Independent safety issue investigation into Queensland Coastal Pilotage
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- Rest before pilotage
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Pilot rest, work and fatigueThe long passage distances, particularly in the Inner Route, and the type and conditions of work of coastal pilots mean that their working hours need to be carefully managed to avoid fatigue and minimise the risk of an incident. FatigueFatigue has been defined by the joint IMO/ILO (International Labour Organization) working group on human factors as follows: A reduction in physical and/or mental capability as a result of physical or emotional exertion which may impair nearly all physical abilities including strength, speed, reaction time, co-ordination, decision making and balance. In the context of human performance, fatigue is a physical and psychological condition that is primarily caused by prolonged wakefulness and/or insufficient or disturbed sleep. Fatigue can result from a number of different sources, including time on task, time since awake, acute and chronic sleep debt, and circadian disruption (factors which affect the normal 24-hour cycle of body functioning). A review of fatigue research relevant to aviation has noted that fatigue can have a range of influences, such as decreased short-term memory, slowed reaction time, decreased work efficiency, reduced motivational drive, increased variability in work performance and increased errors of omission.118 This fatigue review also made the following observations with respect to aircraft pilots: A common symptom of fatigue is a change in the level of acceptable risk that a person tolerates, or a tendency to accept lower levels of performance and not correct errors. Decrements in alertness and performance intensify if the time awake is 16 to 18 hours. Performance decrements of ‘high time-since-awake’ pilots tended to result from ineffective decision-making rather than a deterioration of aircraft handling skills. There is a discrepancy between self-reports of fatigue and actual fatigue levels, with people generally underestimating their level of fatigue. Most people need eight hours sleep each day to achieve maximum levels of alertness and performance. Fatigue is cumulative. The physical environment in which people operate, in terms of factors such as noise and vibration, can also contribute to fatigue. In coastal pilotage, pilot fatigue has been the subject of much discussion and, as described in section 2.6, a number of studies or reviews into fatigue have been conducted. In 2001, AMSA formalised the requirement to manage pilot fatigue through MO 54 (issue 3). Fatigue management measures were implemented through pilot advisory notices (PANs). These measures were incorporated by AMSA into a fatigue management plan in 2007.
Procedures in AMSA’s fatigue management plan specify minimum mandatory rest periods for pilots between each pilotage passage, between tours of duty (based on number of days and voyages) and between consecutive periods of work without defined leave breaks. Pilots and providers are jointly responsible for complying with the plan which includes procedures for monitoring work and rest hours, and fatigue risk mitigation guidelines. In addition, AMSA monitors compliance with the plan by examining REEFVTS records for pilot boarding and disembarking and auditing relevant records kept by providers. The minimum mandatory rest period for a pilot before undertaking an Inner Route pilotage is 24 hours, including an ‘optimal night’s rest’.120 When three consecutive Inner Route pilotages have been undertaken with only one optimal night’s rest before each successive pilotage, the pilot must have two optimal night’s rest before undertaking a further Inner Route pilotage. Rest periods (in any pilotage area) must not include travel of any kind, including pilot transfer times. The minimum rest period between pilotages in both the Great North East Channel and Hydrographers Passage is 12 hours, including at least 6 hours of uninterrupted rest before the pilotage. The 12 hour rest period can be reduced if the pilot has had an optimal night’s rest before the first pilotage and will achieve such a rest period after the second pilotage. Consecutive pilotages in the Great North East Channel and Hydrographers Passage may be performed without any rest period in between if the interval between starting the first pilotage and completing the second is not expected to exceed 18 hours. As outlined in section 3.4.3, a pilot’s maximum tour of duty is 28 days away from home. At least five consecutive optimal night’s rest at home must be taken after each tour. If a tour of duty is 21 days or less, then this period may be reduced to four consecutive nights. In addition, the plan specifies pilot ‘leave’ requirements. A pilot’s tour of duty is also limited by the number of pilotages performed. This is managed though a ‘points’ accrual system. A pilot accrues 2.5 points for each Inner Route pilotage performed and 1 point for each pilotage performed in the Great North East Channel or Hydrographers Passage. A pilot accruing 15 points must return home for five consecutive nights. If, during a 15 point accrual period, the pilot has a planned break of three consecutive nights at home on two occasions, his points score returns to zero. If only one such planned break has been taken while accruing 15 points, then the pilot must return home for another three night break to reset his point score to zero. Pilots