Doc 9966 - UNEDITED VERSION

Fatigue Risk Management Systems

Manual for Regulators

2011 Edition

Overview

OVERV VIEWOFTHISD DOCUME ENT

oseoftheFRM MSManualis stoprovideS Stateswithinf formationon nhowanFRM MSshouldfunction, Thepurpo itsregulat tionanditsoversight.Thechaptersint thisdocumen ntrelatetodif fferentgener ralareasasfo ollows:

Reg gulatory De ecisions, Activ vitiesand d Tools T

Ch hapter1
FRM MSdefined. FRMSSARPsand th heirintent

The eScientifi ic Background d

Com mponents sof anFRMS

Supportin S ng Information

Chapter3 Chapter2
Thescientific T principlesonwhich anF FRMSapproach h isbased Policyand documentation d n

AppendixA A
Glossary

Ch hapter7
Con nsiderations when ndecidingto of fferFRMS re egulations

Chapter4
Fatiguerisk management processes

AppendixB B Chapter8
TheFRMS T approvalprocess Toolsfor measuringfatig m gue

Chapter5
Fatiguesafety assurance processes

Ch hapter9
Prov vidingFRMS oversight o

AppendixC C Chapter6
FR RMSpromotio on processes Proceduresfo or controlledrest c ton theflightdec ck

Ap ppendixD
FRMS SEvaluation Form m(Example)

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Contents

CONTENTS
FRMSManualforRegulators..................................................................................................................1 Chapter1:Introductiontofatigueriskmanagementsystems(FRMS)....................................................11 1.1 Whatisafatigueriskmanagementsystem?.....................................................................................11 1.2WhytheaviationindustryisintroducingFRMS ................................................................................11 . 1.3 ICAOStandardsandRecommendedPracticesforfatiguemanagement..........................................13 1.3.1 Section4.10ofAnnex6,PartI..............................................................................................15 4.10.1....................................................................................................................................15 4.10.2....................................................................................................................................15 4.10.3....................................................................................................................................15 4.10.4....................................................................................................................................16 4.10.5....................................................................................................................................16 4.10.6....................................................................................................................................16 4.10.7....................................................................................................................................17 4.10.8....................................................................................................................................17 1.3.2 Appendix8,Annex6,PartI ..................................................................................................18 . 1.4Structureofthismanual.....................................................................................................................18 Chapter2:ScienceforFRMS..................................................................................................................21 2.1IntroductiontoscienceforFRMS.......................................................................................................21 2.2Essentialsleepscience.......................................................................................................................21 2.2.1Whatishappeninginthebrainduringsleep............................................................................21 2.2.2Theissueofsleepquality..........................................................................................................25 2.2.3Consequencesofnotgettingenoughsleep..............................................................................26 2.3Introductiontocircadianrhythms......................................................................................................29 2.3.1Examplesofcircadianrhythm ..................................................................................................29 . 2.3.2Thecircadianbodyclockandsleep..........................................................................................210 2.3.3Sensitivityofthecircadianbodyclocktolight.........................................................................212 2.3.4Shiftwork..................................................................................................................................213 2.3.5Jetlag........................................................................................................................................214 2.4SummaryofessentialscienceforFRMS.............................................................................................217 Chapter3:FRMSpolicyanddocumentation...........................................................................................31 3.1IntroductiontoFRMSpolicyanddocumentation..............................................................................31

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3.2 Appendix8,1.1:FRMSpolicy............................................................................................................33 3.2.1ScopeoftheFRMS....................................................................................................................33 3.3 ExamplesofFRMSpolicystatements................................................................................................35 3.3.1FRMSpolicystatementforamajoraircarrier..........................................................................35 3.3.2FRMSpolicystatementforasmalleroperator providingmedicalevacuationservices.......................................................................................36 3.4 Appendix8,1.2:FRMSdocumentation.............................................................................................37 3.4.1ExampleofTermsofReferenceforaFatigueSafetyActionGroup.........................................38 Chapter4:FatigueRiskManagement(FRM)Processes..........................................................................41 4.1IntroductiontoFRMprocesses..........................................................................................................41 4.2FRMProcessesStep1:Identifytheoperationscovered....................................................................44 4.3FRMProcessesStep2:Gatherdataandinformation........................................................................44 4.4FRMProcessesStep3:Hazardidentification.....................................................................................46 4.4.1Predictivehazardidentificationprocesses...............................................................................46 4.4.2Proactivehazardidentificationprocesses................................................................................49 4.4.3Reactivehazardidentificationprocesses .................................................................................413 . 4.5FRMProcessesStep4:Riskassessment.............................................................................................414 4.6FRMProcessesStep5:Riskmitigation...............................................................................................416 4.7Example:SettingupFRMprocessesforanewULRroute.................................................................418 4.7.1:Step1Identifytheoperation................................................................................................419 4.7.2:Step2Gatherdataandinformation.....................................................................................419 4.7.3:Step3Identifyhazards..........................................................................................................421 4.7.4:Step4Assesssafetyrisk .......................................................................................................422 . 4.7.5:Step5Selectandimplementcontrolsandmitigations........................................................422 4.7.6: 4.7.5:Step6Monitoreffectivenessofcontrolsandmitigations...................................................422 4.7.7: 4.7.6:LinkingtoFRMSsafetyassuranceprocesses...........................................................................423 Chapter5:FRMSsafetyassuranceprocesses .........................................................................................51 . 5.1IntroductiontoFRMSsafetyassuranceprocesses.............................................................................51 5.2FRMSSafetyAssuranceProcessesStep1:Collectandreviewdata..................................................54 5.3FRMSSafetyAssuranceProcessesStep2:EvaluateFRMSperformance..........................................55 5.4FRMSSafetyAssuranceProcessesStep3:Identifyemerginghazards..............................................56 5.5FRMSSafetyAssuranceProcessesStep4:IdentifychangesaffectingFRMS.....................................56 5.6FRMSSafetyAssuranceProcessesStep5:ImproveeffectivenessofFRMS......................................57 5.7AssigningResponsibilityforFRMSSafetyAssuranceprocesses........................................................57 5.8ExamplesofFRMSsafetyassuranceprocessesinteractingwithFRMprocesses..............................58

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Chapter6:FRMSpromotionprocesses...................................................................................................61 6.1 IntroductiontoFRMSpromotionprocesses......................................................................................61 6.2 FRMStrainingprogrammes...............................................................................................................62 6.2.1 Whoneedstobetrained......................................................................................................62 6.2.2 Curriculum............................................................................................................................62 6.2.3 FRMStrainingformatsandfrequency..................................................................................66 6.2.4 FRMStrainingevaluation......................................................................................................66 6.2.5 FRMStrainingdocumentation..............................................................................................67 6.3 FRMSCommunicationsplan..............................................................................................................67 Chapter7:DecidingtoofferFRMSregulations.......................................................................................71 7.1 IstheStatessafetyoversightsystemmatureenough?....................................................................71 7.2 Dowehaveadequateresources? .....................................................................................................72 . 7.3 IfweofferFRMS,canwepaylessattentiontoourprescriptiveregulations?..................................73 7.4 WhatiftheStatealreadyhasaprocesstoapprove anFRMSand/oroperatorswithanapprovedFRMS?.......................................................................73 7.5 Whenshouldtheoperatorapplyforavariationand whenshouldtheyberequiredtoimplementanFRMS?...................................................................74 7.6 HowwillweassesstheacceptabilityoftheoperatorproposedouterlimitsoftheirFRMS?..........74 7.7 WhataretheaspectsofanoperationforwhichFRMSouterlimitshavetobedetermined?.........75 7.8 WhydontwedevelopregulationsthatrequireFRMStobeacomponentofSMS? .......................76 . 7.9 TheFRMSprovisionsrequirethatsignificantdeviationsinscheduledand actualflighttimes,dutyperiodsandrestperiods,andreasonsforthose significantdeviations,berecordedbyoperators.Howdowemonitorthat?..................................76 Chapter8:TheFRMSapprovalprocess..................................................................................................81 8.1 APhasedapproachtoFRMSimplementation...................................................................................81 8.1.1 PhaseI:Planning...................................................................................................................81 8.1.2 PhaseII:ImplementreactiveFRMprocesses.......................................................................83 8.1.3 PhaseIII:ImplementproactiveandpredictiveFRMprocesses............................................83 8.1.4 PhaseIV:ImplementFRMSsafetyassuranceprocesses......................................................83 8.1.5 OperationalExampleofstagedFRMSimplementation.......................................................84 8.2 FRMSApprovalprocess.....................................................................................................................86 8.2.1 RegulatoryMilestone1Notificationbytheoperator.......................................................87 8.2.2 RegulatoryMilestone2ReviewofFRMSplan,policyanddocumentation.......................87 Regulatorydocumentation.............................................................................................................87 1. ReviewofFRMSplan...................................................................................................................87 2. ReviewoftheinitialFRMSpolicyanddocumentationproposal................................................88

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8.2.3 RegulatoryMilestone3ReviewofinitialFRMprocesses..................................................89 8.2.4 RegulatoryMilestone4ApprovalofFRMS........................................................................810 Chapter9:OversightofanFRMS...........................................................................................................91 9.1 Regulatoryplanningfunctions...........................................................................................................91 9.2 SpecialrequirementsforFRMSoversight.........................................................................................91 9.3 Enforcement......................................................................................................................................92 AppendixA:Glossary.............................................................................................................................A1 AppendixB:Measuringcrewmemberfatigue........................................................................................B1 B1 Crewmembersrecalloffatigue ........................................................................................................B1 . B1.1 Fatiguereportingforms........................................................................................................B1 B1.2 Retrospectivesurveys...........................................................................................................B3 B2 Monitoringcrewmemberfatigueduringflightoperations...............................................................B4 B2.1 Subjectivefatigueandsleepinessratings.............................................................................B4 B2.2 Objectiveperformancemeasurement.................................................................................B7 B2.3 Monitoringsleep...................................................................................................................B8 B2.4 Monitoringthecircadianbodyclockcycle...........................................................................B13 B3 Evaluatingthecontributionoffatiguetosafetyevents....................................................................B16 AppendixC:ProceduresforControlledRestontheFlightDeck..............................................................C1 AppendixD:ExampleofanFRMSEvaluationForm................................................................................D1

[Back to Contents]
Chapter1.IntroductiontoFRMS

[Back to Overview]
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Chapter1.Introductiontofatigueriskmanagementsystems(FRMS)
1.1 Whatisafatiguerisk managementsystem?
ICAOhasdefinedfatigueas: A physiological state of reduced mental or physical performance capability resulting from sleep loss or extended wakefulness, circadian phase, or workload (mental and/or physical activity) that can impair a crew members alertness and ability to safely operate an aircraftorperformsafetyrelatedduties. Fatigueisamajorhumanfactorshazardbecauseit affects most aspects of a crewmembers ability to dotheirjob.Itthereforehasimplicationsforsafety. A Fatigue Risk Management System (FRMS) is definedas: A datadriven means of continuously monitoring and managing fatiguerelated safetyrisks,baseduponscientificprinciplesand knowledge as well as operational experience that aims to ensure relevant personnel are performingatadequatelevelsofalertness. AnFRMSaimstoensurethatflightandcabincrew members are sufficiently alert so they can operate to a satisfactory level of performance. It applies principles and processes from Safety Management Systems(SMS)tomanagetherisksassociatedwith crewmember fatigue. Like SMS, FRMS seeks to achieve a realistic balance between safety, productivity, and costs. It seeks to proactively identify opportunities to improve operational processes and reduce risk, as well as identifying deficiencies after adverse events. The structure of anFRMSasdescribedhereismodelledontheSMS framework. The core activities are safety risk management (described in the SARPS as FRM processes) and safety assurance (described in the SARPs as FRMS safety assurance processes). These coreactivitiesaregovernedbyanFRMSpolicyand supported by FRMS promotion processes. The entire system must be documented to the satisfactionoftheStateoftheOperator. Both SMS and FRMS rely on the concept of an effectivesafetyreportingculture1,wherepersonnel havebeentrainedandareconstantlyencouragedto reporthazardswheneverobservedintheoperating environment.Toencouragethereportingoffatigue hazards by all personnel involved in an FRMS, an operatormustclearlydistinguishbetween: unintentional human errors, which are acceptedasanormalpartofhumanbehaviour and are recognized and managed within the FRMS;and deliberate violations of rules and established procedures. An operator should have processes independent of the FRMS to deal withintentionalnoncompliance. Toencourageanongoingcommitmentbypersonnel toreportingfatiguehazards,theorganizationmust takeappropriateactioninresponsetothosereports. Whenaneffectivesafetyreportingsystemexists,a largepercentageofsafetyreportsfromoperational personnelrelatetoidentifiedorperceivedhazards, insteadoferrorsoradverseevents.

1.2 WhytheAviationIndustryis IntroducingFRMS

The traditional regulatory approach to managing crewmemberfatiguehasbeentoprescribelimitson maximumdaily,monthly,andyearlyflightandduty hours, and require minimum breaks within and betweendutyperiods.Thisapproachcomesfroma longhistory oflimitson working hoursdating back to the industrial revolution. It entered the transportationsectorintheearly20thcenturyina series of regulations that limited working hours in rail, road and aviation operations . The approach

SeeICAOSafetyManagementManual(Doc9859).

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IntroductiontoFRMS does not take into account operational differences ordifferencesamongcrewmembers. In contrast, an FRMS employs multilayered defensivestrategiestomanagefatiguerelatedrisks regardless of their source. It includes datadriven, ongoingadaptiveprocessesthatcanidentifyfatigue hazardsandthendevelop,implementandevaluate controls and mitigation strategies. These include both organizational and personal mitigation strategies. While an FRMS is based on scientific principles, its application within various aviation contexts requires operational experience and knowledge.AnFRMSshouldnotbeprovidedtoan operatorbyaconsultant;itneedstobedeveloped, understood and managed by people who have comprehensive experience in the complex operational environment to which it will apply. In thisway,meaningfulinterpretationscanbemadeof what various data analyses may mean in particular contexts, and workable operational strategies can bedeveloped. The cost and complexity of an FRMS may not be justifiedforoperationsthatremaininsidetheflight anddutytimelimitsand wherefatiguerelatedrisk is low. Some operators may therefore choose to placeonlycertainpartsoftheiroperationsunderan FRMSornotimplementanFRMSatall.Nonetheless, whereanFRMSisnotimplemented,itremainsthe operators responsibility to manage fatigue risks throughtheirexistingsafetymanagementprocesses. Itwouldbeamisconceptiontothinkofanoperator with an FRMS as having no flight and duty time limitations. In fact, an operator continues to have flight and duty time limitations but these are identified through their own FRMS processes, specific to a defined operational context, and are continually evaluated and updated in response to their own risk assessments and the data the operator is collecting. It is up to the regulator to assess whether the risk assessments, mitigations andthedatacollectedareappropriate,andthatthe flight and duty time limitations identified are reasonable responses as evidenced in safety performance indicators. This means that FRMS necessitatesperformancebasedregulation.

reflects early understanding that long unbroken periodsofworkcouldproducefatigue(nowknown astimeontaskfatigue),andthatsufficienttimeis needed to recover from work demands and to attendtononworkaspectsoflife. In the second half of the 20th century, scientific evidencebeganaccumulatingthatimplicatedother causes of fatigue in addition to timeontask, particularlyin24/7operations.Themostsignificant newunderstandingconcerns: the vital importance of adequate sleep (not just rest) for restoring and maintaining all aspectsofwakingfunction;and daily rhythms in the ability to perform mental andphysicalwork,andinsleeppropensity(the ability to fall asleep and stay asleep), that are driven by the daily cycle of the circadian biologicalclockinthebrain. This new knowledge is particularly relevant in the aviationindustrywhichisuniqueincombining24/7 operationswithtransmeridianflight. In parallel, understanding of human error and its role in accident causation has increased. Typically, accidents and incidents result from interactions between organizational processes (i.e. workplace conditionsthatleadcrewmemberstocommitactive failures), and latent conditions that can penetrate current defenses and have adverse effects on safety2. The FRMS approach is designed to apply thisnewknowledgefromfatiguescienceandsafety science. It is intended to provide an equivalent, or enhancedlevelofsafetywhilealsoofferinggreater operationalflexibility. Prescriptive flight and duty time limits represent a somewhat simplistic view of safety being inside the limits is safe while being outside the limits is unsafe and they represent a single defensive strategy.Whiletheyareadequateforsometypesof operations,theyareaonesizefitsallapproachthat

Gander,P.H.,Hartley,L.,Powell,D.,Cabon,P., Hitchcock,E.,Mills,A.,Popkin,S.(2011).Fatiguerisk managementI:organizationalfactors.AccidentAnalysis andPrevention43:573590.

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IntroductiontoFRMS

13 identifysafetydeficienciesratherthanapportioning blame; the sharing of information and best practices; integrated training for operational personnel; effective implementation of standard operatingprocedures(SOPs);andacommitmentto continuous improvement. So, together, the foundations of prescriptive flight and duty time limitations and SMS form the building blocks of FRMS(seeTable1).
Prescriptiveflight anddutytime limitations SMS Addressestransientand cumulativefatigue Sharedoperatorindividual responsibility Effectivesafetyreporting Seniormanagementcommitment Continuousmonitoringprocess Investigationofsafetyoccurrences Sharingofinformation Integratedtraining EffectiveimplementationofSOPs Continuousimprovement

In essence, FRMS regulations will define a process foroperatorsandregulatorstomanagefatiguerisk, rather than prescribing limits that cannot consider aspects specific to the organization or operating environment.

1.3 ICAOStandardsand RecommendedPracticesforFatigue Management

This section describes the Standards and Recommended Practices (SARPs) relating to the management of fatigue experienced by flight and cabin crew. These SARPs provide a highlevel regulatory framework for both prescriptive flight and duty limitations and FRMS as methods for managing fatigue risk. Both methods share two importantbasicfeatures: 1.They are required to take into consideration the dynamics of transient and cumulative sleep loss and recovery, the circadian biological clock, and the impact of workload on fatigue, along with operationalrequirements. 2.Becausefatigueisaffectedbyallwakingactivities notonlyworkdemands,regulationsforbothare necessarily predicated on the need for shared responsibility between the operator and individualcrewmembersforitsmanagement.So, whether complying with prescriptive flight and dutylimitationsorusingandFRMS,operatorsare responsible for providing schedules that allow crewmembers to perform at adequate levels of alertness and crewmembers are responsible for using that time to start work wellrested. The requirement for shared responsibility in relation toFRMSisdiscussedfurtherinChapter3. FRMS also shares the building blocks of SMS. This means that an FRMS is predicated on: effective safetyreporting;seniormanagement commitment; a process of continuous monitoring; a process for investigation of safety occurrences that aims to

Table1:FRMSbuildingblocks However, an FRMS, as a management system focused on fatigue, also has added requirements beyond that which would be expected of an operatorcomplyingwithprescriptiveflightandduty time limitations and managing their fatigue risks through their SMS. In meeting these additional FRMSspecific requirements, an operator with an approved FRMS may move outside the prescribed limits.Therefore,thefatiguemanagementSARPsin Section 4.10, Annex 6, Part I, include particular Standards that enable the effective regulation of FRMS.Theseare,inturn,supportedbyAppendix8, whichdetailstherequirementsforanFRMS. 1.3.1 Section4.10ofAnnex6,PartI: The SARPs related to fatigue management of flight andcabincrewareasfollows:

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IntroductiontoFRMS
Annex6,PartI 4.10FatigueManagement 4.10.1 The State of the Operator shall establish regulations for the purpose of managing fatigue. These regulationsshallbebaseduponscientificprinciplesandknowledge,withtheaimofensuringthatflightandcabin crew members are performing at an adequate level of alertness. Accordingly, the State of the Operator shall establish: a) regulationsforflighttime,flightdutyperiod,dutyperiodandrestperiodlimitations;and b) where authorizing an operator to use a Fatigue Risk Management System (FRMS) to manage fatigue, FRMSregulations. 4.10.2 TheStateoftheOperatorshallrequirethattheoperator,incompliancewith4.10.1andforthepurposes ofmanagingitsfatiguerelatedsafetyrisks,establisheither: a) flight time, flight duty period, duty period and rest period limitation that are within the prescriptive fatiguemanagementregulationsestablishedbytheStateoftheOperator;or b) aFatigueRiskManagementSystem(FRMS)incompliancewith4.10.6foralloperations;or c) an FRMS in compliance with 4.10.6 for part of its operations and the requirements of 4.10.2 a) for the remainderofitsoperations. 4.10.3 Wheretheoperatoradoptsprescriptivefatiguemanagementregulationsforpartorallofitsoperations, theStateoftheOperatormayapprove,inexceptionalcircumstances,variationstotheseregulationsonthebasis ofariskassessmentprovidedbytheoperator.Approvedvariationsshallprovidealevelofsafetyequivalentto,or betterthan,thatachievedthroughtheprescriptivefatiguemanagementregulations. 4.10.4 TheStateoftheOperatorshallapproveanoperatorsFRMSbeforeitmaytaketheplaceofanyorallof theprescriptivefatiguemanagementregulations.AnapprovedFRMSshallprovidealevelofsafetyequivalentto, orbetterthan,theprescriptivefatiguemanagementregulations. 4.10.5 StatesthatapproveanoperatorsFRMSshallestablishaprocesstoensurethatanFRMSprovidesalevel ofsafetyequivalentto,orbetterthan,theprescriptivefatiguemanagementregulations.Aspartofthisprocess, theStateoftheOperatorshall: a) requirethattheoperatorestablishmaximumvaluesforflighttimesand/orflightdutyperiods(s)andduty period(s),andminimumvaluesforrestperiods.Thesevaluesshallbebaseduponscientificprinciplesand knowledge,subjecttosafetyassuranceprocesses,andacceptabletotheStateoftheOperator; b)mandateadecreaseinmaximumvaluesandanincreaseinminimumvaluesintheeventthattheoperators dataindicatesthesevaluesaretoohighortoolow,respectively;and c) approve any increase in maximum values or decrease in minimum values only after evaluating the operators justification for such changes, based on accumulated FRMS experience and fatiguerelated data. 4.10.6 WhereanoperatorimplementsanFRMStomanagefatiguerelatedsafetyrisks,theoperatorshall,asa minimum: a) incorporatescientificprinciplesandknowledgewithintheFRMS; b) identifyfatiguerelatedsafetyhazardsandtheresultingrisksonanongoingbasis; c) ensurethatremedialactions,necessarytoeffectivelymitigatetherisksassociatedwiththehazards,are implementedpromptly; d) provideforcontinuousmonitoringandregularassessmentofthemitigationoffatiguerisksachievedby suchactions;and e) provideforcontinuousimprovementtotheoverallperformanceoftheFRMS. Uneditedversion

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4.10.7 Recommendation.Statesshouldrequirethat,whereanoperatorhasanFRMS,itisintegratedwiththe operatorsSMS. 4.10.8 An operator shall maintain records for all its flight and cabin crew members of flight time, flight duty periods,dutyperiods,andrestperiodsforaperiodoftimespecifiedbytheStateoftheOperator.

TheintentofeachoftheseSARPsisdiscussedbelow.

STANDARD
4.10.1

INTENT
Standard 4.10.1 stipulates the States responsibilities for establishing regulations for fatigue management. The establishment of regulations for prescriptive limitations remains mandatory, whiletheestablishmentofregulationsforFRMSisoptionalfortheState.Bothtypesofregulations need to address the known scientific principles, including the dynamics of transient and cumulativesleeplossandrecovery,thecircadianbiologicalclock,andtheimpactofworkloadon fatigue, along with knowledge gained from specific research and operational experience and requirements.Further,bothtypesofregulationsneedtoemphasizethatwithinanoperation,the responsibility for managing fatigue risks is shared between management and individual crewmembers(discussedinChapter3). Standard 4.10.2 aims to make clear that, where the State has established regulations for FRMS, operatorsthenhavethreeoptionsformanagingtheirfatiguerisks:a)theycandososolelywithin theirStatesflightanddutytimelimitationsregulations;b)theycanchoosetoimplementanFRMS for all operations; or c) they can implement an FRMS in part of their operations and use prescriptiveflightanddutytimelimitationsinotheroperations.Therefore,thisStandardintends to allow the operator to decide which method of fatigue management is most appropriate for theirspecifictypesofoperations.Giventhischoice,itislikelythatmanyoperatorswillembrace thesafetyandoperationalbenefitsofferedthroughanFRMSapproach Where the State does not have FRMS regulations, operators must manage their fatiguerelated risks within the constraints of their States prescriptive flight and duty time limitations or State approvedvariationstothoselimitations.Manywillchoosetodosothroughtheirexistingsafety management processes. However, an FRMS approach, as described here with its added requirements,canalsobeappliedwithinprescriptiveflightanddutyperiodlimitations. It is recognised that prior to the FRMS Standards, many States had approved variations to the prescribedflightanddutytimelimitationsforoperators.Insomecases,thesevariationsrelateto very minor extensions and Standard 4.10.3 allows an operator to continue to have minor extensions to scheduled operations without having to develop and implement a full FRMS. Approval of the variation is subject to the provision of a risk assessment acceptable to the regulator. The intent of Standard 4.10.3 is to minimize regulation through variations and to avoid the approvalofvariationsthatmeetoperationalimperativesintheabsenceofariskassessment.Itis notintendedtoofferaquickandeasyalternativetoanFRMSwhenamorecomprehensivefatigue riskmanagementapproachisrequired.Norisitintendedtobeusedtoaddressdeficienciesdueto inadequateprescriptiveregulations.Importantly,itonlyappliesinexceptionalcircumstances.
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4.10.2

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IntroductiontoFRMS

STANDARD
4.10.4

INTENT
Standard4.10.4meansthatapprovalisgivenwhentheoperatorcanclearlydemonstratethatall FRMSprocessesarefunctioningeffectively.Itisnotsimplygivenbasedonadocumentedplanto putanFRMSinplaceoradesktopreviewofanFRMSmanual.Standard4.10.4alsomeansthat operators need to support an iterative approach to developing an FRMS (also described in Chapter8). ApprovalfortheoverallFRMScanonlybegivenonceallfourcomponentprocesses(discussedin Chapters3,4,5and6respectively)aredevelopedandtheStatehasconfidencethattheoperator canadjustflightanddutytimesappropriately(i.e.bothoverandunderprescriptivelimitations), can put mitigations in place in accordance with evidence provided through their FRMS, and the effectivenessoftheFRMShasbeenprovenovertimeusingthesafetyassuranceprocesses.During the last phase of development, and prior to gaining approval, the operator will be working to agreeduponlimitsdeterminedthroughthefatigueriskmanagementprocesses.Theselimitsmay beoutsideprescriptiveflightanddutyregulationsfortheparticularoperationsonwhichitsinitial FRMS efforts are focused. This last phase of development is necessary in order to validate the FRMSsafetyassuranceprocessesandisessentiallyadefinedtrialperiodfortheentireFRMS. Onceapprovalhasbeengiven,andintheoperationstowhichtheFRMSapplies,theoperatoris abletouseitsFRMStomoveawayfromflightanddutytimelimitationstoanewlimitthatcanbe supportedbydatawithintheStateapprovedupperboundaryoftheFRMS(see4.10.5). ShouldanoperatorseektomisuseanFRMStobenefitfromdutytimesthatcannotbesupported by scientific principles, collected data and other FRMS processes (i.e. that does not meet the minimumrequirementsofanFRMSasidentifiedinAppendix8ofAnnex6,PartI),theStatewould havetowithdrawitsapprovaloftheFRMS.Theoperatorwouldthenberequiredtocomplywith prescriptivelimitations. 4.10.5 is a change management SARP, aiming to assist the regulator in the successful introductionoftheperformancebasedregulationsthatFRMSrequires. 4.10.5a)requirestheoperatortoidentifyanupperboundarywhichflightanddutytimeswillnot exceed, and a lower boundary under which no rest period will be shortened, even when using mitigations and processes within an FRMS. It aims to offer an extra layer of insurance and sets clearexpectationsamongstallstakeholders. 4.10.5b)providesregulatorswithalessdrasticalternativetowithdrawingapprovalforanFRMS when an adjustment will suffice to ensure that an equivalent level of safety is maintained. It intends to be proactive, in that it addresses less serious situations where an operators data indicatesatrendthatsuggeststhevaluesmaybetoohighortoolow. 4.10.5 c) ensures that operators who have demonstrated the responsible and comprehensive managementoftheirfatiguerelatedrisksthroughamatureFRMSarenotpreventedfromgaining itsfullbenefitsbyunnecessarilyrestrictiveconstraints. 4.10.6provideshighlevelminimumrequirementsforanFRMSandnotesmoredetailedminimum requirementsnotappropriateforthemainbodyoftheAnnex,inAppendix8.Essentially,4.10.6 provides the broad brushstrokes of what an FRMS must have, while Appendix 8 fills in the
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4.10.5

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STANDARD INTENT
componentsinmoreofdetail.ThisStandardispresentedinasimilarformatasSMSStandard3.3.4 (Annex 6, Part I) to reflect the similarities and consistencies in approaches between FRMS and SMS. For the regulator, 4.10.6 means that it will be necessary to provide adequate assessment and oversight of a) to e). Processes and documentation will have to be developed that outline the Statesapprovalandoversightcriteriainlinewiththeregulationsthataredeveloped.Thismanual aimstoprovidedetailedinformationtoassisttheregulatorinachievingthis. 4.10.7 4.10.7recognisestherelationshipbetweenFRMSandSMS.BecauseFRMShasasafetyfunction,it should be complementary to existing safety management processes within an operators SMS. Ideally, where multiple systems are utilised to identify hazards and manage risk they should be integrated to maximise their combined effectiveness, to ensure resources are being distributed appropriatelyacrossthesystemsand,wherepossible,toreduceduplicatedprocessesforgreater systemefficiency.So,anoperatorwishingtoimplementanFRMSandwhoalreadyhassufficiently matureSMSprocessesinplaceshouldbeabletoreadilyadoptandunderstandthefundamental processes of an FRMS. Examples of such maturity would include the routine use of hazard identification, risk assessment and mitigation tools, and the existence of an effective reporting culture(referSMM,227).Wheresuchsystemsarealreadyinplace,itshouldnotbenecessaryfor anoperatortodevelopentirelynewprocessestoimplementFRMS.Rather,FRMScanbuildupon theorganisationsexistingriskmanagementandtrainingprocesses. The importance of coordinating FRMS and existing safety management processes cannot be overemphasised in order to avoid overlooking or prioritising risks inappropriately. For example, fromanSMSviewpoint,asuccessionofgroundproximitywarningsatthesamepoint,onthesame approach,andonthesameflightnumber,maywellbeattributedtoinadequatepilottrainingin altitude management and maintenance of the localizer and glide slope. Without the particular focusandmethodsofmeasurementassociatedwithanFRMS,itmaynotbeasobviousthatthe succession of ground proximity warnings occurred on flights that were part of a particularly fatiguing sequence which resulted in tired pilots not paying enough attention. Both possibilities needtobeconsideredandthereforethetwosystemsdesignedtodothiscannotworkinisolation. However,thedegreeofintegrationbetweenanoperatorsSMSanditsFRMSwilldependonmany factors, including the relative maturity of the two systems, and operational, organisational and regulatory considerations. Further, given that the level of maturity for each operators SMS will vary significantly, the operator is not required to have an SMS accepted by the State before establishinganFRMS.Thus,4.10.7isaRecommendedPracticeratherthanaStandard. WhereanoperatordoesnotwishtoimplementanFRMSorhashaditsFRMSapprovalrevoked, theregulatorshouldrequiretheoperatortousetheirSMStomanagefatiguerelatedriskswithin prescriptivelimitations. Irrespective of which method of fatigue management is used (i.e. compliance with prescriptive flightanddutylimitationsorimplementationofanapprovedFRMS),alloperatorsarerequiredto maintainrecordsofworkingperiods,withorwithoutflightduties,forflightandcabincrew.Itisup toeachregulatortostipulatetheperiodoftimewhichtheserecordsmuchbekept.

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IntroductiontoFRMS ThecoreoperationalactivitiesoftheFRMSarethe FRM processes and the FRMS safety assurance processes. They are supported by organizational arrangements defined in the FRMS policy and documentation, and by the FRMS promotion processes.

1.3.2 Appendix8,Annex6,PartI Appendix 8 gives detailed requirements for an FRMS which must include, at a minimum, the followingcomponents: 1.FRMSpolicyanddocumentation; 2.Fatigueriskmanagementprocesses; 3.FRMSsafetyassuranceprocesses;and 4.FRMSpromotionprocesses. Table1.1showshowthesecomponentsmaptothe requirementsofSMS. SMS FRMS Framework
1.Safetypolicy and objectives 2.Safetyrisk management 1. FRMSpolicyanddocumentation

1.4Structureofthismanual
Figure 1.1 shows a basic framework linking the required components of an FRMS. For ease of explanation, Figure 1.1 presents a single, central, functionalgroup,designatedastheFatigueSafety Action Group, responsible for all of these FRMS components. The Fatigue Safety Action Group includes representatives of all stakeholder groups (management, scheduling, and crewmembers) and other individuals as needed to ensure that it has appropriate access to scientific and medical expertise. However, depending on the organizationalstructure,someoftheFatigueSafety ActionGroupfunctionsasdescribedinthismanual may be undertaken by other groups within the organization (discussed further in Chapter 3). The important thing is that, irrespective of who does them, all of the component functions required underanFRMSbeperformed.

3.Safety assurance

4.Safety promotion

2. FRMprocesses Identificationofhazards Riskassessment Riskmitigation 3. FRMSsafetyassuranceprocesses FRMSperformancemonitoring Managementofoperational andorganizationalchange ContinuousFRMSimprovement 4. FRMSpromotionprocesses Trainingprograms FRMScommunicationplan

Table1.1:ComparingSMSandFRMSComponents

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IntroductiontoFRMS

19

Figure1.1:LinkingtherequiredcomponentsofanFRMS CommunicationbetweentheFRMSandtheSMS(in both directions) is necessary to integrate the management of the fatigue risks into the broader riskmanagementactivitiesoftheSMS.Evenso,the regulator will need to be able to distinguish the FRMS activities from the SMS functions to allow adequatemonitoring. ThedetailedstructureofanFRMS,andthespecific waysinwhichitlinkstoanoperatorsSMS,willvary accordingto: thesizeoftheorganization; the type and complexity of the operations beingmanaged; therelativematurityoftheFRMSandtheSMS; and therelativeimportanceofthefatiguerisks. The FRMS approach is based on applying scientific principles and knowledge to manage crewmember fatigue.Chapter2introducestheessentialscientific concepts that are needed to provide adequate oversightof anFRMS.Chapters3,4,5,and6each deal with one of the required FRMS components. Chapter 7 discusses considerations for the State priortomakingthedecisionwhethertoofferFRMS regulations. Chapter 8 steps though the approval process of an FRMS, while the continued oversight ofanFRMSisdiscussedinChapter9. AppendicesA,BandCprovideextrainformationto support the concepts that are provided in the precedingchapters.Foreaseofreference,Appendix Aprovidesaglossaryoftermsusedinthismanual. Appendix B provides more detailed information on methods of measuring fatigue as part of the FRM processes presented in Chapter 8, Appendix C also supportsChapter3byprovidingfurtherinformation on using controlled rest on the flight deck as a mitigator of fatigue risk. Finally, Appendix D provides an example of an FRMS evaluation form foruseintheregulatoryoversightofanFRMS.

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[Back to Contents]
Chapter2.ScienceforFRMS

[Back to Overview]
21

Chapter2:ScienceforFRMS
2.1 IntroductiontoscienceforFRMS
The FRMS approach represents an opportunity for operatorstouseadvancesinscientific knowledge to improvesafetyandincreaseoperationalflexibility.To provideeffectiveoversight,Statesshouldbeawareof thescientificprinciplesonwhichtheFRMSapproach isbased.Thesearereviewedinthischapter. In Chapter 1, the ICAO definition of crewmember fatiguewasgivenas: A physiological state of reduced mental or physical performance capability resulting from sleep loss or extended wakefulness, circadian phase, or workload (mental and/or physical activity) that can impair a crew members alertness and ability to safely operate an aircraft or perform safety related duties. In flight operations, fatigue can be measured either subjectively by having crewmembers rate how they feel, or objectively by measuring crewmembers performance(Chapter4andAppendixB). Anotherwayofthinkingaboutthisisthatfatigueisa statethatresultsfromanimbalancebetween: the physical and mental exertion of all waking activities(notonlydutydemands);and recovery from that exertion, which (except for recoveryfrommusclefatigue)requiressleep. Following this line of thinking, to reduce crewmember fatigue requires reducing the exertion of waking activities and/or improving sleep. Two areasofsciencearecentraltothisandarethefocus ofthischapter. 1. Sleep science particularly the effects of not getting enough sleep (on one night or across multiplenights),andhowtorecoverfromthem; and 2. Circadianrhythmsthestudyofinnaterhythms driven by the daily cycle of the circadian biological clock (a pacemaker in the brain). Theseinclude: rhythms in subjective feelings of fatigue and sleepiness;and rhythms in the ability to perform mental and physicalwork,whichaffecttheeffortrequired to reach an acceptable level of performance (exertion);and rhythmsinsleeppropensity(theabilitytofall asleepandstayasleep),whichaffectrecovery.

2.2

Essentialsleepscience

There is a widespread belief that sleep time can be traded off to increase the amount of time available forwakingactivitiesinabusylifestyle.Sleepscience makes it very clear that sleep is not a tradable commodity. 2.2.1 Whatishappeninginthebrainduringsleep There are a variety of ways of looking at what is happening in the sleeping brain, from reflecting on dreams to using advanced medical imaging techniques. Currently, the most common research methodisknownaspolysomnography(seeAppendix B for details). This involves sticking removable electrodestothescalpandfaceandconnectingthem to a recording device, to measure three different types of electrical activity: 1) brainwaves (electroencephalogram or EEG); 2) eye movements (electroculogram or EOG); and 3) muscle tone (electromyogram or EMG). Using polysomnography, it is possible to identify two very different kinds of sleep. Nonrapideyemovementsleep Compared to waking brain activity, nonRapid Eye Movement sleep (nonREM sleep) involves gradual slowingofthebrainwaves.Theamplitude(height)of the brainwaves also becomes larger as the electrical

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22 ScienceforFRMS Slowwave sleep has a number of important activity of large numbers of brain cells (neurons) properties. Pressure for slowwave sleep builds up becomes synchronized so that they fire in unison. across waking and discharges across sleep. In other Heartrateandbreathingtendtobeslowandregular. words: People woken from nonREM sleep do not usually thelongeryouareawake,themoreslowwavesleep recall much mental activity. However, it is still youwillhaveinyournextsleepperiod;and possible for the body to move in response to acrossasleepperiod,theproportionoftimespentin instructions from the brain. Because of these slowwavesleepdecreases. features,nonREMsleepissometimesdescribedasa relativelyinactivebraininamovablebody. Thisrisingandfallingofpressureforslowwavesleep NonREMsleepisusuallydividedinto4stages,based is sometimes called the sleep homeostatic process, onthecharacteristicsofthebrainwaves. and it is a component in most of the bio mathematical models that are used to predict Stages 1 and 2 represent lighter sleep (it is not very crewmemberfatiguelevels(seeChapter4). difficult to wake someone up). It is usual to enter sleepthroughStage1andthenStage2nonREM. Eveninslowwavesleep,thebrainisstillabout80% Stages3and4representdeepersleep(itcanbevery activated and capable of active cognitive processing. hard to wake someone up). Stages 3 and 4 are There is growing evidence that slowwave sleep is characterized by high amplitude slow brainwaves, essential for the consolidation of some types of andaretogetheroftendescribedasslowwavesleep memory, and is therefore necessary for learning. (ordeepsleep). OPERATIONALNOTE: Mitigationstrategiesforsleepinertia Operationally, slowwave sleep may be important because the brain can have difficulty transitioning out of it whensomeoneiswokenupsuddenly.Thisisknownassleepinertiafeelingsofgrogginessanddisorientation, withimpairedshorttermmemoryanddecisionmaking.Sleepinertiacanoccurcomingoutoflightersleep,but ittendstobelongerandmoredisorientingwhensomeoneiswokenabruptlyoutofslowwavesleep. Thisissometimesusedasanargumentagainsttheuseofflightdecknappingorinflightsleep.Itwouldnotbe desirable to have a crewmember who is woken up because of an emergency, but who is impaired by sleep inertia.Thisargumentisbasedontheeffectsofsleepinertiaseeninlaboratorystudies. However,studiesofnappingon theflight deckandofsleepinonboardcrew restfacilities showthatsleepin flight contains very little slowwave sleep. (It is lighter and more fragmented than sleep on the ground). This meansthatsleepinertiaismuchlesslikelytooccurwakingupfromsleepinflightthanwouldbepredictedfrom laboratorysleepstudies.Theriskofsleepinertiacanalsobereducedbyhavingaprotocolforreturningtoactive dutythatallowstimeforsleepinertiatowearoff. Overall,thedemonstratedbenefitsofcontrollednappingandinflightsleepgreatlyoutweighthepotentialrisks associatedwithsleepinertia.Toreducetheriskofsleepinertiaafterflightdecknapping,therecommendationis to limit the time available for the nap to 40 minutes. Given the time taken to fall asleep, a 40minute opportunity is too short for most people to enter slowwave sleep. Refer to Appendix C for suggested Flight OperationsManualproceduresforcontrollednapping.
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ScienceforFRMS Rapideyemovementsleep DuringRapidEyeMovementsleep(REMsleep),brain activity measured by polysomnography looks similar to brain activity during waking. However in REM sleep,fromtimetotimetheeyesmovearoundunder the closed eyelids the socalled rapid eye movements and this is often accompanied by muscle twitches and irregular heart rate and breathing. People woken from REM sleep can typically recall vivid dreaming. At the same time, the body cannot moveinresponsetosignalsfromthebrainsodreams cannot be acted out. (The signals effectively get blockedinthebrainstemandcannotgetthroughto the spinal cord.) People sometimes experience brief paralysis when they wake up out of a dream, when reversal of this REM block is slightly delayed. Because of these features, REM sleep is sometimes described as a highly activated brain in a paralysed body. Dreamshavealwaysbeenasourceoffascination,but are difficult to study using quantitative scientific methods. They have been interpreted as everything from spiritual visitations to fulfillment of instinctual drives, to being a meaningless byproduct of activity in various parts of the brain during REM sleep. The currentneurocognitiveviewofdreamingarguesthat itresultsfrombriefmomentsofconsciousnesswhen we become aware of all the processing that our brains normally do offline, i.e. when they are not busy dealing with information coming in from the environment through the senses, and are not being directed by our conscious control. This offline processing includes reactivating memories and emotionsfrompreviousexperiences,andintegrating them with experiences from the latest period of waking. Dreams in this view are a glimpse into your brainreshapingitselfsothatyoucanwakeupinthe morningstillyourself,butaslightlyrevisedversionas a result of your experiences yesterday, and ready to startinteractingwiththeworldagain. People vary greatly in their ability to recall dreams, and we generally only recall them when we wake spontaneously out of REM sleep (and then only

23 fleetingly unless we write them down or talk about them). Nevertheless, most adults normally spend aboutaquarteroftheirsleeptimeinREMsleep. NonREM/REMCycles Across a normal night of sleep, nonREM sleep and REM sleep alternate in a cycle that lasts roughly 90 minutes(butisveryvariableinlength,dependingon a number of factors). Figure 2.1 is a diagram describing the nonREM/REM cycle across the night in a healthy young adult. Real sleep is not as tidy as thisitincludesmorearousals(transitionstolighter sleep) and brief awakenings. Sleep stages are indicatedontheverticalaxisandtimeisrepresented acrosshorizontalaxis1.

