Mode Aviation
Reference No. AR201600052
Date reported 24 May 2016
Concern title Fatigue at the Southern Control centre during one-person night shift
Concern summary

The concern related to fatigue which was being experienced at the Southern control centre by controllers who were operating on one-person night shift.

Industry / Operation affected Aviation: Airspace management
Concern subject type Aviation: Air Traffic Control

Reporter's concern

The reporter expressed a safety concern related to the continued use of one-person night shifts in the Bass and Alpine ATC groups.

The reporter advised that these are the only two groups in Melbourne [air traffic control] Centre which continue with the practice of using one-person night shifts, with some doing about 100 a year. Controllers have reported frequently falling asleep at the console for extended periods of time during these shifts, and there is no back-up controller to ensure that safety is not compromised. They are also concerned that the fatigue experienced is resulting in them being unsafe while driving home.

The controllers are also concerned why their reports to managers on this safety breach, of sleeping at the console, have never been discussed, or addressed in writing, to the controllers as a large discussion group to find an appropriate solution.

The reporter also advised that the controllers have never been directly asked by management ‘Are you falling asleep on the single-man night shift’.

The reporter advised that controllers feel intimidated and fear retribution if they raise the issue on the Airservices’ internal website.

The reporter advised that controllers in these groups have advised Airservices Australia’s management and CASA that this is occurring, but no action has been taken.

Reporter comment: It is only a matter of time before a serious accident/incident occurs so we want to make sure all relevant authorities have been made aware in writing.

This has been reported to Airservices on a previous occasion in R201100172.

Operator's response (Operator 1)

Airservices Australia (Airservices) appreciates the opportunity to respond to the reported safety concern regarding the continued use of one-person night shifts in the Bass and Alpine ATC groups.

Airservices would like to clarify that one-person night shifts are not limited to Bass and Alpine groups.

It is also used in Brisbane Centre and a number of remote towers and terminal control units as well as other operational roles such as systems supervisors and flight data coordinators.

All work schedules implemented in the Air Traffic Control (ATC) Group are designed on a solid understanding of fatigue and the science of sleep. Airservices recently undertook a sleep study that reviewed the quantum of sleep achieved by controllers between various shift combinations. The analyses reflected that participants, who worked one-person night shifts, on average, achieved more sleep before their shifts than those rostered to other night resourcing categories.

In addition, ATC rosters incorporate work/life balance and console/staffing requirements. Staffing arrangements on night shift duties are determined by controller workload, taking into consideration console usage, known traffic patterns and actual traffic captures highlighting the maximum and minimum numbers of aircraft in a given airspace. The workload and console usage is also assessed annually to ensure it continues to be appropriate with the ongoing operational demands.

To address the reported concern, Airservices has reviewed the practice of one-person night shifts at Melbourne Centre. It has been confirmed that the established processes and systems for night shift rostering/staffing and fatigue management are appropriately followed in determining and monitoring the night shift arrangements.

Airservices reviewed the average number of night shifts expected to be completed by controllers in one-person and dual staffing night shifts and confirmed that the numbers were comparable. The following average night shifts completed have been confirmed using a sample size of at least 4 controllers per ATC group for the period of 1 June 2015 to 31 May 2016.

  • Bass - 50 (one-person)
  • Alpine - 39 (one-person)
  • Barossa - 44 (dual-staffing)
  • Grampians - 48 (dual staffing).

While these averages are valid for the vast majority of controllers, the review identified one controller in Bass Group that had completed 87 night shifts between 1 June 2015 and 31 May 2016. This controller is managed on an individual flexibility agreement which specifies a set roster, considers the controller's personal preference to complete night shifts and complies with the FRMS strategic roster planning rules (SRPRs).

Melbourne Centre operates in a shared operations environment with twenty four hour supervision and short break arrangements. All night shift staff are located in the same room and at least three staff members are available in each aisle to assist with the identification of controller fatigue and provide short term support if required. Controllers operating on one-person night shifts are offered breaks by controllers on dual staff night shifts and by the systems supervisor at certain times during the shift to minimise the likelihood of a controller becoming fatigued.

To further mitigate the risk to staff health and well-being, Airservices provides stand-down rooms.

Priority is given to staff that have been operating on one-person night shift.

Airservices is committed to providing a safe and healthy working environment for our staff. Part of this commitment is fostering a strong safety culture where staff feel supported and encouraged in reporting safety occurrences/concerns through a range of existing reporting channels (including mandatory, voluntary and confidential reporting). In 2015 and 2016, Airservices launched a number of campaigns to promote the value of safety reporting and reassure staff that they are fully supported to 'speak up for safety'. The confidential reporting process was also strengthened to increase the organisation-wide awareness of the utility of the Airservices Australia Confidential Safety Reporting system. Controllers can also submit fatigue related hazard reports outside their normal line management.

Following this reported concern, Airservices will deliver further communications to remind staff of the available reporting channels and processes and eliminate any potential or perceived obstacles that may prevent safety reporting. Additional educational material will also be provided to controllers regarding preparing, surviving and recovering from night shifts.

Airservices and staff have a shared responsibility for managing fatigue-related risks. The organisational measures through staff rostering, safety promotion and provision of rest arrangements have been detailed above. Staff are also expected to take appropriate measures to adequately manage their fatigue both at work (including reporting of fatigue concerns) and during preparation for work.

Prior to the receipt of the reported concern, the topic of one-person night shifts was recently raised in weekly staff forum discussions. In response to the staff feedback, Airservices plans to complete an assessment of current practices within the Melbourne Operations Room during night shifts, taking into account the controls in place to mitigate fatigue-related risks.

