fatigue‑the rules are changing · pdf file2 fatigue—the rules are changing...

FATIGUE‑THE RULES_ARE CHANGING

DisclaimerThis booklet is for information purposes only. It should not be relied on as the sole source of information, and should always be used in the context of other authoritative sources and the relevant regulations.

© 2013 Civil Aviation Safety Authority

This work is copyright. You may download, display, print and reproduce this material in unaltered form only (retaining this notice) for your personal, non-commercial use, or use within your organisation. Apart from any use as permitted under the Copyright Act 1968, all other rights are reserved. Direct any requests for further authorisation to: Safety Promotion, Civil Aviation Safety Authority, GPO Box 2005 Canberra ACT 2601 (Australia), or email: [email protected]

CASA is changing the fatigue management regulations. This booklet relates to flight crew, but legislation applicable to cabin crew members and air traffic control is in the pipeline.

Managing fatigue—CAO 48.1 timetable

April 2013 New CAO 48.1 rule made – flight crew members and operators

2013 – April 2016 Operators will be expected to commence transition to the new rule set. Operators may apply for an FRMS

April 2016 Standard industry exemptions no longer available after April 2016

April 2016 Transition to the new flight crew member fatigue rules complete

1CIVIL AVIATION SAFETY AUTHORITY

Contents What is happening? 02

Why are the fatigue regulations changing? 03

What is fatigue? 04

What causes fatigue? � Sleep debt � Circadian rhythms

040405

Factors in fatigue 07

What are the effects of fatigue? 08

Are we the best judges of fatigue? 10

Warning signs of fatigue 11

What about fatigue-related accidents and incidents? 12

Flight crew rest and flying duties 14

What does the new CAO 48.1 look like? 16

Benefits of fatigue management and FRMS 17

Managing fatigue � How will FM and FRMS affect operators? � What are the operator’s responsibilities? � What are the individual’s responsibilities?

18182020

Fatigue management within an existing SMS 21

Strategies for managing fatigue in the avitation environment � Risk control � Work-related fatigue factors � Non work-related fatigue factors � Hierarchy of fatigue controls

2323232323

Fatigue-fighting tips 24

Fatigue case study 26

Fit to fly? The finer points of fatigue 27

Glossary 28

Managing fatigue—CAO 48.1 timetable

April 2013 New CAO 48.1 rule made – flight crew members and operators

2013 – April 2016 Operators will be expected to commence transition to the new rule set. Operators may apply for an FRMS

April 2016 Standard industry exemptions no longer available after April 2016

April 2016 Transition to the new flight crew member fatigue rules complete

FATIGUE—THE RULES ARE CHANGING2

What_is_happening?Under the CAO 48.1, introduced in April 2013, operators and flight crew will have shared responsibility to manage fatigue. The new CAO adopts a tiered approach to managing fatigue, ranging from prescriptive requirements to a mix of prescription and risk management to a fully developed fatigue risk management system.

Having a tiered system allows operators to choose an appendix based on operational requirements and with an overlying fatigue risk management strategy appropriate for their organisation. A tiered system also allows for improvements in the light of current sleep and fatigue research.

International evidence suggests the changes will generate safety benefits and significant operational efficiencies, without imposing undue cost or time burdens on operators.

FRMS

FATIGUE MANAGEMENT

BASIC

Limitations

� Customisable� Data-driven

Operator obligations

� Policy and documentation� Risk management processes� Safety assurance processes� Safety promotion processes

� Prescriptive� Type-of-operation specific� More flexible� Less restrictive

� Prescriptive� Somewhat restrictive

� Hazard identification� Limitations taking into account identified hazards� Continuous monitoring� Transitional procedures� Training for FCMs

� No additional obligations

The three-tier approach to fatigue management


Why_are_the_fatigue_regulations_changing? Fatigue increases the likelihood of poor decision making, a greater rate of error and generally impaired performance. In the safety-critical aviation environment any or all of these could result in tragedy.

Current flight crew fatigue regulations have been in place for more than 50 years without significant review. Over those years, the industry has significantly changed. Flying in the era of Constellations was very different to today’s global ultra long-haul

operations, with rapid transit of multiple time zones (up to eight time zones in 24 hours). Advances in technology, and scientific understanding of human performance limitations, and of sleep, mean the old regulations are out of step with contemporary

practice and knowledge. They do not properly address transient and cumulative fatigue, operator and individual responsibilities, the impact of circadian rhythms, and crossing of multiple time zones.

