2.8. Stress and Wellbeing Management in the Workplace
‘Stress management initiatives’ (SMI) and ‘workplace wellbeing programs’ (WWP) address
health and wellbeing in the workplace, including the management of stress, the promotion of
psychological wellbeing, and strategies to bolster human resilience. SMIs focus on restoring
employee health and wellbeing in cases where resources have already been depleted . Wellness
programs are more preventive, focusing on behavior change and the practice of healthy behaviors to
manage wellbeing and the home/work interface. From a strategic perspective, both SMI and WWP
attempt to reduce the costs associated with lack of employee engagement, employee healthcare, and
sick-leave absences .
Interventions can be classified into three types: person-directed, person-work interface, and
organizational interventions . Some argue that workplace wellness and stress management
initiatives should go beyond employee training and the provision of support at individual and group
levels to include both work reorganization (i.e., task design, communication systems, and technology
support) and the external socio-economic environment .
A recent systematic review provides an alternative classification of interventions . These are
educational interventions, multicomponent interventions, counselling interventions, physical
activity interventions, and organizational interventions. Overall, there is mixed evidence in relation
to the success of workplace wellness programs [44,45].
1.2.9. Resilience and Self-Efficacy
In Aristotelian ethics, the concept ‘eudaimonia’ refers to the condition of human flourishing or
‘living well’ . This concept is taken up in ‘positive psychology’ frameworks. For example,
Seligman draws attention to enabling the positive aspects of the human experience that make life
worth living and developing resilience .
Resilience is defined as the ‘demonstration of positive adaptation in the face of significant
adversity’ . It is a response to stressful circumstances, as opposed to a trait or capacity residing in
the person .
Self-efficacy is defined as a ‘person’s belief that they can succeed in a specific situation’ .
One’s sense of self-efficacy can play a major role in how one approaches goals and challenges.
Research indicates that a high level of self-efficacy can help employees cope more effectively with
WRS . In addition, the promotion of self-efficacy is central to managing wellbeing and avoiding
depressive symptoms as we age .
1.3. Pilot: Stress, Sources of Stress and Stress Coping
1.3.1. Types and Sources of Stress
The literature distinguishes three types of stressors for pilots. This includes physical stressors
(i.e., extreme temperature and humidity, noise, vibration, and lack of oxygen), physiological stressors
(i.e., fatigue, poor physical condition, hunger, disease), and psychological stressors (i.e., emotional
factors such as a death or illness in the family, business worries, poor interpersonal relationships with
family or boss, financial worries, etc.) [52,53].
From an operational focus, much of the literature examines the relationship between stress and
workload. Studies indicate that stress is highest during high workload phases of a flight such as take-
off and landing . Further, stress increases during complex situations such as go-around
maneuvers  and when pilots are fatigued .
The impact of critical incidents on pilot stress is also examined along with the benefits of critical
incident stress management (CISM) programs . Post-traumatic stress (PTS) and post-traumatic
stress disorder (PTSD) have also been studied in relation to military pilots .
Three high level causes or sources of stress are also proposed. This includes
environmental/physical stressors, work-related stressors, and personal stressors .
Technologies 2020, 8, 40 6 of 51
1.3.2. Impact of Stress
Sources of WRS have effects on the physical, psychological, and social health of pilots . In
relation to human performance, stress (arising from stressors both inside and outside work) impacts
on the socio-cognitive dimensions of performance including decision making, teamwork, and
communication [52,53]. Recent research indicates that many pilots have normalized WRS and
associated health problems and often fail to identity that they are suffering [7,8].
1.3.3. Pilot Stress Coping Styles
Stress coping is an important psychological construct which moderates/mediates the
relationship between stressors and behavioral outcomes such as flying performance . This in turn
has an impact on aircraft states . Pilot coping styles have been examined in relation to military
pilots. An early study found that military pilots predominantly coped with disruptive emotions and
life crises by seeking constructive solutions . In a study of the stylistic coping strategies of military
pilots in the Unites States of America, researchers found that pilots were more given to active,
problem-solving coping strategies, as compared with the general population . A more recent
study of 160 Indian military pilots suggest that pilots use flexible problem and emotion focused
coping strategies .
1.3.4. Pilot Coping Factors and Stress Coping Strategies
In a 1985 study of the stress coping strategies reported by commercial airline pilots, the dominant
stress coping factors included spousal support and the stability of the marital relationship and home
life . The positive support provided by a spouse has been evidenced in other studies . Further,
an ethnographic study of the lived experience of flying operations highlights the benefits of social
support obtained from fellow pilots .
In a 2019 survey exploring WRS and pilot stress coping mechanisms, nearly 60% of respondents
indicated that they use coping mechanisms to manage WRS and its impact on wellbeing . The top
strategies associated with lower depression severity rates included fatigue and sleep management,
physical exercise, and diet management . This research suggests that pilots are coping and
adopting effective stress management strategies. As pointed out by the authors, there is much to be
learned by both pilots and the aviation industry in relation to using coping strategies to foster
resilience and recovery .
Mindfulness training is being introduced in military aviation. In a recent study, this training has
been demonstrated to reduce anxiety for military pilots .
1.4. Pilot Wellbeing and Mental Health
Traditionally, studies of pilot wellbeing have focused on fatigue and its implications for
performance and flight safety. Shift work and long hours of duty contribute to crew drowsiness and
fatigue . This in turn has an impact on crew attention and can increase the risk of errors .
Recently, there has been a focus on pilot mental health. Psychological problems in pilots include
adjustment disorder, mood disorder, anxiety and occupational stress, relationship problems, sexual
dysfunction, and alcohol problems . Studies have focused on measuring the prevalence of
depression and other common mental disorders (CMD) in pilots, along with investigating the work-
related factors that contribute to depression—such as fatigue. A 2012 study of commercial airline
pilots in Brazil found the prevalence of pilots with common mental disorders to be 6.7% . A 2016
study of pilot mental health found that 12.6% of respondents met the threshold for experiencing
depression in the last fortnight . A recent systematic review of twenty studies examining
depression in commercial pilots found that the prevalence of major depressive disorder ranged from
1.9% to 12.6% . A 2019 survey of 1150 commercial pilot indicates that pilots are suffering from the
same MH challenges as the overall population . However, as indicated in this research, not all
pilots are suffering. Over half met the threshold for mild depression, while a low number of
Technologies 2020, 8, 40 7 of 51
respondents were found to have moderately severe depression (4.38%) or severe depression (1.58%)
Further, the relationship between fatigue and aspects of mental health is receiving increased
attention. A cross-sectional survey of >700 pilots investigating self-reported anxiety and depression
reported that respondents who typically spent longer hours on duty per week (>40 h vs. <25 h) were
three times more likely to report feeling anxious or depressed .
1.5. Safety Management Systems, Performance Monitoring, and Safety-II
As mandated by the European Union Aviation Safety Agency (EASA), airline safety
management systems (SMS) are designed to measure and manage safety risk . The purpose of an
airline SMS is to provide an organized approach to manage safety risks in flight operations . As
defined in the International Civil Aviation Organization (ICAO’s) safety management manual, an
airline SMS should incorporate four elements . This includes safety policy, safety assurance,
safety risk management, and safety promotion.
Overall, there is a strong culture of performance monitoring within the aviation industry.
Performance monitoring forms part of an airline’s safety performance management process and the
‘safety risk management’ component of an airline’s SMS and allied technologies. Performance
monitoring spans five areas. This includes (1) the aircraft, (2) the flight (i.e., voyage reporting
including safety events), (3) the environment, (4) safety performance, and (5) the pilot/crew .
Arguably, the bulk of performance monitoring pertains to the aircraft state/health. Aircraft
health monitoring includes the aircraft flight data monitoring (FDM) system, which tracks aircraft
states including unacceptable aircraft states (for example, unstable approach, over-speed, and hard
landings), and the aircraft technical log, which records all aircraft defects, malfunctions, block times,
fuel consumption, and all scheduled and unscheduled maintenance that has occurred.
Flight reporting includes voyage reporting (fuel, flight times, routing, passengers, cargo, etc.)
and reporting of any safety issues or events linked to the flight. Such reporting has relevance to
different parts of the airline business, including operations management, safety, and commercial
General safety systems reporting includes safety reporting from all relevant aerospace actors—
including anonymous, mandatory, and voluntary reporting. This is directly linked to the ‘safety risk
management’ component of an airline’s SMS.
Monitoring of the environment includes the weather and the physical environment in which the
aircraft operates. In relation to flight operations and the flight dispatch process, pilots are pilots are
provided with detailed weather briefs, information about risks associated with departure and arrival
airports, and associated ‘notice for airmen’ (NOTAMS).
The crew are the key coordinating interface both from a flight operations and safety
management perspective [72,73]. However, from an operational perspective, crew health monitoring
is quite limited. Largely this concerns the monitoring of crew fatigue and duty times (linking to the
airline’s fatigue risk management system). Currently, airline wellbeing interventions focus on the
management of crew fatigue and alertness . Risks pertaining to crew fatigue are monitored as part
of an airline SMS [7,74]. At present, sources of WRS and wellbeing factors (including the biological,
psychological, and social factors) are not accounted for within airline safety management systems .
Further, other dimensions of a pilot’s biopsychosocial health are not monitored in real time.
The health of the pilot (including mental health) is assessed annually using official aeromedical
examiners in accordance with authority requirements regarding the issuing of licenses and a pilot’s
fitness to fly. Airlines are required to follow specific guidelines concerning the aeromedical
assessment of pilots, as mandated by the regulatory authorities. Licenses can be suspended if serious
health problems are detected. This includes mental health problems. As pointed out by Atherton,
given the implications for a pilot’s license, mental health issues are more likely to be underreported
Peer support services have been operating at airlines for many years. This includes American
Airlines, British Airways, Lufthansa, KLM, and Qantas [11,75,76]. Such programs take many forms.
Technologies 2020, 8, 40 8 of 51
However, all involve features such as confidentiality, mutual respect, social inclusion, social support,
and the promotion of resilience [75,76]. Social isolation combined with feelings of lack of belonging,
helplessness, and hopelessness are contributory factors to suicide (including murder suicide) .
Thus, peer support programs are essential to the promotion and management of emotional wellbeing
for pilots along with suicide prevention . In this regard, ‘Project Wingman’, the pilot-assist
program run by American Airlines represents best practice in terms of promoting pilot mental fitness
and emotional well-being and fostering supportive relationships amongst pilot colleagues.
Airlines are now moving towards Safety-II practices and specifically proactive and predictive
safety/risk management approaches to examine workplace factors that have the potential to
contribute to safety events. Recently, this has involved the application of data driven approaches
related to fatigue management in relation to flight planning .
1.6. Existing Tools and Interventions to Support Pilot Wellness and Stress Management
Stress management forms part of an airline’s crew resource management (CRM) syllabus, as
defined by the EASA . CRM training focuses on understanding the factors that lead to stress, as
well as how to cope with stressful situations. However, WRS and techniques for managing
WRS/wellbeing issues spanning the biological, psychological, and social dimensions of a pilot’s
wellbeing are not alluded to. Moreover, the guidance does not address the links between the
home/work interface and stress coping behaviors while on and off duty. Nonetheless, airlines have
implemented stress management courses and obtained some positive effects .
Following crew resource management (CRM) and threat and error management (TEM)
frameworks, pilots adhere to formal briefing procedures at the pre-flight, flight planning, and
briefing stages [73,79]. However, the existing pre-flight briefing processes do not address factors
pertaining to WRS/wellbeing. In addition, pre-flight checklists do not require pilots to assess
individual crew wellbeing and the joint crew state .
Several pilot checklists have been advanced to address pilot risk assessment at an operational
level (and fitness for flight). This includes the ‘I’m Safe Checklist’ [80,81], and the ‘Personal
Minimums Checklist’ [82,83]. However, these do not address the three pillars of wellbeing.
QANTAS is now providing pilots will information on mental health and wellbeing via an app
on their crew iPads . In addition, Jeppesen has introduced a new pilot mobile app, ‘Crew Alert’,
enabling pilots to risk assess their current and future alertness and fatigue levels [77,85]. Some
software companies have advanced electronic flight bags (EFBs) and mobile phone apps which
enable pilots to report on their fatigue levels . However, reporting of crew states linking to
biopsychosocial not part of the normal process—as currently conceived.
