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The Charity

Aviation

Maritime

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FEEDBACK

CCFB 84

A ‘Just Culture’ is a two-way street

274 CHIRP reports from cabin crew have been received thus far in 2024 and 83 of them reference pressures of one kind or another, including time and commercial/financial pressures. Including reports from flight crew, almost 60% of CHIRP reports this year indicate significant pressures in the system, and some of these reports corroborate that crew members may be tempted to take short cuts in order meet deadlines or fulfil targets.

We know that working in aviation requires crew to be flexible of course, but crew must not succumb to the pressures to compromise safety or conduct the task at hand if things aren’t right or sensible, for example skipping a nutritional break on one day is flexible, but doing it consistently isn’t right or sensible. It’s important no matter how small a safety concern may seem that you report it, for example missing just one nutritional break because of heavy loads and delays happen all the time, but you should report that to your operator as who knows what the next few days will bring?

Sometimes on line we don’t have the bigger picture and so it’s difficult to understand management policy and decisions, our perspectives and expectations might differ greatly to that of the operator. Either way, reporting internally into your operator’s safety management system (SMS) processes is important. Effective change cannot happen without data, observations, and open communication to support the need for it. All crew need to do their part and apply procedures and practices in a safe and responsible manner, and crew equally need to highlight when this is not possible to their operator. A ‘Just Culture’ is a two-way street: the organisation must ensure an atmosphere of trust, where people are encouraged to provide essential safety information; that’s easy to say and hard to do, but it’s a fundamental part of safety.

Stay safe! Jennifer Curran.

  • CC6506

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    No flight crew for disembarkation
    No flight crew for disembarkation

    Initial Report

    Landed back into {Airport} from {Airport} after a 12-hour duty. During disembarking the business class passengers disembarked the aircraft, then to our surprise followed by all 3 flight crew with one saying ‘I have a flight to {Airport} to catch’ so all 3 of them left with all the economy passengers still on board. No word to the crew at the rear of the aircraft, if there was an issue or we had to do a rapid disembarkation we would have not been able to facilitate this because they were not there.

    Company Comment

    We have received cabin safety reports about this topic and, along with this CHIRP report, we have updated the procedure in the operations manual. Working with the team in Flight Operations, the revised procedure was communicated in April [2024] which states that when there are passengers onboard one flight crew member must be on the aircraft. There is an exemption during a transit stop for a very small (1-2) number of destinations on the route network, these are supported with a specific process in the operations manual.

    Our company procedures have been updated by Flight Operations as below. [Changes highlighted in italic]

    While passengers are onboard, one flight crew member must be on the aircraft, unless exempt under [OM B reference regarding transit stops]

    One flight crew member should normally be on the flight deck. Cabin crew changes should not be made until the passengers due to leave the aircraft have disembarked. When cabin crew are scheduled to stay on the aircraft:

    A cabin crew member must stay by each open door at all times;

    SCCMs must obtain permission from the Commander before allowing cabin crew to leave the aircraft;

    When flight crew are not present, Cabin crew must ensure that unauthorised people cannot enter the flight deck.

    CAA Comment

    AMC2 ORO.GEN.110(e) Operator responsibilities permits passengers to be on board the aircraft in the absence of Flight Crew provided that suitable procedures are in place to alert aerodrome services in the event of an emergency. It is for the operator to ensure that appropriate procedures are in place, they are being applied correctly, and that they have been robustly communicated to all relevant parties.

    CHIRP Comment

    CHIRP Cabin Crew Advisory Board Comment

    Through crew reporting their concerns internally alongside this CHIRP report a procedural change has been made, a great example of how your report can make a difference!

     

    CHIRP Air Transport Advisory Board Comment

    We commend the company concerned for their rapid response to our observations and the subsequent changes made to their procedures to reflect the reporter’s comments; this reinforces the value of reporting concerns.

    However, other companies seem to be more relaxed about no flight crew being present when passengers are on the aircraft and AMC2 ORO.GEN.110(e) Operator responsibilities (reproduced below) permits this to occur as long as someone can contact the emergency services if something happens. We do not think that this is a particularly robust policy. If an emergency happens, then the cabin crew will be absorbed in getting the passengers off in a hurry and, for their part, ground handling personnel may or may not be quick enough to call emergency services depending on where the emergency starts: they may not even be aware of an emergency for a considerable period (for example an internal cabin fire at the back of the aircraft from a lithium battery runaway might not be obvious to ground handlers for a long time).

