October 26, 2022

Flight Safety Meetings Report-Back

In September, representatives from your member-led flight safety committee met with CASA, ATSB and Air Services Australia in Canberra to discuss questions and concerns which were highlighted in the recent survey.

The meetings have ensured we have a direct line of contact for safety issues in the future, and a platform for open communication with each of the agencies. We’ll be following up on members’ concerns still arising from these answers. Submit fatigue reports and contact your TWU Flight Safety representative at flightsafety@twu.com.au in the event of a fatiguing /potentially fatiguing duty.



Is CASA concerned with how productivity-based pay systems can potentially lead to pilots flying (to raise their income) when its questionable whether they are fit to fly?

Both CAO 48.1 s16.1 and CASR 91.520(1) & (8) place an obligation on Flight Crew Members (FCM) not to commence a flight duty if they believe that they may not be fit for duty due to fatigue. Further, CAO 48.1 s14.1 and CASR 91.520 (4) require that an AOC holder/operator must not assign a FCM for flight duty if the authorisation holder reasonably believes the FCM is unfit for duty. A breach of these requirements may constitute an offence. Responsible operational practice and cognisance of the consequences for non-compliance should provide a sufficient basis on which fatigue-related safety requirements are honoured.

How does CASA monitor the real-world application of current airline FRMS systems (audits?) and the growing practice of airlines using duty limits as targets?

Approved FRMS’s include flight and duty limits based on scientific principles and knowledge and operational experience. CASA must be satisfied with the limits and the principles that underpin them before an approval can be issued.

Limits cannot be changed without CASA approval. Once approved an operator may utilise the extent of the limits in accordance with the approved FRMS manual which include fatigue risk mitigation strategies. CASA audits FRMS holders for compliance with the approved FRMS manuals and effectiveness of the FRMS procedures.

What process is in place in the event CASA find or become aware an airline’s application of their FRMS is creating more fatigue and potential safety risks than it is mitigating? Are airline managers personally liable in the event of an incident?

If CASA receives information that an operator has introduced fatigue risks by scheduling practices that are not compliant with the provisions of the approved FRMS manual, then a Response Surveillance activity (special audit) may be conducted to verify the information. In the absence of wilful, deliberate or reckless action on the part of an operator’s employee, accountability under the civil aviation legislation for non-compliance with applicable requirements rests with the operator.


Upon finding a primary cause of a safety event being fatigue, what weight of responsibility would be assigned to Company management for allowing pilots to be financially pressured into working fatigued? 

The relative contribution assigned to company management would depend on the source of the identified fatigue. For example, if the evidence indicated that an affected individual was working two jobs or otherwise not taking advantage of rest opportunities, then the finding would largely be at the level of the individual and nil/limited influence by the company. Conversely, if there was evidence that the issue was more widespread than a single person and rostering practices were found to be fatigue-inducing, that would be indicative of a flawed risk control at the organisation level. In that case there would likely be a finding/safety issue for the involved operator.

Can an ATSB safety report be amended after submission as additional information is remembered?

In short, yes, ATSB reports can be amended following receipt of additional information. Review of an ATSB draft report by those parties involved in one of our investigations (both individuals and organisations) is a normal part of our process designed to 1) provide natural justice (given we ultimately release a public report) and 2) check the factual accuracy of the report contents. Regarding recollection of additional detail, it is important to recognise that the most reliable recall of events occurs close to the time of the occurrence and often deteriorates with time. As such, any subsequent information recalled later would be assessed against the sources of evidence (including the originally provided information) collected throughout the investigation to determine whether a change to the report is warranted.

Can ATSB investigate current scheduling practices within company FRMS to identify if practices are having an adverse accumulative effect on pilots mental health and wellbeing due to fatigue? 

Short answer, yes, but we wouldn’t usually start at that point. ATSB investigations follow a methodology similar to the Reason Model, which recognises accidents/incidents can be influenced by factors remote from the occurrence itself. The ATSB model considers:

  1. The Occurrence (accident or incident) – what happened?
  2. Individual actions – e.g. what did the crew do/not do that influenced the occurrence?
  3. Local conditions – aspects that may have influenced the actions of the individuals (e.g. operating while fatigued)
  4. Risk controls – preventative and recovery
  5. Organisation influences – aspects that can adversely affect how an organisations risk controls work.

