Multiple reporters have approached the ATSB raising safety concerns in relation to cabin crew fatigue for new duties recently introduced to the cabin crew roster.
One reporter states, [Operator] has recently introduced a [Location 1] to [Location 2] [flight no. 1 and flight no. 2] return duty on the cabin crew roster. Previously, cabin crew would operate [Location 1] to [Location 2], with an overnight rest in [Location 2].
The reporter states, the maximum allowable duty period for cabin crew is [xx] hours as per the [Operator] fatigue risk management system (FRMS). The new [Location 2]-[Location 1] return duty is this number of hours yet does not allow for any delays. The reporter further states this is a 'back of clock' duty commencing [in the evening] and finishing [early morning] the following day, which without an overnight rest in [Location 2] contributes considerably to cabin crew fatigue. The reporter advised cabin crew are required to sign on [xx] minutes prior to departure time from [Location 1] and sign off [xx] minutes post arrival back into [Location 1].
The reporter acknowledges, [Operator] will provide a taxi home if requested by cabin crew should duties extend beyond [xx] hours. This often‑lengthy process requires a fatigue report to be submitted further extending an already exhausting shift. The reporter however queries, why this [xx] hour overnight duty has been added to the roster, when flight delays are common for various reasons with duty times subsequently extending beyond the [xx] hour maximum allowable.
Another reporter states, as well as the [Location 1] to [Location 2] return duty, [Operator] has also introduced another 'back of clock' [Location 1] to [Location 3] cabin crew duty with a total duty time [xx] hours [xx] minutes. This duty again does not allow for delay time. The reporter further states, 'In some instances the aircraft is at capacity leaving no room for crew rest (which the company only allows [xx] minutes at mostly sitting upright and have instructed that crew cannot go to sleep). I personally have operated one such duty and the crew were fine going to [Location 2] but just after leaving [Location 2] ([Location 1 time]) it was evident that the crew were fatigued, and by the time the crew got to [Location 1] everyone was exhausted. I was concerned about the standard operating procedures that needed to be completed on arrival into [Location 1] as small mistakes and oversights were observed just before arrival. This was obviously due to crew fatigue'.
The reporter further states, 'The other concerning issue is that [Operator] will roster these duties followed by [x] days off and then will roster an [early morning] sign on time for the next duty. [Operator] provides us with training on fatigue risk management which clearly states that fatigue is mitigated by regularity. Changing from back of clock flights to the first flight of the day after only [x] days off is not adhering to these FRMS strategies. I am worried that it is a matter of time until a crew member inadvertently [activates] a slide on arrival due to fatigue felt by every crew member'.
In response to REPCON RA2024-00199, please see the below summary. We would like to thank you for providing the information to [Operator] as we see this an opportunity to learn and develop our systems and processes under the Fatigue Risk Management System (FRMS).
The pairings/duties reported were established in the [Roster period A]. Previously, the pairing was constructed without an operating return sector. The concerns raised by the reporter are not a breach of the operator's FRMS as detailed in the [manual] or the Enterprise Agreement (EA). The operator does however acknowledge that whilst it's in line with current FRMS and EA rules, there are multiple factors which can affect fatigue levels of operating crew and as such we take these reports seriously and with a view to reduce fatigue risk for the crew.
It should be noted that operator employs a matured, scientific and data driven FRMS for cabin crew, which runs in parallel to the flight crew FRMS. All pairings and crew rosters are analysed through a bio-mathematical modelling (BMM) program ahead of roster publish and once the rosters have been operated. The [cabin crew fatigue program] is governed by a safety committee which meets monthly to review trends in fatigue reports, material events as well as a review of the biomathematical data. Actions are agreed as appropriate.
In terms of immediate actions in response to the REPCON, it has been entered into the safety system. The report has been entered confidentially and this allows [Operator] to manage the reports in an appropriate manner. In addition to this, the reports were raised at the [Committee] meeting on [date] and were discussed at length.
At the bottom of this response is a detailed list of corrective and preventative actions the operator has taken to manage these reports.
Below is some background and context to the concerns raised by the crew member.