They are also not in accordance with a recent change to Annex 6 by the International Civil Aviation Organization.

CASA’s updates to these regulations will better address the changing, 24-hour nature of the aviation industry, advances in fatigue research, and evidence from accidents and near misses in Australia and overseas. They will therefore better manage alertness levels of flight crew.

Fatigue is not a sign of weakness


What_is_fatigue? We use the word fatigue all the time, but what exactly is it? It has several different origins, some of which are:

� hard physical work

� intense emotions

� heightened concentration on a task

� lack of sleep.

We can distinguish between two types of sleep-related fatigue:

� acute (transient)—this is generally only short term, resulting from an extended period of being awake, and can normally be remedied by a single adequate period of sleep

� chronic (cumulative)—can occur after delayed or incomplete recovery from transient fatigue, or a series of days with insufficient sleep. This tends to be a longer-term problem as there is usually a build-up of sleep debt.

Fatigue can act like a toxin accumulating in our body. We can generally deal with a small amount of it, and work it out of our system by catching up on a night’s sleep. However, a continuous accumulation of fatigue can lead to potentially dangerous effects.

What_causes_fatigue? Fatigue is caused by two processes—sleep debt and circadian rhythms.

Sleep debt

Adults generally sleep between seven and eight hours a night, although the need for sleep varies between people. A century ago, before the widespread use of electric lighting, people typically slept around nine hours per night. Today, family demands, work commitments and even television viewing habits combine to limit the opportunities for night-time sleep. In our busy world, many people are suffering from sleep deprivation without being aware of it. Extreme sleep deprivation has severe health effects, but even mild sleep deprivation can affect health and our ability to perform tasks in our work and personal lives.


If we obtain less sleep than we need, we build up a sleep debt. Each successive night of inadequate sleep adds to the debt. Even reducing our sleep by just one hour each night over several nights (e.g. getting seven hours when we really need eight) can reduce our mental capability.

Shift workers, who sleep during daylight hours, can build up a sleep debt because daytime sleep tends to be briefer and of poorer quality than sleep obtained at night.

A sleep debt may build up when a person’s work and family commitments do not allow them to sleep as long as their body needs. But sleep debts can also occur when sleep is disrupted by alcohol, other drugs, and medical conditions. Medical conditions that can cause sleep disruption include the following:

� Insomnia An inability to get to sleep, or difficulty in staying asleep. In many cases, insomnia is a symptom of another problem, such as a medical condition, side effect of medication, or a sleep disorder. Insomnia can also be caused by worry, stress or other emotional upset.

� Restless legs syndrome (RLS) A disorder that causes a strong urge to move your legs, making it difficult to fall asleep. This urge to move often occurs with strange and unpleasant feelings such as creeping, tingling or burning. Moving your legs relieves the urge and the unpleasant feelings.

� Periodic limb movements (PLM) Involuntary leg movements while asleep. The movements often disrupt sleep and may cause the person or their partner to wake up.

� Sleep apnoea A disorder characterised by abnormal pauses in breathing or instances of abnormally shallow breathing.

If you think you may be experiencing any of these conditions, see your doctor.

Circadian rhythms

Our bodies have steady 24-hour physiological, biochemical and behavioural rhythms. Alertness, body temperature, sleep tendency and human error have been shown to follow a 24-hour pattern.

These rhythms are known as circadian rhythms, the word circadian being Latin for ‘about a day’. The human body clock is affected by exposure to light, particularly early morning light. Humans are basically diurnal creatures—in other words, we are awake during the day and sleep at night, as distinct from nocturnal creatures such as owls.


Our circadian rhythms are so reliable that even if we were removed from the 24-hour rhythm of night and day (such as spending winter in Antarctica), the rhythms continue to run.

Circadian rhythms have an important role in regulating sleep patterns. Chemical changes occur in the body as it prepares for sleep, typically between 8pm and midnight. Body temperature reaches a low point at around 3am and then begins

rising steadily as our body gets ready for the day ahead, even before most people are naturally awake.

One especially critical time for shift workers is from 0200–0500, also known as the window of circadian low. At this time our body temperature is at its lowest, and our mental alertness can be at its poorest. (There is another peak in sleepiness—sometimes called the afternoon nap window [around 1500–1700 for most people]. Restricted sleep at night, or disturbed sleep, may make it harder to stay awake during the next afternoon nap window.)

