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Pilot fatigue management plan

Issue number: MI-2010-011-SI-03
Who it affects: All ship operators, masters, pilots and pilotage providers
Issue owner: Australian Maritime Safety Authority, Australian Reef Pilots, Hydro Pilots and Torres Pilots
Operation affected: Marine: Shipboard operations
Background: Investigation Report 282-MI-2010-011
Date: 24 October 2012

Safety issue description

The coastal pilot fatigue management plan is inadequate.

Factors that limit the effectiveness of the fatigue management plan amongst the 82 pilots surveyed included the:

  • largely self-managed approach where individual pilots may have conflicting priorities relating to remuneration and other working arrangements
  • pilot travel and transfer times regularly being included in rest periods
  • variations in sleep patterns due to irregular working hours and the effect of multiple, consecutive pilotages not being taken into account
  • dispensations being granted from requirements and, when granting dispensations, the pilot’s agreement being used to support the fatigue risk assessment despite a clear conflict of interest with the pilot’s remuneration
  • lack of effective measures to ensure that fatigue during a single-handed pilotage, particularly in the Inner Route, never exceeds an acceptable level
  • reliance on self-recorded and self-monitored rest periods instead of actual fatigue levels and assessing sleep achieved.

Response from the Australian Maritime Safety Authority

The Australian Maritime Safety Authority (AMSA) advised the ATSB that:

AMSA disagrees that the current default plan is ‘inadequate’. This plan was developed based on best practice as provided through consultation with University South Australia sleep experts and the industry. AMSA is continuing to look at ways to improve fatigue issues and has included fatigue as a focus workshop element following the introduction of MO 54 issue 5.

The current research in fatigue, and the focus of the AMSA workshop, is looking to go beyond a ‘level 1’ fatigue plan (straight rostering/hours on and hours off). This includes looking closely at the opportunity for rest as well as the use of self regulating and the organisational response to self regulation.

Experience in the aviation world was presented at the workshop, including the concept of self and peer regulation of fatigue.
AMSA continues to take pilot fatigue seriously, encouraging providers to develop fatigue management plans (MO 54 issue 5 provision 93.3(a)). A process for assessing fatigue management plans has been developed and one such plan is being assessed.

AMSA provides a fatigue training program through the AMSA pilotage portal and e-learning options. AMSA has also put in place processes to enable approval of provider fatigue plans that meet best practice.

AMSA will also investigate the merits of a requirement for two pilots through the Inner Route and under what conditions this arrangement might be required.

In addition, AMSA advised that it had reviewed the fatigue management plan in light of the issues identified in the plan’s independent review in 2010, and worked to address those issues. The action taken includes providing more clarity in the plan, implementing a software program to monitor pilot work periods reported to REEFVTS, providing pilots access to an on-line fatigue training program, encouraging providers to develop their own plans and clarifying the process required for dispensations from plan requirements.

ATSB comment

The ATSB acknowledges the safety action taken and proposed by AMSA to address the safety issue and notes that action by pilotage providers will also be required to adequately address this issue. However, the high level of fatigue risk involved in single-handed pilotage through the Inner Route of the GBR still needs to be specifically and adequately addressed.

 

Recommendation

Action organisation: Australian Maritime Safety Authority (AMSA)
Action number: MI-2010-011-SR-050
Date: 24 October 2012
Action status: Closed

The Australian Transport Safety Bureau recommends that the Australian Maritime Safety Authority takes further safety action to address the safety issue with regard to the high level of fatigue risk involved in single-handed pilotage through the Inner Route of the Great Barrier Reef.

 

Correspondence

Date received: 21 January 2013
Response from: Australian Maritime Safety Authority
Response text:

AMSA has reviewed its Fatigue Risk Management Plan in light of issues identified in the 2010 independent review of the Plan. The review resulted in providing more clarity in the plan, implementing a software program to monitor pilot work periods as reported to the Great Barrier Reef and Torres Strait Vessel Traffic Service (REEFVTS), providing pilots access to an on-line fatigue training program, and encouraging providers to develop their own plans.

The Fatigue Risk Management Plan and AMSA’s Coastal Pilotage System database now better manage fatigue risk by taking into account irregular working hours; the effect of multiple, consecutive pilotages and eliminating the largely self-managed approach to fatigue management.

AMSA has commissioned an investigation of the merits of a requirement for two pilots through the Inner Route and under what conditions this arrangement might be required.

