The operator’s application of its fatigue risk management system overemphasised the importance of scores obtained from a bio-mathematical model of fatigue (BMMF), and it did not have the appropriate expertise to understand the limitations and assumptions associated with the model. Overall, the operator did not have sufficient risk controls in addition to the BMMF to manage the duration and timing of duty, rest and standby periods.
The ATSB notes the operator undertook several actions to address its risk controls regarding fatigue management on its Westwind fleet, and more broadly across its operations. Although not every aspect of the safety issue was specifically addressed, the overall level of action reduced the risk of this safety issue.
After the accident, the operator undertook a series of actions to improve its fatigue management practices. These included:
In October 2017, the operator advised the ATSB:
Since the accident, continuous improvement and advancement has been made to the Pel-Air FRMS including the use of and understanding of the BMMF.
The FRMS has also become an integral part of the Pel-Air and Group Safety Management System and is a standing item that is tracked and reviewed by the Safety Management Group (SMG).
In addition to the existing recorded pro-active actions, other examples of development include;
▸A formal Risk Assessment completed in relation to duty across different time zones and a set of guide lines were published as a result and the document (Acclimatisation Guidelines for Trans-Meridian Operations) is available to crew via the Flight Crew Notices Webpage.
▸All Pel-Air crew, when submitting a report in the Safety Management System online reporting system, must select ‘Yes’ in relation to fatigue report, and submit all the required details, irrespective of whether or not fatigue is considered a contributing factor.
▸Further review, research and improvements were made in relation to the Extension of Duty assessment process.
▸Completion of an FRMS Crew Survey.
▸Pel-Air is also ISO 9001:2015 certified and holds BARS Gold Accreditation both of which are heavily weighted on the Safety Management System which include the FRMS.