A ‘can-do’ attitude – ‘We are paid to do our job, so we can handle it’ – can be very dangerous


Factors_in_fatigue Overwork

Stress Poor_diet

Medications

Pain

Inactivity

Grief Burnout

Alcohol_and_other_drugs

Sleep_difficulties

AnxietyDepression Illness

Circadian_rhythms

Excess_weight

Shift_work

Social_life

Age

Water_intake


What_are_the_effects of_fatigue? Some in the industry see fatigue as a normal and unavoidable part of aviation. They consider that with enough effort, tired workers can continue to perform their jobs effectively. While increased effort or concentration might help for a few minutes, it certainly cannot compensate for fatigue over an entire shift. Fatigue has a very real detrimental impact on safety in aviation and in many other industries.

To continue to perform safety-critical tasks appropriately, there has to be the right balance between work, rest and play. Fatigue can reduce flight crews’ ability to fly safely.

Physical signs of fatigue

� yawning

� heavy eyelids

� eye-rubbing

� head drooping

� inappropriate or unintentional sleep onset—falling asleep while flying or performing other safety-critical tasks

� poor coordination—slowed reaction times

� headache, lightheadedness

Other fatigue effects include:

� reduced vigilance

� reduced mental abilities, including impaired problem solving

� forgetfulness

� increased risk taking

� poor communication

� reduced alertness and concentration

� poor decision making

� fixation on a single task

� errors of expectancy e.g. descending to a certain altitude out of routine when a different altitude has been cleared


� lack of motivation

� inefficiency

� lowered morale and sense of wellbeing

� irritability, moodiness, short temperedness

Effects of fatigue

Performance category Effects

Attention: reduced Leave out steps in tasksPreoccupation with single tasks or stepsTunnel vision, less likely to notice the unexpectedLess aware of poor performanceConcentration requires more effort

Memory: diminished Poor memory for tasks completed or underwayForget to perform task stepsRevert to ‘old habits’More likely to forget to return to interrupted tasks

Mood: withdrawn Reduced communicationMore irritable, frustrated by minor difficultiesTemptation to shortcut tasks

Reaction time: increased Slower to notice problems Less smooth control of equipment or vehicles

Many of the skills required in emergency situations are sensitive to ‘sleep debt’, including:

� being able to filter out distractions and attend to complex information

� keeping track of a situation as it evolves and recognising when it is necessary to update your strategy

� being able to think laterally and innovatively

� assessing risk

� maintaining your interest/concentration

� controlling your mood and behaviour

� monitoring your own performance and knowing your safety capability limits

� decision making, which can be impaired or delayed

� communicating effectively


One obvious hazard of fatigue is that the fatigued flight crew member falls asleep while on duty. This was the scenario in 2008. Air-traffic controllers frantically radioed go! Flight 1002 for 18 minutes on 13 February 2008. According to the National Transportation Safety Board (NTSB), the two go! airline pilots fell asleep while flying from Honolulu to Hilo, cruising past their destination for 18 minutes before waking up and returning for a safe landing.

This falling asleep can also take the form of a microsleep, which is a brief moment (generally between two and thirty seconds) when a person starts to enter the first

stage of sleep, possibly with their eyes still open, sometimes for less than a few seconds before regaining consciousness. The person is typically unaware that they have experienced a microsleep and

may continue to perform simple repetitive tasks while asleep. For someone performing a routine low-risk task this is not critical. However, for flight crew it is very different. An aircraft travelling at 250 knots on a glide path can cover over 400 feet in one second—the duration of a microsleep.

The safety implications of fatigue in aviation are reinforced by findings in other transport industries. When truck drivers volunteered to wear sleep-monitoring equipment while they worked, researchers were amazed to find that some drivers were showing signs of the first stage of sleep while driving on interstate highways.

Sleep deprivation impairs the brain’s effectiveness, with research showing it can produce effects very similar to alcohol consumption. On-the-job performance loss for every hour of wakefulness between 10 and 26 hours is equivalent to about a .004 per cent rise in blood alcohol concentration. Seventeen to 18 hours of wakefulness is usually considered to be equivalent to a blood alcohol concentration of about .05 per cent. In the safety-critical aviation environment, this could result in tragedy.

