Airline pilot training, fatigue and safety culture concerns

On 15 April 2025, [Operator], herein referred to as ‘the operator’, received notification from the Australian Transport Safety Bureau (ATSB) that a report had been received via the REPCON confidential reporting scheme which noted a number of safety concerns related to the operator. These concerns relate specifically to the areas of line training, fatigue management, operations and safety culture. A de-identified copy of the REPCON was provided to the operator on the same day.

We thank the reporter for providing their feedback and the opportunity to review the matters raised in the REPCON. A thorough and objective review has been completed to identify any safety risks or opportunities for improvement. While much of this work continues as part of the operator’s established Safety Management System (SMS), the operator wishes to provide the following response to the matters raised.

Relevant excerpts, reproduced from the REPCON by subject area, are provided below in italics with the operator’s response following.

Line Training

Flight crew are experiencing many days of multi-sector line training. The line training timeframe is intense… Pilots do not have sufficient time to absorb and retain the high volume of information obtained over multiple sectors across consecutive days. Flight crew are quickly burnt out and effectively stop learning through the training process, even after two sectors.

Line training for trainee pilots is planned and conducted in accordance with relevant training objectives and operational requirements, in compliance with all legislative and safety requirements such as flight duty limits and fatigue management. The operator’s approach to line training has been benchmarked and is consistent with standard industry practice for both trainee and trainer pilots in similar sized organisations.

A typical line training roster may include a mix of duty patterns and lengths, including multi-sector days which reflect a normal line operating environment. Line training pathways are developed as a detailed syllabus of learning to ensure a trainee pilot is provided a sufficient level of exposure to both the aircraft and the operation with all pathways having a minimum number of hours and sectors of experience. At the conclusion of line training, a trainee pilot is expected to be performing at a standard required for the normal line operating environment.

In some cases, additional training may be required or requested before a pilot proceeds to an assessment of performance and evidence does exist of this process being used where a trainee was not ready to proceed to a line check.

The current pass rate for the operator’s pilots completing line checks is approximately 94 per cent which is reflective of a healthy training and checking organisation and comparative with similar airlines globally.

Line checks are being enforced at the minimum sector count whether the trainee is ready or not. The only way to access additional sectors is to fail the check to line and undergo remedial training.

All line training is conducted in accordance with the syllabus of line training, as per the approved Check and Training Manual. Trainees must satisfactorily complete all elements of the syllabus before proceeding to a check to line.

If a trainee has not satisfactorily completed all syllabus items at the conclusion of their planned line training phase, whether due to operational disruption, underperformance or some other matter, additional training is provided to ensure all syllabus items are completed.

Detailed feedback from the Training Captain is collected for all trainee pilots and reviewed by the training department prior to a line check being conducted. This feedback may also include recommendations for additional training. Where additional training is required, a training recovery plan is developed in consultation with the trainee pilot. A trainee pilot may also request additional training if they do not feel ready to proceed to a line check.

No allowance has been made for the additional cognitive load that training has placed on the trainee and the trainer.

Whilst it is normal that the line training environment may be more challenging for some trainee pilots than others, accommodations are made to ensure that the trainee is afforded the best opportunity to succeed based on individual circumstances and learning needs.

All pilots complete training in human factors and non-technical skills which focus on skills like situational awareness, decision-making, workload management, communication and leadership. Additionally, all Training Captains complete further training on instructional technique to ensure effective awareness and management of cognitive workload and human performance limitations in the line training environment. In the cases where cognitive load is expected to be highest (that is - during the first day of training), a safety pilot is carried as a supernumerary crew member to provide additional situational awareness and support to the operating crew.

Fatigue Management

The operational flight planning, fuel/alternate policy and performance systems employed by [Operator] is complex and cumbersome. This often prompts pilots to commence work before sign on time in order to digest and understand the volume of information required for the day's flying… The reporter believes pilots have reduced their sleep periods either the night before or on the morning of the flight(s) to achieve this. 

By nature, airline operations are complex. At times, this complexity is driven by the requirement to comply with correspondingly complex legislation. Notwithstanding, pilots are not required, either explicitly or implicitly, to complete operational activities outside of a rostered duty.

The operator acknowledges that there are opportunities for continuous improvement in systems and process efficiencies including those related to flight preparation activities; however, there is no evidence of reports within the Safety Management System where pilots have reported reducing their sleep periods in order to complete pre- or post-flight operational activities.

On-time performance (OTP) is frequently brought to the attention of all staff and thus applies subtle pressure to ‘get the job done’. In addition to this, the desire to complete the rostered duties without having to extend into discretionary time or report fatigued, adds pressure to operating crew fearing potential reprisals from the Flight Operations Management team.

On-time performance is not only an important factor for any commercial airline, it is critical in maintaining a safe and reliable airline operation. The operator continuously reinforces in both written and verbal communications with front line team members that safety must be prioritised over scheduling.

Many factors affecting airline operations are outside the direct control of the operator, including things like weather, air traffic control and passenger behaviour. At times, these factors do cause delays or disruptions, however all pilots are supported in making appropriate decisions on the day of operation. Rarely, additional information may be requested from pilots to understand the cause of a delay in order to improve systems and processes, however there are never reprisals against pilots when delays occur.

No allocated debriefing time leading to either no debrief, debrief in flight or during a turnaround, or debriefings conducted after sign-off where the fatigue risk management system (FRMS) is unable to capture the actual duty time… The [rostering department] who effectively manage the training rosters, have removed the debriefing time in order to make the FRMS work to the detriment of training.