and providers are responsible for keeping track of points and AMSA monitors compliance by auditing records. The fatigue management plan is not specific about managing fatigue levels during pilotage. Instead, the plan requires pilots to manage any rest breaks available during a pilotage. Other than an individual pilot’s own evaluation, there is no monitoring of this rest break management although a pilot’s rest practices are checked during check pilot assessments. Rest breaks are an important element of all Inner Route passages but in the Great North East Channel and Hydrographers Passage most pilots usually do not leave the bridge to rest. Therefore, to a large extent, pilots manage their own fatigue. Providers have significant input in this area because they manage the day-to-day scheduling of pilot transfers, keep track of pilot tours of duty and administer pilot rosters. In addition to regular compliance checks, AMSA audits of a provider for DOC verification have included a review of fatigue management. As outlined in section 2.6, the fatigue management plan was independently reviewed for AMSA in 2010. The review was based on evidence provided by pilotage providers, pilots and AMSA. The findings of the review are consistent with the ATSB survey responses and pilot interviews, in general, and the discussion below refers to these findings. Rest before pilotageThe mandatory rest period before pilotage is intended to ensure that pilots are adequately rested before they board ships. However, in the survey, more than two-thirds of pilots indicated that they were not always adequately rested and fit before a pilotage (Figure 22). Figure 22: Adequately rested before pilotage as indicated by pilots 
The most common reasons given by pilots for inadequate rest were excessive pilot transfer time, excessive air or road travel, substandard pilot transfer vehicle, unsuitable rest or sleep conditions (in some cases at pilot houses) and the need to maximise earnings (Appendix A, item 26). A larger proportion of pilots with Australian Reef Pilots than Torres Pilots indicated these reasons. Many pilots indicated having less than the defined rest period as a factor although this is closely related to the other factors. The factors related to transfer time and transfer vehicle were identified as having the greatest impact on rest before pilotage. Pilot transfer and travel related factors have the potential to significantly affect how rested a pilot is before boarding a ship. A number of pilots advised that they have regularly had to wait in pilot boats for many hours (examples included 6 hours or more). Given the sheer number of transfers, it is hard to determine if such examples are anomalies that occur from time to time, particularly in remote areas such as the Torres Strait, or whether such situations occur frequently. However, waiting for a couple of hours seems to have been common. More importantly, the transfer and travel times have not always been excluded from rest periods as required. The usual reasons for prolonged transfer times are long distances and multiple pilot transfers as described in section 3.4.5. Delays are reportedly also caused by pilot boat breakdowns, slow speed due to weather/sea conditions, helicopter availability and landing a helicopter to refuel it during a Blossom Bank transfer operation. Notwithstanding the practical transfer logistics and these factors, the result is that prolonged transfer times, particularly in rough weather, will adversely affect a pilot’s ability to be in a fully rested state at the start of a pilotage. Therefore, managing transfer times and comfort level during transfers is a critical issue that should be addressed to reduce fatigue risk during pilotage. In general, AMSA maintains oversight of a pilot’s fatigue management through the requirement for pilots to report to REEFVTS. At the time of the survey, pilots reported their boarding and disembarking times, and the times when they started and completed pilotage duties. Usually the pilotage duty times are not significantly different to the times of pilot boarding or disembarking. A few days after a pilotage, the provider also forwards a copy of the pilotage certificate received from the pilot to AMSA. The certificate includes the times of starting and completing the pilotage. None of this monitoring takes account of pilot transfer and travel times. The times reported are used to check compliance with the fatigue plan requirements rather than predicting or assessing fatigue levels that may be experienced. In addition, the motivation of some pilots and providers in particular circumstances can affect the accurate reporting of times required by AMSA. In the survey, pilots indicated that a reason for inadequate rest has been the need to maximise earnings. These pilots may consider that a mandatory rest period is, at times, an unnecessary impediment to performing a pilotage. For example, a night’s rest counts only if it starts no later than 2200. Hence, if the rest period starts a minute after 2200 and the pilot then has 8 hours of good quality sleep, theoretically he must still rest for the following night. This is probably why transfer and travel times have sometimes been ignored. Similarly, some pilots may consider it advantageous to record the earliest start of a rest period and the latest time for starting a pilotage. In submission to the draft report, Australian Reef Pilots advised that it had a robust monitoring system which records pilot house to pilot house times which was