Figure2.1:DiagramofthenonREM/REMcycleacross thenightinayoungadult Sleep is entered through Stage 1 nonREM and then progresses deeper and deeper into nonREM. About 8090minutesintosleep,thereisashiftoutofslow wave sleep (nonREM stages 3 and 4). This is often marked by body movements, as the sleeper transitionsbrieflythroughStage2nonREMandinto the first REM period of the night. (REM periods are indicatedasshadedboxesinFigure2.1).Afterafairly short period of REM, the sleeper progresses back

GanderPH(2003)Sleepinthe24HourSociety. Wellington,NewZealand:OpenMindPublishing.ISBN0 909009597

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24 ScienceforFRMS down again through lighter nonREM sleep and into discharge the homeostatic sleep pressure first. In slowwavesleep,andsothecyclerepeats. contrast, the time from sleep onset to the first bout The amount of slowwave sleep in each non of REM (the REM latency) and the duration of each REM/REMcycledecreasesacrossthenight,andthere REMboutvariesmarkedlyacrossthecircadianbody clock cycle. The circadian drive for REM sleep is maybenoneatallinthelatercycles.Incontrast,the strongest a few hours before normal wakeup time. amount of REM sleep in each nonREM/REM cycle Thesetwoprocessesthehomeostaticsleepprocess increases across the night. The sleeper depicted in and the circadian body clock are the main Figure 2.1 wakes up directly out of the final REM componentsinmostofthebiomathematicalmodels period of the night, and so would probably recall that are used to predict crewmember fatigue levels dreaming. (seeChapter4). Interestingly, slowwave sleep always predominates atthebeginningofasleepperiod,regardlessofwhen sleepoccursintheday/nightcycleorinthecircadian body clock cycle. There seems to be a priority to OperationalNote: MitigationStrategiesforSleepLoss Restoration of a normal nonREM/REM cycle is one measure of recovery from the effects of sleep loss. Lost sleepisnotrecoveredhourforhour,althoughrecoverysleepmaybeslightlylongerthanusual. On the first recovery night, there is more slowwave sleep than usual. Indeed, there can be so much slow wavesleepthatthereisnotenoughtimetomakeupREMsleep. Onthesecondrecoverynight,thereisoftenmoreREMsleepthanusual. Bythethirdrecoverynight,thenonREM/REMcycleisusuallybacktonormal. Operationally,thismeansthatschedulesneedtoperiodicallyincludeanopportunityforatleasttwoconsecutive nightsofunrestrictedsleep,toenablecrewmemberstorecoverfromtheeffectsofsleeploss. This does not equate to 48 hours off. For example, 48 hours off duty starting at 02:00 would only give most peopletheopportunityforonefullnightofunrestrictedsleep.Ontheotherhand,40hoursoffstartingat21:00 wouldgivemostpeopletheopportunityfortwofullnightsofunrestrictedsleep. Additionalnightsmaybeneededforrecoveryifacrewmemberscircadianbodyclockisnotalreadyadaptedto thelocaltimezone(seeSection2.3).

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ScienceforFRMS 25 thenonREM/REMcycleisfragmentedbywakingup, 2.2.2 Theissueofsleepquality orbyarousalsthatmovethebraintoalighterstage of sleep without actually waking up, the less Sleepquality(itsrestorativevalue)dependsongoing restorative value sleep has in terms of how you feel through unbroken nonREM/REM cycles (which suggests that both types of sleep are necessary and andfunctionthenextday. oneisnotmoreimportantthantheother).Themore OperationalNote: MitigationStrategiestoMinimizeSleepInterruptions Because uninterrupted nonREM/REM cycles are the key to good quality sleep, operators should develop proceduresthatminimizeinterruptionstocrewmemberssleep. Rest periods should include defined blocks of time (sleep opportunities) during which crewmembers are not contactedexceptinemergencies.Theseprotectedsleepopportunitiesneedtobeknowntoflightcrewsandall otherrelevantpersonnel.Forexample,callsfromcrewschedulingshouldnotoccurduringarestperiodasthey canbeextremelydisruptive. Operatorsshouldalsodevelopprocedurestoprotectcrewmembersleepatlayoverandnappingfacilities.For example,ifarestperiodoccursduringthedayatalayoverhotel,theoperatorcouldmakearrangementswith the hotel to restrict access to the section of the hotel where crewmembers are trying to sleep (such as no children, crewmembers only) and instruct their staff to honor the necessary quiet periods (for example, no maintenanceworkorroutinecleaning).

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26 Qualityofinflightsleep Asmentionedabove,polysomnographystudiesshow that crewmembers sleep in onboard crew rest facilities is lighter and more fragmented than sleep on the ground2. Sleep during flight deck naps is also lighter and more fragmented than would be predicted from laboratory studies3. Nevertheless, there is good evidence that inflight sleep improves subsequent alertness and reaction speed and is a valuablemitigationstrategyinanFRMS. Studies of sleep in hypobaric chambers at pressures equivalent to cabin pressure at cruising altitude indicatethatthefragmentedqualityofinflightsleep is not due to altitude4. Several studies have asked crewmembers what disturbs their sleep on board. The factors most commonly identified are random noise, thoughts, not feeling tired, turbulence, ambient aircraft noise, inadequate bedding, low humidity,andgoingtothetoilet. Sleepqualityandaging Acrossadulthood,theproportionofsleeptimespent inslowwavesleepdeclines,particularlyamongmen. In addition, sleep becomes more fragmented. For example,onestudywith2,685participantsaged37 92 yrs found that the average number of arousals (transitions to lighter sleep and awakenings) rose from 16 per hour of sleep for 3054 yearolds to 20 perhourofsleepfor6170yearolds5.
2

ScienceforFRMS These agerelated trends are seen in the sleep of flight crewmembers, both on the ground and in the air2,6.AstudyofinflightsleepondeliveryflightsofB 777 aircraft (from Seattle to Singapore or Kuala Lumpur) found that age was the factor that most consistently predicted the quality and duration of bunk sleep. Older pilots took longer to fall asleep, obtainedlesssleepoverall,andhadmorefragmented sleep. Itisnotyetclearwhethertheseagerelatedchanges insleepreduceitseffectivenessforrestoringwaking function. Laboratory studies that experimentally fragment sleep are typically conducted with young adults.Ontheflightdeck,experience(bothin terms offlyingskillsandknowinghowtomanagesleepon trips) could help reduce potential fatigue risk associatedwithagerelatedchangesinsleep. Sleepdisorders The quality of sleep can also be disrupted by a wide variety of sleep disorders, which make it impossible toobtainrestorativesleep,evenwhenpeoplespend enough time trying to sleep. Sleep disorders pose a particular risk for flight crewmembers because, in addition,theyoftenhaverestrictedtimeavailablefor sleep.ItisrecommendedthatFRMStraining(Chapter 6) should include basic information on sleep disorders and their treatment, where to seek help if needed, and any requirements relating to fitness to fly. 2.2.3 Consequencesofnotgettingenoughsleep Even for people who have good quality sleep, the amount of sleep they obtain is very important for restoring their waking function. An increasing number of laboratory studies are looking at the effectsoftrimmingsleepatnightbyanhourortwo (known as sleep restriction). There are several key findings from these studies that are important for FRMS.
6

Signal,T.L.,Gale,J.,andGander,P.H.(2005)Sleep
MeasurementinFlightCrew:ComparingActigraphicand SubjectiveEstimatesofSleepwithPolysomnography.Aviation SpaceandEnvironmentalMedicine76(11):10581063

Rosekind,M.R.,Graeber,R.C.,Dinges,D.F.,etal.,(1994) CrewFactorsinFlightOperationsIX:Effectsofplanned cockpitrestoncrewperformanceandalertnessinlong hauloperations.NASATechnicalMemorandum108839, MoffettField:NASAAmesResearchCenter.

4

Mumm,J.M.,Signal,T.L.,Rock,P.B.,Jones,S.P.,OKeeffe,K.M., Weaver,M.R.,Zhu,S.,Gander,P.H.,Belenky,G.(2009)Sleepat simulated2438m:effectsonoxygenation,sleepquality,and postsleepperformance.Aviation,Space,andEnvironmental Medicine80(8):691697. 5 Redline,S.,Kirchner,H.L.,Quan,S.F.,Gottlieb,D.J.,Kapur,V., Newman,A.(2004).Theeffectsofage,sex,ethnicity,andsleep disorderedbreathingonsleeparchitecture.ArchivesofInternal Medicine164:406418.

Signal,T.L.,Gander,P.H.,vandenBerg,M.(2004)Sleepinflight duringlongrestopportunities.InternalMedicineJournal34(3): A38.

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ScienceforFRMS The effects of restricting sleep night after night accumulate,sothatpeoplebecomeprogressivelyless alert and less functional day after day. This is sometimes described as accumulating a sleep debt. This is a common occurrence for crewmembers (see below),forexamplewhenminimumrestperiodsare scheduledforseveraldaysinarow. Theshorterthetimeallowedforsleepeachnight,the faster alertness and performance decline. For example,onelaboratorystudyfoundthatspending7 hoursinbedfor7consecutivenightswasnotenough to prevent a progressive slowing down in reaction time7. The decline was more rapid for a group of participants who spent only 5 hours in bed each night, and even more rapid for a group who spent only3hoursinbedeachnight.Thisisdescribedasa dosedependenteffectofsleeprestriction. Thepressureforsleepincreasesprogressivelyacross successive days of sleep restriction. Eventually, it becomes overwhelming and people begin falling asleep uncontrollably for brief periods, known as microsleeps. During a microsleep, the brain disengagesfromtheenvironment(itstopsprocessing visualinformationandsounds).Inthelaboratory,this canresultinmissingastimulusinaperformancetest. Drivingamotorvehicle,itcanresultinfailingtotake a corner. Similar events have been recorded on the flightdeckduringdescentintomajorairports5. Full recovery of waking function after sleep restriction can take longer than two nights of recovery sleep (i.e., longer than it takes the non REM/REM cycle to recover). Indeed, chronic sleep restriction may have effects on the brain that can affect alertness and performance days to weeks later8.

27

several days they no longer notice any difference in themselves, even although their alertness and performancecontinuestodecline.Inotherwords,as sleep restriction continues, people become increasingly unreliable at assessing their own functionalstatus.Thisfindingraisesaquestionabout the reliability of subjective ratings of fatigue and sleepiness as measures of a crewmembers level of fatiguerelatedimpairment(seeAppendixB). At least in the laboratory, some people are more resilient to the effects of sleep restriction than others. Currently, there is a lot of research effort aimedattryingtounderstandwhythisis,butitisstill too early for this to be applied in an FRMS (for example, by recommending different personal mitigationstrategiesforpeoplewhoaremoreorless affectedbysleeprestriction). In general, more complex mental tasks such as decision making and communication seem to be more severely affected by sleep loss than simpler tasks. Brain imaging studies also suggest that the brainregionsinvolvedinmorecomplexmentaltasks arethemostaffectedbysleepdeprivationandhave the greatest need for sleep to recover their normal function. Laboratorysleeprestrictionstudiesarecurrentlythe main source of information on the effects of sleep restriction. However, they have some obvious limitations. The consequences of reduced alertness andpoortaskperformancearequitedifferentinthe laboratory than for crewmembers on duty. Laboratory studies usually look at the effects of restricting sleep at night and participants sleep in a dark, quiet bedroom. This may mean that current understanding is based on a best case scenario. Moreresearchisneededontheeffectsofrestricting For the first few days of severe sleep restriction (for sleep during the day, and on the combination of example,3hoursinbed),peopleareawarethatthey restricted sleep and poor quality sleep. Laboratory are getting progressively sleepier. However, after studiesalsofocusontheperformanceofindividuals, notpeopleworkingtogetherasacrew. 7 Belenky,G.,Wesensten,N.J.,Thorne,D.R.,etal.(2003).Patternsof performancedegradationandrestorationduringsleeprestrictionand One simulation study with 67 experienced B747400 subsequentrecovery:asleepdoseresponsestudy.JournalofSleep crewshasdemonstratedthatsleeplossincreasedthe
8

Research12:112. Rupp,T.L.,Wesensten,N.J,Bliese,P.D.etal.(2009).Banking sleep:realizationofbenefitsduringsubsequentsleeprestriction andrecovery.Sleep32(3):311321

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28 totalnumberoferrorsmadebythecrew9.Thestudy designwassetupsothatthepilotin commandwas always the pilot flying. Paradoxically, greater sleep loss among first officers improved the rate of error detection. On the other hand, greater sleep loss amongpilotsincommandledtoahigherlikelihoodof failure to resolve errors that had been detected. Greater sleep loss was also associated with changes in decision making, including a tendency to choose lower risk options, which would help mitigate the potential fatigue risk. Simulator studies like this are expensive and logistically complex to conduct properly, but they provide vital insights on the links between crewmember sleep and operational fatigue risk. Sleeprestrictioninflightoperations The idea of sleep restriction implies that there is an optimumamountofsleepthatpeopleneedtoobtain eachnight.Theconceptofindividualsleepneedisan area of active debate in sleep research. One way to measuresleeprestrictionthatavoidsthisproblemis to look at how much sleep crewmembers obtain when they are at home between trips, compared to howmuchsleeptheyobtainduringtrips. Table2.1summarizesdataonsleeprestrictionacross different flight operations that were monitored by the NASA Fatigue Program in the 1980s. 10 In these studies, crewmembers completed sleep and duty diaries before, during, and after a scheduled commercial trip. For each crewmember, his average sleep duration per 24 hours at home before the trip wascomparedwithhisaveragesleepdurationper24 hours on the study trip. During night cargo and long haul trips, crewmembers often had split sleep (slept morethanoncein24hours). Scheduling has undoubtedly changed since these studies, so the data in Table 2.1 are likely to be 9 Thomas, M.J.W., Petrilli, R.M., Lamond, N.A., et al. (2006).
Australian Long Haul Fatigue Study. In: Enhancing Safety Worldwide: Proceedings of the 59th Annual International Air SafetySeminar.Alexandria,USA,FlightSafetyFoundation. 10 Gander, P.H., Rosekind, M.R., and Gregory, K.B. (1998) Flight crew fatigue VI: an integrated overview. Aviation, Space, and EnvironmentalMedicine69:B49B60

ScienceforFRMS unrepresentative of the current situation in many cases.However,theyindicatethatsleeprestrictionis very common across different types of flight operations. Short Night Long Haul Cargo Haul

crewmembers averagingatleast1 hourofsleep restrictionpertrip day

67%

54%

43%

crewmembers averagingatleast2 hoursofsleep restrictionpertrip day

30%

29%

21%

lengthoftrip

34 days

8 days

49 days

timezonescrossed perday

01

01

08

numberof crewmembers studied

44

34

28

Note: the night cargo trips included a 12 night break in the sequence of night shifts. Splitting long haul trips into 24 hours daysisratherarbitrarybecausetheaveragedutydaylasted10.2 hoursandtheaveragelayoverlasted24.3hours.

Table2.1:Sleeprestrictionduring commercialflightoperations Agrowingamountofevidence,frombothlaboratory studies and from epidemiological studies that track the sleep and health of large numbers of people across time, indicates that chronic short sleep may havenegativeeffectsonhealthinthelongterm.This research suggests that short sleepers are at greater risk of becoming obese and developing type2 diabetes and cardiovascular disease. There is still debate about whether habitual short sleep actually contributes to these health problems, or is just associated with them. In addition, flight crewmembers as a group are exceptionally healthy comparedtothegeneralpopulation.Whatisclearis thatgoodhealthdependsnotonlyongooddietand

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ScienceforFRMS 29 regularexercise,butalsoongettingenoughsleepon a regular basis. Sleep is definitely not a tradable commodity. OperationalNote: MitigationStrategiesforManagingSleepDebt Sleeprestrictioniscommonacrossdifferenttypesofflightoperations.Becausetheeffectsofsleeprestriction are cumulative, schedules must be designed to allow periodic opportunities for recovery. Recovery opportunitiesneedtooccurmorefrequentlywhendailysleeprestrictionisgreater,becauseofthemorerapid accumulationoffatigue. The usual recommendation for a recovery opportunity is for a minimum of two consecutive nights of unrestrictedsleep.Somerecentlaboratorystudiesofsleeprestrictionsuggestthatthismaynotbeenoughto bring crewmembers back up to their optimal level of functioning. There is evidence that the sleeprestricted braincanstabilizeatalowerleveloffunctioningforlongperiodsoftime(daystoweeks). Especiallyinirregularoperations,proceduresthatallowacrewmembertocontinuesleepinguntilneededcan reducetherateofaccumulationofsleepdebt.Forexample,ifanaircraftwithananticipatedrepairtimeof0730 will not actually be ready until 11:30, then a reliable procedure that allows the crew member to continue sleepingwouldbebeneficial.Oneairlinehasasystemwheretheoperatorcontactsthelayoverhoteltoupdate thereporttimebyslippingamessageunderthecrewmembersdoor.Thehotelprovidesawakeupcallonehour beforepickuptime. isslightlylongerthan24hours.Thesensitivityofthe 2.3 Introductiontocircadianrhythms circadianbodyclocktolightenablesittostayinstep with the day/night cycle. However, that same Sleeping at night is not just a social convention. It is sensitivity to light also creates problems for programmed into the brain by the circadian body crewmemberswhohavetosleepoutofstepwiththe clock, which is an ancient adaptation to life on our day/nightcycle(forexampleondomesticnightcargo 24hour rotating planet. Even very ancient types of operations),orwhohavetoflyacrosstimezonesand living organisms have something equivalent, which experiencesuddenshiftsintheday/nightcycle. means that circadian biological clocks have been aroundforseveralbillionyears. 2.3.1 Examplesofcircadianrhythm A feature of circadian clocks is that they are light It is not possible to directly measure the electrical sensitive. The human circadian clock monitors light activityofthecircadianbodyclockinhumanbeings. intensity through a special network of cells in the However, almost every aspect of human functioning retina of the eye (this special light input pathway to (physical or mental) undergoes daily cycles that are thecircadianclockisnotinvolvedinvision).Theclock influenced by the circadian body clock. Measuring itselfresidesinafairlysmallclusterofcells(neurons) overt rhythms in physiology and behaviour is like deeper in the brain (in the suprachiasmatic nuclei watchingthehandsofan(analogue)wristwatch.The (SCN) of the hypothalamus). The cells that make up handsmovearoundthewatchfacebecausetheyare the clock are intrinsically rhythmic, generating driven by the timekeeping mechanism inside the electricalsignalsfasterduringthedaythanduringthe watch, but they are not part of the timekeeping night.However,theyhaveatendencytoproducean mechanism itself. Similarly, most circadian rhythms overallcyclethatisabitslowformostpeoplethe thatcanbemeasured,suchasrhythmsincorebody biologicaldaygeneratedbythecircadianbodyclock
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210 temperature or selfrated fatigue, are driven by the circadian body clock, but they are not part of the biologicaltimekeepingmechanism. Figure2.2showsanexampleofcircadianrhythmsin corebodytemperatureandselfratedfatigueofa46 year old short haul crewmember monitored before, during,andaftera3daypatternofflyingontheeast coast of the USA (staying in the same time zone)11. The crewmember had his core temperature monitored continuously and kept a sleep and duty diary,inwhichhenotedhissleeptimesandratedthe qualityofhissleep,aswellasratinghisfatigueevery 2hourswhilehewasawake(onascalefrom0=most alertto100=mostdrowsy). Core body temperature typically fluctuates by about 1 C across the 24hour day. Note that the crewmember's core temperature starts to rise each morning before he wakes up. In effect, his body is beginning to prepare ahead of time for the greater energy demands of being more physically active. (If bodytemperatureonlybegantoriseafterhestarted tobemorephysicallyactive,itwouldbealotharder togetupinthemorning). Lookingathisselfratedfatigue,thiscrewmemberdid not feel at his best first thing in the morning. He tendedtofeelleastfatiguedabout24hoursafterhe woke up, after which his fatigue climbed steadily across the day. The dashed line across the sleep period indicates that he was not asked to wake up every2hourstoratehisfatigueacrossthistime. Core body temperature is often use as a marker rhythmtotrackthecycleofthecircadianbodyclock because it is relatively stable and easy to monitor. However,nomeasurable rhythmisaperfect marker of the circadian body clock cycle. For example, changes in the level of physical activity also cause changes in core temperature, which explains the smallpeaksanddipsintemperatureinFigure2.2.
11

ScienceforFRMS The daily minimum in core body temperature corresponds to the time in the circadian body clock cyclewhenpeoplegenerallyfeelmostsleepyandare leastabletoperformmentalandphysicaltasks.This is sometimes described as the Window of Circadian Low(WOCL).

Figure2.2:Circadianrhythmsofashorthaulpilot 2.3.2 Thecircadianbodyclockandsleep AsmentionedinSection2.2,thecircadianbodyclock influences sleep in a number of ways. (It has connections to centers in the brain that promote wakefulness and to opposing centers that promote sleep, as well as to the system that controls REM sleep.) Figure 2.3 is a diagram that summarizes the effectsofthecircadianclockonsleep.Itisbasedon data collected from 18 night cargo pilots on their daysoff,i.e.,whentheyweresleepingatnight12.Like the crewmember in Figure 2.2, they also had their core temperature monitored continuously, and kept sleepanddutydiaries. 12 Gander,P.H.,Rosekind,M.R.,andGregory,K.B. (1998)FlightcrewfatigueVI:anintegratedoverview. Aviation,Space,andEnvironmentalMedicine69:B49 B60

Gander,P.H.,Graeber,R.C.,Foushee,H.C.,Lauber,J.K., Connell,L.J.(1994).CrewFactorsinFlightOperationsII: PsychophysiologicalResponsestoShortHaulAirTransport Operations.NASATechnicalMemorandum#108856.Moffett Field:NASAAmesResearchCenter.

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ScienceforFR S RMS The core tem T mperature rh hythm is sum mmarized as a simple (conti s inuous) curv The daily time of th ve. y he minimumint m temperature (shownbyth heblackdot) is the t average f all crewm for members and is used as a d reference po r oint for desc cribing the o other rhythm ms. Note that cha N anges in temperature are not the caus se of o the other rhythms. Th core body temperature he y rhythm is being read like the hands o an analogu r e of ue wrist watch, as a way of following t w the underlyin ng cycleofthecircadianbody c yclock.

211 mperature. T This has bec come known as the n tem eve eningwakem maintenancez zone. show that as body Laboratory studies also s mperature beg gins to rise, there is an increasing tem pressure to wake up. This peaks about 6 hours t afte the circadi temperat er ian ture minimum This is m. som metimes refer rred to as an internal ala n arm clock, bec causeitisver ryhardtofallasleeporst tayasleep duringthisparto ofthecircadianbodyclock kcycle. The in nteraction be etween the homeostatic pressure for sle eep and the circadian v e variation in s sleepiness driven nbythebody yclockresultsintwotime esofpeak sleepinessin24ho ours: ape eakintheea arlyhoursof themorning theso calle Window of Circadian Low (WOC which ed n CL), occursaround3 5amformostpeople;and a peak in the early afternoo sometim called on mes the afternoon n nap window (around 35 pm for w 5 mos people). Restricted sleep at n st night, or dist turbed sleep makes it h harder to sta awake ay duringthenexta afternoonnapwindow. The precise timing of the two peaks in slee g epiness is differe in people who are m ent e morning type (whose es circadian rhythms and prefer s rred sleep t times are earlier than average) and ev r vening types (whose s circadianrhythms andpreferred dsleeptimes sarelater thana average).Acro osstheteena ageyears,mo ostpeople becom more eveningtype. Ac me cross adultho ood, most people ebecomemo oremorning type.Thispr rogressive change towards b becoming mo morning ore type has wmembers a across the been documented in flight crew agera ange2060ye ears. The co ombined effe ects of the h homoeostatic pressure c for sle and the circadian bi eep iological cloc can be ck thought of as de efining wind dows when sleep is promo oted(theear rlymorningandafternoon ntimesof peak sleepiness) and windo ows when sleep is oppos (the time of the inter sed e rnal alarm clo in the ock late m morning, and the evenin wake mai d ng intenance zone). .

oftheinfluen ncesofthe Figure2.3:Summaryo circad dianbodyclockonsleepatnight Figure2.3sum F mmarizesthe efollowingfeaturesofslee ep atnight(whencrewmemb a bersarefullyadaptedtoth he lo ocaltimezon ne). Sleep norm mally begins about 5 hou before th urs he minimumin ncorebodytemperature. Wakeup no ormally occurs about 3 h hours after th he minimumin ncorebodytemperature. REMsleep isenteredfa astest,andRE EMperiodsare d r longest and most intense, just after the minimum in core body temperature. This is sometime es described a the peak of the circad as o dian rhythm in REMprope ensity(thedashedcurvein nFigure2.3). A variety of labo y oratory pro otocols hav ve demonstrat tedpeopleareextremely unlikelytofa all asleep68 hoursbefore etheminimum mincorebod dy

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212 OperationalNote: TheCircadianBodyClock,Sleep,andFRMS

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Thedailyminimumincorebodytemperaturecorrespondstothetimeinthecircadianbodyclockcyclewhen peoplefeelmostsleepyandareleastabletoperformmentalandphysicaltasks.Thisissometimescalledthe Window of Circadian Low (WOCL) and it is a time of high risk for fatiguerelated error. In FRMS incident investigations, it is important to estimate the time that errors occur relative to the expected time of the WOCL. TheWOCLcanoccurinflightduringdomesticnightoperationsandduringlonghaulandULRoperationswhen theduty/restcycleisoutofstepwithcrewmemberscircadianbodyclockcycles. Theeveningwakemaintenancezoneoccursinthefewhoursbeforeusualbedtime.Thismakesitverydifficult tofallasleepearlythenightbeforeanearlydutyreporttime.Thishasbeenidentifiedacauseofrestricted sleepandincreasedfatigueriskinshorthauloperationsthatrequireearlystarts. Theincreasingdriveforwakethataccompaniestheincreaseincorebodytemperatureinthemorningmakes itdifficulttofallasleeporstayasleeplaterinthemorningandintheearlyafternoon.Thishasbeenidentified as a cause of restricted sleep and increased fatigue risk in night cargo operations, which require crewmemberstodelaytheirmainsleepperioduntilthemorning. Theinternal alarmclockandtheeveningwakemaintenance zonecanalsointerferewith theinflightsleep and layover sleep of long haul and ULR crewmembers when the duty/rest cycle is out of step with crewmemberscircadianbodyclockcycles. 2.3.3 Sensitivity of the circadian body clock to lightexposureinthemiddleofthedayhasvery light littleeffect;and light exposure in the evening (before the At the beginning of this chapter, there was a brief temperature minimum) causes the circadian descriptionofhowthecircadianbodyclockisableto clock to slow down temporarily, resulting in a tracklightintensityintheenvironment.Thisenables phasedelay(equivalenttocrossingtimezonesin it to stay in step with the day/night cycle, even awestwarddirection). although it has a tendency to generate a biological daythatisslightlylongerthan24hours. Brightlightcausesbiggershiftsinthecircadianbody clockcyclethandimlight,andtheclockisparticularly The effect of light on the circadian body clock sensitivetobluelight. changesaccordingtowhenintheclockcyclethelight exposureoccurs.Foracrewmemberadaptedtolocal In theory, this means that just the right amount of timeandsleepingatnight: lightexposureatthesametimeeverymorningwould speed up a 24.5hour circadian clock cycle just light exposure in the morning (after the enough to synchronize it to exactly 24 hours. In temperature minimum) causes the circadian practise, staying in step with the day/night cycle is clock to speed up temporarily, resulting in a more complex than this. In modern industrialised phase advance (equivalent to crossing time societies, people have very haphazard exposures to zonesinaneastwarddirection); light,particularlybrightoutdoorlight.Inaddition,the
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ScienceforFR S RMS circadian bod clock is se c dy ensitive to ot ther time cues from the env f vironment, no otably social cues, and ca an alsobemove a edbackwards sorforwardsinitscycle b by boutsofphysicalactivity. b The T ability of the circadia clock to lock on to th f an he 24hour day/ 2 /night cycle is a key f feature of i its usefulness fo most spec u or cies, enabling them to b g be diurnal or no d octurnal as needed to enhance the eir survival. How s wever, it has become a disadvantage in the 24/7 so t ociety because it causes the huma an circadian bod clock to resist adaptation to an c dy ny patternotherthansleepat p tnight. 2.3.4 Shiftw 2 work Fromthepers F spectiveofhu umanphysiology,shiftwork can c be define as any du pattern t ed uty that requires a crewmember to be awak during the time in th c ke he circadian bod clock cycle that they w c dy e would normally beasleep. b Thefurthersl T leepisdisplac cedfromthe eoptimumpa art ofthecircadia o anbodyclock kcycle,them moredifficultit becomes for crewmembe to get adequate slee b ers ep (i.e., the more likely they are to exp perience slee ep restriction). For examp r ple, crewme embers flyin ng domesticnigh d htcargooper rationsarety ypicallyonduty through most of the optimum time fo sleep in th t t or he circadianbodyclockcycle.Thishappen c nsbecauseth he circadian bod clock is lo c dy ocked on to the day/night cycle, and do not flip its orientatio to promote c oes on sleepduringt s thedaywhen ncrewmembe ersareflyingat night. n Figure 2.4 s F summarises what happ pened to th he circadian biol c logical clock and sleep w when the night cargocrewme c embersinFig gure2.3were eflyingatnight and a trying to sleep in the morning. (Recall that the ey had h their cor temperatu monitored continuous re ure d sly across 8 day a trip patterns and kept s s, sleep and duty dairies.) d The core tem T mperature rh hythm is sum mmarized as a simple(contin s nuous)curve. .LookingbackatFigure2. .3, whenthesecr w rewmembers swereoffdut tyandsleepin ng at a night, the average time of the temperature e t e minimum was 05:20. In Figure 2.4, wh they were m F hen

213 workin through t night, the average tim of the ng the e me tempe erature minim mumshifted to08:08(ad delayof2 hours 48 minutes) This confir ). rms that the circadian body clock did not adapt fully to night duty (which y would dhaverequire edashiftofa about12hour rs).

Figure2.4 4:Thecircadia anbodyclock k ands sleepafternightduty The incomplete a adaptation of the circadian clock forced crewmembers to sleep in a differen part of d nt thecir rcadianbodyclockcycleaf fternightdut ty. At home before the trip (Figure 2.3), they went to y sleep about 5 hours before the tem mperature minim mum and wo oke up abou 3 hours after the ut tempe eratureminim mum. After nightduty(Fi igure2.4),theywenttosl leepclose tothe ecircadiante emperaturem minimumandwokeup about 6 hours late The avera time of w er. age waking up afterm morningsleepperiodswas14:13.The predicted time o the intern alarm clo (6 hours after the of nal ock tempe erature minimum) was 14:08. Crew wmembers were not asked what woke the up, but they rated em thems selves as no feeling we ot ellrested aft these ter restric ctedmorningsleepepisod des. Anoth conseque her ence of the incomplete adaptation of the circadian b e body clock to night duty was that o crewm memberswer reoftenoper ratingthelas stflightof the ni ight in the W Window of C Circadian Low (WOCL) w when they would be expecte to be sle d ed eepy and having to make a g additional eff fort to maint tain their perfor rmance. No fatiguerela ated inciden nts were

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214 ScienceforFRMS observed on these flights (all crews were accompaniedbyaflightdeckobserver).However,all flights were routine, i.e., there were no operational events that tested the capacity of these crewmemberstorespondtononroutinesituations. OperationalNote: MitigationStrategiesforNightDuty Nightdutyforcescrewmemberstosleeplaterthannormalintheircircadianbodyclockcycle.Thismeansthat theyhavealimitedamountoftimetosleepbeforethecircadianbodyclockwakesthemup.Consequently, theyneedtogettosleepassoonaspossibleaftercomingoffduty. Gettingoffdutyearlierincreasesthetimeavailableforsleepinthemorning,beforethecircadianbodyclock makesitdifficultforcrewmemberstostayasleep. Nappingbeforegoingondutyisbeneficialtohelpmaintainalertnessandperformancethroughtotheendof thenight Nappingduringthedutyperiod(forexample,onthegroundwhileaircraftarebeingloadedandunloaded)is beneficial to help maintain alertness and performance through to the end of the night. The napping opportunity should be limited to 4045 minutes, with an additional 1015 minutes allowed to ensure that sleepinertia(ifany)hasdissipated. Insomeoperations,itmaybepossibletoschedulealongersleepopportunityduringthenight,forexample during loading and unloading of freight, or during continuous duty overnight periods. Providing a sleeping room away from the aircraft and protected time to sleep would increase the amount of sleep that crewmembersareabletoobtain.Onceagain,andadditional1015minutesshouldbeallowed,toensurethat sleepinertia(ifany)hasdissipated. 2.3.5 Jetlag Thisprobablyreflectsthefactthatmostpeoplehave acircadianbodyclockthathasaninnatecycleslightly Flying across time zones exposes the circadian body longer than 24 hours, which makes it easier to clocktosuddenshiftsintheday/nightcycle.Because lengthen the cycle to adapt to a westward shift (a ofitssensitivitytolightand(toalesserextent)social phasedelay). time cues, the circadian body clock will eventually After eastward flights across 6 or more time zones, adapt to a new time zone. Studies with participants thecircadianbodyclockmayadaptbyshiftinginthe flown as passengers have identified a number of oppositedirection,forexampleshifting18timezones west rather than 6 time zones east. When this factors that affect the rate of adaptation to a new happens some rhythms shift eastward and others timezone.Thesefactorsincludethefollowing. westward (known as resynchronization by partition) andadaptationcanbeparticularlyslow. The number of time zones crossed adaptation generally takes longer when more time zones are crossed. Rhythmsindifferentfunctionscanadaptatdifferent The direction of travel adaptation is usually faster rates,dependingonhowstronglytheyareinfluenced after westward travel than after eastward travel bythecircadianbodyclock. acrossthesamenumberoftimezones.
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ScienceforFR S RMS This means that during ad T daptation to the new tim me zone, rhythm in different body fun z ms nctions can b be disturbed fro d om their us sual relation nships to on ne another. a Adaptationis fasterwhen thecircadian A nbodyclock is more exposed to the time cues that it needs to lock m d e t ontointhene o ewtimezone e.Thisrelates stotheextent to t which peo ople adopt th pattern of sleep, eatin he ng etc, e in the ne time zone and the am ew mount of tim me theyspendou t utdoorsinthe efirstfewday ys. Beginningatripwithasle B eepdebtseemstoincreas se thedurationa t andseverityo ofjetlagsymptoms. During the p D period of ada aptation to the new tim me zone,commo z onsymptoms includewant tingtoeatan nd sleep at time that are out of step with the loc s es o cal routine, pro r oblems wit th digestio on, degrade ed performance on mental and physic tasks, an p cal nd moodchanges. m Thesituation forlonghaulandultralo T ongrangeflight crewisdiffere c enttothatfo orthepassen ngerwhoplans tospendlong t genoughatth hedestination ntoadaptfully to t local time. Typically, la . ayovers in ea destinatio ach on la only 12 days, after which crew ast 2 r wmembers are askedtooper a rateareturnflightoradditionalflightsin the destination region, followed b the return t by flight(s) to th f heir city of origin. This m o means that th he circadian bod clock does not have enough time t c dy s to adapt to any of the destination ti a ime zones. In addition,thecombinationofalongdut a tydayfollowe ed by12daylay b yoversgives aduty/restc cyclethatdoes notfollowar n regular24ho ourpattern,sothecircadia an bodyclockcannotlockontotheduty/r b restcycle. Relatively few studies have tracked the circadia R w an bodyclockac b crosscommerciallonghau ultrippatterns and none ha a ave tracked it across UL operation LR ns. Figure 2.5 d F depicts data from one NASA stud a dy conducted in the mid1980s on B c n B747 200/30 00 operations (3 o 3person crew consisting of a pilot in ws g command,fir c rstofficer,an ndflightengin neer)13.Similar trippatterns arestillbeingflownbyso t omeoperato ors
13

215 but w with an addit tional pilot, not a flight engineer. Participants had their core body tem e mperature monitored continu uously and kept sleep and duty diaries before, du s uring, and a after this tri which ip, included 4 transP Pacific flights plus one ro s ound trip within Asia (NRTS n SINNRT). Th dots on t he the graph indicate the time of the te e emperature minimum (avera agedfor6cre ewmembersp perday).

ure2.5:Study ytrackingthecircadianbod dyclock Figu acrossmu ultipletransP Pacificflights s By the end of th trip patte his ern, the tem mperature minim mum had dela ayed by abou 4.5 hours, giving an ut averag drift rate of about 30 minutes per 24 hours ge (or an average cy n ycle length o the circad of dian body clock ofabout24.5 5hours).The edriftpresum mablywas esultofthefactthatthecircadianbody yclockdid there not ha any 24h ave hour time cue to lock on to, with es n the no on24 hr duty y/rest cycle a every lay and yover in a differe enttimezone e. at mperature One consequence was tha the tem minim mum(correspo ondingtothe eWindowofCircadian Low o WOCL) sometimes occurred in f or flight, for examp pleonthelas stflightfrom mNRTtoSFO. .Atthese times, ,crewmembe erswouldbe expectedto besleepy andha avingtomake eadditionale efforttomain ntaintheir

Gander,P.H., ,Gregory,K.B.,Miller,D.L.,Ro osekind,M.R., Connell,L.J.,andGraeber,R.C C C.(1998)FlightcrewfatigueV V: lo onghaulairtra ansportoperations.Aviation,Space,and EnvironmentalMedicine69:B3 E 37B48

