Confidential Human Factors
Incident Reporting Programme
The Charity
Aviation
Maritime
CC6569
Initial Report
Upon receiving my roster I felt the minimum rest between a long duty day, my ground based training followed by another long duty day was unacceptable. I was primarily concerned with being taken off the ground duty upon encountering a delay and having this disrupt another month of rostering, but also felt concerned this wasn’t sufficient rest time. I contacted the crewing team to request either a shorter duty to achieve more rest given the organisation is seemingly over-crewed at present. I was told that while the timings were restrictive the duty was both EASA FTL and industrial agreement compliant and they wouldn’t accommodate my request.
I slept very poorly after the long duty day and felt very unrested for the ground duty and continued on. I also slept badly the following night however, I felt I was able to attend work though. On the last sector back to the UK I began to feel the effects of fatigue strongly. My speech was impaired, I was very slow at reacting and responding, thinking was challenging, and I was unable to locate my car for a long period of time, more so than usual after such a duty.
After speaking to a manager in person back at base they supported my desire to report fatigued and said it was encouraged as part of a Just Safety culture. None of the on duty managers at the time knew what the correct process was for reporting fatigue. I took it upon myself hours later to phone the management team and was told by an advisor that they didn’t understand why I was phoning fatigued when my duty had been completed. I explained that I thought this was the most appropriate action and also said I was feeling very confused and struggling to articulate myself well due to my fatigued state. Eventually I was registered fatigued and I completed a safety report to accompany this. I was emailed by a manager the next day and told I would be called the day after at 9am to discuss my report.
The manager stated that I was not fatigued and was in fact unrested. I disputed this and said I didn’t feel this to be the case as I truly felt awful and I was feeling so slow cognitively too. The manager stated they would continue with an unrested report and advised me to phone back to report as fit as I had been removed from my next duty in a few daysâ time. My roster was updated to reflect unrested instead of fatigue.
I was initially fearful of reporting fatigued through fear of negative repercussions from the company – upon discussing this with a number of other crew they all stated that it was not right to put in an actual fatigue report as “you get into big trouble” for doing so. It appears that my concerns were valid since I felt the manager dismissed the severity of my fatigue concerns and advised me that they didn’t agree with my own assessment of my fitness to operate. I have serious concerns over the robustness of the companies fatigue safety management system and the culture internally regarding expressing fatigue concerns.
The company also operate a 72 hour mandatory window for reporting safety related matters, which is why I felt it was prudent to report my concerns immediately after operating when I learnt that I was experiencing the effects of fatigue.
Company Comment
When a crew member reports for a duty, they have a personal responsibility to report fully fit and rested and able to complete all duties and requirements associated with the duty. If a crew member is not fit to fly, then they should follow the local processes documented in operations manual part A (OMA) available to cabin crew which details the fatigue process. When crew report for a duty, they are reporting to safely operate the maximum flight duty period. If there are any changes during this time to the crew membersâ level of alertness, the must inform the Commander and the SCCM. A crew member shall not perform duties in an aircraft if they know or suspect to be feeling the effects of fatigue or feels otherwise unfit, to the extent that the flight may be endangered.
The crew member said that they reported fatigue during their rest period or days off after a trip. It is typical that a crew member will feel the effects of tiredness when completing a duty or a period of duties and their rest days are a time to rest and catch up on sleep while they are free of all work-related tasks. If the crew member was still feeling the effects of fatigue and were unable to sleep ahead of their next duty i.e. the evening before or on the day, depending on the start of their report time, then they should follow the fatigue process in OMA.
The safety team conduct fatigue investigations based on the information shared in their safety report and during the conversation with the crew member. This information will determine the outcome of the follow up. Regardless of the outcome decided by the safety manager, the period of time they are off the roster will form part of the fatigue process. The outcome of this conversation will likely place the crew into one of the following categories, Fatigue, Unfit or Unrested.
We strongly encourage crew to report not only when they have been ‘fatigued’ but also if they feel a roster has the ‘potential’ for being fatiguing, the safety management system has the functionality to support this. This has been communicated to crew on many occasions as well as forming part of the SCCM course so they can also support crew if asked at any time. Whether ‘unrested’, ‘unfit’ or ‘fatigued’ all fall under our fatigue management and are non-punitive when recorded. All instances also form part of the data that is reviewed at our Fatigue Action Group attended by Flight Operations and Trade Union Reps.
CHIRP Comment
ICAO defines fatigue as âa physiological state of reduced mental or physical performance capability resulting from sleep loss or extended wakefulness, circadian phase, or workload (mental and/or physical activity) that can impair a crewmemberâs alertness and ability to safely operate an aircraft or perform safety-related dutiesâ. The effects of fatigue and an individualâs susceptibility to it are not an exact science and there is often the debate about fatigue vs unrested vs tiredness. Naturally, following a lengthy duty day, one may anticipate to feel a certain amount of tiredness, particularly if the duty has disrupted their circadian rhythm and an individual is responsible for using their rest periods appropriately.
Fatigue reporting should be a clear process that both crew and management are aware of and regardless of whether it is classified as unrested or fatigued either roster code should be non-punitive. Fatigue is a hazard (as is unrested and tiredness) and the risks should be managed within the operators safety management systems (SMS) and/or the Fatigue Risk Management System (FMRS). The regulations state that the company must report a Mandatory Occurrence Report (MOR) within 72hrs which is why this is often reflected in internal reporting policies.
Once a crew member has reported fatigued operators have a responsibility to see if the fatigue could have been caused by a roster, rest or something else but that should be done at an appropriate time when the crew member is not in a fatigued state, the opportunity to rest is very important, and a fatigued crew member shouldnât be worried about what the next steps are.