Queensland Rail’s fatigue management processes for Citytrain train crew had limited processes in place to actively identify and manage the risk of restricted sleep opportunity resulting from late-notice roster changes.
The ATSB acknowledges that Queensland Rail has recognised the risk associated with this issue, and the ATSB agrees that the action taken by Queensland Rail will reduce the risk of this safety issue. However, as previously noted, the ATSB is concerned that the process still places substantial reliance on an employee assessing their own level of fitness for work and there is no explicit requirement or guidance for the employee to complete a formal self-assessment, including explicitly considering their hours of sleep prior to commencing the duty period.
In January 2022, Queensland Rail (QR) advised:
Queensland Rail acknowledges the ATSB’s comments relating to the management of risk related to restricted sleep opportunity resulting from late-notice roster changes. The appropriate management of fatigue is of critical importance to Queensland Rail and is of mutual responsibility shared by Queensland Rail and its employees through the application of our fatigue risk management standard and associated documents and risk control measures.
Queensland Rail will issue an Important Safety Notice (to Rail Safety Workers and staff who roster or supervise Rail Safety Workers) reminding them about the relevant requirements and responsibilities in our Fatigue controls to appropriately manage fatigue when calling in workers arising from short notice roster changes by 15 February 2022.
Queensland Rail’s Fatigue Risk Management Standard (MD-10-178) is due for review in 2022. It is proposed as part of this review that non-work-related fatigue as well as operational controls relevant to late notice shift changes is further reviewed as part of this process. Queensland Rail will review, consult and re-publish MD-10-178 Fatigue Risk Management Standard (and supporting documents) by 30 November 2022.
On 21 February 2022, QR issued an important safety notice (ISN) to all workers titled Fatigue Risk Management – Unplanned Shifts and Emergency and unplanned events. The notice stated:
For unplanned shifts, the relevant supervisor or roster officer must ensure the change:
- does not breach Fatigue Risk Management standard MD-10-178 hours of work principles (section 2.3.1 or where relevant Appendix 3).
- is assessed using FAID and is compliant with the FAID Tolerability Framework (section 2.3.4 Fatigue Risk Management standard MD-10-178).
A recent review has identified a deficiency in the Fatigue Risk Management standard MD-10-178 within our Safety and Environment Management System (SEMS). This ISN authorises an emergency change to Fatigue Risk Management standard MD-10-178 to include the below new requirement.
The notice referred to an emergency change to MD-10-178, which stated:
If the unplanned shift has been arranged with less than 12 hours’ notice to commence the unplanned shift the supervisor or roster officer must complete a Fatigue Risk Management – Callout checklist MD-11-1335 (or other checklist/process approved by WHS Discipline Head which meets the principles outlined in the Fatigue Risk Management – Callout checklist MD-11-1335) to confirm the change complies with the hours of work principles, the worker is fit for duty and risk mitigation has been documented. Evidence must be documented and retained for auditing purposes.
The notice also included the following reminder:
All workers are responsible for ensuring they are not presenting to work in a fatigued state and have the responsibility for understanding and managing non-work-related fatigue. This includes workers confirming they are fit for duty to their supervisor/rostering team when responding to a request for an unplanned shift. Whilst at work, workers must report instances of fatigue to their supervisor…
QR’s fatigue management callout checklist required a range of information to be completed. This included confirmation regarding whether the change to the planned roster would exceed a maximum FAID score of 100 or the hours of work principles. It also required the worker to be specifically asked (and answer) the question ‘Do you assess yourself to be fit for duty?’. The form also required rostering personnel to consider the differences between the planned shift and proposed shift and the expected commute time. It also asked what mitigators would be put in place, and listed 6 specific examples.
ATSB Response
The ATSB acknowledges that Queensland Rail (QR) has recognised the risk associated with this issue and has taken action to address the issue. The important safety notice (ISN) places more emphasis on ensuring that fatigue is considered by rostering personnel and workers when considering late notice changes to planned rosters. Workers will now be specifically asked if they are fit for duty, and QR had previously provided rail traffic crew with guidance on how to assess their level of fatigue.
Given that people generally underestimate their level of fatigue, it would be beneficial to specifically ask rail traffic crew to complete a formal self-assessment. The ATSB also notes the potential limitations associated with a FAID score limit of 100.
Nevertheless, the ATSB agrees that the action taken by QR will reduce the risk of this safety issue and that QR is proposing to further review this topic later in 2022. The ATSB will monitor QR’s further revision of MD-10-178 later this year.
In January 2023, Queensland Rail provided the ATSB with an updated version of its Fatigue Risk Management Standard (MD-10-178), which had been updated on 27 April 2022.
The updated content in the standard was consistent with the previous safety notice. It stated:
Where an unplanned shift has been arranged with less than 12 hours’ notice from the commencement of the shift, the following process must be followed:
Queensland Rail also advised, that in addition to the Important Safety Notice issued in February 2022 titled ‘Fatigue Risk Management – Unplanned Shifts and Emergency and unplanned events’, the Fatigue Risk Management MD-10-178 were updated in April 2022. This update included section 2.3.2 Unplanned Shifts, detailing requirements for the Fatigue Risk Management - Callout checklist Form to be completed where an unplanned shift has been arranged with less than 12 hours’ notice from the commencement of the shift.
The new procedures do not reduce the risk of rail safety workers having inadequate sleep in situations when shifts are changed unexpectedly at late notice. The circumstance highlighted in the ATSB report was that rostering personnel contacted a rail safety worker late at night, and requested the rail safety worker perform a shift early the following morning. This situation created a high probability that the rail safety worker would not achieve sufficient sleep prior to starting their next shift.
The additional requirement to analyse unplanned shift changes using the FAID biomathematical model of fatigue will not mitigate the risk of a similar circumstance arising again. FAID calculates a fatigue exposure score based on the amount of time a shift pattern provides away from work, and the times of day those breaks occur. In the case of a late change to the start time of a forthcoming shift, the problem is not that the overall rest period provides insufficient opportunity for sleep, but that there is insufficient opportunity from the time the worker is notified of an earlier start, to when they have to wake for that shift. For the same reason, elements of the Callout Checklist requiring the change to not violate Queensland Rail fatigue rules will not mitigate the problem identified by the ATSB.
The additional requirement to capture a worker’s self-declaration of being fit to work is also unlikely to significantly reduce fatigue risks. There are other existing risk controls within the Queensland Rail safety system with similar intent or effect. As identified in the ATSB investigation report, self-assessments of fatigue may be ineffective due to the tendency of most people to underestimate the extent they are affected by fatigue, as well as factors such as financial incentives which may bias individuals against self-declaring if they are feeling fatigued.
