not really reflected in the accident report, he simply had a "brain-snap" and did something completely out of not only training and indoctrination frameworks, but character.
To state that the PIC simply had a brain snap does him a great disservice. If someone as well qualified and experienced as the PIC of QF1 can overrun a runway and cause significant damage with no better explanation than "he had a brain snap" then the technology of getting the human out of the cockpit needs to be accelerated.
When the report on QF1 was written the science and research behind fatigue was still in its early stages. The crew reported that they didn't feel fatigued. We know now that the people who are least able to report their fatigue levels are the crew. We also know that the period of continuous wakefulness can have a blood alcohol equivalency. Being awake for 17 hours continuously is equivalent to .05, 21 hours is equivalent to .08.
https://www.ausenco.com/en/did-you-k...ontent-of-0-05
The PIC woke up at 5:00am on the day of the accident and had not slept prior to the accident at 00:47EST. To dismiss fatigue as a significant factor in the event is to ignore
current science on the matter, keeping in context that QF1 occurred 19 years ago.
The changes to CAO48 should be implemented now and not sent to yet another review or extended so that industry can get familiar with it. The current exemption was designed for airline rostering practices that are no longer followed.With the shortage in crew and the pressure on costs, airlines need to be forced into a proper FRMS that is scientifically based. The fact they can implement one at any time and have chosen not to suggests they want to squeeze the last possible drop out of the CAO 48 exemption lemon that they possibly can.
The lessons from QF 1 when it relates to fatigue show that, far from being a brain snap by a well trained professional crew, was in fact impairment of judgement, reduced reaction times and impulsive behaviour which are all markers of fatigue. In this case fatigue that was equivalent to a BAC of .08