Mode Aviation
Reference No. AR201800060
Date reported 06 June 2018
Concern title Cabin crew fatigue
Concern summary

Cabin crew fatigue operating the [Location 1 - Location 2] pairing.

Industry / Operation affected Aviation: Air transport
Concern subject type Aviation: Cabin safety

Reporter's concern

Multiple reporters expressed a safety concern regarding cabin crew fatigue operating the [Location 1 - Location 2] pairing.

Each reporter has stated that the slip time in [Location 2] is insufficient for adequate rest to safely operate the return flight to [Location 1]. The reporters have advised that crew are rostered on either a four day or five day pattern. The four day pattern involves the [Location 1 flight number], which is 16.45 hours, with a total duty time of 18.45 hours with 28.15 hours slip time allocated prior to 17.45 hour return flight, with a total duty time of 19.45 hours. The reporters advise that routinely, 3.00 hours rest is obtained during the flights. The five day pattern involves the same flight times with a 52 hour slip time; however, requires being on standby after 25 hours. One reporter noted that the Sydney to [Location 3] sector is shorter in flight time than the [Location 1 - Location 2] sector; however, it is deemed safer to give 56 hours rest in [Location 3], where [Location 1 - Location 2] crew are allocated 28 hours rest on the longest flight and duty time on the network.

The reporters further advise that these duty times and in-flight rest times assume no delays, either to the flight or travel from the airport. Any abnormal situation in-flight, such as a medical emergency, unwell cabin crew member, disruptive passenger or regular turbulence, results in an increased workload to crew and in-flight rest time is significantly reduced.

The reporters all mentioned experiencing high levels of fatigue, including significantly reduced levels of alertness and exhaustion. Most reporters mentioned struggling to stay awake during landing phases and being concerned that they would not be able to operate effectively in the event of an emergency.

Several reporters advised that although [Operator] has a policy that outlines cabin crew members that are experiencing fatigue must report it and may stand themselves down if necessary, they feel that senior management pressures cabin crew not to utilise this policy and believe that they will face scrutiny if they come forward. One reporter advised that management reiterated that [Operator] was “not going to tolerate bad behaviour (sic) if crew go fatigued just because they are on a 4 day pattern with 28 hour slip duty or are on standby”. The reporter advises that this language infers that if cabin crew deem themselves fatigued whilst in [Location 2], they will be scrutinised with the possibility of being disciplined or even dismissed.

Reporters have also advised that [Operator] has offered free transport or hotel accommodation on their return to [Location 1] to prevent cabin crew attempting to drive home fatigued. The reporters query how [Operator] deem it safe for cabin crew to complete safety roles during a routine landing, let alone an emergency event, but [Operator] do not deem it safe for cabin crew to drive half an hour later.

Reporters’ comments:

“…. On each one feeling totally incapable of safe operations after the issued rest period”

“… Once again, I was very sleepy on descent into [Location 1] and when in the jump seat found it difficult to remain alert”

“… I have seen crew operating after just 27 hours rest who are operating in a non-normal situation”

“…Upon landing preparations into [Location 1] I felt completely exhausted and knew that I was fatigued”

“I did not feel able to stand myself down for landing so was counting on adrenaline to kick in if an emergency arose”

“Thankfully I was operating as an assist crew and not a door primary otherwise I would have stood myself down”

“By the time I checked into my room this was actually below 24 hours rest. As I was still on [Location 2] time when the standby started (14.45 local) I had not slept adequately before this duty and at the time of it starting, was physically unable to stay awake”

“My alertness was not 100% due to poor rest down route and on board so I was struggling to stay awake during landing”

“The entire rest for this sector is inadequate. The [Location 1 Regulator] would not allow [Location 1] crew to operate these hours”

“… sleepy on decent and dozing off whilst sat on jump seat. Would I be able to operate my door in the case of an emergency?”

“Something must be done about on board rest and slip times before an error is made due to crews ability to stay alert”

“When I operated the return flight on this slip pattern I was concerned that I was not alert enough to operate a door in an emergency situation at the end of the flight”

“The company does tell us to report fatigue however we also had a message [details removed] that going fatigued would have consequences… so I was fearful of being reprimanded for doing so”

“Many crew, including myself have felt under pressure from management [name removed] to not see ourselves unfit for duty due to fatigue”

“I’m concerned that the company are not taking the concerns of the crew or the union seriously”

“There has been many reports to our management team but unfortunately it does get dismissed”

“The issues were made very clearly to managers, their replies, ‘we are on a trial period’, ‘you will adjust’, ‘the base will not be viable if we don't operate to these specifications’”

“Many of my crew have been in a total fatigue stage when operating flights back to [Location 1]”

“I have felt unsafe many times during our landing in [Location 1], as awareness is at its lowest and the risk at its highest”

Operator's response (Operator 1)

[Operator] has a robust method for preventing, reporting, and managing Cabin Crew fatigue. Training programs and resources are available to educate crew on techniques to proactively and reactively manage fatigue, both on the ground and inflight. If required, any crew member is able to remove themselves from service, both before and during the flight, in order to manage fatigue levels. [Operator] has also introduced increased oversight on the effects of the long-haul flying associated with the [Location 1 – Location 2] flying conducted by the [Location 1]-based cabin crew. 