Are_we_the_best_judges of_fatigue? People are notoriously poor judges of their own level of fatigue. Asking a fatigued person if they are OK to keep working is a bit like asking someone who is drunk if they are OK to drive.

Even if we are not good judges of how tired we are, we can still keep track of how long we have been awake, how much sleep we have had recently, and the quality of that sleep.

There is no blood test for fatigue


Before starting work, you could ask yourself these questions:

� How much sleep have I been getting over the last few nights?

� How long have I been awake?

� Will I be working at a time when I would rather be sleeping?

� Have I had good quality sleep?

Your answers to these questions can help you to assess how likely you are to be at risk because of fatigue.

Warning_signs_of_fatigueHow tired are you?

Epworth sleepiness scale developed by Dr Murray Johns of Epworth Hospital in Melbourne

How likely are you to doze off or fall asleep in the following situations, in contrast to just feeling tired? This refers to your usual way of life over recent times. Even if you have not done some of these things recently, try to work out how they would have affected you. Use the following scale to choose the most appropriate number for each situation:

Situation Chance of dozing

Sitting and reading _________________

Watching TV _________________

Sitting inactive in a public place (e.g. a theatre or a meeting) _________________

As a passenger in a car for an hour without a break _________________

Lying down to rest in the afternoon when circumstances permit _________________

Sitting and talking to someone _________________

Sitting quietly after a lunch without alcohol _________________

In a car, while stopped for a few minutes in traffic _________________

1 – 6. Congratulations, you are getting enough sleep! 7 – 8. Your score is average 9 and up. Seek the advice of a sleep specialist without delay!

no chance of dozing

slight chance of dozing

moderate chance of dozing

high chance of dozing

0123


What_about_fatigue‑related_accidents_and incidents? Evidence shows that fatigue is a safety issue or contributing factor in a number of Australian aviation accidents and near misses. The Australian Transport Safety Bureau (ATSB) has identified 12 accidents and 64 near misses over the last 10 years in which fatigue was considered relevant. There were two deaths as a result of these accidents.

International aviation accidents in which fatigue was implicated

Date Airline/location Description

21 December 1994 Air Algerie/Warwickshire UK

Five people killed: flight crew and passengers. The flight crew were fatigued—they had had 10 hours of flight duty, with five flight sectors which included six approaches to land.

6 August 1997 Korean Air/Guam Boeing 747-300 crashed on approach to Guam’s international airport, killing 223 passengers and crew at the crash site. Captain’s fatigue was cited in the report as a contributing factor.

18 August 1998 Kalitta DC-8-61F/Guantanamo Bay

The Guantanamo Bay accident was the first in which pilot fatigue was cited as the primary cause. The pilot stalled a perfectly serviceable aircraft into the ground on approach. His inability to monitor the aircraft’s safe flight was accepted as being the direct result of fatigue. The flight crew had been on duty for 18 hours, and flying for nine hours, and were suffering from circadian rhythm disturbance and lack of sleep.

1 June 1999 American Airlines/Little Rock USA

Douglas MD-82 overran runway on landing and crashed, killing the captain and 10 passengers. Knowing that they were approaching their 14-hour duty limits, the pilots might have exhibited ‘get-there-itis’.


25 June 2007 Cathay Pacific 747F/ground collision at Stockholm (Arlanda)

Swedish investigator said crews had been awake for 18-20 hours; the time was 0330 local; and fatigue was a factor. Hong Kong CAD dissented, saying the crew had been given sufficient rest opportunity, so it was not fatigue.

12 February 2009 Colgan Air/Buffalo

Fifty people killed in the crash of a Bombardier Dash 8-Q400. Fatigue was cited as a factor—the young co-pilot frequently commuted across the USA to report for duty.

22 May 2010 Air India Express/Mangalore

All six crew members and 152 passengers killed when the Boeing 737-800 crashed at Mangalore. The report found that the chief cause of the accident was the captain’s failure to discontinue the ‘unstabilised approach’ and his persistence in continuing with the landing, despite three calls from the first officer to ‘go around’ and a number of EGPWS alerts. The report also identified that in spite of the availability of adequate rest before the flight, the captain slept for a prolonged one hour and forty minutes during flight, awakening just prior to approach. This could have led to sleep inertia, possibly causing impaired judgement, accentuated because he was in the window of circadian low.

