[Peetwo]

Popinjay to the rescue on fatigued ATCOs?? -

Via PJ's media minions:

Fatigue management improvements underway after Brisbane Centre controller found asleep at end of their night shift


A Brisbane Centre air traffic controller who was found asleep at their workstation towards the end of their shift had worked multiple consecutive night shifts resulting in sleep debt, an ATSB investigation report details.

The approach controller, who was managing the Cairns Terminal Control Unit (TCU) within Airservices Australia’s Brisbane Air Traffic Services Centre (‘Brisbane Centre’) was found asleep at about 5:15 am on 9 December 2022. The oncoming approach controller found the night shift controller lying across 2 chairs with a blanket covering them. 
Several factors contributed to the controller failing asleep, the investigation found. 

“These included the time of day, the very low workload in their sector, a roster pattern with multiple consecutive night shifts, and the controller increasing their risk of falling asleep by lying across 2 chairs, not moving, and not undertaking activities to maintain mental alertness,” ATSB Chief Commissioner Angus Mitchell said.

“The controller had also been working multiple night shifts with reduced extended rest periods, which likely reduced their ability to obtain restorative sleep.”

When the controller was found asleep, there was no traffic in the Cairns TCU airspace, which was usual for that time of day, and there were no scheduled flights until after their shift.

However, had the controller been woken by a radio broadcast, they may have experienced ‘sleep inertia’, with the risk of delayed communications, or incorrect instructions/actions, and likely affecting their ability to manage any conflicts arising from traffic infringing their airspace without a clearance.

“There were no negative consequences from this occurrence, but it does highlight areas for improvement in work scheduling and fatigue risk management,” Mr Mitchell said.

The investigation also identified issues relating to Airservices Australia’s broader management of fatigue.
“An over-reliance on tactical changes to manage the roster at Airservices was likely due to an underlying lack of resources,” Mr Mitchell explained.

“As a result, cumulative fatigue was not being effectively managed strategically, and an over-reliance on tactical principles did not identify or manage fatigue risks arising from the work schedule.”

Following the incident, Airservices has increased its overall number of air traffic controllers, including in the North Queensland group.

The investigation also identified Airservices’ fatigue assessment and control tool (FACT) had the means of identifying situational factors that influenced fatigue, but the tool’s effectiveness was limited as supervisors were not identifying low workload as a fatigue hazard.

Airservices has subsequently developed additional guidance and training on the fatigue risk assessment process, including information on how low traffic situations should be treated as high risk.

Separately, the Civil Aviation Safety Authority has recently introduced changes to air traffic service fatigue risk management system requirements. Airservices is working with CASA to trial its existing system against the new requirements, and is using feedback to make improvements.

“Fatigue remains one of the most relevant ongoing concerns for safe transport, despite increased awareness across the transport sector,” Mr Mitchell said.

“We urge transport operators to investigate fatigue events to identify and remedy deficiencies in work scheduling, fatigue risk management processes and risk controls.”

Read the report: Air traffic controller incapacitation, Brisbane, Queensland, on 9 December 2022

Publication Date: 03/09/2024

This investigation was apparently a defined investigation that took 1 year, 8 months and 26 days to complete. There was also 2 safety issues identified and bizarrely only published yesterday?

Fatigue risk management system

Safety issue number: AO-2022-065-SI-03

Safety issue description: Likely due to an underlying lack of resources within Airservices Australia, there was an over‑reliance on tactical changes to manage the roster. As a result, cumulative fatigue was not being effectively managed strategically and an over‑reliance on tactical principles did not identify or manage fatigue risks arising from the work schedule.

Fatigue assessment of low workload

Safety issue number: AO-2022-065-SI-04

Safety issue description: Although Airservices Australia’s fatigue assessment and control tool (FACT) had the means of identifying situational factors that influenced fatigue, it had limited effectiveness as supervisors were not identifying low workload as a fatigue hazard. 

 
Reading the basic timeline for these 'safety issues' it would appear that ASA was only made aware of the SIs in recent months:

Action description

On 16 June 2024, Airservices Australia advised the ASTB that:

Airservices Air Traffic System Fatigue Safety Assurance Group is currently working to review and develop additional guidance material, training or coaching sessions that will assist end users in the application of the FACT process. (Action FSAG/27) An understanding of the possible impact of low workload will be included as part of this action.
Additionally, Airservices Australia provided the ATSB with a copy of supporting documentation on 29 July 2024 and advised that it:

…will be published this week…[and]…provides clearer guidance regarding breaks and reiterates the information contained in the FACT guide regarding low traffic volume being high fatigue volume. A representative from the human performance team will attend a line leader meeting to provide advice on the use of FACT, fatigue, workload and break management advice.