1.7. Self Monitoring, Wearables, and Health Apps
Self-monitoring is ‘the process of observing one’s own behavior and evaluating it in relation to
goals’ . As part of this, a self-monitoring plan is used to track all sorts of daily behaviors, which
can include exercise, diet, sleep, and mood. Wearables and other ‘self-tracking devices’ enable health
and behavior information to be auto-harvested for later analysis . There has been significant
growth in relation to the development of mobile health apps (mHealth apps) and mental health apps
(Mhapps) targeted at the general population to manage different aspects of a person’s health and
wellbeing . Currently, about 40,000 apps are related to healthcare . Further, smartphone apps
for mental health (Mhapps) represent a new approach for the prevention and management of MH
problems—in line with the ‘stepped care’ model. Anecdotally, it is known that such tools are used by
pilots. However, the prevalence, use, and health outcomes relating to the use of these tools is not
1.8. The Quantified Self at Work
Corporate wellness programs are now deploying self-tracking technologies—referred to as
corporate wellness self-tracking (CWST) . Workers are invited to measure and manage their own
Technologies 2020, 8, 40 9 of 51
health, to improve their wellbeing, while also enhancing productivity, engagement, and
performance. Such tools harness the personal goals of workers for health, fitness, happiness, and
meaningful social connection, for the purpose of introducing self-disciplinary methods to enhance
work performance . Some argue that CWST approaches conflate work and health and increase
worker anxiety levels [91,92]. Sensory tracking technologies which aim to regulate employee
behavior via workplace wellness initiatives raise many ethical issues . Many argue that such
systems should only be used on an opt in and opt out basis .
1.9. Data Protection
General Data Protection Regulation (GDPR) legislation confers specific rights on individuals in
terms of how their personal data is collected and used in different contexts including the workplace
. Special protections are conferred on certain types of personal data such as health data. These
rights must be upheld by employers. Developing and using digital technologies presents many
individual and organizational risks pertaining to data protection . In this case, there is a duty for
the organizations producing these technologies (for example, mobile applications) to ensure that
consumers are protected. If these technologies are used in a work context, there are obligations also
for employers. Importantly, the processing of such data in a work context (as with others) requires a
lawful basis such as consent and performance of a contract . Under GDPR legislation, ‘public
interest’ is also treated as a lawful basis under which personal data may be processed. Individuals
have rights to object to their personal data being processed, but such objections can be over-ridden
by a ‘public interest’. These issues have been discussed in the context of sharing of information about
pilot mental health, particularly in relation to conflicts of interest such as protecting the pilot (i.e.,
privacy/confidentiality) and disclosures that are in the public interest (i.e., flight safety). In the
aftermath of the Germanwings tragedy, there was much discussion of how conflicting rights and
principles might be addressed. Lastly, this legislation also provides protections for individuals in
relation to automated profiling and processing of private data used to evaluate and predict behaviors
1.10. COVID-19 Crisis and Pilot Wellbeing
The current Covid-19 pandemic poses a huge occupational health and safety threat. Many pilots
are either working reduced hours or not working at all. This has had a detrimental impact on their
sense of purpose and financial security [19,96]. Others who are still working are working in very
different environments, with additional stressors. In the ‘new normal’, there are significant changes
to obtaining support from others, and indeed providing support. The current restrictions regarding
social distancing along with existing work changes is impacting all three pillars of a pilot’s health
The Flight Safety Foundation has identified three operational scenarios to be managed during
the COVID-19 crisis and beyond . This includes (1) being at work during the COVID outbreak,
(2) being off work, and (3) returning to work . Crucially, a preventative approach is required to
ensure that pilots are fit for duty when they return to work. It is likely that some pilots may develop
psychological issues during the period of being off work. Social isolation and confinement may lead
some pilots to develop maladaptive coping strategies. As pilots are off work, some of the occupational
barriers to maladaptive coping are not there (i.e., intoxicant testing by employer). Further, the
enablers of adaptive coping (i.e., support from social network, access to peer support, and access to
support groups within the community) are not there.
Following a preventative and self-management approach, the Flight Safety Foundation have
produced a guide to support wellbeing management and resilience for aviation professionals both
during the COVID-19 crisis and after . The guide invites aviation professionals to consider three
key wellbeing questions: (1) how am I feeling, (2) how am I coping, and (3) what am I going to
do/what am I doing ? Drawing upon the ‘biopsychosocial’ model of health and wellbeing, the
guide proposes the use of specific self-management strategies. These concern six core behaviors
pertaining to the three pillars of wellbeing. The selection of these behaviors follows prior research
Technologies 2020, 8, 40 10 of 51
pertaining to stress coping for pilots [7,16]. As indicated in Figure 1 below, these include activities,
physical exercise, diet, sleep, stress management, and social relationships.
Figure 1. Wellbeing wheel (An Aviation Professional’s Guide to Wellbeing, Flight Safety Foundation,
2. Materials and Methods
2.1. Methodological Framework
The methodological approach adopted in this study stems from human factors and behavior
science, along with recent methodological approaches in healthcare. As defined in ISO 6385, the
discipline of human factors (HF) refers to ‘the practice of designing products, systems, or processes
to take proper account of the interaction between them and the people who use them’ . The
human factors approach follows a ‘socio-technical systems design’ perspective, which addresses the
functions and benefits of technology from the perspective of all relevant stakeholders. This is an
approach to organizational work design that recognizes the interaction between people/behavior,
technology/tools, work processes, workplace environments, and work culture .
In line with socio-technical systems approaches, the advancement of new technology is situated
in the context of the design of a broader socio-technical system—including training, safety culture,
and the design of safety/risk processes. It is conceived as one of many behavior and organizational
change interventions. Another central aspect of the ‘human factors approach’ is the importance it
places on the person and how work processes and the overall system should be designed so that the
person is set up for success.
Behavior models focus on understanding the psychological factors that explain or predict a
specific behavior. Models of behavior change seek to explain the factors that contribute to behavior
change and/or how to change behavior. Behavioral theory is very useful in relation to the design of
new technologies. Importantly, it focuses attention on design features and broader design solutions
that enable behavior change. This research draws upon the Fogg behavior model . The Fogg
behavior model has been applied widely to technology interventions supporting behavior change
[67,68]. According to Fogg, behavior is the result of three specific elements coming together at one
moment [67,68]: motivation, ability, and a prompt. As defined by Fogg, when a behavior does not
occur, at least one of those three elements are missing [99,100].
Healthcare is now adapting human factors principles and concepts, and specifically the human
factors concept of a ‘person-centered sociotechnical system’ . This is evidenced by the
application of the Systems Engineering Initiative for Patient Safety (SEIPS 1.0 and SEIPS 2.0) .
As stated in the SEIPS model, the structure of an organization (or, more generally, the work system)
affects how safely care is provided (the process). Further, the means of caring for and managing the
patient (the process) affects how safe the patient is (outcome). As defined in the model, technology
designers must consider the relationship between outcomes for patients, service providers/care
Technologies 2020, 8, 40 11 of 51
givers, and care organization (i.e., interrelated outcomes). By implication, systems supporting pilot
wellbeing and flight safety should be jointly optimized for all stakeholders (i.e., pilots, airlines, the
aviation industry, and society).
2.2. Research Overview
Over the last five years, action research has been undertaken with pilots and other aviation
industry stakeholders to understand the contributory factors to WRS, the outcomes of WRS, and how
best to design checklists and technology tools (including mobile apps) to support pilot self-efficacy
The specific objectives of this research include:
• Promoting an understanding of pilot lived experience and the allied wellbeing/performance/safety
problems from a systems perspective
• Advancing a behavior model supporting the conceptualization of the problem, its impact, and the
• Identifying the requirements for solutions at different levels (i.e., pilots, airlines, and other aviation
Specific field research with stakeholders is defined in Table 1. All subjects gave their informed
consent for inclusion before they participated in the study. The study was conducted in accordance
with the Declaration of Helsinki, and the protocol was approved by the Ethics Committee of the
School of Psychology, Trinity College Dublin (February 2018 and August 2018)
Technologies 2020, 8, 40 12 of 51
Table 1. Research parts and phases.
Part # Objective and Description Method
A Advancement of initial lived
and explorative interviews
Pilots, (N = 103)
Analysis of airline processes to
manage pilot WRS and
wellbeing (including MH) and
Literature review N/A
Validation of the lived
experience model—phase 1.
Assessment of the impact of
WRS on pilot health, human
performance, and flight safety.
with pilots Pilots (N = 33)
Analysis of problem.
Specification of problem and
change requirements from a
Modelling problem from
Validation of lived experience
Survey with pilots (N = 325)
Pilots (N = 325)
C Analysis of coping strategies.
Initial data analysis
following first wave of
Specification of interventions
and tools requirements—
airline and pilot levels.
Situate concepts in relation to
Research analysis N/A
Validation of lived experience
Survey with pilots (N = 1050)
Pilots (N = 1050)
Specification of tools
Specification of preliminary
prototypes (Tool 1 and 2).
Specification of airline
process—existing and to be.
Process mapping—as is and
Analysis and advancement
of tool framework
Preliminary validation of tools
framework with stakeholders.
Preliminary validation of Tool
1 and 2 with stakeholders.
research with airlines
research with software
Preliminary review with
(European Aviation Safety
Authority (EASA) and Irish
Aviation Authority (IAA)
(N = 7)
Business analysis and
development of business
model canvas (BMC) about the
Analysis of customer need.
Analysis of customer journey.
Specification of business
logic and allied tools concept
from perspective of
Specification of existing and
future customer journey
N = 1
Refinement of problem
analysis from a systems
Analysis of problem
Application of Fogg model
of behavior change to
Technologies 2020, 8, 40 13 of 51
Specification of problem and
solution in context of a
behavior change framework.
problem and solution
Understanding pilot use of
coping strategies in relation to
Specification of risk algorithm.
Analysis of survey findings
(N = 1050)
Regression model and odds
C Further specification of tools.
5 A Review of problem in context
of COVID need.
Documentation of problems
Panel of pilots
experts (N = 9)
Collectively, the studies have produced evidence-based recommendations for technologies and
other socio-technical interventions (i.e., process change, training, culture, and so forth) to promote
wellbeing in the workplace, both at a pilot self-management level and airline operational and safety
management level. To date, this research has been structured into five parts. Table 1 below provides
an outline of research parts and phases. A description of specific field research methodologies is
provided in Appendix A. Much of parts 1 and 2 of this research has been previously reported as
indicated in Appendix B. This paper focuses on reporting the outcomes of parts 3, 4, and 5.
2.3. Part 1
The first part of this study focused on advancing a preliminary specification of the wellbeing
problem and its impact. This comprised three research phases. In the first phase, semi-structured
interviews were undertaken with pilots (N = 103). A scoping literature review was undertaken to
identify existing airline processes to manage pilot WRS and wellbeing and any gaps therein. This
included an examination of specific operational and safety processes. The existing regulation in
relation to aeromedical assessment and supporting pilot wellbeing was analyzed. Following this,
three participatory workshops were undertaken with commercial pilots (N = 33). Appendix A
provides an overview of the methodology for both the interviews and workshop sessions. The detail
of this research is reported in an earlier paper .
2.4. Part 2
In part 2, there was a deeper dive into the problem definition and potential solution in relation
to the goals, experiences, and requirements of one stakeholder group—pilots. Overall, the purpose
was to identity how sources of WRS and wellbeing issues might be better managed both from a pilot
and airline perspective. This comprised five stages of research. In the first stage, the wellbeing
problem was mapped from a systems perspective. As part of the analysis, the different systems
relevant to the problem definition were mapped along with the associated contributory factors. In
the second stage, the initial ‘pilot lived experience’ model was further validated using an anonymous
online survey. The first wave of data analysis (N = 365) focused on modelling (1) contributory factors
and outcomes and (2) coping mechanisms. Following this, the collective evidence from part 1 and
part 2 was integrated and analyzed to identify the requirements for solutions at a pilot and airline
level. The proposed solutions were situated in terms of the new IR outlined by the EASA (i.e., in line
with IR, gap in relation to IR/extending existing IR), along with therapeutic approaches to managing
wellbeing (including mental health). Further, they were classified in terms of different types of socio-
technical intervention. This includes process redesign, training, new technology, culture change, and
so forth. In parallel to this, a second wave of survey data were collected. The survey methodologies
and data analysis approach are defined in Appendix A. The detail of this research is reported in an
earlier paper .
Technologies 2020, 8, 40 14 of 51
2.5. Part 3
The objective of part 3 was to further elaborate on the requirements for solutions at different
levels and to validate such solutions with aviation industry stakeholders. In particular, the purpose
was to identity how emerging technologies might be used to develop solutions to enable pilots and
other airline and aviation stakeholders (for example, an airline Employee Assistance Program (EAP),
airline flight rostering/flight safety, and aeromedical examiners) collect and share information, so that
wellbeing issues and risks might be better managed from a systems perspective.
This involved three phases of research. In the first phase, the high-level solution requirements
defined in part 2 were further elaborated in terms of a proposed ‘tools framework’ encompassing five
interrelated tools. Following this, preliminary prototypes for Tool 1 and 2 were modelled using the
prototyping tool Balsamiq Process maps were then advanced to define the existing process and the
location of these tools in a future improved process (i.e., the ‘to be’ process). The process maps were
elaborated from process maps advanced by the researcher in a prior research project . Specifically,
the maps addressed four pertinent processes: (1) flight planning and crew rostering, (2) real-time
flight operations process, (3) quality and safety management process, and (4) processes pertaining to
human resource management, aeromedical assessment, the EAP function, and health promotion.
