Some Perspectives on Fatigue Risk Management Systems EUROCONTROL Table of contents 1. Introduction 5 2. Fatigue Risk Management Systems (FRMS) 6 What they are 6 An FRMS Model 7 Advantages for stakeholders 9 Some Myths 10 3. History of FRMS 11 4. The FRMS Forum 12 5. Status of FRMS in Aviation 13 Status in Regulators 13 Status of FRMS in the Airline Industry 14 Studies in the aviation domain 16 UK Rail Industry 17 6. Modelling 19 On choosing a model 21 7. Suggested initial steps when starting to explore FRMS 22 8. Summary 23 3 1. Introduction Shift workers who work at night, late evenings or early mornings will experience some degree of sleep deprivation leading to a fall in alertness during the duty period. For night workers, this is exacerbated by naturally falling performance that is driven by the circadian rhythm. With the exception of night workers on oil rigs, there is unlikely to be any improvement due to adaptation. The degree of sleep deprivation varies with the individual and becomes more pronounced with aging. Although counter measures such as napping before and during duty can help, it is likely that some adverse effects will persist. The consequence of a fall in alertness leads to slowed reaction times and reduced vigilance, poor decision making and lack of communication. In extreme cases this may contribute to incidents and accidents as evidenced by Exxon Valdiz and the Challenger space mission disaster. Unless individuals actually fall asleep, the incident or accident is normally a combination of faulty decision making within a critical situation. In the case of the Challenger disaster, there was a technical fault in some fuel line components that caused the failure but the managers making the decision to proceed were chronically sleep deprived and failed to take into account the state of the faulty components voiced by NASA engineers. Indeed, Professor David Dinges at University of Pennsylvania states that fatigue contributes between 30 and 90% of all serious incidents across industries. Working hours are controlled by a variety of prescriptive schemes in most countries in the world. The European Union introduced their working time directive to guide all workers apart from military personnel and aircrew; the latter having had customised schemes in place for decades, In addition, a number of unions have negotiated terms to restrict duty times to cover specific industries and occupations. All of these are based on prescriptive rules that have little or no flexibility and treat on-call duties as work duties. This creates a capacity issue as being on call is counted as duty time thereby reducing the real duty time available. Health workers are particularly affected by this approach, as medical staff can no longer use on call duties to increase their availability for work, leading to a shortage of doctors at night and during the weekends. A recent report claimed that deaths in UK hospitals increase by 10% at weekends due to the lack of sufficient doctors to cover these periods In any prescriptive rules set, there may be anomalies and in the aviation industry there are examples where less fatiguing schedules fall outside the rules yet more fatiguing alternatives are permitted. Accordingly, there are good safety and business benefits that flow from managing employee alertness in a less prescriptive manner. 5 2. Fatigue Risk Management Systems (FRMS) What they are FRMS is an alternative to the use of prescriptive rules when managing risks that are a consequence of a reduction in d. Assessment and a. Measure and Assess Feedback Current Conditions employee alertness when on duty. The International Civil Aviation Organisation The FRMS (ICAO) has a definition of fatigue: Process A physiological state of reduced mental or c. Manage and Mitigate b. Modeling and Analysis Fatigue Risk of Fatigue Risk physical performance capability resulting from sleep loss or extended wakefulness, circadian phase, or workload (mental and/or physical activity) that can impair a crew member’s alertness and ability to safely operate an aircraft or perform safety related duties. This definition can be easily adapted to reflect any appropriate occupation. ICAO recognises that fatigue is a major human factors hazard because it affects most aspects of a crewmember’s ability to do their job safely. It therefore has implications for safety. ICAO defines a Fatigue Risk Management System (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 rele- vant personnel are performing at adequate levels of alertness. The key statements here are “data driven”, “scientific principles” and “operational experience”. An important part of management is making sound decisions. These can only be made if the base data for them is available and of course is both appropriate and reliable. Data that is not based on scientific principles is worthless and if the decisions on good data do not take into account the operational context, then risks are run that the decisions may not be appropriate 5 or simply won’t fit. All three must be present as a precursor to getting a sound decision. 