Operator’s fatigue management
Date issue released
Safety Issue Description

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.

Issue number
Transport Function
Aviation: Air transport
Issue Owner
Pel-Air Aviation
Mode of Transport
Issue Status Justification

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.

Proactive action
Action number
Pel-Air Aviation
Action date
Action Status
Action description

After the accident, the operator undertook a series of actions to improve its fatigue management practices. These included:

  • revised the callout time for air ambulance tasks from 2 hours to 3 hours
  • developed and introduced a face-to-face introductory course on fatigue management and revised the content of the computer-based training course
  • developed a fatigue assessment form to be used to assess the likelihood of fatigue prior to the assignment of ad hoc charter flights to flight crew who were on standby (with the form including a small number of questions to obtain basic information about a pilot’s recent sleep and rest)
  • introduced a requirement to reduce the maximum period of 24 hour standby to 28 days (after which crew required a minimum of 8 days off duty)
  • modified the FRMS to include longer required rest periods following duty periods involving large time-zone changes (more than 3 hours)
  • conducted a workshop with a sample of the operator’s managers and flight crew (across all fleets) to identify fatigue hazards and risk controls.

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.