In the second phase, the tools framework, prototypes, and process maps were validated with a
panel of stakeholders. A series of individual participatory workshop/co-design sessions were
undertaken with industry stakeholders (N = 7). As part of the sessions, the researcher presented the
background to this research, the tools framework, and the indicative prototypes for Tool 1 (pilot off
duty) and Tool 2 (pilot on duty). Participants were invited to provide feedback about the overall tools
framework and specific features of Tool 1 and 2. This included the logic and ethos, behavior change
motivations, enablers and barriers, and implementation requirements (both short and longer term).
The panel included the Senior Aeromedical Officer of the Irish Aer Corps, a safety manager from an
Irish airline, representatives from the national aviation authority (IAA) and EASA, the CTO of an
aviation software company responsible for the electronic flight bag (EFB) and mobile app solutions,
the product owner of an aviation software company responsible for pilot app solutions and fatigue
risk management software, and the CEO of an aviation training company.
The third stage addressed the production of a business model canvas (BMC) for the emerging
tools. This followed the requirement to justify tool concepts both from a human factors/ethical
perspective and a business perspective. The BMC followed the paradigm developed in Osterwalder’s
business model canvas . The purpose of this analysis was to articulate and locate the emerging
tools framework and concepts, in terms of the diverse needs of different actors in the aviation
industry (for example, pilots, airlines, families of pilots, aeromedical examiners, aviation software
developers, companies providing training support to airlines, the regulator, and so forth). As part of
this, the researcher engaged in a series of participatory sessions with (1) an aviation industry expert
and (2) a business analysis expert, to define the value proposition for different stakeholders and how
the individual tools would address this. Three sessions were undertaken with (1), while two sessions
were undertaken with (2). The output of this included a refinement of the tools framework in relation
to the needs of the aviation community, a BMC for the proposed tools, a specification of the customer
journey from the perspective of the two primary stakeholders (i.e., the pilot and the airline), and an
analysis of implementation motivations, enablers, and barriers. In relation to motivations, specific
dimensions of the value proposition were integrated with prior research addressing the problem
framing and an allied model of six interacting systems.
2.6. Part 4
The research in part 4 focused on further validation of the problem definition, the behavior
model, and the emerging solution. This comprised three analysis stages. In the first stage, the problem
was further specified from a systems perspective and assessment in relation to the needs of the
aviation industry/community. This included additional elaboration of the six interacting systems
which contribute to the problem space, the potential solution, and the implementation case (i.e.,
including both human/ethical and business considerations). Further, the behavior change model was
Technologies 2020, 8, 40 15 of 51
elaborated. As part of this, additional motivations, enablers, and barriers were specified in relation
to each of the six systems impacting on the problem definition and solution.
In the second stage, the second wave of survey data was analyzed. The purpose of the data
analysis was to (1) identify sources of WRS and wellbeing impact, (2) measure depression levels in
pilots, (3) examine the use of coping strategies (CS), and (4) examine the relationship between coping
strategies used by pilots and their mental health, specifically in terms of depression severity levels.
Sources of WRS and wellbeing impact were reported based on pilot self-reported data. Depression
levels were scored using the depression severity scale . The prevalence of pilots using CS and
the most frequently used CS were also examined. An ordered logistic regression model was advanced
to explore the relationship between the PHQ-9 scores and each of the coping strategies for WRS (i.e.,
those listed in the survey). The objective was to model the relationship between each frequency level
of each coping strategy and PHQ-9 scores. Following this, the odds ratio was interpreted, to assess
statistically significant coping strategies. Appendix A provides further detail on the analysis
In the third stage, the prototypes for Tool 1 and 2 were further elaborated, using Balsamiq
Further, a preliminary risk algorithm was specified.
2.7. Part 5
Part 5 refers to our most recent research with stakeholders, as part of the COVID response for
pilots and other aviation professionals led by the Flight Safety Foundation (2020). Two members of
the research team participated in a series of remote workshops/discussion sessions with a panel of
stakeholders, to support the specification of a wellness guide for aviation professionals (Flight Safety
Foundation, 2020). As part of this, the team presented a subset of research findings relevant to the
production of the wellbeing guide. This included findings in terms of framing the problem, the
biopsychosocial approach and allied pilot lived experience model, the behavior model, the
relationship between stress coping and depression, the tools framework, and specific checklist ideas.
Although these sessions did not focus on evaluating the ‘lived experience’ approach and/or the tools
framework and specific concepts, the panel provided useful feedback on this. Overall, the panel
included pilots and industry experts (N = 5), stakeholders involved in safety promotion (N = 2), a
stakeholder involved in aeromedical assessment (N = 1), and a stakeholder involved in the promotion
of healthy behavior (N = 1).
3.1. Understanding the Problem
As indicated in Table 2, the problem of pilot wellbeing exists at six different levels. These are:
1. Pilot level (lived experience, practices/behavior, culture)
2. Airline level
3. Community level (i.e., social system)
4. Health and safety regulation
5. Aviation regulation
6. Broader aviation system
Research indicates that each of these levels should be treated as a system to be managed.
However, there are also inter-relationships between these system levels. As such, we also need to
model the inter-relationship between factors within and across the six different levels/systems and
assess how these might be better managed in terms of new technologies and wider socio-technical
considerations. As highlighted by stakeholders, any solution will need to consider the design of each
of these systems and their role in relation to contributing to the problem and supporting a solution
that is acceptable to all stakeholders and adopted and sustained over time.
Technologies 2020, 8, 40 16 of 51
Table 2. Different levels and problems.
Pilot level (lived
Attitudes to mental health
Health behaviors amongst pilots
Machoism and culture
Reporting and disclosure culture
Sociotechnical system level—
processes, training, technologies,
business model, and culture and
Link to wider aviation
community and industry
Inflexible working schedules
Presenteeism, restrictions on sick
leave and difficulties reporting
Machoism and culture
Reporting and disclosure culture
Nature of airline Employee
Assistance Programe (EAP) and
access to support
Design of existing safety
management system (lack of
focus on risks relating to the
3 Community and social
Public expectations, pricing, 24/7,
health system, and access to
Public expectations, pricing, 24/7,
also health system and access to
Health and safety in
Health and safety authorities at
national and European level
Current strategy for evaluating
Current strategy for managing
psychological wellbeing in work
and associated stress
5 Aviation regulator and
Aviation authorities at national
and European level
Regulation pertaining to
safety/risk management, HF
management, wellbeing and
mental health monitoring and
Design of existing regulation—
mental health assessment,
6 Broader aviation
Technology providers, aircraft
Current process for insuring
airlines—flight safety, human
Available technology to support
wellness management for pilots
3.2. Pilot Wellbeing Behavior Model
As indicated in Figure 2, the behavior comprises four interrelated layers: (1) the lived experience
model, (2) the impact model and scenarios, (3) the model of coping, and (4) the analysis of behavior
change (including motivations, enablers, and barriers). This follows from the analysis and integration
of several phases of literature analysis and field research with stakeholders.
Technologies 2020, 8, 40 17 of 51
Figure 2. Pilot wellbeing behavior model.
The first strand of the behavior model is the model of pilot lived experience. This is represented
in a series of infographics which depict the lived experience of pilots in terms of the three pillars of
wellbeing and associated issues, sources of WRS/contributory factors, and health outcomes.
Appendix C provides an overview of the high-level model. Appendix D provides a summary of the
sources of WRS.
The second layer is the impact scenarios. As indicated in Figure 5, six impact scenarios are
proposed reflecting much diversity in terms of the ‘pilot lived experience’, along with a spectrum of
impact (i.e., spectrum of impact in terms of the pilot’s wellbeing, performance, and flight safety). The
six impact scenarios include:
1. Pilot mostly coping well
2. Pilot mostly coping well but impact on physical health
3. Pilot experiencing difficulties but mostly coping well
4. Pilot mostly coping but long-term impacts
5. Pilot not coping
6. Extreme cases
As suggested by workshop participants (part 1, phase 3 research), wellbeing interventions
should primarily focus on addressing routine suffering (scenario 1 and 2), the avoidance of scenario
3 (i.e., pilot not coping on the day with potential implications for flight safety) and scenario 5 (i.e.,
pilot suffering which leads to self-harm). Scenario 6 specifically pertains to a person who might have
a pre-existing MH issue. Currently, such a person is not obtaining adequate support at an airline
level. Participants noted that such a scenario is comparable to the Germanwings accident. Figure 3
provides an overview of the impact scenarios.
Technologies 2020, 8, 40 18 of 51
Figure 3. Impact scenarios.
In relation to conceptualizing the impact of wellbeing on performance and flight safety,
participants noted that there are many factors to consider, and the specific impact of these factors on
performance and flight safety is hard to quantify. Participants remarked that (a) the specific spread
of factors occurring at any one time (i.e., general features of job/WRS, personal stressors, the
operational situation), (b) how these factors might interact in real time, and (c) how these factors
might potentially impinge on wellbeing and by implication performance and flight safety is hard to
predict. This is also complicated by individual differences in relation to pilot coping ability. Further,
as observed by participants, although positive, pilot coping can lead to a false impression of actual
The third layer is the model of coping. This includes two interrelated parts: (a) predictors of good
mental health and wellbeing (see Table 3 below) and (b) analysis of coping strategies in relation to
Table 3. Influencing factors.
Use of coping mechanisms—sleep, exercise,
Awareness of issue/challenges/suffering
Normalisation of problem/suffering
Concern for own health (self or family)
Positive attitude to seeking help/support
Pre-existing MH issue
Existing health and wellbeing (if fatigue,
Shift pattern/shift time
Type of operation
Social capital and network
Existing habits and behaviours (sleep, diet,
Interest in physical exercise
Convenience and access (24/7)
Pilot education and awareness schemes
Social acceptability and demonstration of
‘socially desirable’ values and practices (self-
* has an influence.
The fourth and final layer is the model of behaviour change in relation to motivation (see Table
4), enablers (see Table 5), and barriers (see Table 6). As indicated in Table 4, these are linked to the
different systems as defined in relation to modelling the problem space.
Technologies 2020, 8, 40 19 of 51
Table 4. Motivations.
Pilot interest in developing/augmenting their health and wellbeing
Health attitudes of family and social network
Social supports from family and social network
Improved experience of home/work interface
Public acceptability—addressing MH and wellbeing challenges
1, 2, 3
Commercial reasons—reduction in costs of absenteeism, operational changes, flight
cancellations, due to pilot illness
Work incentives and rewards
Productivity and reduction in absenteeism costs
Normalisation of health and wellbeing supports across all industries
Aviation industry embrace requirement for change
Integrated approach across the aviation industry—solve the problem at different
levels (actors, process, operational timeline, etc.) 6
Acceptance that these issues exist for all workers and not just pilots and must be
Table 5. Enablers.
Culture change at pilot level—normalisation of MH, acceptability of self-care
Use of new digital tools for pilots—supporting awareness, monitoring, and self-
management of health
Culture change at airline industry level
Airline support—new training, enhancements to airline safety management systems SMS,
Acceptance of holistic model of pilot wellness (including factors pertaining to all three
Management of pilot wellbeing as a risk within an airline safety management system
Acceptance of MH and wellbeing challenges—community
Change in terms of public expectation—24/7 and low cost
Enhancements to existing health systems—public and private
Normalisation of health and wellbeing supports across all industries
Regulatory support—particularly in area of data protection
Availability of new technologies supporting stress coping and healthy behaviour
Transparency in terms of technology design in relation to how data is shared and data
Technologies 2020, 8, 40 20 of 51
Table 6. Barriers.
Pilot awareness of need to develop resilience and cope
Culture of presenteeism
Pilot attitudes to health and wellbeing and practice of resilience
Managing privacy issues
Pilot trust in system
Airline business models and work contracts for pilots
Existing pilot culture (not declaring suffering, presenteeism, macho culture)
Existing industry culture (stigma around MH and wellness challenges)
Lack of support within community for pilots—impact of job on wellbeing
Public expectations—expectation of low costs flights, 24/7 operations, flexibility for
Existing approach across all industries re management of health and wellbeing in
work—lack of focus on psychosocial dimensions
Aviation regulatory requirements
Lack of transparency in terms of technology design—specifically, in relation to how
data is shared and data protection
3.3. Challenges Associated with COVID-19
As indicated in Appendix E, different pressures and sources of stress can be associated with the
three scenarios, as outlined by the FSF (2020). There are wellbeing and safety risks for those currently
in work. Those off work face significant challenges. Sleep and diet may have improved, but there are
increased pressures in relation to financial insecurity, physical confinement, and social isolation.
Furthermore, there are many risks once a pilot returns to work. The pilot must be able to assess their
own wellbeing and fitness for a flight, along with that of their co-pilot and broader crew. Further,
new assessment processes may be required to manage the gap in operational practice, along with the
assessment of pilot wellbeing. Airlines’ EAP staff will need to identity what normal is, bearing in
mind that the landscape has fundamentally changed. EAP and peer support staff will require
assessment metrics and data to identify pilots that are coping well and others that are at risk or in
need of immediate crisis support. In line with a stepped care approach, this will support processes
which identity those who fit the criteria for EAP support and those who require referral to specialist
services provided by trained clinicians.