14 January 2011 Air Canada/ Boeing 767-333/North Atlantic

Approximately halfway across the Atlantic, at night, the aircraft experienced a 46-second pitch excursion. This resulted in an altitude deviation of minus 400ft to plus 400ft from the assigned altitude of 35,000ft above sea level. Fourteen passengers and two flight attendants were injured. The first officer had reported not feeling altogether well. The father of young children, his home sleep was frequently interrupted, and his 75-minute controlled rest (nap) on the aircraft meant it was highly likely he was suffering from sleep inertia. See case study on page 26.


Aviation industry trends suggest fatigue-related accident risk may increase in the future. As the airline industry becomes more competitive, operators are more likely to extend pilot work period limits and utilise more shift work in order to improve productivity. Aircraft are also becoming more sophisticated, and are capable of flying for longer periods, therefore increasing the demands on flight crew.

Flight_crew_rest_and flying_dutiesFlight crew scheduling must consider various important factors, such as time of sustained wakefulness, time on task, types of tasks, extensions of normal duty periods and cumulative duty times.

Time since awakening is a significant factor in building fatigue levels. It can be prolonged before flying by issues such as:

� the effects of crossing time zones

� early waking due to disturbances in the sleep environment

� the extra time needed to get up, check out of a hotel and travel to the airport

� pre-flight delays, such as mechanical problems or inclement weather

A good night’s sleep is the only cure for fatigue and its impact on performance. An adequately restorative sleep will usually last for an average of seven to eight hours and will include transition, light sleep, slow wave sleep (SWS), and rapid eye movement (REM) sleep. If the balance between these phases is upset it can lead to fatigue. Deficits in REM or SWS can lead to decreased mental performance, impaired psychological wellbeing, and increased complaints of fatigue.

Sleeping in the afternoon increases SWS and reduces REM sleep. Morning sleep (perhaps after an overnight flight) increases REM and reduces SWS. To avoid fatigue the balance needs to be restored.

Fatigue problems are compounded when work/sleep routines do not allow for acclimatisation. Our internal/biological clocks can take days to adjust to a novel work/sleep pattern, so duty times that swap rapidly from night to day can cause desynchronosis (a mismatch between the biological clock and environmental sleep/wake cues such as daylight) and sleep loss.

There is no magic anti-fatigue bullet


‘ If you fly aircraft, fatigue is just something both the operator and individual have to manage. The worst of it is the long overnight sectors. Your circadian rhythm is right out of whack and to manage it you must strictly adhere to standard operating procedures, plus slow it all down and err on the conservative side. Fatigue is insidious and you may fail to recognise it. The multi-crew environment helps in that others are checking your actions. Never short-cut checklists or procedures when you’re tired because that’s when errors occur. Some aspects of the new CASA flight time limitations are not popular and from a crew perspective have been industry driven.

Our airline has conducted a fatigue management study but little has changed and the problem is some crew through personal greed will fly anything without considering the risk. Some years back we had some ridiculous flying patterns over the Tasman and the first officer and I hopped off rather than struggle to stay awake. It wasn’t well received by management, but better than sticking out the side of a hill with another 250 followers. Other crew did the same with that flying pattern and it was changed. You have to be strong with them sometimes for safety’s sake.

International pilot for a major airline

’


WHAT_DOES_THE_NEW_ CAO 48.1_LOOK_LIKE?The new fatigue rules will have three tiers, ranging from simple prescription to the more complex and sophisticated fatigue risk management system (FRMS). These tiers recognise that fatigue is a complex aviation safety issue—that there is no ‘one-size- fits-all’ solution.

� The first tier is the basic prescriptive level (basic limitations)

� The second is fatigue management, This still uses prescriptive rules, but improves safety through a greater emphasis on operator-managed risk control and requirements for training and promotion of awareness regarding fatigue

� The third and most sophisticated level is a fatigue risk management system (FRMS).

FRMS

FATIGUE MANAGEMENT

BASIC

Limitations

� Customisable� Data-driven

Operator obligations

� Policy and documentation� Risk management processes� Safety assurance processes� Safety promotion processes

� Prescriptive� Type-of-operation specific� More flexible� Less restrictive

� Prescriptive� Somewhat restrictive

� Hazard identification� Limitations taking into account identified hazards� Continuous monitoring� Transitional procedures� Training for FCMs

� No additional obligations

The three-tier approach to fatigue management


The first tier, the basic duty periods and flight time limits, may well suit smaller operators with few staff and simple operations.