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216 ScienceforFRMS days are often associated with extended periods of performance.Thiswouldbeanidealtimetotakean waking. For example, in a series of long haul trips inflight nap (crewmembers did not have inflight studied by the NASA Fatigue Program the average sleepopportunitiesonthistrip). period of waking associated with a duty day was 20.6hours (the average length of a duty period was Another consequence was that when crewmembers 9.8hours)13.Acrosstheselongperiodsofwaking,the returned home, their circadian body clocks were on homeostatic pressure for sleep builds so that average4.5hoursdelayedwithrespecttolocaltime crewmemberstendtosleep,atleastforashorttime, andtookseveraldaystoreadapt. soonafterarrivalatthedestinationlayoverhotel.For example, this is a common pattern after eastward LayoversleeppatternsonlonghaulandULRtrips nightflightsacrossmultipletimezones.Ashortsleep The fact that long haul and ULR crewmembers istakensoonafterarrival,duringthelocalafternoon, seldomstaylongenoughinanydestinationtimezone andthen themainsleep periodisthentakenduring tobecomeadaptedtolocaltimehaseffectsontheir localnight. layover sleep. Often, crewmembers split their sleep, having one sleep period on local night and another FRMS training for long haul and ULR crewmembers needs to include discussion of the effects of trans correspondingtolocalnightintheirhometimezone, meridian flights on the circadian body clock and which overlaps the preferred part of the circadian sleep. One way to reduce the complexity of this bodyclockcycleforsleep(atleastforthefirst2448 hoursinanewtimezone). materialistodevelopspecificguidanceforsleepand the use of personal fatigue mitigation strategies on Anotherfactoraffectinglayoversleep,particularlyfor differentroutes. unaugmented crews who do not have the opportunity for inflight sleep, is that long haul duty OperationalNote: EffectsofDifferentTypesofLongHaulTripPatternsontheCircadianBodyClock Relativelyfewstudieshavetrackedthecircadianbodyclockacrosslonghaultrippatterns,andmanyareover20 years old. The available studies suggest that different types of trip patterns affect the circadian body clock in differentways. Sequences of backtoback transmeridian flights (separated by 24 hour layovers) that do not return to the domiciletimezoneforlongperiodsoftime(suchasthepatternillustratedinFigure2.5)tendtocausethe circadianbodyclocktodriftonitsinnatecycle,whichistypicallyslightlylongerthan24hours.Thisisprobably because these trips contain no regular 24hour pattern to which the circadian body clock can synchronize. Whentheyarrivebackintheirhometimezone,crewmembersneedadditionaldaystoreadapttolocaltime. Sequencesofoutandbacktransmeridanflights(separatedby24hourlayovers)thatreturntothehometime zoneonalternatelayoversseemtoenablethecircadianbodyclocktoremainsynchronizedtothehometime zone.Forexample,atrippatternstudiedbytheNASAFatiguePrograminvolvedthreebacktobackreturn flightsbetweentheUSWestCoastandLondon(6flightsintotal)with24hourlayoversbetweeneachflight. Returningtotheirhometimezoneoneverysecondlayoverappearedtokeepcrewmemberscircadianbody clocks (monitored by the core temperature rhythm) synchronized to West Coast time. As a result, crewmembersobtainedrelativelygoodsleepontheWestCoastlayoversanddidnotneedadditionaldaysto readapttoWestCoasttimeattheendofthetrip.
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ScienceforFRMS 217 There is some evidence that when crewmembers stay longer in the destination region, for example doing several days of local flying with minimal time zone changes before flying the long haul trip home, their circadian body clocks begin to adapt to the destination time zone. This may improve layover sleep. On the other hand, when they arrive back in their home time zone, they need additional days to readapt to local time. Thescarcityofdataonwhathappenstothecircadianbodyclockacrossdifferentlonghaultrippatternsisone reasonmostcurrentbiomathematicalmodelsdonothaveavalidatedapproachforsimulatingwhathappensto thecircadianclockacrosssequencesoftransmeridianflights(seeChapter4). controlsandmitigationstomanagefatigueriskinan 2.4Summaryofessentialsciencefor FRMS. FRMS The scientific basis for FRMS can be continuously Discoveries in sleep science and circadian rhythms improved if data that are routinely collected as part provideastrongscientificbasisforFRMS.Thescience of FRM processes (Chapter 4) and FRMS Assurance doesnotaddresseverydetailedoperationalquestion processes (Chapter 5) can be shared in appropriate anditneverwill.Inotherwords,therewillalwaysbe waysinthepublicdomain. a need to combine operational experience and scientific knowledge to come up with workable OperationalNote: Keyfactsaboutsleep Sleepisvitalforrecoveryfromfatigue.Twoaspectsofsleepareimportanttheamountofsleepandthequality ofsleep. Amountofsleep Sleeprestrictioniscommoninflightoperations. Notgettingenoughsleepleadsto:feelingsleepier,difficultystayingalert,gettingirritable,slowerreactions, poorercoordination,slowerthinking,gettingfixatedonpartofaproblemandlosingthebigpicture(lossof situationawareness),lesscreativeproblemsolving,andreducedmemoryconsolidation(impairedlearning). Theeffectsofrestrictedsleepaccumulate: the rate of accumulation of fatigue is related to the rate of sleep loss (less sleep per day = more rapid accumulationoffatigue); sleep pressure eventually becomes uncontrollable, which results in unintentional sleep (microsleeps or unintendednaps). Losthoursofsleepdonotneedtoberecoveredhourforhour. Atleasttwoconsecutivenightsofunrestrictedsleeparerequiredtorecoverfromthecumulativeeffectsof multiplenightsofrestrictedsleep.Unrestrictedsleepmeansbeingfreetofallasleepwhentiredandwakeup spontaneously,withsleepoccurringattheappropriatetimeinthecycleofthecircadianbodyclock.Insome
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218 ScienceforFRMS cases,thisrecoveryperiodcanbebuiltintoschedules(forexamplewithshortdaytimedutyperiods). Controlled napping can temporarily relieve the symptoms of sleep loss. It is a valuable personal mitigation strategy,forexamplepriortoanightdutyperiodoronlonghaulflights. A NASA study of flight deck napping showed improved alertness at the end of unaugmented long haul flights(89hrs)whenflightcrewmembersweregivena40minnapopportunityintheirflightdeckseat. Qualityofsleep GoodqualitysleepinvolvesregularcyclesthroughtwodifferenttypesofsleepRapidEyeMovementsleep (REMsleep)andnonREMsleep.AfullnonREM/REMsleepcycletakesroughly90minutes. Sleepthatisfragmentedbymultipleawakenings,orarousalsintolighterstagesofsleep,breaksupthenon REM/REMcycleandislessrestorativethancontinuoussleep. Sleepinonboardcrewrestfacilitiesislighterandmorefragmentedthansleepinhotelsorathome.This doesnotappeartobeaneffectofaltitude. BothflightdecknapsandinflightsleepincrewrestfacilitiescontainverylittledeepnonREMsleep(known asslowwavesleep),sosleepinertiaislesslikelyafterinflightsleepthanispredictedbylaboratorystudies. Twomainphysiologicalprocessesinteracttoregulatesleep: Thehomeostaticsleepprocessisevidentinthepressureforslowwavesleepthatbuildsupacrosswakingand dischargesacrosssleep. ThecircadianbodyclockregulatesthetimingofREMsleepanddictatesthepreferenceforsleepatnight. Theinteractionbetweenthehomeostaticpressureforsleepandthecircadianbodyclockresultsintwotimesof peaksleepinessin24hours: apeakintheearlyafternoon(theafternoonnapwindow)thatoccursaround35pmformostpeople;and apeakintheearlyhoursofthemorning(thewindowofcircadianloworWOCL)thatoccursaround35am formostpeople. Note:thesetwoprocessesarethemaincomponentsinmostofthebiomathematicalmodelsthatareusedto predictcrewmemberfatiguelevels(seeChapter4). OperationalNote: Keyfactsaboutthecircadianbodyclock The circadian body clock is a pacemaker in the brain that is sensitive to light through a specialized input pathwayfromtheeyes(separatefromvision). Thecircadianbiologicalclockgeneratesaninnatebiologicaldaythatisslightlylongerthan24hoursformost people.Itssensitivitytolightenablesittostayinstepwiththe24hourday/nightcycle.
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ScienceforFRMS 219 Almosteveryaspectofhumanfunctioning(physicalormental)undergoesdailycyclesthatareinfluencedby thecircadianbodyclock. Thedailyminimumincorebodytemperaturecorrespondstothetimeinthecircadianbodyclockcyclewhen peoplefeelmostsleepyandareleastabletoperformmentalandphysicaltasks.Thisissometimescalledthe WindowofCircadianLow(WOCL)anditisatimeofhighriskforfatiguerelatederror. Shiftwork Shiftworkcanbedefinedasanydutypatternthatrequiresacrewmembertobeawakeduringthetimeinthe circadianbodyclockcyclethattheywouldnormallybeasleep. Theabilityofthecircadianclocktolockontothe24hourday/nightcyclemakesitresistadaptationtoany patternotherthansleepatnight. The fact that the circadian body clock does not adapt fully to altered sleep/wake patterns has two main consequences: duty days that overlap crewmembers usual sleep times (particularly allnight operations) tend to cause sleeprestriction;and crewmemberswhoareworkingthroughthewindowofcircadianlow(WOCL)canbeexpectedtobesleepy andhavetomakeadditionalefforttomaintaintheirperformance. Thefurthersleepisdisplacedfromtheoptimumpartofthecircadianbodyclockcycle,themoredifficultit becomesforcrewmemberstogetadequatesleep. Inscheduling,thefrequencyofrecoverybreaks(atleast2consecutivenightsofunrestrictedsleep)needsto reflecttherateofaccumulationofsleepdebt. Jetlag Flyingacrosstimezonesexposesthecircadianbodyclocktosuddenshiftsintheday/nightcycle.Becauseof itssensitivitytolightand(toalesserextent)socialtimecues,thecircadianbodyclockwilleventuallyadaptto anewtimezone. The rate of adaptation depends on the number of time zones crossed, the direction of travel (faster after westwardflights)andtheextenttowhichthecircadianbodyclockisexposedtothe24hourcuesinthenew timezone(outdoorlight,sleepingandeatingonlocaltime,etc). Layoversof2448hoursarenotlongenoughtoallowthecircadianbodyclocktoadapttolocaltime. Differenttypesoflonghaultrippatternsaffectthecircadianbodyclockindifferentways. Sequences of backtoback transmeridian flights that do not return to the domicile time zone for long periodsoftimetendtocausethecircadianbodyclocktodriftonitsinnatecycle.Onreturntothehome timezone,additionaldaysareneededtoreadapttolocaltime.
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220 ScienceforFRMS Sequencesofoutandbacktransmeridanflightsthatreturntothehome timezoneonalternatelayovers seemtoenablethecircadianbodyclocktoremainsynchronizedtothehometimezone. Ontripsthatincludelongerperiodsinthedestinationregion,forexampleseveraldaysoflocalflyingbefore the return flight home, the circadian body clock begins to adapt to the destination time zone. This may improvelayoversleep.Ontheotherhand,onreturntothehometimezone,additionaldaysareneededto readapttolocaltime. On long haul layovers, sleep is affected by competition between physiological processes (the homeostatic sleepdriveandthecircadianbiologicalclock)andapreferenceforsleepingduringthelocalnight. RoutespecificrecommendationsforpersonalfatiguemitigationstrategiesmaybeusefulinFRMStrainingfor longhaulandULRcrewmembers. OperationalNote: Howmuchsleepin24hoursisenough? Thiscommonquestionisusuallyaimedattryingtogetamagicnumberfortheminimumamountofsleepthat a crewmember needs, or the minimum rest period that needs to be scheduled. From a sleep science perspective,theanswerisitdependsonmanyfactors,includingindividualdifferences.Someofthethingsit dependsonare: Recentsleephistoryonerestrictedsleepperiodisasmallerfatigueriskforacrewmemberwhoisstarting outwellrestedthanforacrewmemberwhohasalreadyaccumulatedasleepdebt; Theamountofsleepacrewmemberneedstobefullyrested(whichvariesamongcrewmembers); Whether the crewmember is likely to obtain good quality sleep during the restricted sleep period. (For example, is sleep at home, in an onboard crew rest facility, in a layover hotel? Does the sleep opportunity occuratanappropriatetimeinthecircadianbodyclockcycle?); Whether sleep is shortened because a crewmember has to stay awake for an extended time beforehand (increasingthehomeostaticpressureforsleepandtheriskofmicrosleepspriortothesleepperiod); Whether sleep is shortened because a crewmember has to stay awake for an extended time afterwards (increasingthehomeostaticpressureforsleepandtheriskofmicrosleepspriortothenextsleepperiod); Whetherthecrewmemberwillbetryingtoworkthroughtimesofincreasedcircadiansleepdrive(theearly hoursofthemorningandmidafternoonwhenthecircadianbodyclockisadaptedtolocaltime); Thecriticalityofthetasksthatacrewmemberwillbeundertakingaftertherestrictedsleepperiod; Otherdefensivestrategiesthatareinplacetomanagethesafetyriskifthatcrewmemberisfatigueimpaired asaresultoftherestrictedsleepperiod;and Whentheopportunitywilloccurforrecoveryfromtheeffectsoftherestrictedsleepperiod(forexample,isit thefirstinaseriesofrestrictedsleepperiods,orisitfollowedbytwounrestrictednightsofrecoverysleep?).
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ScienceforFRMS 221 From a safety perspective, the answer is that no single defensive strategy is 100% sure. (The same desire for simplicityisariskwithbiomathematicalmodelsthatdefineasafetythresholdforcrewmemberfatigue.For example,thereisatendencytobelievethatanoperationissafeifitispredictedtobebelowthethreshold,but unsafeifitispredictedtobeaboveit.)InanFRMS,safetycomesfromhavingadatadrivenmultilayeredsystem of defenses to manage fatigue risk, not from a reliance on simple thresholds. The FRMS answer is measure crewmember fatigue levels, do a risk assessment and implement controls and mitigations as needed. These processesarethesubjectofChapters5and6.

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[Back to Contents]
Chapter3.FRMSpolicyanddocumentation

[Back to Overview]
31

Chapter3.FRMSpolicyanddocumentation

3.1IntroductiontoFRMSpolicyand documentation
ThisChapterdescribeswhatshouldbeincludedinan FRMS policy, and other documentation required to record its activities. The policy and documentation define organizational arrangements that support the core operational activities of the FRMS (the FRM processesandtheFRMSsafetyassuranceprocesses). Thelinkagesbetweenpolicyanddocumentationand otherFRMScomponentsareoutlinedinFigure3.1. TheFRMSpolicyspecifiestheoperatorscommitment and approach to the management of fatigue risk. If acceptable to the State, it may be appropriate in somecasesfortheoperatortoincorporateitsFRMS

policyinitsSMSpolicy.However,itshouldbenoted that ICAO Annex 6, Part I, Appendix 8 requires an operatortoclearlydefineallelementsoftheFRMSin itspolicy.TheoperatorsFRMSpolicymustbeableto be distinguishable from the general SMS policy to allowseparatereview. TheFRMSdocumentationdescribesthecomponents andactivitiesoftheentireFRMS.Itmakesitpossible for the effectiveness of the FRMS to be audited (internally and externally) to check whether it is meeting the safety objectives defined in the FRMS policy. Maintaining the required documentation is one of the recommended functions of the Fatigue SafetyActionGroup.

Figure3.1:LinkagesbetweenFRMSpolicyanddocumentationandotherFRMScomponents

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32 FRMSpolicyanddocumentation TheICAOrequirementsforFRMSpolicyanddocumentationareasfollows(Appendix8,Annex6,PartI). Annex6,PartI,Appendix8

1.FRMSpolicyanddocumentation 1.1FRMSpolicy 1.1.1 TheoperatorshalldefineitsFRMSpolicy,withallelementsoftheFRMSclearlyidentified. 1.1.2 The policy shall require that the scope of the FRMS operations be clearly defined in the OperationsManual. 1.1.3 Thepolicyshall: a)reflectthesharedresponsibilityofmanagement,flightandcabincrews,andotherinvolved personnel; b) learlystatethesafetyobjectivesoftheFRMS; c c)besignedbytheaccountableexecutiveoftheorganization; d)be communicated, with visible endorsement, to all the relevant areas and levels of the organization; e)declaremanagementcommitmenttoeffectivesafetyreporting; f)declaremanagementcommitmenttotheprovisionofadequateresourcesfortheFRMS; g)declaremanagementcommitmenttocontinuousimprovementoftheFRMS; h) equire that clear lines of accountability for management, flight and cabin crews, and all r otherinvolvedpersonnelareidentified;and i) requireperiodicreviewstoensureitremainsrelevantandappropriate. Note.EffectivesafetyreportingisdescribedinDoc9859,SafetyManagementManual(SMM). 1.2FRMSdocumentation AnoperatorshalldevelopandkeepcurrentFRMSdocumentationthatdescribesandrecords: a)FRMSpolicyandobjectives; b) RMSprocessesandprocedures; F c)accountabilities,responsibilitiesandauthoritiesfortheseprocessesandprocedures; d) echanismsforongoinginvolvementofmanagement,flightandcabincrewmembers,and m allotherinvolvedpersonnel; e)FRMStrainingprograms,trainingrequirementsandattendancerecords; f)scheduledandactualflighttimes,dutyperiodsandrestperiodswithsignificantdeviations andreasonsfordeviationsnoted;and g)FRMSoutputsincludingfindingsfromcollecteddata,recommendations,andactionstaken.

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FRMSpolicyanddocumentation

33 theFRMS.Thiscouldbeviewedasanaturalevolution of the FRMS, and the regulator will need to give considerationtotherequirementsthatwouldgovern expandingthescopeofanFRMS. The following text boxes show examples of statementsofthescopeofanFRMS. Example1 AirlineAlargeinternationalcarrier with11differentfleettypes TheFRMSforAirlineAwillapplytoalloperationsas specificallyidentifiedintheFlightOperationsManual (FOM). All other operations will be conducted under theprescriptiveflightanddutytimeregulations. In Example 1, the Flight Operations Manual initially lists the entire B777 fleet and UltraLong Range (ULR) flights on the B787, and only includes pilots. Subsequently, Airline A decides that it wants to add itsA330fleettotheFRMS. Withapprovalfromtheregulator,theA330fleetcan be added to the list in the Flight Operations Manual that identifies operations covered by the FRMS, without requiring a change to the FRMS policy statement. This change makes the Fatigue Safety Action Group responsible for establishing FRMS processes to identify fatigue hazards in the A330 operations, assess the risks, and develop and implement controls and mitigations. FRMS safety assurance processes also need to be established to monitor the effectiveness of the FRMS in managing fatigueriskintheA330operations. The addition of cabin crewmembers to the FRMS would require an amended policy statement, as follows. TheFRMSforAirlineAwillapplytoalloperationsas specificallyidentifiedintheFlightOperationsManual (FOM)andCabinOperationsManual(COM).Allother operations will be conducted under the prescriptive flightanddutytimeregulations.

3.2Appendix8,paragraph1.1:FRMS policy
1.1.1 TheoperatorshalldefineitsFRMSpolicy, withallelementsoftheFRMSclearlyidentified. The FRMS policy provides the umbrella under which the FRMS operates. While an FRMS may be an integral part of an operators SMS, SMS and FRMS require two separate approval processes. Consequently, whether the operators FRMS Policy has been written as a standalone document, as a componentofitsSMSPolicy,oraspartofitsoverall SafetyPolicy,anyaspectsoftheFRMSpolicymustbe easilyidentifiableassuch.ThismeansthattheFRMS policy can be reviewed in its entirety and is clearly distinguishablefromothersafetypolicystatements. 3.2.1 ScopeoftheFRMS 1.1.2 Thepolicyshallrequirethatthescopeof FRMSoperationsbeclearlydefinedintheOperations Manual. ICAOStandard4.10.2(Annex6,PartI)requiresthat, where FRMS regulations are provided, States allow an operator to choose whether it will use the FRMS tomanagefatigueriskinallitsoperations,oronlyin designatedspecifictypesofoperations(forexample, a particular fleet, a particular route, only ULR operations, etc.). All operations not covered by the FRMSmustoperateundertheapplicableprescriptive flightanddutytimelimits. Because a policy statement is typically a short and stabledocument,itdoesnothavetodetailthescope of the operations to which the FRMS applies, but it does have to identify where these are detailed. For example, an operator policy statement may indicate that the scope of the FRMS is defined in the Flight Operations Manual. This means that Stateapproved changes in scope do not require a rewrite of the initialFRMSpolicystatement. As an operators familiarity and experience with FRMS builds, they may wish to expand the scope of

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34 Example2 AirlineBdomesticcarrieroperatingbothscheduled andcharteroperationswith3fleettypes.AirlineB choosestooperateitscharteroperationsunder FRMSandtooperateitsscheduledoperationsunder theprescriptiveflightanddutytimeregulations. The FRMS for Airline B will apply to all flight crew membersinallcharteraircraftoperations. Example3 AirlineCTwoairplaneondemandcarrier thatchoosestocoverallitsoperationsunderFRMS The FRMS for Airline C will apply to all flight crew membersinalloperations. 1.1.3 Thepolicyshall: a) reflect the shared responsibility of management, flight and cabin crews, and other involved personnel; b) clearlystatethesafetyobjectivesoftheFRMS; c) be signed by the accountable executive of the organization; d) be communicated, with visible endorsement, to all the relevant areas and levels of the organization; e) declare management commitment to effective safetyreporting; f) declare management commitment to the provisionofadequateresourcesfortheFRMS; g) declare management commitment to continuous improvementoftheFRMS; h) require that clear lines of accountability for management,flightandcabincrews,andallother involvedpersonnelareidentified;and i) require periodic reviews to ensure it remains relevantandappropriate. Note. Effective safety reporting is described in Doc 9859,SafetyManagementManual(SMM).

FRMSpolicyanddocumentation Appendix 8, Section 1.1.3 identifies the minimum requirements that must be addressed in the FRMS policy.Essentially,theseidentifytheprerequisitesof an FRMS. As for the management of fatiguerelated risks within prescriptive flight and duty limitations, FRMSnecessitatessharedresponsibilitybetweenthe operator and individual crew members, because of theparticularnatureoffatigue. Fatigue is affected by all waking activities, not only workdemandssometimesdescribedasawholeof lifeissue.Forexample,crewmembershavepersonal responsibilitybecausetheycanchoosetheamountof time they spend trying to sleep during available rest breaks, and choose when to use personal fatigue mitigation strategies (Chapter Four). They have a responsibility to use rest periods effectively prior to dutyperiodstoenablethemtostartworkfitforduty. In addition, their cooperation is vital for voluntary reportingoffatiguehazards,andwhenfatiguelevels need to be measured for FRM processes (Chapter Four)andFRMSsafetyassuranceprocesses(Chapter Five). Crewmembers willingness to cooperate will depend on their confidence that the operator is committed to the principles of an effective safety reportingculture1(ChapterOne). However, management is also, and primarily, responsible for the management of fatigue risk becauseitschedulestheworkactivitiesofpersonnel andthedistributionofresourcesintheorganization2. The FRMS is an organizational system that enables managementtomeetthatresponsibility. Like SMS, the Accountable Executive when signing theFRMSpolicyacceptsaccountabilityfortheFRMS, either directly or through supervision and managementofothers,includingthosetowhomthe AccountableExecutivehasdelegatedresponsibility. ThesafetyobjectivesintheFRMSpolicyspecifywhat the operator wants the FRMS to achieve. To track whether the FRMS is meeting these objectives, its performance needs to be monitored. Examples of
1 2

ICAOSafetyManagementManual(Doc9859) ICAOSafetyManagementManual(Doc9859)

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FRMSpolicyanddocumentation safetyperformanceindicatorsandtargetsthatcanbe used to measure how well the FRMS is meeting the safety objectives can be found in Chapters Four and Five. TheFRMSpolicyneedstobereviewedperiodicallyby the operator, to ensure that it is adequate to meet changingoperationaldemands.Inaddition,itshould besubjecttoperiodicreviewbytheregulator.

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3.3 ExamplesofFRMSpolicy statements

The following examples are intended to be used as guidance, not templates. Each operator needs to develop an FRMS appropriate their specific organizationalcontextandoperationalneeds.

3.3.1 FRMSpolicystatementforamajorair carrier

[InsertCompanyName]FatigueRiskManagementPolicy Asacommitmenttothecontinuousimprovementofsafety,XCompanyhasanFRMStomanagefatiguerelatedrisks. This Fatigue Risk Management System (FRMS) applies to the operations as defined in the Flight Operations and Cabin Operations Manuals. All other operations will operate under the prescriptive flight and duty time regulations. The FRMS Manual describes the processesusedforidentifyingfatiguehazards,assessingtheassociatedrisks,anddeveloping,implementing,andmonitoringcontrolsand mitigations.TheFRMSManualalsodescribesthesafetyassuranceprocessesusedtoensurethattheFRMSmeetsitssafetyobjectives, andhowtheFRMSisintegratedwithourindustryleadingSMSprograms. Underthispolicy: Managementisresponsiblefor: ProvidingadequateresourcesfortheFRMS; providingadequatecrewinglevelstosupportrostersthatminimizefatiguerisk; providingflightandcabincrewwithadequateopportunityforrecoverysleepbetweenduties; creatinganenvironmentthatpromotesopenandhonestreportingoffatiguerelatedhazardsandincidents; providingfatigueriskmanagementtrainingtoflight,cabincrewandotherFRMSsupportstaff; demonstratingactiveinvolvementinandunderstandingoftheFRMS; ensuringthatthefatigueriskswithintheirarea(s)ofresponsibilityaremanagedappropriately; regularlyconsultingwithflightandcabincrewregardingtheeffectivenessoftheFRMS;and demonstratingcontinuousimprovementandprovidingannualreviewoftheFRMS. Flightandcabincrewarerequiredto: makeappropriateuseoftheirrestperiods(betweenshiftsorperiodsofduty)toobtainsleep; participateinfatigueriskmanagementeducationandtraining; reportfatiguerelatedhazardsandincidentsasdescribedintheFRMSManual; complywiththeFatigueRiskManagementPolicy; informtheirmanagerorsupervisorimmediatelypriortoorduringworkif: o theyknoworsuspecttheyoranothercrewmemberaresufferingfromunacceptablelevelsoffatigue;or o theyhaveanydoubtabouttheiroranothercrewmemberscapabilitytoaccomplishtheirduties. FatigueRiskManagementmustbeconsideredacorepartofourbusinessasitprovidesasignificantopportunitytoimprovethesafety andefficiencyofouroperationandtomaximizethewellbeingofourstaff. Policyauthorizedby: (Signed)___________________________________ InsertTitle(AccountableExecutive) Date:___________________________

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36 FRMSpolicyanddocumentation 3.3.2 FRMSpolicystatementforasmalleroperatorprovidingmedicalevacuationservices

[InsertCompanyName]FatigueRiskManagementPolicy Theuniquechallengesthatwefaceinourinternationalmedicalevacuationoperationshereat[InsertCompany]include24houron call schedules, a need for immediate response in all weather conditions, and many flights landing at unprepared locations. These challengesrequireourflightcrewstoperformatthehighestlevelsofcompetenceandprofessionalismatalltimes.Theyalsomean thatweareexposedonaregularbasistoelevatedfatiguerisks,whicharebestmanagedthroughaFatigueRiskManagementSystem (FRMS). Weneedtomanagetheseriskscarefullyinordertomakeconsistentlysounddecisions,particularlytobalancethecriticalneedsof patientswiththerequirementforsafeoperations.Thiscanonlybeachievedthroughthesharedresponsibilityandcommitmentof management, crew members (pilots, doctors and nurses) and our support staff (e.g. crew schedulers) to ensure our fatigue risks remainacceptable. [InsertCompanyName]willensurethatmanagement,crewandsupportstaff,andallotherrelevantpersonnelareawareof: thepotentialconsequencesoffatiguewithinourcompany; theuniquechallengesandfatiguerisksconfrontingourstaffduetothenatureofouroperations; theimportanceofreportingfatiguerelatedhazards;and howtobestmanagefatigue. To achieve this we have developed specific policies and procedures within our Safety Management System (SMS) for the managementoffatiguerisks.ThesearedocumentedintheFRMSsectionsofourSMSManualandapplytoalloperationalstaff. Managementareresponsiblefor: appropriatelyresourcingtheSMS; providingadequatecrewinglevelstosupportrostersthatminimisefatiguerisk; providingcrewwithadequateopportunityforrecoverysleepbetweenduties; creatinganenvironmentthatpromotesopenandhonestreportingoffatiguerelatedhazardsandincidents; providingfatigueriskmanagementtrainingtocrewandothersupportstaff; demonstratingactiveinvolvementinandunderstandingofourfatiguerisks; regularlyconsultingwithcrewregardingtheeffectivenessoffatiguemanagement;and demonstratingcontinuousimprovementandprovidingannualreviewoffatiguemanagement. Crewandsupportstaffarerequiredto: makeappropriateuseoftheirrestperiods(betweenshiftsorperiodsofduty)tosleep; participateinfatigueriskmanagementeducationandtraining; reportfatiguerelatedhazardsandincidents; complywiththeFatigueRiskManagementPolicyandPracticesascontainedwithinourSMS; informtheirmanagerorsupervisorimmediatelypriortoorduringworkif: o theyknoworsuspecttheyoranothercrewmemberaresufferingfromunacceptablelevelsoffatigue;or o theyhaveanydoubtabouttheiroranothercrewmemberscapabilitytoaccomplishtheirduties. seekexternalsupportinaccordancewithourcompanypoliciesandprocedurestoensure,wheneverpossible,thatthirdparties (e.g. Chief Pilot, Operations Manager) who are not part of your crew are used to support crew decision making. Whenever crewmembershavedoubtsabouttheirfatiguerisktheyarerequestedtousethecompanys24hourhotline. Theeffectivemanagementoffatigueiscriticaltoensuringthatourcompanycandeliveraqualityservicetoourcustomers. Policyauthorizedby: (Signed)___________________________________ InsertTitle(AccountableExecutive) Date:___________________________

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FRMSpolicyanddocumentation

37 However, in order to ensure that the focused management of fatigue risks does not result in unintended consequences in overall risk management, some of the functions of the Fatigue SafetyActionGroupasdescribedheremayinfactbe undertaken by the SMS team or other functional groups. Regardless of who undertakes these functions, the regulator will need to observe and monitorallofthefunctionsrequiredunderanFRMS. The composition of the Fatigue Safety Action Group shouldreflectthesharedresponsibilityofindividuals and management by including representatives of all stakeholder groups (management, scheduling staff, and crewmembers and/or their representatives) and other individuals as needed to ensure that it has appropriate access to scientific and medical expertise. It should operate under Terms of Reference that are included in the FRMS documentation and which specify the lines of accountability between the Fatigue Safety Action GroupandtheoperatorsSMS. ThesizeandcompositionoftheFatigueSafetyAction Groupwillvaryfordifferentoperators,butshouldbe related to the size and complexity of the operations coveredbytheFRMS,andtotheleveloffatiguerisk in those operations. In small operators, a single individualmayrepresentmorethanonestakeholder group, for example the chief pilot may also be the primaryscheduler.Inverysmalloperators,theremay not even be a designated Fatigue Safety Action Group, simply extra items on the Safety Meetings agenda, as long as long as all fatigue risk management activities are documented. Larger airlines will have specialised departments that interactwiththeFatigueSafetyActionGroup. While the regulator may wish to observe Fatigue SafetyActionGroupmeetingsaspartofitsoversight activities, the regulator is not a required part of this group. The regulator may also wish to review the minutesandoutputsofsuchmeetingsaspartoftheir continuousoversightactivities(seeChapter9). Appendix 8, paragraph 1.2 f) also requires that significant deviations in scheduled and actual flight times,dutyperiodsandrestperiods,andreasonsfor

3.4 Appendix8,paragraph1.2FRMS documentation

1.2 An operator shall develop and keep current FRMSdocumentationthatdescribesandrecords: a)FRMSpolicyandobjectives; b)FRMSprocessesandprocedures; c)accountabilities,responsibilitiesandauthoritiesfor theseprocessesandprocedures; d)mechanisms for ongoing involvement of management,flightandcabincrewmembers,and allotherinvolvedpersonnel; e)FRMStrainingprograms,trainingrequirementsand attendancerecords; f) scheduledandactualflighttimes,dutyperiodsand restperiodswithsignificantdeviationsandreasons fordeviationsnoted;and g)FRMS outputs including findings from collected data,recommendations,andactionstaken. Thedocumentationdescribesalltheelementsofthe FRMS and provides a record of FRMS activities and anychangestotheFRMS.Thedocumentationcanbe centralized in an FRMS Manual, or the required information may be integrated into an operators SMSManual.However,itneedstobeaccessibletoall personnel who may need to consult it, and to the regulatorforaudit. As a way of meeting these requirements, it is expected that an operator create a functional group that is responsible for coordinating the fatigue management activities within the organisation. Such a group is referred to here as the Fatigue Safety Action Group. The principle functions of the Fatigue SafetyActionGroupareto: developandmaintaintheFRMSdocumentation; managetheFRMprocesses(ChapterFour); contribute to the FRMS safety assurance processes(ChapterFive);and be responsible for the FRMS promotion processes(ChapterSix).

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38 thosesignificantdeviationsberecordedbyoperators. Asaninitialstep,theFatigueSafetyActionGroup,or otherappropriateentitywithintheorganisation,will need to identify through a risk assessment process, differences between scheduled and actual flight times, duty periods and rest periods that will be considered significant within the context of their specificoperations. For example, identified significant differences may include: for a particular city pair, any occasion where actualflighttimeexceedsplannedflighttimeby 30minutes; for a particular trip, any occasion where actual duty time exceeds planned duty time by 60 minutes; foraparticularlayover,anyoccasionwherethe rest period is reduced from the planned rest periodby60minutes. Asaresult,thesignificantdeviationsshouldbeused asindicatorstohelpidentifypotentialfatiguehazards (discussedinChapterFour)andmayalsobeusedto

FRMSpolicyanddocumentation monitortheperformanceoftheFRMSitself(Chapter Five). Further, the Fatigue Safety Action Group will also be responsible for establishing a process for monitoring such significant deviations and documentinganysubsequentactionstaken. Such definitions will need to be provided to the regulatorfortheiracceptanceanditwillbeimportant that there is a clear understanding between the regulator and the operator as to what constitutes a significant deviation. The regulator may also use thesetoidentifycriteriaforreportingrequirements. 3.4.1 Exampleoftermsofreferenceforafatigue safetyactiongroup Thisexampleisdesignedtocovertheneedsofalarge operator. This is not a template. Not all the items suggestedherewillbeneededbyeveryoperator.The regulatorneedstobeconfidentthattheoperatorhas considered its operational and organizational profile in deciding the composition of the fatigue safety action group, its activities, and its interactions with otherpartsoftheoperatorsorganization.

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FRMSpolicyanddocumentation
[InsertCompanyName]TermsofReference:FatigueSafetyActionGroup(FSAG)

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Purpose TheFatigueSafetyActionGroup(FSAG)isresponsibleforcoordinatingallfatigueriskmanagementactivitiesat[insertCompanyname]. Thisincludesresponsibilityforgathering,analyzing,andreportingondatathatfacilitatestheassessmentoffatiguerelatedamongflight crewmembers.TheFSAGisalsoresponsibleforensuringthattheFRMSmeetsthesafetyobjectivesdefinedintheFRMSPolicy,thatit meetsregulatoryrequirements,andthattheFRMSinformstheSMStofacilitatethemanagementofsafetyrisksingeneral.TheFSAG existstoimprovesafety,anddoesnotgetinvolvedinindustrialissues. TermsofReference The FSAG is directly responsible to the Senior VP Flight Operations and reports through the Departmental Safety organization. Its membershipwillincludeatleastonerepresentativeofeachofthefollowinggroups:management,scheduling,andcrewmembers,with otherspecialistsasrequired. ThetasksoftheFSAGareto: develop,implement,andmonitorprocessesfortheidentificationoffatiguehazards; ensurethatcomprehensiveriskassessmentisundertakenforfatiguehazards; develop,implement,andmonitorcontrolsandmitigationsasneededtomanageidentifiedfatiguehazards; develop,implement,andmonitoreffectiveFRMSperformancemetrics; cooperate with the Safety Department to develop, implement and monitor FRMS safety assurance processes, based on agreed safetyperformanceindicatorsandtargets; beresponsibleforthedesign,analysis,andreportingofstudiesthatmeasurecrewmemberfatigue,whensuchstudiesareneeded fortheidentificationofhazards,orformonitoringtheeffectivenessofcontrolsandmitigations(suchstudiesmaybecontractedout buttheFSAGisresponsibleforensuringthattheyareconductedwiththehighestethicalstandards,meettherequirementsofthe FRMS,andarecosteffective); be responsible for the development, updating, and delivery of FRMS education and training materials (these activities may be contractedoutbuttheFSAGisresponsibleforensuringthattheymeettherequirementsoftheFRMSandarecosteffective); ensurethatallrelevantpersonnelreceiveappropriateFRMSeducationandtraining,andthattrainingrecordsarekeptaspartof theFRMSdocumentation; developandmaintainstrategiesforeffectivecommunicationwithallstakeholders; ensurethatcrewmembersandothersreceiveresponsetotheirfatiguereports; communicatefatiguerisksandtheperformanceoftheFRMStoseniormanagement; developandmaintaintheFRMSintranetsite; developandmaintaintheFRMSdocumentation; ensurethatithasadequateaccesstoscientificandmedicalexpertiseasneeded,andthatitdocumentsrecommendationsmadeby thesespecialistadvisorsandthecorrespondingactionstaken; keepsinformedofscientificandoperationaladvancesinfatigueriskmanagementprinciplesandpractice; cooperatefullywiththeregulatorinrelationtoFRMSauditing;and manageeffectivelyandbeaccountableforFRMSresources. TheFSAGwillmeetmonthly.Minuteswillbetakenduringmeetingsanddistributedwithin10workingdaysaftereachmeeting.TheFSAG willpresentanannualbudgetrequestin[designatedpartofthefinancialcycle]andanannualreportofallexpenditures.

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[Back to Contents]
Chapter4.FRMprocesses

[Back to Overview]
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Chapter4.Fatigueriskmanagement(FRM)processes
4.1IntroductiontoFRMprocesses
ThisChapterworksthroughthebasicstepsforsetting upFRMsafetyriskmanagementprocesses,whichare very similar to SMS safety risk management processes1. The main difference is that SMS processes are designed to address all types of risks. FRM processes within an FRMS are specifically designedtomanagetherisksrelatedtocrewmember fatigue. FRMprocesses(representedintheblueboxinFigure 4.1below)areonepartofthedaytodayoperations of the FRMS. They are designed to enable the operator to achieve the safety objectives defined in its FRMS Policy, and are managed by the Fatigue SafetyActionGroup. FRMprocesses identifywherefatigueisahazard;and assess the level of risk that a given fatigue hazard represents;and if necessary, put in place controls and mitigation strategies, and monitor to make sure that they managetheriskatanacceptablelevel. To do this, FRM processes require different sorts of data, including: a) measures of the fatigue levels of crewmembers; and b) measures of operational performance. Examples of these types of measures are described later in this Chapter. The key is choosingtherightcombinationofmeasuresforeach operationthatiscoveredbytheFRMS.However,just collectingdataisnotenough.Dataanalysisneedsto be used to inform decisions made by the Fatigue Safety Action Group and others accountable for the FRM processes and for FRMS safety performance (Chapter 5). The ICAO requirements for FRM processesareasfollows(Annex6,PartI,Appendix8).

Figure4.1:LinkagesbetweenFRM processesandotherFRMScomponents

SeeICAOSafetyManagementManual(SMM),2ndEdition 2009,Doc9859. Uneditedversion

42 Annex6,PartI,Appendix8
2.Fatigueriskmanagementprocesses

FRMprocesses

2.1Identificationofhazards Anoperatorshalldevelopandmaintainthreefundamentalanddocumentedprocessesforfatiguehazardidentification: 2.1.1Predictive.Thepredictiveprocessshallidentifyfatiguehazardsbyexaminingcrewschedulingandtakingintoaccount factorsknowntoaffectsleepandfatigueandtheireffectsonperformance.Methodsofexaminationmayincludebutare notlimitedto: a)operatororindustryoperationalexperienceanddatacollectedonsimilartypesofoperations; b)evidencebasedschedulingpractices;and c)biomathematicalmodels. 2.1.2 Proactive The proactive process shall identify fatigue hazards within current flight operations. Methods of examinationmayincludebutarenotlimitedto: a)selfreportingoffatiguerisks; b)crewfatiguesurveys; c)relevantflightandcabincrewperformancedata; d)availablesafetydatabasesandscientificstudies;and e)analysisofplannedversusactualtimeworked. 2.1.3Reactive.Thereactiveprocessshallidentifythecontributionoffatiguehazardstoreportsandeventsassociatedwith potentialnegativesafetyconsequencesinordertodeterminehowtheimpactoffatiguecouldhavebeenminimized.Ata minimum,theprocessmaybetriggeredbyanyofthefollowing: a)fatiguereports; b)confidentialreports; c)auditreports; d)incidents;and e)flightdataanalysisevents. 2.2Riskassessment Anoperatorshalldevelopandimplementriskassessmentproceduresthatdeterminetheprobabilityandpotentialseverity offatiguerelatedeventsandidentifywhentheassociatedrisksrequiremitigation. 2.2.1Theriskassessmentproceduresshallreviewidentifiedhazardsandlinkthemto: a)operationalprocesses; b)theirprobability; c)possibleconsequences;and d)theeffectivenessofexistingsafetybarriersandcontrols. 2.3Riskmitigation 2.3.1Anoperatorshalldevelopandimplementriskmitigationproceduresthat: a)selecttheappropriatemitigationstrategies; b)implementthemitigationstrategies;and c)monitorthestrategiesimplementationandeffectiveness.

Figure4.2summarizesthestepsinFRMprocesses.Eachstepisdescribedinmoredetailbelow.

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FRMprocesses 43 FRMPROCESSES Differentoperations(e.g.,ULRoperations,night flights, charter operations, or particular fleets, 1. 1.Identifyoperation(s)to routes,crewbases,etc)havedifferentcausesof fatigueandmayneeddifferentmitigations. whichFRMprocessesapply Collect and analyze data, and use available information on potential fatigue hazards. 2. Decidehowthisappliestoyouroperation. Gather additional data on your operation if 2.Gatherandanalyzedata necessary. Identify the specific nature of the fatigue 3. hazard(s)thatmayneedtobemanaged. 3.Identifyhazards Conduct a safety risk assessment for each 4. identifiedhazard. Decidewhichrisksrequiremitigation. 4.Assesssafetyrisk Implement appropriate mitigation strategies and communicate them to all relevant personnel. 5. 5a.Selectandimplement Set safety performance indicator(s), to be able to assess whether the mitigation strategies are controlsandmitigations deliveringtherequiredlevelofriskreduction. 5b.Setsafetyperformance indicators If mitigation strategies perform to an acceptable standard, they become part of normal operations and are monitored by the FRMSsafetyassuranceprocesses. 6. If mitigation strategies do not perform to an 6.Monitoreffectivenessof acceptable standard, then reenter the FRM mitigations processesattheappropriatestep. Not Effective Effective FRMSassuranceprocesses Figure4.2:FRMProcesses
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FRMprocesses
Averageflighthoursper 24hours Averagedutyhoursper 24hours Averagedurationofrest breaks(hours) 0 10 20 ShortHaul NightCargo LongHaul

4.2 FRMProcessesStep1:Identify theoperationscovered

TomeetICAOFRMSStandards,Statesshouldallow anoperatortochoosewhetheritwillusetheFRMS to manage fatigue risk in all its operations, or only in specific types of operations (for example, only a particular fleet, only ULR operations, etc.). It is important that the operator clearly identifies to whichoperationstheFRMSpertains. Further, as described in Chapter 2, different types of flight operations can involve different causes of crewmember fatigue and may require different controls and strategies to mitigate the associated risks.WithinitsFRMS,anorganizationmayneedto developmultiplesetsofdifferentFRMprocessesfor different operations. These should be clearly identifiable.Ontheotherhand,insomecasesitwill be possible to include multiple types of operations underonesetofFRMprocesses.

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4.3 FRMProcessesStep2:Gather dataandinformation

In Step 2, the Fatigue Safety Action Group gathers requireddataandinformationtobeconfidentthat they can identify the likely fatigue hazards in operationsthatarecoveredbytheFRMprocesses. To do this, the group needs to have a good understanding of the operational factors that are likelytocausecrewmemberfatigue. Toillustratesomeoftheconsiderationsindifferent operations, Figure 4.3 compares flight and duty times in daytime short haul, domestic night cargo, and long haul operations studied by the NASA FatigueProgram2.

GanderPH,RosekindMR,GregoryKB(1998).Flight crewfatigueIV:asynthesis.Aviation,Spaceand EnvironmentalMedicine69(9):B49B60. Uneditedversion

Figure4.3:Averageflight,duty,andrestperiodsina sampleofdaytimeshorthaul,domesticnightcargo, andlonghauloperations Thedaytimeshorthauloperations(2personcrews) hadthelongestdailydutyhours,averaged5flights per day, and had the shortest rest periods. However, they crossed a maximum of 1 time zone per24hoursandtherestbreaksoccurredatnight, duringtheoptimalpartofcrewmemberscircadian body clock cycle for sleep. The main causes of fatigueidentifiedinthisscientificstudywere: restrictedsleepcausedbyshortrestperiodsand earlydutyreporttimes;and high workload, flying multiple sectors in high densityairspaceacrosslongdutydays. The domestic night cargo operations (2 pilots, 1 flight engineer) had the shortest duty periods, averaged 3 flights per duty period, and had longer rest periods than the short haul operations. They also crossed a maximum of 1 time zone per 24 hours.However,thenightcargocrewmembersrest periodsoccurredduringthedayandtheircircadian body clocks (tracked by their core body temperaturerhythms)didnotadapttothispattern. The main causes of fatigue identified in this scientificstudywere: shorter,lessrestorativesleepduringtheday;and beingrequiredtoworkatnight,atthetimeinthe circadianbodyclockcyclewhenselfratedfatigue and mood were worst, and when additional effort would be required to maintain alertness andperformance.

FRMprocesses Thelonghauloperations(2pilots,1flightengineer) had long duty periods, but averaged only 1 flight per duty period and had the longest rest periods. However, every layover was in a different time zone,withamaximumof8timezonescrossedper 24hours.Thecrewmemberscircadianbody clocks (tracked by their core body temperature rhythms) did not adapt to the time zone changes or to the non24hour duty/rest pattern (averaging 10 hours of duty and 25 hours of rest). The main causes of fatigueidentifiedinthisscientificstudywere: long periods of wakefulness (average 20.6 hrs) associated with duty days (there were no onboardcrewrestfacilities); onsomeflights,havingtooperatetheaircraftat the time in the circadian body clock cycle when selfrated fatigue and mood were worst, and additional effort was required to maintain alertnessandperformance; split sleep patterns and short sleep episodes on layovers (usually some sleep at local night and someatbodyclocknight);and on some trip patterns, the circadian body clock drifted away from crewmembers domicile time zone.Asaresult,additionaltimeforcircadianre adaptationwasneededforfullrecoveryafterthe trip. Theseexamplesillustrateafundamentalprinciplein FRMS that flight and duty time limitations do not captureallthecausesoffatigue,whicharedifferent indifferenttypesofoperations. Table 4.1 summarizes the different dutyrelated causes of fatigue identified in these studies , all of whichpredatedULRflightsandinvolvedscheduled operations. The very long duty days in ULR operationsmightbeexpectedtocausefatigue,but theuseofaugmented crewsandtheavailabilityof onboard crew rest facilities for inflight sleep are important mitigation strategies. Unscheduled operations pose particular challenges, because it is hardtoplansleepwhenyoudonotknowwhenyou havetowork,orforhowlong.

45
TYPEOFOPERATIONS CauseofFatigueHazard
Domestic shorthaul Domestic night cargo Long haul

Restrictedsleepduetoshortrest X periods Restrictedsleepduetoearlyduty X reporttimes Multiplehighworkloadperiods X acrossthedutyday Multiplesectors X X Highdensityairspace X Longdutydays X X Extendedwakefulnessonduty X days Highworkloadduringcircadian X X low Shortersleepperiodsatwrong X X timesinthecircadiancycle Circadiandisruption(duetonight X X work) Splitsleeppatternsandshortsleep X X episodesonlayovers Circadiandisruption (dueto X crossingmultipletimezones) Circadiandrift(changesin X circadianpattern)following extendedpatterns Note. These are the causes of fatigue identified in these particularstudies,notanexhaustivelist.

Table4.1:Summaryofidentifiedworkrelated fatiguecauses(fromNASAfieldstudies18) Other potential causes of workrelated fatigue include: additional tasks that are performed immediately priortoaflightoratintermediatepointsduringa seriesofflights; hightotaldutytimeandflighttimeoverspecified periods (per month, per year), which increases theriskofcumulativefatigue; not having the opportunity for adequate recovery sleep after one trip (or set of consecutive duties) before starting the next trip; and other related tasks that crew members may be required to perform before or after flight duty,

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46 for example training activities, administrative duties,orbaggageloadingandunloading. When FRM processes are being set up, it is not always necessary for the operator to gather new data for Step 2. It may be possible to identify potentialfatiguehazardsbasedoninformationand operational experience from similar types of operationsflownbytheoperatororothercarriers, or from published scientific studies of fatigue in similar operations. This is illustrated at the end of theChapter,intheexampleonhowtosetupFRM processesforanewULRroute. For existing routes being moved into the FRMS, data that is already routinely collected by the operator can be analyzed to help identify fatigue hazards,forexampletheuseofcaptainsdiscretion, ontime performance, violations of prescriptive flight and duty time rules, level of sickness absences, and standby usage, or Aviation Safety Reports (ASRs) that mention fatigue. It should be noted that it is a requirement of the FRMS SARPs (Annex 6, Part I, Appendix 8, 1.2 g) that the operator collects data on significant deviations to scheduledandactualflighttimesanddutyperiods, with the reasons for these significant deviations (previouslydiscussedinChapter3). Once the FRM processes become fully operational, data collection and analysis are part of the operators daytoday function, so a range of data willbeavailableroutinelyforStep2.Inaddition,the FatigueSafetyActionGroupmaysometimesdecide to undertake nonroutine data collection to better understandspecificfatiguehazards(forexample,a oneofffatiguesurveyatacrewbase,oratargeted monitoring study on a route where fatigue is identified as a concern). The different types of information and data that can be collected are described in the following sections and in AppendixB.