4 A further pillar of FRMS is the adoption of a so called Just Culture that empowers employees fatigue (7-pt) fatigue 3 to make safety related decisions that impact operational performance sensibly, responsibly 2 2-3 3-4 4-5 5-6 6-7 7-8 8-9 9-10 10-11 11-12 12-13 and without fear of retribution. An example time into duty (h) would be if a pilot with a young family is kept 6 awake all night tending to a sick child, then the pilot ought to be able to responsibly alert his manager that he is unfit for duty without fear of retribution. It is clearly in all stakeholders’ inter- ests to ensure that the pilot on duty is properly rested and fit to fly. An FRMS Model Managing occupational alertness uses a similar approach to managing any risk. Data should be collected, compared to a preset standard and analysed within an operational context to monitor activity and highlight risks of objectives being compromised. With the right kind of data analysis by subject matter experts, an experienced decision making body can assess the risks and decide what actions are or are not necessary to return the activity under scrutiny back on track. Level Focus Key Process Areas Result 5. Optimasing Continuous improvement Monitoring of FRMS performance Well being Safety Managing organisational and safety and Assurance operational changes business performance 4. Managed Pro-active processes: Establishment and direction of predicting fatigue hazards Fatigue Management Action Group and mitigation Development of just culture Development of metrics Use of SAFE model 3. Repeatable Reactive processes: Identication of fatigue hazards identifying fatigue hazards Measurement of fatigue and and mitigation risk assesment Use of tools: SAFE model Training and Promotion Continuous Policy & Documentation Development & Documentation Policy Risk mitigation strategies RISK Continuous Development of Just and Fair Culture of Just and Fair Development Continuous 2. Evaluation Airline current capability Gap Analysis evaluation and FRMS planning Policy and Documentation 1. Initial Prescriptive rules Flight times limitations rules © Copyright FMRS 2011 FRMS Maturity Model There is a five level maturity model that can be used to demonstrate the steps required to develop an FRMS. The processes mature as each level is attained. Throughout the FRMS maturity process, the benefits of FRMS and the progress of the project must be promoted and all stakeholders should be educated in the causes of fatigue and countermeasures. Moreover the process should be integrate into the Safety Management System and Occupational Health and Safety processes Similarly, the organisational environment must be capable of supporting a culture where pilots are encouraged to responsibly report fatigue issues without fear of repercussions. Such Just and Fair Cultures often need to be carefully developed as the FRMS process matures else it will self 7 limit at a low level. All stakeholders have to act responsibly and with care to develop mutually trusting relationships that focus on the goal of creating an organisation that effectively manages its fatigue risk. It’s a collective responsibility: no one stakeholder group can succeed alone. The initial level is where every organisation starts. The organisation is relying on prescriptive regulations such as the European Working Times Directive or CAP371 in UK for aircrew for their guidance. This is already in place and the organisation reacts to these rules. Level 2 is achieved when the employing organ- isation makes a choice to move outside of the prescriptive rules to manage alertness. A Policy will be written to describe how alertness will be managed; a gap analysis against industry standards or Best Practise will be completed to find areas where measures are already in place and where action is needed. Level 3 is still a reactive level but by now the organisation is collecting data to identify the hazards and investing resources to design mitigation strategies. Part of the data gathering and analysis may include the use of a predictive bio-mathematical tool that identifies problematic duty periods for further investigation. Models are a very useful method of assessing risk quickly but are not a solution by themselves. This paper will discuss models in more depth in later chapters. Reactive metrics will be used to track performance. At Level 4, the organisation is starting to be proactive by managing the alertness issues when they form their Fatigue Action Safety Group (FSAG). The FSAG should be equipped with Terms of Reference so they have authority to take action within a boundary, to manage fatigue.