Mode Aviation
Reference No. AR201800057
Date reported 08 June 2018
Concern title Flight crew fatigue
Concern summary

Flight crew at [Location] experiencing high levels of fatigue and stress.

Industry / Operation affected Aviation: General aviation
Concern subject type Aviation: Policies & Procedures

Reporter's concern

Multiple reporters have expressed a safety concern regarding line pilots at [Location] experiencing high levels of fatigue and stress.

The reporters have advised that [Operator] has recently suffered an aircraft loss and staffing reductions, which have resulted in [Operator] operating for extended periods with three line pilots at [Location], when their contract minimum is four.

The reporters further advise that [Operator] removed Fatigue Audit InterDyne (FAID) from their fatigue risk management system because the FAID scores pilots were receiving would have prevented flying. The reporters query how [Operator] is managing pilot fatigue and how the current line pilots are maintaining operations under the current staffing levels without breaching maximum flight hours.

The reporters state that the recent resignation of experienced pilots is due to the poor safety culture at [Operator], including a culture of suppression and intimidation in which staff are afraid to speak up about safety concerns and fear they will be punished if they do so.

Noting a previous accident, the reporters are concerned that another accident is imminent if [Operator] does not transition to an open reporting culture, whereby management are proactive in identifying and addressing safety concerns, particularly around fatigue. 

Operator's response (Operator 1)

[Operator] confirms that the roster at the time of the REPCON had three pilots available for operations. A recruitment process for an additional two pilots has been completed with the induction, training and checking components of the successful applicants on boarding process currently underway. Whilst four pilots are normally rostered at this base at any one time, the roster generally requires the use of three pilots, with the fourth pilot covering standby for sickness or fatigue and additional charter flying.

At the time of the REPCON [Operator] and [Contractor] had mandated that if any pilot on duty believed that they were fatigued, then they were to report as such and an alternative method of transporting [clients] to their intended destination would be employed. Note that this alternative method had been established and communicated to [Operator] pilots prior to the date of the referenced REPCON report.

There is no evidence to support that the resignation of pilots is connected with the [previous] accident if this is the assertion of the reporters. An internal preliminary investigation and ATSB’s preliminary investigation into the accident does not site fatigue as a potential contributing factor to the accident.

[Detailed circumstances of pilots that had recently resigned – removed to protect individuals]

[Operator] safety department received an email from a pilot raising safety concerns that are of a similar nature to those in the REPCON. The [Operator] safety department commenced investigating these concerns as per their documented processes. Coincidentally, [clients] also sent a letter to [Contractor] outlining internal company roster, fatigue and FRMS concerns. Based on the content of this letter, it was clear that there had been a breach of the confidentiality clause contained in [Operator] employee’s contracts. In order to address this breach, [name removed] issued letters to each [Operator’s employees] based in [Location] on [Date] drawing their attention to the confidentiality and intellectual property clauses and the non-disparagement condition stipulated on their respective contracts.

The safety department investigation into the concerns raised is currently ongoing.

[Operator] utilises an Individual Fatigue Likelihood Score (IFLS), which was introduced in 2013 to improve the identification and management of fatigue-based risk. Consequently, [Operator’s] CASA approved Fatigue Risk Management System (FRMS) does not support/include FAID. The IFLS program is built around the existing FRMS; it is a sleep log and a predictive Excel spreadsheet and highlights in red when the required sleep as per the FRMS has not been met. If this occurs, the pilot is to notify the senior base pilot and be removed from duty. If a replacement pilot cannot be found, the [client] transfers (as described above) must be utilised. The IFLS “fatigue evaluation” is based on a self-evaluated assessment of the pilot’s fatigue score – it is not based on a computer-generated score.

The [Operator] safety department functions independently from commercial and operational factors. [Operator] has an open and transparent reporting system whereby personnel are able to directly communicate any concerns to the safety department. This is utilised, and [Operator] has evidence to support this statement. [Operator] utilizes Air Maestro where reporters are also able to submit confidential safety reports. Upon receipt of safety reports/concerns, Safety carries out investigations to identify and reduce safety related risk.

The above summary outlines the circumstances whereby pilots have been unavailable for the roster and [details removed to protect identity of individual] demonstrates the integrity of the Flight Operations department when considering the pressures placed on [Operator] by commercial factors. There has been no evidence to support that resignations were due to a poor safety culture at [Operator].

Additionally, there has also been no evidence found to support an assertion of suppression and intimidation within the organisation in these matters.

Regulator's response (Regulator 1)

CASA’s certificate management team overseeing the operator:

Requested on 13 July 2018 that the group’s Safety Manager provide the following documents for review and assessment:

  • Pilot rosters for the previous 3 months
  • Pilot rosters for the next 2 months
  • Copies of any reported flight and duty breaches in the past 6 months
  • Copies of any identified flight and duty breaches in the past 6 months

Scheduled a Level 2 surveillance event – onsite inspection- for September 2018. The scope for the event includes:

  • Crew scheduling
  • Operational standards
  • Operational support systems
  • Safety assurance
  • Safety risk management

Over the past 12 months, CASA has conducted one Level 1 surveillance event and several flights with the operator at its [Location 1] and [Location 2] bases. These activities did not raise concerns regarding the operator’s rostering practices or its flight and duty periods. The operator’s [Location regarding REPCON report] base roster and flight and duty records were not specifically examined however.