However, mid- and larger-sized operators, whose businesses are more complex, with changing 24-hour operational demands, are likely to work under the more flexible rules of the second tier. This introduces higher risk management requirements, including hazard ID, and continuous monitoring and improvement of fatigue management, as well as training and safety promotion.

It is likely that most operators will fall into this group, with only a small percentage applying to operate under an FRMS.

Benefits_of_fatigue management_and_FRMS A fatigue risk management system is designed to create a flexible operating environment in which potential fatigue risks can be highlighted. Operators must anticipate and address fatigue risks and amend their systems accordingly. An FRMS can be implemented as part of an existing safety management system (SMS), if one exists.

A well-implemented and supported FRMS should improve flight safety, efficiency, productivity and operational flexibility, as well as satisfy the organisation’s duty of care to its employees and the public. It can also offer health and wellbeing benefits.

The elements of an FRMS can be grouped as follows:

� Safety policy and objectives

� Safety assurance

� Safety risk management

� Safety promotion

These are similar to the sections of the safety management system (SMS) that many operators already have.


You cannot train yourself to need less sleep and you cannot store sleep

Managing_fatigue Fatigue is a recognised potential safety and health risk factor and needs to be managed and controlled as part of duty-of-care responsibilities of the operator/employer and the FCM. Increasing scientific evidence supports the benefits of recovery on performance in a number of industries.

Ways of enhancing recovery include:

� sleep and rest

� nutrition

� periodisation

� stretching

� massage

� relaxation techniques

� travel strategies

How will FM and FRMS affect operators?

Fatigue cannot be eliminated, but the risks associated with it can be managed through a partnership between the operator and flight crew member. Some of the causes of fatigue originate within company policies and practices; for

example, length of shift, the extent to which work is performed during the night, and the predictability of work schedules. Other causes originate from the employee’s personal situation, including commuting time, family responsibilities, and the demands of second jobs.

The diagram opposite shows some of the main sources of fatigue. Employer and employee share responsibility for managing fatigue to the best of their abilities.


Employer and employee responsibilities for managing fatigue

Adapted from Australian National Transport Commission

Workload breaks

Organisational factors

Life away from work

Work demands

Work duration

Workload breaks

Sleep quality

Work duration StaffingTeam climate

Commuting

Regulations

Sleep duration

Circadian rhythms

Type of work

Socio-economic factors

Personal factors

FATIGUE

Family and social life


What are the operator’s responsibilities?

Operators should:

� schedule work hours and time off to give employees sufficient opportunity for restorative sleep.

� manage flight duty times and breaks.

� ensure employees are informed of the risks associated with fatigue and how to participate in controlling these risks.

� ensure working hours, shift rosters and shift cycles are structured and managed to avoid or minimise fatigue.

� increase surveillance to ensure that exposure to workplace contaminants, such as noise and hazardous substances, are controlled to within acceptable limits.

� provide conditions that are conducive to sleep where necessary.

� if onsite accommodation is provided, ensure employees are offered a balanced diet.

Operators may wish to conduct a risk assessment on each route and duty period, taking into account the risk factors associated with fatigue.

Operators should document details of the assessment in their operations manual. You can find more information about the legislative framework in NPRM 1202OS.

CASA estimates there are currently 663 aviation operators that would potentially be affected by changes to the fatigue regulations.

What are the individual’s responsibilities?

Flight crew should:

� manage their personal time to ensure they are rested and fit for duty

� inform the operator of factors that may mean they are not fit for duty

� not put other people in danger by performing a flight duty time when excessively fatigued

� when reporting incidents, note whether fatigue was a factor.


Fatigue management is not intended to control people’s lives. Its goal is that employees understand that they need to arrive at work in a fit state for duty. This includes managing their time away from work so that they have adequate rest and sleep. If, for whatever reason, flight crew are not able to get enough rest, it is their responsibility to report this as a potential risk.

Fatigue_management_within an_existing_SMS Around the world, safety-critical industries such as railways, road transport and airlines are beginning to introduce scientifically-based risk management approaches to dealing with fatigue-related hazards. These approaches are known as fatigue risk management systems (FRMS), and are often part of an organisation’s overall safety management system (SMS). If your organisation does not have an SMS, it can still have an FRMS. A typical FRMS includes education and training for staff, incident reporting systems, and work schedules that take into account knowledge of human fatigue.

