Pilot Fatigue Survey

Fatigue Assessment Report

09/02/11 8:45 PM EST

Please Note: Fields with an asterisk * are required for submission.

Pilot Fatigue Survey

Pilot Last Name First Name
Crew Number Flight Number
Date of Fatigue Event Location of Rest
1. How many days off did you have prior to beginning this assignment?
2. Did you commute to your domicile for your assignment? Yes No
      - If so, did you commute by air or by car?     Air Car
      - How long did it take you to commute?    
      - Is there a time zone change?     Yes No
      - If yes, what time zone did you commute from?    
3. How much restful sleep?    
      - Past 24 hours?    
      - Past 48 hours?    
      - Past 72 hours?    
4. How much did you sleep prior to the fatigue call?    
5. What hours did you sleep?    
6. Did you awake rested or tired?    
7. How many times did you awake?       Were you able to fall back asleep?    Yes No
8. What time(s) did you awake?   
9. How many hours on duty?    
      - Today    
      - Yesterday    
      - Days previous    
10. How many hours flown?    
      - Today    
      - Yesterday    
      - Days previous    
11. Do any of the following apply?    
      - Time since awake    
      - Jetlag?     Yes No
      - Early awakening due to disturbance?    Yes No
      - Extra time needed to get up and get to airport    
      - Delays in getting started (mechanical, weather, etc)    
      - Change in flight schedule    
12. Type of tasks   
      - Crew position (Captain / First Officer / IRO)    
      - Nature of flights (IMC, VMC, Turbulent, etc)    
13. Extension of normal duty period (Events that prolong the flight longer than scheduled).
      - Enroute weather    
      - Reroute due to traffic    
      - Diversions    
      - Customer delay    
      - Others    
14. Cumulative duty times
    - Consecutive flying days with minimal or near minimal crew rest periods
      None One Two Three     More  
15. Did you have any of the following warning signs?
              Eyes going in and out of focus
              Head bobs involuntarily
              Persistent yawning
              Wandering or poorly organized thoughts
              Spotty near term memory
              Missed or erroneous performance of routine procedures
              Degradation of control accuracy
16. Did you eat breakfast?       Yes No
17. When and what was your last full meal?
18. Did you eat anything unusual or out of the ordinary?       Yes No
19. Do you drink coffee or other caffeine beverages?       Yes No
        After 6pm?       Yes No
20. Do you smoke?       Yes No
21. Do you feel your inability to rest properly was compounded by either personal or medical problems you are presently experiencing?       Yes No
      If Yes, please explain:
     
     
     
22. Did you take any OTC medications for a minor malady during your rest period and if so, what type or brand?       Yes No
      Type:
      Brand
23. Are you presently using OTC or prescription sleep aid medication Yes No
24. Did you consume alcohol during your rest period? Yes No
         If yes, how much and when did you discontinue relative to your report-for-duty?
         
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25. How would you characterize your overall job contentment/satisfaction on a scale of 1 to 10; with 1 being extremely unhappy and 10 being very satisfied? 1 2 3 4 5 6 7 8 9 10
26 What would you cite as the primary cause of your fatigue or inability to rest adequately to report for duty rested?
27. Narrative and Additional Comments: