AVPA-SA FATIGUE REPORT FORM

AVPA-SA FATIGUE REPORT FORM
ALL REPORTS WILL BE KEPT CONFIDENTIAL
Name (optional - confidentiality will be ensured)

First NameLast Name
What is your line of work?
Name of Company (optional - confidentiality will be ensured)
Date of Fatigue Event

MonthDayYear
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?

Other
If relevant, on what flight?
Route
If relevant, on what flight?
Aircraft type
Duty Details
Early or late?
Duty day number
Number of 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:

Other
If a specific Fatigue Event, tick PHYSICAL signs of fatigue apparent in the 2 hours leading up to the event:

Other
If a specific Fatigue Event, tick COGNITIVE signs of fatigue in the 2 hours leading up to the event:

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?
Please specify what type of inflight rest was utilised:
Where was the inflight rest?

Other
Countermeasures used:

Other
Should be Empty:

ALL REPORTS WILL BE KEPT CONFIDENTIAL