Regulator's response (Regulator 1)

CASA has reviewed the REPCON and notes the response from Airservices. In addition, the Fatigue Risk Management System (FRMS) is considered by CASA to be part of the Airservices safety management system and contributes, in part, to calculations for the required number of Air Traffic Control staff under the Part 172 Manual of Standards (MOS) Paragraph 2.2.1 (d) and Airservices Operations Manual Part 172 Paragraph 6.1 (b). As such, these aspects of FRMS are considered under CASA's ongoing regulatory oversight of Airservices.

Additionally, International Civil Aviation Organization state letter AN 13/13.1 - 16/39 advises that from 5 November 2020, signatories to the convention will be required to implement FRMS for air traffic control services. CASA will be taking this initiative into account with regard to necessary updates to the Civil Aviation Safety Regulation 1998 Part 172 and the applicable MOS.

ATSB comment:

The ATSB received comments from the reporter to these responses and further questions were sent to Airservices. The following is a summary of these questions:

Airservices reports that solo ops are occurring in multiple aisles, how widespread are these issues of sleeping at the console?

If their recent sleep study revealed that solo night shift staff are sleeping more in preparation and this is better for fatigue, then why aren’t all groups solo on the ‘doggo’ [night shift] as its not warranted 'traffic wise' on most groups?

The sample size that Airservices used to average the number of night shifts worked was not a sufficient representation. Night shift numbers vary between 0 and 110+ and the one controller who was highlighted as completing 87 night shifts was actually over 110. A wider sample base is required to get an accurate figure.

To even suggest there are multiple people in the row that could 'save the day' is absolutely ridiculous. There is NO WAY either the Melbourne Approach or the Alpine controller would know if the Bass controller was sleeping and vice versa. The Supervisor is at the front desk and has no line of sight to see if the controllers are sleeping. (Not to mention the amount of times the supervisor is actually asleep)
So what are the other controllers supposed to do, leave their console to wake up a sleeping controller, what about their traffic? Is that really an appropriate and safe solution to the problem?

Breaks offered to solo night shift controllers are patently insufficient and rarely accepted due to traffic and the inability of, in one case, approach rated staff to provide verbatim instructions to en route break relief staff. That is, Tasmania Approach controllers may be offered breaks by en route staff from a different aisle. Taking a break whilst two or more aircraft approach the critical phase of flight and issuing verbatim instructions to a non-approach controller on scenarios that may change in an instant is fraught with danger. It is also not possible to cover the breadth of possibilities that may occur such as missed approaches, variable conditions demanding alternate approaches by aircrew and the like.

Stand down rooms are not available to solo night shift staff during the shift, because we are at the console ALL night.  They are only offered as a priority, post-shift completion, which begs the question as why a controller is considered not fit to drive home, yet was fit to control aircraft at the end of the shift, minutes before, where traffic loads are often peaking for the night. So a controller is unfit to drive home at 6.01 am but at 5.59 am they are fit to operate their busiest period of traffic, is this correct?

Reluctance to report fatigue related issues continues and anecdotally there are still reports of staff being harassed in such circumstances.

Airservices response:

As mentioned in our previous response, controllers have a responsibility for managing fatigue-related risks for every shift, including on one-person night shifts. In respect of the reporters concerns regarding the unavailability of short breaks, controllers have the opportunity to notify the system supervisor to arrange a short break, if required, during the night shift. Controllers providing short breaks should ideally do so at a time when there is minimal or no traffic and individuals are encouraged to take advantage of these times to take a break.

Airservices reaffirms that traffic volumes are reviewed nationally each year to ensure appropriate staffing arrangements are in place. Single person night shifts will be rostered where the volume is insufficient to justify dual person night shifts.

Southern Operations has initiated a review of the night time operations within Melbourne Centre. The review outcome is likely to result in an increase in single person night shifts and is intended to encourage controllers to work closely together as a team across the operations room to assist with the provision of breaks. Airservices will also establish systems and processes to manage breaks within this team-based environment.

The specific example given in Airservices previous response regarding rostered night shifts was determined based on standard night shifts completed for the period 1 June 2015 to 31 May 2016. Airservices clarifies that 'mutual change of shift' (MCOS) and additional shifts were not included in the count however the cumulative count including these extra shifts is a total of 90 worked night shifts for the period.

A broader evaluation of the number of nights rostered per person across Southern Operations will be included in the night time operations review. Expressions of interest to participate will be sought.

In regards to reporters comments on stand down rooms, Airservices clarifies that they are offered to staff that have completed single person night shifts on a priority basis as a gesture of fairness. Airservices acknowledges that any shift can be fatiguing and staff are encouraged to utilise the rooms to recharge and provide a delineation between operations and home life. It is the responsibility of each individual to make a determination of their fitness for duty at work and in their home lives.

Airservices code of conduct sets out the framework to ensure all staff behave in a safe, professional and ethical manner at all times by upholding appropriate standards of conduct.

Any reports of staff harassment for reporting any issues, whether safety, professional or otherwise will be addressed swiftly once known. Bullying and inappropriate behaviour is not tolerated by Airservices and any formal notification will be acted upon immediately.

CASA response:

CASA has reviewed the comments from Airservices and there is no change to previous advice provided in relation to this REPCON.

ATSB comment

The ATSB received a copy of the southern operations night shift review report on the 15 of December and notes that seven recommendations were made, and there is a plan and timeline for these recommendations to be actioned.

Last update 12 July 2018