used to monitor rest periods under the fatigue management plan. Similarly, Torres Pilots submitted that its system, where staff calculated pilot rest periods with allowances for travel, did not allow pilots to manipulate the fatigue management plan. With regard to claims of ‘excessive pilot transfer times’, the provider stated: The claimed excessive pilot transfer times on pilot launches would be a safety issue if it compromised the pilots’ rest times ashore and compliance with the pilotage provider’s fatigue management plan. Torres Pilots monitors pilot rest periods and compliance with the fatigue management plan to ensure the rest break includes time ashore before the next pilotage. In addition, Torres Pilots submitted the following with respect to managing fatigue: The draft report does not differentiate between different circumstances of pilot transfers and different conditions, which need to be considered for a proper evaluation of any safety consequence. For example: If the pilot is boarding an eastbound GNEC vessel, then an extra 1.5 hours on the pilot launch is generally not considered by Torres Pilots to be critical for fatigue management as the time the pilot can expect to spend on the piloted vessel is 9 hours or less. It is relevant that pilots often experience 3 hour pilot transfer times before boarding westbound vessels in the GNEC due to the long transfer from the pilot base on Coconut Island to the Dalrymple Island pilot boarding grounds, as identified in the draft report. If the second or any subsequent movement in the same transfer voyage (the trip undertaken before returning to Thursday Island jetty) is for the pilot to disembark, then the fatigue aspect of the ‘excessive pilot transfer time’ in a launch is not a safety issue in terms of adequacy of the pilot’s rest before a pilotage. However, rest periods can be difficult to monitor because they rely on accurate reporting and a clear understanding of, and compliance with, fatigue management plan requirements. In May 2011, and again in June, Australian Reef Pilots advised its pilots of the increased focus on compliance with the plan’s requirements once issue 5 of MO 54 was implemented. The provider’s memo on the subject asked pilots for cooperation in reporting relevant times so that travel could be excluded from rest periods. The memo noted that matters which are sometimes overlooked include ‘the requirement for travel time (pilot boat and helicopter transfers and air travel between jobs) to be excluded from rest break considerations’. In the survey and at interview, some pilots claimed that providers have at times ignored fatigue plan requirements, such as excluding transfer times from rest periods. However, the evidence they provided in support of their claims can have other interpretations. A pilot engaged by Torres Pilots submitted that while he personally did not accept the deliberate and improper recording of rest periods, he believed that ambiguous wording in the fatigue management plan had resulted in pilots improperly recording rest periods. Similarly, one of Australian Reef Pilots’ senior pilots submitted that travel time, including air travel and waiting in pilot boats is frequently treated as part of a rest period. These comments by pilots and the efforts by Australian Reef Pilots to monitor rest periods serve to highlight that AMSA’s monitoring (recording the times for boarding/disembarking ships and starting/completing pilotage duties instead of starting/ending travel) does not capture travel/transfer time. Torres Pilots’ comment above regarding ‘rest times ashore’ also suggests confusion about rest periods, which can only be had ashore as per the fatigue management plan (as opposed to rest breaks during a pilotage). Moreover, the provider’s views/policies in relation to managing fatigue risk cited above need to be consistent with the agreed fatigue management plan. In any case, transfer time after a pilotage is relevant because it impacts the pilot’s rest period before his next pilotage. Mandatory rest periods can create difficulties for a provider when they do not have a rested pilot available to service a ship booking. When a provider does not have a pilot available, the usual practice has been to apply for a dispensation of the required rest period from AMSA rather than offer a competing provider an opportunity to service the ship. Providers have formally applied to AMSA for dispensations by confirming that a rested pilot is not available, that the pilot proposed for the pilotage is in agreement and that a qualitative risk assessment has been conducted. At times, a FAID121 or similar fatigue analysis has been completed. In the 5 years from 2006 to 2010, AMSA granted 176 dispensations from fatigue plan requirements, an average of 35 per year (Figure 23). In this period, three dispensation requests were refused. The 32 dispensations granted in 2010 represent about 0.7 per cent of the pilotages conducted. A finding of the 2010 review of the fatigue management plan, referred to above in section 3.6.2, was that the process for dispensations required significant revision. While AMSA advised that the process was clarified and that dispensations since have been rare, a pilot’s agreement as part of the process is of limited value because of potentially conflicting priorities of safety and loss of income (Appendix A, item 19). Frequent dispensations from requirements also tend to suggest that the requirements need to be reviewed. Figure 23: Dispensations from fatigue plan requirements 
