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A Brisbane air traffic controller was found lying asleep across two chairs while on duty in December 2022.
An Australian Transport Safety Bureau (ATSB) investigation into the incident concluded that the employee had worked multiple night shifts in a row with “reduced extended rest periods”, which likely reduced their ability to “obtain restorative sleep”.
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While no flights were scheduled until after the shift ended, investigators ruled that “sleep inertia” could have delayed their communication in the event of an unexpected broadcast.
In its final report into the incident, the transport safety watchdog found “several factors” that had led to the controller falling asleep.
“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 two chairs, not moving, and not undertaking activities to maintain mental alertness,” said ATSB chief commissioner Angus Mitchell.
While the airspace was clear at the time, Mitchell noted that, had the controller been woken up by a radio broadcast, they would have risked “sleep inertia”, delaying their communications and causing them to give incorrect instructions, as well as difficulty managing any airspace conflicts from aircraft operating without clearance.
“There were no negative consequences from this occurrence, but it does highlight areas for improvement in work scheduling and fatigue risk management,” he said.
“An over-reliance on tactical changes to manage the roster at Airservices was likely due to an underlying lack of resources.
“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.”
In a statement, an Airservices spokesperson said the air traffic management body had taken measures on fatigue management and roster resourcing as a result of its own investigations.
“Airservices has reviewed and updated guidance to our staff on fatigue management processes, and is working with CASA to explore further improvements on our fatigue risk management system,” the spokesperson said.
“We will continue to refine and improve our processes based on feedback. We note the ATSB report states that they consider these measures adequately address this safety issue.
“With regard to rostering, Airservices has recruited and trained additional experienced air traffic controllers in the Cairns terminal control unit to better manage service requirements, and is keeping the ATSB updated on staffing numbers.
“As part of our ongoing recruitment strategy, Airservices endorsed 53 new controllers during FY24 and expects to deliver an additional 37 new endorsed controllers from July to December 2024.”
The incident came four years after an unrelated occurrence in which Brisbane air traffic controllers missed a PAN PAN call from a Malaysia Airlines A330 in July 2018.
