AVPA-SA FATIGUE REPORT FORM
ALL REPORTS WILL BE KEPT CONFIDENTIAL
Name (optional - confidentiality will be ensured)
First Name
Last Name
What is your line of work?
Pilot
Engineer
Cabin Crew
Air Traffic Controlle5r
Name of Company (optional - confidentiality will be ensured)
Date of Fatigue Event
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Time of Event (specify local or UTC)
How long had you been on duty?
What were you doing at the time of the event?
On duty
Home
Hotel
Positioning
Driving
Other
If relevant, on what flight?
Route
If relevant, on what flight?
Aircraft type
Duty Details
Early or late?
Early
Late
Duty day number
Day 1
Day 2
Day 3
Day 4
Day 5
Day 6
Day 7
Number of sectors
1 sector
2 sectors
3 sectors
4 sectors
Other
Rostered Start Time (24 hour clock)
Hour Minutes
Rostered Finish Time (24 hour clock)
Hour Minutes
Actual Start Time (24 hour clock)
Hour Minutes
Actual Finish Time (24 hour clock)
Hour Minutes
Tick all the factors you feel contributed to this event:
Home rest
Hotel rest
Health
Commute
Home/personal issues
Cumulative fatigue
Time zone change
On board rest/facility
Positioning
Delay(s)
Roster disruption
Insufficient rostered rest time
Early start time
Late start time
Long duty day
Swapped flight
Other
If a specific Fatigue Event, tick PHYSICAL signs of fatigue apparent in the 2 hours leading up to the event:
No physical signs
Rubbing eyes
Yawning
Difficulty keeping eyes open
Frequent blinking
Head nodding
Falling asleep
Headache
Other
If a specific Fatigue Event, tick COGNITIVE signs of fatigue in the 2 hours leading up to the event:
No cognitive signs noted
Increase in slips
Increase in lapses
Impaired attention
Impaired memory
Reduced communication
Negative mood
Impaired situational awareness
Impaired problem solving
Other
How long had you been awake when the event happened?
How much sleep did you have in the 24 hours before the event?
How much sleep did you have in the 72 hours before the event?
Was inflight rest utilised?
Yes
No
Please specify what type of inflight rest was utilised:
Where was the inflight rest?
Bunk
Flight deck seat
Cabin seat
Other
Countermeasures used:
Advised colleague of fatigue risk
Included in threat briefing
Controlled rest of the flight deck
Caffeine
Use of lighting
Additional crew members
Food and drink
Increased use of automation for the approach
Other
Submit
Should be Empty: