REPCON number
RR2025-00077
Date reported
Published date
Mode
Affected operation/industry
Concern subject type
Reporter's deidentified concern

The reporter has raised safety concerns in relation to a new fatigue management system recently introduced at [Operator]. 

[Operator] has introduced a new fatigue management system called ‘[system name]’. The system utilises a 'traffic light' indication to determine fatigue levels based on questions required to be answered when Rail Safety Workers (RSW) sign on at the start of their shift.

  • Green indicates the RSW is well rested and there is no restriction.
  • Amber indicates some additional fatigue mitigation measures are to be put in place to manage fatigue. The mitigation measures may include regular radio calls to the train driver and/or a reduced shift length.
  • Red indicates RSWs are not able to work and will be sent home.

The reporter advised that in most cases, the additional fatigue mitigation measures for an 'amber' fatigue level are not put in place with RSWs being signed on by their leaders to conduct their shift without additional controls.

The calculation of fatigue levels are based on the following questions when the RSW signs on for their shift:

  • hours of sleep in the past 48 hours
  • hours of sleep in the past 24 hours
  • time awake prior to signing on for duty.

The reporter is concerned that limitations with the new system could allow RSWs to sign on with a green indication when they are either fatigued or become fatigued throughout their shift and provided the following example:
A RSW could realistically obtain 8 hours sleep in the previous 24 hours (green indication) however that sleep may have commenced at the beginning of the previous 24-hour period. The RSW may then have an additional 5-minute sleep 30 minutes prior to signing on which would satisfy the third question of time awake prior to sign on. Based on this scenario, the RSW would receive a green indication status meaning they are well rested and ready to commence their shift. 

The reporter acknowledges individual RSWs have a responsibility to manage fatigue however is ultimately concerned about the limitations of the new fatigue management system. The reporter advises, this system may lead to people working and falling asleep because they are fine at sign on but not 6 hours later. The reporter further advises, this has been highlighted by many in the workforce although many have been told it has been tested and works in other transport modes such as the aviation and heavy vehicle industries.

Named party's response

Thank you for your REPCON No RR2025-00077 dated 18 September 2025. [Operator] acknowledges the reporter’s concerns and provides a response on each element below.

To clarify, [Operator] advises that the [system name] tool referenced in the REPCON is not 'the [Operator] Fatigue Management System'. The [system name] tool is one component of the [Operator] Fatigue Risk Management System (FRMS), outlined in detail further below.

[Operator]’s Fatigue Risk Management System

[Operator] is currently implementing a new FRMS across its national [Operator] operations and [Operator] network accredited activities. [Operator]'s enhanced FRMS adopts a risk-based approach to fatigue management built off the multilayered, ‘Defence in Depth’ model of fatigue management.

The model emphasises processes to both identify and minimise fatigue-related hazards, and where signs of fatigue may be present, introduces mitigative controls to maintain safe working conditions. Additionally, this new approach maintains our existing shared responsibility model of fatigue management whereby [Operator], its leaders, and workers all have responsibilities that contribute to the efficacy of the system.

Our risk-based approach includes (but is not limited to):

  • Risk assessment of both static and dynamic worker roster designs, focused on fatigue risks applicable to the roster that is then used to implement controls to mitigate fatigue risk to 'So Far As Is Reasonably Practicable' (SFAIRP) for every roster reviewed.
  • Fatigue risk determination assessed using the FAID - Fatigue Assessment Tool by InterDynamics system on a shift-by-shift basis.
  • Fatigue mitigation strategies, supported by worker and leader education and training.
  • In day of operations, completion of a fatigue self-assessment tool called a ‘[system name]’ tool that is completed by workers prior to commencing their shift.

[Operator] developed the new framework in collaboration with leading sleep science experts at [University] following a multi-year review of fatigue across [Operator] (2021-2022). Formal consultation on the framework occurred on [date] and was later published into the SMS on [date].

It is important to note that the FRMS rollout has been staged across our divisions and the final stage of each implementation is a detailed review and co-endorsement of risks, proposed controls and training completion by both the [management positions].

The [system name] tool

The [system name] tool is designed to provide workers with an indication of their risk likelihood of fatigue. It is a self-assessment, completed by the worker as part of their sign on process.

As a day of operations self-assessment tool, the purpose of the [system name] tool is to provide a simple, practical way to assist the worker to comply with their personal health and safety obligations (both Work Health and Safety and Rail Safety National Law) in the shared duty of fatigue risk management.

A [system name] outcome is generated from two steps:

1. A scaled question of 'how alert are you feeling?'; and
2. A [system name] score calculated on actual hours of sleep in the preceding period and how many hours the worker will have been awake for at the end of their shift.

Regardless of the overall assessment, the result is determined by the most restrictive outcome from either 'How alert are you feeling' or the '[system name] calculation'.