    In regulatory terms, CAT.GEN.MPA.105 Responsibilities of the commander simply states at Para (a)(1) that: “The commander…shall be responsible for the safety of all crew members, passengers and cargo on board, as soon as the commander arrives on board the aircraft, until the commander leaves the aircraft at the end of the flight;” but it is silent as to who this responsibility falls to if the commander leaves the aircraft at the end of the flight before the passengers. At the very least, we consider that CAT.GEN.MPA105 should require commanders to positively ensure that someone else takes on their responsibilities if they leave the aircraft before the passengers and other crew.

    We also think that more consideration ought to be given to the appropriateness of AMC2 ORO.GEN.110(e) given that if an aircraft emergency did occur without flight crew on the aircraft, what is the reality of the cabin crew being able to coordinate aerodrome services in a timely manner whilst potentially simultaneously trying to evacuate passengers from the aircraft?

    AMC2 ORO.GEN.110(e) Operator responsibilities

    GROUND OPERATIONS WITH PASSENGERS ON BOARD IN THE ABSENCE OF FLIGHT CREW

    For ground operations, whenever passengers are embarking, on board or disembarking in the absence of flight crew members, the operator should:

    (a) establish procedures to alert the aerodrome services in the event of ground emergency or urgent need; and

    (b) ensure that at least one person on board the aircraft is qualified to apply these procedures and ensure proper coordination between the aircraft and the aerodrome services.

     

     

  • CC6524

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    Fit to Fly
    Fit to Fly

    Initial Report

    Approximately four weeks ago, I developed mild cold/flu like symptoms. I felt unwilling to call unfit as I had had a period of absence recently and a second period of absence within that time scale would have triggered the first stage of the absence management policy. With each additional stage, the number of absences before disciplinary proceedings are started, reduce. The pressure not to trigger a stage overwhelms better judgement about self-assessing fitness to operate. When calling unfit, initial reactions are often hostile and suspicious with a feeling of being interrogated and pressured into describing sickness details and divulging medical information to colleagues. I continued to fly and my cold symptoms worsened. After managing to secure a doctor’s appointment I was told I had a large perforation to my eardrum. Having already had a period of six days absence, I face the prospect of losing pay entirely after three weeks, which conflicts with my unwillingness to return to work too soon after this injury and risk permanent hearing damage.

    When routine illnesses are picked up, there is an unwillingness to report unfit due to the absence management process which can result fairly quickly in disciplinary procedures from a relatively small number of absences. This is in direct conflict with the legal requirement to not exercise the privileges of our attestation when unfit. In the case of longer absences for injuries/ medical conditions where flying is not possible or recommended by a physician, the sick pay provision is not adequate. 4 weeks’ pay in any 12 month rolling period which can quickly be exhausted through a small number of short term absences. The nature of the pay structure where base salary is very low and variable pay represents a large proportion of total pay also contributes to an unwillingness to report unfit.

    Due to the above factors, a situation arises where crew members continue to come to work when they shouldn’t in order to continue to receive enough variable pay resulting in the higher chance of developing more severe conditions (e.g. perforated eardrums) and then there is an increasing likelihood that cabin crew will return to work sooner than they should because of the prospect of losing pay altogether and the risk of entering a disciplinary process under the absence management policy.

    The resulting significantly increases the risk of significant escalation of medical conditions/ injuries. E.g.; permanent hearing loss after receiving pressure to return to work following a perforated eardrum, the cause of which was continuing to fly whilst experiencing cold symptoms.

    Although there isn’t one specific individual that is verbally persuading us to go to work when sick, the systems, policies and procedures in place are built to do so. The threat of going into performance and attendance stages/ development plans, the worry of not being paid, the way you’re spoken to when calling in to inform them you are not fit to fly, the passive aggressive emails/phone calls from managers. It all intertwines to create an environment in which you’re scared/ worried about having to call in sick.

    Company Comment

    Cabin crew must report for duty ‘fit to fly’.  There is a sickness management process, the management team utilises this process to support colleagues.  At no time should a crew member feel they must operate a flight if they are not fit.  If a crew member has been pressured to operate in some way, we would encourage them to complete a safety report.  This will allow the report to be reviewed and managed under our Just Safety culture programme.

    CAA Comment

    Whilst it is recognised that operators have a need to monitor and manage sickness absence from a duty of care and in order to identify any potential decrease in medical fitness that could affect the validity of a medical report, such policies should be fair and ensure that cabin crew are not encouraged to operate when unfit to do so.  Examples being financial reward for low individual sickness absence or the withholding of financial reward for higher sickness absence.