The ATSB also examined the pilot boarding and disembarking times for a total of 1658 pilotages reported to REEFVTS in October, November and December 2010 (Figures 24A and 24B). Other than some peak times for boarding or disembarking, and that the times recorded take no account of pilot transfer times and travel, these records did not indicate any obvious breaches of mandatory rest periods. The ATSB survey revealed that it was not just the boat or helicopter transfer time that compromised a pilot’s level of alertness. Some pilots indicated that rest was seriously compromised when prolonged air/road travel or waiting at airports/hotels is involved before a pilot transfer. An example of travelling from Cairns to board a ship off Booby Island at 2100 on the same day was given. By the time the pilot had boarded the ship, he had been travelling for most of the day before the pilotage. According to him, similar instances regularly occur where pilots undertake many hours of travel before a pilotage. It is inevitable that a prolonged period of wakefulness will affect the pilot’s alertness and decision making ability by the time he boards the ship. Notably, the 2010 review of the fatigue management plan found that the issue of travel time had not been clearly addressed in the plan. Figure 24A: Pilot boarding times reported to REEFVTS 
Figure 24B: Pilot disembarking times reported to REEFVTS 
In the survey, pilots indicated that the effectiveness of the 12 hour rest periods between the pilotages in the Great North East Channel and Hydrographers Passage was greatly reduced when prolonged pilot transfers or adverse weather conditions were involved. Successive pilotages at night were identified as another factor reducing the adequacy of rest. In any case, prolonged irregularity in working hours and irregular sleep patterns contribute to the build-up of fatigue. In recent years, it has been common for pilots to perform consecutive pilotages in the Great North East Channel or in the Hydrographers Passage during a single work period. It is worth noting that an optimal night’s rest was required for a Great North East Channel pilotage before pilotage there became compulsory in 2006. A number of pilots indicated in the survey that performing consecutive pilotages significantly reduced rest and sleep, particularly when the pilotages were performed mainly during the night. As described in section 3.4.5, it is common to wait in a pilot boat or helicopter carrying out multiple transfers. Such operations prolong a pilot’s time on board the ship and increase their transfer time. The consecutive pilotages above involve working up to 18 hours without taking into account the transfer time in assessing fatigue risk. Research in the aviation industry has shown a significant increase in accident rates for commercial pilots as their duty time increases, particularly when their duty times are more than 12 hours.122 In submission to the draft report, a Cairns based pilot noted the often busy Great North East Channel traffic sometimes resulted in a pilot working there for weeks and increased fatigue. He suggested fatigue risk could be reduced by capping the number of consecutive pilotages there to four or a maximum of 1 week. He stated such limits would reduce the period a pilot was away from home and felt a tour of duty of 3 or 4 week was excessive. Another pilot submitted that repeated, night time Great North East Channel pilotages significantly impacted pilot fatigue. One pilot submitted that helicopter transfers in the Torres Strait could address the issue of long transfers. According to him, winch down helicopters had been considered before 1993 but the greater focus on costs since 1993 resulted in no further action. The following findings of the 2010 fatigue management plan review are particularly relevant with regard to rest before pilotage. The current commercial pressures and organisational structures create an environment which can work at odds to the effective management of fatigue-related risk. The practice of ‘double headers’ [multiple pilotages within a single work period] represent an area of elevated fatigue-related risk for Queensland coastal pilotage. The current QCPFMP [fatigue management plan] does not provide adequate risk management for these operations. The current definition of ‘rest’ is open to misinterpretation and in some instances is taken to include time on the pilot launches [and] other forms of work-related activity. The current system does not take into consideration the inherent variation in sleep opportunity that results from different lengths of pilotages, or pilotages at different times of day, even though these sleep opportunities are a critical component of fatigue risk management. There is evidence of non-compliance with the QCPFMP. There is no mechanism to establish or monitor compliance beyond random audits. The process for dispensations requires significant revision such that robust and auditable risk mitigation is evident, and so that specific individuals’ expertise within AMSA does not form the sole basis for decision-making around extensions to duty.123 These findings, the ATSB survey and pilot interviews indicate that pilots are not always adequately or fully rested (as specified in the fatigue management plan) before pilotage. In many cases, travel and pilot transfer time has incorrectly been included in mandatory rest periods. At times, long transfer/travel times and arduous conditions during the transfer reduce the adequacy of the rest periods.
