An incident in which an air traffic controller was found asleep at his desk in Brisbane highlights the need for better fatigue management, Australia’s transport watchdog says.

The Airservices Australia controller was found lying across two chairs with a blanket covering them at 5.15am on December 9, 2022, a report by the Australian Transport Safety Bureau (ATSB) said.

The controller had completed multiple night shifts with reduced extended rest periods, “which likely reduced their ability to obtain restorative sleep,” the report said.

ATSB chief commissioner Angus Mitchell said the controller had increased their chances of falling asleep “by lying across two chairs, not moving, and not undertaking activities to maintain mental alertness”.

When a colleague discovered the controller asleep, there was no traffic in the Cairns airspace they were responsible for managing, which was usual for that time of day, and there were no scheduled flights until after their shift.

But had the controller been woken by a radio broadcast, they may have experienced “sleep inertia”, with the risk of delayed communications, or incorrect instructions or actions, the report said.

“There were no negative consequences from this occurrence, but it does highlight areas for improvement in work scheduling and fatigue risk management,” said Mitchell .

The ATSB report found changes to the worker’s shifts were introduced on short notice because of rostering issues.

Since the incident, Airservices Australia has increased its overall number of air traffic controllers, including in the North Queensland group.

It has also drawn up new guidelines and training about fatigue risk assessment.

“Fatigue remains one of the most relevant ongoing concerns for safe transport, despite increased awareness across the transport sector,” said Mitchell.