ATSB comment

Whilst not necessary, the operator provided significant detail regarding the circumstances of the resignation of pilots from the organisation. The circumstances surrounding one pilot states “On [Date], [Operator] Safety received an email from the pilot raising safety concerns of that are of a similar nature to those in the REPCON”.  The ATSB does not usually make any comment on the origin of REPCON reports; however, it is pertinent to advise that none of the REPCON reports received in relation to this concern originated from pilots currently or previously employed by the operator.

Additionally, there is no assertion by the ATSB that the resignation of pilots is connected with the [previous] accident, nor is there any assertion that fatigue was a contributing factor to the [previous] accident. The accident is the subject of ATSB investigation [number] which is separate to the ATSB REPCON.

As stated by the operator in their response to the REPCON, there is no direct evidence to support an assertion of suppression and intimidation within the organisation in relation to safety matters. However, if, as the operator suggests, employees are raising safety concerns external to their own organisation, this could be suggestive that employees do not feel comfortable raising safety concerns internally, and/or employees may believe that no safety action will be forthcoming if their concerns are raised.

The ATSB takes this opportunity to remind the operator that under the Transport Safety Investigation (Voluntary and Confidential Reporting Scheme) Regulation 2012  the purpose of the REPCON scheme is to provide information to the operator about an identified unsafe procedure, practice or condition with the view to facilitate action and awareness; and if necessary, improvements in safety. Further, a person must not use information in a report to: a) take disciplinary action against an employee of the person; or b) make an administrative decision under an Act or an instrument made under an Act, against a person.

In summary, the operator responded as follows:

The operator objected to release of the information on confidentiality grounds.  Further, the operator advised that nothing has occurred which could constitute conduct of the nature referred to in the final substantive paragraph in the ATSB’s email.

The ATSB advises that information was forwarded in the interests of safety.

The operator subsequently provided the following update:

An investigation into the safety concerns raised has been completed.  There was no evidence to support any allegation that the operator required pilots to operate if they exceeded their duty times.  There was one discretionary report during the period investigated, when a pilot exceeded duty time. However, he was not conducting flying duties but fulfilling emergency response activities during the aftermath of a major incident.  There were no discretionary reports alleging that pilots were conducting flying duties with exceeded duty times (12 hours in a single duty period).

CASA requested copies of the operator’s pilot roster for the previous 3 months and the next 2 months, and any identified or reported breaches of pilot flight and duty times over the previous 6 months.  This was in order to examine the roster, flight and duty records specifically at the relevant base of the operator’s operations.  These records were provided to CASA.

The reporters provided the following comments to the responses received:

The operator’s response that the roster generally requires the use of three pilots is inaccurate and clear misrepresentation. A four pilot roster allows avoidance of fatigue incidents. The [previous Operator] relied on a nine pilot / twelve hour roster. This successful management of fatigue was recognised by [Contractor] and stipulated in the new contract i.e provision of four pilots.

[Operator] commenced operations in [Location] on [Date]. Five months later they were experiencing fatigue incidents through the use of three pilots. This fatigue issue was identified by pilots use of the FAID program which the previous operator relied upon as part of their fatigue management system. This fatigue / FAID score was known to be reaching 90-100 for some pilots and causing concern. The operator removed the FAID calculation (evidence of fatigue) citing its non-requirement with their own fatigue system. The FAID calculation was removed from pilots Air Maestro calculation and remains absent.

The use of FAID has shown to be an important tool in managing and avoiding fatigue. FAID is a scientifically based calculation that is in addition to any self-evaluation. The IFLS assertion that a pilot can decide, upon being fatigued, that they have a 66 score (i.e possible cut-off for no flying) and not a 64 (can fly) or 68 (definitely not fly) is flawed. It is illogical in that, a pilot deciding they are too fatigued to fly must then assert that they must be 66 or above. This requires further investigation.

The assertion that a fatigued pilot can decide a supposedly numerically representative figure that supports a fatigue claim is illogical.

The operator’s response that the ATSB preliminary investigation does not cite fatigue as a potential contributing factor is disingenuous. The report does not cite any contributing factors due to the preliminary nature of the report. The final report may find otherwise with respect to fatigue. Until this is completed no assertion can be made about fatigue as a contributing factor to [previous accident].

The operator’s onsite safety rep [position] is at odds with the [State legislation] in particular Part [#] (Safety and health representatives and committees) that operator confirmed applies to them.

A pilot raising safety concerns does not alter the fact just because they have been advised that they are bound by confidentiality clauses.

Request REPCON remain open whilst the above mentioned safety department investigation is ongoing.

ATSB comment

The purpose of the REPCON scheme is to raise awareness of safety concerns with the safety organisations that are best placed to address the concern/s and take action if necessary.  REPCONs are not safety investigations. The ATSB is satisfied that appropriate action has been taken by CASA in response to this REPCON. As such, this REPCON is considered closed by the ATSB. Should the reporter/s have any further safety concerns they are encouraged to contact ATSB REPCON.

Last update 05 August 2019