The initial result from the study does not provide evidence of a high level of fatigue risk involved in the current single-handed pilotage, noting ongoing adherence to the existing fatigue risk management plan. These results are consistent with results of the previous study into coastal pilot fatigue (the 2010 review). Notwithstanding this, AMSA is working with Pilotage Providers to identify additional means to manage risk due to fatigue, going beyond the basic level of rostering to verify wake / sleep opportunities and pilot self-identification of fatigue.

AMSA recognises that providers may develop specific fatigue management plans (Marine Orders Part 54 issue 5 provision 93.3(a)) and has put in place processes to enable approval of provider fatigue plans that meet best practice.

 

ATSB response:

The safety action taken and proposed has the potential to adequately address the safety issue.

Date received: 05 September 2013
Response from: Australian Maritime Safety Authority
Response text:

The results of the study [Analysis of Two-Pilot Operations-Inner Route] have been received and released to stakeholders – Pilotage Providers and ATSB. The report does not provide an unequivocal recommendation for the adoption of a two-pilot regime for the inner route.

AMSA feels that this is an initial step in the process, and is looking to implement a follow up study that includes field assessments.

In developing the next step in the study, the AMSA Human Factors (HF) expert is drafting a scope of work.  In addition, the HF expert will assist the pilotage section in overseeing the work once it commences.

ATSB response:

The safety action taken and proposed has the potential to adequately address the safety issue.

Date received: 06 May 2014
Response from: Australian Maritime Safety Authority (AMSA)
Response text:

AMSA released a Request for Quotation for the conduct of coastal pilot fatigue-related field trials in November 2013. Submissions received were not accepted by AMSA for various reasons. AMSA intends to revise the scope of work and return to the market.

AMSA will undertake a series of focus audits on pilotage providers related to compliance with pilot fatigue management and AMSA’s Fatigue Risk Management Plan. (May 21-22 2014).

Date received: 06 August 2014
Response from: Australian Maritime Safety Authority (AMSA)
Response text:

AMSA released a Request for Quotation for the conduct of coastal pilot fatigue-related field trials in November 2013. Submissions received were not accepted by AMSA for various reasons. AMSA intends to revise the scope of work and return to the market.

AMSA conducted focused fatigue risk management compliance audits with each pilotage provider at the end of May 2014. The audits noted that each pilotage provider has a system in place for fatigue management as part of their Safety Management System (SMS). A spot check of piloted voyages noted some inconsistency in the application of the systems. AMSA has met with the pilotage providers and they will be required to review their SMS’s noting the outcomes of the audits. Follow-up audits will be conducted in November 2014.

ATSB response:

The ATSB will reassess the further proposed safety action by AMSA to address the issue when such action has been progressed or completed.

Date received: 11 February 2015
Response from: Australian Maritime Safety Authority
Response text:

AMSA conducted follow up audits of each pilotage provider’s fatigue risk management compliance in November 2014.  All issues identified in the May 2014 audits were adequately addressed and have subsequently been closed out.
AMSA conducted consultation with pilots and pilotage providers in Jan 2015 regarding proposed changes to the default Fatigue Risk Management Plan (FRMP).  As a result, AMSA intends to publish a revised plan with new inclusions aimed to improve coastal pilot fatigue management arrangements, including:

  • Reinstatement of the requirement for 24hrs rest (including core rest period) after 5 consecutive 1 point pilotages.
  • Redefine optimal core rest period to be any 8 hours between 2100hrs – 0700hrs local time
  • Minimum leave period to be reduced from 14 days down to 10 days in order to count towards the 63 days annual leave requirement.
  • Pilots flying in from a distance greater than 1000km (before starting their roster) must have a mandatory rest period before commencing the first pilotage.

These changes will provide better protection for pilots and greater flexibility for pilotage providers.
AMSA considers the actions taken to date in response to the ATSB’s original recommendation have adequately addressed the issue.
AMSA will however continue to monitor and where possible, enhance fatigue related matters into the future.

ATSB response:

The ATSB acknowledges the adjustments AMSA has made to its default fatigue risk management plan (FRMP) and its auditing of compliance with the plan. The default FRMP, however, continues to rely on a largely self-managed approach by individual pilots. The FRMP does not incorporate assessment of actual fatigue levels and sleep achieved to ensure fatigue risk during a single-handed pilotage does not exceed an acceptable level -  particularly in the Inner Route.

In its response, AMSA did not provide an update on the intended field assessments of pilot fatigue (as indicated by AMSA in August 2014). Objective and subjective fatigue data from the field assessments should provide for an evidence-based understanding of the actual fatigue impairment experienced by pilots, and a measure of the effectiveness of the default FRMP.