Unless a pilot rests from time to time during the 25 to 40 hour Inner Route pilotage, it cannot be completed without the pilot being affected by a dangerous level of fatigue. Traditionally, pilots have taken short rests in certain areas of the Inner Route which they consider can be safely navigated by the ship’s crew without continuous pilot advice. The opportunity to rest in these areas is dependent upon the ship’s transit speed124, and suitable prevailing weather, traffic and other conditions such as the ship’s crew and equipment. In 2004, the Fairway Channel and LADS Passage within the Inner Route was opened for use by all ships. There are sections of this new route totalling about 80 miles, most of which can be used by pilots to rest during a stage of the pilotage where previously the old route had offered an opportunity to rest over a leg of about 15 miles. The additional rest opportunity occurs about halfway through the transit, making it very useful. The new route also shortened the pilotage by about 20 miles. It has been estimated that use of this route by ships reduced navigational risk in the area by approximately 30 per cent.125 However, while the new route has provided pilots more rest opportunity, it has not eliminated fatigue risk for the Inner Route. The amount of sleep and rest available to a pilot during Inner Route pilotages can vary significantly. For example, a northbound transit on a deep draught bulk carrier is typically 40 hours (at 12.5 knots with no stoppages) that, in ideal conditions, may include a total of about 14 hours of rest opportunity over about eight separate rest breaks. This is the total time that a pilot may be away from the bridge and, depending on the time of the day and other variables, this time can be used to sleep. A fast ship (about 20 knots) means a 25 hour transit with shorter and fewer rest breaks. In ideal conditions, these breaks may total 7 or 8 hours for meals, rest and sleep. However, often little or no sleep can be achieved during this quicker transit. In submission to the draft report, a pilot stated that Inner Route transits on fast ships effectively reduced the number of sleep breaks to three. According to him, subject to the prevailing conditions, one break could be about 2.5 hours and two breaks about 1 hour each. Another pilot cited a recent example of a 38 hour Inner Route transit during which he achieved 3 hours of sleep due to adverse conditions, stating that such a level of reduced sleep was not uncommon. He noted that on that particular transit the ship deviated from the planned track while he was away from the bridge resulting in a risk of grounding but there was no intervention from REEFVTS (he did not indicate if he reported this matter). In general, rest areas are navigationally less challenging than various confined passages and sections of the Inner Route. When referring to these confined parts, a pilot who joined the pilot service before 1993 described the Inner Route as ‘many pilotages linked together’. The areas linking these ‘many pilotages’ are generally known as rest areas. These areas are referred to by pilots and providers variously as ‘recognised’, ‘designated’, ‘usual’ or ‘possible’ rest areas. However, no issue of MO 54 refers to rest areas and AMSA does not officially recognise any rest areas. In addition, rest areas are not defined in any standard procedures and a PAN states that there are no officially approved rest areas.126 However, this PAN notes that rest may be taken in some areas if the pilot conducts a risk analysis and considers it safe to rest. The check pilot assessment checklist refers to factors including traffic, hazards, visibility and tides that should be taken into account for a risk analysis but there is no specific guidance on acceptable rest areas. There is no measurement or assessment of actual fatigue levels or sleep that a pilot achieves. Nor is any method used to predict potential fatigue levels during a particular pilotage (best and worst case scenarios) despite a previous ATSB recommendation.127 Therefore, rest break management depends on an individual pilot’s assessment of prevailing conditions (on board the ship and externally) and his usual practices. There can be marked variations in the rest breaks availed by different pilots. For example, in the LADS Passage (usually a rest area) in the Inner Route some pilots return to the bridge for every planned course alteration while other pilots may not. Similarly, practices vary in the Great North East Channel, where some pilots remain on the bridge throughout while others leave to rest for an hour or two in areas such as between Twin Island and Kirkcaldie Reef. In the Hydrographers Passage, most pilots remain on the bridge throughout although some may leave the bridge for a period in the area between Tern Island and Creal Reef. Pilots also have their own individual procedures, not necessarily similar, for recall to the bridge. While rest on board a ship is critical for a pilot, particularly in the Inner Route, its effectiveness can be limited. In the survey, more than 92 per cent of pilots indicated that at times they were very tired during, or at the end, of a pilotage (Figure 25). The reasons most often cited by pilots for getting tired were unsuitable rest or sleep conditions, poor ship equipment or crew, adverse weather or visibility, single-handed pilotage and inadequate sleep opportunities with the first three of those reasons cited as having the greatest impact (Appendix A, item 27). This indicates that these variable factors can create significant problems in managing fatigue. Figure 25: Tiredness during, or at the end, of a pilotage as indicated by pilots 