3.4. Proposed Technologies and Behaviour Change
As indicated in Table 7 below, behaviour targets and the means of achieving them (for example,
motivation, ability, and prompt) can be defined in the context of the Fogg model [99,100] while
considering the six intersecting systems and sociotechnical systems theory (for example, the
interrelationship between people, process, technology, culture, and training).
Technologies 2020, 8, 40 21 of 51
Table 7. Behaviour targets and Fogg model.
WRS and wellbeing awareness and
Increased awareness of WRS and
wellbeing (including MH)
Acceptability of MH/self-management of
wellbeing and MH
Increased acceptability of MH
Normalisation of MH
Acceptability of self-care
Shift to self-management
Interface between life in and outside
Safety, health and wellbeing, work policy, health attitudes, social acceptability, work
incentives and rewards, etc.
Health, time availability, work flexibility, family support
(1) Mobile apps + (2) airline tools—profiles info and model of behaviour/trends
(artificial intellgience + machine learning—available to airlines to direct
rostering/planning + tools for other stakeholders (EAP, aeromedical examiner etc.)
3.5. Tool Concepts and Framework
The combined field research justifies the requirement to advance tools to (1) promote and
maintain wellbeing for pilots (i.e., practice of healthy behaviors, coping strategies, and resilience), (2)
prevent the development of wellbeing/MH issues, and (3) support pilots experiencing wellbeing/MH
problems. Five integrated sets of tools for different stakeholders are required: (1) self-management
tools for pilots (off duty), (2) pilot operational tools (on duty), (3) tools for aeromedical examiners, (4)
tools for airline staff working in employee assistance roles (i.e., EAP), and (5) tools for airline staff
working in flight planning, crew rostering, safety management, and safety promotion roles.
Pending user consent, information captured in one tool could be made use of by different
actors/stakeholders using other tools. Research indicates that Tool 1 (self-management for pilots
while off duty) could be used without any integration with the other airline or aero-medical tools and
systems. However, there are potential benefits to linking up information flows across these tools,
pending user agreement and appropriate protections. This is discussed in a later section.
Stakeholder validation research indicates that the tools will transform the existing process and
require full specification in relation to this process transformation. Appendix G provides an overview
of the existing process and the future process involving the application of these tools. This is a
preliminary and high-level process specification and requires further elaboration with stakeholders.
3.6. Wellness Assessment Concept Underpinning Technologies/Tools
A key structuring principle underlying the proposed tools, is the conceptualization of wellbeing
in relation to the biospychsocial model of health and wellbeing. As such, wellness reporting and
assessment is undertaken from the perspective of the relationship between factors within and across
the three pillars of wellbeing. The overall wellness assessment framework is indicated in Table 8.
Table 8. Wellbeing assessment: three pillars. H = high, M = medium, L =low.
Wellbeing Pillar Example
H M L
Sleep, diet, exercise
Stress management, attitude, emotions, how
Seeing and talking to other people, getting
help when needed
Technologies 2020, 8, 40 22 of 51
Survey analysis indicates that certain coping strategies are associated with lower depression
levels. These include sleep management, physical exercise, and diet/nutrition management. As such,
from a reporting perspective, reporting of certain biological factors is critical (i.e., sleep, exercise, and
diet). Pilot social interaction with others has a large impact on their wellbeing. In addition, obtaining
support from others is critical. This too will need to be factored into the wellness assessment. Each
pilot is different and has a specific baseline stress level. This baseline level will need to be calculated
for different pilots and then factored into the risk assessment. The specific weighting of factors will
need to be determined. An algorithm is being developed to determine how this might be
implemented in practice. Preliminary validation research with stakeholders indicates that a simple
assessment technique might first be trialed/demonstrated. As the adoption of self-monitoring
strategies and the use of wearable and mobile self-monitoring technologies grows, this approach
might be scaled up to include tracking of additional factors. This might include the pursuit of hobbies,
creative activities (for example, the practice of art, music, and dance) and spiritual activity, along with
a more sophisticated assessment of the relationship between such factors. For more information,
please see Appendix G.
3.7. Data Protection, Privacy, and Pilot Safeguards
Preliminary validation with stakeholders indicates that a core implementation challenge will be
ensuring that pilot rights in relation to privacy and data protection are upheld (i.e., privacy by
design). Critically, a pilot’s license depends on a positive evaluation of their health and wellbeing as
part of annual aeromedical assessment processes. Further, pilots are required to present for work ‘fit
to fly’. This includes an assessment of their fatigue status (undertaken by flight planning and
operations personnel in relation to crew roster and duty times), their own self-assessment of fitness
pre-flight, and routine alcohol/drugs testing and monitoring, in line with regulatory requirements.
As emphasized by stakeholders, safeguards need to be defined in relation to providing access to and
enabling the use of any data (1) collected about a pilot and/or (2) collected by the pilot and shared
with others. This pertains to information collected in Tool 1 (off duty) and Tool 2 (on duty).
As noted previously, data collected by pilots might feed into tools used by different airline
personnel (airline safety and operational functions) and by aeromedical examiners. In relation to the
airline level, it is suggested that this information should be de-identified. This would be in keeping
with established norms in the aviation industry regarding the use of aircraft and flight data (i.e., flight
data monitoring—FDM). Information might be aggregated at a fleet level but should not identify
individual pilots. As highlighted by pilots and aviation industry stakeholders, this system might be
part of an overall strategy to foster a wellbeing culture and allied wellbeing component within the
airline’s safety management system. To achieve this, pilots and pilot data must be protected. As such,
the airline could not have access to health monitoring information and the routines/behaviors of
individual pilots. Nonetheless, pilots might be able to compare his/her data against cohort norms
(i.e., pilots flying specific fleets or operation types). In relation to the aeromedical examiner level, a
pilot might opt to share a range of data in different formats with the aeromedical examiner. Some of
this data might be identifiable (for the purpose of supporting individual assessment and support as
part of the aeromedical assessment process), while other data might be de-identified (i.e., for trends
analysis). This might be integrated with the new requirements for aeromedical assessment—
including the focus on stress coping behaviors and activities. Again, this information would be used
to gain insights about pilot behaviors and routines (at different levels—individual/group level, with
relevant protections), to strengthen aeromedical assessment and support pilots (for example,
understanding of norms and benefits of specific coping strategies). It should not be used in a punitive
manner. In both cases, protection of personal data would need to be enshrined in law and follow
established protections such as general data protection rules (GDPR).
Technologies 2020, 8, 40 23 of 51
3.8. Tool 1: Pilot Self Management (Off Duty)
3.8.1. Objectives and Functions
Stakeholder research indicated the requirement to advance new digital tools to support pilot
self-management of their health and the home/work interface, while off duty. The point of an ‘off
duty’ tool is to nudge the pilot towards healthy behavior (to keep them well), to prevent the onset of
problems, and to provide the right support/tools if problems arise and in line with the stepped care
approach as described earlier. The tool can also be used to share de-identified information about the
pilot’s state with the airline to support safer rostering and flight planning practices. Further, it can be
used to report near misses and safety events (linking to SMS processes).
In terms of scenarios, the off-duty tool addresses issues around routine suffering and their
impact on both wellbeing (i.e., scenarios 4 and 5) and safety (i.e., scenarios 1, 2, and 3). It also supports
the management of psychological distress (scenarios 5 and 6)—providing access to crisis supports
following from the ‘stepped care’ approach.
Stakeholder feedback indicates that the proposed tools might include a range of functionality
1. Wellness tracking, assessment, and reporting
2. Provision of general resources/information and relaxation exercises
3. Personalized tips/information, assessment, and wellness plans
4. Self-assessment tools
5. Virtual coaching and access to support
6. Link to airline information systems (for example, roster, notices, safety information)
7. Link to airline SMS
8. Reporting of wellness issues and safety events
In terms of wellness monitoring, reporting, and assessment, stakeholder feedback suggests that
such tools should not increase pilot workload and related cognitive and social burdens. Ideally, data
might be auto harvested from any existing wearables used by the pilot. For example, this might
include Fitbits or Garmins which capture information associated with the biological pillar—such as
sleep and physical exercise data. Additional information pertaining to the other two pillars might be
self-reported by pilots. Appendix H provides additional information about what data might be auto
harvested and/or self-reported.
3.8.2. Wellbeing Assessment and Associated Checklists
Checklists have been specified to promote awareness and prompt action. The checklist concept
enables assessment in relation to (1) self-awareness and acceptance and (2) coping. This links to the
two core questions identified in this research: (1) how am I feeling, and (2) how am I coping/what am
I doing and/or going to do to support coping for myself and others? As highlighted by stakeholders,
risk exists both in relation to (1) awareness/acceptance and (2) coping practices. In relation to (1), if
issues are avoided or hidden, this can lead to problems. In relation to (2), if the person is doing
nothing and/or adopting maladaptive practices (i.e., binge eating, taking intoxicants, withdrawing
from others, and engaging in negative self-talk), then there is also a risk. Table 9 below provides an
example of an early stage prototype for such a checklist. As indicated, the checklist covers all three
pillars of wellbeing and each pillar is sub-divided into core areas which require the practice of healthy
Technologies 2020, 8, 40 24 of 51
Table 9. Self-assessment checklist.
Current Status: How
Rating? H M L
What I Am Going to
What Am I Doing?
H M L
H M L
Sleep and fatigue
How feeling (stress)
Emotional stability and
Further, as indicated in Figure 4, the checklist could also feature on a mobile app.
Figure 4. Prototype of mobile app.
3.8.3. Wellbeing Management: Weekly Plan and Review
Supporting healthy behaviour requires the development of plans and targets and the monitoring
of one’s achievement in relation to this. Table 10 below provides an example of an indicative weekly
plan and review chart.
Technologies 2020, 8, 40 25 of 51
Table 10. Example wellness weekly plan and review.
Pillar Area Current
What I Am Going to
Do? Weekly Plan—
Target Actions for
Review (Day 7)—How
Did I Get on?
Implications for Next
Talking to others,
getting help if
Again, the wellness plan and review chart could feature on a mobile application. Further, as
indicated in Figure 5 below, the pilot could track their progress and obtain customized feedback as
to key focus areas. Appendix I provides some additional examples.
Figure 5. Tracking progress on wellbeing plan and targets.
3.9. Tool 2: Pilot Operational Tools (On Duty)
The analysis of stakeholder research indicates the requirement to advance tools to support pilots
while on duty. Here, the goal is to manage wellbeing issues among pilots and address
performance/safety implications, while in work. Such a tool might involve several different
1. Enable joint assessment of crew state at the pre-flight stage
2. Enable reporting in relation to WRS and wellbeing threats
3. Enable safety reporting
4. Reporting of WRS/wellbeing issues and safety event (in flight)
5. Enable access to support services within airline
6. Provide support in crisis situations
In relation to (1), existing pre-flight checklists might be augmented to enable the crew to evaluate
their health and wellbeing. This would represent a step beyond the existing regulatory guidance for
managing wellbeing/MH at an operational level (i.e., assessment of fatigue and pre-flight testing of
Technologies 2020, 8, 40 26 of 51
pilots for alcohol and drugs). It is proposed that the checklist items would link to the findings of this
analysis in terms of assessment of (1) their biopsychosocial health status (i.e., three pillars of
wellbeing) and (2) how they are coping/using coping strategies. Appendix J provides an example of
an adaption of the existing ‘I’m Safe Checklist’ from this perspective. This includes assessment in
relation to current emotional (including mood and attitude) and social state, not just physical health.
Stress coping is included alongside stress levels. Further, physical exercise is also incorporated. It
should be noted that this might be done at an individual level (in advance of the flight and the joint
crew meeting) and at a joint crew level. Both crew members would need to be briefed on their
respective crew member’s health and wellness.
As highlighted by stakeholders, the specific implementation of this tool at an operational level
requires careful consideration. Potentially, a pilot might review the checklist and ‘make a decision as
to their fitness’ at least eight hours before the flight. This would allow the airline sufficient time to
manage the staffing consequences (i.e., substitute the pilot). Further, this necessitates a supportive
culture, at an airline and pilot level.
3.10. Safety Promotion and Training Tools and Technologies
A fundamental aspect of the airline SMS is safety promotion. Stakeholder feedback indicates
that existing training needs to be extended to include training in relation to coping and promoting
resilience (i.e., preventative wellbeing and mental health approaches). This training should increase
a pilot’s ability to cope. Educational strategies are required to promote learning about personal
health, maintaining work family balance, wellbeing/MH risk assessment, and managing stress.
Critically, stress management strategies need to suit both the person and the occupational demand.