FRMprocesses 1. predictiveprocesses; 2. proactiveprocesses;and 3. reactiveprocesses. All of these processes gather various kinds of information and data to continuously monitor the levelsoffatigueriskintheoperation(s)coveredby the FRMS. These processes enable the Fatigue Safety Action Group to make datadriven decisions based upon scientifically valid principles and measurements as stated in the ICAO definition of FRMS. As already mentioned, various types of data are involved including measures of operational performance, which operators are familiar with, and measures of the fatigue levels of crewmembers, which will be less familiar to most operators. The following sections and Appendix B provide guidance about measuring crewmember fatigue.Interpretingcrewfatiguedataalsorequires expertise. On some occasions, it may be appropriate for the Fatigue Safety Action Group to seekexternalscientificadviceinthisarea.However, it is also possible for an operator to develop in house expertise in fatigue data collection and analysis. This usually involves a fatigue champion whoisinterestedandmotivatedtodevelopskillsas required. The complexity of operations and the level of fatigue risk need to be considered when evaluatingtheneedfor,andlevelof,expertadvice. 4.4.1 Predictivehazardidentificationprocesses InanFRMS,predictivehazardidentificationfocuses on establishing crew schedules and conditions that consider factors known to affect sleep and fatigue in order to minimise their potential future effects. ICAOAnnex6,PartI,Appendix8liststhreepossible ways of doing this: a) previous experience (of the operator or others in the industry); b) evidence basedschedulingpractices;andc)biomathematical models. a)Previousexperience The collective experience of managers, schedulers, and crewmembers is an important source of

4.4 FRMProcessesStep3:Hazard Identification

ICAO Annex 6, Part I, Appendix 8 requires that an operator develop, maintain, and document three typesofprocessesforfatiguehazardidentification:

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FRMprocesses information for identifying aspects of a proposed schedule that may be associated with increased fatigue. For example, crewmembers may recognize aparticulardestinationwithinaproposedschedule asgeneratingahighleveloffatiguebecauseoftheir past experience of regular delays there caused by heavytraffic.Schedulersmayknowthataparticular city pairing regularly exceeds planned flying time. Management may organize for crew to stay in anotherhotelwherenoiseisaknownproblem. Various information sources should be used. For existing operations, information about schedules mayalreadybeavailablethatcouldbeanalyzedto check for potential fatigue hazards. Examples include the use of captains discretion, ontime performance, violations of prescriptive flight and duty time rules, standby usage, Aviation Safety Reports(ASRs),andleveloffatiguereports. When operational demands are changing, reliance on previous experience can have some limitations. Scheduling based only on previous experience may notgivethemostrobustorinnovativesolutionsfor new situations. It may also be important to collect data on actual levels of crew fatigue, to check whether the lessons from previous experience are stillvalidinthenewcontext. Another way to identify fatigue hazards related to scheduling,forexistingornewroutes,istolookfor information on similar routes. This could include incident reports and crew fatigue reports, or publishedscientificresearchandotherinformation available on similar routes flown by other operators. The amount of confidence that can be placed in this approach depends directly on how similar these other operations really are to the operationinwhichyouaretryingtoidentifyfatigue hazards (see the ULR example at the end of this Chapter). b)Evidencebasedschedulingpractices The value of experience can be enhanced when fatigue science is also applied in the building of schedules. This means considering factors such as the dynamics of sleep loss and recovery, the circadian biological clock, and the impact of

47 workload on fatigue, along with operational requirements. Since the effects of sleep loss and fatigue are cumulative, evidencebased scheduling needs to address both individual trips (multiple, successivedutyperiodswithoutextendedtimeoff), and successive trips across rosters or monthly bid lines. The following are examples of general schedulingprinciplesbasedonfatiguescience. The perfect schedule for the human body is daytimedutieswithunrestrictedsleepatnight. Anythingelseisacompromise. The circadian body clock does not adapt fully toalteredschedulessuchasnightwork.Itdoes adapt progressively to a new time zone, but full adaptation usually takes longer than the 2448hoursofmostlayovers. Whenever a duty period overlaps a crewmembers usual sleep time, it can be expected to restrict sleep. Examples include earlydutystarttimes,latedutyendtimes,and nightwork. The more that a duty period overlaps a crewmembersusualsleeptime,thelesssleep the crewmember is likely to obtain. Working rightthroughtheusualnighttimesleepperiod istheworstcasescenario. Night duty also requires working through the time in the circadian body clock cycle when selfrated fatigue and mood are worst and additional effort is required to maintain alertnessandperformance. Acrossconsecutivedutieswithrestrictedsleep, crewmembers will accumulate a sleep debt andfatiguerelatedimpairmentwillincrease. To recover from sleep debt, crewmembers needaminimumoftwofullnightsofsleepina row, when they are fully adapted to the local time zone. The frequency of rest periods should be related to the rate of accumulation ofsleepdebt. These sorts of principles can be used by an expert reviewer, for example by a scheduler trained in fatigue hazard identification, or by the Fatigue Safety Action Group, to develop evidencebased scheduling rules. The scientific basis for the scheduling rules should be recorded in the FRMS documentation.Thisapproachcanbevalidated,by

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48 monitoring the reported or estimated levels of fatigue across the schedules, using the tools describedbelowandinAppendixB.Validationdata can be used, in turn, to refine and improve evidencebasedschedulingrulesforanoperation. c)Biomathematicalmodels Biomathematical models begin life as computer programs used by scientists to test their current understanding of how factors like sleep loss, circadian rhythms, and workload interact to affect human alertness and performance. The modeling processbeginsbytryingtowriteaprogramthatcan simulate a developmental data set for example selfrated fatigue and performance measured during a sleep loss experiment in the laboratory. If this works, then the model is used to predict a different situation. Data are then collected in this new situation (a validation data set) and model predictionsaretestedagainstthenewdata. Scientific modeling is a continuous improvement process. As scientific tools, biomathematical models are accepted as being incomplete and transient. In scientific best practice, scientists continue designing new experiments to try to find out where their models fail. In this way, they find out where their current understanding is incompleteorpossiblywrong.(Thisisamuchmore efficientwayofincreasingscientificknowledgethan justdoingrandomexperiments.) A range of biomathematical models have been commercialized and are marketed as tools for predicting fatigue hazards relating to scheduling. Therearealsoseveralmodelsavailableinthepublic domain.Usedproperly,thesemodelscanbehelpful tools in FRMS, because it is hard to visualize the dynamic interactions of processes like sleep loss and recovery, or the circadian biological clock. To use models properly requires some understanding ofwhattheycanandcannotpredict.Animportant question to ask about any model is whether it has beenvalidatedagainstfatiguedatafromoperations similartothosethatyouareinterestedin.

FRMprocesses Currentlyavailablemodels: predict group average fatigue levels, not the fatiguelevelsofindividualcrewmembers; do not take into account the impact of workload or personal and workrelated stressorsthatmayaffectfatiguelevels; cannot take into account the effects of personal or operational mitigation strategies thatmayormaynotbeusedbycrewmembers (caffeineconsumption,exercise,improvedrest facilities,etc.); do not predict the safety risk that fatigued crewmembers represent in a particular operation,i.e.,theyarenotasubstituteforrisk assessment (Step 4 in FRM processes see below).Severalavailablemodelstrytopredict safetyriskbymergingsafetydatafromarange of operations in different industries, but their applicability to flight operations has not yet beenvalidated. Themostreliableuseofcurrentlyavailablemodels isprobablyforpredictingrelativefatiguelevelsis the fatigue hazard likely to be greater on this schedule versus that schedule? However, model predictionsshouldnotbeusedwithoutreferenceto operational experience, when making decisions about schedule design. On the other hand, data collectedinthecourseofFRMprocessescouldbea richresourceforimprovingtheperformanceofbio mathematical models, if model designers follow a continuousimprovementphilosophy. Note that Appendix 8, Annex 6, Part I states that methodsforpredictivefatiguehazardidentification may include but are not limited to: operator or industry operational experience and data collected on similar types of operations, evidencebased schedulingpractices,andbiomathematicalmodels. In other words, none of these methods are required,andothermethodsmaybeused.

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FRMprocesses 4.4.2 Proactivehazardidentificationprocesses In an FRMS, proactive hazard identification processes focus on monitoring fatigue levels in an operation. Because fatiguerelated impairment affectsmanyskillsandhasmultiplecauses,thereis nosinglemeasurementthatgivesatotalpictureof acrewmemberscurrentfatiguelevel.andmultiple sourcesofdataarerequired. To decide on which types of data to collect, the most important thing to consider is the expected leveloffatiguerisk.Inotherwords,itisnotagood useoflimitedresourcestoundertakeintensivedata collectionwithmultiplemeasuresonaroutewhere the fatiguerelated risk is expected to be minimal. Resources should be targeted towards operations wheretheriskisexpectedtobehigher. Theimportanceofcollaboration Appendix 8, Annex 6, Part I, requires that an operators FRMS Policy reflect the shared responsibility of management, flight and cabin crews, and other involved personnel. Regulators will need to find evidence of this sharing of responsibility. The success of proactive processes (and of the FRMS)dependsonthewillingnessofcrewmembers to continue participating in data collection. This makesitimportanttoconsiderthedemandsplaced on crewmembers by different types of fatigue relateddatacollection(forexample,measuressuch as filling out a questionnaire once, keeping a sleep/duty diary and wearing a simple device to monitor sleep every day before during and after a trip, doing multiple performance tests and fatigue ratingsacrossflights,etc). The willingness of crewmembers to participate will also reflect their level of understanding of their roles and responsibilities in FRMS, and their confidencethatthepurposeofthedatacollectionis to improve safety. Gathering fatiguerelated data mayinvolvemonitoringcrewmembersbothonduty and off duty, because fatigue levels on duty are affected by prior sleep patterns and by waking activities outside of duty hours. There are ethical

49 considerationsaroundissuessuchastheprivacyof crewmembers,confidentialityofdata,andwhether crewmembers are really free to refuse to participate(voluntaryparticipationisarequirement in scientific studies involving human participants). Many countries have specific legislation around privacy and workplace responsibilities for safety that may need to be considered, in addition to conditionsspecifiedinindustrialagreements. Appendix 8 lists five possible methods of proactive fatiguehazardidentification: a) selfreportingoffatiguerisks; b) crewfatiguesurveys; c) relevantflightcrewperformancedata; d) available safety databases and scientific studies;and e) analysisofplannedversusactualtimeworked. The following sections describe each of these methods in some detail. It should be noted that these are options they are not all required all of thetime. a)Selfreportingoffatiguerisks Crewmembersreportsabouthighfatiguelevelsor fatiguerelatedperformanceissuesarevitaltokeep the Fatigue Safety Action Group informed about fatiguehazardsindaytodayoperations.Aseriesof fatiguereportsonaparticularroutecanbeatrigger for further investigation by the Fatigue Safety ActionGroup. An effective fatigue reporting system requires an effectivereportingculture3.Itneedsto: use forms that are easy to access, complete, andsubmit; have clearly understood rules about confidentialityofreportedinformation; have clearly understandable voluntary reportingprotectionlimits; includeregularanalysisofthereports;and

SeeICAODoc9859SafetyManagementManual. Uneditedversion

410 provide regular feedback to crewmembers aboutdecisionsoractionstakenbasedonthe reports,andlessonslearned. A fatigue report form (either paperbased or electronic) should include information on recent sleepanddutyhistory(minimumlast3days),time of day of the event, and measures of different aspectsoffatiguerelatedimpairment(forexample, validated alertness or sleepiness scales). It should also providespace for written commentary so that thepersonreportingcanexplainthecontextofthe event and give their view of why it happened. An example of a fatigue report form can be found in AppendixB. b)Crewfatiguesurveys Crewfatiguesurveysareoftwobasictypes: 1. retrospective surveys that ask crewmembers abouttheirsleepandfatigueinthepast.These can be relatively long and are usually completedonlyonce,oratlongtimeintervals (forexample,onceayear);and 2. prospective surveys that ask crewmembers abouttheirsleepandfatiguerightnow.These are typically short and are often completed multipletimestomonitorfatigueacrossaduty period, trip, or roster. They usually include measures such as sleepiness, fatigue, and moodratings. Appendix B describes some standard fatigue and sleepinessmeasures(ratingscales)thatcanbeused for retrospective surveys, and others that can be usedforprospectivemonitoring.Thesescaleshave been validated and are widely used in aviation operations. Using standard scales enables the Fatigue Safety Action Group to compare fatigue levels between operations (run by their own operatororothers),acrosstime,andwithdatafrom scientific studies. This can be helpful in making decisionsaboutwherecontrolsandmitigationsare mostneeded. Crewfatiguesurveyscanbefocusedonaparticular operationorissue.Forexample,aseriesoffatigue reports about a particular trip might trigger the

FRMprocesses Fatigue Safety Action Group to undertake a survey ofallcrewmembersflyingthattrip(retrospectiveor prospective), to see how widespread the problem is. The Fatigue Safety Action Group might also undertakeasurvey(retrospectiveorprospective)to get crewmember feedback about the effects of a schedulechange. Surveys can also be more general, for example providinganoverviewoffatigueacrossaparticular aircraftfleetoroperationtype.Figure4.4showsan analysis of the effects of time of day and duty length on fatigue ratings at top of descent (using the SamnPerelli fatigue scale see Appendix B). These data come from the Air New Zealand FRMS and include 3181 ratings made across a 3month period,attheendof12sectorshorthauldutydays that stayed in the crewmembers domicile time zone(twopersoncrews)4.Forshortdutyperiods(2 4 hours) there is a clear timeofday variation in how fatigued crewmembers feel at the top of descent, with highest average ratings between 03:00 and 06:00, and lowest average ratings between15:00and18:00.Incontrast,attheendof long duty periods (1012 hours), fatigue ratings remain high from 00:00 to 09:00 and there is a secondpeakinfatiguebetween12:0015:00.These ratings show an interaction between timeontask fatigue (duty duration) and the daily cycle of the circadian body clock. In addition, crew members who are at the end of a 1012 hour duty period between12:00and15:00will havehadtheirsleep restrictedbyanearlydutyreporttime.

PowellD,SpencerMB,HollandD,PetrieKJ(2008). Fatigueintwopilotoperations:implicationsforflight anddutytimelimitations.Aviation,Spaceand EnvironmentalMedicine79:10471050. Uneditedversion

FRMprocesses Figure4.4:Effectsoftimeofdayanddutylengthon fatigueratingsattopofdescentinshorthaul operationsacrossa3monthperiod Compared to some other types of fatigue monitoring,crewfatiguesurveyscanbeconducted relatively quickly and inexpensively to provide a snapshot of subjective fatigue levels and their potential causes. If a high proportion of crewmembers participate in a survey (ideally more than70%),itgivesamorerepresentativepictureof the range of subjective fatigue levels and opinions across the whole group. Since the information gathered in surveys is subjective (crewmembers personalrecallandviews),gettingarepresentative picture can be important for guiding the decisions andactionsoftheFatigueSafetyActionGroup. c)Crewperformancedata Performancemeasurementsprovideobjectivedata thatcanbeusedtosupplementthesubjectivedata collected in fatigue reports and survey responses. Currently, there are three main approaches to monitoring crewmember performance: 1) simple tests developed in the laboratory, which measure aspects of an individuals performance (for example, reaction time, vigilance, shortterm memory, etc.); 2) flight data analysis (FDA), which examines the relationship between identified elements of aircraft performance and pilot performance; and 3) having trained flight deck observersratingtheperformanceofcrewmembers on the flight deck (for example, LineOriented SafetyAudit). For monitoring crewmember fatigue levels during an operation, the first approach is currently the most practical. A range of objective performance tests are used in scientific research. Things to consider when choosing a performance test for measuring crewmember fatigue include the following. 1. How long does the test last? Can it be completed at multiple time points (for example, in the operations room during pre flightpreparations,neartopofclimb,neartop

411 ofdescent,andpostflightbeforedisembarking from the aircraft), without compromising a crewmembers ability to meet duty requirements? 2. Has it been validated? For example, has it been shown to be sensitive to the effects of sleep loss and the circadian body clock cycle undercontrolledexperimentalconditions? 3. Is the test predictive of more complex tasks, e.g., crew performance in a flight simulator? (Unfortunately, there is very little research addressingthisquestionatpresent.) 4. Has it been used in other aviation operations, and are the data available to compare fatigue levelsbetweenoperations? Appendix B describes a performance test that is commonlyusedtomeasurecrewmemberfatigue thePsychomotorVigilanceTaskorPVT5. Thereisconsiderableinterestinfindingwaystolink crewmemberfatiguelevelstoFDAdataparticularly during approach and landing. FDA data has the advantages that it is routinely collected and is relevant to flight safety. The difficulty is that a multitude of factors contribute to deviations from planned flight parameters. To use FDA data as an indicator of crewmember fatigue would require demonstratingconsistentchangesinFDAdatathat are reliably linked to other indicators of crewmemberfatigue(forexamplesleeplossinthe last24hours,timeinthecircadianbodyclockcycle, etc).Researchinthisareaisongoing. Using trained flight deck observers to rate the performance of crewmembers on the flight deck is very laborintensive and expensive. Having the observer present may also have an alerting effect and place additional demands on crewmembers. These factors currently limit the usefulness of this approachforproactivefatiguehazardidentification inanFRMS. 5 BalkinTJ,BliesePD,BelenkyG,SingH,ThorneDR,ThomasM,
RedmondDP,RussoM,WesenstenNJ(2004).Comparative utilityofinstrumentsformonitoringsleepinessrelated performancedecrementsintheoperationalenvironment. JournalofSleepResearch,13:219227.

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412 d)Availablesafetydatabasesandscientificstudies More general guidance about fatigue hazards may beavailablefromexternalsafetydatabases,suchas Aviation Safety Reports (ASRs) and Mandatory Occurrence Reports (MORs) maintained by safety authorities, or databases maintained by airline organizations or research institutions. Because safety events are relatively rare, databases that collect and analyse them are an important additionalsourceofinformationthatcomplements direct assessment of fatigue levels in the operation(s)coveredbytheFRMS. Afairlylargeamountofscientificresearchhasbeen undertaken on crewmember fatigue in flight operations.Someofthisisavailableontheweb,for example many studies from the NASA Fatigue CountermeasuresProgramcanbedownloadedfree from
http://human factors.arc.nasa.gov/zteam/fcp/FCP.pubs.html

FRMprocesses exceedances of the flight and duty time limits specified in the FRMS, and schedule manipulation byindividualcrewmembers. Monitoringcrewmemberssleep Given the primary importance of sleep loss and recovery in the dynamics of crewmember fatigue, another valuable and commonly used method for proactive fatigue hazard identification is sleep monitoring. Sleep can be monitored in a variety of ways, all of which have advantages and disadvantages (for details,seeAppendixB). The simplest and cheapest method of monitoring sleep is to have crewmembers complete a daily sleep diary before, during, and after the trip(s) being studied. They are typicallyaskedtorecordwhentheysleep,and to rate the quality of their sleep, as soon as possible after waking up. This can be done usingapaperdiaryoranelectronicdevicesuch asaPersonalDataAssistant(PDA). A more objective measure of sleep/wake patterns can be obtained by continuously monitoring movement, using an actigraph. This is a wristwatchlike device that is worn continuously (except when showering or bathing).Dataontheamountof movementis recordedregularly(typicallyeveryminute)and is downloaded to a computer after several weeks, for subsequent analysis. Because actigraphs are not cheap (yet), usually only a sampleofcrewmembersonagiventripwould havetheirsleepmonitoredinthisway.Current systems also require a trained person to processandanalyzethedata. Inrarecases,wheretheexpectedfatigueriskis highoruncertain(forexampleinnewtypesof operations), portable polysomnographic recordingsmaybeusedtomonitorsleepboth inflight and during layovers. This involves applying electrodes to the scalp and face to recordelectricalsignalscomingfromthebrain (electroencephalogram or EEG), eye

Thistypeofresearchtendstobecostlyandlabour intensive and not all types of aviation operations havebeenstudiedindepth.Theparticularvalueof these studies is in their use of more rigorous scientificapproaches,whichincreasesthereliability oftheirfindings.Thelevelofdetailinsomestudies may be more than is needed for proactive identification of fatigue hazards. However, most reports and published papers have executive summaries or abstracts that outline the key findings. e)Analysisofplannedversusactualtimeworked The planning of schedules and rosters based on fatiguescienceaswellasoperationalrequirements permits predictive identification of fatigue hazards (Section 4.4.1 above). However, numerous unforeseen circumstances can cause changes to plannedschedules,forexampleweatherconditions, volcanic ash, unexpected technical problems, or crewmember illness. Crewmember fatigue relates towhatisactuallyflown,notwhatisplanned.Thus another proactive approach for identifying fatigue hazards is to analyze actual schedules and rosters for factors such as ontime performance,

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FRMprocesses movements (electrooculogram or EOG) and chin muscles (electromyogram or EMG). Polysomnography is the gold standard method for evaluating sleep quality and quantity, but it is relatively invasive for participants and expensive both in terms of equipment and because it requires manual scoringandanalysisbyatrainedtechnician. Selectingmeasuresofcrewmemberfatigue Several options have just been described for assessing crewmember fatigue levels in order to identifyfatiguehazards.Appendix8isclearthatthe five methods it lists can be used it does not say that they must be used, or that other methods cannot be used. The following general points are intendedtohelpregulatorsindeterminingwhether operators are using appropriate measures for the appropriatepurpose. 1. Fatiguerelated impairment affects many skills and has multiple causes, so there is no single measurement that gives a total picture of a crewmemberscurrentfatiguelevel. 2. Themostimportantthingtoconsiderinchoosing fatiguemeasuresistheexpectedleveloffatigue risk.Allmeasuresrequireresources(financialand personnel) for data collection and analysis. Limited resources need to be used effectively to identify fatigue hazards and to help the Fatigue SafetyActionGroupprioritizewherecontrolsand mitigationsaremostneeded. 3. A core set of measures can be selected for routine monitoring. For example, crew fatigue reports and regular analyses of scheduling and rostering variations could be used for ongoing monitoringoffatiguehazards. 4. Anadditionalrangeofmeasurescanbeavailable tobeusedifapotentialhazardisindentifiedand the Fatigue Safety Action Group decides that it needs more information about that hazard. Again,themeasuresselectedneedtoreflectthe expectedlevelofrisk.Forexample: A series of complaints about a particular layoverhotelpromptsabriefonlinesurveyof crewmembers using that hotel, to see how

413 widespread the problem is and whether it meritsaction. A series of fatigue reports is received about a tag flight on the end of a particular trip. This prompts monitoring of the sleep, sleepiness, andfatigueratingsofcrewmembersflyingthat trip, using sleep dairies and subjective rating scales. Data collection continues for a month, followed by data analysis, so that within 3 months the Flight Safety Action Group will have the information it needs to reach a decision and plan any necessary controls and interventions (for example, having another crewtakethetagflight). An operator with limited long haul experience gets the regulators agreement to begin developinganFRMSinordertoundertakeULR operations on a specified city pair. As part of gaining regulatory approval for the overall FRMS, the operator is required to undertake intensive monitoring of crewmember fatigue duringthefirst4monthsoftheoperation.This includes monitoring sleep before, during, and after the trip using actigraphs and sleep diaries, as well as ratings of sleepiness and fatigue and PVT performance tests preflight, within30minutesoftopofclimb,beforeeach inflight rest period, within 30 minutes of top of descent, and post flight before leaving the aircraft.Theregulatorrequiresareportonthe findings no later than 6 months after the launchoftheoperation. 5. Balance needs to be maintained between gathering enough data for the Fatigue Safety Action Grouptobeconfidentaboutitsdecisions andactionsandtheadditionaldemandsthatdata collectioncanplaceoncrewmembers. 4.4.3 ReactiveHazardIdentificationProcesses In an FRMS, reactive processes are designed to identifythecontributionofcrewmemberfatigueto safety reports and events. The aim is to identify how the effects of fatigue could have been mitigated, and to reduce the likelihood of similar

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414 occurrences in the future. Appendix 8 lists five examplesoftriggersforreactiveprocesses: a) fatiguereports; b) confidentialreports; c) auditreports; d) incidents;and e) Flight Data Analysis (FDA) events (also known as FlightOperationsQualityAssuranceorFOQA). Depending on the severity of the event, a fatigue analysiscouldbeundertaken bytheFatigue Safety ActionGroup,theoperatorssafetydepartment,or an external fatigue expert. The findings of any fatigue investigation should be recorded as part of theFRMSdocumentation. There is no simple test (such as a blood test) for fatiguerelated impairment. To establish that fatiguewasacontributingfactorinanevent,ithas tobeshownthat; 1. the person or crew was probably in a fatigued state; 2. the person or crew took particular actions or decisions that were causal in what went wrong; and 3. thoseactionsordecisionsareconsistentwiththe typeofbehaviorexpectedofafatiguedpersonor crew. Toshowthatthepersonorcrewwerelikelytobein afatiguedstate,ideallyyouwouldhaveinformation about: howmuchsleeptheyneedtofeelfullyrested; howmuchsleeptheyhadinthe24hoursbefore theaccident(acutesleeploss); howmuchsleeptheyhadinthe72hoursbefore theaccident(cumulativesleepdebt); howlongtheyhadbeenawakeatthetimeofthe event(extendedwakefulness); whether their workload was unusually heavy or lightleadinguptoandduringtheevent; whether they were in a sleepy part of the circadian body clock cycle at the time of the event (early morning or midafternoon, body time);and

FRMprocesses when they last had the opportunity for full recovery from sleep debt (at least two nights of unrestricted sleep in a row, fully adapted to the localtimezone). Thisinformationgenerallyhastobegatheredafter the event, based on the recall of the people involved, and should be confirmed where possible byanyonewithwhomtheyspenttimeleadingupto the event. Where it is not possible to get this information, the duty history can give an idea of what opportunities the person or crew had for sleep. There are no simple rules for interpreting this information (how much acute sleep loss do you needtobefatigueimpaired?howmuchcumulative sleep debt?). Transport Canada has proposed a method for fatigue investigation that provides usefulguidanceforansweringthesequestions,and for deciding if the crewmembers actions or decisions are consistent with the type of behavior expected of a fatigued person or crew, although it has not yet been validated in aviation operations. ThismethodissummarizedinAppendixB.

4.5 FRMProcessesStep4:Risk assessment

Onceafatiguehazardhasbeenidentified,thelevel of risk that it poses has to be assessed and a decisionmadeaboutwhetherornotthatriskneeds to be mitigated. Fatigue risk assessment follows SMS principles (combining risk probability and risk severity). It evaluates the potential for injury, equipmentdamage,orlossduetoafatiguehazard, andprovidesrecommendationsaboutmanagement ofthatrisk,assummarizedinthefollowingtables6.

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FRMprocesses FatigueRiskProbability

415

Meaning Likelytooccurmanytimes(hasoccurredfrequently)

Value

Frequent

Occasional

Likelytooccursometimes(hasoccurredinfrequently)

Remote

Unlikelytooccur,butpossible(hasoccurredrarely)

Improbable

Veryunlikelytooccur(notknowntohaveoccurred)

Extremelyimprobable

Almostinconceivablethattheeventwilloccur

Table4.2a:DefiningFatigueRiskProbability FatigueRiskSeverity

Meaning Multipledeaths Equipmentdestroyed

Value A B

Catastrophic

Hazardous

A large reduction in safety margins, physical distress or a workload such thatcrewmemberscannotbereliedupontoperformtheirtasksaccurately orcompletely Seriousinjury Majorequipmentdamage

Major

A significant reduction in safety margins, a reduction in the ability of crewmembers to cope with adverse operating conditions as a result of increaseinworkload,orasaresultofconditionsimpairingtheirefficiency Seriousincident Injurytopersons

Minor

Nuisance Operatinglimitations Useofemergencyprocedures Minorincident

Negligible

Nosignificantconsequences

Table4.2b:DefiningFatigueRiskSeverity

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416

FRMprocesses

Fatiguerisk
Riskprobability Frequent Occasional Remote 5 4 3 Catastrophic A 5A 4A 3A 2A 1A Riskseverity Hazardous Major B C 5B 5C 4B 3B 2B 1B 4C 3C 2C 1C Minor D 5D 4D 3D 2D 1D Negligible E 5E 4E 3E 2E 1E

Improbable 2 Extremely 1 Improbable

Table4.2c:FatigueRiskAssessmentMatrix
SuggestedCriteria Intolerable Region Tolerable Region Acceptable Region AssessmentRiskIndex 5A,5B,5C 4A,4B,3A 5D,5E,4C,4D 4E,3B,3C,3D 2A,2B,2C 3E,2D,2E,1A 1B,1C,1D,1E SuggestedCriteria Unacceptableundertheexistingcircumstances Acceptablebasedonriskmitigation.May requiremanagementdecision Acceptable

Table4.2d:ICAORiskTolerabilityMatrix However, it should be noted that these tables are 4.6 FRM Processes Step 5: Risk provided as general examples only. In reality, each mitigation operator must develop their own criteria for levels of severity and probability. There are no right and When it is decided that a particular fatigue hazard wrongcriteria,but whatevercriteriaareidentified, requiresaction,thencontrolsandmitigationsmust they must be agreed upon and widely understood be identified and implemented. The specific bythepeoplewhowillthenusethemtomakerisk expertiseoftheFatigueSafetyActionGroupshould assessments. Depending on an operators safety be used in the selection of these controls and management structure, the Fatigue Safety Action mitigations. All involved personnel should clearly Group may identify the severity and probability understand the hazard and the controls and criteria, and then use these to assess the fatigue mitigationsdesignedtoreducetheassociatedrisk. related risks and the need for mitigation in an FRMS. Table 4.3 provides some examples of organizationallevel mitigations for managing fatigue hazards. These are examples only, not exhaustivelists.
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FRMprocesses FatigueHazard
Backtobacknightflights

417

Controls
Schedulingrulesdonotpermitbacktoback nightflights. Allflightsscheduled>12hoursrequire evaluationofstaffinglevelsatcrewbasein departurecity. Establishedcrewstaffingpoliciestosupport operationand monitorstaffinglevelstoensurethatpolicy requirementsarebeingmet. Establishreservecrewstaffingatenroutebase tosupportdiversions Schedulingrules,tripconstruction,rostering, crewaugmentationpoliciestoenableinflight rest,improvedonboardcrewrestfacilities Payattentiontodesignofcrewrestfacilities whenorderingaircraft.Retrofitproblem aircraft. Flightopsmanualcontainsrulesfororganizing inflightrest Schedulingrules,tripconstruction,rostering.

Mitigations
Softwareisprogrammedtoprohibitschedulingofbacktoback nightflights. Reservecrewavailabletocoverexceptionalcircumstances. Relocateadditionalcrewmemberstodeparturecitybase. EnsurethatsufficientreservecrewareavailabletosupportULR flightschedules

LackofULRcrewindeparturecitybase

LackofULRcrewinenroutedivertbase Reportsofinadvertentcrewnappingon theflightdeck

Reservecrewcallout Schedulingchangestoimprovelayoversleepopportunities. FlightOperationsManualprocedureforcontrolledflightdeck nappingdeveloped. Providecrewmemberswitheducationonhowtoobtainoptimalin flightsleep Captainsdiscretiononthedayallowedfororganizationofinflight rest. Internalprocedurestorestrictcrewcontactsduringrestperiods Hotelsrequiredtoprovidesegregatedcrewresthotelareas, minimizingnoise Protocolsforinflightrestandcontrolledflightdecknapping.

Crewmembersnotgettingenoughsleep inonboardrestfacilities

Interruptedsleepperiodsincrewhotels

Landingsataconfluenceofcircadianlow, Schedulingrules,tripconstruction,rostering. extendedworkperiod,andhighwork demands.

Table4.3:ExamplesofFatigueHazardsandOperatorControls andMitigations(notanexhaustivelist)

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418 The effectiveness of implemented mitigations must be assessed, which requires setting safety performanceindicatorssuchasthefollowing. Schedulerelatedindicators: Number of flight deviations (or flight completion not accomplished) on specific city pairings, due to fatigue,lackofstaff,medicalemergencies,etc. Number of bids for pairings identified as high fatiguerisk(e.g.backtobacknightflights). Number of crew duty day exceedances into allowable excesses (as determined through risk assessment.Forexample,longerthan14hours.) Number of flight duty periods determined to be significantlylaterthanscheduled*.. Number of flight duty periods longer than a specified number of hours without a rest break withintheduty. Number of flight times more than a specified numberofminuteslongerthanplanned(e.g.,30or 60minutes). Number of flight duty periods starting within windowofcircadianlow(WOCL). NumberoflandingswithintheWOCL. Numberofdutyperiodswithmorethanaspecified numberofflightsectors. Numberofdutyperiodswithmorethanaspecified numberofaircraftchanges. Number of successive early wakeups, especially combined with long sits between flights or long dutydays. Number of reduced rest breaks within duties (by more than a specified number of minutes determinedtobesignificant)*. Numberofreducedrestbreaksbetweenduties(by more than a specified number of minutes determinedtobesignificant)*. Number of reserve crew callouts (on particular flights,ataparticularcrewbase,etc). *ThisindicatorisaspecificrequirementofanFRMS, (Section 1.2 f), Appendix 8, Annex 6, Part I), and is discussedinChapter3.

FRMprocesses Proactive/reactivefatigueindicators Measureddataoutsideacceptablethresholds(e.g., sleepiness ratings, PVT scores, or inadequate layoversleepduration). Numbers of fatigue reports (sorted in many ways suchasbycrewbase,seat,augmentedflights,fleet types,operationaltypes,etc). Numberoffatiguerelatedincidents. NumberoffatiguerelatedFOQAeventsassociated withaparticularscheduleforwhichfatiguereports havebeenreceived. Absenteeism/fatiguecalls. The implications of such safety performance indicatorsshouldbeconsideredwithinthecontextof the entire operation, to distinguish between acceptableandunacceptablerisk. If the controls and mitigations perform to an acceptablestandard(i.e.,theybringtheriskintothe tolerableregionseeTable4.2d),theybecomepart ofnormaloperationsandaremonitoredbytheFRMS safety assurance processes. If the controls and mitigations do not perform to an acceptable standard, then it will be necessary to reenter the FRM processes at the appropriate step. As indicated in Figure 4.2, this could require: gathering of additionalinformationanddata;and/orreevaluation ofthefatiguehazardandtheassociatedrisks;and/or identification, implementation, and evaluation of neworrevisedcontrolsandmitigations.

4.7 Example: Setting up FRM processes foranewULRroute

In2005,recommendedguidelinesforULRoperations were developed by a Flight Safety Foundation consortium group the Ultra Long Range Crew Alertness Steering Committee. This group identified ULR operations as scheduled operations that exceed 16hours.This16hourdistinctionforULRoperations hassincebecomebroadlyaccepted. This example works through FRMS processes that couldbeusedforestablishinganewULRoperation.It isdevelopedfromanactualsafetycaseforanewULR route that received regulatory approval, but it is an

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FRMprocesses examplenotarecipe.TheacceptedapproachforULR operationsistoevaluateeachcitypairtobeflown7. Figure4.5summarizestheFRMprocesses,whichare explainedinmoredetailinthetext. 4.7.1 Step1Identifytheoperation TheoperationtowhichtheseFRMprocessesapplyis a new ULR route between City A and City B (describedhereastheABAroute). 4.7.2 Step2Gatherdataandinformation Information and data are potentially available from two types of existing operations: longhaul operations that are similar but have flight times under 16 hours; and ULR operations already being flown by other operators. The relevance of the available information depends on how closely the existing operations resemble the proposed new ULR operation. The following factors need to be considered. Crewcomplementandfacilitiesforinflightrest. Crew domicile (if crewmembers are domiciled in the departure city and they have had sufficient timeoffsincetheirlasttransmeridianflight,itcan be assumed that their circadian body clocks are adaptedtodomiciletime). Departure time of the outbound flight (local time andlikelybodyclocktime). Outboundflightdurationandtimezonescrossed. Arrivaltimeoftheoutboundflight(localtimeand likelybodyclocktime). Durationofthelayover. Departuretimeofthereturnflight(localtimeand likelybodyclocktime). Returnflightdurationandtimezonescrossed. 7 FlightSafetyFoundation(2005).FlightSafetyDigest 26.

419 Arrival time of the return flight (local time and likelybodyclocktime). Dependingontheactualcitypairsbeingserved,it may also be relevant to compare winter and summer schedules for takeoff and landing times andflightdurations. In this case, another operator has been flying a ULR tripbetweenCityCandCityD.Thisexistingoperation has the same crew complement and similar departure times, flight durations, layover durations, and patterns of time zone crossings as the ABA route.Aspartoftheregulatoryapprovalprocessfor the CDC route, the operator was required to conduct a 6month operational validation, which included intensive monitoring of crewmember sleep and fatigue. The operator generously makes these findings available for use in the ABA safety case, through an independent scientific team who were involved in the CDC data collection and analysis. (Theexpertiseofthescientificteamensuresthatthe findings are interpreted and applied to the ABA routeinanappropriatemanner.)

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420 FRMPROCESSES 1.Identifyoperation(s)to whichFRMprocessesapply 2.Gatherandanalyzedata 3.Identifyhazards 4.Assesssafetyrisk 5a.Selectandimplement controlsandmitigations 5b.Setsafetyperformance indicators 6.Monitoreffectivenessof mitigations Not Effective Effective FRMASSURANCEPROCESSES

FRMprocesses

1. NewULRrouteCityACityBCityA Route is very similar to an existing ULR route flown by another operator (City CCity DCity C) who 2. collected and analysed data. The other operator agreestoshareinformation. Proactive: biomathematical model predictions are tested against the data from City CCity DCity C. Most reliable model is used to predict fatigue levels onCityACityBCityAroute. 3. Proactive: existing fatigue surveillance methods plus enhancedmonitoringduringthefirst4monthsofthe CityACityBCityAroute. Reactive:systemsareinplaceforanalysisoffatigue contributiontoanysafetyevents. Biomathematical model simulations predict that, withtwocrewsandinflightsleep,fatigueriskisless 4. thanonsomeexistinglonghaulroutes. City CCity DCity C ULR has flown daily for 4 years withoutfatiguerelatedincident. Multiple controls and mitigation strategies implemented(seetext). Datacollectionduringfirst4monthsofoperationto checkbiomathematicalmodelpredictionsoffatigue 5. levels. Performance indicator by4th month ofoperation, nomorefatiguereportspermonththanexistinglong haulroutes. Intensivefatiguemonitoringduringfirst4monthsof 6. operation. Revert to routine monitoring if performanceindicatorsareacceptable.

Figure4.5:FRMprocessesinsettingupanewULRroute
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FRMprocesses 4.7.3 Step3Identifyhazards Predictiveprocesses The operator already has experience with several long haul routes using the same aircraft and crew complement and with similar departure times and time zone crossings to the ABA route, but that remain under the 16hour flight time limit that is used to define ULR. This experience has guided development of the operational plan for the ABA ULRroute. Two biomathematical models are available that can be used to predict the likely levels of crewmember fatigue or alertness on the ABA route. The data collected on the CDC route are used to test how well these models can predict the sleep and fatigue of crewmembers before, during, and after ULR operations. OnemodelmakesthefollowingpredictionsfortheC DC route: that crewmember fatigue levels increase significantly across both the outbound and return flights; that layover sleep is too short to enable recovery before the return flight; and that fatigue levels are potentially unsafe by the end of both flights.Thesepredictionsaredirectlycontradictedby PVTperformancedataandsubjectivesleepinessand fatigueratingscollectedduring thefirst6monthsof the CDC operation, which has flown daily without major incident for four years. The operational data and experience are considered more reliable than thesebiomathematicalmodelpredictions. On the other hand, the second model reliably predicts the duration of inflight sleep on the CDC route (to within the range of variability seen among the crewmembers monitored). This model is chosen topredictcrewmemberalertnessontheABAroute. Proactiveprocesses The following proactive processes for identifying fatiguehazardsareproposedforintensivemonitoring during the first 4 months of the new operation, to validatethepredictionsaboutfatiguelevelsandfine tunethemitigationstrategies,asneeded.

421 Crewmembers are reminded about and encouragedtouseexistingfatiguereportingforms. Forthefirstmonthoftheoperation,aseniorflight crewmember will be present in the Flight Operations Centre for the first and last few hours ofeveryflightontheABAroute,toensurerapid and appropriate management response to any fatiguerelatedissuesarising. ForthefirstmonthoftheABAoperation,asubset ofcrewmembervolunteersisaskedtocompletea sleep and duty diary (with fatigue and sleepiness ratings) before, during, and after an ABA trip. These data will be compared with the same measures collected during the CDC operational validation. Other proactive fatigue monitoring processes that couldbeusedinclude: Asking all crewmembers to complete fatigue and sleepiness ratings at the top of descent on each flight,forthefirstmonthoftheABAoperation. Surveying all crewmembers after the ABA operation has been flown for 3 months, to obtain anoverviewoftheirexperienceoffatigueandthe effectiveness of different mitigation strategies (scheduling, inflight rest facilities, layover hotels, etc). Having a subset of crewmember volunteers who wear actiwatches and complete sleep diaries before,during,andafteracompletetripontheA BAroute.Inadditiontheywouldcompletefatigue and sleepiness scales and undertake PVT performance tests at key times across each flight. These data would be compared with the same measuresfromtheCDCoperationalvalidation. Reactiveprocesses The operator has systems in place for analyzing the contribution of fatigue to safety reports and events, and for determining how to reduce the likelihood of similar events occurring in future. Special attention will be paid to ensuring that any fatigue reports or incidents from the ABA operation are analyzed quicklyandappropriateactiontaken.

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422 4.7.4 Step4Assesssafetyrisk The biomathematical model used to predict crewmember alertness on the ABA route has previouslybeenusedtopredictalertnessonarange of 2person and 3person long haul routes. These predictionsindicatethatminimumalertnesslevelson theABAroutearelikelytobehigherthanonsome existinglonghaulroutes,notably3personwestward return night flights with duty periods of about 14 hours,andlongovernightflightswith2personcrews. Two sets of operational experience support the prediction that the ABA route does not pose excessivefatiguehazards:1)thesafetyrecordofthe CDCoperationwhichhasflowndailyforfouryears; and 2) the ABA operators experience with similar long haul routes using the same aircraft and crew complement,butremainingunderthe16hourflight timelimit. 4.7.5 Step5Selectandimplementcontrolsand mitigations Inthisexample,thefollowingcontrolsandmitigation strategiesareproposedfortheABAoperation. The aircraft chosen for the route has the best availableonboardcrewrestfacilities. All crewmembers flying the new operation are domiciledinthedeparturecity. Allcrewmembersflyingthenewoperationreceive specific education on personal and organizational strategies for managing fatigue on the ABA operation.Thisincludesdiscussiononhowtomake best use of inflight and layover sleep opportunities. All crewmembers have protected time off duty to enabletwofullnightsofsleepinthedeparturecity time zone, so that they have the opportunity to begintheABAoperationfullyrested. There is a clear policy defining oncall arrangementsandtheprovisioningofreliefcrew. The flight crew includes 2 captains and 2 first officers,sothatasinglecaptaindoesnothavesole commandresponsibilityforentireULRflights.This is in accordance with the Flight Safety Foundation ULRrecommendations.