Training Captains are responsible for determining the timing and content of a debriefing to ensure optimum training outcomes for the trainee. The aim is to conduct a debriefing as soon as possible after a flight component to ensure effective and timely feedback. This may occur during or after a flight so long as the debriefing discussion does not adversely interfere with normal duties and responsibilities.

In the case where additional time is required to complete a debriefing after the last flight of the duty, the Training Captain and trainee may contact the operations department and request that their sign-off time be extended accordingly. This process is covered by an existing policy and is designed to ensure that pilot rosters always reflect hours worked and remain in compliance with the associated flight duty limitations and rest requirements.

The standard sign-off time is governed by both company policy and enterprise agreements and is consistent with the majority of similar operators.

The [Flight Safety committee] who oversee the FRMS, is regularly attended and controlled by the Flight Operations management team who actively quell any suggestion that the rostering and training schedules are a fatigue risk… Several [Flight Safety committee] members are due to resign from the role due to the overbearing nature of the Flight Operations management team. 

The operator has implemented a [Flight Safety committee] as part of its FRMS. The [Flight Safety committee] has cross-functional membership including Flight Operations management, training, safety and pilot representatives. At times, [Flight Safety committee] meetings are also attended and observed by representatives from the Civil Aviation Safety Authority (CASA).

The [Flight Safety committee] is appropriately structured and governed in accordance with legislation and as a key element of the operator’s overall SMS. All [Flight Safety committee] meetings follow a standard agenda with minutes and actions recorded. Matters reviewed and discussed during the meeting include reviewing fatigue reports, identification of fatigue hazards in the workplace and evaluation of fatigue risks. Where issues or trends are identified, actions are taken to reduce fatigue risk.

At no point has feedback been provided to the operator, either by members of the [Flight Safety committee] or observers from CASA, that meetings are overly dominated by Flight Operations management personnel.

In relation to commentary that pilot representatives are intending to resign from the [Flight Safety committee], these roles are of a fixed term nature, and it is entirely appropriate and normal for members to elect not to continue at the end of their term. There is no evidence of elevated attrition of pilot representatives at the [Flight Safety committee].

Pilots are reluctant to submit fatigue reports stemming from the training schedule, as they are fearful of potential reprisals from the Flight Operations management team. 

General fatigue hazard reporting from pilots remains healthy and in accordance with organisational expectations and a developing FRMS. Fatigue risk reporting does not indicate any increased trend in relation to training activities.

All fatigue reports are reviewed and actioned in accordance with standard processes. There have been no instances of reprisals to pilots who report fatigue hazards.

Operational

The fuel/alternate policy is unnecessarily complex. Few, if any pilots fully understand it however are required to memorise and apply this document to each sectors fuel scenario quickly and accurately.

While the fuel policy remains compliant with relevant legislation, feedback has been received from the pilot group in relation to the practicality of the policy. This feedback has been collated and the fuel policy is currently under review by the operator to reduce complexity and improve simplicity.

In the meantime, all pilots receive specific training and an assessment of competency on the fuel policy to ensure understanding prior to commencement of line training. The policy is further reinforced as a syllabus item during line training where trainees have the opportunity to apply their knowledge in a practical environment as well as clarify any questions with their Training Captain. Outside of the training environment, duty pilots are available to provide assistance if required. A copy of the policy is always readily available to pilots via their iPads.

Despite the feedback received, there is no pressure on pilots to rush this element of the pre-flight preparation.

The flight plan issued to pilots regularly contains errors where the plan fails to reflect the true nature of the planning scenario.

At times, operational flight plans may contain errors due to changes to weather, aircraft assignments and crew members. Safety reporting data validates that this is not a frequent occurrence and in the small number of occasions where errors are identified, it is a simple process to contact the dedicated dispatch team to request an amended flight plan which is issued electronically to pilot iPads.

No allowance is given to aircraft swaps during turnarounds prompting pilots to rush to another aircraft and then rush the pre-departure sequence to ensure OTP.

Aircraft swaps are generally planned to facilitate required maintenance activities or to support operational requirements. Swaps are also sometimes required as a result of operational disruptions. Planned aircraft swaps factor in the necessary pre-departure activities however it is acknowledged that unplanned swaps may reduce the ground time available for crew to complete their pre-departure activities. In such cases, it is accepted that delays may occur, and pilots are never required or expected to rush the pre-departure sequence in order to meet scheduling targets. This messaging is continuously reinforced to all work groups.

Safety Culture

The Flight Operations management team are known for their rejection of any constructive criticism. There has been a large volume of feedback and suggestions for improvement provide by pilots, which has fallen on deaf ears resulting in a critically low level of moral. 

There are many forums and mechanisms for pilots to provide feedback to management including confidential reporting and anonymous surveys. All feedback is reviewed and actions taken where appropriate. In some cases, large programs of work have been initiated directly as a result of feedback including improvements to systems, processes and work conditions.

In addition to internal feedback channels, pilot feedback can also be tabled for discussion between the operator and the pilot union(s). In such cases, both parties have the opportunity to provide input and work towards a resolution.

It is acknowledged that not all feedback can be actioned on all occasions however management is committed to ensuring pilots have a voice and opportunity to provide feedback on an ongoing basis.

Several Training Captains have resigned due to cultural and workload issues.

While there has been some resignations in recent months, attrition within the Training Captain rank remains in line with industry norms and feedback from Training Captains is generally positive.

The operator is currently recruiting for additional Training Captains and interest from internal candidates has been strong.

In conclusion, the operator thanks the reporter for their submission and has noted the feedback provided. Strong safety reporting remains a critical element of the operator’s SMS however, the operator is confident that there are no serious safety risks present which require immediate intervention. Notwithstanding, actions are underway to improve relevant systems and processes for the whole pilot group.