Date received: 01 February 2016
Response from: Australian Maritime Safety Authority
Response text:

The fatigue management arrangements detailed in the existing default fatigue risk management plan (FRMP) were developed in consultation with independent subject matter experts (SMEs), including the Centre for Sleep Research, University of South Australia. The fundamental concept of the FRMP is to deliver effective fatigue management arrangements for coastal pilots, based on relevant science and SME input which reinforces the FRMP. The effectiveness of the current FRMP is evidenced by a number of factors, including:

-   Marine incident statistics involving vessels under pilotage (i.e. there have been no coastal pilotage related marine incidents reported to AMSA where fatigue has been identified as a contributing factor since the establishment of the FRMP as a regulatory requirement for coastal pilots and pilotage providers);

-   Wide-spread acceptance and support for the plan by licensed pilotage providers and extremely high levels of compliance by individual pilots; and

-   Indications received from coastal pilots regarding the effectiveness of the FRMP (as part of annual FRMP effectiveness review procedures where input is sought).

It should be noted that it is a condition of both an individual pilot’s licence and a pilotage provider’s licence to ensure the fatigue management requirements detailed in the FRMP (or an alternative AMSA-approved fatigue management plan), are complied with.

Whilst the default FRMP does incorporate the concept of individual pilots self-assessing their level of fatigue so as to protect a pilot’s capacity to decline work, the primary responsibility for ensuring pilots do not exceed minimum rest periods lies with providers. As a condition of a pilotage provider licence, a provider is required to ensure that pilots comply with the terms of the default FRMP (or an alternative AMSA-approved fatigue management plan).

Marine Order 54 (Coastal pilotage) 2014 (MO54) requires a pilotage provider to have a safety management system (SMS). It is a mandatory requirement that the SMS describes, to AMSA’s satisfaction, how the provider’s work practices are conducted safely, and how the provider complies with the applicable FRMP. AMSA conducts compliance audits on providers in accordance with the provisions of MO54. These compliance audits specifically include an assessment of the provider’s compliance with all fatigue management requirements.

The regulatory arrangements outlined above are considered to provide appropriate guidance and incentives to pilotage providers to ensure compliance with the FRMP requirements in order to ensure the provider’s licence is not jeopardised as a result of potential systemic non-compliance with fatigue management provisions.

Online fatigue management training and assessment has also been reviewed and implemented by AMSA for the benefit of coastal pilots (AMSA Fatigue Management e-Learning Course). The course is designed to provide pilots with focussed information on the unique challenges and realities of fatigue and personal fatigue management in their working environment. Completion of this course is a mandatory requirement for the issue of a (Restricted) coastal pilot’s licence and a certificate is issued upon successful completion.

As provided previously, AMSA approached the market via a ‘request for quotation’ for the conduct of possible coastal pilot fatigue field assessment. Subsequently, due to the prohibitive costs quoted, AMSA has not pursued this further.

ATSB response:

The ATSB acknowledges the safety action taken by AMSA to address this safety issue. The action includes changes to the default fatigue risk management plan (FRMP) to more effectively address matters related to rest and work hours limits, transfer times, and multiple, consecutive pilotages. The changes provide increased assurance that pilots can access sufficient sleep opportunity between pilotages and, thus, are more likely to start a pilotage not affected by fatigue. Pilotage provider-initiated changes to the employment conditions of a proportion of pilots, whereby many are salaried employees rather than independent contractors, has also reduced the risk due to conflicting priorities arising from their remuneration and working arrangements.

However, the FRMP still requires an individual pilot to ‘manage’ the effects of fatigue during a 36-48 hour, single-handed pilotage. Therefore, the central challenge of a pilot self-managing fatigue during a long pilotage remains. While AMSA has ensured all pilots have undertaken fatigue awareness training, the risks associated with the combination of time of day, time on task, and the variable nature of task effects are largely uncontrolled during a pilotage. The principal method to self-manage fatigue by accessing rest/sleep in certain ‘rest areas’ is dependent on time of day, weather conditions, ship equipment and crew, traffic and other variable factors. Further, this approach relies heavily on self-assessment of fatigue impairment, which has been shown to be problematic.

The ATSB notes AMSA’s reason for not pursuing its proposed field assessment of fatigue. However, such a study would be invaluable to inform the industry about fatigue impairment experienced by pilots, and the effectiveness of alertness management strategies. In this regard, ATSB recognises that actual fatigue levels are difficult to determine due to individual variability across a range of factors. While self-recording and monitoring may well form part of a data collection strategy, ideally this would be supplemented by the collection of sample, objective and subjective data to assess the sleep quantity and quality obtained, as well as alertness levels.