Step 1: Personal assessment

1. How alert are you feeling? (individual’s general fatigue risk)

Individual worker uses a sliding scale to select how they are feeling at the time of commencing work.

Extremely alert - [ok]
Very alert - [ok]
Alert - [ok]
Rather alert - [ok]
Neither alert nor sleepy - Look after yourself
Some signs of sleepiness - Look after yourself
Sleepy, but no effort to keep awake - Look after each other
Sleepy, some effort to keep awake - Do not commence work
Very sleepy, great effort to keep awake, fighting sleep - Do not commence work

Note: in the event a worker chooses any option other than an “[ok]” result for this question, the result must be discussed with the worker’s leader and controls put in place to manage the risk of fatigue to the worker.

Step 2: [system name] calculation

2. How many hours sleep did you get in the past 24 hours?
3. How many hours sleep did you get in the past 48 hours?
4. How many hours will you have been awake for at the end of your planned shift?

[System name] outcomes will be green, yellow, amber, or red, based on the level of fatigue related risk identified. A worker must inform their leader if the [system name] produces an amber or red outcome. When a red outcome is produced a fatigue event report in [program name] must also be completed.

[System name] calculation example

[Operator] acknowledges the example provided by the person raising this complaint. [Operator] submits that the examples of hours of rest for step 2 of the assessment tool provides the most extreme example possible. While it is possible for a worker to truthfully provide the data as an accurate depiction of their periods of rest, the example does not provide the information needed for step 1 of the [system name] tool.

Therefore, the example does not provide the full picture of the assessment outcome, and so it is not reasonable to conclude that the overall assessment rating would be ‘green’ and it is difficult to comment on the example further.

[Operator] acknowledges workers have the choice to answer the questions contained within the [system name] tool honestly or in a way that gets them the result they desire at that point in time.

As the [system name] tool is a self-assessment tool, it is theoretically open to manipulation by the worker. If a worker were to choose to provide responses in their assessment to artificially reduce their fatigue risk rating, [Operator] would be limited in its ability to support that worker to manage their risk of fatigue. However, it is important to note that this would also be the case if the tool was not implemented, and a worker simply chose not to disclose that they were feeling fatigued at the beginning of their shift. For example. [Operator] provides workers and leaders with training in all aspects of our FRMS, including both the intention and use of the [system name] tool, and how to respond in the event of an amber or red assessment result.

As the reporter acknowledges in the report, both workers and [Operator] have a shared responsibility to prevent and manage the risk of fatigue.

Implementation of controls for Amber results in a [system name] tool

All Amber [system name] results are reviewed by the leader and the worker to identify controls that mitigate the level of fatigue risk, which are agreed and implemented by the worker and regularly reviewed for effectiveness by their leader during the shift.

Completed tools capture additional agreed actions put in place to assist workers to manage the risk of fatigue, where an amber or red result is reported. [Operator] has reviewed holistically the completed [system name] tools captured in our event reporting system ([Program name]). All valid amber/red reports (that is, not tools completed for training or testing) show additional controls implemented, including, but not limited to:

  • additional leader check-ins with worker during their shift and confirming safe arrival home from shift
  • wearing of ‘worker down’ alarms
  • role rotation
  • organising a ride home at end of shift
  • worker removed from duty.

Consultation on the FRMS

All [Operator] workers who are included in the implementation of the [Operator] FRMS were invited to participate in the consultation process, as part of [Operator]’s Safety Health Environment (SHE) change management and our SHE communication and consultation processes. Consultation for the new [Operator] FRMS was open to all workers, contractors and worker representative groups from [date] – [date] (a period of one month), with 6 consultation briefing sessions held during this period. The consultation period was extended for [Operator] contractors by two weeks closing on [date].

Additional briefing sessions were also held in leadership forums and worker WHS committee meetings. In all, [Operator] received over 100 submissions. All feedback received was reviewed and where appropriate, incorporated in the final processes. All feedback received was responded to by the FRMS design team, in line with [Operator]’s SHE communication and consultation process.

Feedback and Issue Resolution Processes

[Operator] has in place a robust SHE resolution process for workers to raise concerns they may have with a SHE management system (SMS) process or hazard through their leader, health and safety representatives, or union representatives. On an ongoing basis, [Operator] personnel are also encouraged to provide feedback on [Operator]’s SMS documents, processes and forms at any stage during that process’ lifecycle through the [Operator] SHE management system hub.

Regulator's response

ONRSR confirms receipt of ATBS REPCON report number RR2025-00077, dated 25 September 2025, regarding the subject: New fatigue management system.

ONRSR has reviewed the reporter’s concerns and the operator’s response.

As part of the National Work Program, ONRSR has undertaken a significant number of regulatory activities focused on the operator’s fatigue risk management including the rollout of their revised fatigue management system.
This remains a focus for the National Work Program going forward with additional regulatory activities focusing on fatigue risk management scheduled for 2025-2026.