    CHIRP Comment

    Sickness and absence are routinely tracked (as is customary in all businesses) and all operators will have various policies in place. Whereas working with blocked ears might be ok in a ground based job, it is not ok in the flying environment and could cause an illness to worsen. The Office for National Statistics reported that ‘In 2022 there were 185.6 million working days lost to sickness in the UK. This is an average of 5.7 days off sick per employee’ which is possibly higher than some operators attendance programmes.  https://www.safeworkers.co.uk/health-wellbeing/average-sick-days-uk

    The reporter raises concerns about some crew feeling that they are too afraid to report sick or unfit. As the UK CAA stipulates in MED.A.020 ‘Decrease in medical fitness: Cabin crew members shall not perform duties on an aircraft and, where applicable, shall not exercise the privileges of their cabin crew attestation when they are aware of any decrease in their medical fitness, to the extent that this condition might render them unable to discharge their safety duties and responsibilities’ is it likely that cabin crew on average may be off sick more than the 5.7 days mentioned above?

    CHIRP continues to voice its concerns to the UK CAA regarding absence policies and CHIRP is aware that the CAA Flight Ops Liaison Group (FOLG) is developing guidance on industry best practices for absence and sickness management plans.

    This topic was discussed further in the editorial of CCFB edition 79. For advice on healthy living please visit the NHS website https://www.nhs.uk/live-well/

  • CC6660

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    Push back whilst pax still boarding
    Push back whilst pax still boarding

    Initial Report

    Boarding was from door 2 Left. Lots of hand baggage. The last pax boarded and the ground staff requested for the main pax door to be closed. I closed the pax door and immediately  called the flight crew to advise of the situation on the cabin. Advising them that the last pax had just boarded but the queue for the pax making their way to their seats was congested and backed all the way back to door 2. So pax queuing from door 2 Left and Right virtually down to door 4 Left and Right. I also advised  them that all the overhead lockers were still open and loaded with heavy bags. I asked the flight crew to hold off pushing back until we had the situation under control. Despite this a couple of mins later we started to push back.  This delayed us being to arm our doors as some crew on the left hand side could not get to their door due to the congestion in the cabin and them being  in the cabin trying to manage the situation of hand baggage and the queue of pax still making their way to their seats. After take-off I spoke with the captain and asked why after communicating the situation in the cabin did we still push back. I was told to look at OM where it states that “This procedure should not prevent the aircraft from pushing back”.

    Company Comment

    We know that boarding is the busiest time of the crew members’ duty. During boarding, it is important for crew members who do not have door ground responsibility to manage the cabin, overhead lockers and stowage of passengers’ smaller items under the seat in front.  The SCCM may consider crew from other cabins to assist where required and reduce the offering of the pre-departure service until after take-off.  We would recommend completing the required report. The reporter is correct, that our procedure cited in the manual permits the aircraft to push back, yet taxi will not commence unless the cabin is in an acceptable state which relies on the SCCM maintaining communication with the flight crew, which it appears in this situation did occur. If it is felt that the conditions in the cabin are not being taken into consideration we encourage reporting on this also.

    CAA Comment

    Pushback is not specifically covered under regulatory requirements as other phases of flight, including taxi, are.

    CAT.OP.MPA.225 Seats, safety belts and restraint systems

    (b) Passengers

    (1) Before take-off and landing, and during taxiing, and whenever deemed necessary in the interest of safety, the commander shall be satisfied that each passenger on board occupies a seat or berth with his/her safety belt or restraint system properly secured.

    CAT.OP.MPA.230 Securing of passenger compartment and galley(s)

    (b) The commander shall ensure that before take-off and landing, and whenever deemed necessary in the interest of safety, all equipment and baggage are properly secured.

    AMC1 CAT.OP.MPA.160 Stowage of baggage and cargo

    (g) checks should be made before take-off, before landing and whenever the ‘fasten seat belts’ signs are illuminated or it is otherwise so ordered to ensure that baggage is stowed where it cannot impede evacuation from the aircraft or cause injury by falling (or other movement), as may be appropriate to the phase of flight.

    CAT.GEN.MPA.105 Responsibilities of the commander

    (a) The commander, in addition to complying with CAT.GEN.MPA.100, shall:

    (1) be responsible for the safety of all crew members, passengers and cargo on board, as soon as the commander arrives on board the aircraft, until the commander leaves the aircraft at the end of the flight.

    Under CAT.OP.MPA.225 and CAT.OP.MPA.230, the provision of ‘whenever deemed necessary in the interest of safety’ was intended to cover eventualities such as turbulence, decompression and other emergencies or unforeseen circumstances. Amending the regulations above, or CAT.OP.MPA.205, is not a quick process as inferred by CHIRP, and is not currently on the Flight Operations Rulemaking programme. Amending implementing rules is currently a 2-3 years-long process.