On 25 March [Operator] launched the [Location 1 – Location 2] direct service which is crewed by [Location 1]-based [Operator] Cabin Crew [Location] team. The total planned length of duty of these sectors is 18:30 from [Location 1 – Location 2] and 18:50 from [Location 2 – Location 1]. As part of our Fatigue Risk Management System, [Operator] uses bio-mathematical modelling when reviewing patterns for fatigue levels.  Prior to operations commencing in March, [Operator] Medical in conjunction with the Human Factors team completed a fatigue study which provided initial modelling of the proposed roster patterns for the [Location 2] based cabin crew, based on both the 28 hr and 52 hr rest periods in [Location 1]. This assessment uses ‘SAFE biomathematical’ modelling which provides a predictive view on how rostered flying patterns may impact a crew member’s fatigue levels. The report showed predicted Samn-Perelli scores within the category range of “moderately tired, let-down”. 

Following this study, education material titled Fatigue Management Guidelines was released to all [Location 1]-based Cabin Crew by our Human Factors team. This information provided practical guidance and advice to crew to assist them in managing their fatigue levels during the rostered flying duties. This advice covered information relating to diet, exercise and how to effectively manage sleep opportunities.

Additionally, the [Location 1] Cabin Crew ground managers were provided with an additional training session to assist them in more effectively understanding fatigue, and how to manage crew concerns around fatigue as they arose. The following were topics covered in this training:

  • Fatigue & Sleep Science
  • The [Operator] Fatigue Risk Management System
  • Overview of Processes
  • Responsibilities & Accountabilities
  • Open and Fair Reporting
  • Fatigue Tools
  • Additional Resources & Support

A Post-Implementation Review (PIR) was planned to occur on the 30 June 2018.  The PIR was scheduled after two roster periods had elapsed, which equals three months after the commencement of the service.

Fatigue Training

All [Operator] cabin crew are provided with fatigue training during their initial training. Additionally, fatigue management training refreshers are provided during annual Emergency Procedures training. The following topics are covered during these training sessions:

Cabin Crew Human Factors Initial – fatigue module

  • Define fatigue and explain why it is important to manage the risk of fatigue in aviation
  • Describe the causes, symptoms and effects of fatigue
  • Describe the importance of quality sleep in fatigue management
  • Describe the impact of sleep inertia, circadian rhythm and jetlag on performance
  • Identify strategies to reduce the impact of fatigue
  • Understand crew responsibilities when reporting unfit for duty due to fatigue

Cabin Crew HF Recurrent (2017/18)

  • Why fatigue is an issue
  • Practical strategies that can be used (napping, caffeine, sleep hygiene, exposure to light / exercise, nutrition)
  • Application of these strategies to a practical example
  • Reporting fatigue

Fatigue Reporting

[Operator] has multiple channels for crew to report the effects of fatigue, and actively encourages our crew to do so. Below are the current channels that are available and are being monitored for the [Sector]:

  • Intelex Fatigue Reporting
  • Cabin Crew Safety or Injury Report (CCSIR) via the App on the CSM’s iPad
  • Crew fatigue survey – a bespoke survey form which has been loaded onto each OBM’s (On Board Manager) iPad since 25 March for [Location 1] crew to complete their feedback on both their ‘Inflight’ and ‘Hotel’ rest and fatigue levels. This survey is to ensure we captured all data points on the impacts of the flying on our crew and not just through safety reporting when fatigued.

Cabin Fatigue Identification Panel (CFIP)

As part of the [Operator] Safety Management System, a functional committee exists, that identifies, assesses and advises on the management of fatigue risks in a collaborative manner. The committee is made up of Cabin Crew management, Cabin Crew representatives, Subject Matter experts, Human Factors experts, Operations and Workforce Planning representatives. The Cabin Fatigue Identification Panel (CFIP) feeds into the formal safety governance committees and is responsible for hazard identification, risk management, and developing strategies to manage fatigue for Cabin Crew. A summary of CFIP data and meeting minutes is reported to the Customer Operations Safety Sub-committee.

CFIP meetings occur on a bi-monthly basis. The Cabin Crew representatives meet without management presence every alternate month. A data pack is generated monthly which encompasses all reports submitted by Cabin Crew operating on [Operator] registered aircraft.

