The reporter has raised a safety concern relating to cabin crew fatigue when operating the [Location 1] - [Location 2] - [Location 1] sectors back-to-back.
The reporter states they were rostered to operate [flight no.] [Location 1] to [Location 2] late last year. The flight was delayed leaving [Location 1] by 22 hours resulting in a rest time in [Location 2] of just 30 hours after a 20-hour duty. The reporter advised they did not have adequate sleep in [Location 2] due to the time difference and jet lag.
The reporter advised they considered calling in fatigued prior to the return sector [flight no.] back to [Location 1] but they were reluctant to do so as they called unavailable for duty with an illness on a different flight a couple of weeks prior and were concerned of potential punishment and being placed on a 'watch list' by the ground management team.
The reporter states during the [Location 2] to [Location 1] sector (as well as the previous sector [flight no.]) they were responsible for arming and disarming/manning a door during taxi, take-off and landing as well as evacuating or ditching the aircraft should this become necessary. The reporter advised 'during take-off out of [Location 2], myself and other crew whilst extremely tired but alert, experienced a 'hairy' take-off. Immediately I focused on part of my impact drills on how I was going to get the door open and where my equipment was and how to get my passengers and potential incapacitated crew to safety'.
The reporter states, 'The flight carried on as normal whilst my fatigue was building. I slept for five hours during crew rest which for me is not normal. This means I'd received 7 hours solid rest in more than 48 hours'. The reporter further advised they completed a fatigue report with their cabin [manager] and confirmed they were able to operate a door should they need to evacuate or ditch the aircraft.
The reporter states - 'After my call back I rehearsed my silent review, the same as I do every single take-off and landing. This time I couldn't remember anything except how to get the door open. I attempted to rehearse in my head my commands but couldn't think of anything other than "evacuate". As the seatbelt sign was on, I could not contact anyone. We landed into [Location 1] without issue, and I disarmed my door and completed my duty. I left the aircraft distressed I'd felt so pushed that I put the aircraft, its occupants and myself in danger at any point during any phase of flight out of fear of repercussions.'
[Operator] has a robust method for preventing, reporting, and managing cabin crew fatigue. Training programs and resources are available to educate crew on techniques to proactively and reactively manage fatigue, both on the ground and inflight. If required, any crew member is able to remove themselves from service, both before and during the flight, in order to manage fatigue levels. [Operator] continues to monitor the effects of the long-haul flying associated with the [Location 1] - [Location 2] flying conducted by the [Location 1]-based cabin crew.
As part of our fatigue risk management system, [Operator] uses bio-mathematical modelling when reviewing patterns for fatigue levels. Prior to [Location 2] - [Location 1] long-haul operations commencing, [Operator] medical in conjunction with the Human Factors team completed a fatigue study which provided initial modelling of the proposed roster patterns for the [Location 1]-based cabin crew, based on different rest periods in [Location 2]. This assessment uses [program 1] modelling which provides a predictive view on how rostered flying patterns may impact a crew member’s fatigue levels. The report showed predicted [program 2] scores within the category range of “moderately tired, let-down”.
Following this study, education material titled [Fatigue document] was released to all [Location 1]-based cabin crew by our Human Factors team. This information provided practical guidance and advice to crew to assist them in managing their fatigue levels during the rostered flying duties. This advice covered information relating to diet, exercise and how to effectively manage sleep opportunities.
Additionally, the [Country] cabin crew ground managers were provided with an additional training session to assist them in more effectively understanding fatigue, and how to manage crew concerns around fatigue as they arose. The following were topics covered in this training:
- fatigue and sleep science
- the [Operator] Fatigue Risk Management System
- overview of processes
- responsibilities and accountabilities
- open and fair reporting
- fatigue tools
- additional resources and support.
Fatigue Training
All [Operator] cabin crew are provided with fatigue training during their initial training. Additionally, fatigue management training refreshers are provided during annual emergency procedures training. The following topics are covered during these training sessions:
Cabin crew Human Factors (HF) Initial – fatigue module
- define fatigue and explain why it is important to manage the risk of fatigue in aviation
- describe the causes, symptoms and effects of fatigue
- describe the importance of quality sleep in fatigue management
- describe the impact of sleep inertia, circadian rhythm and jet lag on performance
- identify strategies to reduce the impact of fatigue
- understand crew responsibilities when reporting unfit for duty due to fatigue.
Cabin crew HF Recurrent (2023/24)
- why fatigue is an issue
- practical strategies that can be used (napping, caffeine, sleep hygiene, exposure to light / exercise, nutrition)
- application of these strategies to a practical example
- reporting fatigue.
Fatigue reporting
[Operator] encourages crew to report the effects of fatigue via the [reporting program].
[Fatigue committee]
As part of the [Operator] Safety Management System, a functional committee exists, that identifies, assesses and advises on the management of fatigue risks in a collaborative manner. The committee is made up of cabin crew management, cabin crew representatives, subject matter experts, human factors experts, operations and workforce planning representatives. The [Fatigue committee] feeds into the [Safety committee] and is responsible for hazard identification, risk management, and developing strategies to manage fatigue for cabin crew. A summary of [Fatigue committee] data and meeting minutes is reported to the [Safety committee].
[Fatigue committee] meetings occur on a bi-monthly basis. The cabin crew representatives meet without management presence every alternate month. A data pack is generated monthly which encompasses all reports submitted by cabin crew operating on [Operator] registered aircraft.
Summary
Fatigue management is a shared responsibility between the company [Operator] and the crew member. [Operator] provides the tools and resources to educate crew to be aware of the symptoms and effects of fatigue and also the mechanisms to report fatigue or elect to not attend work due to fatigue.
In the case reported in the REPCON, the reporter was afforded all the avenues to report unfit for duty due to fatigue, however elected not to utilise these and may have attended work in a state of fatigue or in a state that would potentially result in higher levels of fatigue later in the planned duty.
Thank you for the opportunity to review the REPCON.
CASA considers a situation in which a cabin crew member cannot recall the pertinent aviation safety (memory) items at the phase of flight described by the reporter - in accordance with the operator’s safety procedures - to be a safety concern which should be internally reported, investigated with remedial action(s) applied, and appropriate corrective actions implemented, to reduce the likelihood of recurrence.
CASA has recently met with the operator and discussed matters relating to cabin safety fatigue management, including:
- the current volume of reporting and requisite data trending
- inflight service provision changes introduced in concert with maximising cabin crew rest break opportunities
- training and awareness provided to cabin crew to understand the fatigue identification process
- training and awareness provided to onboard managers in relation to inflight agile mitigation strategies
- initial and ongoing education provided to [Location 1]-based cabin crew management pertaining to support mechanisms available for fatigued cabin crew.
The meeting provided an opportunity for CASA to gain further insight into the operator’s management of fatigue reporting through the operator’s safety management system. CASA did not note any concerns with the operator’s management approach in these matters.
CASA will continue to monitor information pertaining to cabin crew fatigue and initiate surveillance activities where appropriate.