Fatigue Risk Management System

Safety Management System

A fatigue risk management system (FRMS) can be part of a safety management system (SMS)


ICAO defines an FRMS as: ‘A data‐driven means of continuously monitoring and managing fatigue‐related safety risks, based upon scientific principles and knowledge as well as operational experience that aims to ensure relevant personnel are performing at adequate levels of alertness.’

An FRMS often includes the use of commercial computer software systems to design shift rosters. Software models take into account the sleep the person is estimated to have obtained, as well as circadian variations in alertness to produce an estimate of the fatigue level that may result from a particular shift pattern.

The following elements are common to most formal FRMS:

� Organisational policies

• Commitment from management and staff

• Safety reporting culture policy to enable staff to report incidents

� Education and training

• For front line staff, as well as managers, supervisors and scheduling personnel

� Risk assessment

• Identifying tasks at greatest risk from fatigue

• Developing strategies to reduce the risk to these tasks

• Determining how much fatigue can be tolerated to get the job done

� Changes to work schedules to reduce fatigue

• Applying maximum duty time limits

• If necessary, using software modelling to fine-tune schedules and estimate fatigue levels

� Continual monitoring and assessment of fatigue and fatigue-related events

• Incident and event reporting system

� Periodic evaluation and continuous improvement of the FRMS

Fatigue cannot be overcome with coffee and willpower


Strategies_for_managing fatigue_in_the_aviation environment Risk control

� Shift length and roster design

� Flight schedules

� Commuting arrangements

Work-related fatigue factors � Hours employees are required to work (and the impact of these hours on

sleep opportunities)

� Duration and time of day of duty periods

� Time and duration of breaks within duty times

� Complexity of tasks flight crew must perform

� Work environment and conditions

� Conditions and environment in the hotels used for overnights

� Fluctuations in the body’s circadian rhythm due to shift work

Non work-related fatigue factors � Long commutes to and from work

� Sleep disorders affecting quantity and/or quality of recovery sleep

� Individual factors relating to family and social responsibilities

Hierarchy of fatigue controls � Organisational controls

� Employee controls

� Behavioural controls

� Reactive controls

Documented policy on secondary employment—communicated to all employees

Personal minimums for safety-critical personal—‘as an operating crew member on overnight trips, my personal minimum would be to consume no alcohol to ensure I am fit for duty’.


Fatigue‑fighting_tips

Sleep baby, sleepAim for at least seven hours each night. If you really think you can manage on less, do an experiment. Sleep for least seven hours a night for two weeks and compare how you feel and perform.

2

3

4

1Plan a power nap Napping is better than falling asleep on the job. A 10 to 15-minute nap has been shown to improve alertness for about an hour.

Flex those pecs Aerobic exercise increases levels of the neurotransmitters dopamine, noradrenalin and serotonin, all of which are good for mood and energy levels.

Water on the brainYour brain is about 80 per cent water – and it doesn’t work as well if you become dehydrated. The recommended daily amount is around two litres per day; more if your work is physically demanding, or in hot conditions.


Pigs can’t flyYour diet can have a significant impact on how you feel. Large meals require energy to digest and a full stomach draws blood away from the brain, leaving you feeling tired. Smaller meals, more often, can avoid this effect. 5

6

7

8

Begin with breakfast Breakfast acts as an energy booster that defends against fatigue throughout the day. A healthy breakfast should contain protein (from eggs, meat, or other sources) and complex carbohydrates (as opposed to sugars).

Use caffeine strategicallyThe caffeine in coffee, soft drinks and tea has been proved to be useful in increasing alertness, reaction speed and thinking ability for up to three hours, but it is not the ultimate solution to fatigue. Too much can cause restlessness and sleeping difficulties. If ingested near the end of the day or shift, caffeine can lead to sleeplessness – which increases fatigue.

Do it in the darkSleeping in the day is unnatural – our bodies are designed to react to light. Therefore, try to limit your exposure to daylight after a night shift and keep your bedroom as dark and quiet as possible.


A fatigued Air Canada first officer on a transatlantic flight sent his plane into a dive after mistaking the planet Venus for another plane, according to an official report.

Fourteen passengers and two crew members were injured after the ‘confused’ and ‘disorientated’ first officer pushed the controls sharply downwards to avoid a U.S. plane that he wrongly thought was on a collision course with the jet.

