Reporter's deidentified concern
The reporter has raised a safety concern outlining an ongoing safety-critical issue related to the rostered [Location 1]-[Location 2]-[Location 1] back-of-clock (BoC) pairing ([flight number 1/flight number 2]). The reporter states, 'The pairing results in crew operating a minimum 11 hour and 55 minute duty period with very limited opportunity to obtain restorative in-flight rest and insufficient recovery time post-duty. Due to frequent delays, the duty often extends well beyond the published hours, significantly increasing cumulative fatigue'.
The reporter advised an additional safety risk arises from the cumulative load created by dense rosters, high-intensity duties immediately before and after the pairing, and ongoing rostering practices restrict sleep over time. This cumulative fatigue footprint is an identifiable and foreseeable hazard to aviation safety, amplifying the likelihood of operational errors across multiple flights.
The reporter is further concerned that all of the aircraft operating this pairing do not have privacy curtains installed in the Cabin Crew rest area, resulting in exposure to bright lavatory lighting. Passengers frequently occupy these seats as they are not consistently blocked for the purpose of crew rest.
The reporter advised, [Operator] has stated that the pairing cannot be re-instated into a [Location 2] overnight for [Location 1] based Cabin Crew (as it was pre-[year]) due to cost and crewing constraints. This is despite the same pairing being scheduled as an overnight for [Location 3] based Cabin Crew ([flight number 3/flight number 4) who have 1d 4h 05m rest in between duties. Further, Cabin Crew from other bases such as [Location 3] or [Location 4] that operate the [Location 1]-[Location 2]-[Location 1] pairing, are provided an overnight rest in [Location 2] prior to re-commencing duty the following day.
The reporter states, 'When crew have reported fatigue, these reports have routinely been classified as personal fatigue rather than operational fatigue. This practice undermines both transparency and the perception of a just culture within the organisation. It also creates a behavioural disincentive for crew to report fatigue, particularly given the company’s negative responses when crew declare themselves fatigued'. Furthermore, 'This approach is concerning, as it conflicts with the shared obligations of both crew and the operator under the Civil Aviation Act to manage fatigue as a safety risk, rather than a personal failing, and it directly impacts the ability to identify and mitigate foreseeable hazards to aviation safety'.
Key Safety Impact
Contributory Factors
The reporter provided several environmental, human, and organisational factors as follows:
Environmental
The absence of privacy curtains and the bright lavatory lighting next to the crew rest rows create an unsuitable environment for in-flight rest.
Human factors
Crew are operating under severe cumulative fatigue, increasing the likelihood of fatigue-induced impairment and reducing the ability to perform safety critical duties.
Organisation
Current rostering practices do not align with fatigue science. The requirement for crew to sign on again within the same calendar day after a full BoC duty significantly compromises recovery. Inconsistent application of crew rest seating (Seats A, B and C hard-blocks and soft-block on seats D, E and F) reduces the ability of crew to rest, while the perceived punitive approach to fatigue declarations discourages honest reporting, further exacerbating the issue.
Recommendations and Proposed Solutions
The reporter has identified the following recommendations and potential solutions as follows:
A comprehensive review of the [Location 1]-[Location 2]-[Location 1] BoC pairing is urgently required. Converting the pairing into an overnight duty for [Location 1] crew, consistent with [Location 3] based operations, would significantly reduce cumulative fatigue and safety risk. Installing privacy curtains on all [aircraft type 1]/[aircraft type 2] aircraft operating BoC sectors would allow crew to obtain meaningful in-flight rest. As part of the comprehensive review, the reporter queries how often flight [flight number 1] and [flight number 2] depart late as a direct result of the current pairing?
Seats A, B and C in the preferred Cabin Crew rest row must be consistently blocked on all BoC flights in line with the [Operator] Operational Manual. Seats D, E and F in this row must be blocked as well to provide necessary separation for crew rest.
Rest requirements should be reviewed to ensure that crew are not required to sign on again within the same calendar day following a BoC duty.
Training for [various Cabin Crew management positions] must be strengthened to ensure fatigue reports are handled in a supportive, non-punitive manner. Managers should be trained to assess operational fatigue objectively and avoid treating declarations as interrogations. This approach will foster a just culture, improve transparency, and encourage crew to report fatigue without fear of negative consequences, aligning with both safety obligations and Civil Aviation Act requirements.
To conclude, the reporter states, 'The conditions associated with this pairing constitute a safety-critical issue with a direct impact on flight safety. The lack of proper rest facilities, extended duty periods, and insufficient post-duty recovery time, combined with dense rosters and repeated high-intensity duties, create a cumulative fatigue footprint that significantly increases the likelihood of fatigue-induced error. There is a clear risk to flight safety, particularly during safety-critical phases of flight, when cabin crew are operating under this foreseeable, cumulative fatigue exposure'.