In submission to the draft report, at least 18 pilots made specific comments in relation to fatigue risk during Inner Route pilotages. Many comments included similar themes and thoughts. Several pilots consider that the number of working hours involved in Inner Route pilotages cannot be managed by one pilot consistent with any recognised method to manage fatigue. A number of comments referred to the increased risk of an incident whilst a pilot was resting and, while several felt that having a rested pilot on the bridge at all times was necessary, they noted that this was impossible in the Inner Route. One comment related to an inability to rest or sleep properly when away from the bridge because of a lack of confidence in the ship’s crew. Examples to support these comments included past incidents, unreported near misses in rest areas, comparisons with limitations on the working hours of seafarers and that long pilotages in Canada were conducted by two pilots. One pilot submitted that fatigue was the core safety issue in coastal pilotage but ignored by AMSA, impeded by the competitive model due to costs and disregarded by pilots competing with each other for work. Another pilot stated that costs, not proper fatigue management, were the focus of commercial interests in the sector. The fatigue management plan, a pilot stated, did not manage fatigue but attempted to manage rest before or after a pilotage, leaving the pilot to somehow manage fatigue during 30 to 40 hours of pilotage by resting after assessing risk. Another pilot noted that the plan could not manage fatigue during a long pilotage. At least three pilots made the observation that the stress caused by the competitive environment amongst pilots (a reference to their turn for the next job) unnecessarily exacerbated fatigue. Long working hours and mental stress from issues related to remuneration, working conditions, inadequate training and pressure from pilotage providers was claimed to result in a state of being constantly fatigued. One pilot stated that single-handed pilotage was extremely dangerous in terms of both the risk of a serious shipping incident and the long term health of pilots. Some pilots made suggestions to manage fatigue risk. One suggested that a single pool of pilots available to any pilotage provider would better utilise available resources to service shipping traffic and reduce pilot fatigue. As an example, he pointed out that it was not uncommon for the pilots of competing providers to concurrently be boarding flights in opposite directions (between Thursday Island and Cairns) to meet the service demand of their respective provider in the Torres Strait and Cairns. Another pilot suggested the use of the Outer Route to/from the Torres Strait, which some ships already use. He considers this would reduce fatigue risk and help manage the greater demand for pilots as traffic increased although it would mean higher costs (to ship owners or operators) due to the increased distance. He believes ports within the Inner Route, for example Cape Flattery, could be accessed via established openings in the GBR, such as those near Lizard Island. Some of these suggestions could be used to improve fatigue management. However, each matter would need to be appropriately assessed. For example, use of the Outer Route may reduce fatigue risk but a large number of ships transiting that route would mean considering risks due to increased traffic at key entry/exit points and the greater likelihood of a disabled ship off the outer edge of the GBR. Maritime Safety Queensland (MSQ) submitted that there was a need to comprehensively review fatigue management, particularly in the Inner Route. According to MSQ, the custom of single-handed pilotage in this route is at odds with contemporary practice in other modes of transport. It noted that the issue of fatigue was exacerbated by the international trend of declining crew competency (MSQ did not offer any evidence to support its view on crew competency). Almost all the reasons given for experiencing a level of tiredness which may impair judgement or ability are associated with single-handed pilotage. The main reasons for single-handed pilotage lie in tradition, cost and the absence of an intermediate economical or convenient transfer point between Cairns and Thursday Island. It is likely that such considerations played a part when the Inner Route was defined as a single compulsory pilotage area. Subsequently, when AMSA’s fatigue management plan was formally implemented, the plan simply included mention of the usual practice