____________

A report released by Canada’s Transportation Safety Board (TSB) has shed light on the January 2011 incident on the 767 jet – which was half way over the Atlantic en route from Toronto to Zurich, Switzerland at night.

____________

According to the report, the first officer had just woken up after a 75-minute rest – more than the 40-minute maximum permitted by airline regulations – when the captain warned him there was a U.S. Air Force C-17 in the area.

The first officer – disorientated after falling into a deep sleep – saw a bright object ahead of the plane – later believed to have been the planet Venus – and mistook it for the plane, the report read.

____________

The captain corrected him and advised that the plane was in fact ‘at 12’oclock’ and passing in the opposite direction roughly 1000 feet below them.

____________

‘When the FO [first officer] saw the oncoming aircraft, the FO interpreted its position as being above and descending towards them,’ the report continued.

____________

The first officer then pushed forward on the controls, forcing the plane to descend 400ft and towards the C-17.

Fatigue_CASE_STUDY


‘The captain immediately disconnected the autopilot and pulled back on the control column to regain altitude. It was at this time the oncoming aircraft passed beneath them.’

None of the injured passengers were wearing seat belts, even though the seat belt sign was switched on.

____________

After interviews with the flight crew, the safety board concluded that the crew did not fully understand the risks of tiredness during night flights.

____________

It added that crew misunderstood why controlled rest was limited to 40 minutes – to avoid increasing the risks of sleep inertia (temporary grogginess and disorientation felt when waking up).

____________

‘They were aware of the term (sleep inertia) but not of how significantly impaired a recently awakened pilot could be,’ the report said.

Fit_to_fly?_The_finer points_of_fatigue

� There is no magic anti-fatigue bullet

� Fatigue is not a sign of weakness

� Fatigue cannot be overcome with coffee and willpower

� There is no blood test for fatigue

� A ‘can-do’ attitude – ‘We are paid to do our job, so we can handle it’ – can be very dangerous

� You cannot train yourself to need less sleep and you cannot store sleep.


Glossary

AOC Air operator’s certificate

Augmented crew Comprises more crew members than the basic flight crew. Each crew member can therefore be replaced by another suitably qualified crew member for some part of the flight

ATSB Australian Transport Safety Bureau

CAAP Civil Aviation Advisory Publication

CAO Civil Aviation Order

CASA Civil Aviation Safety Authority

CASR Civil Aviation Safety Regulations 1998

Circadian low Time (0200–0500) when performance can be at its poorest, and body temperature is at its lowest. [Also parallel afternoon nap window (1500–1700 for most people) when sleepiness/fatigue peaks.]

Circadian rhythms Body functions (e.g. sleep/wakefulness, motor activity, hormonal processes, temperature, and performance) that are controlled by internal biological clocks and vary over a 24-hour cycle. As a result, levels of human performance also vary significantly during that 24-hour period.

FCM Flight crew member (pilot/flight engineer)

Flight duty period A period which starts when a flight crew member is required to report for a duty period in which a flight as an operating crew member (OCM) is undertaken, and finishes no fewer than 15 minutes after the end of the scheduled time of the final flight as an OCM.

FM Fatigue management

FRMS Fatigue risk management system

ICAO International Civil Aviation Organization

NFRM Notice of Final Rule Making

NPRM Notice of Proposed Rule Making


Off duty period Time during which a flight crew member is free of all employment–related duties and standby provisions

OH&S Occupational health and safety (also now workplace health and safety—WHS)

Periodisation Strategies for bringing performance to peak at a predefined point in time

SARP Standards and recommended practice

SCC Standards consultative committee

Sector One segment of a flight, comprising one take-off and one landing

SIE Standard industry exemption

SMS Safety management system

Split duty Flight duty period which includes a rest period during which the flight crew member is relieved of all duties.

Standby Time during which a flight crew member is required by an operator to hold him/herself available for a flight duty period

WOCL Window of circadian low. See entry for circadian low

Further reading

For the latest information on fatigue, access to a fatigue management toolkit, and links to an extensive number of fatigue resources from around the world, see www.casa.gov/fatigue

@CASABriefing Follow CASA at

GPO Box 2005 Canberra ACT 2601 • T 131 757 • E [email protected] • W www.casa.gov.au

at www.youtube.com/CASABriefing

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