Based on the matters described above, particularly the key challenge of self-managing fatigue during single-handed Inner Route pilotages, the ATSB does not consider that this safety issue has been adequately addressed.

Proactive Action

Action organisation: Australian Reef Pilots
Action status: Closed

Response to safety issue from ARP

Australian Reef Pilots advised the ATSB that it has a robust monitoring system to exclude pilot travel and transfer times from rest periods. Australian Reef Pilots also advised that it recognises the fatigue risk involved with single-handed pilotage in the Inner Route and was working with fatigue analysts to model an improved fatigue management plan for the route.

ATSB response:

The ATSB acknowledges the action taken and proposed by Australian Reef Pilots and notes that it will complement measures taken by AMSA to address the safety issue.

Recommendation

Action organisation: Australian Reef Pilots (ARP)
Action number: MI-2010-011-SR-051
Date: 24 October 2012
Action status: Closed

The Australian Transport Safety Bureau recommends that Australian Reef Pilots takes further action to facilitate action taken by the Australian Maritime Safety Authority to address the safety issue

Correspondence

Date received: 22 January 2013
Response from: Australian Reef Pilots (ARP)
Response text:

ARP disagrees that the pilot fatigue management plan is inadequate.

In response to the first ATSB comment “largely self-managed approach where individual pilots may have conflicting priorities relating to remuneration and other working arrangements”, please note the following:

ARP has instigated a salary system for pilots. Pilots are paid a set monthly salary which is totally independent of the number of ships piloted and thus completely removes the perceived need to pilot more ships to earn more money.

ARP is moving all pilots on to the salary payment system. No newly employed trainee pilots are offered the alternative of being self-employed contractors. All newly employed pilots are automatically paid via a salary.

All self-employed contractor pilots were made the offer to change to the salary payment system. Currently 63% of ARP pilots are paid via a salary. Many of the pilots remaining as self-employed contractors are senior pilots who have long standing personal tax and financial arrangements. Some of these pilots are approaching retirement.

ARP expects that by mid-2013 at least 69% of ARP pilots will be paid by salary. This figure will naturally rise as more senior pilots retire and new trainee pilots commence as employees.

ARP expects that other pilots will also see the advantages of employment over self-employed contractor status.

In response to the second ATSB comment 'pilot travel and transfer times regularly being included in rest periods', please note the following:

ARP pilots comply with the AMSA Fatigue Risk Management Plan. This plan has been reviewed by experts at the University Of South Australia Centre for Sleep Research, a world leader in its field, working to extend our understanding and perception of human performance, sleep, biological rhythms, fatigue and behaviour.

Furthermore, ARP recently implemented the following enhancements (over and above the AMSA default fatigue management plan):

After 3 consecutive jobs in the Hydro/GNEC with less than 24 hours between each, pilots will have a Core 24 hours rest before the next job.

Pilots will not be required to depart the pilot house (bag time) before 07:00 following a core rest break.

Pilots never work more than 23 days (including travel to/from home) and never have less than 10 days off between tours.
- A laundry service will be provided so that pilots will not be required to wash sheets, towels, dish towels etc.
- Sound insulation will be installed to improve rest especially during the day.
- A system of pre-ordered delivered evening meals will be provided.

To assist pilots get better rest in the Cairns & Mackay pilot houses the following initiatives will be instigated:

ARP has commissioned a computer based dispatch system (Microsoft Dynamics CRM-Ulysses) that automatically monitors the location and working arrangements of pilots and thus any impact on the fatigue management requirements set by AMSA, (including the travel times of pilots). This system has been audited by both AMSA and an independent ISO9001 QMS auditor and found to be effective.

If the despatcher inadvertently assigns a pilot to a ship that can potentially generate a violation, the system detects the potential violation of the fatigue rules. A message is then automatically sent to the pilot concerned and the entire management team to ensure the potential violation is rectified.

ATSB response:

The safety action taken and proposed has the potential to adequately address the safety issue.

Date received: 21 August 2013
Response from: Australian Reef Pilots (ARP)
Response text:

Our response to ATSB of 22 January noted our implementation of enhanced fatigue management over and above the AMSA default fatigue management plan.

