The operator's fatigue risk management system relied extensively on a sleep reporting spreadsheet (sleep log) that was based on the prior sleep wake model, and the spreadsheet had a transparent rule set that made the recorded data easy to modify to achieve results that met the operator’s minimum sleep and wake requirements. In the context of perceived pressure to present as fit for duty, multiple pilots on multiple occasions had entered unrealistic or inaccurate sleep times and there were limited effective controls in place to assure that the sleep times being entered by pilots was accurate.
The ATSB is satisfied that the proactive safety action taken by the operator appropriately addresses this issue.
The operator advised that a new fatigue risk management system (FRMS) was developed, consistent with the requirements of Civil Aviation Order 48.1 (Appendix 7). This process included a fatigue study and historic fatigue data analysis conducted by a FRMS subject matter expert. The operator’s FRMS was approved by the Civil Aviation Safety Authority (CASA) for a trial period that commenced on 23 February 2022. The operator’s new FRMS does not include the sleep reporting spreadsheet utilised at the time of the occurrence.
The FRMS utilises a system of tools to manage and measure fatigue, including:
