Non-adherence to documented rostering principles

[Operator] Response to ATSB REPCON RR2026-00015

Executive summary

[Operator] reviewed REPCON RR2026-00015 as a safety-motivated concern relating to Train Crew rostering and fatigue risk management.

The review considered master roster design, consultation, working roster changes, overtime, day of operations controls, training, health assessments and operational safety incident trends.

The evidence reviewed does not support systemic non-adherence to documented rostering or fatigue management principles.

[Operator] will continue monitoring roster exceptions, elevated fatigue indicators, recovery opportunities and fatigue risk controls as part of ongoing assurance.      

Key evidence from the review included:

• Driver master roster review: [>10,000] working shifts reviewed, with 0 shifts above FAID 90.
• Guard master roster review: [>10,000] working shifts reviewed, with 0 shifts above FAID 90.
• Driver rosters did not indicate more than 12 working days in any 14-day period.
• Guard master rosters did not exceed the 13 consecutive day control.
• Operational safety incident data did not show a notable increase over the review period.
• The review did not identify evidence supporting the allegation of approximately 2,000 current active breaches across the reviewed suburban Train Crew rosters.

1. Complaint and review scope

On 24 July 2026, [Operator] received ATSB REPCON RR2026-00015. The complaint predominantly relates to fatigue management for Train Crew, including Drivers and Guards. [Operator] has treated the matter seriously and reviewed relevant rostering, fatigue management and operational controls.

The review considered the end-to-end rostering process, from master roster design and consultation through to working roster changes and day of operations management. It also considered relevant controls for overtime, leave, relief, health assessment, fatigue training and safety incident trends.

2. Grounds of complaint

The complaint raised the following matters for consideration:

• Inconsistent application of rostering principles.
• Alleged non-adherence to [fatigue risk management documents].
• Inadequate recovery between shift cycles.
• Backward rotation or movement between sleep cycles.
• Financial disincentive to report fatigue or unfitness.
• Pressure to work overtime, longer hours or further distances.
• Reported increase in safety incidents.

3. Master roster design and controls

Master rosters are developed by the [rostering and support staff] using known work in the standard working timetable. They are designed and checked against applicable rostering and fatigue controls, including Enterprise Agreement requirements, [Driver and Guard industrial arrangements], [fatigue risk management documents] and related fatigue management procedures.

Relevant roster design controls include days-off requirements, maximum shift lengths, break requirements, limits on consecutive work patterns, recovery opportunities, shift rotation principles, overtime controls, exchange arrangements and fatigue risk controls.

[Rostering software] is used to support roster construction. System controls are in place to prevent rostering outside accepted parameters, supplemented by manual checks before roster finalisation.

Driver master roster review

• [>10,000] working shifts reviewed.
• 0 shifts above FAID 90.
• [1.5 per cent] shifts at FAID 90.
• [9.5 per cent] shifts between FAID 80 and 89.
• [8.0 per cent] shifts between FAID 70 and 79.
• [10.7 per cent] shifts between FAID 60 and 69.
• [70.3 per cent] shifts below FAID 60.
• No indication of more than 12 working days in any 14-day period.
• Rostered shift lengths and kilometre limits were reviewed against applicable controls.

Guard master roster review

• [>10,000] working shifts reviewed.
• 0 shifts above FAID 90.
• [1.4 per cent] shifts at FAID 90.
• [9.7 per cent] shifts between FAID 80 and 89.
• [7.7 per cent] shifts between FAID 70 and 79.
• [10.6 per cent] shifts between FAID 60 and 69.
• [70.6 per cent] shifts below FAID 60.
• No master roster line exceeded the 13 consecutive day control.
• No shifts above the [mandatory upper limit] suburban weekday maximum were identified.

4. FAID and fatigue risk indicators

FAID is a bio-mathematical fatigue risk indicator used by [Operator] as an additional control. It considers matters such as time of work, duration of work and rest, recent work history and likely recovery opportunity.

FAID is not the only measure of fitness for duty and does not, by itself, prove or disprove fatigue. Higher FAID indicators require additional controls, including review, welfare questions, recorded fitness-for-duty discussions and [rostering and support staff] checks where applicable.

5. Roster consultation and working roster changes

Master rosters are published in draft form for consultation. Depot representatives may review and adjust rosters within applicable system and policy controls before rosters are finalised.