An action for the next CFIP meeting (9 August) is to present data from LHR fatigue survey, including verbatim comments, to the committee.

Future Flying Committee (FFC)

The Future Flying Committee (FFC) is a [Location] base initiative where crew have volunteered to take part in discussions about fleet and destination developments. The FFC was set up in November 2017 and provides staff with a quarterly forum for discussion on current operations with base management.

In November 2017 the FFC set up a pre-route operations survey that was sent out to all crew, to gather information on preferences for the upcoming long-haul operations to [Location 1]. Questions in the survey encompassed preferences about on-board breaks, days-off following [Location 2] patterns, transport provisions to and from work, accommodation provisions and crew meals. Included in the survey were questions relating to the crew members understanding of the current Fatigue Management processes. 62% of the [Location 1] based Cabin Crew responded to the survey.

Six weeks later [Location 1] Cabin Crew management conducted a dial-in meeting where the results and actions from the FFC survey were reviewed and discussed. Most of the concerns that had been raised in the survey were addressed.

Post-Implementation Review

The planned Post-Implementation Review was conducted in June 2018.  Consideration was given to the feedback received via the various reporting channels and the survey (860 responses).

Changes recently implemented after the PIR

The following changes to cabin crew scheduling on the [sector] flights will be implemented from the next roster period commencing 23 July 2018:

  • The 4-day flying pattern is being cancelled
  • Standby duty for crew on the 5-day pattern will be discontinued.

Regulator's response (Regulator 1)

There are several statements that suggest that the reporting of fatigue has been discouraged.

The responses indicate a lack of clear communication and feedback by [Operator] to the cabin crew. While the responses by [Operator] indicates best practice, there is a “gap” that exists or existed between the Fatigue panel and the crew.

There are a couple of statements that indicate a lack of response to raised fatigue issues.

As in the previous comment, for all their efforts and consideration [Operator] is somehow not conveying their ongoing monitoring and responses in a manner that was clear to staff.

Several comments indicate that the rest period allotted is insufficient.

The majority of statements are non-specific, so the actual source of the fatigue cannot be considered to be a single source. On board rest, slip time, and other factors appear to be contributing to the levels of fatigue upon the return leg to the [Location 1]. While there has been training, monitoring, active efforts to address issues, there remains crew who are not adapting to the scheduled work practice hours.

The potential ineffectiveness of the training, messaging or adoption of the practice of fatigue related behaviours/lifestyle, and/or expectation management may be factors influencing the fatigue reports.

Most of the statements/comments in the REPCON are too vague to identify:

  • Cause of the fatigue. Statements like I had 6.5 hours of sleep during a 12-hour layover was due to poor room facilities that allowed too much noise, light, etc… which interfered with my ability to sleep;
  • Outcome of “fatigue,” i.e., On the return leg I was not able to concentrate effectively and had to be repeatedly asked to …, or I experienced a “microsleep” on descent and had to be awoken by a peer – during my time asleep I was not aware of the conditions of the cabin and could not have assisted in case of an emergency; and
  • My role in the fatigue experience. i.e., I used several fatigue countermeasures (caffeine, pre-flight rest, eating times, that were not effective at preventing the tiredness at the end of the flight.

Biomathetical modelling

Information provided by [Operator]

There are significant limitations to all fatigue algorithms or bio mathematical models. For example, SAFE populates the model with expected sleep, which may not reflect the actual experience of crew operating particular patterns. To increase the predictive validity of a model’s outputs, the expected/automated sleep function needs to be recalibrated preferably via actigraphy to reflect the average actual crew wake/sleep cycles when operating those patterns. In-flight alertness surveys and fatigue reports will also help inform the utility of the model’s predictions.

General comments:

Information provided by [Operator]

The response from [Operator] was an articulation of a very good example of a best practice approach to fatigue.

The areas where the response is vague is in the actual adoption/acceptance/integration of the training and information regarding fatigue management strategies by the cabin crew. What comments were made about the quality and utility of the training provided?

The longer route and new aircraft is a “change of culture.” Within a changing culture appropriate monitoring will highlight areas where the “old culture” or values, attitudes, and behaviours are hindering the acceptance and use of new values and behaviours that are necessary for positive change to occur. In addition, there is an acknowledgement that the new culture is different and requires organisational and individual changes in order to move in the intended direction of change.

The lack of clarity and specificity in the comments makes it difficult to assess what precisely is contributing to the experience of fatigue. Crew are feeling tired, believe that it is at a level of risk that is too high, but is this due to lack of understanding, preparation, work conditions such as break times, break timings, or rest periods is not possible to comment on.

Last update 30 August 2018