[Location 1]-[Location 2]-[Location 1] Pairing [Roster period A]
In accordance with the FRMS process, the pairing (or duty) raised by the reporter through REPCON was flagged for further analysis (14 instances of the pairing being planned in the roster period were found) ahead of roster publish due to the modelled fatigue levels being close to the thresholds defined in the [Policy manual related to cabin crew]. Engagement between the operator's Safety and the Rostering department is then to occur to determine whether the pairing/duty should be accepted or whether changes are required. In this instance, the roster was published with fatigue scores at or below the thresholds which would normally require formal acceptance (or treatment) in line with the [cabin crew fatigue program]. After the roster was published, the operator's cabin crew senior management was contacted by a relevant union, prompting additional actions to seek how this occurred. The issue was found to arise from an interpretation error when applying EA work rules in the operator's system. A rule template was inadvertently missed by the [team] at pairing creation, which coincided with the airline schedules changing from [schedule 1], to [schedule 2], leaving room for incorrect interpretation by an operator in the team. The applicable EA states that duties between [time frame] can be operated to a maximum of [x] sectors, however there is no Back of Clock (BOC) limitation under this rule. The rule that limits BOC duties between [time frame] states that a duty includes operating and positioning sectors, not operating both sectors which is the duty subject to the REPCON. Previous to [Roster period A], the duties were rostered with only a single operate sector.
Fatigue Provisions
Accompanying proactive processes employed to manage fatigue risk through the established FRMS, the operator has a comprehensive post‑duty fatigue provision program, which includes access to company arranged hotel accommodation in home base, taxi vouchers for transport home from work (and back to collect their vehicle) which are utilised by a healthy majority of crew when needed, and without prejudice. The program offers multiple mitigating actions that can be taken by crew who are experiencing fatigue prior to, during or after a duty. Where crew have requested any of these mitigating actions, the FRMS reporting process requires a fatigue report to be submitted within [designated time frame], there is no direction or requirement to spend time at the airport competing this report at the time of removal.
The operator would also like to clarify, there is no reference in company documentation that states a cabin crew member cannot sleep during rest periods. In the company's [policy manual related to cabin crew], a reference is made to 'achieving controlled rest on BOC duties’, whereby it is written that controlled rest may be used, allowing crew to obtain limited periods of light sleep during BOC flights or subsequent sectors. Further, the manual also provides alternative areas for controlled rest when the last seat row is not available, which was also queried by the reporter. Alternate locations include the flight deck jump seat, or a rear cabin crew jump seat. Crew are encouraged to use controlled rest strategies when permissible.
Time free of duty after a BOC
In relation to the concern raised that a BOC duty is flown, followed by [x] days off, then an [early morning] sign-on, the operator wishes to clarify this. If a crew member is rostered [x] Rostered Day Off (RDOs) after a BOC with a duty signing on at [early morning] after these [x] RDO’s, they will achieve [xx] hours of time free of duty. This is in excess of an agreed directive within the [policy manual related to cabin crew], which is defined as [less than half of this number of hours] minimum. The operator's BMM assesses all pairing and roster patterns to ensure that duties are sequenced and rostered in a way that mitigates the risk of fatigue. [Committee] members meet monthly to discuss mitigations and future directives, taking a data driven risk-based approach, and consistently seeks feedback on the FRMS.
In summary
The operator does acknowledge there may have been a higher fatigue likelihood associated with the rostering error, however responded as soon as it was made aware. Further, the operator maintains that its FRMS operates effectively, and continues to strengthen using a data driven, risk-based approach.
Overview of corrective and preventative actions
- The operator's rostering department has applied additional template application checks at the pairing build stage, which will mitigate against the omission of a template.
- A pre-roster publish analysis meeting has been introduced, to ensure the operator's safety, cabin crew and rostering teams collaborate effectively ahead of roster publish to consider alternate pairing solutions if required.
- To prevent a recurrence in [Roster period B] and [Roster period C], the rostering team have converted one sector to pax in each duty and rostering the duties in a way such that individual crew are not operating the BOC sector consecutively in a roster period.
- To bolster existing controls, the operator will explore options to strengthen pre-roster publish fatigue analysis processes, which may include an additional BMM threshold being added in the [policy manual related to cabin crew]. This will be raised with cabin crew management for consideration.
- The operator's FRMS team will also conduct refresher training for the rostering team, to aide understanding of BMM scores.
- The operator's safety department has recorded the event in the safety management system (SMS) interface, and will capture all causal factors, corrective and preventative actions as part of the SMS processes.
The REPCON and associated fatigue impacts have already been raised at the applicable [committee] on [date], which includes relevant union delegates, line and safety management to ensure ongoing collaborative risk management and continuous improvement.
CASA considers the matters contained within the REPCON to be a valid concern that may impact safety and acknowledge the Operator's immediate actions. CASA would like to highlight the requirements of CASR 91.520 regarding that crew members should not carry out any duties for a flight where they are, or likely to be, unfit to perform a duty on the flight or a duty that is related to the safety of the aircraft, persons or cargo on the aircraft. CASA will include the information provided within the REPCON in its oversight approach for the identified operator.