The reporter further states that immediate action is required to address these fatigue hazards, to protect crew wellbeing and prevent further safety impacts. The operational conditions highlight an operational hazard, including inadequate crew rest provisions, procedural inconsistencies, and rostering practices that fail to mitigate fatigue. The inability to consistently secure Cabin Crew rest seats A, B and C hard-blocks and the 'soft-block' on seats D, E and F demonstrates how safety procedures are compromised, and the perception of punitive responses to fatigue reporting illustrates an underreported issue and a risk to just culture principles.
Regulator's response
Thank you for the opportunity to review the REPCON.
CASA considers the matters contained within the REPCON to be a valid concern that may impact safety and acknowledge the Operator's immediate actions.
CASA would like to highlight the requirements of CASR 91.520 regarding that crew members should not carry out any duties for a flight where they are, or are likely to be, unfit to perform a duty on the flight or a duty that is related to the safety of the aircraft, persons or cargo on the aircraft. CASA will include the information provided within the REPCON in its oversight approach for the identified operator.
Named party's response
[Operator] acknowledges receipt of REPCON RA2026-00017 and thanks the reporter for raising these important safety concerns.
As a high-reliability organisation operating within a complex and highly regulated environment, [Operator] actively and continuously manages safety during all operations. Fatigue is recognized as a hazard inherent in aviation operations. While there is currently no prescriptive regulatory framework specific to Cabin Crew fatigue management beyond compliance with CASR 91.520, [Operator] has developed a ‘Fatigue Risk Management (FRM)’, drawing on ICAO guidance, to govern the management of fatigue-related risk as part of our broader Safety Management System (SMS).
[Operator] has reviewed the REPCON submission in detail and appreciates the opportunity to provide information in relation to the matters raised. Our responses below outline the relevant operational context, safety processes, and fatigue management controls:
1. [Operator] recognises that delays, disruptions, and voluntary crew swaps into preferred rosters can tighten duty buffers and reduce the margin available for recovery. While such changes may occur, minimum rest requirements are never compromised, and ensuring adequate crew recovery remains a core safety priority. When roster patterns or circumstances limit rest opportunities, crew members have multiple tactical mitigations via our FRM available to manage fatigue risks throughout the duty cycle:
- At roster publication, if a crew member identifies a potential fatigue risk in their roster, they may request a formal roster review through their manager. The roster may then be amended to reduce the identified risk, or the crew member may receive appropriate fatigue mitigation advice.
- Before commencing duty, if a crew member identifies they are fatigued, they should contact [Operations department] and withdraw from the duty if they determine they are unfit to operate.
- During duty, if a crew member experiences fatigue, they should notify the Cabin Manager or Pilot so that operational adjustments such as modified workload or rest opportunities can be implemented. If they are unable to continue, the crew member should contact the [Operations department] using the fatigue reporting option and they will be removed from the remainder of their duty, with fatigue mitigation support such as transport or hotel accommodation arranged regardless of location.
- Post duty, if a crew member experiences fatigue, they will be supported with hotel accommodation or safe transport home to ensure they are not placed in a situation were travelling while fatigued presents a safety risk.
2. [Operator] acknowledges that Back of the Clock (BoC) duties present an increased fatigue exposure due to circadian factors. To address this, strategic rostering controls are applied at the point of roster planning designed to reduce cumulative fatigue and optimise recovery opportunities, including:
- maximum four BoC duties per calendar month
- protected pre-BoC period (no sign-on before 0930; latest pre-BoC sign-off 0200)
- minimum 34-hour separation between consecutive BoC duties
- additional rest penalties when post-BoC recovery would fall below safe thresholds.
3. Prior to publication, rosters are assessed using a biomathematical modelling tool to identify elevated fatigue risks. Duties flagged as high risk are removed, while those rated as moderate risk are monitored through the Fatigue Management Working Group and supported with appropriate mitigations.
- [Flight number 1]/[flight number 2] ([Location 1]-[Location 2]-[Location 1]) consistently produces acceptable fatigue risk scores through biomathematical modelling. These scores are stable and comparable across crew operating the sector from different bases.
- This pairing sits within the acceptable band under the organisation’s ALARP (As Low as Reasonably Practicable) framework when assessed alongside the strategic and tactical fatigue mitigations available to crew. It is subject to ongoing oversight, with its controls regularly reviewed to ensure inherent fatigue risks continue to be managed effectively.