For clarity, the master roster provided commencing [date] is the same master roster applicable to the dates covered by the actual worked roster review. Although the calendar dates do not align directly, the roster pattern remained unchanged and therefore provides the relevant master roster baseline for comparison against the actual worked roster.

Working rosters may change after publication due to leave, training, relief work, shift exchanges, operational disruption and employee-requested changes. These movements are not uncontrolled. They are reviewed against applicable roster parameters and managed through additional operational controls.

Some elevated fatigue indicators can arise after roster publication through employee-requested exchanges, leave coverage, relief work, training and operational changes. These movements are managed through additional controls, including roster review, welfare checks, recorded fitness-for-duty discussions and [rostering and support staff] checks. [Operator] retains responsibility for managing fatigue risk across these processes.

Driver working roster review

The actual worked roster period from [4-week timeframe] was reviewed across two fortnightly roster periods. No Driver roster line was identified as exceeding 12 working days in a 14-day period, and shift lengths were reviewed against the maximum [rostered time limit] threshold.

Guard working roster review

For Guards, the worked roster review identified [>10,000] extracted worked shift entries. Of these, 34 shifts were over 9 hours 5 minutes, representing 0.12 per cent of worked shift entries. The review also identified 132 out of 1,611 roster lines showing more than 10 workdays in a fortnight, with no lines showing more than 12 shifts. These were reviewed as isolated operational exceptions and did not indicate systemic non-compliance.

Where exceptions are identified, controls include monitoring, fatigue checks, agreement where required, roster review, relief consideration and operational review. The review characterises these items as matters for ongoing monitoring rather than evidence that roster design controls are not being applied.

6. Overtime, fitness for duty and employee supports

Overtime is voluntary and can be declined. Train Crew can nominate 'not to alter' for rostered days off, access leave, request relief, and self-report fatigue, illness or unfitness for duty.

Where overtime or roster changes indicate elevated fatigue risk, crew are asked welfare and fitness-for-duty questions, with calls recorded where required. [rostering and support staff] checks provide a further opportunity to identify and manage fatigue or fitness concerns when crew present for duty.

[Operator] treats fatigue and fitness-for-duty reporting as a safety obligation and supports reporting through leave, relief, voluntary overtime controls, welfare checks and fitness-for-duty pathways.

7. Day of operations controls

On the day of operations, rosters and schedules are managed through the [operations centre]. Controls relevant to the complaint include:

• 24/7 [rostering management staff].
• [Staff resourcing position] oversight for Drivers and Guards.
• Standby coverage, typically around [adequate] standby Drivers and [adequate] standby Guards each weekday, with adjustments for special events and projected absenteeism.
• Relief arrangements to support breaks, shift limits and displaced crew during disruption.
• Monitoring of breaks, shift limits and relief requirements.
• Service adjustment or cancellation where work cannot be safely covered.

Train Crew are not required to accept voluntary overtime or additional work where they are not fit or willing to do so. Where work cannot be safely covered, operational plans are adjusted.

8. Training, health assessment and leave

Train Crew are Category 1 rail safety workers and are subject to mandatory health assessments. These assessments support ongoing fitness for safety critical rail work and may include triggered or time-based medical review. Current health assessment arrangements include screening relevant to fatigue risk, including sleep-related risk factors.

Train Crew also receive fatigue management training and have access to leave and relief pathways, including annual leave, sick leave, accrued days off, long service leave, parental leave, relief arrangements and fitness-for-duty processes.

9. Operational safety incident trend

Operational safety incident data reviewed between January 2024 and July 2026 did not show a notable increase. While kilometres operated increased after the [date] standard working timetable change, the rolling 12-month [safety incident data] count remained broadly consistent, within a variance of less than 4 per cent.

10. Ongoing assurance and improvement

[Operator] will continue to:

• Monitor working roster exceptions.
• Review elevated FAID outcomes after roster publication.
• Check recovery opportunities after extended work patterns.
• Reinforce fatigue self-reporting and relief pathways.
• Review overtime and shift extension controls.
• Use findings to support continuous improvement in fatigue risk management.

11. Conclusion

Based on the review undertaken, [Operator] does not consider that the evidence supports systemic non-adherence to documented rostering or fatigue management principles. The reviewed master rosters were developed within applicable roster design controls, and working roster changes were subject to additional operational controls.

[Operator] recognises that fatigue risk is an ongoing safety management obligation. The organisation will continue monitoring exceptions, reviewing elevated fatigue indicators and reinforcing reporting, relief and fitness-for-duty pathways to support safe operations.