2 months ago
9
The Australian Transport Safety Bureau (ATSB) has introduced new regulations in response to a concerning incident at Brisbane's Air Traffic Services Centre, where an air traffic controller was found asleep during an early-morning shift on December 9, 2022.
The controller, responsible for overseeing the Cairns Terminal Control Unit (TCU) within the Brisbane Centre, was discovered by the oncoming shift controller at around 5:15 am, prompting a thorough investigation and review of
fatigue management practices
.
An ATSB investigation revealed that the staff member was discovered sleeping across two chairs, covered by a blanket, following the completion of a night shift. The report indicated that the employee had undertaken a total of 10 night shifts within a 12-day period.
ATSB chief Commissioner Angus Mitchell explained that several factors contributed to the controller's drowsiness, including "the time of day, the very low workload in their sector, a roster pattern involving multiple consecutive night shifts, and the controller's decision to lie across two chairs, which further increased the risk of falling asleep."
The controller's repeated night shifts with inadequate rest periods likely affected their ability to obtain restorative sleep, a release from Australian Transport Safety Bureau said.
Although the incident took place during a period of no air traffic in the Cairns TCU airspace, and no flights were scheduled until after the shift ended, the potential consequences of a controller experiencing 'sleep inertia' upon being awakened by a radio alert could have led to delayed communications, incorrect instructions, or difficulties managing unexpected traffic intrusions.
"There were no immediate negative consequences from this occurrence, but it underscores the need for improvements in work scheduling and fatigue risk management," Mitchell said.
The investigation also revealed systemic issues within Airservices Australia's overall approach to fatigue management, particularly the overreliance on tactical adjustments to rosters due to resource shortages, which failed to effectively address the cumulative impact of fatigue. "An over-reliance on tactical changes did not adequately identify or mitigate fatigue risks arising from the work schedule," Mitchell noted.
In response to the findings, Airservices Australia has increased its workforce, especially in North Queensland, and has updated its fatigue assessment and control tool (FACT).
The tool, which was initially limited in its effectiveness due to supervisors not recognizing low workload as a fatigue hazard, has been enhanced with new guidance and training, focusing on treating low-traffic situations as high-risk scenarios.
The Civil Aviation Safety Authority (CASA) has introduced new requirements for air traffic service fatigue risk management systems, and Airservices is working with CASA to align its practices with these updated standards, incorporating feedback to drive further improvements.
