Crew fatigue - domestic commercial passenger and vehicle ferry operations

A reporter has approached the ATSB to raise a systemic crew fatigue related safety concern involving the operation of domestic commercial passenger and vehicle ferries. 

The reporter states, 'The concern relates to roster design, operational timetables, break arrangements, fatigue monitoring processes, and recent timetable changes that appear to increase fatigue exposure rather than reduce it'. The reporter believes the current system creates a situation where crew, particularly vessel Masters, may be operating while experiencing cumulative fatigue, despite company systems indicating that breaks and fatigue controls are in place. The reporter further states, 'The core concern is that fatigue controls appear effective on paper but are not realistically achievable in live operations.' 

Shift durations routinely exceed safe fatigue thresholds

The reporter advised Masters and crew regularly work shifts exceeding 12 hours, with some scheduled shifts extending to approximately 13 hours – 13 hours 30 minutes and provided the following examples:

Shift 'A' - [time frame] (13 hours) 
Shift 'B' - [time frame] (13 hours 30 minutes) 
Shift 'C' - [time frame] (12 hours 50 minutes) 
Shift 'D' - [time frame] (12 hours 7 minutes actual recorded shift)

The reporter states the shift times do not account for crew travel and for some could be an hour each way resulting in a duty day potentially exceeding 15 hours. For early-start shifts, crew may need to wake as early as 0200–0230, reducing available sleep opportunity and subsequently increasing fatigue risk.

The reporter advised, the shift lengths above are occurring in a high-workload marine environment involving repetitive critical tasks. The tasks require sustained situational awareness and decision-making over long periods including, however not limited to, the following:

• berthing and unberthing 
• collision avoidance 
• passenger safety management 
• vehicle loading supervision 
• radio communications 
• emergency preparedness.

Shift breaks

The reporter is concerned that scheduled breaks are often not genuine restorative breaks. The reporter states, 'Although breaks are scheduled within the timetable, they frequently occur during vessel turnaround periods.' During these periods, Masters may still be required to conduct duties such as:

• supervise unloading of vehicles 
• supervise loading of vehicles 
• monitor passenger movement 
• remain at the helm 
• maintain propulsion readiness (vessel often remains in gear during loading/unloading) 
• departure preparation.

The reporter states, 'In practice, a “30-minute break window” may include approximately 20 minutes of operational duties associated with loading and unloading. This leaves little or no genuine rest opportunity. A break cannot be considered restorative if the crew member remains operationally engaged, on-call, or mentally responsible for safety-critical tasks.'

Break recording system may mask true fatigue exposure

The reporter advised, the company uses an electronic workforce management system ([program name]) to record attendance and breaks. A process exists for employees to log missed breaks using missed-break codes ([code name]), which triggers payment of a meal allowance. However, a significant concern is that even when a break is missed and recorded as such, the employee is compensated financially yet the '[program name]' timesheet still displays the break as 'taken'. The reporter states, 'Compensation for missed breaks does not reduce fatigue and should not be treated as an effective fatigue control.' The reporter is concerned of compromised fatigue data, as this may result in fatigue records that underestimate actual fatigue exposure across the operation.

Timetable changes may increase fatigue risk

The reporter advised crew have repeatedly raised concerns regarding fatigue and missed breaks through consultation processes and internal communications. Management previously indicated fatigue concerns would be reviewed and better managed. Despite this, recent timetable changes have reportedly:

• increased shift lengths to approximately 13 hours 
• reduced break feasibility 
• introduced a single stern loader arrangement at [Location] (only one vessel may load/unload at a time resulting in schedule delays and missed breaks)
• increased likelihood of vessel delays 
• increased likelihood of missed breaks.

Consultation appears inadequate

The reporter is concerned that operational changes affecting fatigue risk were implemented without adequate consultation with frontline crew. The reporter states, 'Under fatigue risk management principles, consultation with those performing the work is essential because they are best positioned to identify practical operational constraints.'

Safety risk pathway

The reporter advised the concern does not relate to an isolated incident of crew fatigue - the concern is systemic. In particular, the operating model may allow for crew fatigue with the combination of long shifts and inadequate breaks. Fatigue is known to impair:

• reaction time 
• vigilance 
• decision-making 
• situational awareness 
• threat detection 
• communication quality.

These impairments can occur gradually and may not be recognised by the affected individual.

Potential consequences

The reporter is further concerned that fatigue can contribute to occurrences such as collisions with other vessels or infrastructure, grounding and loading incidents involving passengers or vehicles. Environmental occurrences such as pollution from diesel or oil spills along with damage to sensitive ecosystems may also be contributed to fatigue.

Relevant safety principles and regulatory context

The reporter believes inadequate crew rest breaks may be relevant to obligations under:

• AMSA Marine Order 504 (Safety Management Systems) 
• National Standard for Commercial Vessels (NSCV) operational safety requirements 
• fatigue risk management principles recognised by AMSA.

The reporter recommends the operator's fatigue management system be reviewed, specifically:

• independent assessment of roster design and shift duration 
• review of whether scheduled breaks are genuinely achievable in live operations 
• audit of missed-break data versus actual break opportunity 
• review of [program name] recording logic where missed breaks still appear as taken 
• assessment of fatigue risks introduced by revised timetables and crewing models 
• meaningful consultation with operational crew regarding fatigue controls.

To summarise, the reporter believes fatigue should be actively prevented through system design, not merely compensated after missed rest opportunities. In order to properly achieve the required rest breaks, the timetable needs to change resulting in one less operation in the schedule each day which is not favoured by the operator. The reporter finally states, 'The primary concern is that current administrative controls may create an appearance of fatigue management without ensuring genuine restorative rest. This may allow fatigue risk to accumulate undetected until a serious marine occurrence occurs.'