    If an operator permits passengers to be standing during pushback, what would be of interest is what risk assessment has been performed, and how identified risks are managed/mitigated.

    CHIRP Comment

    CHIRP Cabin Crew Advsiory Board Comment 

    CHIRP has received several reports of this nature. Whilst the Air Navigation Order (ANO) is clear about PAX being seated during taxi and ‘prior to taxiing…’, there’s no specific reference to push-back – provided that the PAX are seated prior to taxiing under the aircraft’s own power (i.e. after push-back?) then the regulation is said to have been complied with.

    The Air Navigation Order 2016 PART 5, CHAPTER 2, SECTION 2, Article 71 states that:

    Passengers to be seated and properly secured

    1. The pilot in command of an aircraft other than a balloon must ensure that—

    (a)prior to and during taxiing, take-off and landing; and

    (b)whenever deemed necessary in the interest of safety,

    each passenger on board occupies a seat or berth and has their safety belt or restraint device properly secured.

    As always if the conditions in the cabin are as this report states and unsafe, then communication must take place with the flight crew to advise them of the situation in the cabin. We would hope that if conditions in the cabin were as above, and that the flight crew had been advised of the conditions that the safety of the passengers and crew on board would be taken into consideration.

     

    CHIRP Air Transport Advisory Board Comment 

    There are clear risks in conducting pushback whilst passengers are not seated, and even greater when they may still be stowing bags; it wouldn’t take much for a sudden stop during pushback to cause chaos and potentially passenger injuries. Also, if there was not enough room for bags in the overhead lockers then some might need to go into the hold so, if the aircraft doors are closed and pushback has begun, this would obviously not be possible. The fact that the cabin crew could not make their way to the doors in some of these situations during pushback also has clear safety implications if an emergency were to occur. We do not think that it is sensible to pushback whilst passengers are not seated, no matter what the operational pressures might be to do so.

    More philosophically, passengers will be unlikely to be able to differentiate between pushback and taxiing and so, if they perceive that the aircraft is moving for pushback and they are not required to be seated, they will not understand why there is a restriction when the aircraft is taxiing (either before take-off or after landing); in their minds there is, understandably, no difference.

    As noted by the CAA, CAT.OP.MPA.230 Securing of passenger compartment and galley(s) does not include any reference to pushback and simply requires operators to have procedures for securing the cabin for only taxi, take-off and landing, not during pushback.

    For its part, AMC1 CAT.OP.MPA.205 Push back and towing – aeroplanes seems to refer to pushback and towing as ‘pre- or post-taxi positioning…’ thereby implying pushback is not a part of taxiing and seeming to reinforce the inapplicability of Article 71 to have passengers seated.

    It appears then that there is a loophole in the regulations because pushback is not necessarily within the definition of ‘taxiing’. It seems common-sense to us that passengers should be seated before pushback and that this loophole could be closed by the ANO including something like: “Prior to and during pushback, taxiing, take-off and landing…’ but we recognise that ANO changes are not a quick solution.

    In the interim, the CAA might consider amending CAT.OP.MPA.205, CAT.OP.MPA.225 and CAT.OP.MPA.230 to specifically include passengers being seated for pushback. With some airports moving towards aircraft being towed to the holding point in future to save fuel/ noise/ emissions etc, this issue will only become more pertinent.

    For those companies that allow pushback with passengers standing and potentially stowing bags, we assume that they have processes in place to risk-assess such practices; this risk assessment should probably involve their legal teams in consideration of any potential injuries that might be caused to passengers from falls or from baggage drops from overhead bins should an abrupt stop, abnormality or unsteady progress occur during the pushback.

  • CC6489

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    Crewing disturbing resting periods
    Crewing disturbing resting periods

    Initial Report

    Crewing disrupted my resting period after a long day shift. I finished my duty and arrived home at around 00.15 AM. Crewing called me constantly from 05.39AM. It only stopped after I was fully awake and switched off my phone. This was 4 hours after I went to bed to have my rest. My duty had been a long 4 sector day which finished at 23:41. Because of this situation, I suffered from sleep deprivation the whole day.

    Company Comment

    Crew are not required to answer their phone during their rest period and we do encourage crew to utilise the do not disturb feature of their device. We also encourage crew to report any such concerns they have in relation to their duty or interrupted rest. This allows a thorough investigation to take place and crew reports are updated with findings. All our operations personnel are trained in FTLs and are aware of when they can contact crew.