Instruction might go beyond traditional classroom formats. For example, it could include online
formats. Pilot-specific serious games might be developed, relevant to the two high level contexts: (1)
on duty and (2) off duty. Pilots might also benefit from training in medication and mindfulness. This
might be pilot specific and include opportunities for practicing mindfulness while in the cockpit.
Further, pilots might benefit from participating in an interactive game or virtual challenge. Existing
wearables might be used to track their own health and wellness. As part of this, pilots might obtain
points for achieving wellness goals and/or demonstrating different levels of behaviour change.
4.1. Framing Problem, Need for Stakeholder Engagement, and Behaviour Change
As indicated in Figure 6, the ‘pilot wellbeing problem’ can be framed in relation to the six
interacting systems and model of diversity, as identified in this research. Evidently, this problem is
worsened by the current COVID-19 context and requires consideration in relation to the three
scenarios outlined by the Flight Safety Foundation (2020).
Figure 6. Framing Problem—six systems and COVID scenarios.
Technologies 2020, 8, 40 27 of 51
Overall, pilots, the aviation community (i.e., airlines, the aviation industry, and the aviation
authority), and society must accept their role and responsibilities in relation to supporting pilot
wellbeing and enabling behavior change. Stakeholders will have differing goals and perspectives on
the problem. These perspectives will influence how the problem is framed and how the emerging
solution is conceived. Thus, all stakeholders must be engaged in finding a solution.
Improved working environments necessitate behavior change on the part of employers,
employees, and society. This means changing how we conceptualize work and how we design
systems to promote wellness, resilience, and safety. As illustrated in this research, such behavior
change needs to be framed in the context of the six interacting systems. It is argued that behavior
change for airlines will be driven by change at a pilot level. Furthermore, it will be driven by what
happens at levels three (society/community), four (health and safety regulation), five (aviation
regulators), and six (aviation community and industry). As noted previously, we are focusing on
pilots first. This is premised on a view that the development of a wellbeing culture starts with pilots
first. This has already been demonstrated by peer support programs. Nonetheless, it needs support
from airline management and the regulator. If a growing number of pilots are practicing behavior
change and adopting technologies capturing data around their wellness, then this may drive change
at an airline level in terms of making use of the data collected by these tools. In line with the
technology-mediated behavior change as outlined by Fogg (2020), these new digital tools will provide
a trigger for pilot assessment of wellness, along with motivating and supporting the individual and
organizational behavior required. In addition, the above tools will provide a link into
societal/community supports and enabling change at a societal level.
The pilot’s ‘lived experience’ and associated home/work interface needs to be designed so that
the pilot is set up for success. However, this requires a fundamental rethinking of the design of the
overall aviation system and the human role within it. More progress is required to ensure that the
person (i.e., the human factor) is at the center of the system. From an airline operations and safety
management perspective, pilot interaction with different aspects of the socio-technical system (i.e.,
training, culture, process, tools) at different career time points (i.e., training, early stage career, mid-
career with family and mortgage, etc.) and at different operational points (i.e., while on duty and off
duty) must be considered. Following a systems approach, change at an organizational level will be
multicomponent and at different levels (i.e., culture, training, process design, etc.). As part of this, the
motivations, enablers, and barriers, as defined in the pilot wellbeing behavior model, will need to be
In addition, the social model which underpins the ‘human factor’ needs to be mapped and
addressed. In terms of examining social interactions and relationships, attention must be given to the
quality and value of a pilot’s interactions with those who (1) provide support to the pilot (i.e., pilot
wellbeing benefiting from support from social network, health providers, and colleagues) and (2)
those the pilot provides support to (i.e., pilot wellbeing benefiting from support given to others,
volunteering, and contributing within their social community). On the flipside, this social community
can potentially create barriers to identifying wellbeing problems, accepting the need for change,
fostering wellbeing behaviors, maintaining wellbeing, and providing sincere and credible support
for the routine practice of healthy behaviors.
Overall, we are seeking to change the relationship between the individual and employer and
other aviation stakeholders (for example, the aeromedical examiner) and societal actors (i.e., families
and those people providing support to pilots in the community, etc.). This includes information
sharing relationships (for example, sharing information about our personal health, lifestyle, and
fitness for duty). In many cases, regulation also needs to change and/or catch up. Evidently, such
information is sensitive and ethical dimension such as consent, autonomy, and protection of the
personal sphere must be considered.
4.2. Tripple Bottom Line and Ethics/Business/Legal Case
Healthy work relates to the creation of positive wellbeing within workplaces and workforces
and has significant implications at an individual (i.e., pilot) and societal level. In line with ‘responsible
Technologies 2020, 8, 40 28 of 51
work concepts’, airlines have a responsibility to pilots (i.e., their employees), to shareholders, and to
society. Specifically, airlines and the aviation industry need to engage with ideas around the ‘triple
bottom line’ and enabling social justice in the workplace (i.e., decent work agenda). By practicing
corporate citizenship, airlines and the industry can become aware of the impact they are having on
different aspects of society and proactively address the challenges associated with WRS and pilot
There is a moral, business, and legal case for addressing issues pertaining to WRS, pilot
wellbeing, and healthy work practices (including the management of the home/work interface). First,
employers have a duty of care to their employees in terms of the promotion of healthy and safe work.
Such duties are legally enshrined in workplace legislation. The operating environment and terms of
work should not adversely impact an employee’s wellbeing and/or create the conditions conducive
to the onset of wellbeing issues (including MH issues) and/or contribute to the worsening of a pre-
existing issue. Workplace systems and practices should foster trust and engagement, the promotion
of wellbeing (including psychological wellbeing), and the avoidance of work-related stress (WRS)
and burnout. Moreover, the operating environment should not present a threat to the person’s safety
or that of other stakeholders (for example, other aviation workers and the travelling public).
Society and the travelling public expect and have a right to transparency in relation to how safety
is managed including the measurement and assessment of human capital. It is expected that all risks
(including human factors risks) are adequately managed. Further, given the significant challenges
faced by pilots and the aviation industry in terms of COVID-19, the public have (or will have)
legitimate concerns around the fitness to fly of pilots who are re-entering the workforce. On the
flipside, we (as a society) have responsibilities to pilots. We need to accept our role in relation to
supporting the wellbeing of pilots. Further, we need to consider the implications of public
expectations for low cost flights and 24/7 flight schedules. This is discussed in more detail below.
This is not to minimize the contribution of individuals to harmful work practices. As stated
previously, workplace wellbeing relates to the creation of positive wellbeing within both workplaces
and workforces. Employees also need to understand their role and responsibilities here. As with their
employers, pilots must be educated about boundaries between our life inside and outside of work
and managing conflicting demands.
Psychological problems amongst aircrew present a threat to flight safety, given the ensuing
impairments to task performance. Factors such as stress, physical state (for example, fatigue), and
emotional state (for example, anxiety and depression) are considered to substantially increase the
likelihood of human error. This presents a risk both from a flight safety and commercial perspective
(i.e., potential for injuries and aircraft damage, brand damage, legal exposure, and associated costs).
Pilot absenteeism along with the impacts of absenteeism on flight operations (i.e., replacing crew,
flight delays, flight operations changes) represents a significant cost to airlines. This is likely to be a
significant motivating factor for airlines to address the development of a wellbeing culture, along
with addressing wellbeing as part of the wider safety management system.
4.3. Problem to be Addressed and Impact Scenarios
This research raises questions as to where the problems and/or risks are and, by implication,
where the focus of attention should be. Arguably, the greatest needs and risks pertain to the ‘human
factor’. To this end, the map defining operational and safety needs (and allied risk quantification)
needs to be redrawn.
From the perspective of the research evidence collected, the aviation industry/community
should focus on promoting and supporting positive wellbeing while also addressing different types
and levels of suffering. Specifically, the focus needs to be on routine suffering (scenarios 2 and 3), and
not simply extreme events (scenario 6). Overall, scenario 3 is most critical. This is where there is a
potential for something more serious/a safety event.
As highlighted in this research, pilots are practicing stress managing strategies and supporting
each other (i.e., scenarios 1, 2, and 3). However, this fact should not be used to underestimate the
impact of routine suffering and/or sources of WRS (from minor to more severe) and the potential
Technologies 2020, 8, 40 29 of 51
safety risk. Although positive, such coping can be interpreted as a potential safety risk. Moreover, it
gives the impression that all risks are identified and properly managed. Risk is managed within the
context of a functional safety management system, which makes safety assessments in relation to
different timeframes (i.e., past, present, future), using a diversity of evidence pertaining to different
subject elements (i.e., crew, aircraft, environment), and the socio-technical system. A resilient and
robust safety management system does not rely on opportunistic and/or ad hoc prevention. It is not
acceptable to depend on coping (i.e., the identification and correction of a slip or error by the co-pilot
in real time—impact scenarios 1, 2, and 3). Moreover, important outcomes linked to pilot wellbeing
and suffering (from minor to severe) are not being managed (see scenarios 2, 4, and 5).
4.4. Safety Quantification and Wellbeing Culture
Wellbeing challenges are real. Further, they are being compounded in the current COVID-19
crisis. As highlighted in this research, existing proactive risk/safety management fail to consider pilot
wellbeing and associated factors (including factors linked to sources of WRS and the home/work
interface) as a risk to be managed in the SMS. To this end, it can be argued that a significant number
of safety risks are not being adequately identified and managed. Based on the evidence collected in
this research, it seems prudent to question the apparent avoidance of integrating ‘biopsychosocial’
wellbeing issues into the existing airline safety/risk assessment approach (i.e., beyond fatigue).
Arguably, the current frameworks and associated risk assessment metrics result in an incomplete
picture of (1) routine performance (i.e., variability in relation to pilots coping with stress and safety
being maintained), (2) the contributory factors to accidents, and (3) flight safety/risk estimates. From
this perspective, there are significant vulnerabilities in the existing risk/safety management approach
and allied safety quantifications. If we were to use different metrics (for example, Key Performance
Indicators (KPI) linked to factors pertaining to the three pillars of wellbeing and WRS), this might
yield different conclusions.
Addressing scenario 3 requires the advancement of a wellbeing culture—in the same way as
‘just culture’. This should be bolstered by tools which foster and nurture wellbeing. These are
discussed in more detail below. Further, it requires the specification of a minimally acceptable
standard for pilots to be fit to fly. This includes the COVID-19 time and beyond.
4.5. Concept of Pilot, Professionalism, and Wellbeing Culture
The pilot is conceived as an agent of change in relation to (1) managing their own health and
wellbeing and (2) contributing to the advancement of a wellbeing culture.
In relation to (1), there needs to be a strong focus on self-efficacy and fostering/nurturing
resilience. This is not to underestimate the impact of the significant challenges that some pilots are
facing. Further, it is accepted that a self-management approach is not appropriate for those
experiencing acute difficulties and are in crisis situations. In line with the stepped care approach,
such pilots will need additional support, beyond the practice of healthy behaviors and support from
their social network.
In relation to (2), the development of a wellbeing culture needs to be embedded in concepts of
professionalism and flight safety. The existing culture will take time to change. As with the
advancement of a ‘just culture’, the development of a new ‘wellbeing culture’, will require support
in terms of airline leadership and the authorities. However, pilots have a huge role in relation to
fostering this culture. Through increased awareness of the home/work interface and the practice of
self-care and associated self-management strategies, pilots have an opportunity to lead the way in
terms of fostering this culture and demonstrating the relationship between wellbeing, performance,
and safety. This of course depends on the provision of robust protections for pilots in relation to
privacy and data protection.
Technologies 2020, 8, 40 30 of 51
4.6. Theoretical Foundations for Tools
The proposed tools have their theoretical underpinnings in frameworks used in health
management and behavior change and those used in industry (i.e., airline safety/risk management
concepts). In relation to health management and behavior change, this includes concepts of
wellbeing, self-efficacy, self-management of health, acceptance, and behavior change and associated
therapeutic approaches. In this way it is credible from a therapeutic perspective. In terms of industry
concepts, it also has its theoretical underpinnings in the concepts and lexicon of crew resource
management (CRM), threat and error management (TEM), Safety II, and predictive risk management.
As stated, the ‘biopsychosocial’ model of health and wellbeing underpins the wellness
management approach. Mental health is not assessed in isolation from the other dimensions of health
and wellbeing. Further, wellbeing is addressed from different perspectives. This includes health
promotion, maintaining positive wellbeing, and addressing wellbeing challenges (including mental
health difficulties and illness).
The proposed tools are framed in relation to safety/risk assessment and link to EASA’s
rulemaking in terms of managing pilot wellbeing and mental health (and specifically advisory
material/best practice which focuses on improving existing safety behavior and culture). There are
links across all five tools in relation to end user workflows and information flows. Pending
permissions and data protection safeguards, information captured in one tool can be made use of by
different actors/stakeholders using other tools. Further down the line, this technology might be
customized for other occupations that have similar sources of WRS. For example, other aviation staff
(cabin crew, ATM, airport operators, maintenance, and ground personnel), truck drivers, healthcare
workers, and first responders.