We are however cognizant of the potential risk of single handed pilotages in the Inner Route. Accordingly, we have been working with FAID consultants Interdynamics Pty Ltd to model potential two-pilot rostering arrangements. The theoretical results of these studies were inconclusive. AMSA also conducted similar studies in conjunction with an academic research institution with inconclusive results.

We have therefore committed to a field-based fatigue management research project using Readiband and Smartcap technologies which is being designed and managed by Associate Professor Matthew Thomas, Appleton Institute – Central Queensland University. This study is currently in progress and will assess the actual fatigue state of pilots in both single-handed and two-handed situations over a three month period.

We will make a decision whether and how to deploy a two-handed pilotage regime on the Inner Route on completion of this study.

It should be noted that we will require the regulatory support of AMSA to enable us to implement any change to the current system.

ATSB response:

The safety action taken and proposed has the potential to adequately address the safety issue.

Date received: 29 July 2014
Response from: Australian Reef Pilots (ARP)
Response text:

Update in regard to ATSB Issue MI-2010-011-SI-03 “Pilot Fatigue Management Plan” and further to ARP correspondence dated 22 January 2013 and 21 August 2013:

Subject: Single pilot versus two pilot Inner Route pilotage

Following inconclusive theoretical studies by both ARP (through FAID consultants Interdynamics Pty Ltd) and AMSA (through the Appleton Institute / CQU), ARP commenced a field study of single pilot fatigue utilising “Smartcap” monitoring technology. A modest number of field recordings were captured prior to developments announced by AMSA at the Combined

Pilotage Group meeting on 30/10/2013 (CPG65).

At that meeting, AMSA advised Pilot Providers that field trials would be undertaken to verify results from the earlier theoretical study and that AMSA would be progressing this via a request for quotation for such field studies. ARP suspended its own field studies at that time given the matter is now being progressed at the federal regulatory level. AMSA noted at the

Combined Pilotage Group meeting on 06/03/2014 (CPG66) that bids received in response to the request for quotation (for field studies) did not represent value for money and that the process was taking longer than expected but was continuing and that AMSA recognises fatigue management as a very important safety factor.

Subject to specific details of the proposed AMSA field study, ARP intends to be a willing participant in this process.

ARP remains cognisant of fatigue risk concerns raised by the ATSB however does not view field studies conducted independent of AMSA to be appropriate or beneficial to the coastal pilotage industry as a whole. ARP will continue to adhere to the fatigue risk management controls as established by the AMSA Default Fatigue Risk Management Plan (dated March 2013) until such time as AMSA studies are able to identify shortcomings in that plan.

ATSB response:

The ATSB considers that the safety action taken by ARP, in the context of the safety issue, is sufficient for a pilotage provider within the current regulatory framework.

 

Proactive Action

Action organisation: Hydro Pilots
Action status: Closed

Response to safety issue from HP

Hydro Pilots did not make a submission.

Recommendation

Action organisation: Hydro Pilots (HP)
Action number: MI-2010-011-SR-053
Date: 24 October 2012
Action status: Closed

The Australian Transport Safety Bureau recommends that Hydro Pilots takes safety action to address the safety issue and facilitate action taken by the Australian Maritime Safety Authority to address this issue.

Correspondence

Date received: 22 January 2013
Response from: Hydro Pilots (HP)
Response text:

Hydro Pilots do not operate with a self-managed approach. Our Pilots work to a structured roster. Our Pilots work to a 20 day on 10 day off cycle. This roster has been implemented and agreed upon between all pilots and management.

In addition to this Hydro Pilots in conjunction with Torres Pilots Pty Ltd have recently submitted an alternative FRMP to AMSA. This plan has been developed with the assistance of sleep/fatigue experts Sally Fergusson and Mathew Thomas from the Appleton Institute of Adelaide. You will be aware that their input and expertise has also been sought by AMSA on the issue of fatigue within coastal pilotage.

The main purpose of the new FMP is to increase the frequency of pilot rostered leave and to increase the certainty of pilot time off roster. The proposed FMP will not increase Mackay resident pilot’s work commitments. It will provide those pilots with more certainty regarding their time at home by increasing the number of days they enjoy off roster, that is, the proposed FMP will allow the use of a more efficient roster and more planned time at home for the pilot.

The 10-day rest period allows for more frequent periods of long breaks from work, and as such is seen as an important mechanism in reducing the likelihood of cumulative fatigue. The plan also looks at Risk Identification and Assessment taking into account many factors. The plan is based on a “safety-case” approach which is what AMSA have requested.