While on the subject of the dubious performance of the Popinjay version of the ATSB, I noted I missed 2023-24 Supp Estimates AQON that is quite revealing and fills a number of gaps in the vacuous oversight/non-oversight of transport safety and it's associated alphabet agencies:

Senator Bridget McKenzie asked:

1. Chief Commissioner ’s review 2021–22 states that ATSB ‘flagged our ongoing concern about collisions between trading ships and small vessels on the Australian coast’ following an incident in February 2020. What additional actions have been taken to mitigate the risk of these collisions?

2. In 2021-22 the ATSB failed to meet the performance criterion that ‘85% of safety issues [are] addressed in the previous financial year’. Given that only 74% of safety issues were addressed in 2021-22, what needs to happen to meet this performance criterion?

3. In 2021-22 the ATSB missed its target median times to complete short (8 months), defined (16 months) and systemic (22 months) investigations. How can ATSB investigations be completed within the target times?

4. Despite a substantial increase in air traffic, the ATSB received approximately $500,000 less in government funding in 2021-22 compared to 2020-21. Did this impact the agency’s functions?

Answer:

1. There were three collisions between trading ships and small vessels between 2015 and 2018 and a further collision between a fishing boat and bulk carrier on 29 February 2020 (investigated by the Australian Transport Safety Bureau (ATSB) as MO-2020-001). That investigation (and others previously) highlighted the importance of maintaining an adequate look out and the value of surveillance technology to increase traffic awareness. The ATSB continues to monitor such occurrences and notes that there have not been any collisions related to inadequate look out over the last few years.

2. The ATSB is a ‘no-blame’ safety investigator and does not have any power to enforce the addressing of safety issues identified during ATSB investigations. However, the ATSB does work with safety issue owners to encourage appropriate safety actions, both during an investigation and afterwards. Some safety issues take time to address, especially when new regulations are involved. As such, safety issues will continue to be addressed in later years. For 2021-22 this particular measure was not met as a number of safety issues identified in that year rolled over into 2022-23 where they were addressed. This is reflected in the 2022-23 ATSB Annual report which shows that for the 2021-22 year, 85 per cent of safety issues had been addressed.

3. The ATSB has been actively targeting the performance of investigation times, and this is reflected in the 4-year decreasing median for Short and Defined investigations shown in the 2022-23 ATSB Annual Report. Measures in place are restricting the number of active investigations to an average of two per investigator, adherence to a project management approach to investigations, and an even distribution of investigations across three directors. In 2023, the ATSB strategic plan led to a dedicated Short investigation team (to conduct the majority of office-based short investigations), and a dedicated Data Recovery team, Safety Analysis and Research, Marine investigation team and Rail investigation team. While there will always be some variability in the length of investigations depending on complexity (especially the larger systemic investigations), the above measures are expected to continue to reduce the median time of investigations in the forthcoming years.

4. To ensure, as far as practicable, that the ATSB can resource the investigations it takes on, the ATSB limits the number of investigations to an average of two per investigator (although investigators work across multiple investigations). With the ATSB’s present resourcing this accommodates approximately 90 investigations a year across aviation, marine and rail. There are currently no budget measures associated with industry growth, however the Australian Government provided an additional $4.6 million in the 2023-24 Budget (in addition to its ordinary annual appropriation) to allow ATSB to retain a staffing base of 110 ASL and conduct safety investigations across all modes of transport within its remit. The Government has commissioned a Review of Operations and Financial Sustainability of Australia’s Transport Safety and Investigatory Bodies, announced in the 2023-24 Budget, which is expected to make recommendations to Government relating to agency resourcing.

 
"..Some safety issues take time to address, especially when new regulations are involved. As such, safety issues will continue to be addressed in later years. For 2021-22 this particular measure was not met as a number of safety issues identified in that year rolled over into 2022-23 where they were addressed..."

Hmm...I wonder if that's why PJ's crew don't actually notify the issuance of a safety issue till the day the final report is released, therefore delaying as long as possible the performance monitoring of the individual safety issue?

  "..the ATSB missed its target median times to complete short (8 months), defined (16 months) and systemic (22 months)..." investigations.

So this investigation overshot it's target median time by 2 months and 26 days, for what would appear to be a relatively straight forward operational control (IE FRMS deficiency) investigation - I wonder where the hold up was??  

MTF...P2