The analysis process considers the elements in this order, staring from the occurrence and working upwards as far as the evidence permits. So, to investigate the risk controls (scheduling aspects) stated in this question, there would need to be an evidentiary trail that led to it.


The recent increase in TIBA has many airline crews concerned. Is this planned to continue and if so, for how far into the future? 

As experienced across the aviation industry, we have experienced high rates of unplanned staff unavailability likely due to Covid-19 and one of the worst influenza seasons. In situations where we cannot cover multiple instances of staff unavailability in a single location at short notice, we apply contingency procedures which have inbuilt risk controls to manage the risk of aircraft conflicts.  These CASA-approved contingency procedures include the application of Temporary Restricted Areas (TRAs) and Traffic Information Broadcast by Aircraft (TIBA). TIBA is an internationally recognised procedure applied when ATS is not available. These contingency controls provide a second line of defence by ensuring air traffic is provided access to the volume of airspace provide situational awareness to each other. It is worth noting that, although unplanned absence has been higher than expected, we continue to provide services at 99.9% of our published service levels. We also note there is a great misunderstanding of TIBA/TRA and we have recently published an AIC to provide greater information and awareness.

Why is it taking so long to implement a tower at Ballina Airport, considering there is such a high RPT presence, combined with light aircraft?

Designation of CTA and CTR is the remit of CASA Office of Airspace Regulation (OAR). They have been consulting on an airspace review and we await the determination. We have been proactive in this space, implementing a Surveillance Flight Information Service (SFIS) and giving a proposal to CASA at the start of this year to provide an approach service to the ground which was included in the airspace review. See slide deck for information regarding the significant recent change in Ballina movements compared to pre-Covid levels.

Why is the Unicom operator at Ballina/Byron based in Brisbane and not on site at Ballina? Why do they not at least have a camera at the airfield to monitor the movement areas?

The service provided at Ballina is not a Unicom and is not providing an aerodrome service but a Flight Information Service (FIS) utilising surveillance, as such the service is best provided from Brisbane Centre. The aerodrome and airspace continues to be non-controlled. In regards to cameras, this would need to be included as potentially part of an aerodrome service and we await CASA’s determination from the airspace review.

Why are the control towers at YBCG, YBSU, YBHM being closed so early? 

As noted in question 1, we have been managing unplanned staff unavailability.  In regard to YBCG we are also working on getting new controllers fully endorsed and expect that we will return to ERSA hours in January. With regards to YBHM, it is important to note that the hours of operation are promulgated by NOTAM as described in ERSA. We endeavour to provide the service to meet RPT needs but we are also constrained by the island owner as ATC are not allowed to stay on the island and must travel to/from the island each day.

With the large amount of CTAFs on 126.7 it is exceptionally difficult to operate safely into Proserpine – that is, given the high frequency of RPT flights, helicopters and private operations. Can ASA change the frequency of Proserpine and Shute Harbour to a discrete frequency?

Issues relating to frequency congestion should be raised with CASA-OAR who can undertake a study to look at amending frequencies at Proserpine.

When will Launceston get STAR’s and RNP approaches?

Following the 2019 and 2021 airspace reviews of Launceston by CASA-OAR, we are working with CASA-OAR on their proposal to amend the airspace for Launceston to facilitate the introduction of SIDs and STARs.

What is being done to address the continued threat created by the volume of high-capacity traffic passing regularly through Pilbara mining Ports?

CASA-OAR published a draft review of the Pilbara Basin Airspace in March 2021. We believe this has not been finalised but it did not make any determination to amend the airspace within the region.

Why does Boolgeeda (YBGD) have no VHF coverage below 7000’?

Our closest VHF site to Boolgeeda region is Paraburdoo VHF site (125.7 and 133.5 Services) which has a mountain range between the site and Boolgeeda region. Other VHF sites are far from this region and the range is beyond reach.



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