ALPA-SA Fatigue Report Form
ALL REPORTS WILL BE KEPT CONFIDENTIAL
Name (Optional - confidentiality will be ensured)
First Name
Last Name
Type of Operation
Airline
Commercial
Contract
Training
Other option
Name of Company (optional - confidentiality will be ensured)
Date of Fatigue Event
Time of Event (Local/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 option
If relevant, on what flight?
Route
If relevant, on what flight?
Aircraft type
Duty Details
Early or late?
Early
Late
Duty day
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 option
Rostered Start Time
1
2
3
4
5
6
7
8
9
10
11
12
:
Hour
00
10
20
30
40
50
Minutes
AM
PM
Rostered Finish Time
1
2
3
4
5
6
7
8
9
10
11
12
:
Hour
00
10
20
30
40
50
Minutes
AM
PM
Actual Start Time
1
2
3
4
5
6
7
8
9
10
11
12
:
Hour
00
10
20
30
40
50
Minutes
AM
PM
Actual Finish Time
1
2
3
4
5
6
7
8
9
10
11
12
:
Hour
00
10
20
30
40
50
Minutes
AM
PM
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 option
If a specific Fatigue Event, tick PHYSICAL signs of fatigue apparent in the 2 hours leading up to event
No physical signs
Rubbing eyes
Yawning
Difficulty keeping eyes open
Frequent blinking
Head nodding
Falling asleep
Headache
Other option
If a specific Fatigue Event, tick COGNITIVE signs of fatigue apparent in the 2 hours leading up to 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 option
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 in-flight rest utilised? If yes, please specify when in "other"
No
Yes
Other option
Where was the in-flight rest?
Bunk
Flight deck seat
Cabin seat
Countermeasures used
Advised colleague of fatigue risk
Included in threat briefing
Controlled rest on the flight deck
Caffeine
Use of lighting
Additional crew members
Food and drink
Increased use of automation for the approach
Other option
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