4.7. COVID and Need for Resilience and Immediate Changes
Post Covid-19, the aviation industry will not be the same. Further, much will have changed for
those who remain working in the industry. Airline peer support services will need to be stepped up.
Further, pilots will require some level of ‘return to work’ evaluation. In relation to wellbeing for
pilots, the industry and the regulator will need to define a minimally acceptable standard for pilots,
in terms of fitness to fly (Dickens, 2000). However, the adoption of healthy behaviors will go some
away to preventing the onset and/or worsening of wellbeing problems, including psychological
wellbeing. In the short-term, pilots can pose the key questions: (1) how I am feeling and (2) how I am
coping/what am I and/or can I do for myself (and others)? These link to the core practices of self-
awareness, self-assessment, and self-management. From a pilot perspective, the checklists and digital
tool concepts arising from these questions can be implemented in paper format. Further, we need to
investigate creative ways in which the community (including the aviation community) can provide
help to those who are suffering.
As stated previously, the FSF have defined three operational scenarios during the COVID-19
crisis. This includes in work, not in work, and returning to work. Given the demands on global health
systems, some pilots may not be getting the support (public or private health service support) that
they previously obtained. This is separate to what may have been provided by their airline EAP or
peer support process. Overall, a preventative approach is required. Interventions are required now
for pilots to mitigate issues arising during scenarios 1 and 2, which may potentially increase the risk
associated with scenario 3. This might involve certain small steps. Pilots might be invited to use their
existing technology (for example, Fitbits) to monitor their wellbeing. The checklists proposed in this
research might be adapted for the COVID context. In addition, an adaption of the ‘Dutch reach’ for
pilots might be implemented in different contexts (both on duty and off duty). This would involve a
physical gesture to either draw attention to wellbeing and/or signal wellbeing issues. Overall, such
initiatives might empower pilots and support self-efficacy and resilience while also considering
existing attitudes to health promotion and self-declaring wellness challenges.
Technologies 2020, 8, 40 31 of 51
4.8. Relevance to Other Aviation Professionals and Others
Many of the sources of work-related stress examined in pilots are common to other aviation
workers, who are also shift-workers, such as cabin crew, ground staff, engineers, and air traffic
controllers to name but a few. Hence, it is reasonable to conclude that many of these lifestyle factors
and coping strategies adopted by the resilient group of pilots, might also offer substantial benefits to
other worker groups within aviation.
4.9. Limitations and Areas for Further Research
Study limitations should be considered. Workshop and survey participants were recruited using
social media. As such, issues pertaining to the self-selection of candidates and the potential for bias
in terms of interest in wellbeing and/or experience of suffering should be considered. Survey data
were self-reported. There may be discrepancies between the person’s actual health and experience of
WRS and their perception of this. Further, as survey data is cross-sectional, the results can only be
used to evaluate the sample for this time period. As such, a cause-and-effect relationship cannot be
inferred. Additional research is required to unpack the specific WRS issues and wellbeing factors as
reported by stakeholders across the different studies.
Primarily, this research reflects the perspective of one stakeholder group (namely pilots).
Validation with other stakeholder groups is at an early stage. In addition, further research is required
in relation to advancing a road map for the implementation of solutions at an airline level. This would
need to include the participation of representatives from both airlines and relevant authorities.
There may be different challenges in terms of tool acceptability and adoption and use for
different cohorts (for example, younger and older pilots). Further, the existing impact scenarios may
require additional specification, in terms of the COVID 19 context and the challenges pertaining to
the three scenarios defined by the FSF (i.e., in work, out of work, and returning to work).
Moreover, the wellbeing algorithm requires further analysis and specification. In particular, the
weighting of factors within and across the wellbeing pillars will need to be determined. Further, the
baseline level will need to be calculated for different pilots, and then factored into the risk assessment.
4.10. Next Steps
The proposed tool concepts are preliminary and require additional validation with stakeholders.
This will require in-depth co-design activities with pilots and other aviation industry stakeholders.
Currently, the focus is on Tool 1 and 2. Further attention will need to be given to the design of Tool
3, 4, and 5—including addressing privacy issues. As noted earlier, from the perspective of the tools
framework, there are two contexts in which privacy challenges need to be addressed. In the airline
context, this includes the potential to share pilot information (in a de-identified format) with the
airline EAP, safety department, and with crew rostering and flight planning. The second context
includes potential sharing of pilot data with aeromedical examiners.
In relation Tool 1 and 2, a subset of this functionality will be further explored. Early stage
prototypes will be evaluated with a small group of pilots. As part of this, we will address the practice
of specific stress coping activities (for example, creative activities, hobbies, and spiritual activity) and
how these might be monitored, assessed, and supported. The specific implementation of these tools
at an operational level requires further research. We will also address issues regarding device
usability, social acceptability, and ethics (including issues pertaining to managing privacy).
In relation to airline solutions, broader stakeholder evaluation-based research will be
undertaken to validate the preliminary solutions and address their specific implementation at an
airline level. Lastly, additional field research will be undertaken with other aviation professionals
(i.e., cabin crew, Air Traffic Control [ATC], maintenance engineers, and ground operations).
Technologies 2020, 8, 40 32 of 51
Pilots face many occupational hazards that are endemic to their jobs. Pilots, the aviation
industry, and society should recognize and support the many activities that contribute to positive
wellbeing for pilots.
The aviation community needs the right tools to safeguard the wellbeing and mental fitness of
pilots and ensure flight safety. Overall, work should be designed to benefit all stakeholders. Airlines
and the aviation industry need to be socially accountable. Behavior change is required at an
individual, organizational, and societal level. Further, this change needs to be conceptualized from a
socio-technical perspective and deliver benefits to employers, employees, and society.
There is a moral, legal, and business case for supporting pilot resilience and addressing
wellbeing factors within an airline’s safety management system. Post Covid-19, the aviation industry
will not be the same, and nor will those who remain working in the industry. Solutions are required
for pilots and other stakeholders to address (1) the new requirements proposed by EASA  (2) gaps
in relation to existing regulatory requirements and enabling a preventative and holistic approach to
wellbeing management and supporting resilience, (3) the existing evidence on pilot wellbeing
challenges, the prevalence of suffering, and the use of coping strategies, and (4) the immediate
COVID need and allied three scenarios defined by the flight safety foundation.
Pilots are adapting to the job and managing wellbeing issues. However, there is much variation
in relation to coping ability. This variation needs to be considered in terms of (1) operational safety
risk assessments and (2) designing wellbeing interventions at pilot and airline levels. Pilot wellbeing
needs to be treated from a holistic perspective (biopsychosocial). Pilots, airlines, and the regulator
can learn from the existing use of coping strategies as evidenced in this research. New tools are
required at different levels (i.e., pilot, airline, aeromedical examiners) to support pilot self-
management of their health and wellbeing.
In support of the EASA directives, best practice in relation to preventative approaches to health
management, predictive risk management, and associated data driven approaches, preliminary
concepts and prototypes for tools have been advanced. These prototypes pave the way for rethinking
how pilots and airlines effectively manage issues pertaining to WRS and its impact on pilot
wellbeing/mental health, pilot performance, and flight safety. Stress cannot be eliminated from the
work life of pilots. However, the proposed tools can support the management of pilot WRS and its
effects on pilot wellbeing, performance, and safety. The tool concepts are predicated on significant
field research and validation with pilots and the industry. The concepts emerge from a framing of the
wellbeing problem from a systems perspective and a focus on addressing outcomes (i.e., impact
scenarios). Further, they are linked to behavior change frameworks and practices, at an individual,
organizational, and societal level.
Existing pre-flight checklists should be extended to enable the crew to evaluate their health and
wellbeing. New checklists might be developed for use by pilots while off duty, supporting an
assessment of (1) their biopsychosocial health status (i.e., three pillars of wellbeing) and (2) how they
are coping/using coping strategies. This research underscores the need to introduce digital tools to
enable pilot self-management of wellbeing and safety behavior. This might involve the advancement
of a phone app with different wellness functions. Data captured in this tool might be shared in a de-
identified format with the pilot’s airline.
Tools to support pilot coping and resilience are recommended. Nonetheless, airlines must also
manage these risks. This might involve the adoption of Safety II approaches—predicated on data
driven risk assessment. To this end, there is a requirement for corresponding tools for other
stakeholders. Existing airline SMS and flight rostering/planning systems might be extended to make
use of pilot data from an operational and safety management perspective. Fatigue risk management
systems (and by implication airline rostering/flight planning systems) need to be extended to
consider the relationship between fatigue risk and the other dimensions of a pilot’s wellbeing. This
requires making use of a pilot’s wellbeing data within the airline SMS and raises significant issues
pertaining to privacy rights and the protection of personal data. In addition, a new training format
should be devised to support pilot development of coping skills. Pilot information might also be
Technologies 2020, 8, 40 33 of 51
shared with the airline EPA to support coping and the targeting of interventions at a cohort/fleet
level. Moreover, information might also be shared with aeromedical examiners.
The proposed tool concepts are preliminary and further validation research is planned with
pilots and other stakeholders. As part of this, specific information sharing roles, processes, and
safeguards will need to be defined, in line with legal frameworks and societal values.
Author Contributions: conceptualization, J.C., P.C.; methodology, J.C., P.C., S.A., S.W.; software, J.C., S.A.;
validation, J.C., P.C., K.G.; formal analysis, J.C., P.C., S.A., SW.; investigation, J.C., PC.; writing—original draft
preparation, J.C.; writing—review and editing, S.A., P.C.; visualization, J.C., P.C.; supervision, S.W.; project
administration, J.C.; all authors have read and agreed to the published version of the manuscript.
Funding: This research received no external funding.
Acknowledgments: The authors would like to thank the pilots for their participation in this study. The views
expressed in this study do not represent the views of the authors’ employers. The authors would like to thank
Mark Atherton and Thomas Anthony for their feedback on this paper. We acknowledge their contributions but
do not infer that they take responsibility for the content of the article.
Conflicts of Interest: The authors declare no conflicts of interest.
Appendix A: Field Research and Data Analysis Methods
Table A1. Field Research & Data Analysis Methods.
Part 1: A
Semi-structured scoping interviews were conducted with N = 103
commercial pilots. The interviews were conducted opportunistically by
Captain Paul Cullen and took the form of a casual conversation between
peers. Participants obtained an informal briefing and verbal consent was
established. Written consent was not elicited. Participants were informed
that interview data was not being shared with others and that the findings
were to be used to advance a model of the lived experience of being a pilot.
Pilots were asked open ended questions about sources of WRS and the
lived experience of being a pilot. They were also asked about the health
impact/outcomes of these issues. These interviews were conducted on a
preliminary exploratory basis. Research findings were documented after
the event and not at the time.
Part 1: C
The workshops had two objectives:
To validate the preliminary model of pilot lived experience in relation
to sources of WRS
To map the relationship between WRS, pilot wellbeing, pilot
performance, and flight safety.
Workshop participants were recruited using word of mouth and through
social media (advertisements posted with the Irish Airline Pilots
Association (IALPA) and on Irish-based pilot discussion boards). The
sample composition is made up of pilots flying from Ireland only. Overall,
33 commercial pilots (spanning three airlines) attended the workshops.
Workshop participants had on average 9,178 h of flying experience and
included 20 captains and 13 first officers. Of the 33 participants, 7 were
female and 26 were male. Eight participants had part-time work contracts,
while 25 were working full-time. In terms of flight operations, this included
4 short range, 7 long range, and 22 mid-range pilots.
Three workshops were undertaken with 33 commercial pilots (workshop 1:
N = 12, workshop 2: N = 10, workshop 3: N = 11). The workshops were
undertaken between March and May 2018.
A workshop presentation was compiled for each of the three workshops.
This presentation provided the structuring framework for each of the
workshops and guided the interaction between the workshop facilitator
and the workshop participants. In the case of all three workshops, the
Technologies 2020, 8, 40 34 of 51
workshops started with a short presentation about project goals and
concepts. Participants were then invited to provide written consent for their
participation in the workshop. There were some differences between the
workshop structure/format and specific questions posed to participants in
workshop 1, 2, and 3. In workshop 1, specific pilot personae were presented
to participants. Each participant received a printed page with the personae
information. These included descriptions of three different pilots—with
different situations and each experiencing a spectrum of suffering. The
workshop facilitator reviewed the different persona and invited feedback.
Participants were then presented with the preliminary definition of the
sources of WRS—grouped in terms of the biopsychosocial framework. In
relation to sources of WRS, participants were invited to review and edit the
list of sources presented. Following this, participants were presented with a
preliminary safety case and three worked examples, corresponding to the
biopsychological framework of health and wellbeing. Participants
discussed the safety case and associated worked examples. There was then
a group discussion concerning the relationship between WRS, pilot
wellbeing, pilot performance, and flight safety.
Workshop 2 was designed to address the findings of workshop 1. There
were two format changes. First, the personae were not presented to pilots.