FRMprocesses There is a clear policy on the distribution of in flightrestopportunities,sothatcrewmemberscan planhowbesttousethem. Each crewmember has two rest opportunities per flight, to ensure that they have at least some rest timeoverlappingtheirnormalsleeptimeandthat theyhaveasecondopportunitytogetsomesleep if, for any reason, they are unable to sleep during theirfirstinflightrestperiod. Mealsmaybetakenbytheflightcrewontheflight deck,inordertomaximizetheamountoftimefor sleepduringinflightrestperiods. The layover hotel has been carefully vetted to ensurethatitprovidesadequatefacilitiesforsleep, eating,andexercise. A procedure is implemented between Flight Operations and the layover hotel to provide notification of delays without having to wake crewmembers. Thereareclearproceduresonthemanagementof flightdelays. Thereareclearproceduresonthemanagementof flightdiversions. The following safety performance indicators are identified: Datacollectedduringthefirst4monthsoftheAB A operation will be compared with model predictionsandwiththesamemeasuresfromthe CDC validation, to establish whether crewmemberfatigueandalertnesslevelsareinthe rangepredicted. By the fourth month of the ABA operation, the fatiguereportingrate(reports/flightsegment)and average fatigue report risk level should be comparable to existing long haul routes. No intolerable fatigue reports should be received (seeTable4.2.d). 4.7.6 Step 6 Monitor effectiveness of controls andmitigations Thereisadefinedvalidationperiodforthefirstfour monthsoftheoperationthatinvolvesmoreintensive monitoring.TheFatigueSafetyActionGroupwillhave regular oversight of all data and fatigue reports cominginandwillactinatimelymannerwhenissues arise.

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FRMprocesses At the end of the validation period, a report will be compiled and routine processes will be defined for fatigueriskmonitoringandmanagementontheAB Aroute.Thisreportwillbeavailabletoallinterested parties.Iftheperformanceindicatorsareacceptable, theABAoperationwillreverttoroutinemonitoring. 4.7.7 LinkingtoFRMSsafetyassuranceprocesses Normally, the FRM processes do not operate in isolation from the FRMS safety assurance processes (described in detail in the next Chapter). However, when setting up FRMS in an organization, or for a new type of operation, the data needed for FRMS safety assurance processes are not available before the operation(s) begin flying. This means that it is necessary to have a staged approach to FRMS implementation,whichisdescribedinChapter7.

423

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[Back to Contents]
Chapter5.FRMSsafetyassuranceprocesses

[Back to Overview]
51

Chapter5:FRMSsafetyassuranceprocesses

5.1 IntroductiontoFRMSsafety assuranceprocesses

The FRM processes described in Chapter 4 are the partofthedaytodayFRMSoperationsthatfocuses on identifying fatigue hazards, assessing safety risks, putting in place controls and mitigation strategies, andmonitoringtheireffectiveness. This Chapter works through the basic steps in FRMS safetyassuranceprocesses,whichformanotherlayer inanoperatorsdefensesagainstfatiguerelatedrisk. FRMSsafetyassuranceprocessesarealsopartofthe routine operation of the FRMS, and they monitor howwelltheentireFRMSisfunctioning.They: checkthattheFRMSisfunctioningasintended; check that it is meeting the safety objectives definedintheFRMSpolicy; checkthatitismeetingregulatoryrequirements; identify where changes in the operating environmenthavethepotentialtoincreasefatigue risk;and identifyareasforimprovementinthemanagement of fatigue risk (continuous improvement of the FRMS). Todothis,FRMSsafetyassuranceprocessesusea variety of data and information as safety performanceindicatorsthatcan bemeasuredand

monitored over time. Having a variety of safety performance indicators, plus a safety target for each, is expected to give better insight into the overall performance of the FRMS than having a single measure. Safety performance targets must fall in the tolerable region defined in the risk assessment process (see Section 4.5), and they may need to be revised as operational circumstanceschange.

Figure 5.1 outlines the linkages between the FRMS safetyassuranceprocessesandothercomponentsof the FRMS. The information, data, and safety performance indicators from the FRM processes provide a source of information for the FRMS safety assurance processes. In addition, the FRMS safety assuranceprocesses: useinformationandexpertisefromothersources, both from within the operators organization and external to it, to evaluate the functioning of the FRMS; evaluatetrendsinsafetyperformanceindicatorsto identify emerging or changed hazards and refer thesebacktotheFRMprocesses; identifychangesintheoperatingenvironmentthat couldaffectfatigueriskandreferthesebacktothe FRMprocesses;and provideinputaboutwaystoimprovetheoperation oftheFRMS. Figure5.1:LinkagesbetweenFRMSassuranceprocessesandotherFRMScomponents
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52 SomeoftheFRMSsafetyassuranceprocessescanbe undertakenbytheFatigueSafetyActionGroup,while others (for example audits of the FRMS) would normally be undertaken by other units within the operators organization. The responsibility for different FRMS safety assurance activities may be distributed differently, depending on the size of the organization.Forexample,largeroperatorsmayhave a separate FRMS safety assurance team and/or a designated FRMS safety assurance manager. Communication (in both directions) between the FRMS safety assurance processes and the SMS is

FRMSsafetyassuranceprocesses necessary,sincethesafetyperformanceoftheFRMS will impact on the overall safety performance of the operator. The ICAO requirements for FRMS safety assurance processesareasfollows. Figure 5.2 summarizes the steps in FRMS safety assurance processes. Each step is described in more detailbelow.

Appendix8: 3.FRMSSafetyAssuranceProcesses 3.1TheoperatorshalldevelopandmaintainFRMSsafetyassuranceprocessesto: a)provideforcontinuousFRMSperformancemonitoring,analysisoftrends,andmeasurementtovalidatethe effectivenessofthefatiguesafetyriskcontrols.Thesourcesofdatamayinclude,butarenotlimitedto: 1)hazardreportingandinvestigations; 2)auditsandsurveys;and 3)reviewsandfatiguestudies; b)provideaformalprocessforthemanagementofchangewhichshallincludebutisnotlimitedto: 1)identificationofchangesintheoperationalenvironmentthatmayaffectFRMS; 2)identificationofchangeswithintheorganizationthatmayaffectFRMS;and 3)considerationofavailabletoolswhichcouldbeusedtomaintainorimproveFRMSperformancepriorto implementingchanges;and c)provideforthecontinuousimprovementoftheFRMS.Thisshallincludebutisnotlimitedto: 1)the elimination and/or modification of risk controls have had unintended consequences or that are no longerneededduetochangesintheoperationalororganizationalenvironment; 2)routineevaluationsoffacilities,equipment,documentationandprocedures;and 3)thedeterminationoftheneedtointroducenewprocessesandprocedurestomitigateemergingfatigue relatedrisks.

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FRMSsafetya F assurancepro ocesses Figure5.2:FRMSSafe fetyAssurance eProcesses

53

SafetyAssu S urancePro ocesses

1.Collectandrevie ew data

1. 2.

FRMS safe ety assuranc processes draw ce together in nternal and external sou urces of information to check that the F n FRMS is functioningasintended. RMS effectiveness agains safety st Evaluate FR performanc cetargets.Is itmeetingth hesafety objectives d defined in th FRMS policy? Is it he meetingreg gulatoryrequ uirements? Dotrendsinperformanc ceindicators identify emerging o changed h or hazards? (If s loop so, back to F FRM process ses to asse ess risk, develop an implement appropria nd ate and relevantcontrolsandmi itigations.)

2.Evaluat teoverallFR RMS perf formance

3.Ident tifyemergin ng fatigu uehazards

3. 4. 5.

4.Iden ntifychanges affec ctingFRMS

Use FRM processes t identify potential to fatigue haz zards arising from changes in the operating environmen or organizational nt evelop and im mplement change. Assess risk, de controlsand dmitigations s.

5.Improv veeffectiven ness ofFRMS

Revieweffe ectivenessofallFRMScom mponents. Review controls and mitigations. Effective controls r require no change. In neffective controlssho ouldbemodi ified.Controlsthatare nolongerneededcanbe eeliminated.

FRM Processes FRM MProcess ses

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54

FRMSsafetyassuranceprocesses

5.2

FRMSsafetyassuranceprocesses Step1:CollectandReviewData

Step 1 involves bringing together and reviewing information gained through the FRM processes to examine the overall performance of the FRMS. Performance of the FRMS should be examined through indentifying a variety of safety performance indicators.Theseshouldincludethosespecifictothe FRMS as well as SMS safety performance indicators. Examplesofsafetyperformanceindicatorsspecificto anFRMSwillincludemeasuresobtainedthroughthe FRMprocesses,suchas: The number of exceeded maximum duty days in operationscoveredbytheFRMS; The number of voluntary fatigue reports per month; Theaveragefatiguecallratebyflightcrewsona specificpairing(trip); The ratio of fatigue reports from ULR operations covered by the FRMS to fatigue reports from the long haul operations covered by the prescriptive flightanddutytimeregulations. AttendanceatFRMStrainingsessions; ResultsonFRMStrainingassessments; Thelevelofcrewmemberparticipationinfatigue relateddatacollection; The number times fatigue is identified as an organizationalfactorcontributingtoanevent. ICAO Annex 6, Part I, Appendix 8 indicates that identification of safety performance indicators may resultthroughexaminationof: 1. hazardreportingandinvestigations; 2. auditsandsurveys;and 3. reviewsandfatiguestudies. 1. Hazardreportingandinvestigations Trendsinvoluntaryfatiguereportsbycrewmembers and others can provide valuable insights into the effectiveness of the FRMS. Safety events in which crewmember fatigue has been identified as a contributing factorwill belesscommonthanfatigue reports.However,regularreviewoftheseeventsmay

also highlight areas where functioning of the FRMS could be improved. The value of both these sources of information depends on using appropriate methods for analyzing for the role of fatigue (see Chapter4andAppendixB). 2. Auditsandsurveys Audits and surveys can provide measures of the effectiveness of the FRMS without having to rely on fatigue levels being high enough to trigger fatigue reports or fatiguerelated safety events (both of whicharerelativelyrareevents). Audits focus on the integrity of, and adherence to, the FRM processes. These audits should answer questionssuchas: are all departments implementing the recommendations of the Fatigue Safety Action Group? are crewmembers using mitigation strategies as recommendedbytheFatigueSafetyActiongroup? istheFatigueSafetyActionGroupmaintainingthe requireddocumentationofitsactivities? Audits can also periodically assess the effectiveness oftheFRMS,forexamplebylookingatthestatusof FRMSsafetyperformanceindicatorsandtargets. Audits are external to the Fatigue Safety Action Group,butmaystillbeinternaltotheoperator,i.e., conducted by other units within the organization. In addition,feedbackfromregulatoryauditscanprovide useful information for FRMS safety performance monitoring.Anothertypeofauditthatcanbeusedin this context is to have an independent scientific reviewpanelthatperiodicallyreviewstheactivitiesof the Fatigue Safety Action Group, and the scientific integrity of their decisions. A scientific review panel canalsoprovidetheFatigueSafetyActionGroupwith periodic updates on new scientific developments relevanttotheFRMS. Surveyscanprovideinformationontheeffectiveness of the FRMS. For example they can document how schedules and rosters are affecting crewmembers, either by asking about their recent experiences

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FRMSsafetyassuranceprocesses (retrospective) or tracking them across time (prospective).Surveysforthispurposeshouldinclude validatedmeasures,suchasstandardratingscalesfor fatigue and sleepiness, and standard measures of sleeptimingandquality(seeChapter4andAppendix B). A high response rate (ideally more than 70%) is needed for survey results to be considered representative of the entire group, and response rates tend to decline when people are surveyed too frequently(participantfatigue). 3. Reviewsandfatiguestudies In general, safety reviews are used to ensure that safety performance is adequate during times of change, forexampleduringtheintroductionofanew type of operation or a significant change to an existingoperationcoveredbytheFRMS. A review would start by identifying the change (for example, moving a trip to a crew base in a different time zone, changes in onboard crew rest facilities, significant changes in the total trip, a change of equipmentbeingusedforthetrip,etc).Itwouldthen evaluatetheappropriatenessandeffectivenessofthe FRMS activities relating to the change (for example, proposed methods for fatigue hazard identification, the risk assessment process, proposed controls and mitigations to address the fatigue hazard(s), and measuresoftheireffectivenesstobeusedduringthe implementationofthechange). Fatigue studies as part of FRMS safety assurance processes are undertaken when an operator is concerned about a broad fatiguerelated issue for whichitisappropriatetolookatexternalsourcesof information. These could include the experience of otheroperators,industrywideorStatewidestudies, and scientific studies. These sources of information can contribute in situations when safety arguments based on the limited experience and knowledge within that operator may not be enough. Fatigue studies in this context are mainly used for gathering information about largescale issues in FRMS, rather thanforidentifyingspecificfatiguehazards.

55

5.3

FRMSsafetyassuranceprocesses Step2:EvaluateFRMS Performance

The aim of Step 2 is to validate the effectiveness of the fatigue controls and mitigations (ICAO Annex 6, Part I, Appendix 8). It involves analyzing the informationgatheredinStep1tocheckwhether: all specified FRMS safety performance targets are beingmet; all specified FRMS safety performance indicators remain in the tolerable region defined in the risk assessmentprocess(seeSection4.5); theFRMSis meetingthe safetyobjectivesdefined intheFRMSpolicy;and theFRMSismeetingallregulatoryrequirements. The following are examples of safety performance targets that could be used in FRMS safety assurance processes and that correspond with the safety performance indicators identified above (for additionalexamplesseeSection5.8below). The length of the maximum duty days in operations covered by the FRMS does not exceed the limits defined in the FRMS policy. This is reviewed monthly by a computer algorithm and trendsacrosstimeareevaluatedevery3months. By the fourth month after the introduction of a new operation, there should be a stable low numberofvoluntaryfatiguereportspermonth,or acleardownwardtrendinthenumberpermonth (allowing time for crewmembers and other affectedpersonneltoadjusttothenewoperation). The Fatigue Safety Action Group should provide a written report on the validation phase of the new operation, including analysis of all fatiguerelated events and voluntary fatigue reports, and documentation of the corresponding adjustments madeinfatiguecontrolsandmitigations. No specific pairing (trip) exceeds the average fatiguecallratebyflightcrewsbymorethan25%. ULRoperationscoveredbytheFRMSdonotattract any more fatigue reports than the long haul operations covered by the prescriptive flight and dutytimeregulations.

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56 Inthelastquarter,theFatigueSafetyActionGroup hasmetasoftenasisrequiredintheFRMSpolicy and has maintained all the documentation of its activities that is required for internal and regulatoryauditing. All personnel responsible for schedule design and rostering have met annual FRMS training requirements as specified in the FRMS promotion processes. MeasuresoftheeffectivenessofFRMtrainingand educationprograms(seeChapter6forexamples). Quarterly levels of absenteeism are below the targetspecifiedforeachoperationcoveredbythe FRMS. WhenFRMS safetyperformancetargetsarenotmet orwhensafetyperformanceindicatorsarenotatan acceptable level, the controls and mitigations in use may need to be modified by reentering the FRM processes at Step 2 or beyond (see Figure 4.2). Regulatorsshouldrequirethatoperatorsnotifythem when values for specific safety performance indicatorsreachparticularvalues.Theregulatorcan thenassesshowtheoperatorintendstoaddressthis problemandmonitortheirprogress. For the operator, it may be appropriate to seek additionalinformationfromoutsidetheorganization (forexample,bylookingatfatiguestudies).Itmaybe necessary to undertake a review of compliance of crewmembers and other departments with the recommendations of the Fatigue Safety Action Group.Itmayalsosometimesbenecessarytoreview the functioning of the Fatigue Safety Action Group itself, to find out why the FRMS is not working as intended. Figure 5.3 tracks a measure of the effectiveness of the Air New Zealand FRMS across time1. It shows that the percentage of pilots reporting dutyrelated fatigue occurring at least once a week has declined across a series of surveys conducted between 1993 and2006.
1

FRMSsafetyassuranceprocesses

Figure5.3:Decliningreportsofcrewmemberfatigue acrosssuccessiveAirNewZealandsurveys

5.4

FRMSsafetyassuranceprocesses Step3:Identifyemerginghazards

Analysis of trends in safety performance indicators may indicate the emergence of fatigue hazards that have not previously been recognized through the FRM processes. For example, changes in one part of theorganizationmayincreaseworkloadandfatigue related risk in another part of the organization. Identifying emerging fatigue risks is an important function of FRMS safety performance processes, which take a broader system perspective than FRM processes. Any newly identified fatigue risk, or combination of existing risks for which current controls are ineffective, should be referred back to the Fatigue Safety Action Group for evaluation and management using FRM processes (risk assessment, design and implementation of effective controls and mitigations).

5.5

FRMSsafetyassuranceprocesses Step4:Identifychangesaffecting FRMS

Figure5.3isusedbykindpermissionofDrDavidPowell.

In our dynamic aviation environment changes are a normalpartofflightoperations.Theymaybedriven by external factors (for example, new regulatory requirements, changing security requirements, or

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FRMSsafetyassuranceprocesses changes to air traffic control) or by internal factors (for example, management changes, new routes, aircraft, equipment, or procedures). Changes can introduce new fatigue hazards into an operation, whichneedtobemanaged.Changesmayalsoreduce the effectiveness of controls and mitigations that have been implemented to manage existing fatigue hazards. Step 4 of the FRMS safety assurance processesaimstoidentifywhennewhazardsmaybe aresultofchange. ICAO Annex 6, Part I, Appendix 8 requires that an operator has FRMS safety assurance processes that provide a formal methodology for the management of change. These must include (but are not limited to): 1. identification of changes in the operational environmentthatmayaffectFRMS; 2. identification of changes within the organization thatmayaffectFRMS;and 3. consideration of available tools which could be used to maintain or improve FRMS performance priortoimplementingchanges. A change management process is a documented strategy to proactively identify and manage the safetyrisksthatcanaccompanysignificantchangein an airline1. When a change is planned, the following stepscanbefollowed. Use the FRM processes to identify fatigue hazards, assess the associated risk, and propose controls and mitigations. Obtain appropriate management and/or regulatory signoffthatthelevelofresidualriskisacceptable. During the period of implementation of the change, use the FRMS safety assurance processes to provide periodic feedback to line managers that the FRMS is functioning as intended in the new conditions. An example would be having a validation period for a newULRroute,duringwhichadditionalmonitoringof crewmember fatigue is undertaken, together with more frequent assessment of FRMS safety performance targets and indicators. Documentation of the change management strategy in relation to

57 fatigue management is also the responsibility of the FatigueSafetyActionGroup. Changes in the operational environment may also necessitate changes in the FRMS itself. Examples include bringing new operations under the scope of the FRMS, collecting different types of data, adjustments to training programs, etc. The Fatigue Safety Action Group should propose such changes and obtain approval for them from appropriate management.

5.6

FRMSsafetyassuranceprocesses Step5:Improveeffectivenessof FRMS

Ongoing evaluation by the FRMS safety assurance processes not only enables the FRMS to be adapted to meet changing operational needs, it also allows the FRMS to continuously improve the management of fatigue risk. In doing so, risk controls that have unintended consequences or that are no longer needed due to changes in the operational or organizational environment can be identified, then modified or eliminated through the FRM processes. Examplesinclude: 1. routine evaluations of facilities, equipment, documentationandprocedures;and 2. thedeterminationoftheneedtointroducenew processes and procedures to mitigate emerging fatiguerelatedrisks. It is important that changes made to the FRMS are documented by the Fatigue Safety Action Group so that they are available for internal and regulatory audit.

5.7

Assigning responsibility for FRMS safetyassuranceprocesses

Todelivereffectiveoversightofthefunctioningofthe FRMS, and to examine its functioning in relation to the SMS, the FRMS safety assurance processes need to operate in close communication with the Fatigue Safety Action Group, but with a degree of independencefromit.TheaimistoavoidtheFatigue

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58 Safety Action Group reviewing its own performance. Figure5.4describesanexampleofhowresponsibility for the FRMS safety assurance processes might be assignedinalargeorganization. In this example, the Fatigue Safety Action Group is accountabletotheSafetyTeamforFlightOperations. TheSafetyTeamforFlightOperationsisaccountable in turn to the Executive Safety Team. In Figure 5.4, these lines of accountability are indicated by heavy arrows. (In a large organization, there might eventually be separate FRMSs and Fatigue Safety Action Groups for flight operations, maintenance, ground operations, and inflight services.) The thin linesrepresentinformationflows. Primaryresponsibilityfor theFRMSsafetyassurance processes is assigned to a Quality Assurance person or team that is accountable to the Executive Safety Teamand: maintains close communication with the Fatigue SafetyActionGroup; makes recommendations to the Safety Team for Flight Operations, as needed to improve the functioningoftheFRMS; makes recommendations to the Safety Team for Maintenance, as needed to improve the functioningoftheFRMS; makes recommendations to the Safety Team for Ground Operations, as needed to improve the functioningoftheFRMS; makesrecommendationstotheSafetyTeamforIn Flight Services, as needed to improve the functioningoftheFRMS;and monitors changes in the regulatory environment andtheoperatingenvironmentthatmayaffectthe functioningoftheFRMS. In a smaller operator, responsibility for the FRMS safety assurance processes might reside with an individual rather than a team. This individual may also have a variety of other quality assurance responsibilities. A single safety team might be responsible for flight operations, inflight services, groundoperationsandmaintenance.

FRMSsafetyassuranceprocesses

Figure5.4:Exampleofassignmentofresponsibilityfor FRMSsafetyassuranceprocessesintheflight operationsdepartmentofalargeorganization

5.8

ExamplesofFRMSsafety assuranceprocessesinteracting withFRMprocesses

Figure5.5summarizesinteractionsbetweentheFRM processes and the FRMS safety assurance processes. Together, these two sets of processes form the engine of the FRMS. Both function in a dynamic way in response to the information and data collected and each is responsive to changes in the other. The following examples illustrate some FRMS safety assuranceprocessesanddescribethespecificwaysin whichtheyinteractwiththeFRMprocesses.

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F FRMSsafetya assurancepro ocesses Figure5.5:In nteractionsbe etweenFRMp processesand dFRMSsafety yassurancep processes

59

FRMProces sses
1.Identifyoper ration(s)to whichFRMproc cessesapply

Safet tyAssuranc ceProcess ses

1.C Collectandr review informatio on

2.Gatheranda analysedata

2.Eva aluateovera allFRMS performance

No otOK

3.Identifyhazards

3.I Identifyeme erging f fatiguehaza ards

4.Assesssa afetyrisk

5a.Selectandimplement co ontrolsandm mitigations 5b.Setsafety performanceindicators p

4.Identifycha anges a affectingFR RMS

6.Monitoreff fectiveness ofc controlsandmitigations Not effective

5.Im mproveeffec ctiveness ofFRMS

Effective

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510 Figure5.6:FRMSSafetyAssuranceProcesses

FRMSsafetyassuranceprocesses

Example1 1.Collectandreview information

1.

FRMSPerformanceIndicator ExceedenceofRosteringParameters
Collect and evaluate monthly exceedances ofthe13hourscheduleddutylimit.

2.EvaluateoverallFRMS performance

2.
3.Identifyemerging fatiguehazards

Monthly reviews by the Fatigue Safety Action Group indicate that duties exceeding 13 hours have been trending upwards for 3 monthsinB747operations. Further analysis shows that most of the trend is due to one hub where crews are frequently positioned (dead head) before outboundflightsorafterinboundflights.

3.
4.Identifychanges affectingFRMS

4. 5.

5.Improveeffectiveness ofFRMS

Due to a change in marketing strategy, the totalnumberofB747flightsinandoutofthe hubhasbeensteadilyincreasingfor6months. The the Fatigue Safety Action Group recommends an increase in the size of the crewbaseatthehub.

An improvement to the FRM processes is introduced. Monthly data are collected and analyzed to monitor the number of flights fromallcrewbases.

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FRMSsafetyassuranceprocesses In the example in Figure 5.6, as the result of a risk assessment (FRM processes Step 4), the Fatigue SafetyActionGroupsetsadutylengthof13hoursas oneofitsFRMSsafetyperformanceindicators(SPIs). Thetargetis tohavenomorethan twoinstancesof duties in excess of 13 hours per week in B747 operations.Itcollectsandassessesmonthlydataon scheduled and actual exceedances of the 13hour dutylimitacrossallitsB747flightsinandoutofthe hub.For3consecutivemonths,thereisanincreasing trendinexceedances. AshorthaulexampleisdescribedinFigure5.7.Here, theuseofcaptainsdiscretionistrackedasanFRMS safetyperformanceindicator.MostStateregulations allow for flight duty periods to be increased on the day of operation at the discretion of the relevant captain. In this example, in the FRMS processes, the Fatigue SafetyActionGrouphasconductedariskassessment (see Table 4.2 d) and decided to set the following thresholdsforshorthaulflights: intolerableregiondiscretionusedonatleast25% offlightdutyperiodsinatwomonthperiod;

511 tolerable region discretion used on 1025 % of flightdutyperiodsinatwomonthperiod; acceptable region discretion used on less than 10%offlightdutyperiodsinatwomonthperiod. In addition, delays of more 2 hours must be logged andpresentedtotheFatigueSafetyActionGroup. Data on use of discretion are collected in a log generated by the operators crew management system.TheFatigueSafetyActionGroupanalyzesthis data monthly, to ensure that the trips being created by the scheduling software are realistic, given the usual operating conditions. The data are sorted by trip (sequence of consecutive flight duty periods), distinguishing between regular scheduled trips (that recur for several roster periods, e.g., monthly bid lines) and trips that are introduced temporarily to cover variations in scheduling or crewmember availability at a particular crew base. Data are also analyzed by crewmember rank, category, and qualifications to see, for example, if trips with more frequentuseofdiscretionareavoidedbymoresenior crewmembers).

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512 Figure5.7:FRMSSafetyAssuranceProcesses

FRMSsafetyassuranceprocesses

Example2 1.Collectandreview information

1.

FRMSPerformanceIndicatorUseof CaptainsDiscretion
Use of captains discretion recorded in the OperationsLogandanalyzedmonthly An outandback daily shorthaul trip has had an unacceptable level of use of captains discretion (at least 25% of flights) for 3 consecutive months, averaging 30 minutesdelaybeyondtheplannedbufferof 40minutesforallflights. Further analyses identify the main causal factors as air traffic control en route and ground handling, especially of late passengerstothegate. Schedule Planning and Ground Operations are notified. They had not previously identifiedtheissue.

2.EvaluateoverallFRMS performance

2.

3.Identifyemerging fatiguehazards

3. 4. 5.

4.Identifychanges affectingFRMS

Notapplicable

5.Improveeffectiveness ofFRMS

SchedulePlanningandNavigationServicesfile a different route that delivers time and fuel savings. Ground Operations management negotiateanewServiceLevelAgreementwith the handling agent that reduces turnaround times and improves passenger satisfaction ratings. Average length of duty periods reduced,useofcaptainsdiscretionreturnsto theacceptableregion.

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FRMSsafetyassuranceprocesses The next example (Figure 5.8) looks at an operator whose FRMS uses scheduled maximum values for planning purposes that are well within the established riskassessed, regulatorapproved, outer boundaries of the FRMS. In this example, on a particular day at a particular crew base, the maximum value of scheduled duty time periods defined in the FRMS have been exceeded multiple times Every exceedance of the scheduled duty times requiressubmissionofareporttotheFatigueSafety Action Group, which is added to the FRMS documentation for regulatory audit. In addition, the FRMS safety assurance processes require that the reasons for each exceedance are investigated and that, if required, corrective action is taken. In this example,thefunctionsofFRMSsafetyassuranceare undertakenbytheSMSteamaspartoftheirbroader SMS safety assurance functions. This is to ensure thatthemanagementoffatiguerisksdoesnotresult in unintended consequences in overall risk management, that the actions taken by the Fatigue SafetyActionGrouparenotselfmonitored,andthat there is appropriate distribution of resources across boththeFRMSandtheSMS. In this example, the monthly review of exceedances by the SMS team responsible for FRMS safety assurance processes identifies a cluster of

513 exceedences that occurred on the same day in the same place. They notify the Fatigue Safety Action Group.TheFatigueSafetyActionGroupcontactsthe line manager responsible for crewing resources on thedayandaskshimtointerviewthestaffondutyon thatday.Theinvestigationrevealsthattherewerea series of problems that coincided on that particular day, which combined to produce the outcome of multiple exceedances of the scheduled duty time limits. It is unlikely that this same combination of problemswouldrecur.However,theeffectivenessof the FRMS is improved by a series of measures that improvesthemanagementofstaffinthecrewoffice intimesofunexpectedhighworkload. Monthly analyses of exceedances of the scheduled dutytimelimitsspecifiedintheFRMScouldconsider: the total number of Level 1 and Level 2 exceedances; the areas of the organization involved in exceedances; causesandextenuatingcircumstances;and patterns of overdue submission of reports on exceedances. The Fatigue Safety Action Group is responsible for developing and implementing any recommended mitigations,inconsultationwiththeteamresponsible fortheFRMSsafetyassuranceprocesses.

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514 Figure 5.8: FRMS Safety Assurance Processes

FRMSsafetyassuranceprocesses

Example3 1.Collectandreview information

1.

FRMSPerformanceIndicator Exceedancesofscheduleddutytime limitsspecifiedintheFRMS

The SMS team responsible for FRMS safety assurance processes identifies multiple exceedances of FRMS scheduled duty time limits on a specific day at a particular location. TheSMSteamaskstheFatigueSafetyAction Group to conduct an investigation in conjunction with staff members who were workingonthatday. Causalfactorsidentifiedwere: aircrafttechnicalproblemsatthelocation; temporary shortage of standby flight crewmembers due to a peak in sickness levels; lack of staff on duty in the Crewing Departmentduetoadepartmentalmeeting; and absenceofanycontingencyplantomanage thesituationwhenworkloadofcrewingstaff becomesexcessive.

2.EvaluateoverallFRMS performance

2.

3.Identifyemerging fatiguehazards

3.
4.Identifychanges affectingFRMS

4. 5.

Notapplicable. StaffinglevelsintheCrewingDepartmentare reviewed and increased, and a contingency plan is developed and implemented for managingextremeworkload. Subsequently, this enables the operation to withstand significant winter weather disruption, resulting in safety and financial benefits.

5.Improveeffectiveness ofFRMS

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FRMSsafetyassuranceprocesses Figure 5.9 describes an example that uses another type of FRMS safety performance indicator a code incorporatedintherosteringsoftware thatindicates when a crewmember is approaching the limit for maximumallowablemonthlyflighthours.Ifthecode issettotriggerbelowtheflighthourslimitdefinedin the FRMS policy, then this provides a buffer that enables some flexibility and reduces the risk of exceedances.Ineffect,itactsasanalertlevel. Each month, the Fatigue Safety Action Group analyses how often the code is activated, i.e., how often crewmembers are approaching the maximum monthlyflighthours,andwherethisishappening.An increasing trend in code indicates increasing workloadforflightcrewmembers,andcanbedueto anincreasingnumberofflightsbeingscheduled,ora reduced number of crewmembers available to fly them,orboth.Seasonalanalysesarealsoundertaken to indicate whether this is a normal cyclical pattern that requires shortterm remedial action, or a separate upward trend that requires long term remedialaction. In this example, monthly analyses by the Fatigue Safety Action Group have revealed that occurrences

515 of scheduled and actual flight hours triggering the codehaveincreasedin Julycompared withJune,for Captainsataparticularcrewbase. Note: Itispossibletoincorporateavarietyofcodesinthe rostering software to track when different rostering parameters are approaching limits specified in the FRMS.Thesecodescanbeseparatedintocategories, for example by fleet, crewmember rank and crew base,andanalyzedinavarietyofways,including: numberoftimesthatcodesoccurforactualversus rosteredschedules; analysisofwhich dutyor flighthourslimitismost frequently approached, and in which part of the operationthisismostlikelytooccur; monthbymonth trends in numbers of codes occurring; rolling 13month trends (recalculated each month for the last 13 months, to cover a full cycle of seasonalchanges); longertermtrends,forexample3yearlytrendsby crewmemberrank.

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516 Figure 5.9: FRMS Safety Assurance Processes

FRMSsafetyassuranceprocesses

Example4 1.Collectandreview information

1.

FRMSPerformanceIndicatorCode TrackingHighMonthlyFlightHours
Code (scheduled and actual) is triggered for CaptainsatCrewBaseA morefrequentlyin JulythaninJune. Code relates to the limit of 100 hours of flighttimein28consecutivedays. Further analyses show that the number of Captains available at Crew Base A has been stable for the last 3 months. However, CaptainsfromCrewBaseAareincreasingly being positioned to cover a shortage of CaptainsatCrewBaseB.

2.EvaluateoverallFRMS performance

2.
3.Identifyemerging fatiguehazards

3. 4. 5.

4.Identifychanges affectingFRMS

Notapplicable.

5.Improveeffectiveness ofFRMS

Captains from Crew Base C are added to the rosterto help cover shortages at CrewBase B. Captains from Crew Base A that are assigned flightsservicedbyCrewBaseBarelimitedto operating shorter flights to help reduce their totalflighthours. In August, the number of times the code is triggered decreases for rostered duties for CaptainsatCrewBaseA.Subsequentanalyses indicatethatthischangehasreducedtheuse ofstandbyandincreasedrosterstability.

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[Back to Contents]
Chapter6.FRMSpromotionprocesses

[Back to Overview]
61

Chapter6:FRMSpromotionprocesses
6.1 IntroductiontoFRMSpromotion processes
This Chapter details the requirements for FRMS promotion processes that include training programs and a communication plan. Figure 6.1 outlines the linkagesbetweentheFRMSpromotionprocessesand otherFRMScomponents.AlongwiththeFRMSpolicy and documentation, the FRMS promotion processes support the core operational activities of the FRMS (FRM processes and FRMS safety assurance processes). Like SMS, FRMS relies on effective communication throughout the operators organization1. On the one hand, there needs to be regular communication about the activities and safety performance of the FRMStoallstakeholders.Dependingonthestructure of the organization, this may come from the Fatigue Safety Action Group, the SMS, or from an accountable executive responsible for the FRMS communication plan. On the other hand, crewmembers and other stakeholders need to communicate promptly and clearly about fatigue hazards to the Fatigue Safety Action Group or other relevantmanagement. All involved personal should be trained and competent to undertake their responsibilities in the FRMS,andstandardsforinitialandrecurrenttraining should be specified in the FRMS documentation. A specialfeatureofFRMStrainingisthatkeyprinciples of fatigue science managing sleep and understandingtheeffectsofthecircadianbodyclock are relevant not only to individuals roles in the FRMSatworkbutalsototheirlivesoutsideofwork, for example in safe motor vehicle driving and in stayinghealthy.ThusFRMStrainingcoversissuesthat everyone can identify with personally, and this can helppromotetheconceptofsharedresponsibilityin anFRMS.

Figure6.1:LinkagesbetweenFRMSpromotion processesandotherFRMScomponents

ICAOSafetyManagementManual(Doc9859),Section9.1 Uneditedversion

62 The ICAO requirements for FRMS promotion processesareasfollows(Annex6,PartI,Appendix8). Annex6,PartI,Appendix8 4.FRMSpromotionprocesses 4.1 FRMSpromotionprocessessupporttheongoing development of the FRMS, the continuous improvement of its overall performance, and attainment of optimum safety levels. The following shall be established and implemented by the operatoraspartofitsFRMS: a)training programs to ensure competency commensurate with the roles and responsibilitiesofmanagement,flightandcabin crew,andallotherinvolvedpersonnelunderthe plannedFRMS;and b)aneffectiveFRMScommunicationplanthat: 1) explains FRMS policies, procedures and responsibilities to all relevant stakeholders; and 2) describes communication channels used to gather and disseminate FRMSrelated information.

FRMSpromotionprocesses appropriate training. This includes crewmembers, crew schedulers, dispatchers, operational decision makers, all members of the Fatigue Safety Action Group,andpersonnelinvolvedinoveralloperational risk assessment and resource allocation. It also includes senior management, in particular the executive accountable for the FRMS and senior leadership in any department managing operations withintheFRMS. 6.2.2 Curriculum The content oftrainingprogramsshouldbeadapted according to the knowledge and skills required for eachgrouptoplaytheirparteffectivelyintheFRMS. All groups require basic education about the dynamics of sleep loss and recovery, the effects of the daily cycle of the circadian body clock, the influence of workload, and the ways in which these factorsinteractwithoperationaldemandstoproduce fatigue(seeChapter2).Inaddition,itisusefulforall groups to have information on how to manage their personalfatigueandsleepissues. The ICAO SMS guidance (Doc 9859) recommends a buildingblock approach to training. Applying this approach to FRMS, training for crewmembers could addressthefollowingareas. An overview of the FRMS structure and how it worksintheoperatorsorganization; Theirresponsibilitiesandthoseoftheoperator,in theFRMS,includingeffectivesafetyreporting; Causes and consequences of fatigue in the operation(s)inwhichtheywork; FRM processes in which they play a vital role, particularlyintheuseoffatiguereportingsystems andimplementingmitigations; The importance of accurate fatigue data (both subjectiveandobjective); Howtoidentifyfatigueinthemselvesandothers; Personal strategies that they can use to improve their sleep at home and to minimize their own fatigue risk and that of others, while they are on duty;and

6.2 FRMStrainingprogrammes
Inadditiontotheaboverequirements,ICAOAnnex6, PartI,Appendix8requiresthatanoperatormaintain documentation that describes and records FRMS training programs, training requirements, and attendance records. It further recommends that regulators have competency requirements for FRMS traininginstructors,whomaybepartofanoperators internaltrainingdepartmentorexternalcontractors. 6.2.1 Whoneedstobetrained For an FRMS to be effective, all personnel who contributetoFRMSsafetyperformanceneedtohave

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FRMSpromotionprocesses Basic information on sleep disorders and their treatment, where to seek help if needed, and any requirementsrelatingtofitnesstofly. FRMS training for personnel involved in crew schedulingcouldaddressthefollowingareas. An overview of the FRMS structure and how it worksintheoperatorsorganization,includingthe concepts of shared responsibility and an effective reportingculture; A robust understanding of how scheduling affects sleep opportunities and can disrupt the circadian biological clock cycle, the fatigue risk that this creates, and how it can be mitigated through scheduling; Comprehensive training in the use and limitations of any scheduling tools and biomathematical models or other algorithms that may be used to predict the levels of crewmember fatigue across schedulesandrosters; TheirroleintheFRMSinrelationtofatiguehazard identificationandriskassessment; Processes and procedures for assessing the potential fatigue impact of planned scheduling changes, and for ensuring that the Fatigue Safety Action Group is engaged early in the planning of changes with significant potential to increase fatiguerisk; Processes and procedures for implementing scheduling changes recommended by the Fatigue SafetyActionGroup; Howtoidentifyfatigueinthemselvesandothers; Personal strategies that they can use to improve their sleep at home and to minimize their own fatigue risk, and that of others, while they are at work;and Basic information on sleep disorders and their treatment,andwheretoseekhelpifneeded. FRMS training for members of the Fatigue Safety Action Group, and for others with responsibility for safety decisionmaking that affects FRMS performance, could address (at least) the following areas.

63 A full understanding of all FRMS components and elements(policyanddocumentation;processesfor hazard identification, risk assessment, mitigation, and monitoring; safety assurance processes for monitoring FRMS performance, managing change, andforcontinuousimprovementoftheFRMS;and FRMS promotion processes, including training and communication); The responsibilities and accountabilities of differentstakeholdersintheFRMS; Linkages between the FRMS and parts of the operatorsoverallsafetymanagementsystem; LinkagesbetweentheFRMSandotherpartsofthe organization, for example the scheduling department, flight operations, medical department,etc.; RegulatoryrequirementsfortheFRMS; Howtoidentifyfatigueinthemselvesandothers; Personal strategies that they can use to improve their sleep at home and to minimize their own fatigue risk, and that of others, while they are at work;and Basic information on sleep disorders and their treatment,andwheretoseekhelpifneeded. FRMStrainingforseniormanagementcouldaddress thefollowingareas. An overall understanding of crewmember fatigue and the safety risk that it represents to the organization; An overview of the FRMS structure and how it works, including the concepts of shared responsibility and an effective reporting culture, andtheroleoftheFatigueSafetyActionGroup; The responsibilities and accountabilities of different stakeholders in the FRMS, including themselves; An overview of the types of fatigue mitigation strategiesbeingusedbytheorganization; FRMS safety assurance metrics used by the organization; LinkagesbetweentheFRMSandotherpartsofthe operatorssafetymanagementsystem; LinkagesbetweentheFRMSandotherpartsofthe organization, for example the scheduling

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64 department, flight operations, medical department,etc.; RegulatoryrequirementsfortheFRMS; Howtoidentifyfatigueinthemselvesandothers; Personal strategies that they can use to improve their sleep at home and to minimize their own fatigue risk, and that of others, while they are at work;and Basic information on sleep disorders and their treatment,andwheretoseekhelpifneeded.

FRMSpromotionprocesses safety and scientific data, and to reflect current operating conditions. Nevertheless, they provide usefulexamplesofthetypeandlevelofinformation thatcanbeusedininitialFRMStraining,particularly for flight crew. They are useful examples, but each operator will need to look at how relevant the training materialsarefortheirparticularoperational needs. Table6.1providessomeexamplesofpersonalfatigue mitigation strategies that might be covered in FRMS trainingforflightcrew.

Examples of training materials developed by the NASA Fatigue Countermeasures Program for flight crew in different types of operations are freely availableontheinternet.2 TheoriginalgenerictrainingpackageCrewFactors in Flight Operations X: Alertness Management in FlightOperationsEducationModuleisavailableat: http://ntrs.nasa.gov/archive/nasa/casi.ntrs.nasa.go v/20020078410_2002126547.pdf The training package Crew Factors in Flight OperationsXIV:AlertnessManagementinRegional FlightOperationsEducationModuleisavailableat: http://human factors.arc.nasa.gov/zteam/PDF_pubs/REGETM_XI V.pdf The training package Crew Factors in Flight Operations XV: Alertness Management in General AviationEducationModuleisavailableat: http://humanfactors.arc.nasa.gov/publications/B_ Flight_Ops_XV_GAETM1.pdf These training packages draw on fatiguerelated safety data and scientific research. Each package includes a slide presentation with explanatory text. Theyaredesignedtobeusedasapersonalresource by crewmembers, and/or as a live presentation that lasts at least an hour. In addition, the Regional and GeneralAviationModulesincludesummariesfrom a numberofNASAstudiesandsafetyreports.Itshould be noted that these materials date from 20012002 and need to be updated to include more recent
2

WebaddressesaccurateasofAugust2,2010 Uneditedversion

FRMSpromotionprocesses Table6.1:Examplesoffatiguehazardsandpersonalmitigationstrategies(notanexhaustivelist) FatigueHazard PersonalMitigationStrategies

65

Sleep at home disturbed by Movetoaquietpartofthehouseforfinalsleepbeforedeparture. newbaby Maximizesleepin24hoursbeforedeparture. Controlledflightdecknapping,maximizesleepduringinflightrestperiods(if available). Strategicuseofcaffeineinflight. Inflight sleepiness on non Maximizesleepin24hoursbeforedeparture. augmentedflights Controlledflightdecknapping,strategicuseofcaffeineinflight. Difficulty sleeping in onboard Maximizesleepin24hoursbeforedeparture. crewrestfacilities Useeyemask,earplugs,arrangeasuitablewakeupcall. Avoidcaffeinefor34hoursbeforetryingtosleep. Strategicuseofcaffeineafterinflightrestperiod. Difficulty sleeping in noisy, SubmitafatiguereporttotheFatigueSafetyActionGroup. poorlycurtained rooms in Useeyemask,earplugs,arrangeasuitablewakeupcall. layoverhotel Avoidcaffeinefor34hoursbeforetryingtosleep. Nonrestorativesleep Seeasleepdisordersspecialist. Complyfullywithrecommendedtreatment. Unpredictablecallouts Ensure that sleep environment is dark and quiet, and use sleep hygiene measurestomaximizesleepquality. Maximiserecoverysleeponoffdutydays. Whenfeelingsleepywhilewaitingforcallout,attemptsleep(prioritisesleep overotheractivities). Controlledflightdecknapping,maximizesleepduringinflightrestperiods(if available) Strategicuseofcaffeineinflight. Aspecificcitypairingresultsin SubmitafatiguereporttotheFatigueSafetyActionGroup. landing when extremely Controlledflightdecknapping. fatigued. Maximizesleepduringinflightrestperiods(ifavailable). Strategicuseofcaffeineinflight. Extended commute prior to Arriveatdutylocationwithsufficienttimetoallowadequatesleep,ensuring scheduledflightdutyperiod. fitnessforduty.