of rest breaks as a strategy to manage fatigue during pilotage. The designation of a pilotage area as ‘compulsory’ raises the expectation that a pilot will conduct the ship throughout its transit. In the survey and at interview, a number of pilots suggested two pilots for an Inner Route pilotage would resolve the issue of working hours. However, practical matters such as pilot accommodation on board the ship, handovers between the pilots jointly conducting a pilotage and pilots’ fees, remain. While it has been suggested that check pilot assessments (where two pilots are on board) show that such matters could be managed, it should be noted that less than 2 per cent of Inner Route pilotages have been check voyages. Anchoring for a rest break (even if sleep/rest has been impossible) is difficult for a pilot to contemplate as the master would need to agree as there are significant commercial implications involved in delaying a ship. The option of the master overseeing the navigation while the pilot rests also presents practical difficulties. In submission, a pilot stated that masters expected the pilot to be on the bridge at all times. He also pointed out that some masters remained on the bridge at all times while a pilot was on board, whether or not the pilot was on the bridge. The following findings of the 2010 fatigue management plan review provide further insight into pilot fatigue. Without creating a culture of effective fatigue risk management, little improvement is likely. The Inner Route operation is an area of elevated fatigue-related risk for Queensland coastal pilotage. The current QCPFMP [fatigue management plan] does not provide adequate risk management for these operations. The current training provided to staff of providers and to individual pilots themselves is insufficient. The QCPFMP is not responsive to a range of factors that can mediate or elevate fatigue-related risk. The QCPFMP does not take account of the actual sleep achieved by pilots prior to, or during, a work period. Actual sleep obtained is perhaps the most important variable with respect to fatigue-related risk.128 Some action has been taken or proposed by AMSA to address the findings of the 2010 review (refer section 5.1.3). The survey data and information could be useful in progressing action to address the review’s findings. In the survey, pilots indicated that they found the rest periods before a pilotage, rest days after a tour of duty, rest areas during pilotage and defined leave periods, in that order, the most effective methods in managing their work and rest (Figure 26). Amongst other methods identified by pilots were rosters and accurate ship arrival and departure times. Figure 26: Methods pilots find most effective in managing work and rest 
SummaryThe ATSB survey, pilot submissions and the findings of the independent review into pilot fatigue in 2010 indicate that pilot work and rest hours have not been effectively managed and high levels of fatigue-related risk exist. The fatigue management plan relies on mandatory rest periods before pilotage but the actual fatigue levels experienced during pilotage are not monitored. Pilot fatigue levels are affected by the period and quality of rest/sleep achieved before pilotage. Travel related matters, including the duration of pilot transfers, and weather/other conditions, are a factor reducing the adequacy of pilot rest before pilotage. This is complicated by the disincentive of loss of income or time to pilots for compliance with plan because they are paid per pilotage ‘job’ rather than for their time. The fatigue management plan’s effectiveness is further limited because it does not take into account variations in sleep patterns due to irregular working hours, actual sleep achieved by pilots and the effect of multiple consecutive pilotages. Since the pilotage is single-handed, pilots self-manage fatigue by resting or sleeping when possible during a pilotage, although there are no approved rest areas or standard procedures for rest breaks. The opening of the Fairway Channel and LADS Passage in 2004 reduced fatigue risk by increasing pilot rest/sleep opportunity in the Inner Route but it has not eliminated fatigue risk. Pilots regularly experience high levels of fatigue during Inner Route transits (25 to 40 hours). The rest/sleep available to pilots depends on factors such as weather, traffic, ship’s speed, equipment, crew and other conditions. Longer transits (i.e. slow ships) offer greater rest/sleep opportunity but this may sometimes be greatly reduced. Examples include 3 hours of sleep during a 38 hour transit due to unfavourable conditions. The 25 hour transits on fast ships offer shorter and fewer sleep opportunities even in favourable conditions. Achieving 4 hours of sleep over three or four breaks during these shorter transits would be considered a good result although often little or no sleep is possible. Adequately managing fatigue is critical to reducing the risk of a serious shipping incident. Therefore, the shortcomings of the fatigue management plan need to be addressed.
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