Secondly, the preliminary safety case and worked example was replaced
with a definition of six impact scenarios which emerged in workshop
1.Participants were invited to review/validate the six scenarios. Participants
were invited to provide feedback about the scenarios defined in workshop
1—specifically in relation to impact on (1) wellbeing, (2) performance, and
(3) safety. This was followed by a group discussion concerning the
relationship between WRS, wellbeing, performance, and safety.
In workshop 3, the integrated findings of workshop 1 and 2 were presented
to participants. In relation to the six impact scenarios, participants also
provided an estimation of the frequency in which such a situation would
In all three workshops, participants were invited to complete a homework
exercise. At the end of each workshop, there was a full participant
The workshops were led by two human factors researchers (JC and PC).
During each of the three workshops, the researchers alternated roles
between leading the workshop and recording workshop notes. This
followed the structured agenda. In each case, the researcher recorded
workshop notes on their computer.
Ethics approval for the workshops and additional interviews (to happen
after the workshops) was granted by the School of Psychology, Trinity
College Dublin (TCD) – in February 2018.
Part 2: E Survey Design
This involved an anonymous web-based survey targeted at commercial
pilots. The survey ran over a fifteen-month period (between 7th November
2018 and the 24 January 2020).
The survey examined the effects of work-related stress (WRS) on pilot
wellbeing and the associated impact on both pilot performance and flight
safety. The survey also investigated pilot coping methods and pilot
perception of the airline role in relation to managing WRS and wellbeing
The survey incorporated several standardized instruments to measure
levels of common mental health issues. This includes the Patient Health
Questionnaire-9 (PHQ-9), the Oldenburg Burnout (OLBI 8), and the
Oldenburg Burnout (Modified Instrument).
First, pilots received a short briefing about the study and its background.
The electronic consent was then completed. Following this, relevant survey
questions were answered. This was followed by a debriefing.
Technologies 2020, 8, 40 35 of 51
Pilots were recruited using social media platforms such as LinkedIn and
Twitter. The survey was powered by the SurveyMonkey service and did
not collect any identifying information about the person. Further, no
internet protocol (IP) addresses were collected. It was assumed that each
participant was a pilot and only completed one survey. Several questions in
the survey required knowledge that would only be readily available to
pilots. An active pilot (co-author in this study: PC) reviewed surveys for
potential non-pilot participants. All surveys passed this screening.
Ethics approval was granted by the School of Psychology, Trinity College
Dublin (TCD), in August 2018.
Part 4 B
The purpose of the data analysis was to (1) identify sources of WRS and
wellbeing impact, (2) measure depression levels in pilots, (3) examine the
use of coping strategies (CS), and (4) examine the relationship between
coping strategies used by pilots and their mental health—secifically
depression severity levels.
In relation to (1), sources of WRS and wellbeing impact were reported
based on pilot self-reported data.
In relation to (2), depression levels were scored using the depression
severity scale (Kroenke, Spitzer and Williams, 2001).
In relation to (3), we examined the prevalence of pilots using CS and
the most frequently used CS.
In relation to (4), an ordered logistic regression model was advanced
to explore the relationship between the PHQ-9 scores and each of the
coping strategies for WRS (i.e., those listed in the survey).
The objective was to model the relationship between each frequency level
of each coping strategy and PHQ-9 Scores. Following this, we interpreted
the odds ratio, to assess statistically significant coping strategies. Logistic
regression is a statistical method for analyzing a dataset in which there are
one or more independent variables that determine an outcome. The
outcome is measured with a dichotomous variable (in which there are only
two possible outcomes). The response variable Y is assumed to be binary
(i.e., either a failure or success). In our case, we took the two outcomes of
the response variable to be: (1) pilot has a PHQ-9 score below 10 (Y_i = 0) or
(2) pilot has a PHQ-9 score of at least 10 (Y_i = 1). We are interested in
drawing inferences on coping strategies and how they are related to
depression severity levels, that is co-relation not causality (coping strategy
causing the PHQ score to be below 10 or vice versa). This analysis does not
consider interaction between different coping methods.
Interpretation of results addressed the odds ratio. If the odds ratio is less
than 1, then it is associated with a probability of having a lower depression
severity level. Statistically significant coping strategies were set at p = 0.05.
For more, please see Appendix 3, 4, and 5. It should be noted that the p-
value tells us only whether a coping strategy at a certain frequency level
was statistically significant. The odds ratio is what tells us whether that
coping strategy is associated with a higher (if > 1) or lower (<1) depression
Technologies 2020, 8, 40 36 of 51
Table A2. Research parts and phases.
Outcomes Date Status
May 2015 to
June 2017 Complete
to June 2017 Complete 
Pilots (N =
April to May
2018 Complete 
June 2018 to
Pilots (N =
Jan to April
2019 Complete 
April to May
2019 Complete 
April to July
2019 Complete 
Technologies 2020, 8, 40 37 of 51
(N = 1050)
– phase 2
Pilots (N =
on of tool
—as is and
ent of tool
(Tool 1, 2, 3, 4,
Tool 1 and 2
of Tool 1
and 2 with
N = 7
Tool 1 and 2
N = 2 Customer
2019 Complete N/A
n of Fogg
relation to five
Jan to Feb
2020 Complete 
Technologies 2020, 8, 40 38 of 51
on of tools
Tool 1 and
(N = 1050)
to April 2020 Complete 
on of tools
on of risk
Tool 1 and 2
to April 2020 Complete N/A
in the field
(N = 9)
April 2020 Complete N/A
Technologies 2020, 8, 40 39 of 51
Appendix C: Lived Experience Model (High Level)
Figure A1. Lived experience model (Cahill et al., 2019).
Technologies 2020, 8, 40 40 of 51
Appendix D: Sources of WRS (Pre COVID-19)
Figure A2. Sources of WRS, Pre COVID-19 (Cahill et al., 2019).
Technologies 2020, 8, 40 41 of 51
Appendix E: COVID-19, Wellness Positives and Challenges
Table A3. COVID-19, pilot wellness positives and challenges.
Wellbeing Challenges and
Sources of Stress
1 In work
Salary and financial wellbeing
Getting out of the house
Purpose obtained from job
Flying in a different environment
Keeping track of changing
Managing childcare while
Uncertainty as to future financial
Different treatment of
Uncertainty about status of co-
pilot (severity of suffering)
Loss of social network
Difficulties maintaining social
Potential illness/health challenges
2 Out of work
More time with family
Opportunity to take exercise (albeit
limited with government rules/2 km)
salary or unemployment
Uncertainty as to financial
Loss of social network
Difficulties maintaining social
Not enough ‘me time’
Too much time with family
Lack of routine
Loss of social network
Difficulties maintaining social
Potential illness/health challenges
3 Returning to
Getting out of the house
Purpose obtained from job
Loss of social network
Job proficiency and potential loss
Training and competency—out of
Ability to assess own wellbeing
If suffering, confidence in own
ability to do the job safely
Uncertainty about status of co-
pilot (severity of suffering)
Technologies 2020, 8, 40 42 of 51
Health challenges in family
Appendix F: Tools and Processes
Figure A3. As Is Process.
Figure A4. Future process.
Figure A5. Pilot on duty: Tool 1 and process, Tool 1 (pilot off duty).
Technologies 2020, 8, 40 43 of 51
Figure A6. Pilot off duty: Tool 2 and process, Tool 2 (pilot on duty).
Appendix G: Provisional Risk Assessment Algorithm
Table A4. Provisional risk assessment algorithm.
Classification Factor Factor
Risk Rating (Based on Data
Sleep and fatigue
How feeling (stress)
Emotional stability and mood
Talking to others/seeing
Overall Biological Rating
H M L
Overall Psychological Rating
H M L
Overall Social Rating
H M L
Overall Wellness Risk
H M L
Technologies 2020, 8, 40 44 of 51
Appendix H: Auto Harvesting Pilot Wellness Information
Table A5. Auto harvesting pilot wellness information.
ion Factor Factor Specific Info
Wellness App or
Other App (Auto
1 Sleep and
No. of hours
If using other, get
Otherwise, 1 or 2
Alert (if using)
Or Garmin or
No of steps Garmin or Fitbit
If not other app, 1
question each day?
If using MH
app, take self-
report from that
If not other app, 1
question each day?
If using MH
app, take from
1 question each
If using mobile
you do X?
Appendix I: Prototype Examples (Tool 1)
Figure A7. Pilot phone: dashboard.
Technologies 2020, 8, 40 45 of 51
Figure A8. Tool 1: dashboard.
Figure A9. Tool 1: Tracking and reporting dashboard.
Figure A10. Tool 1: my airline dashboard.
Technologies 2020, 8, 40 46 of 51
Figure A11. Tool 1: anonymous safety reporting.
Appendix J: Extended I am Safe Checklist
Table A6. Extended I am Safe Checklist.
I Illness and
Do I have an illness or any symptoms of an illness?
Am I feeling good/well? How is my overall health and wellbeing?
Emotional/Psychological Health? What is my mood and attitude like?
Social Health? Have I seen family/friends? Getting help/support if needed?
Have I been taking prescription or over-the-counter drugs?
S Stress and Stress
Am I under psychological pressure from the job? Worried about financial
matters, health problems or family discord?
Am I actively managing my stress? Exercise? Social? Do I need help?
Have I been drinking within eight hours? Within 24 h?
Am I tired and not adequately rested? Have I been managing my sleep?
Am I adequately nourished and hydrated? Am I taking physical exercise?
1. Elkington, J. Enter the Triple Bottom Line. 1994. Available online: https://johnelkington.com/archive/TBL-
elkington-chapter.pdf (accessed on 11 October 2019).
2. Elkington, J. Cannibals with Forks: The Triple Bottom Line of 21st Century Business; Capstone: Oxford, UK,
3. Elkington, J. 25 Years Ago I Coined the Phrase “Triple Bottom Line.” Here’s Why It’s Time to Rethink It; Harvard
Business Review; 2018. Available online: https://hbr.org/2018/06/25-years-ago-i-coined-the-phrase-triple-
bottom-line-heres-why-im-giving-up-on-it (accessed on 11 October 2019).
4. Sengenberger, W. The International Labour Organization: Goals, Functions and Political Impact; Friedrich Ebert
Stiftung: Berlin, Germany, 2013.
5. International Labour Organisation. Decent Work Agenda. 2020. Available online:
https://www.ilo.org/global/topics/decent-work/lang--en/index.htm (accessed on 24 April 2020).
6. Rodgers, G.; Lee, E.; Swepston, L.; Van Daele, J. The International Labour Organization and the Quest for
Social Justice, 1919–2009 (PDF). Geneva: International Labour Organization. 2019. Available online:
04643.pdf (accessed on 23 January 2020).
Technologies 2020, 8, 40 47 of 51
7. Cahill, J.; Cullen, P.; Gaynor, R. Interventions to support the Management of WRS & Wellbeing Issues for
Commercial Pilots. Cogn. Technol. Work 2019, doi:10.1007/s10111-019-00586-z.
8. Cahill, J.; Cullen, P.; Gaynor, K. Estimating the Impact of Work-Related Stress on Pilot Wellbeing and Flight
Safety’. In Proceedings of the 2nd International Symposium on Human Mental Workload: Models and
Applications (H-WORKLOAD 2018), Netherlands Aerospace Centre (NLR), Amsterdam, The Netherlands,
20–21 September 2018.
9. European Aviation Safety Agency (EASA) rules European Union Aviation Safety Agency (EASA). (2019).
Commission Regulation (EU) No 965/2012 on Air Operations and associated EASA Decisions (AMC, GM
and CS-FTL.1), Consolidated version for Easy Access Rules, Revision 12 March 2019. Part ORO, Annex II,
Part ORO, ORO.GEN.200 Management Systems and associated Acceptable Means of Compliance (AMCs)
and Guidance Material (GMs). Available online:
ch%202019.pdf (accessed on 2 May 2018).
10. Bureau d'Enquêtes et d’Analyses pour la Sécurité de l’Aviation Civile (BEA). Accident on 24 March 2015 at
Prads-Haute-Bléone (Alpes-de-Haute-Provence, France) to the Airbus A320-211 registered D-AIPX
operated by Germanwings. Final Report. March 2016. Available online:
https://www.bea.aero/uploads/tx_elydbrapports/BEA2015-0125.en-LR.pdf (accessed on 2 May 2018).
11. Atherton, M. A question of psychology. 2019. Available online: https://www.aerosociety.com/news/a-
question-of-psychology/ (accessed on 6 March 2019).
12. European Union Aviation Safety Agency (EASA). (2017). Part-ORO—Organisation Requirements for Air
Operations. Available online: https://www.easa.europa.eu/acceptable-means-compliance-and-guidance-
material-group/part-oro-organisation-requirements-air (accessed on 17 July 2019).
13. Anthony, T. Avoiding another Germanwings. Proceedings of the International Pilot Peer Assist Conference
(IPPAC)—October 25-26, 2019, Texas USA. Available online: http://pilotpeerassist.com/international-pilot-
peer-assist-conference/ (accessed on 13 May 2020).