    This issue has now been resolved and feedback was provided to the reporter via CHIRP. It was found that the crew member was called inadvertently following a mix up in telephone numbers

    CHIRP Comment

    As mentioned in editorial of CHIRP CC FEEDBACK edition 84 ‘Pressure’ is one of the most commonly reported key-issues to CHIRP and this report shows how pressure can originate from a variety of sources and is not limited to the crew members’ experiences on board the aircraft.

    CHIRP have received several reports of this nature and have raised their concerns regarding this practice. Crew are under no obligation to answer a call from crewing when they are off-duty. An operator should not be disturbing crew during their rest periods especially when it is clear that the crew member will be asleep and resting.

  • CC6669

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    Offload Cabin Crew
    Offload Cabin Crew

    Initial Report

    Recently with hundreds of promotions to cabin manager & an updated SCCM promotion course there is no procedure for crew to be offloaded when they do not display the required knowledge during the preflight briefing.  We are advised to “coach” them after an option discussion however this does not provide them with the required safety knowledge for the sectors that day. Subsequently if they are “coached” the SCCM has no way of following up their knowledge has improved.  This can lead to real concerns the crew member is potentially a safety risk / concern not only for that day but future flights. My operator has no protocol for offloading crew as on time departure is the priority.

    This is becoming more apparent as new cabin crew have no further mandatory training after their initial course. Their “recurrent training” is an automatic pass as their knowledge is “refreshed” there is no requirement for self-study or monthly quiz / areas highlighted to study.

    We now fear the lack of knowledge will result in mistakes through lack of up to date knowledge.

    Offloading crew will highlight self-study / refreshing knowledge is paramount for the role. Yet SCCM old & new have no defined process to offload a crew member of concern.

     

    Company Comment

    Our cabin crew training programmes meet and exceed that required of regulation. They require our crew to demonstrate their competency via a number of methods, including written proficiency checks (including online assessments) and practically in a simulated cabin environment. Training is the process to ensure that crew are competent to complete their role to the required standard. Our crew have a personal responsibility to maintain a thorough working knowledge of all safety and security procedures within the operations manuals and Notices to Crew.

    The pre-flight briefing is an opportunity to review this knowledge and learn from other crew members who may have experienced situations on board. Questions are determined based on recent events, either internally or by other operators and safety-related trends or identified risks, and all areas of the operations manuals are covered to maintain an overall good working knowledge. It is important to remember that crew members may feel under pressure in such situations and therefore our SCCMs are encouraged to coach crew to the correct answer, it is not a testing environment.

    If there were significant safety concerns related to a crew member’s ability to operate (this could apply to any number of situations, e.g. crew member become unfit on the way to work) then it may be that a decision is taken to stand the crew member down and a replacement sought. It is important that should this occur, a safety report is submitted so that we can investigate and ensure that the right level of support is offered to the crew member. It should also be noted that there have been many changes to ways of working in recent years, and the company is currently reviewing opportunities to support cabin crew knowledge between training cycles, with a number of initiatives being considered/implemented over the coming months.

    CAA Comment

    There is no regulatory requirement to establish individual cabin crew competency during a pre-flight briefing.  Where concerns are identified regarding a crew member’s knowledge of operational procedures, particularly where there is a deviation from procedure, it is appropriate that this is investigated to identify and address any causal factors.

    CHIRP Comment

    Operators procedures on dealing with crew members who may struggle during a briefing vary. Initially a well-being check is appropriate, after confirmation that it is appropriate to continue this may incur further questioning and/or coaching from the SCCM. It isn’t unusual for some people to feel put on the spot during a briefing, some people do just freeze in this situation, but it doesn’t mean that a crew member isn’t capable of performing the cabin crew role.

    Just as briefing procedures vary between operators, so do the next steps following an unsatisfactory briefing. Some operators have a question bank that can be used in this situation whilst others continue with the flight and coach throughout the day with the ability to raise concerns further if necessary.

    Of course new crew will need support because although they may have completed the training course, the next step is taking all of that training and to put things into practice. It is so important to support your colleagues at work, we were all new once and showing kindness and empathy can create a positive and productive environment on board.

  • CC6569

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    Issues Relating to Fatigue Safety Management System
    Issues Relating to Fatigue Safety Management System

    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 days’ 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 members’ 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 “a 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 crewmember’s alertness and ability to safely operate an aircraft or perform safety-related duties”. The effects of fatigue and an individual’s 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 shouldn’t be worried about what the next steps are.