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66 6.2.3 FRMStrainingformatsandfrequency There are a variety of ways in which FRMS training can be delivered, each of which has strengths and limitations. Live training sessions with a trained instructorhavetheadvantagethatcrewmemberscan askquestionsabouttheirspecificissuesorconcerns, andcanlearnfromeachothersexperiences.Faceto facecontactwithdifferentstakeholdersintheFRMS can facilitate relationships and information sharing, and foster trust. However, live training requires coordinating a time and place that groups of participants can attend, and involves time getting to andfromthevenue,inadditiontothetimerequired fortheactualtrainingsession. Webbased learning or distributed training (for example,usingDVDs)allowsgreaterflexibilityinthe time and place that training occurs. Individual participation allows participants to proceed at their own pace through the training materials. In web based learning, sessions can be networked so that multipleparticipantscanjoininwithatutoronline. Material can also be made interactive (a task has to be completed, for example a short quiz answered, before the participant can move on to the next part of the training). Participants and tutors can interact via designated chat rooms. Webbased learning programs can also direct participants to explore a variety of other resources available on the internet. Ontheotherhand,itishardertoeliminatecheating when learning assessments are completed online than when they are completed in a classroom. This maybeimportantfortrainingevaluation(seebelow). Providing different materials and formats for recurrent training can help to maintain interest. For example, recent fatigue reports or Fatigue Safety Action Group interventions can be used as case studies to illustrate and revise concepts covered in the initial training material. Recurrent training can also cover changes to the operations or the FRMS, andscientificandregulatoryupdates.Thefrequency andnatureofrecurrenttrainingneedstobedecided by the Fatigue Safety Action Group, in consultation withprofessionaltrainers(internalorexternaltothe operator) as needed. Many regulators may also

FRMSpromotionprocesses prescribe requirements on the frequency of FRMS training. 6.2.4 FRMStrainingevaluation The effectiveness of FRMS training and education programsshouldbeperiodicallyevaluated.Examples ofevaluationtoolscanincludethefollowing. Toevaluateimmediateknowledgetransferfrom a training session, participants can be given a short quiz assessing fatigue knowledge, to be completed before and after the training session (foranexample,seethetextboxbelow). Toevaluate theamountofknowledge retained, crewmembers use of suggested countermeasure strategies, and perceived usefulness of training, a survey can be conducted at a fixed time after training (for example,6months). Findings from the quiz and surveys can be used to: o revisethe contentofthe trainingpackage,to improve the training on topics which a significant proportion of crewmembers have notfullyunderstood; o provide feedback to trainers on areas where they may need to change or improve their teachingapproaches;and o identify areas that need to be reviewed or addedinrecurrenttraining.

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FRMSpromotionprocesses QUIZ(forusebeforeandafterinitialtraining)
Aretheseideastrueorfalse? 1. 2. 3. 4. 5. 6. 7. 8. Sleepisatimewhenyourbrainswitchesoff. Dreamingsleepisbetterforyouthannondreamingsleep. Intheend,theonlywaytogetridofsleepinessistogetsomesleep. Youcanalwaysbeatsleepiness,ifyoutryhardenough. Asyougetsleepier,yourreactiontimeslowsdown. Nappingisasignoflaziness. Thecircadianbodyclockadaptseasilytosleepingduringtheday. Therearetwotimesofdaywhenyourcircadianbodyclockmakesyoufeelmostsleepy, around35amand35pm. 9. 10. 11. 12. 13. Havingaregularroutineatbedtimecanhelpyoutofallasleepmoreeasily. Adark,quietroomhelpsyousleepbetter. Ifyoudrinktoomuchcoffeeandcantsleep,youshoulddrinksomealcoholtohelpyourelax. Evenifyouarenotsleepy,youshouldstarteachflightwithacupofcoffee,tofightfatigue. Youareinthecockpitandyoufeelincrediblysleepy.Thebestthingtodoisnottotellanyone, andtotryextrahardtostayfocused. 14. Fatiguewouldnotbeaproblemifthescheduleswereproperlydesigned. True False True True True True True False False False False False

67

Pleasetickoneboxforeachquestion. True True True True True True True True False False False False False False False False

6.2.5 FRMStrainingdocumentation ICAO Annex 6, Part I, Appendix 8 requires that an operator keep documentation that describes and records FRMS training programs, training requirements,andattendancerecords.

describes communication channels used to gather and disseminate FRMSrelated information. TheFRMStrainingprogramsareclearlyanimportant part of the communication plan. However, training generally occurs at fairly long intervals (for example annually). In addition, there needs to be ongoing communication to stakeholders about the activities andsafetyperformanceoftheFRMS,tokeepfatigue on the radar and encourage the continuing commitmentofallstakeholders.Avarietyoftypesof communication can be used, including electronic media(websites,onlineforums,email),newsletters,

6.3 FRMScommunicationsplan
ICAOAnnex6,PartI,Appendix8requiresanoperator tohaveanFRMScommunicationplanthat: explains FRMS policies, procedures and responsibilitiestoallstakeholders;and

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68 bulletins, seminars, periodic poster campaigns in strategiclocations,etc. Communications about the activities and safety performance of the FRMS (from the Fatigue Safety ActionGrouporotherdesignatedmanagement)need to be clear, timely and credible, i.e., consistent with the facts and with previous statements, The informationprovidedalsoneedstobetailoredtothe needs and roles of different stakeholder groups, so that people are not swamped by large quantities of informationthathaslittlerelevancetothem. Communications from crewmembers are vital for fatigue hazard identification, for feedback on the effectiveness of controls and mitigations, and in providing information for FRMS safety performance indicators (for example, by participating in surveys and fatigue monitoring studies). For these communications to be open and honest, all FRMS stakeholders need to have a clear understanding of the policies governing data confidentiality and the ethicaluseofinformationprovidedbycrewmembers.

FRMSpromotionprocesses There also needs to be clarity about the thresholds that separate nonculpable fatiguerelated safety events from deliberate violations that could attract penalties. Timelyfeedbacktocrewmemberswhosubmitfatigue reports is vital. Feedback does not require completionofafullinvestigation.Everycrewmember shouldreceiveatimelyresponsetotheirreportwith some indication of the planned followup activity. For example To Capt Smyth; thank you for your fatiguereportyesterdayregardingflight123fromAA toZZ.ThisreporthasbeenforwardedtotheFatigue Safety Action Group, which is currently investigating an adverse trend in fatigue reports associated with this trip and is evaluating a number of potential mitigationstrategies. Thecommunicationplanneedstobedescribedinthe FRMS documentation and assessed periodically as partofFRMSsafetyassuranceprocesses.

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[Back to Contents]
Chapter7.DecidingtoofferFRMSregulations

[Back to Overview]
71

Chapter7:DecidingtoofferFRMSregulations
FRMS requires a performancebased regulatory approach and any performancebased regulation offers particular challenges to the regulator. Instead of identifying and then monitoring compliance with prescribed requirements, performancebased regulation requires the identification of acceptable performance outcomes and validation of the system bywhichtheoutcomesareachieved.Thisdifference in approach necessitates a change in the knowledge baseandskillsetsofthevariousindividualsinvolved in developing the regulations and providing the oversightofthesesystems.Italsohasimplicationsfor the way in which the regulator and the operator interactandontheregulatorsresources. However, according to 4.10.1 (Annex 6, Part I), the regulatordoesnothavetodevelopFRMSregulations. Only flight and duty time limitation regulations are mandatory.Thischapterdiscussessomeoftheissues that should be considered in making the decision whether to provide FRMS regulations and when establishingFRMSregulations. USOAP audits focus on the State's capability for providing safety oversight by assessing whether the critical elements of a safety oversight system have been implemented effectively (Refer to ICAO Doc 9734 for additional details). Additionally, the LEI measurement is based on the applicable USOAP protocol questions that are not satisfactorily addressed by the State for each critical element. Consequently,theLEIcanbeusedasameasurement ofthematurityoftheStatesoversightsystem. A State with a low LEI score (<30%) should already havethefollowing: Comprehensive regulation in conformity with InternationalStandards Consistentregulatoryoversight Aneffectiveincidentandaccidentinvestigation Employment of a sufficient number of qualified personnel Consistent compliance with regulatory requirementsbytheindustry Effectivehazardsandincidentsreportingsystem ConsistentcoordinationofRegionalProgrammes Effective hazards and incidents reporting and analysisintheindustry ThismeansthatalowLEIStateisabletoconcentrate onthefollowingareas: FullimplementationofitsStateSafetyProgramme (SSP) Useoftechnologytoenhancesafety Continuous improvement of the civil aviation system Consistent use of Safety Management Systems (SMS)bytheindustry Consistent adoption of industry best practices by theindustry Alignmentofindustrysafetystrategies These are the types of focus areas that effective FRMSregulationdemands.Stateswithmedium(30 50%) or high LEI (> 50%) scores do not have safety

7.1 IstheStatessafetyoversight systemmatureenough?

FRMS has the potential of both improving safety performance and allowing increased operational flexibility. As a performancebased approach however, appropriate, experienced and knowledgeableregulatoryoversightisasessentialas effective implementation by the operators for these benefitstoberealized.Regulatorswhohavenothad significant experience with performancebased regulations should consider very carefully whether they have the resources to develop and oversee FRMSregulations. The States Lack of Effective Implementation (LEI) measurement, identified through participation in ICAOs Universal Safety Oversight Audit Programme (USOAP),mayprovidesomeguidancetoStatesasto theircapabilitytoregulateandoverseeanFRMS.The

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72 oversight systems mature enough to allow them to focus on these areas and are likely to have difficulty inadequatelyregulatingandoverseeingFRMS.

DecidingtoofferFRMSregulations development process. These include, but are not limitedto,thefollowing: a) Thematurityofexistingprescriptiveflightandduty limitations and the resources required to enhance these limitations to ensure that current scientific principles and knowledge related to fatigue underpinthoseregulations; b) Development of specialist fatigue competency requirements (knowledge, skills, experience) for inspectoratestaffwhowilloverseeFRMS.Thiswill requiredevelopmentofcompetencybasedtraining programmes and may also require on the job training and instruction (OJTI) to ensure staff are aware of the intricacies of an FRMS from an operational perspective, particularly where staff have had limited operational exposure to fatigue managementand/orSMS; c) Knowledge in the development, design and implementation of training programmes to allow assessment of the efficacy of learning outcomes developed by the operator within its own FRMS trainingprogrammes; d) The availability of fatigue scientists to provide supportwithmoretechnicalelementsoftheFRMS such as the limitations of various tools (e.g. biomathematical models). Where limited specialistsareavailable,theremaybeaconflictof interest if the same specialist is supporting the development of State regulations and also providing direct support with developing an operators FRMS. Limited access to fatigue specialists may also increase the time needed to develop FRMS regulations, train inspectorate staff and limit the number of FRMS applications the Statecanhandleatanygiventime; e) The resources and time required to develop clear guidelinesforoperatorstoensuretheyunderstand the States regulatory processes, timelines (e.g. howlongitmaytakeforapproval),howtheFRMS willbeassessed,costs,etc; f) Development of tools to provide standardization and support to FRMS surveillance activities e.g.

7.2

Dowehaveadequateresources?

New regulatory approaches create an initial, increased regulatory workload. For States, the decision to allow their operators the option of using FRMS will mean establishing performancebased regulations in accordance with the ICAO Standards for FRMS, while continuing to maintain and oversee prescriptive flight and duty limitations. State employees designated to be responsible for the development of FRMS regulations and for the oversight of FRMS will require adequate knowledge, experience and training with regards to fatigue science and FRMS, and they may initially need the supportoffatiguescientists/specialistsasadvisors.A thorough familiarization with this manual is a good start, but further training and information gathering might be necessary and may require consultation with ICAO or other States with more advanced and matureFRMSregulationsandpractices. Detailedplanningtodeterminethetasksrequiredto support regulatory development of FRMS will maximize the opportunity for a State to adopt processes commensurate with resources. In most cases this may warrant initial activity that adopts a gradual and phased approach to developing FRMS regulations,e.g.updatingprescriptiveflightandduty time limitations and developing specialist fatigue knowledgeandskillsoftheinspectoratestaffpriorto commencementoftheFRMSregulatoryprocess. Detailedplanningwillprovideabetterunderstanding oftheworkloadandhowtheresourcesrequiredcan best be used. For example, the State may need to prioritizeinitialapplicationstouseFRMS.Inadequate planning of the States resources can lead to inefficientregulatoryprocessesduetolengthydelays with operators gaining FRMS approval. To better understand the resources required, States should consideranumberofareastosupporttheregulatory

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DecidingtoofferFRMSregulations structured questionnaires for inspectorate staff to use with crewmembers to elicit feedback on their understanding and the effectiveness of the FRMS. These can be useful in determining such things as the level of understanding of fatigue science and thelimitationsofvariousFRMStools; g) Assessment of the contribution of fatigue in accident and incident investigations. States may need to consider further training of inspectors or rely on the expertise of the local accident investigationagency; h) The likely timeframes and resources for ongoing surveillance e.g. reviewing and collating fatigue data provided by the operator, conducting observation flights, interviewing key staff within the FRMS, reviewing previous State audits to monitorthesystemovertimetoprovideindicators ofsystemperformance,etc. i) Resources to ensure the State remains up to date withemergingfatiguescience,includingupdatesto theregulatoryprocess,inspectoratetrainingetc. TomeettheirFRMSoversightobligations,Stateswill have to establish and maintain a database that identifies what means of fatigue management each operator is using and, where FRMS is being used, to whatpart(s)oftheoperationitapplies.

73 operator should not underestimate the workload required with developing guidance material, processing applications and providing suitable oversighttotheFRMS.Iftheprescriptiveregulations are not aligned with appropriate fatigue science or theyre too restrictive, it could force larger numbers of operators towards FRMS with a significant and potentially unmanageable workload for all parties. Theregulatormaynotbeabletoprocessapprovalsin adequate timeframes to the frustration and commercial detriment of the operator and the operatorsmaynothaveaccesstoadequatespecialist resources to support development. Robust prescriptive regulations remain an essential element oftheregulatoryframework. Further, prescriptive flight and duty time limitations providethebaselinefromwhichtheFRMSisassessed in terms of an equivalent level of safety. An FRMS provides the evidence by which a regulator can approve an alternative means of compliance to the prescriptivelimitationsformanagingfatigue. The regulator must also consider fallback options should an operator consistently fail to demonstrate appropriate use of an FRMS (see Chapter 9). Well developed prescriptive regulations remain a viable option through which an operator can be returned shouldtheybeunsuccessfulintheuseoftheirFRMS.

7.3 IfweofferFRMS,canwepayless attentiontoourprescriptiveregulations?

No. Prescriptive flight and duty time limitations remain a mandatory ICAO requirement. Both flight anddutytimelimitationsandFRMShavetheirplace within the regulatory framework. It is the States responsibility to develop scientificallybased prescriptive flight and duty time limitation regulations. Guidance on developing scientifically based prescriptive regulations are provided in AttachmentA,Annex6,PartI. While FRMS offers significant benefits over prescriptive regulations, both the regulator and

7.4 WhatiftheStatealreadyhasa processtoapproveanFRMSand/or operatorswithanapprovedFRMS?

It would be necessary for the State to conduct a review of its existing regulations, guidance material, procedures and processes to identify any gaps between existing practices and the ICAO SARPs. It wouldalsobearequirementtoreviewanyapproved FRMSagainsttheICAO SARPstodeterminewhether any critical gaps exist and whether this may be exposing the operator to unacceptable fatigue risk. For example, if there was no evidence the operator hadproactivelycollectedanyfatiguedatatofurther understand the impact of fatigue on any operations being managed by an already approved FRMS, its

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74 possibletheoperatorandtheregulatorareunaware of the actual impact of fatigue and the potential fatigue risk. Furthermore, without adequate data it would be difficult to meet the requirements of 4.10.6(c)(d)inprovidingevidencetodevelopquality assurance processes and to confirm that continuous improvementoftheFRMShasoccurred. So,itwillalsobenecessaryfortheStatetoidentifya process for the operator to amend their current FRMS to comply with the new FRMS requirements. There will also have to be an identified process for managing operators back under prescriptive flight anddutylimitationregulationswhocannotorwillnot amendtheirFRMSasrequired.

DecidingtoofferFRMSregulations that the operator can correctly manage the variationandtherequiredmitigations. Where there are preexisting approved variations, a means for assessing their continued acceptability needstobeidentified.Whereitisdeterminedthatan FRMS is required rather than a variation, a process fortransitionalsoneedstobeidentified.

7.6 Howwillweassessthe acceptabilityoftheoperatorproposed outerlimitsoftheirFRMS?

States should require that the operator provide a safetycasetosupporttheproposedvaluesforouter limits. The decision to accept or deny the proposed outerlimitswillrelyonavarietyoffactorsincluding: Whether or not the operators safety case is supported by wellestablished scientific principles andoperatingexperience; Research findings from multiple studies and differentauthors; Operational insights from multiple sources, includingallrelevantstakeholders; Demonstrated maturity of the operators SMS practices and/or demonstrated ability to manage riskappropriately; Previous history of regulatory compliance of that operator; Experience gained through regulatory oversight of a variety of operators implementing an FRMS or givingapprovalofvariationstoflightanddutytime limitationregulations. Where the operator wishes to use the FRMS in different types of operations (e.g. where they operatelonghaulandseparatelyoperateshorthaul), outer limits should be identified for each operation type.Forexample,anoperatorsULRoperationsmay require a maximum value of 22 hours within which the FRMS can function but this does not mean that thesamemaximumvalueisanacceptableboundary for their FRMS with regard to their short haul operations.

7.5 Whenshouldtheoperatorapply foravariationandwhenshouldtheybe requiredtoimplementanFRMS?

Standard4.10.3,Annex6,PartIallowsforvariations to prescriptive flight and duty time limitations in exceptional circumstances without full FRMS requirements. When establishing its regulations, a Statewillneedtoclearlyidentifywhatconstitutesthe exceptional circumstances for application to a variation,sothatadistinctionismadebetweenwhen variations to prescriptive flight and duty time limitations may be sought by an operator and when they are required to implement an FRMS. Variations tend to be short term in nature, routespecific, and relate to very minor extensions beyond prescriptive regulations.Theyareapprovedonthebasisofarisk assessmentanduseofmitigationsacceptableto the regulator. As a minimum, for an individual operator seeking variation without FRMS, the regulator must be assuredthat: a) there is an acceptable focal person(s) or fatigue management subject matter expert within the organization;and b) the operator has proven high standards demonstrated through their routine regulatory oversight audits, so that the State has confidence

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DecidingtoofferFRMSregulations It should be kept in mind, however, that overly restrictive outer limits may mean that an operator achieves no extra operational flexibility in implementinganFRMS.Therehastobesomeroom for movement to allow the FRMS to function 3. properly. On the other hand, because these values 4. are extreme limits, they cannot be considered as targets. So, the identified maximum flight and duty and minimum rest values should lean to the outer limits of acceptability taking into consideration the types of operations being undertaken, physiological sleep requirements and circadian factors (following Attachment A guidance), although these should be rarely, if ever, reached. When reached or exceeded, these should be documented, trended and reported to the State. Based on these trends, more stringent oversight of the FRMS may be adopted by the regulator(seeChapter9).
. 4.7.1.1 Themaximumflighttimemaynotexceed: a) (*)hoursinanyflightdutyperiod; b) (*)hoursinany[7]consecutivedaysor(*)hoursinany[28]consecutivedays;and c) (*)hoursinany[365]consecutivedays. . 4.7.2.1 Dutyhoursmaynotexceed: a) (*)hoursinany[7]consecutivedaysorinaweek;and b) (*)hoursinany[28]consecutivedaysorinacalendarmonth. . 4.7.3.1 Themaximumflightdutyperiodshouldbe(*)hours. . 4.8.1 Theminimumrestperiodimmediatelybeforecommencingaflightdutyperiodmaynotbelessthan (*)hours. .

75 dispelledbyasinglesufficientperiodofrestorsleep) and cumulative fatigue (incomplete recovery from transient fatigue over a period of time) need to be addressed. ThismeansthatStatesshouldrequirethatthereare identified outer limits for a day and across multiple days (e.g. weekly, monthly, annually). The guidance material for the development of prescriptive fatigue managementregulationsinAttachmentAofAnnex6, PartIcanbehelpfulhere.Forexample,excerptsfrom Attachment A indicate that limitations should be specifiedforthefollowing:

7.7 Whataretheaspectsofan operationforwhichFRMSouterlimits havetobedetermined?

When identifying the aspects of an operation for which the operator has to identify maximum values for flight and duty periods and minimum values for rest periods, both transient fatigue (fatigue that is

7.8 Whydontwedevelopregulations thatrequireFRMStobeacomponentof SMS?

On the face of it, FRMS is simply a clearlydefined, singlefocused management system, so it would appearthatthefunctionsofanFRMSshouldjustbe incorporatedintothefunctionsofanSMS.Whilethe

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76 SARPs do not preclude such an approach, there a several complex issues that must be considered before regulating for such an organizational structure. First,despitefirstappearances,FRMSandSMShavea different focus and functions. FRMS is an optional management system which focuses only on fatigue related risks. It allows an operator to establish their ownflightanddutytimelimitationsasdeterminedby the FRMS risk management and safety assurance processes. SMS is a required management system, which covers mitigation of all operational risks with nofocusononeovertheother.UnlikeFRMS,anSMS does not permit an operator to move outside of prescriptive flight and duty time limitations. So, the particularrequirementsofanFRMSfarexceedwhat would be expected of an SMS to manage fatigue related risks. It is important that the focus and functions of an SMS do not override those of an FRMSandviceversa. Nevertheless, information from an FRMS should inform an operators SMS, and vice versa (discussed earlier in Chapter 1, under Standard 4.10.7). Therefore, FRMS must be supported by an oversight processthatincludesexaminationoftheinformation flow between the FRMS and the SMS. This is discussedinChapter9. Second, regardless of the similarities in framework and their complementary nature, FRMS has an approval process that differs from the process of acceptanceforSMS.HavinganapprovedFRMSdoes not mean that an operators SMS is automatically accepted,andconversely,thewithdrawalofapproval of an FRMS does not mean that an operator is absolved of the responsibility of managing their safety risks (including fatigue) through their SMS processes.

DecidingtoofferFRMSregulations

7.9 TheFRMSprovisionsrequirethat significantdeviationsinscheduledand actualflighttimes,dutyperiodsandrest periods,andreasonsforthosesignificant deviations,berecordedbyoperators. Howdowemonitorthat?

Not every flight that exceeds a scheduled time by a minute, or rest period that is cut short by two minutes, needs to be recorded. The amount of data collectionthatwouldrequireisnotonlyonerous,but unnecessary. The requirement is for the operator to record significant deviations that can be used to highlight when there might be increases in fatigue relatedrisk.Thisdatacanprovideinformationthatis useful for both the operator and the regulator. The operatorcanuseinformationprovidedbyanalysisof such data to help manage their fatiguerelated risks andtheregulatorcanusetheinformationasapartof theirroutinemonitoringofanFRMSandasameans toidentifywhenanoperatormustimmediatelynotify theregulator.

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[Back to Contents]
Chapter8.FRMSapprovalprocess

[Back to Overview]
81

Chapter8:TheFRMSapprovalprocess
Once the State has decided that it will offer FRMS regulations, it will be necessary for the regulator to identify exactly what they expect operators to do throughout the implementation process to gain final approval for an FRMS. The regulator needs to document their requirements in detail. This chapter deals with establishing a documented approval process. Figure 8.1 summarizes a phased approach to FRMS implementation. 8.1.1 PhaseI:Planning TheobjectiveofPhaseIisfortheoperatortoarrive at an overall plan to demonstrate to the regulator howtheFRMSwillfunction,howitwillbeintegrated with other parts of the operators organization, who will be accountable for the FRMS, and who will be responsible for making sure that FRMS implementationissuccessfullycompleted. Itisrecognisedthatsomeoperatorsmaywishtouse outside consultants to come in and provide them withanFRMSasaquickandrelativelypainlessway of meeting their regulatory obligations. However,an FRMS requires ownership and commitment by the peoplewho willbeusing it,andtheregulatorneeds to see evidence of that ownership and commitment from the early stages of its inception. While experts

8.1 AphasedapproachtoFRMS implementation

ThereisnoofftheshelfversionofanFRMSthatwill suitalloperators.Eachoperatorneedstodevelopan FRMS that is appropriate to its organization and operations and the nature and level of the fatigue risk(s). A fully functioning FRMS doesnt happen overnight.TheFRMSprocessestaketimetoplanand develop so the operator needs to implement their FRMSinstages,asisrecommendedforSMS1.

Figure8.1:PhasedapproachtoFRMSimplementation
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82 can offer invaluable assistance within an FRMS at certain times, they do not have the operational knowledgeandexperienceoftheoperator. They should not be the interface between the regulatorandtheoperator.Therelationshipbetween theregulatorandtheoperatorconcerningtheuseof FRMS should be identical to their relationship concerning the prescriptive flight and duty time limitationregulations. GapAnalysisandDevelopinganImplementationPlan ManyelementsneededforanFRMSmayalreadybe inplaceinanoperatorsorganization.Oneofthefirst steps in FRMS implementation is therefore for the operatortoundertakeagapanalysisto: identify elements of the FRMS that are already availableinexistingsystemsandprocess; identifyexistingsystemsandprocessthatcouldbe modifiedtomeettheneedsofFRMS(tominimize reinventingthewheel);and identifywherenewsystemsandprocessesneedto bedevelopedfortheFRMS. For example, an operator may already have a confidential safety reporting system as part of its SMS.Existingreportformsmayneedtobemodified toincludetheinformationneededtoanalyzetherole offatigueinsafetyevents.Additionaltrainingmaybe needed for the staff responsible for analysing safety data,toensurethattheyknowhowtoanalyzeforthe roleoffatigueinevents.Aprocedurewillneedtobe addedforinformationonfatiguerelatedeventstobe communicated on a regular basis to the Fatigue Safety Action Group. Fatigue reports may also be usedasanFRMSsafetyperformanceindicator.Inthis case, a procedure would need to be added for this information to be evaluated regularly as part of the FRMSsafetyassuranceprocesses. Data on scheduled and actual flight and duty times are required to be collected under the prescriptive flight and duty time regulations. An operator that is moving some of its operations into an FRMS could add a variable to the existing flight and duty time databases to identify the operations covered by the

FRMSapprovalprocess FRMS, so that this information can be analyzed separatelyasrequiredfortheFRMS(4.10.8,Annex6, Part I). Procedures will need to be added for this information to be communicated to the Fatigue SafetyActionGroupandrecordedasrequiredinthe FRMSdocumentation. Rosteringrelated data may already be available for FRMS performance indicators, for example monthly exceedences on duty limits, use of captains discretion, use of extended duties, or violation occurrence reports. A procedure will need to be added for this information to be evaluated regularly aspartoftheFRMSsafetyassuranceprocesses. It may be efficient to schedule FRMS training to coincide with other training activities that already bringthetargetgroupstogether. The results of the gap analysis are used as the basis for the development of the operators FRMS implementationplan.Essentially,thisprovidesaroad mapdescribinghowthedevelopmentofeachofthe FRMSprocesseswillproceed,withtimelines. BytheendofPhaseI,theoperatorshouldhave: completedagapanalysis. An FRMS Policy Statement signed by the accountable executive. Developing the policy at thebeginningoftheFRMSimplementationprocess willassistindefiningthescopeoftheFRMS. AnFRMSimplementationplan. An FRMS documentation plan. This can be expected to evolve as the FRMS becomes operational. An FRMS communication plan. This can be expected to evolve as the FRMS becomes operational. Allocation of financial and human resources. The AccountableExecutivefortheFRMSneedstohave the authority and control to ensure that this happens. A Fatigue Safety Action Group (or equivalent) is established. Thestageat whichtheFatigueSafety Action Group is established will vary, according to thesizeandcomplexityoftheorganizationandthe

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FRMSapprovalprocess FRMS, and whether there are suitably qualified people in other parts of the organization who are availabletobeginthePhaseIactivities. InordertomoveontoPhaseII,theoperatorshould be required to provide their FRMS plan to the State for review. This is an opportunity for the State to assess and identify potential problem areas prior to the State or the operator investing excessive time andeffort. 8.1.2 PhaseII:ImplementreactiveFRMprocesses PhaseIIrequirestheoperatortoimplementthe(first version) of the FRM processes. It does this by gathering and analyzing existing sources of information and data that are relevant to the operations covered by the FRMS. Types of information that may be available include confidential safety reports, accident reports and incident investigations, audits, and historical rostering data (for example, data on scheduled and actual flight and duty times, exceedances, etc.). In effect, Phase II activities consolidate existing fatigue risk management processes and procedures in the organization, and introduce controls and mitigations to manage identified deficiencies in the existing system. By the end of Phase II, the operator should have accomplishedthefollowingsteps: FRM processes based on reactive hazard identification are operational, including risk assessmentandthedevelopment,implementation, and monitoring of appropriate controls and mitigations. FRMSdocumentationprocessesareestablishedto supportthecurrentversionoftheFRMS. FRMStrainingactivitiesareestablishedtosupport the current version of the FRMS. (Stakeholders needtrainingtoensurethattheyarecompetentto undertaketheirresponsibilitiesintheFRMSasthe implementationplanrollsout). FRMScommunicationprocessesareestablishedto supportthecurrentversionoftheFRMS. Theoperatorisready to undertake coordinated safetyanalysesofthisfirstversionoftheFRMS,

83 similar to the process used when implementing SMS(ICAOSMM10.4). 8.1.3 PhaseIII:ImplementProactiveand PredictiveFRMProcesses PhaseIIIaddsproactiveandpredictivefatiguehazard identificationprocesses(discussedinChapter4)into theFRMprocessesestablishedinPhaseII. By the end of Phase III, the operator should have accomplishedthefollowingsteps: FRM processes based on reactive, proactive, and predictive hazard identification are operational, including risk assessment and the development, implementation, and monitoring of appropriate controlsandmitigations. FRMSdocumentationprocessesareestablishedto supportthecurrentversionoftheFRMS. FRMStrainingactivitiesareestablishedtosupport the current version of the FRMS. (A single programmetothelevelrequiredforthefullFRMS implementation may be more efficient than part trainingateachPhaseoftheimplementation.) FRMScommunicationprocessesareestablishedto supportthecurrentversionoftheFRMS. The operator is ready to undertake coordinated safety analyzes of this version of the FRMS (ICAO SMM10.4). 8.1.4 PhaseIV:ImplementFRMSsafetyassurance processes Phase IV activates the FRMS safety assurance processes (Chapter 5 of this manual). By the end of Phase IV, the following steps need to be accomplished. Roles and responsibilities for assuring the safety performanceoftheFRMSareestablished. The necessary authorities and communication channelsareactive. FRMS safety performance indicators have been developedandagreedon.

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84 The procedures and processes for periodic evaluationofthesafetyperformanceindicatorsare established. Appropriate feedback is established between the FRM processes and the FRMS safety assurance processes. FRMS documentation processes are fully implemented. FRMStrainingprocessesarefullyimplemented. FRMS communication processes are fully implemented. In other words, by the end of Phase IV, the FRMS should be fully functional and integrated with the operatorsSMSandotherpartsoftheorganizationas appropriate.Itshouldbecontinuouslyimprovingand able to respond to changes in the organization and theoperatingenvironment. RegulatoryapprovalforthefullFRMSissoughtatthe endofPhaseIV. 8.1.5 OperationalexampleofstagedFRMS implementation OperatorAisamajorairlinethatfliesprimarilylong range,transoceanicflightswithmultinationalcrews. Ithasbeenflyingfor20yearswithanexcellentsafety record. Operator A is interested in starting an FRMS for both of its long range fleets. The CEO decides to implementFRMSfortheentireoperationtoenhance safetyandefficiency. ThisexampleworksthroughthestepsthatOperator AcouldfollowtoestablishafullyoperationalFRMS.It assumesthatmanagementatOperatorAarefamiliar withinformationintheFRMSImplementationGuide for Operators (2011, a joint publication by ICAO, IATA,IFALPA)andarereadytostartimplementation. PhaseI 1. ResponsibilityforFRMSimplementationassigned toadesignatedFRMSmanager. 2. FRMS manager assembles an implementation team, and organizes training for the team on FRMSbasicsandfatiguescience.

FRMSapprovalprocess 3. Accountable Executive for the FRMS allocates resources and authority to support FRMS development. 4. FRMS manager identifies internal stakeholders (departmentrepresentatives). 5. FRMSpolicystatementisdrafted. 6. Gap analysis undertaken by FRMS manager and implementationteam. 7. FRMS documentation plan developed and first draftestablished. 8. FRMS communication plan developed and first draftestablished. 9. Implementation plan developed, with initial timeline. 10. Fatigue Safety Action Group established with required stakeholder membership and meets regularly with the implementation team (if differentemployees)todiscussprogress. PhaseII 11. Fatigue Safety Action Group works through the FRM process diagram (Chapter 4), using existing information and data for reactive fatigue hazard identification. a) Step 1 decide whether domestic, international long haul and ULR operations require different FRMprocesses.Carryoutthefollowingstepsfor eachsetofFRMprocesses. b) Step 2 collect and analyze available data and information (for example confidential safety reports, accident reports and incident investigations, audits, and historical rostering data). c) Step3Identifyfatiguehazards(s) d) Step4establishriskassessmentprocessesand procedures. Clarify linkages to SMS risk assessment and processes for prioritization of risks to be mitigated. (In this large airline example, the FRMS policy statement indicates that the Fatigue Safety Action Group is responsible for prioritizing fatigue risks, and for developing, implementing, and monitoring fatiguecontrolsandmitigations.Itisrequiredto

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FRMSapprovalprocess providemonthlyreportsoftheseactivitiestothe SMS Safety Review Board, with the intent that thisreportwillbecomepartoftheFRMSsafety assuranceprocessintheoverallFRMS.) e) Step 5 select and implement controls and mitigations. Set safety performance indicators. f) Step 6 set up processes for monitoring the effectivenessofcontrolsandmitigations. 12. Perform training to ensure that stakeholders are competent to undertake their roles and responsibilitiesintheFRMS.Inthisexample,itis decidedtoundertaketrainingtosupportthefull FRMS. Communication channels are set up to provide training updates and reminders when Phases III and IV of the FRMS implementation becomeactive. 13. FRMScommunicationchannelsestablished. 14. Fatigue Safety Action Group provides a coordinatedsafetyanalysesoftheexistingFRMS totheSMSSafetyReviewBoard.(TheSMSSafety ReviewBoardareresponsiblefortheFRMSsafety assurancefunctions,inthisexample). PhaseIII 15. For each set of FRMS processes established in Phase II, the Fatigue Safety Action Group identifies appropriate tools for proactive and predictivefatiguehazardidentification. a) Proactive fatigue identification tools are used forassessingroutineandcomplexhazards. 16. Proactive and predictive fatigue hazard identification are integrated in to the FRM processesestablishedinPhaseII. 17. All stakeholders have received suitable training and are competent to undertake their roles and responsibilitiesintheFRMS. 18. FRMScommunicationchannelsareoperational. 19. Fatigue Safety Action Group provides a coordinatedsafetyanalysesoftheexistingFRMS totheSMSSafetyReviewBoard.

85 PhaseIV 20. FRMS safety performance indicators are decided collaboratively by the Fatigue Safety Action Group and the SMS Safety Review Board and approved by the Accountable Executive for the FRMS. 21. Decide which information that will be analyzed for trends (e.g., fatigue reporting ratesbetweensimilarcitypairs,operations,or fleets) Develop criteria for comparing performance with safety objectives (for example, is the overall risk level increasing, is the number of higher risk events increasing, are safety objective in the FRMS policy being achieved, areregulatoryrequirementsbeingmet). Decide how emerging fatigue hazards are identified.Forexample,settriggerstoidentify when action is needed (at what level do adverse trends in performance indicators trigger an investigation of the causes of the trend). 24. Processesareestablishedforidentifyingchanges thatcouldimpacttheFRMS. 25. Processesareestablishedforevaluatinghowwell Fatigue Safety Action Group recommendations are implemented in other parts of the organization,forexampleinschedulingandflight operations. 26. The following safety assurance processes are established. MonthlyreportingbytheFatigueSafetyAction Group to the SMS Safety Review Board. To include updates on fatigue hazards identified and on the status of agreed safety performanceindicators. SMS Safety Review Board is able to call for special reports from the Fatigue Safety Action Group, for example after significant operational changes such as a newly establishedroute. Quarterlyreviewoftrendsinconfidentialcrew reportsrelatingtofatigue,tobeundertakenby

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86 8 the Fat tigue Safety Action Group and reporte A p ed totheS SMSSafetyRe eviewBoard. Quarterly review of trends in e f exceedances of and duty tim limits sp me pecified in th he flight a FRMS P Policy, to be undertaken by the Fatigu ue Safety Action Group and reported to the SM p MS SafetyR ReviewBoard d. Quarterly review of trends in FRMS safe o ety perform mance indicat tors identifie in the FRM ed MS policy, tobeundert takenbythe FatigueSafe ety r ety Action Group and reported to the SMS Safe Review wBoard. Annual review of fa atigue hazard identificatio d on and mi itigation activ vities of the Fatigue Safe ety Action Group by an indepe endent FRM MS Scientif ficAdvisoryG Group. Interna alauditofthe eFRMSbya teamselecte ed bytheS SMSSafetyReviewBoard. . Annual report of the Fatigue Safety Actio t on Groupt totheSMSSa afetyReviewBoardandth he Accoun ntableExecutivefortheFR RMS,toinclud de the re ecommendations of the independent e FRMS S Scientific Advisory Group findings of p, audits,andactionst takeninrespo onsetothem. 27. 2 Firstquar rterlyauditof fFRMSsafetyperformanc ce by the team selected by the SMS Safety Revie ew 1 1 2

FRMSapprova alprocess F oard. If audi are satisf its factory for o one year, Bo internalauditw willreverttoevery6mont ths. 28. FR RMSdocumen ntationfullyi implemented d. 29. FR RMStrainingf fullyimpleme ented. 30. FR RMScommun nicationsfully yimplemente ed.

8.2

FRMSap pprovalpro ocess

Thepr rogressiveim mplementationofanFRMS Srequires a regulatory appr roval process that monitors and docum mentsitsprog gression. regulatory m milestones th hroughout th FRMS he The r approvalprocessa areidentified atthearrow wpointsin Figure 8.2. All of t e these need t be achieve before to ed finala approvalofth heFRMScanb begiven. ain roval, an FR RMS for a large and To ga full appr compl operator is likely to t lex take several years, so thate enoughtimeh haselapsedt toallowasses ssmentof safety assurance f y functions. Ho owever, the regulator can st allow the operator to use FRM pro till ocesses to move beyond pr rescribed fli ight and duty time limitat tions on a tr basis in order that the safety rial assura ancefunction nscanbedeve eloped.