14. Atherton, M. Mental Wellbeing & Human Performance Seminar. Published by the RaeS. 2020. Available
online: https://youtu.be/pT8uB7fVV44 (accessed on 11 May 2020).
15. Dickens, P. Cleared for Take-off. A Pilot’s Guide to Returning to Flying. 2020. Available online:
https://www.core-ap.co.uk/challenging-times (accessed on 11 May 2020).
16. Cahill, J.; Cullen PAnwer, S.; Gaynor, K.; Wilson, S. Pilot Work Related Stress (WRS), Effects on Wellbeing
and Mental Health, and Coping Methods. Part of the Mental Wellbeing & Human Performance Seminar.
Published by the RaeS. 2020. Available online: https://youtu.be/pT8uB7fVV44 (accessed on 11 May 2020).
17. Flight Safety Foundation. An Aviation Professional’s Guide to Wellbeing. 2020. Available online:
https://flightsafety.org/wp-content/uploads/2020/04/Guide-to-Wellbeing.pdf (accessed on 11 May 2020).
18. European Union Aviation Safety Agency (EASA). Together 4 Safety. 2020. Available online:
https://www.easa.europa.eu/easa-and-you/safety-management/safety-promotion/ (accessed on 11 May
19. Josephs, L. American Airlines cutting international summer schedule by 60% as coronavirus drives down
demand. CNBC News, 2 April. Available online: https://www.cnbc.com/2020/04/02/coronavirus-update-
american-airlines-cuts-summer-international-flights-by-60percent-as-demand-suffers.html (accessed on 30
20. Sobieralski, J. COVID-19 and Airline Employment: Insights from Historical Uncertainty Shocks to the
Industry. 2020. Available online: https://www.sciencedirect.com/science/article/pii/S2590198220300348
(accessed on 30 April 2020).
21. Engel, G. The need for a new medical model: A challenge for biomedical science. Science 1977, 196, 126–129.
22. Ghaemi, S. The rise and fall of the biopsychosocial model. Br. J. Psychiatry 2009, 195, 3–4.
23. Borrell-Carrió, F.; Suchman, A.L.; Epstein, R.M. The biopsychosocial model 25 years later: Principles,
practice, and scientific inquiry. Ann. Fam. Med. 2004, 2, 576–582, doi:10.1370/afm.245.
24. Lehman, B.J.; David, D.M.; Gruber, J.A. Rethinking the biopsychosocial model of health: Understanding
health as a dynamic system. Soc. Pers. Psychol. Compass 2017, 11, e12328.
25. World Health Organisation. Mental Health. 2019. Availble from https://www.who.int/mental_health/en/
(accessed on 23 January 2019).
Technologies 2020, 8, 40 48 of 51
26. Flinchbaugh, C.; Luth, M.; Li, P. A Challenge or a Hindrance? Understanding the Effects of Stressors and
Thriving on Life Satisfaction. Int. J. Stress Manag. 2015, 22, doi:10.1037/a0039136.
27. Houtman, I.; Jettinghoff, K. Raising Awareness of Stress at Work in Developing Countries a modern hazard
in a traditional working environment. In WHO Protecting Workers Health, Series 6; WHO Press: Geneva,
28. Skybrary. Stress and Stress Management. Available online:
https://www.skybrary.aero/index.php/Stress_and_Stress_Management (OGHFA_BN) (accessed on 12
29. Lazarus, R S. Theory-based stress measurement. Psychol. Inq. 1990, 1, 3–13.
30. Leka, S.; Griffiths, A.; Cox, T. Work Organisation & Stress: Systematic Problem Approaches for Employers,
Managers and Trade Union Representatives. (Protecting Work-ers’ Health Series: No. 3). World Health
Organization: Geneva, Switzerland, 2003.
31. Theorell, T.; Karasek, R.A. Current issues relating to psychosocial job strain and cardiovascular disease
research. J. Occup Health Psychol. 1996, 1, 9–26.
32. Joseph, C. Stress Coping Strategies in Indian Military Pilots: Preliminary Observations. Int. J. Aviat.
Aeronauctics Aerosp. 2016, 3, doi:10.15394/ijaaa.2016.1147.
33. Lazarus, R.; Folkman, S. Stress, Appraisal, and Coping. Springer: New York, NY, USA, 1984.
34. Morimoto, H.; Shimada, H. The Relationship between Psychological Distress and Coping Strategies: Their
Perceived Acceptability Within a Socio-Cultural Context of Employment, and the Motivation Behind Their
Choices. Int. J. Stress Manag. 2015, 22, 159–182, doi:10.1037/a0038484.
35. World Health Organisation (WHO). Mental Health. Available online:
https://www.who.int/mental_health/en/ (accessed on 12 May 2020).
36. Clark, D.M. Realizing the Mass Public Benefit of Evidence-Based Psychological Therapies: The IAPT
Program. Annu. Rev. Clin. Psychol. 2018, 14, 159–183.
37. Ijaz, S.; Davies, P.; Williams, C.J.; Kessler, D.; Lewis, G.; Wiles, N. Psychological therapies for treatment-
resistant depression in adults. Cochrane Database Syst. Rev. 2018, doi:10.1002/14651858.CD010558.pub2.
38. Pompoli, A.; Furukawa, T.A.; Imai, H.; Tajika, A.; Efthimiou, O.; Salanti, G. Psychological therapies for
panic disorder with or without agoraphobia in adults: A network meta-analysis. Cochrane Database Syst.
Rev. 2016, doi:10.1002/14651858.CD011004.pub2.
39. National Institute for Health and Clinical Excellence (NICE). Common Mental Health Problems:
Identification and Pathways to Care. Clinical Guideline [CG123] Published date: 25 May 2011. Available
online: https://www.nice.org.uk/guidance/cg123/chapter/1-guidance (accessed on 12 May 2020).
40. National Institute for Health and Clinical Excellence (NICE). Mental Wellbeing at Work. Public health
guideline [PH22] Published date: 05 November 2009. Available online:
https://www.nice.org.uk/guidance/ph22 (accessed on 12 May 2020).
41. Tetrick, L.; Winslow, C. Workplace Stress Management Interventions and Health Promotion (April 2015).
Annual Review of Organizational Psychology and Organizational Behavior, Volume 2, Issue 1, pp. 583–
603, 2015. Available at SSRN: https://ssrn.com/abstract=2594246 (accessed on 20 May 2020).
42. Ruotsalainen, J.; Serra, C.; Marine, A.; Verbeek, J. Systematic review of interventions for reducing
occupational stress in health care workers. Scand. J. Work Environ. Health 2008, 34, 169–178,
43. Karasek, R. Stress prevention through work reorganization: A summary of 19 international case studies. In
ILO: Conditions of Work. Digest—Preventing Stress at Work; International Labour Organisation, Geneva,
Switzerland. 1992; Volume 11, pp. 23–41.
44. Tarro, L.; Llauradó, E.; Ulldemolins, G.; Hermoso, P.; Solà, R. Effectiveness of Workplace Interventions for
Improving Absenteeism, Productivity, and Work Ability of Employees: A Systematic Review and Meta-
Analysis of Randomized Controlled Trials. Int. J. Environ. Res. Public Health 2020, 17, 1901.
45. Odeen, M.; Magnussen, L.H.; Maeland, S.; Larun, L.; Eriksen, H.R.; Tveito, T.H. Systematic review of active
workplace interventions to reduce sickness absence. Occup. Med. 2013, 63, 7–16.
46. Kenny, A. Aristotle: The Eudemian Ethics; Oxford University Press: Oxford, UK, 2011.
47. Seligman, M. Authentic Happiness: Using the New Positive Psychology to Realize Your Potential for Lasting
Fulfillment; Free Press: New York, NY, USA, 2002.
Technologies 2020, 8, 40 49 of 51
48. Fikretoglu, D.; McCreary, D.R. Psychological Resilience: A Brief Review of Definitions, and Key
Theoretical, Conceptual, and Methodological Issues. Technical Report DRDC Toronto TR 2012-012. 2012.
Available online: www. cradpdf.drdc-rddc.gc.ca/PDFS/unc121/p536951_A1b. pdf (accessed on 3 July 2018).
49. Bandura, A. Self-efficacy mechanism in human agency. Am. Psychol. 1982, 37, 122–147.
50. Jordan, T.R.; Khubchandani, J.; Wiblishauser, M. The Impact of Perceived Stress and Coping Adequacy on
the Health of Nurses: A Pilot Investigation. Nurs. Res. Pract. 2016, 2016, doi:10.1155/2016/5843256.
51. Blazer, D.G. Self-efficacy and depression in late life: A primary prevention proposal. Aging Ment. Health
2002, 6, 315–324.
52. Harris, D. Human Performance on the Flight Deck; Ashgate Publishing Limited, Taylor & Francis Group,
Surrey, England: 2011.
53. Moriarty, D. Practical Human Factors for Pilots; Academic Press: London, UK, 2015.
54. Roscoe, A.H. Stress and workload in pilots. Aviat. Space Environ. Med.1978, 49, 630-633.
55. Stokes, A.; Kite, K. Flight Stress: Stress, Fatigue and Performance in Aviation; Routledge, London. 1994.
56. Eurocontrol. Human Factors Module Critical Incident Stress Management. Available online:
https://www.skybrary.aero/bookshelf/books/4578.pdf (accessed on 11 June 2020).
57. Civil Aviation Authority. Aeronautical Information Circular. Post-Traumatic Stress. Available online:
https://www.skybrary.aero/bookshelf/books/2628.pdf (accessed on 11 June 2020).
58. Fine, P.M.; Hartman, B.O. Psychiatric strengths and weaknesses of typical Air Force pilots. In Brooks Air
Force Base; Report No SAM- TR-68-121; USAF School of Aerospace Medicine: Texas, USA, 1968;
59. Picano, J. An empirical assessment of stress-coping styles in military pilots. Aviat. Spaceenviron. Med. 1990,
60. Cooper, C.; Sloan, S. Occupational and psychological stress among commercial airline pi-lots. J. Occup. Med.
1985, 27, 570–576.
61. Karlins, M.; Koss, F.; McCully, L. The spousal factor in pilot stress. Aviat. Space Environ. Med. 1989, 60, 1112–
62. Bennett, S.A. A longitudinal ethnographic study of aircrews’ lived experience of flying operations at a low-
cost airline. Risk Manag. Int. J. 2006, 8, 92–117.
63. Meland, A.; Fonne, V.; Wagstaff, A.; Pensgaard, A.M. Mindfulness-based mental training in a high-
performance combat aviation population: A one-year intervention study and two-year follow-up. Int. J.
Aviat. Psychol. 2015, 25, 48–61.
64. Caldwell, J. Fatigue in the aviation environment: An overview of the causes and effects as well as
recommended countermeasures. Aviat. Space Environ. Med. 1997, 68, 932–938.
65. Bor, R.; Eriksen, C.; Oakes, M.; Scragg, P. (Eds.) Pilot mental health assessment and support. In A
Practitioner’s Guide; Routledge: Abington, UK, 2016.
66. Feijó, D.; Luiz, R.R.; Camara, V.M. Common mental disorders amonst civil aviation pilots. Aviat. Space
Environ. Med. 2012, 83, 509–513.
67. Wu, A.C.; Donnelly-McLay, D.; Weisskopf, M.G.; McNeely, E.; Betancourt, T.S.; Allen, J.G. Airplane pilot
mental health and suicidal thoughts: A cross-sectional descriptive study via anonymous web-based survey.
Environ. Health 2016, 15, 1–12, doi:10.1186/s12940-016-0200-6 9.
68. Pasha, T.; Stokes, P. Reflecting on the Germanwings Disaster: A Systematic Review of Depression and
Suicide in Commercial Airline Pilots. Front. Psychiatry 2018, 9, 89, doi:10.3389/fpsyt.2018.00086.
69. O’Hagan, A.D.; Issartel, J.; Nevill, A.; Warrington, G. Flying into Depression. Workplace Health Saf. 2017, 65,
70. International Civil Aviation Authority (ICAO). Annex 19—Safety Management. 2013. Available online:
%20ICAO%20presentation%20-%20self%20instruction%2024September2013.pdf (accessed on 17 July 2019).
71. International Civil Aviation Authority (ICAO). Safety Management Manual (SMM), Document 9859. Third
Edition. Available online: https://www.skybrary.aero/bookshelf/books/644.pdf (accessed on 2 May 2020).
72. Cahill, J.; McDonald, N.; Losa, G. Enhancing human performance and overall flight safety through
improvements in airline system information flow. In Proceedings of the 28th Conference of the European
Association for Aviation Psychology, Valencia, Spain, 27–31 October 2008.
73. Cahill, J. Flight Crew Task Performance and the Requirements for a New Tool Supporting the Pre-flight,
Flight Planning and Briefing Task. 2010. Doctoral dissertation, Trinity College Dublin, Dublin, Ireland.