With regard to the inclusion of pilot travel and transfer times this is not the case within our operations. Prior to commencement of pilotage a “Job Risk Analysis” is completed which look at many factors including the pilots previous rest to ensure that the 12 hour rest has been complied with. Upon completion of the pilotage our pilots provide our operations with the completed “certificate of pilotage” where the landing time back at Mackay is recorded as the completion time. Marine Pilots do not allocate themselves to ships. This is done by operations and is based on compliance with the current FRMP.

ATSB response:

The safety action taken and proposed should adequately address the safety issue for the operations of HP, which does not operate in the high fatigue-risk Inner Route.

Proactive Action

Action organisation: Torres Pilots
Action status: Closed

Response to safety issue from Torres Pilots

Torres Pilots advised the ATSB that it rejects the safety issue. The reasons submitted by Torres Pilots in support of this statement included:

  • pilot allocation to a ship is determined by the provider’s operational staff based on the estimated time of arrival provided by its master;
  • pilot transfers are determined by the provider’s operational staff and not by pilots;
  • pilot rest breaks are calculated by the provider’s operational staff, including making allowances for pilot transfer times.
  • potential conflicts of interest with some disaffected pilots exaggerating or overstating potential safety issues to increase calls for the creation of a Government-controlled monopoly pilot service;
  • no linkage identified in the report to suggest that the financial interests of pilots and pilotage providers have any impact on safety;
  • separation of responsibilities between coastal pilots and providers means that each can focus on delivering an independent, high quality and safe service without potential conflicts of interest;
  • an Australia-wide shortage of pilots means sufficient work for pilots without any need for competition between them;
  • competition in the airline industry has not compromised safety standards; and
  • other self employed professionals, such as those in the medical profession, are also paid a fee for service.

ATSB response:

The ATSB has reviewed Torres Pilots' submission, addressed its comments in detail within the report and does not consider that they address the safety issue.

Recommendation

Action organisation: Torres Pilots
Action number: MI-2010-011-SR-055
Date: 24 October 2012
Action status: Closed

 The Australian Transport Safety Bureau recommends that Torres Pilots takes safety action to address the safety issue and facilitate action taken by the Australian Maritime Safety Authority to address this issue.

 

Correspondence

Date received: 21 January 2013
Response from: Torres Pilots
Response text:

1.1 Torres Pilots partially accepts and partially rejects the Fatigue Safety Recommendation.

1.2 Torres Pilots accepts the recommendation to facilitate action taken by the Australian Maritime Safety Authority (AMSA) to address any perceived issues with the AMSA-approved fatigue management plan. To give effect to the recommendation, Torres Pilots: (1) will cooperate with any AMSA investigation into the requirement for two pilots through the Inner Route;

(2) is developing a new fatigue management plan specifically for those pilots who reside in Mackay and work in Hydrographers Passage, and has engaged fatigue consultants for this purpose;

(3) is implementing further checks for fatigue in addition to AMSA's CPS monitoring, including:(a) maintaining a register of future vessel bookings including pilot boarding times matched to the time of completion of the pilots previous pilotage job, that is the time he stepped ashore after disembarkation;
(b) Torres Pilots' operations staff conducting random checks of pilots' records. Pilots are required to monitor their fatigue and record the fatigue management points accumulated and the actual times of disembarkation on certificates of pilotage.
(c) Torres Pilots' operations staff confirm the recorded rest times by crosschecking the calculated travel times on pilot launches, helicopters and the imputed time the pilot stepped ashore with actual launch and helicopter logs;
(d) conducting a monthly random audit of pilot fatigue management as part of Torres Pilots' Risk Management Framework; and
(e) investigating future software monitoring options;

(4) will continue to reduce pilot transfer times and times pilots are away from home by:
(a) continuing to have pilots living in Mackay being dedicated to Hydrographers Passage and pilots living in Cairns being dedicated to the Inner Route and Great North-East Channel. Berthing programs frequently change at short notice at the coal ports, and having access to all of the GBR pilots, who live in Mackay and Cairns,
allows Torres Pilots to avoid delays which would otherwise be encountered if another pilot was required to be flown into the area. By requiring pilots to live in Cairns and Mackay, the pilots are able to spend more time at home, visit home more frequently and enjoy shorter swings away from home;
(b) giving pilots at Torres Pilots' Thursday Island pilot base the option of flying home if a wait of more than 3 days is expected in the Torres Strait;
(c) building a new pilot launch to allow 3 pilot launches to remain on station at Thursday Island, so as to ensure 2 launches are always available when one launch may be unserviceable. Maintaining 2 pilot launches and multiple crews at Thursday Island avoids excessive pilot time spent in launches;
(d) requiring 2 launches to be used for Booby Island pilot transfers when there is a difference of more than 1.5 hours between vessel arrival times;
(e) using Yorke Island, where possible, for all Dalrymple Island pilot transfers to reduce pilot time in launches;

(5) will update its SMS to factor in the practices for reducing pilot transfer times; and

(6) will continue to monitor and update its fatigue management plan based on AMSA recommendations, amendments to Marine Order 54 (MO 54) and industry best practice.