4. [Operator] recognises that modelling tools have limitations in fully capturing workload related fatigue effects and therefore continues to refine its approach using multiple data sources. The Fatigue Working Group meets [regularly] to review sectors where crew have raised concerns, to evaluate emerging fatigue risks, and proactively address issues that may affect Cabin Crew safety and wellbeing.
5. In relation to the current [Location 2] pairing being scheduled as an overnight for [Location 3] based Cabin Crew, the aircraft for this rotation is based in [Location 2] where the scheduled slot times do not support a same day turnaround. [Flight number 3] arrives in [Location 2] at approximately 1830 (2030 on [day] only), while the next flight back to [Location 3], [flight number 4], is not scheduled to depart until around five hours later at [time]. Operating the flight as a turnaround will exceed permissible duty limitations.
6. Mandatory hard blocks are applied to crew rest rows on all BoC duties to protect rest opportunities. The [flight number 1]/[flight number 2] ([Location 1]–[Location 2]–[Location 1]) pairing has a mandated hard block documented in the [crew rest seating document], and where loads permit, an additional adjoining three seats are also blocked to increase separation and minimise disturbance. A review of [twelve month time frame] operations identified nine instances where these procedures were not followed on this flight pairing and represents a small portion of [Location 1]-[Location 2]-[Location 1] BoC operations. Upon receipt of these reports, they are addressed at the time with the team responsible to ensure compliance with controls is maintained.
7. Whilst not all aircraft are fitted with privacy curtains, [Operator] continues to incorporate them progressively through new aircraft deliveries and planned cabin refresh programs. [Operator] notes that the practice of allocating passenger seats as crew rest locations is consistent with broader industry standards when no dedicated crew rest facility exists. These seats are not classified as formal crew rest facilities under regulatory definitions, and therefore the installation of curtains is not mandated unless the area is formally designated as a class 3 rest facility. To support comfort and mitigate environmental disturbances such as cabin lighting or nearby lavatory use, crew are provided and encouraged to use crew rest comfort aids which includes eye masks, and ear plugs.
8. [Operator] takes its responsibility to support Just Culture very seriously. In reviewing this REPCON, [Operator] reviewed all fatigue related reports associated with the [Location 1]–[Location 2]-[Location 1] BoC pairing between [12-month time frame]. During this period, 10 per cent of fatigue reports were classified as personal fatigue, the remaining fatigue events were recognised as operationally related. For reports assessed as personal fatigue, classification was based on specific information provided within the report itself and reflected circumstances where a personal contributor was clearly identified. Fatigue reports are not routinely categorised as personal; each is assessed on its merits through a structured review process designed to distinguish operational causes from individual circumstances. [Operator] remains committed to working closely with and supporting Crew Managers to ensure they can effectively assist crew in fostering a proactive, open, and Just Culture aligned fatigue reporting environment.
9. The mechanism for raising fatigue concerns extends well beyond individual report submission or direct reporting to a Crew Manager.
- [Operator] has an established escalation pathway that allows any personal fatigue declaration to be reviewed by an independent fatigue specialist, providing expert validation and ensuring impartiality. Crew Managers do play a critical role in handling initial conversations, but this specialist escalation mechanism strengthens the overall process by ensuring that crew have access to Subject Matter Expertise support and that fatigue determinations are not reliant on managerial assessment alone.
- Cabin Crew also have access to an alternative reporting pathway through the [fatigue related] page in our intranet, where they can confidentially raise concerns or seek guidance outside of their direct reporting line. This resource also provides crew with direct access to fatigue related information, self-assessment tools, and links to submit issues or queries.
- Fatigue concerns can also be escalated confidentially through Health and Safety Committee meetings, where Health and Safety Representatives (HSRs) are empowered to highlight concerns about pairings, rostering practices, and systemic contributors to fatigue. A review of Health and Safety Committee meeting minutes from the [four selected months] [year] safety packs demonstrates that fatigue related issues were recently and actively discussed.
Safety and crew welfare remain central to [Operator]’s operating philosophy. This commitment is demonstrated through existing rostering safeguards, fatigue management processes, and accessible reporting channels, as well as ongoing investments and policy enhancements. Consistent with industry recognised best practice, the FRM approach emphasises shared responsibility. The organisation provides structured guidance, education, and tools to support effective fatigue mitigation, while crew members are expected to manage personal rest and non work related activities to ensure readiness for duty. [Operator] will continue to work collaboratively with crew to promote awareness of fatigue management expectations, encourage the use of established reporting pathways, and support the consistent application of available fatigue mitigation strategies across the operation.
REPCON details
| Date reported | 20/01/2026 |
|---|---|
| Published date | 08/05/2026 |
| Affected operation/industry | Cabin Safety |
| Concern subject type | Fatigue |
| Transport mode | Aviation |