An ATSB investigation report reveals that a Brisbane Centre air traffic controller, found asleep at their workstation near the end of their shift, had worked several consecutive night shifts, leading to sleep deprivation. The controller, in charge of the Cairns Terminal Control Unit (TCU) at Airservices Australia's Brisbane Air Traffic Services Centre, was discovered asleep around 5:15 am on the 9th of December 2022. The incoming controller found them draped with a blanket, lying across two chairs.
The investigation identified multiple factors that led to the controller's sleep incident.
These factors included the time of day, the controller's very low workload, a series of successive night shifts, and the increased likelihood of falling asleep due to the controller's position across two chairs without movement or engaging in activities to stay mentally alert, stated ATSB Chief Commissioner Angus Mitchell.
"The controller had been working multiple night shifts with reduced extended rest periods, which likely impaired their ability to get restorative sleep."
When the controller was discovered asleep, there was no traffic in the Cairns TCU airspace, typical for that time of day, with no scheduled flights until after their shift.
However, if the controller had been awakened by a radio broadcast, they might have experienced 'sleep inertia,' risking delayed communications or incorrect instructions/actions, potentially impacting their ability to manage conflicts from traffic entering their airspace without clearance.
"While this incident had no negative outcomes, it does underscore the need for improvements in work scheduling and fatigue risk management," stated Mr. Mitchell.
The investigation also revealed issues with Airservices Australia's broader fatigue management.
"An over-reliance on tactical changes to manage the roster at Airservices likely stemmed from an underlying resource shortage," Mr. Mitchell elaborated.
Consequently, cumulative fatigue wasn't being managed effectively on a strategic level, and a heavy reliance on tactical principles failed to identify or manage fatigue risks from the work schedule.
Post-incident, Airservices has increased the number of air traffic controllers, including those in the North Queensland group.
The investigation also found that although Airservices' fatigue assessment and control tool (FACT) could identify situational factors affecting fatigue, its effectiveness was limited because supervisors did not recognize low workload as a fatigue hazard.
Airservices has since developed more guidance and training for the fatigue risk assessment process, including how to treat low traffic situations as high risk.
Additionally, the Civil Aviation Safety Authority has recently implemented changes.
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