3 3

4 4

gure8.2:TheFRMSApprovalProcess Fig
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FRMSapprovalprocess Suggested documentation to be completed by the regulatorduringthecourseoftheapprovalprocessis highlighted in each of the sections below. All of the information and evidence collected by the regulator duringtheapprovalprocesscontributestotheoverall assessment when deciding to grant final approval of theFRMS. 8.2.1 RegulatoryMilestone1Notificationbythe operator Throughout the progressive implementation of an FRMSthereshouldbecontactbetweentheregulator andtheoperator,startingfromthetimetheoperator begins the implementation process. Such early interaction helps establish an open and informed working relationship between the regulator and the operator and allows the regulator to provide clear indicationoftheirexpectationsandrequirements. One way the regulator can encourage early contact with an operator planning to develop an FRMS is to require written notification of intent. Some States maysimplyrequirealetterfromtheoperatorstating theirintentions,whileothersmayuseamoreformal application such as a Notice of Proposed Amendment.Theregulatormayalsochoosetomeet theoperatorfacetofacetodiscusstheirplans. At this point, the regulator may expect that the operator has already undertaken some preparatory actions.Thesemayinclude: Designation of a specific organizational manager(s)withproperauthority; Ensuring that a key person(s) has gained or are gainingadequateknowledge; Allocation of resources to support FRMS development. Once initial contact has been established by the operator, the regulator should then provide the operatorwithadetailed checklistoftheirregulatory requirements for an FRMS. While necessarily detailed, this checklist should allow the operator flexibility in the way they can meet these requirements. Developing such a detailed checklist takes time and effort but once this is achieved,

87 provides a key tool for both the operator and the regulator.ItwillformthebasisoftheoperatorsGAP analysis,requiredaspartofthedevelopmentoftheir FRMS implementation plan. For the regulator, it formsthefirstpartofthesubsequentauditprocesses forbothapprovalandoversightpurposes.Anoutline of the checklist items for each of the subsequent regulatorymilestonesisdiscussedbelow. 8.2.2 RegulatoryMilestone2ReviewofFRMS Plan,PolicyandDocumentation BasedupontheFRMSchecklistdevelopedearlier,the regulator can develop a more comprehensive tool that can be used to record where each required componentoftheFRMShasbeendocumentedinthe operators procedures, the method used by the operator to demonstrate compliance with the required FRMS components, and any regulator comments on the operators proposal. Again, development of such a tool (referred to here as the FRMSevaluationform)takestimeandeffortbutisa worthwhile investment given that the resulting document becomes the primary oversight tool. An example of an FRMS evaluation form is provided in AppendixD. RegulatoryDocumentation 1. ReviewofFRMSplan The regulator should review the operators implementationplan,includingtheGAPanalysis,the operations to which the FRMS is intended to be applied, the key personnel involved and expected timelines, to allow early detection of any areas needing improvement in the operators ability to implementanFRMSpriortotheStateortheoperator investingexcessivetimeandeffort. A positive review of the FRMS implementation plan means that the regulator has been provided with evidence that the operator understands what is required

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88 RegulatoryChecklist: ChecklistforReviewofFRMSImplementationPlan Reflects a commitment to an effective safety reportingculture DefinesthesafetyobjectivesoftheFRMS; Defines roles and responsibilities for all stakeholders in the FRMS, including identifying theAccountableExecutive; Identifies to what specific operations the implementationplanspertain; Identifies an overall timeline for seeking final approval. Plan for the development of documentation (Chapter3): o Milestones o Method Plan for the development of FRM processes (Chapter4) o Milestones o Method Plan for the development of FRMS safety assuranceprocesses(Chapter5) o Milestones o Method Plan for the development of FRMS Training (Chapter6) o Milestones o Method Plan for the development of FRMS Communication procedures and processes (Chapter6.6.3) o Milestones o Method 2. ReviewoftheinitialFRMSpolicyand documentationproposal Using theFRMSevaluationform(mentionedabove), theregulatorshouldconductadesktopreviewofthe policyanddocumentation,todeterminewhetherthe operators initial FRMS policy and documentation proposal adequately addresses the regulatory requirements.Thiswillincludeevaluating: policycontent;

FRMSapprovalprocess theorganizationalstructure; the riskbased deviation recording process that will document the extent and reason for significant exceedances of scheduled flight and duty periods, significant reductions of rest periods; and significant numbers of uses of the captains authority to complete the flight period); theproposedfatigueriskassessmentprocess; theproposedsafetyassuranceprocess; integration processes with the safety department; qualitycontrolauditprocedures; initial training plan, procedures (including fatiguereporting); termsofreferencefortheFatigueSafetyAction Group; detailsofthesafetypromotionactivities;and methods for monitoring and managing changes totheFRMS. The regulator may also wish to conduct some documented interviews of key personnel involved withthedevelopmentoftheimplementationplanto check the level of organizational knowledge and commitmenttotheplan. A positive review of the FRMS policy and documentation proposal means that the regulator has been provided with evidence that the operator has a commitment to meet these requirements of implementinganFRMS. RegulatoryChecklist: ChecklistforreviewoftheinitialFRMSpolicy anddocumentation (Chapter3) AnFRMSpolicyisinplace. The FRMS policy reflects organizational commitmentsregardingfatigueriskmanagement. TheFRMSpolicyincludesaclearstatementabout the provision of the necessary resources for the implementationofthepolicy. FRMSreportingproceduresareidentified. There is clear indication of which types of operational behaviours are unacceptable within

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FRMSapprovalprocess thecontextoftheFRMS. The conditions under which disciplinary action wouldapplyareclearlyidentifiedinthecontextof theFRMS. The policy is communicated, with visible endorsement,throughouttheorganization. The Accountable Executive, who has ultimate responsibility and accountability for the implementation and maintenance of the FRMS and full control of the necessary resources, is identified. Deliverofinitialdocumentationincluding: o FRMprocesses o FRMSsafetyassuranceprocesses o FRMSTraining o FRMS Communication procedures and processes

89 targets, supporting scientific documentation, Fatigue Safety Action Group meeting minutes, other operational best practices, the fatigue hazard log, and further proposed mitigations to reducetherisk; 3. reviews the results of all the risk assessment processes (reactive, proactive and predictive) and agrees on initial FRMS performance indicatorsandtargets; 4. directly sample some of the records quoted in the risk assessment and assess the operators proceduresagainstsuppliedriskassessments; 5. conducts the final review of the initial training programme and training records (and may possibly attend one of the initial training courses). The regulator will need to review the training proposals for the operators employees to check that they cover both generic fatigue material and operationspecific FRMS aspects. Trainingwillneedtobegiveninaproportionate mannertotheemployeegroupsinvolvementin theFRMS.Aspartofthetrainingprogramme,all employees who are involved with the fatigue reporting system need to be specifically trained on how the system works, how they use the system information, and at what point an individual would need to be further assessed due to trends in their filed fatigue reports. The regulator may choose to attend a training session rather than just review the training materialandorsyllabus. 6. conducts documented interviews with a selection of employees from all the areas involvedwiththeFRMS,and 7. mayinvolveotherregulatorexpertsorresources (bothinternalandexternaltotheState)aspart oftheirreviewoftheinformation; 8. reviews the outer limits for the proposed FRMS operation and adjusts them accordingly if there isinsufficientevidencetosupportthecase; 9. producesanauditreportandwherenecessarya listofcorrectiveactions. If the operator is required by the regulator to make corrective actions, the regulator should agree to an action plan to make these corrections. Once the operator has taken the corrective actions, the regulatorwillneedtogobackintotheaboveprocess

8.2.3 Regulatory Milestone 3 Review of initial FRMprocesses OncetheplanforthedevelopmentoftheFRMSand the policy and documentation proposal has been positively reviewed, the operator can begin implementing the FRM processes. This incorporates Phases II and III of the operators implementation processandmaytakeasignificantperiodoftimeand mayrequireseveralmeetingswiththeoperator. To achieve the third milestone of the regulatory process,theregulator: 1. reviews the operators reactive risk assessment process, including the tools used, such as the fatigue hazard log, how the risk matrix was developed and the use of the agreed upon severity and likelihood measures, the methodologyforthedevelopmentof mitigation strategies, fatigue report procedures, any crew surveys, Fatigue Safety Action Group meeting minutes; 2. reviews the proactive and predictive hazard identificationprocesses,includingassessmentof agreed fatigue roster metrics, any information from biomathematical modeling, development of FRMS performance indicators and their

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810 at the relevant point and produce an audit closure report. Where no corrective actions are necessary, or once corrective actions are complete, the regulator may thenpermittheoperatortotrialtheproposedFRMS operations within the newly agreed outer limits. At thispoint,theFRMSdoesnothavefinalapprovalas the safety assurance processes have not yet been implemented. RegulatoryChecklist: GeneralRequirements EstablishmentofFSAG o AppointmentofFSAGmembers. o Appointment of a qualified person to manage andoverseethefunctionsoftheFSAG. o All FSAG members fulfil the required job functionsandresponsibilities. Establishment of outer limits (maximum values for flight times and/or flight duty period(s) and duty period(s), and minimum values for rest periods). Maintenanceofrecordsofflighttime,flightduty periods,dutyperiods,andrestperiods. ValidationofinitialFRMprocesses(Chapter4) Aneffectivefatiguereportingsystemisinplace. The operations covered by each set of FRMS processesisidentified(4.2). Dataandinformationiscollected(4.3,4.4). Hazardsareidentified(4.4). Risk assessments are undertaken and documented.(4.5) Appropriateriskmitigationisundertaken(4.6). There is a demonstrable information flow betweentheFRMSandothersafetysystems(e.g. their SMS through the Safety Action Group meetingsortheirsafetydepartment). ValidationofinitialFRMSpromotionprocesses (Chapter6) Training plan implemented (6.2) with personnel involved in FRMS displaying required level of knowledge of sleep and fatigue, and their responsibilities and procedural requirements in relationtotheFRMS. Trainingrecordsmaintained(6.3).

FRMSapprovalprocess FRMSrelated information is disseminated in a timelymannertoallnecessarystakeholders. 8.2.4 RegulatoryMilestone4ApprovalofFRMS Before final approval of the FRMS can be given, evidenceisrequiredtodemonstratethattheFRMSis delivering the required safety outcomes. The operatornowneedstovalidatethesafetyassurance processes and demonstrate a fully functioning FRMS withintheagreedouterlimits,whichmaybeoutside oftheprescriptivelimitations.Validationofthesafety assurance processes will take time, and this will require the regulator to conduct regular visits, desktop reviews of sample data, analyses and documentation and interviews of key personnel. All of the components of an FRMS, including the safety assurance processes, need to be functioning in a coordinated way within the operators overall safety processes. During this trial period, the regulator needstobecloselymonitoringallactivities. Importantly,atimelimitneedstobeidentifiedbythe regulator for the course of this trial period. While adequate time needs to be given to allow the operator to demonstrate that all components of an FRMS (including the safety assurance processes) are functioning, an operator cannot be allowed to operate outside of the prescriptive limits for an indefinite period. Protracted trial periods diminish thevalueofhavinganapprovedFRMS,ifanoperator cancontinueusinganFRMSinprogressthatisnot activelytryingtomeetapprovalrequirements. The operator will need to demonstrate that their FRMSsafetyassuranceprocessesareusedtoreview the FRMS performance indicators against their agreed targets and can identify and undertake any necessary actions. Where trends demonstrate that either the mitigations or the outer limits are not appropriate to achieve the safety performance targets,orwherechangesaffectingtheoverallFRMS are detected by the safety assurance processes, the failingareasoftheFRMSoperation(s)arereassessed throughtheFRMprocesses.

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FRMSapprovalprocess These processes are documented and form part of theFatigueSafetyActionGroupreviewofthesystem and are recorded in the minutes. The functioning of the Fatigue Safety Action Group must also demonstrate the identification and management of any new fatigue hazards and their subsequent risk assessment and management. The assurance functionsmonitortheeffectivenessofthemitigations and suitability of the outer limits of the FRMS. The wholesystemwillalsobeinternallyauditedtocheck the procedures are being correctly applied and the effectiveness of risk mitigations and assumptions made.Theseauditsmustbedocumented. During the course of this trial period, the regulator will have the opportunity to gain confidence in the operators ability to respond appropriately to the data being collected and should be supplied with evidence that the operator is managing their fatigue riskappropriately.Thisshouldincludethemonitoring of the operators safety performance after any changes. In some cases, the regulator may have observedtheoperatorloweringflightanddutytimes that would otherwise be permitted using prescribed limitationsusingtheirFRMSprocesses. Inthisfinalphasepriortoapproval,theoperatorwill also have demonstrated that they have added effective recurrent training into their training programme. Further, the regulator should ensure that all initial training as identified in the accepted implementation plan has been completed prior to finalapprovaloftheFRMS. Still using the FRMS evaluation form, the regulator shouldthenconductthefinalauditoftheoperators FRMS. By now, this evaluation form documents the progress made by the operator throughout the approval process. At the final approval audit, the regulator should examine evidence of the operators FRMS safety assurance functions by reviewing the agreed FRMS performance targets and assesses any trends. They should also check that the system has been subject to internal auditing of the processes. The regulator may choose to audit some of the primarysourcesofinputintothesystem(e.g.fatigue reports). However, they will need to be mindful of the confidential nature of some the methods of

811 reporting (such as fatigue reports) examining such reportsonlytoconfirmtheoperatorsassessmentof trends.Theintegrityoftheoperatorseffectivesafety reporting system, and the maintenance of reporter confidentiality that is required to support it, should be a priority for the regulator. The regulator should expect the operator to have already documented trendsandreevaluatedthefatiguerelatedriskusing theriskassessmentfunctions. The regulator should also conduct a review of the operators final documentation and procedures to ensure required corrections or additions have been made. Finally, they should review the final training package,includingtherecurrenttrainingprogramme. Once all the criteria in each of the steps have been met,andalloftheFRMSprocessesarefunctioningin a cohesive manner with regards to the specific operationstowhichtheyhavebeenapplied,approval can be given. This means that the operator is no longeronatrialperiodandmaynowusetheFRMSto adjust flight and duty hours within the approved outer limits for the particular operations identified. Any changes to the scope of the FRMS cannot be implemented without regulatory approval for its applicationtonewoperations. Thefollowingtableprovidesachecklistofthegeneral requirements for validating the safety assurance processes. RegulatoryChecklist: ValidationofFRMSsafetyassuranceprocesses (Chapter5) Safety performance indicators are identified and acceptabletotheregulator(5.2). ThesafetyperformanceoftheFRMSismonitored through monitoring of trends in safety performanceindicators(5.2,5.3). Mitigations and controls are changed where necessaryinresponsetothefindings(5.3,5.4). There is an existing process for identifying and managingchangesthataffecttheFRMS(5.5). There is an existing process for continual improvementoftheFRMS.

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812 ReviewfinalFRMSdocumentation,including: o FRMprocesses o FRMSsafetyassuranceprocesses o FRMS Training (including recurrent training programme) o FRMS Communication procedures and processes Thefinalpartoftheapprovalprocesswillbeforthe regulator to set up the ongoing audit requirements andtheauditcalendar.Aspartofthis,theregulator mayrequirethattheoperatorsendsmonthlyupdates (or another designated period of time) of trends on all or some of the agreed FRMS performance indicators. In the same way that normal oversight audit functionsarerecorded,regulatorswillneedtoensure that where an operator uses an FRMS, they have an

FRMSapprovalprocess adequate record keeping process. These records will store the outcomes, findings and rectification notifications of the approval process and ongoing oversight.

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[Back to Contents]
Chapter9.OversightofanFRMS

[Back to Overview]
91

Chapter9:OversightofanFRMS
OnceapprovalofanoperatorsFRMShasbeengiven, itistheStatesresponsibilitytocontinuemonitoring the effectiveness of the FRMS, that it complies with the regulations, and that it demonstrates an acceptable level of performance. Organizational conditions change, and many, such as external pressuresontheoperator,economicissues,andthe overall performance of the operator, may have consequences for the effectiveness of the FRMS. Therefore, after final approval, the oversight of the FRMS forms part of the regulators periodic surveillanceprogrammeoftheoperator. to confirm that the operator is documenting trends and, where necessary, is identifying potentially adverse trends and managing them appropriately as part of the risk assessment functions. The regulator will also conduct a review of the operators documentation and procedures to assess any corrections or additions that have been made post approval. They will also review the current training package,includingallstafftrainingrecords. As part of normal oversight, the regulator will conductinterviewswitha varietyofpeopleinvolved with the FRMS, and monitor changes of key FRMS personnel. Where key personnel have changed, the regulator should seek to ensure the new personnel areincludedintheirlistofinterviewees.Occasionally, a State inspector might also ask to attend an operators Fatigue Safety Action Group meeting to gain better insight in its FRMS processes, although the inspector cannot be part of the Fatigue Safety ActionGroupactivities. The regulator is seeking to ensure that all of the FRMSprocessesarefunctioninginacohesivemanner withregardstothespecificoperationstowhichthey havebeenapplied. RegulatoryChecklist: OversightofanFRMS FRMSperformanceindicatorandtargetreview Targetedsamplingofrecordsanddocumentation Documentedinterviews Continuousreporting Attendanceatmeetings,trainingsessions Evidence of information flow between SMS and FRMS FatigueSafetyActionGroup o Reviewofhazardlog o Reviewofmeetingminutes Collection of information from external sources, e.g. scientific reviews, experience gained from oversightofotheroperatorsFRMSs. Reviewingouterlimits

9.1

Regulatoryplanningfunctions

In order to ensure appropriate levels of oversight, formalauditswillneedtobeplanned.Consideration willneedtobegivento: EstablishinganFRMSaudit/inspectionscheduleas partoftheoversightprogramme. Theregulatorwillneedtovisittheoperatorat leastonceayear.Adhocvisitscouldalsobemade andaspartoftheoversight,theregulatormayalso wishtohavemorefrequentdocumentationsentto thembytheoperator. Inspectorateresources: Inspectorsneedtohaveknowledgeoffatigue science(seeChapter6),experienceinregulating FRMS,aswellaspracticalknowledgeofthe operator.

9.2 SpecialrequirementsforFRMS oversight

InoverseeingtheoperatorsFRMS,theregulatorwill examine evidence of the operators FRMS safety assurance functions by reviewing the agreed FRMS performancetargetsandassessanytrends.Theywill also check that the system has been subject to internalauditingoftheprocesses.Theregulatormay choosetoauditsomeoftheprimarysourcesofinput intothesystem(e.g.fatiguereports).Theywillneed

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92 Reviewing FTLs identified within the FRMS operations Assessmanagementofchanges,e.g. o TheoperationstowhichtheFRMSapplies o Keypersonnel

OversightofanFRMS limitations. While complying with the prescriptive flight and duty limitations, the operator may attempt to improve their FRMS processes and other safety systems and SMS processes, in order to reestablish regulatory confidence and reapply forFRMSapproval.ShouldtheStateconsiderthat the operators FRMS meets their requirements at this point, the State may approve the FRMS on restricted conditions (e.g. decreased maximum values for flight and duty periods and minimum values for rest periods) until such time as they wereconfidentofthematurityandeffectivenessof thesystem.

9.3

Enforcement

Regulators will need to establish a process for use when deficiencies in an FRMS are identified. Enforcementactionsshouldbecommensuratetothe level of risk resulting from the deficiency. These actions may range from administrative changes, FRMS operational changes, toa withdrawal of FRMS approval. The following discusses various enforcement alternativesinincreasingseverity: OperatoronnoticetoimproveFRMSprocesses: Where the States oversight produces concerns thattheoperatorsFRMSmaynotmeetregulatory requirements, then the operator should first be given an opportunity to improve the specific aspectsofitsFRMSsothatitdoesmeetregulatory requirements. Based on the findings of the audit process, the regulator will need to provide advice to the operator and identify a mutuallyagreed correctiveactionplan. Regulatormandated lowering of maximum values (and/orincreasingminimumvalues): Where the States oversight produces concerns that an element of an operators FRMS may be ineffective, then the State may need to revise an operators maximum and minimum values. These regulatorsetlimitsshouldremaininplaceuntilthe operator can provide evidence that their FRMS processesareeffectiveandtheStatehasregained regulatoryconfidenceintheoperator. WithdrawalofFRMSapproval: Wherethereisasignificantsafetyconcernthathas not been addressed by the above enforcement alternatives,itistheStatesobligationtowithdraw the FRMS approval and require the operator to operate within prescriptive flight and duty

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[Back to Contents]
AppendixA.Glossary

[Back to Overview]
A1

AppendixA:Glossary
*denotesanICAOdefinition Actiwatch. A wristwatchlike device containing an accelerometer to detect movement. Activity counts are recorded per unit time, for example every minute. The patterns of movement can be analyzed using purposebuilt software to estimate whentheweareroftheactiwatchwasasleep,and toprovidesomeindicationofhowrestlessasleep period was (i.e., sleep quality). Actiwatches are designedtorecordcontinuouslyforseveralweeks so they are valuable tools for monitoring sleep patterns, for example before, during, and after a trip. Actiwatches provide graphs of movement as output(actigraphs). Actigraphy. Use of actiwatches to monitor sleep patterns.Foractigraphytobeareliablemeasureof sleep,thecomputeralgorithmthatestimatessleep from activity counts must have been validated against polysomnography, which is the gold standard technology for measuring sleep duration and quality. The main weakness of actigraphy is thatsleepandstillwakefulnesslooksthesameon an actigraph (since an actiwatch measures movement). Afternoon nap window. A time of increased sleepiness in the middle of the afternoon. The precise timing varies, but for most people it is usuallyaround15:0017:00.Thisisagoodtimeto try to nap. On the other hand, it is also a time when it is more difficult to stay awake, so unintentional microsleeps are more likely, especiallyifrecentsleephasbeenrestricted. Augmentedflightcrew.Aflightcrewthatcomprises more than the minimum number required to operate the aeroplane so that each crewmember canleavehisorherassignedposttoobtaininflight rest and be replaced by another appropriately qualifiedcrewmember. Augmentedlongrangeoperations.Flightswherethe flight duty period is extended through the use of augmented crews, allowing crewmembers the opportunityforinflightrest. Biomathematical model. A computer programme designed to predict crewmember fatigue levels, based on scientific understanding of the factors contributing to fatigue. All biomathematical models have limitations that need to be understood for their appropriate use in an FRMS. Anoptionaltool(notarequirement)forpredictive fatiguehazardidentification(ICAOAnnex6,Part1, Appendix8,Section2.1.) Chronicfatigue.Infatigueriskmanagement,chronic fatigue refers to the sleepiness and performance impairment that accumulate when sleep is restricted day after day. These effects can be reversed by obtaining adequate recovery sleep (alsoseecumulativesleepdebt). Chronic fatigue syndrome. A medical condition for which the diagnosis requires a person must meet twocriteria: 1. Haveseverechronicfatigueforatleast6months orlongerthatisnotrelievedbyrestandnotdue to medical or psychiatric conditions associated with fatigue as excluded by clinical diagnosis; and 2. Concurrentlyhavefourormoreofthefollowing symptoms: selfreported impairment in short termmemoryorconcentrationsevereenoughto causesubstantialreductioninpreviouslevelsof occupational, educational, social, or personal activities; sore throat that is frequent or recurring; tender lymph nodes in the neck or armpits; muscle pain; multijoint pain without swelling or redness; headaches of a new type, pattern, or severity; unrefreshing sleep; and postexertional malaise (extreme, prolonged exhaustion and sickness following physical or mentalactivity)lastingmorethan24hours. The fatigue and impaired memory or concentration must have impaired normal daily activities,alongwithothersymptomsthatmust have persisted or recurred during 6 or more consecutivemonthsofillnessandmustnothave

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A2 predated the fatigue. (http://www.cdc.gov/cfs/general/case_definitio n/index.html) Circadian body clock. A neural pacemaker in the brain that monitors the day/night cycle (via a special light input pathway from the eyes) and determines our preference for sleeping at night. Shiftworkisproblematicbecauseitrequiresashift in the sleep/wake pattern that is resisted by the circadianbodyclock,whichremainslockedonto theday/nightcycle.Jetlagisproblematicbecause itinvolvesasuddenshiftintheday/nightcycle to which the circadian body clock will eventually adapt,givenenoughtimeinthenewtimezone. Controls. Systemlevel defensive strategies designed to minimize fatigue risk on an ongoing basis. Examples include: scheduling rules, monitoring staffing levels at crew bases, selection of appropriate inflight crew rest facilities, and protocols for inflight rest and controlled rest on theflightdeck. Controlled flight deck napping. An effective mitigation strategy to be used as needed in response to fatigue experienced during flight operations. Recommended procedures for controlled flight deck napping can be found in Appendix C. It should not be used as a scheduling tool,i.e.,asaplannedstrategytoenableextended dutyperiods. Countermeasures.Personalmitigationstrategiesthat crewmemberscanusetoreducetheirownfatigue risk. Sometimes divided into strategic countermeasures (for use at home and on layovers, for example good sleep habits, napping before night duty), and operational countermeasures for use in flight, for example controlledrestontheflightdeck. *Crewmember.ApersonassignedbyanOperatorto dutyonanaircraftduringaflightdutyperiod. Crew pairing. A set of scheduled flights on which a crewmemberisrosteredforoneormoredays.

Glossary Cumulativesleepdebt.Sleeplossaccumulatedwhen sleep is insufficient for multiple nights (or 24hr days)inarow.Ascumulativesleepdebtbuildsup, performance impairment and objective sleepiness increaseprogressively,andpeopletendtobecome less reliable at assessing their own level of impairment. *Duty. Any task that crew members are required by the Operator to perform, including, for example, flight duty, administrative work, training, positioningandstandbywhenitislikelytoinduce fatigue. *Dutyperiod.Aperiodwhichstartswhenaflightor cabin crew member is required by an Operator to reportforortocommenceadutyandendswhen thatpersonisfreefromallduties. Evening type. A person whose natural sleep time is laterthanaverageasaresultofthecharacteristics of their circadian biological clock. There is also a developmental trend to become more evening type across puberty, which reverses for most peopleinadulthood. Eveningwakemaintenancezone.Aperiodofseveral hoursinthecircadianbodyclockcycle,justbefore usual bedtime, when it is very difficult to fall asleep. Consequently, going to bed extra early usuallyresultsintakingalongertimetofallasleep, rather than getting extra sleep. Can cause restricted sleep and increased fatigue risk with earlydutystarttimes. *Fatigue.A physiological stateofreduced mentalor physical performance capability resulting from sleep loss or extended wakefulness, circadian phase, or workload (mental and/or physical activity)thatcanimpairacrewmembersalertness andabilitytosafelyoperateanaircraftorperform safetyrelatedduties. FRMS training. Competencybased training programmes designed to ensure that all stakeholders are competent to undertake their responsibilitiesintheFRMS.

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Glossary Fatigue safety action group (FSAG). A group comprised of representatives of all stakeholder groups (management, scheduling, crew representatives) together with specialist scientific, data analysis, and medical expertise as required), that is responsible for coordinating all fatigue managementactivitiesintheorganization. Fatigue risk management. The management of fatigueinamannerappropriatetothelevelofrisk exposureandthenatureoftheoperation,inorder to minimize the adverse effects of fatigue on the safetyofoperations Fatigue risk management system policy. A required component of an FRMS (ICAO Annex 6, Part 1, Appendix 8, Section 1.1). THE FRMS Policy must: identify the elements of the FRMS and its scope; reflectthesharedresponsibilityofallstakeholders in the FRMS; state the safety objectives of the FRMS; be signed by the accountable executive of theorganization;becommunicatedthroughoutthe organization; declares management commitment toeffectivesafetyreporting,toprovidingadequate resourcing for the FRMS, and to continuous improvement of the FRMS; identify clear lines of accountabilityforthefunctioningoftheFRMS;and requireperiodicreviewsoftheFRMS. *Fatigue risk management system (FRMS). A data driven means of continuously monitoring and managing fatiguerelated safety risks, based upon scientific principles and knowledge as well as operational experience that aims to ensure relevant personnel are performing at adequate levelsofalertness. Fatigue safety assurance. FRMS safety assurance processesmonitortheentireFRMStocheckthatit is functioning as intended and meeting the safety objectives in the FRMS policy and regulatory requirements. FRMS safety assurance processes also identify operational and organizational changes that could potentially affect the FRMS, andidentifyareaswherethesafetyperformanceof the FRMS could be improved (continuous improvement).

A3 *Flight data analysis (FDA). A process of analyzing recordedflightdatainordertoimprovethesafety ofoperations. *Flight duty period. A period which commences whenacrewmemberisrequiredtoreportforduty thatincludesaflightoraseriesofflightsandwhich finishes when the aeroplane finally comes to rest and the engines are shut down at the end of the lastflightonwhichhe/sheisacrewmember. *Flight time aeroplanes. The total time from the momentanaeroplanefirstmovesforthepurpose of taking off until the moment it finally comes to restattheendoftheflight. Homeostatic sleep pressure. See Sleep homeostatic process. Internal Alarm Clock. A time in the circadian body clock cycle when there is a very strong drive for waking and it is difficult to fall asleep or stay asleep.Occursabout6hoursafterthewindowof circadian low in the late morning to early afternoon and can cause restricted sleep and increasedfatigueriskafternightduty. Jet lag. Desynchronization between the circadian body clock and the day/night cycle caused by transmeridianflight(experiencedasasuddenshift in the day/night cycle). Also results in internal desynchronization between rhythms in different body functions. Common symptoms include wanting to eat and sleep at times that are out of step with the local routine, problems with digestion, degraded performance on mental and physical tasks, and mood changes. Resolves when sufficient time is spent in the new time zone for the circadian body clock to become fully adapted tolocaltime. Microsleep. A short period of time (seconds) when the brain disengages from the environment (it stops processing visual information and sounds) and slips uncontrollably into light nonREM sleep. Microsleeps are a sign of extreme physiological sleepiness.

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A4 Mitigations. Systemlevel interventions designed to reduce a specific identified fatigue risk. Examples include: increasing the number of crewmembers at a base, use of reserve crew, educating crewmembers on how to obtain optimal inflight sleep, Captains discretion to reorganize inflight restarrangementsonthedayofflightinresponse to crewmembers fatigue levels and operational conditions,etc. Morning type. A person whose natural sleep time is earlier than average as a result of the characteristics of their circadian biological clock. There is also a developmental trend to become moremorningtypeacrossadulthood. Nap. A brief period of sleep, usually defined as less thanhalfofafullnighttimesleepperiod.Napsas short as 5 minutes have been shown to provide (temporary) relief from the cumulative effects of sleep loss also see controlled flight deck napping. Nonrapid eye movement sleep (NonREM Sleep). A type of sleep associated with gradual slowing of electricalactivityinthebrain(seenasbrainwaves measuredbyelectrodesstucktothescalp,known asEEG).AsthebrainwavesslowdowninnonREM sleep, they also increase in amplitude, with the activity of large groups of brain cells (neurons) becoming synchronized. NonREM sleep is usually divided into 4 stages, based on the characteristics ofthebrainwaves.Stages1and2representlighter sleep. Stages 3 and 4 represent deeper sleep and arealsoknownasslowwavesleep. NonREM/REM cycle. Regular alternation of non REMsleepandREMsleepacrossasleepperiod,in acyclelastingapproximately90minutes. Rapid eye movement sleep (REM Sleep) A type of sleep during which electrical activity of the brain resemblesthatduringwaking.However,fromtime to time the eyes move around under the closed eyelids the rapid eye movements and this is often accompanied by muscle twitches and irregular heart rate and breathing. People woken fromREMsleepcantypicallyrecallvividdreaming.

Glossary At the same time, the body cannot move in response to signals from the brain, so dreams cannotbeactedout.Thestateofparalysisduring REMsleepissometimesknownastheREMblock. Recoverysleep.Sleeprequiredforrecoveryfromthe effects of acute sleep loss (in one 24hour period) or cumulative sleep debt (over multiple consecutive 24hour periods). Recovery sleep may be slightly longer than usual, but lost sleep is not recovered hourforhour. Two nights of unrestricted sleep (when a crewmember is fully adapted to the local time zone) are typically required for recovery of normal sleep structure (nonREM/REMcycles).Recentlaboratoryresearch suggests that recovery of optimal waking function maytakemorethantwonightsofrecoverysleep. *Rest period. A continuous and defined period of time subsequent to and/or prior to duty, during whichflightorcabincrewmembersarefreeofall duties. Roster/rostering. Assignment of crewmembers to a schedule. Safetymanagement.Thesystematicmanagementof the operational risks associated with flight, engineering and ground activities in order to achieveashighalevelofsafetyperformanceasis reasonablypracticable. *Safety management system (SMS). A systematic approach to managing safety, including the necessary organizational structures, accountabilities,policiesandprocedures. Safetyperformance.Thelevelofsafetyachievedina risk controlled environment measured against a safety level deemed as low as reasonably practicable. Schedule. Sequence of flights designed to meet operational requirements and effectively manage resourcesincludingcrewmembers. Shift work. Any work pattern that requires a crewmembertobeawakeatatimeinthecircadian

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Glossary body clock cycle that they would normally be asleep. Problematic because the circadian body clock is sensitive to light and tends to remain locked on to the day/night cycle rather than adaptingtotheworkpattern.Shiftworkisusually associated with sleep restriction, together with a requirement toworkduringtimesin thecircadian body clock cycle when performance and alertness aresuboptimal(forexample,throughthewindow ofcircadianlow). Sleep.Areversiblestateinwhichconsciouscontrolof the brain is absent and processing of sensory informationfromtheenvironmentisminimal.The brain goes offline to sort and store the days experiences and replenish essential systems depleted by waking activities. A complex series of processes characterized by alternation between two different brain states: nonREM sleep and REMsleep. Sleepdebt.SeeCumulativesleepdebt. Sleep disorders. A range of problems that make it impossible to obtain restorative sleep, even when enoughtimeisspenttryingtosleep.Morethan80 differentsleepdisordershavebeenidentified,that can cause varying amounts of sleep disruption. Examples include obstructive sleep apnea, the insomnias, narcolepsy, and periodic limb movementsduringsleep. Sleep homeostatic process. The bodys need for slowwave sleep (nonREM stages 3 and 4), that builds up across waking and discharges exponentiallyacrosssleep. Sleep inertia. Transient disorientation, grogginess andperformanceimpairmentthatcanoccurasthe brainprogressesthroughtheprocessofwakingup. Sleepinertiacanoccuronwakingfromanystageof sleep but may be longer and more intense on waking from slowwave sleep (nonREM stages 3 and4),oraftersleepperiodsornapscontaininga highproportionofslowwavesleep. Sleepneed.Theamountofsleepthatisrequiredona regular basis to maintain optimal levels of waking

A5 alertness and performance. Very difficult to measure in practice because of individual differences.Inaddition,becausemanypeoplelive withchronicsleeprestriction,whentheyhavethe opportunityforunrestrictedsleep,theirsleepmay belongerthantheirtheoreticalsleepneeddueto recoverysleep. Sleep quality. Capacity of sleep to restore waking function. Good quality sleep has minimal disruption to the nonREM/REM cycle. Fragmentation of the nonREM/REM cycle by wakingup,orbybriefarousalsthatmovethebrain to a lighter stage of sleep without actually waking up,decreasestherestorativevalueofsleep. Sleep restriction. Obtaining less sleep than needed (trimming sleep) across at least two consecutive nights.Theeffectsofsleeprestrictionaccumulate, with performance impairment and objective sleepiness increasing progressively. The need for sleep will eventually build to the point where peoplefallasleepuncontrollably(seemicrosleep). Slowwave sleep. The two deepest stages of non REM sleep (stages 3 and 4), characterized by high amplitudeslowbrainwaves(EEGdominatedby0.5 4Hz). Standby/standby duty. A defined period of time, at theairport,atthehotel,orathome,duringwhich a flight or cabin crew member is required by the Operator to be available to receive an assignment for a specific duty without an intervening rest period. Transient fatigue. Impairment accumulated across a single duty period, from which complete recovery ispossibleduringthenextrestperiod. Trip. A scheduling expression describing the time fromwhenacrewmemberinitiallyreportsforduty until he/she returns home from the sequence of flightsandisreleasedfromduty.Atripmayinclude multipleflightsandmanydaysoftravel. Ultra long range operations (ULR). Augmented long range operations involving any sector between a

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A6 specific city pair in which the planned flight time exceeds 16 hours, taking into account mean wind conditionsandseasonalchanges(asdefinedbythe Ultra long range Crew Alertness Steering Committee,FlightSafetyFoundation(2005).Flight SafetyDigest26.) Unforeseenoperationalcircumstance.Anunplanned event, such as unforecast weather, equipment malfunction,orairtrafficdelaythatisbeyondthe control of the operator. In order to be considered unforeseen, the circumstance would occur or becomeknowntotheoperatoraftertheflighthas begun (after the moment the aeroplane first movesforthepurposeoftakingoff). Unrestricted sleep. Sleep which is not restricted by duty demands. Sleep can begin when a crewmemberfeelssleepy,anddoesnothavetobe delayedbecauseofdutydemands.Inaddition,the crewmembercanwakeupspontaneouslyanddoes nothavetosetthealarmtobeupintimeforduty. Window of circadian low (WOCL) Time in the circadian body clock cycle when subjective fatigue and sleepiness are greatest and people are least able to do mental or physical work. The WOCL occurs around the time of the daily low point in core body temperature usually around 03:00 05:00 when a person is fully adapted to the local time zone. However, there is individual variability intheexacttimingoftheWOCL,whichisearlierin morningtypes (larks) and later in eveningtypes (owls), and may move a few hours later after consecutivenightshifts.

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[Back to Contents]
AppendixB.Measuringcrewmemberfatigue

[Back to Overview]
B1

AppendixB:Measuringcrewmemberfatigue
FRM Processes (Chapter 4) and FRMS safety assurance processes (Chapter Five) sometimes require the measurement of crewmember fatigue. There is no single measurement that is the gold standard,becausefatiguerelatedimpairmentaffects manyskillsandhasmultiplecauses.Awidevarietyof fatigue measures are used in scientific research. The measures described here are examples that have beenchosenbecause: they have been shown to be sensitive for measuringwhattheyclaimtomeasure(i.e.,they havebeenscientificallyvalidated); they do not jeopardize crewmembers ability to performtheiroperationalduties;and they have been widely used in aviation, so data can be compared between different types of operations. New ways to measure fatigue and sleep are always being developed and some will become valuable tools to add to the list below, once they have been validatedforuseinaviationoperations.Meanwhile, in an FRMS it is important to use measures that are accepted by regulators, operators, crewmembers, and scientists as being meaningful and reliable. This avoids the unnecessary cost and inconvenience of collectingdatathatisofdoubtfulvalue. Fatigue measurements can be based on crewmembers recall or current impressions of fatigue (subjective measures) or on objective measurements, such as performance tests and different types of physical monitoring. Each type of measure has strengths and weaknesses. To decide which types of data to collect, the most important considerationshouldbetheexpectedleveloffatigue risk.

B1.

Crewmembersrecalloffatigue

B1.1 FatigueReportingForms Fatiguereportsallowindividualcrewmemberstogive vital feedback on fatigue risks where and when they occur in an operation. Crew members are encouragedtodothisthroughaneffectivereporting system (ICAO Doc 9859, Safety Management Manual). It is necessary to provide a clear understanding of the line between acceptable performance (which can include unintended errors) and unacceptable performance (such as negligence, recklessness, violations or sabotage). This provides fair protection to reporters but does exempt them from punitive action where it is warranted. Crewmembersalsoneedtobeconfidentthatreports will be acted on, which requires feedback from the Fatigue Safety Action Group, and they need to be assuredthattheintentofthereportingprocessisto improve safety, not to attribute blame. A series of fatiguereportsonaparticularroutecanbeatrigger forfurtherinvestigationbytheFatigueSafetyAction Group. Fatigue report forms need to be easy to access, complete,andsubmit.Considerationshouldbegiven to making fatigue report forms available for completion electronically, for example on lap top computers or smart phones (IPod, Blackberry, etc). The following example is adapted from a form that has been routinely used in an operators FRMS for morethan10years.

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B2 Ifconfidentialityrequiredtickhere
Name

Measuringcrewmemberfatigue

FatigueReportForm

EmployeeNo. Pilot/CCM (circle) WHENDIDITHAPPEN? Localreportdate Timeofevent(local reporttime) Dutydescription(trippattern) Sectoronwhichfatigue From To occurred Hoursfromreporttimetowhenfatigueoccurred Disrupt? Yes/No Aircrafttype Numberofcrew WHATHAPPENED? Describehowyoufelt(orwhatyouobserved) Pleasecirclehowyoufelt 1 Fullyalert,wideawake 5 Moderatelyletdown,tired 2 Verylively,somewhatresponsive,butnotatpeak 3 OK,somewhatfresh 6 Extremelytired,verydifficulttoconcentrate 4 Alittletired,lessthanfresh 7 Completelyexhausted PleasemarkthelinebelowwithanXatthepointthatindicateshowyoufelt alert drowsy WHYDIDITHAPPEN? Fatiguepriortoduty? Yes/No Hotel Home Dutyitself Inflightrest Disrupt Personal Yes/No Yes/No Yes/No Yes/No Yes/No Yes/No Howlonghadyoubeenawakewhenthe eventhappened? Howmuchsleepdidyouhaveinthe24hrs beforetheevent? Howmuchsleepdidyouhaveinthe72hrs beforetheevent? flightdecknap? Yes/No Ifyes,when hrs hrs hrs start mins mins mins end

Othercomments

WHATDIDYOUDO?

WHATCOULDBEDONE?

Actionstakentomanageorreducefatigue(forexample,flightdecknap) Suggestedcorrectiveactions

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Measuringcrewmemberfatigue When fatigue report forms are first introduced, or other activities that raise fatigue awareness are launched, there is likely to be an increase in fatigue reporting.Thisspikedoesnotnecessarilyrepresent an increase in fatigue occurrences or risk. It may simplybeduetopeoplebeingmorelikelytoreport. OtherFRMSsafetyperformanceindicatorsmayneed to be evaluated, to decide whether the increase in reportingshouldtriggerfurtheractionbytheFatigue SafetyActionGroup. B1.2 Retrospectivesurveys Retrospective surveys are a comparatively cheap way to obtain information from a group of crewmembersonarangeoftopicssuchas: demographics (age, flying experience, gender, etc); amount and quality of sleep at home and on trips; experienceoffatigueonduty;and views on the causes and consequences of fatigueonduty. Wherever possible, validated scales and standard questions should be used for gathering information on common topics such as sleep problems. This enables the responses of crewmembers to be compared across time, or with other groups. 1 For example,theEpworthSleepinessScaleisavalidated tool for measuring the impact of sleepiness on daily life.Itiswidelyusedclinically,toevaluatewhetheran individual is experiencing excessive sleepiness, 2 and information is available on its distribution in large community samples. 3 Figure B1 shows the Epworth Sleepiness scale. The crewmember is asked to rate
Note that some measures, for example the Karolinska Sleepiness Scale and the SamnPerelli Crew Status Check are not designed to be used retrospectively. They are meanttobeansweredinrelationtohowyoufeelnow. 2 Johns MW (1994). Sleepiness in different situations measured by the Epworth Sleepiness Scale. Sleep 17:703 710. 3 Gander PH, Marshall NS, Harris R, Reid P (2005). The Epworth sleepiness score: Influence of age, ethnicity and socioeconomicdeprivation.Sleep28:249253
1

B3 each situation from 0=would never doze to 3 high chance of dozing, for a total possible score of 24. Scoresabove10aregenerallyconsideredtoindicate excessivesleepiness.Scoresabove15areconsidered toindicateextremesleepiness.

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B4 Measuringcrewmemberfatigue Howlikelyareyoutodozeofforfallasleepinthefollowingsituations,incontrasttofeelingjusttired?This referstoyourusualwayoflifeinrecenttimes. PLEASE TICK ONE BOXONEACHLINE wouldnever slight moderate high doze chance chance chance Sittingandreading......0 ............. ............2 ............3 1 . watchingTV......0 ............. ............2 ............3 1 . Sittinginactiveinapublicplace(eg.theatre,meeting)......0 ............. ............2 ............3 1 . Asapassengerinacarforanhourwithoutabreak......0 ............. ............2 ............3 1 . Lyingdownintheafternoonwhencircumstancespermit..0 ............. ............2 ............3 1 . Sittingandtalkingtosomeone......0 ............. ............2 ............3 1 . Sittingquietlyafteralunchwithoutalcohol......0 ............. ............2 ............3 1 . Inacar,whilestoppedforafewminutesintraffic......0 ............. ............2 ............3 1 . FigureB1:TheEpworthSleepinessScale provide complete information on questionnaires. Retrospective surveys can also be used to track the effectiveness of an FRMS across time (i.e., as an Despite limitations, retrospective surveys from time FRMSsafetyassuranceprocessseeFigure5.3). totime can be a useful source of information in an FRMS. Strengthsandweaknessesofretrospectivesurveys B2. Monitoringcrewmemberfatigue Retrospectivesurveysareacomparativelycheapway duringflightoperations togatherarangeofinformation.However,timeand costs are involved in developing and distributing the B2.1 Subjectivefatigueandsleepinessratings survey questionnaire, entering the information into databasesandanalyzingit. The following things should be considered when choosing rating scales for monitoring crewmember A limitation of retrospective surveys is that the fatigueandsleepinessduringflightoperations. information gathered is subjective, and therefore its reliability is open to question. Reliability is a i. Isthescalequickandeasytocomplete? particular issue when crewmembers are asked to ii. Is it designed to be completed at multiple time accurately recall details of past events, feelings, or points,e.g.,acrossaflight? sleeppatterns.Thisisnottoquestioncrewmembers iii. Has it been validated? For example, has it been integrity inaccurate recall of past events is a showntobesensitivetotheeffectsofsleeploss common and complex human problem. Concerns and the circadian body clock cycle under aboutwhethersomecrewmembersmightexaggerate controlledexperimentalconditions? intheirresponses,forpersonalorindustrialreasons, iv. Is it predictive of objective measures such as should be minimal in a just reporting culture as is performanceormotorvehiclecrashrisk? required for FRMS. In addition, extreme ratings are v. Hasitbeenusedinotheraviationoperations,and obviouswhencomparedwithgroupaverages. arethedataavailabletocomparefatiguelevels? Crewmembers confidence in the confidentiality of Thefollowingtwoscalesmeetthesecriteria. their data is likely to be a very important factor in their willingness to participate in surveys and to
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Measuringcrewmemberfatigue TheKarolinskaSleepinessScale(KSS) This scale asks people to rate how sleepy they feel rightnow. 4Anyofthevaluesfrom19canbeticked, notonlythosewithaverbaldescription. 1=extremelyalert 2 3=alert 4 5=neithersleepynoralert 6 7=sleepy,butnodifficultyremainingawake 8 9=extremelysleepy,fightingsleep FigureB3:TheKarolinskaSleepinessScale(KSS) Figure B4 shows KSS ratings from 25 flight crewmembers across ultralong range flights from SingaporetoLosAngeles5.