1.3 Torres Pilots otherwise rejects the Fatigue Safety Recommendation for the following reasons:

(1) Many of the criticisms about travel time do not apply to pilots engaged by Torres Pilots, because such pilots are required to live in Mackay and Cairns. This:

(a) allows pilots to spend more time at home;
(b) eliminates pilots' idle time spent at Cairns and Mackay in pilot base accommodation;
(c) eliminates pilot time flying from southern ports remote from the compulsory pilotage areas; and
(d) eliminates pilot travel to or from Cairns and Mackay.

(2) Torres Pilots' Brisbane operational staff set the rosters for pilots, based on estimated vessel arrival times. In setting the rosters, the staff factor in rest periods in accordance with the fatigue management plan and do not include travel time as part of the rest period.

(3) Torres Pilots monitors compliance with the fatigue management plan by having their operational staff calculate rest periods in accordance with the plan, including making allowances for travel time and excluding travel time from periods of rest. The system does not allow for pilots to manipulate their fatigue management plan.

(4) The staff also calculate the time spent in launches as part of monitoring compliance with the fatigue management plan, without relying on pilots for that calculation.

(5) AMSA audits Torres Pilots' records annually to ensure compliance with the fatigue management plan and calculation of pilot rest breaks.

(6) The report offers no sound reasoning as to why financial incentives would result in pilots and pilotage providers compromising safety and is based on flawed methodology.

(7) Torres Pilots estimates its contractor pilots earn about $80,000 more per year than those employed by its competitors, while at the same time spend more time at home.

(8) All existing pilots have been offered employment conditions, but all have decided to remain as contractors. Torres Pilots employs trainee pilots.

(9) Torres Pilots does not accept that its pilots lack professional ethics and would willingly manipulate Torres Pilots' fatigue management plan at the risk of safety.

(10) There is no credible evidence presented in the report for suggesting that Torres Pilots' pilots manipulate their required rest periods.

1.3 Torres Pilots otherwise rejects the Fatigue Safety Recommendation for the following reasons:
(1) Many of the criticisms about travel time do not apply to pilots engaged by Torres Pilots, because such pilots are required to live in Mackay and Cairns. This:
(a) allows pilots to spend more time at home;
(b) eliminates pilots' idle time spent at Cairns and Mackay in pilot base accommodation;
(c) eliminates pilot time flying from southern ports remote from the compulsory pilotage areas; and
(d) eliminates pilot travel to or from Cairns and Mackay.
(2) Torres Pilots' Brisbane operational staff set the rosters for pilots, based on estimated vessel arrival times. In setting the rosters, the staff factor in rest periods in accordance with the fatigue management plan and do not include travel time as part of the rest period.
(3) Torres Pilots monitors compliance with the fatigue management plan by having their operational staff calculate rest periods in accordance with the plan, including making allowances for travel time and excluding travel time from periods of rest. The system does not allow for pilots to manipulate their fatigue management plan.
(4) The staff also calculate the time spent in launches as part of monitoring compliance with the fatigue management plan, without relying on pilots for that calculation.
(5) AMSA audits Torres Pilots' records annually to ensure compliance with the fatigue management plan and calculation of pilot rest breaks.
(6) The report offers no sound reasoning as to why financial incentives would result in pilots and pilotage providers compromising safety and is based on flawed methodology.
(7) Torres Pilots estimates its contractor pilots earn about $80,000 more per year than those employed by its competitors, while at the same time spend more time at home.
(8) All existing pilots have been offered employment conditions, but all have decided to remain as contractors. Torres Pilots employs trainee pilots.
(9) Torres Pilots does not accept that its pilots lack professional ethics and would willingly manipulate Torres Pilots' fatigue management plan at the risk of safety.
(10) There is no credible evidence presented in the report for suggesting that Torres Pilots' pilots manipulate their required rest periods.

 

ATSB response:

The safety action taken and proposed has the potential to adequately address the safety issue.

Date received: 27 August 2013
Response from: Torres Pilots (TP)
Response text:

This response from TP repeats its response of 21 January 2013 with the following relevant additions.

TP has engaged fatigue consultants to develop a new fatigue management plan (FMP) specifically for those pilots who reside in Mackay and work in Hydrographers Passage. This FMP has been completed and will soon be submitted to AMSA for approval.

TP has further a mitigated accumulated fatigue by implementing the following pilot rostering changes whenever possible:

a)  reduced the length of pilot swings allowed under AMSA’s default FRMP. TP now routinely refreshes a pilots points and ends a pilot’s swing / time on roster after the pilot has accumulated 12 points;

b)  reduced the number of consecutive inner route pilotages from three as allowed under AMSA’s default FRMP, to two after which a pilot now routinely has a minimum two optimal nights (22:00 to 06;00 hours) rest;

c)  increased TP pilot manning numbers such that the average number of vessels piloted by TP pilots licensed for the IR / GNEC decreased by 9% in fiscal 2013.

ATSB response:

The further safety action taken and proposed has the potential to adequately address the safety issue.

Date received: 29 May 2014
Response from: Torres Pilots (TP)
Response text:

Torres Pilots is still of the view the independent review was based on data collected from sources that demonstrates bias and self- servant reaction. No further exploration was completed in the form scientific collection of data that could be verification and open to peer review.

Torres Pilots considers that although pilotage in the inner route is long we believe the fatigue of TP pilots is well-managed and at an acceptable risk.

Torres Pilots has continued to recruit pilots with a requirement that they live in Cairns and Mackay to minimise fatigue by;
Shortening the length of swings and more frequent visits to pilot residences.
Minimising pilot air travel.

Separation of pilot involvement in the allocation of pilot to pilotage assignments to ensure pilot competition for work is not a safety issue.

Pilotage remuneration has been increased to lessen commercial and income pressures claimed by the ATSB
Recruitment of sufficient pilots to limit the total number of vessels piloted per year by each pilot commensurate with Service demand and work commitments. Work commitments are limited to 225 days per year and compliant with the AMSA default FMP.

TP has continued to mitigate fatigue by increasing allowances for pilot time in pilot launches. TP’s FMP requires longer breaks between vessels than the rest periods specified in the AMSA default FMP. TP’s Brisbane operations has upgraded our procedures and now;

Requires a 28 hour break between inner route pilotages from time of disembarkation to time of boarding. AMSA’s default FMP requires 24 hours net of time spent on pilot launches.

Requires a 17 hour break between GNEC pilotages from time of disembarkation to time of boarding. AMSA’s default FMP requires 12 hours net of time spent on pilot launches.

Conducts daily internal audits of pilot compliance with the AMSA default FMP based on launch records & logs.

Assigned additional operations staff to monitor pilot compliance with the AMSA default FMP.
Documented pilot SMS risk assessments required of pilots before taking rest periods / absences from the bridge on piloted vessels.

Conducts monthly internal audits of pilot compliance with SMS risk assessments for rest periods.
Ceased requests from AMSA for dispensation to relax the requirements of the AMSA default FMP.

TP launch replacement and fleet expansion;
Expanded the pilot launch fleet to reduce the amount of time in pilot launches. MPTs are conducted with multiple pilot launch operating at the one time to minimise pilot time in launches.

Enhanced the quality of the launches by an extensive pilot launch new building program. The pilot launches are a tailored designed specifically for Torres Strait MPTs, are ‘fit for purpose’ and are not an ‘off the shelf’ design. This has improved the comfort of pilot and safety during MPTs.

Increased the number of launch crew on roster to allow multiple pilot launch operations at the one time and to minimise pilot time in launches.

The use of charter helicopters in the GNEC during peak activity to minimize pilot travel time between pilot bases.

ATSB response:

The ATSB considers that the safety action taken by TP, in the context of the safety issue, is sufficient for a pilotage provider within the current regulatory framework.

   
Current issue status: Not addressed
Status justification:

The ATSB acknowledges the safety action taken by AMSA to address this safety issue mainly through its default fatigue risk management plan (FRMP). Changes to the FRMP and other relevant measures have reduced the level of risk. However, the FRMP still requires individual pilots to self-manage their fatigue, and the fatigue risk during the long, single-handed Inner Route pilotages can be high. In the absence of evidence to the contrary, the ATSB does not consider this largely self-managed approach to fatigue risk provides an appropriate level of assurance that the risk is being effectively managed.

 
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Last update 22 April 2016