B5

8.00

Sleepiness Rating

6.00

4.00

2.00

Rating Time

FigureB4:KSSsleepinessratingsonflightsfrom SingaporetoLosAngeles Solidlinedataforthecommandcrew Dottedlinedataforthereliefcrew Each flight had two crews (two captains, two first officers). The command crew (solid line) flew both thetakeoffandthelandingandwasallocatedthe2nd and 4th inflight rest periods. The relief crew (dotted line)wasallocatedthe1stand3rdinflightrestperiods (they became the command crew for the return flight). Ratingsweremadeatthefollowingtimes: rating1preflight; rating2attopofclimb; rating3beforeeachcrewmembers1stinflight restperiod; rating 4 after each crewmembers 1st inflight restperiod; rating5beforeeachcrewmembers2ndinflight restperiod; rating6aftereach crewmembers2ndinflight restperiod; rating7attopofdescent;and rating8postflightbeforedepartingtheaircraft.

kerstedt T, Gillberg M. Subjective and objective sleepinessintheactiveindividual.IntJNeurosci52:2937, 1990. Gillberg M, Kecklund G, kerstedt T. Relations between performance and subjective ratings of sleepiness duringa nightawake.Sleep17(3):236241,1994. Harma M, Sallinen M, Ranta R, Mutanen P, Muller K. The effectofanirregularshiftsystemonsleepinessatworkin train drivers and railway traffic controllers. J Sleep Res 11(2):141151,2002. Gillberg M. Subjective alertness and sleep quality in connection with permanent 12hour day and night shifts. ScandJWorkEnvironHealth24(Suppl3):7680,1998. Reyner LA, Horne JA. Evaluation of incar countermeasures to sleepiness: cold air and radio. Sleep 21(1):4650,1998. 5 FlightSafetyFoundation(2006).FlightSafetyDigest24 (89). SignalTL,vandenBergM,TravierN,GanderPH(2004). Phase3ultralongrangevalidation:inflight polysomnographicsleepandpsychomotorperformance. Wellington,NewZealand:MasseyUniversity,Sleep/Wake ResearchCentreReport.

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B6 The command and relief crews have different patterns in their sleepiness ratings across the flight, partly as a result of their different inflight rest periods. TheSamnPerelliCrewStatusCheck This scale asks people to rate their level of fatigue right now, and is a simplified version of the Samn PerelliChecklist6. 1=fullyalert,wideawake 2=verylively,responsive,butnotatpeak 3=okay,somewhatfresh 4=alittletired,lessthanfresh 5=moderatelytired,letdown 6=extremelytired,verydifficulttoconcentrate 7=completelyexhausted,unabletofunctioneffectively FigureB5:TheSamnPerelliCrewStatusCheck Figure B6 shows SamnPerelli ratings for the same ULR crewmembers on the same flights as in Figure B4.

Measuringcrewmemberfatigue

6.00

Fatigue Rating

4.00

2.00

0.00 1 2 3 4 5 6 7 8

Rating Time

Samn SW, Perelli LP. Estimating aircrew fatigue: A technique with implications to airlift operations. Brooks AFB, TX: USAF School of Aerospace Medicine. Technical ReportNo.SAMTR8221,1982. SamelA,WegmannHM,VejvodaM,DrescherJ,GundelA, Manzey D, Wenzel J. Twocrew operations: Stress and fatigue during longhaul night flights. Aviat Space Environ Med68:67987,1997. Samel A, Wegmann HM, Vejvoda M. Aircrew fatigue in longhaul operations. Accid Anal & Prev 29(4); 439452, 1997.
6

FigureB6:SamnPerellifatigueratingsonflightsfrom SingaporetoLosAngeles Solidlinedataforthecommandcrew Dottedlinedataforthereliefcrew Strengthsandweaknessesofsubjectiveratings Subjective sleepiness and fatigue ratings are relatively cheap and easy to collect and analyze. Furthermore, how a crewmember feels is likely to influencetheirdecisionsaboutwhentousepersonal fatigue countermeasure strategies. On the other hand,subjectiveratingsdonotalwaysreliablyreflect objective measures of performance impairment or sleep loss, particularly when a person has been getting less sleep than they need (sleep restriction) acrossseveralconsecutivenights. Concernsaboutsomecrewmembersexaggeratingon subjectivefatigueandsleepinessratings,forpersonal or industrial reasons, should be minimal in a just reportingcultureasisrequiredforFRMS.Inaddition, extreme ratings are obvious when compared with groupaverages. InanFRMS,subjectivesleepinessandfatigueratings areparticularlyusefulfor:

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Measuringcrewmemberfatigue gathering information from large groups of crewmembers; where data are needed fairly quickly to decide whether more indepth monitoring is warranted or if additional fatigue risk mitigation strategies areneeded;and amongarangeofmeasureswhenmoreintensive monitoring is undertaken in an FRMS (for example during validation of a new route), because they provide valuable insights on crewmembersexperienceoffatigue. Decisionmaking by the Fatigue Safety Action Group can be guided by comparing average (and/or extreme) ratings with data gathered on other operations. B2.2 Objectiveperformancemeasurement A range of objective performance tests are used in laboratory studies, but they usually measure very specific aspects of performance (for example, reactiontime,vigilance,shorttermmemory,etc),not the complex combinations of skills needed by crewmembers in the course of flight duties. Laboratory tests usually also measure the performance of individuals, not the combined performanceofthecrew.Nevertheless,somesimple performance tests are considered probes or indicators of a crewmembers capacity to carry out hisorherduties. The following things should be considered when choosing performance tests for monitoring crewmember fatigue and sleepiness during flight operations. I. Howlongdoesthetestlast? II. Can it be completed at multiple time points, (e.g.,anumberoftimesacrossaflight),without compromising a crewmembers ability to meet dutyrequirements? III. Hasitbeenvalidated? Forexample,hasitbeen showntobesensitivetotheeffectsofsleeploss and the circadian body clock cycle under controlledexperimentalconditions?

B7 IV. Isitpredictiveofmorecomplextasks,e.g.,crew performance in the simulator or during an in flight emergency? (Unfortunately, there is very little research addressing this question at present.) V. Has it been used in other aviation operations, and are the data available to compare fatigue levels? Oneperformancetestthatmeetsthesecriteriaisthe Psychomotor Vigilance Task or PVT7. In the most widely used version of the PVT, the test lasts for 10 minutes and is carried out on a purposebuilt hand held device. However, some recent studies8 and large aviation field studies currently in progress are usinga5minuteversionofthePVTprogrammedon aPersonalDataAssistant(PDA)device. FigureB7showsmeanreactiontimesonthePVTfor thesameULRcrewmembersonthesameflightsasin Figures B4 and B6. In this study, the 10minute versionofthetestwasused.PVTtestsweredoneat thefollowingtimes: test1closetotopofclimb; test 2 at the start of the second inflight rest opportunity; test3closetotopofdescent;and test4postflight,beforedepartingtheaircraft.

7 Dinges,D.F.andPowell,J.P.(1985).Microcomputeranalysisof
performanceonaportable,simplevisualRTtaskduringsustained operation.BehaviorResearchMethods,Instruments,and Computing,17:652655 Balkin,T.J.,Bliese,P.D.,Belenky,G.,Sing,H.,Thorne,D.R., Thomas,M.,Redmond,D.P.,Russo,M.andWesensten,N.J. (2004).Comparativeutilityofinstrumentsformonitoring sleepinessrelatedperformancedecrementsintheoperational environment.JournalofSleepResearch,13:219227. 8 LamondN,Petrelli,R,DawsonD,RoachGD.Theimpactof layoverlengthonthefatigueandrecoveryoflonghaulflight crew.ProceedingsoftheFatigueinTransportationConference (Session13c),Seattle,September1125,2005.USDepartmentof Transport.

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B8

Measuringcrewmemberfatigue other hand, more complex tests to measure these types of skills usually require many practice trials beforetheycanbeconsideredfullylearntandready tobeusedformeasuringchangesduetofatigue.The PVT does not require practice trials, except to make sure that crewmembers know how to operate the testingdevice. B2.3 MonitoringSleep Sleep loss is a key contributing factor to fatigue. In addition,crewmembersneedtogetrecoverysleepto return to their optimum level of waking function. Sleepcanbemonitoredduringflightoperationsusing subjectivesleepdiariesand/orbyobjectivemeasures such as actigraphy or polysomnography. Each of theseisdescribedinmoredetailbelow. SleepDiaries Sleep diaries ask crewmembers to record the followinginformationabouteachsleepperiod: wheretheysleep(home,layoverhotel,inflightin acrewrestfacilityorabusinessclassseat,etc); whattimetheygotobedandgetup; howmuchsleeptheythinktheyget;and howwelltheythinktheysleep. Crewmembers may also be asked to rate their sleepinessandfatiguebeforeandafterplannedsleep periods.Whensleepisbeingmonitoredduringflight operations, crewmembers are also asked to record actualdutytimes. Diariescanhavedifferentlayoutsandtheyareoften adapted to include specific information for a given study (for example, reminders about when to do performance tests or workload rating scales). Paper based diaries are still more common, but electronic versionsarealsoused(e.g.,programmedonaPDA). Differentlayoutsmayberequiredfor different parts of a study, for example pretrip, during flights, and duringlayovers. FigureB8showsanexampleofaninflightsleepdiary designed to be used during ultralong range flight when crews have multiple inflight rest periods

Mean Reaction Time (ms)

300.00

275.00

250.00

225.00 1 2 3 4

Test Number

FigureB7:MeanReactionTimeonthePVTTaskon FlightsfromSingaporetoLosAngeles Solidlinedataforthecommandcrew Dottedlinedataforthereliefcrew StrengthsandweaknessesofthePVT ThePVTrequiresacrewmembersconstantattention during the test. In the study in Figure B7, for example, this meant that crewmembers were requiredtobeoutoftheoperationalcontrolloopfor atotalof30minutesduringtheflight.Thisisaneven greaterchallengewhencrewsarenotaugmented. In the study in Figure in B7, crewmembers were asked to complete PVT tests on the flight deck and there were clearly occasions when their attention was distracted by operational events. This increased thevariabilityofperformanceonthePVTtestacross the group and made it more difficult to find statistically significant changes in PVT performance across the flight. Only the postflight test (Test 4) in Figure B7 is significantly different from any of the others. The PVT does not measure important skills such as situation awareness and decisionmaking. On the

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Measuringcrewmemberfatigue (courtesy of the Sleep/Wake Research Centre). This example includes Karolinska Sleepiness and Samn Perelliratingsbeforeandaftereachsleepperiod,as well as a sleep quality rating scale for each sleep period.

B9 777 flight crewmembers in a layover hotel and in flight.9Forinflightsleep: averagesleepdurationsfromdiariesweresimilar to those recorded using polysomnography (the acceptedgoldstandardforrecordingsleep);but thevariabilityamongindividualswashigh.Some crewmembers overestimated how long they slept,andothersunderestimated;and crewmembers estimates of how long they took to fall asleep, and their ratings of sleep quality were not reliably related to polysomnography measures. Thus diaries alone may be useful for measuring the sleep duration of groups but cannot be considered accurateforestimatingthesleepdurationofanyone individual. In addition, diaries are not generally considered reliable for measuring sleep quality. (However, some very new research suggests that peoplesreportsoftheirsleepqualitymayberelated tochangesinpartsofthebrainthatarenotdetected by polysomnography, so scientific opinion about the valueofselfreportedsleepqualitymaychange). Despitetheselimitations,sleepdiariesarearelatively cheap way of gathering reasonable information on the average amount of sleep obtained by groups of crewmembers. They are also used to help interpret objectivesleepdata,asdescribedbelow. Actigraphy Anactigraphisasmalldevicewornonthewristthat contains an accelerometer to measure movement and a memory chip to store activity counts at regular intervals (for example every minute). Dependingontheamountofmemoryavailable,they can be worn for weeks to months before the data need to be downloaded to a computer for analysis. Figure B9 shows an example of an older style actigraph.
9

FigureB8:Exampleofaninflightsleepdiary forULRoperations Strengthsandweaknessesofsleepdiaries Sleepdiariesarecheapcomparedtoobjectiveforms of sleep monitoring. However, information from paper diaries needs to be manually entered into databases, which can slow down the process of gettinganswerstoaparticularoperationalquestion, andanalysisofdiarydatahascostsassociated. Sleep diaries are known to be less reliable than objectivesleepmonitoring.Onestudyhascompared sleepdiariesandobjectivesleepmeasuresfrom21B

Signal,T.L.,Gale,J.,andGander,P.H.(2005)Sleep

MeasurementinFlightCrew:ComparingActigraphicand SubjectiveEstimatesofSleepwithPolysomnography.Aviation SpaceandEnvironmentalMedicine76(11):10581063

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B10 There are a number of manufacturers of actigraph devices, and each type comes with custom software that scans through the activity record and decides (basedonavalidatedalgorithm),whethertheperson was asleep or awake in each recorded epoch (for example every minute). Some devices have light sensors and some also have a regular watch face so that the wearer does not need to wear a normal watchaswell,tokeeptrackoftime.

Measuringcrewmemberfatigue trying to sleep during his 1st rest period, but the algorithmcouldnot(atthattime)scoresuchashort sleepperiod. The following Sunday, he flew as a command crewmember on the LAXSIN segment and had two inflight rest opportunities (195 minutes and 300 minutes), both of which he took in the crew rest facility. According to the actigraphy scoring algorithm,heobtained2hrs14minofsleepinhis1st restperiod,and4hrs3mininhis2ndrestperiod.

FigureB9:anexampleofanactigraph Figure B10 shows an actigraphy record from a crewmember before, during, and after a Singapore LosAngelesSingaporeULRtrip.Eachverticalgraybar indicates an hour, with 24 hours (from midnight to midnight) plotted across the diagram. Consecutive days are shown down the page. The vertical black bars indicate the level of activity for each minute of therecording(higherbarsindicatemoremovement). Periods with minimal movement (short, scattered black bars) correspond to times when the crewmemberwasasleep. On the first Thursday, the crewmember flew as a relief crewmember on the SINLAX segment, during which he had three inflight rest opportunities (1 hr 30mins,4hrs,and2hrs),but(accordingtohisdiary) he only went to the crew rest facility for the 2nd of these. The actigraphy scoring algorithm calculated thatheobtained2hrs55minsofsleepduringthe2nd rest period, and 1 hr 12 mins of sleep during his 3rd rest period, which he took in a passenger cabin. His sleep diary indicated that he also spent 44 minutes

FigureB10:Actigraphyrecordofacrewmember before,during,andafteraSingaporeLosAngeles SingaporeULRtrip Strengthsandweaknessesofactigraphy AsFigureB10illustrates,actigraphyisveryusefulfor obtaining objective records of the sleep/wake patterns of crewmembers across multiple days. This is currently the most practical and reliable way to look at whether a crewmember accumulates a sleep debtacrossalineofflying,comparedtotheamount of sleep they average when off duty. Actigraphy can

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Measuringcrewmemberfatigue also provide useful information on recovery sleep afteratrip. Actigraphs are small and unobtrusive to wear, and actigraphy is cheap compared to polysomnography. The main limitation of actigraphy is that it monitors activity(notsleep)anditcannotdistinguishbetween someone being asleep versus being awake but not moving. The study described previously 9 also compared actigraphy and polysomnographic sleep recordings from the 21 B777 flight crewmembers. For both hotelsleepandbunksleep: average sleep durations calculated from actigraphy were similar to those recorded using polysomnography;but for individual crewmembers, actigraphy could overestimateorunderestimatepolysomnographic sleep duration by more than an hour. This amount of inaccuracy is particularly problematic forinflightsleepperiods,whichtendtobeshort; and comparing actigraphy and polysomnography minutebyminute, the study concluded that actigraphic estimates of how long crewmembers took to fall asleep, and of how often they woke upduringasleepperiod(sleepquality),werenot reliablyrelatedtopolysomnographicmeasures. On the positive side, the study demonstrated that actigraphy was not significantly contaminated by in flight factors such as turbulence or aircraft movement, and that it is reliable for estimating the average sleep duration of groups of crewmembers, bothintheairandontheground. Actigraphs are currently not particularly cheap, although some manufacturers are working on new generationdevicesthatmaypushcostsdown.Notall actigraphs on the market have been validated (by comparing their algorithms for estimating sleep quantity and quality with polysomnography), and some have not yet been demonstrated to be robust and reliable for sleep monitoring during flight

B11 operations (battery life can be a problem in some devices). At present, the accepted standard for analyzing actigraphy records is to use a sleep diary to identify whenacrewmemberwastryingtosleep(asopposed to just sitting still or not wearing the watch). The sections of the record where the crewmember was trying to sleep are then analyzed for sleep duration and quality. This type of analysis requires a trained persontoworkthroughactigraphyrecordsmanually, which is time consuming and fairly costly. Several manufacturers and research groups are looking at ways to bypass the need for this manual scoring, which would make actigraphy much cheaper and faster to analyze. However, the reliability of these new approaches for estimating sleep quantity and quality(comparedtopolysomography)remainstobe demonstrated. Someoperatorsmaychoosetodevelopthecapacity inhousetocollectandanalyzeactigraphy.Aspartof theFRMSAssuranceProcesses,anexternalscientific advisory group could be convened periodically to review the actigraphy analyses and the resulting decisionsmadebytheFlightSafetyActionGroup. Polysomnography Polysomnography is the accepted gold standard for monitoring sleep and is currently the only method that gives reliable information on the internal structure of sleep and on sleep quality. It involves sticking removable electrodes to the scalp and face and connecting them to a recording device, to measurethreedifferenttypesofelectricalactivity:1) brainwaves (electroencephalogram or EEG); 2) eye movements(electroculogramorEOG);and3)muscle tone(electromyogramorEMG). In addition to monitoring sleep, polysomnography can be used to monitor waking alertness, based on the dominant frequencies in the brainwaves, and patterns of involuntary slow rolling eye movements that accompany sleep onset. Figure B11 shows a flight crewmember on the flight deck wearing polysomnographyelectrodes,whichtheresearcheris connectingtoaportablerecordingdevice.

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B12

Measuringcrewmemberfatigue FigureB12showsananalysisofthepolysomnography recordofthe1stinflightsleepperiodontheSINLAX flight for the same crewmember whose actigraphy recordisshowninFigureB10(timesinUTC).Figure B12 is a graph created by a trained sleep technician who has gone through the entire polysomnographic recording and, using an internationally agreed set of rules, has decided for each 30 seconds whether the crewmemberwasawake,orinwhichtypeofsleephe spent most of that 30 seconds. Figure B12 shows thathetook13minutestofallasleepandthenspent atotalof17.5minutesinlightnonREMsleep(S1and S2). However, he woke up 6 times across the sleep period.HedidnotenterdeepnonREMsleep(S3and S4),orRapidEyeMovement(REM)sleep.

FigureB11:Polysomnographicrecordinginflight

FigureB12:Polysomnographicrecordforthe 1stinflightrestperiodontheSINLAXflight (samecrewmemberasinFigureB10) FigureB13:Polysomnographicrecordforthe 2ndinflightrestperiodontheSINLAXflight (samecrewmemberasinFigureB10)

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Measuringcrewmemberfatigue Figure B13 shows the polysomnographic record for the same crewmember during his 2nd inflight rest periodontheSINLAXflight.Inthisrestperiod(inthe bunk),hefellasleepin19.5minutes andthenslept foratotalof144.5minutes,interruptedbynumerous briefperiodsofwakingwhichtotaled52minutes.He spent 1.5 minutes in deep nonREM sleep (S3), 2 minutesinREMsleep,andtherestofthetimeinlight nonREMsleep(S1andS2). Strengthsandweaknessesofpolysomnography Figures B12 and B13 show the detailed information about sleep quality that can only be obtained from polysomnographic recordings. When it is important tobecertainabouttheamountandtypeofsleepthat crewmembers are obtaining, polysomnographic monitoringisthemosttrustedmethod. On the other hand, polysomnography is relatively obtrusiveandtimeconsuming.Ittakesawelltrained technician about 30 minutes to attach the recording electrodes to a persons scalp and face, and check thatalltheelectricalconnectionsareworking.Forin flight recordings, the electrical contacts need to be checked periodically (for example before each in flight rest period) to make sure that the signals are still clean. Crewmembers can be shown how to remove the electrodes themselves. However, the equipmentisexpensiveandfragileandatechnicianis required to download the data from the recording device to a computer, and to clean the equipment. Thismeansthatitisusualforatleastonetechnician toaccompanycrewmembersthroughoutatripduring whichtheirsleepisrecordedusingpolysomnography. Thisiscostly. As previously mentioned, the currently accepted standardforanalyzingpolysomnographyistohavea trained sleep scoring technician work through the entire recording to decide for each 30 seconds whether the crewmember was awake, or in which type of sleep he/she spent most of that 30 seconds. For quality assurance, it is usual to have a second trainedtechnicianscoreatleastsomeoftherecords to check the reliability of scoring between the two technicians. This is time consuming and relatively

B13 expensive. A number of groups are working on automated scoring systems for polysomnography, butasyetnoneofthesearewidelyaccepted bythe sleep research and sleep medicine communities. Beyondthescoringprocess,itisnecessarytohavea qualified person to interpret that significance of diagramssuchasFiguresB12andB13. Despite these costs and inconveniences, there have been a number of studies of flight crew sleep that have used polysomnography and these have been very informative. While it is unlikely that any airline would need to develop inhouse capacity to record andanalyzepolysomnographyasaroutinepartofits FRMS, there are situations where the detailed information from polysomnography is needed. For example,inlaunchingthefirstcommercialpassenger ULRflights,SingaporeAirlinesandtheSingaporeCivil Aviation Authority agreed that a subgroup of crewmembers would have their sleep monitored by polysomnography during the operational validation oftheSINLAXroute.ThedatainFiguresB4,B6,B7, B10,B12,andB13comefromthisvalidationandare used with the kind permission of the Singapore Civil AviationAuthority(DrJarnailSingh)andprovidedby the Sleep/Wake Research Centre at Massey University,NewZealand. B2.4 Monitoringthecircadianbodyclockcycle The circadian body clock cycle is a key contributing factor to crewmember fatigue, but it is difficult to monitor during flight operations. In the laboratory, the cycle of the body clock is usually monitored by measuringtwooftheovertrhythmsthatitdrives: 1. thedailyrhythmincorebodytemperature;and 2. the daily rhythm in levels of the hormone melatonin, which is secreted by the pineal gland atnight.Melatoninlevelscanbemeasuredfrom blood, saliva, or urine samples collected at regularintervals. During the 1980s, a number of research teams monitoredthecircadianbodyclocksofcrewmembers by tracking the rhythm of core body temperature. FigureB14showsthetimesofthedailytemperature

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B14 minimum of one participating B747 crewmember acrossan8daylonghaultrippattern10. At home in SFO prior to the trip, his temperature minimum (inverted triangle) occurred about 5 hours intohissleepperiod(blackhorizontalbar).Duringthe trip, he repeatedly flew westward then back eastward across multiple time zones, spending around 24 hours in each location. The circadian temperature minimum could not follow this disruptedpattern(itshiftedbynomorethan2hours fromonedaytothenext).Acrossthetrippattern,it drifted progressively later, so that by the time the crewmember arrived back in SFO at the end of the trip,ithaddriftedabout6hourslater.Thus,whenhe got home, the crewmembers circadian body clock was6hoursoutofstepwithhishometimezoneand tookseveraldaystoreadapt. Anotherinterestingfeatureofthisrecordisthatthe temperature minimum (when physiological sleep drive is highest), sometimes occurs in flight, for example on the flight from NRT to HKG. At these times, the crewmember is at greatest risk of falling asleep unintentionally on the flight deck. Alternatively, if he has the opportunity for a rest break(whichwasnotthecaseinthisoperation),this wouldrepresentaverygoodtimetotrytogetsome inflightsleep.

Measuringcrewmemberfatigue

10 Gander,P.H.,Gregory,K.B.,Miller,D.L.,Rosekind,M.R.,Connell,
L.J.,andGraeber,R.C.(1998)FlightcrewfatigueV:longhaulair transportoperations.Aviation,Space,andEnvironmentalMedicine 69:B37B48

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Measuringcrewmemberfatigue

B15

Sleep(fromdiary) Flight Localnight Nap Temperatureminimum FigureB14:Sleeptimes(diarydata)andtimesofthecircadian temperatureminimum ofacrewmemberduringalonghaultrippattern Clearly,FigureB14providesvaluableinformationthat can be related to the crewmembers sleep, fatigue, mood, and performance capacity. However, it has been several decades since this type of monitoring has been undertaken primarily because of the logisticsandcostoftrackingcircadianrhythmsduring flightoperations. Thereisongoingresearchaimedatdevelopingmore robust and less intrusive methods for continuously monitoringcircadianrhythmsoutsidethelaboratory, including a new generation of temperature pills, that are swallowed and transmit temperature measurements as they transit through the digestive system.However,bodytemperatureisalsoaffected by the level of physical activity, and it is complex to separate out this masking effect from the actual

circadianclockdrivencomponentofthetemperature rhythm(thiswasdonemathematicallyinFigureB14). The second rhythm that is commonly monitored in thelaboratorytotrackthecycleofthecircadianbody clock is the level of the hormone melatonin. Melatonin can be measured in blood or saliva samples taken at regular intervals, and its metabolitescanbemeasuredinurinesamples.There areobviousdifficultiesassociatedwithcollectionand frozen storage of body fluid samples during flight operations. Another complicating factor is that synthesisofmelatoninisswitchedoffbybrightlight. Thus,ifacrewmemberisexposedtodaylightduring his/her biological night (for example, a few hours either side of the of the temperature minimum in FigureB14),melatoninsecretionwillstop.Thismakes itimpossibletotrackitsnormalcircadiancyclecross

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B16 a trip such as that in Figure B14. Analyzing for hormone levels in body fluids is a highly skilled task thatneedstoundertakenbyareputablelaboratory. Strengthsandweaknessesofmonitoringthecircadian bodyclockcycle There is remarkably little information available on howthecircadianbodyclockisaffectedbyanykind offlightoperations.Wheredatahavebeencollected, thereisevidenceofconsiderablevariabilitybetween individuals on the same trip patterns. Better informationinthisareawouldimprovethepredictive powerofbiomathematicalmodelsforfatiguehazard identification, and might provide insights on how to tailor personal mitigation strategies for crewmembers who are morningtypes versus eveningtypes. A number of groups are actively working on new technologies for monitoring the circadian body clock cycle, but as yet none of these has been validated or demonstrated to be robust enoughandpracticalforuseduringflightoperations.

Measuringcrewmemberfatigue In 1997, the Canadian Transportation Safety Board producedguidelinesforfatigueanalysis.Theysuggest fourinitialquestionstodecidewhetherornotfatigue wasacontributingfactortoanevent.11 1. At what time of day did the occurrence take place? 2. Wasthecrewmembersnormalcircadianrhythm disrupted? 3. How many hours had the crewmember been awakeatthetimeoftheoccurrence? 4. Does the 72hour sleep history suggest a sleep debt? Iftheanswertoanyoneofthesequestionsindicates a problem, then fatigue should be investigated in greater depth. This requires working through two checklists(adaptedfromtheCanadianTransportation SafetyBoardguide). Checklist 1 is designed to establish whether the person or crew were in a fatigued state, based on a seriesofquestionsorprobesthataddresskeyaspects offatigue.Theanswertoeachquestioniscompared tothebestcaseresponse,inordertobuildanoverall pictureofthefatiguehazard.Anydeparturefromthe bestcaseresponseindicatesincreasedriskoffatigue. Checklist 2 is designed to establish whether the unsafe action(s) or decision(s) were consistent with thetypeofbehaviorexpectedofafatiguedpersonor crew.

B3. Evaluatingthecontributionof fatiguetosafetyevents

There is no simple formula for evaluating the contribution of crewmember fatigue to a safety event. For the purposes of the FRMS, the aim is to identify how the effects of fatigue could have been mitigated,inordertoreducethelikelihoodofsimilar occurrences in the future. Basic information can be collected for all fatigue reports and safety events, with more indepth analyses reserved for events whereitismorelikelythatfatiguewasanimportant factorand/orwheretheoutcomesweremoresevere. Toestablishthatfatiguewasacontributingfactorin anevent,ithastobeshownthat: thepersonorcrewwasinafatiguedstate;and the person or crew took particular actions or decisions that were causal in what went wrong; and thoseactionsordecisionsareconsistentwiththe typeofbehaviorexpectedofafatiguedpersonor crew.

TransportationSafetyBoardofCanada,1997.AGuide forInvestigatingforFatigue.TransportationSafetyBoard ofCanada,Gatineau,Quebec.

11

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Measuringcrewmemberfatigue Checklist1:Establishingthefatiguedstate
QUESTIONS BESTCASERESPONSES QUANTITYOFSLEEP (Establishwhetherornottherewasasleepdebt) 7.5to8.5hours Normalcircadianrhythm,lateevening Normalcircadianrhythm,earlymorning No yes Had opportunity for restorative (1.52 hrs) or strategic (20 min) nap prior to startoflateshift 2creditsforeachhourofsleep;lossofonecreditforeachhourawake should beapositivevalue QUALITYOFSLEEP Normalcircadianrhythm,lateevening/earlymorning

B17

INVESTIGATORSNOTES

Howlongwaslastconsolidatedsleepperiod? Starttime? AwakeTime? Wasyoursleepinterrupted(forhowlong)? Anynapssinceyourlastconsolidatedsleep? Durationofnaps? Describeyoursleeppatternsinthelast72hours.(Apply sleepcreditsystem) (Establishwhetherornotsleepwasrestorative) Howdidthesleepperiodrelatetotheindividualnormal sleepcyclei.e.,start/finishtime? Sleepdisruptions? Sleepenvironment? Sleeppathologies(disorders)

Noawakenings Proper environmental conditions (quiet, comfortable temperature, fresh air, ownbed,darkroom) None

WORKHISTORY (Establishwhetherhoursworkedandtypeofdutyoractivitiesinvolvedhadanimpactonsleepquantityandquality) Hoursondutyand/oroncallpriortotheoccurrence? Situation dependent hours on duty and/or on call and type of duty that ensureappropriatelevelofalertnessforthetask Workhistoryinprecedingweek? Numberofhoursondutyand/oroncallandtypeofdutythatdonotleadtoa cumulativefatigue

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B18 Checklist1:Establishingthefatiguedstate(continued)
QUESTIONS BESTCASERESPONSES

Measuringcrewmemberfatigue

INVESTIGATORSNOTES

IRREGULARSCHEDULES (Establishwhethertheschedulingwasproblematicwithregardstoitsimpactonquantityandqualityofsleep) Wascrewmemberashiftworker(workingthroughusual sleeptimes)? Ifyes,wasitapermanentshift? Ifno,wasitrotating(vsirregular)shiftwork? Howareovertimeordoubleshiftsscheduled? Schedulingofcriticalsafetytasks? No (The circadian body clocks and sleep of shift workers do notadaptfully) Yesdays Yes Rotating clockwise, rotation slow (1 day for each hour delayed),nightshiftshorter,andattheendofcycle Scheduledwhencrewmembersareinthemostalertpartsof thecircadianbodyclockcycle(latemorning,midevening) SScheduledwhencrewmembersareinthemostalertparts ofthecircadianbodyclockcycle(latemorning,midevening)

Has crewmember had training on personal fatigue Yes mitigationstrategies? JETLAG (Establishtheexistenceandimpactofjetlagonquantityandqualityofsleep) Numberoftimezonescrossed? Ifmorethanone,atwhatrateweretheycrossed? Inwhichdirectionwastheflight? one theslowerthebetter westward

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Measuringcrewmemberfatigue Checklist2:Establishingthelinkbetweenfatigueandtheunsafeact(s)/decision(s)
PERFORMANCEINDICATORS INVESTIGATORSNOTES

B19

Attention
Overlookedsequentialtaskelement Incorrectlyorderedsequentialtaskelement Preoccupiedwithsingletasksorelements Exhibitedlackofawarenessofpoorperformance Revertedtooldhabits Focusedonaminorproblemdespiteriskofmajorone Didnotappreciategravityofsituation Didnotanticipatedanger Displayeddecreasedvigilance Didnotobservewarningsigns

Memory
Forgotataskorelementsofatask Forgotthesequenceoftaskortaskelements

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B20
Inaccuratelyrecalledoperationalevents

Measuringcrewmemberfatigue

Alertness
Succumbedtouncontrollablesleepinformofmicrosleep, nap,orlongsleepepisode Displayedautomaticbehaviorsyndrome

ReactionTime
Respondedslowlytonormal,abnormaloremergencystimuli Failedtorespondaltogethertonormal,abnormalor emergencystimuli

ProblemSolvingAbility
Displayedflawedlogic Displayedproblemswitharithmetic,geometricorother cognitiveprocessingtasks Appliedinappropriatecorrectiveaction Didnotaccuratelyinterpretsituation Displayedpoorjudgmentofdistance,speed,and/ortime

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Measuringcrewmemberfatigue PERFORMANCEINDICATORS Mood Waslessconversantthannormal Didnotperformlowdemandtasks Wasirritable Distractedbydiscomfort Attitude Displayedawillingnesstotakerisks Ignorednormalchecksorprocedures Displayedadontcareattitude PhysiologicalEffects Exhibitedspeecheffects Exhibited reduced manual dexterity keypunch entry errors,switchselection

B21 INVESTIGATORSNOTES

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[Back to Contents]
AppendixC.Proceduresforcontrolledrest

[Back to Overview]
C1

AppendixC:Proceduresforcontrolledrestontheflightdeck
Controlled rest on the flight deck is an effective fatigue mitigation for flight crews. It should not be used as a scheduling tool. It is not a substitute for proper preflight sleep or for normal crew augmentation, but is intended as a response to unexpected fatigue experienced during operations. Somebasicprinciples: Itshouldbeconsideredasafetynet. The Fatigue Safety Action Group should be able to monitor the use of controlled rest on the flight deck to evaluate whether existing mitigation strategies are adequate. Crew reportsareencouraged. It should only be used on flights of sufficient length that it does not interfere with required operationalduties. It should only be used during low workload phasesofflight(e.g.,duringcruiseflight). Itshouldnotbeusedasamethodforextending crewdutyperiods. Proceduresforcontrolledrestontheflightdeck should be published and included in the OperationsManual. Recommended Procedures for Controlled Rest on theFlightDeck The following recommended procedures are based on a survey of major air carriers. They represent considerable experience in many regions of the globe and include options reflecting variations betweendifferenttypesofoperations. Note: this is not intended to be an all inclusive list, norarealloftheseproceduresnecessarilyrequired. Each operator should work with their regulator to defineappropriateprocedures. Planning Onlyonepilotmaytakecontrolledrestatatime inhis/herseat.Theharnessshouldbeusedand the seat positioned to minimize unintentional interferencewiththecontrols. The autopilot and autothrust systems (if available)shouldbeoperational. Any routine system or operational intervention which would normally require a cross check, should be planned to occur outside controlled restperiods. Controlledrestontheflightdeckmaybeusedat the discretion of the captain to manage both unexpected fatigue and to reduce the risk of fatigue during higher workload periods later in theflight. Itshouldbeclearlyestablishedwhowilltakerest, and when it will be taken. If the pilot in command requires, the rest may be terminated atanytime. The pilot in command should define criteria for whenhis/herrestshouldbeinterrupted. Handover of duties and wakeup arrangements shouldbereviewed. Flight crews should only use controlled rest if theyarefamiliarwiththepublishedprocedures. Someoperatorsinvolveathirdcrewmember(not necessarily a pilot) to monitor controlled flight deck rest. This may include a planned wakeup call,avisittobescheduledjustaftertheplanned rest period ends, or a third crewmember on the flightdeckthroughoutcontrolledrest. The controlled rest period should be no longer than 40 minutes, to minimize the risk of sleep inertiaonawakening. Controlledrestshouldonlybeutilizedduringthe cruiseperiodfromthetopofclimbto20minutes

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C2 before the planned top of descent. This is to minimizetheriskofsleepinertia. Ashortperiodoftimeshouldbeallowedforrest preparation. This should include an operational briefing, completion of tasks in progress, and attention to any physiological needs of either crewmember. Duringcontrolledrest,thenonrestingpilotmust performthedutiesofthepilotflyingandthepilot monitoring, be able to exercise control of the aircraft at all times and maintain situational awareness. The nonresting pilot cannot leave his/her seat for any reason, including physiologicalbreaks. Aidssuchaseyeshades,necksupports,earplugs, etc.,shouldbepermittedfortherestingpilot.

Proceduresforcontrolledrest

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[Back to Contents]
AppendixD.ExampleofanFRMSEvaluationForm

[Back to Overview]
D1

AppendixD:ExampleofanFRMSEvaluationForm

TOBECOMPLETEDANDSIGNEDFORBYTHESAFETYMANAGERORACCOUNTABLEMANAGER Organization: Approval reference: Signature: Position: Printname: Dateof signing: FRMSManualrevision:

FORAUTHORITYUSEONLY Staffname: Signature:

Dateof assessment:

0.

GENERALISSUESANDFRMSIMPLEMENTATION

FRMSScopeandImplementation TheOrganizationshoulddefinethescopeoftheuseofFRMSwithinitsoperation.InestablishinganFRMSaGAPanalysis shouldbecarriedoutandanimplementationplanthatwilladdresshowtheorganizationwilltransitiontoafullyfunctioning andeffectiveFRMS.

In place1

Documented2 Reference:

Howisitachieved?3

Inspectorsassessment remarks4

0.1 Inrespectofthemanagement system,hasthestructure,activitiesand thescopeoftheFRMSoperationsbeen defined? 0.2 DoestheFRMScorrespondto thesize,natureandcomplexityofthe operationandthehazardsand associatedrisksinherentwithits activities? 0.3 Hasagapanalysisbeencarried out? 0.4 IsthereanFRMS implementationplanthatreflectsthe gapanalysis?

1 2

Yes(Y),No(N)orPartial(P) Whereisitdocumentedinyourdocumentation? 3 Providedetailsthatdescribeordemonstratesyourresponsetothequestion. 4 ThiswillbecompletedbytheAuthorityduringtheassessmentprocess Uneditedversion

D2
1. SAFETYPOLICYANDOBJECTIVES

ExampleofanFRMSEvaluationForm

1.1 ManagementCommitmentandResponsibility TheorganizationshoulddefineitsFRMSpolicywhichshouldbeinaccordancewithinternationalandnationalrequirements, and which shall be signed by the Accountable Manager of the organization. This policy should reflect organizational commitmentsregardingfatiguerisk,includingaclearstatementabouttheprovisionofthenecessaryhumanandfinancial resourcesforitsimplementationandbecommunicated,withvisibleendorsement,throughouttheorganization.TheFRMS policy should include the fatigue reporting procedures and management commitment to continuous improvement of the FRMS.Itmustalsoreflectthesharedresponsibilityforthemanagementoffatigueriskswithallthestakeholders. The policy should be periodically reviewed to ensure it remains relevant and appropriate to the organization and the operationstowhichFRMSapplies. (WheretheFRMSisintegratedwithintheOrganizationsSMS,thesemanagementcommitmentsandresponsibilitiesmaybe included in the SMS safety policy. If this is done it must still be possible to demonstrate these responsibilities as clearly referencedtofatigue.)

In place1

Documented2 Reference:

Howisitachieved?3

Inspectorsassessment remarks4

1.1.1 IsthereawrittenFRMSpolicy clearlystatingthesafetyobjectivesof theFRMSandendorsedbythe accountablemanager? Orarethereclearreferencestofatigue riskmanagementwiththeSMSpolicyas endorsedbytheaccountablemanager? 1.1.2 Werekeystaffconsultedinthe developmentoftheFRMSpolicy/ integrationofFRMSintotheSMS? 1.1.3 HastheFRMSpolicybeen communicatedeffectivelythroughout theorganization?

1.1.4 Doesseniormanagement continuouslypromoteanddemonstrate itscommitmenttothecontinuous improvementoftheFRMS? 1.1.5 DoesthePolicyincludea commitmentto;strivetoachievethe highestsafetystandards,observeall applicablelegalrequirements,standards andbestpractice,providingappropriate resourcesasaprimaryresponsibilityof allManagers? 1.1.6 DoestheFRMSpolicyactively encouragefatiguereporting? Uneditedversion

ExampleofanFRMSEvaluationForm
In place1 Documented2 Reference: Howisitachieved?3

D3
Inspectorsassessment remarks4

1.1.7 IstheFRMSmanagement systembasedontheFRMSpolicy? 1.1.8 DoestheFRMSpolicyreflect thesharedresponsibilityofthe managementoffatiguewithall stakeholders? 1.1.9 DoestheFRMSpolicyreflect theneedforperiodicreview?

1.2 Accountabilities The organization shall identify the accountable executive who, irrespective of other functions, shall have ultimate responsibilityandaccountability,onbehalfoftheorganization,fortheimplementationandmaintenanceoftheFRMS.The organizationshallalsoidentifythefatigueriskaccountabilitiesofallmembersofseniormanagement,irrespectiveofother functions, as well as of employees, with respect to the performance of the FRMS. Responsibilities, accountabilities and authoritiesshallbedocumentedandcommunicatedthroughouttheorganization,andshallincludeadefinitionofthelevels ofmanagementwithauthoritytomakedecisionsregardingfatiguerisktolerability. (Where the FRMS is integrated within the Organizations SMS, these accountabilities may be included in the SMS documentation.Ifthisisdoneitmuststillbepossibletodemonstratetheseaccountabilitiesasclearlyreferencedtofatigue.)

In place1

Documented2 Reference:

Howisitachieved?3

Inspectorsassessment remarks4

1.2.1 DoestheAccountableManager havefullresponsibilityand accountabilityfortheFRMSand corporateauthorityfortheorganization? 1.2.2 DoestheAccountableManager haveanawarenessoftheirFRMSroles andresponsibilitiesinrespectofthe FRMSpolicy,fatigueriskmanagement withinthesafetycultureofthe organization? 1.2.3 Arefatigueriskmanagement accountabilities,authoritiesand responsibilitiesdefinedthroughoutthe organization? 1.2.4 Arethereclearlydefinedlines offatigueriskmanagement accountabilitiesthroughoutthe organization?

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D4
In place1 Documented2 Reference:

ExampleofanFRMSEvaluationForm
Inspectorsassessment remarks4

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1.2.5 Areallstaffawareofand understandtheiraccountabilities, authoritiesandresponsibilitieswith regardtofatigue?

1.3Appointmentofkeysafetypersonnel TheorganizationshallidentifyaFRMSmanagertobetheresponsibleindividualandfocalpointfortheimplementationand maintenanceofaneffectiveFRMS.Thereneedstobeaclearmechanismforongoinginvolvementofallinvolvedpersonnel through a functional group responsible for coordinating FRMS activities throughout the organization, which should be definedanddocumented.(ThereferenceusedinthisdocumentistotheFatigueSafetyActionGroup(FSAG).) (WheretheFRMSisintegratedintotheSMS,theFRMSmanagerwouldnormallyreporttotheSafetyManager,whowould haveadirectreportinglinetotheAccountableManager.WheretheorganizationissmallbutwithafunctioningSMS,itmay notbepracticaltohaveaFSAGbuttohavefatigueasanagendaitemontheSafetyActionGroupmeetings.)

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1.3.1 HasaFRMSManager(or equivalent)beenappointedwiththe appropriateknowledge,skillsand experienceasdefinedintheguidance material? 1.3.2 Isthereadirectreportingline betweentheFRMSManagerandthe AccountableManager?(Orwhere integratedwithSMS,betweentheFRMS managerandtheSafetyManager.) 1.3.3 DoestheFRMSManagercarry outthefunctionsasdetailedintheICAO guidancematerial? 1.3.4 HasaFatigueSafetyAction Grouporequivalentbeenestablished? 1.3.5 DoestheBoardmonitorthe performanceandeffectivenessofthe FRMSasdetailedintheguidance material? 1.3.6 IstheFatigueSafetyAction Groupsmembershipandfrequencyof meetingsdefinedandminuted?

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1.3.7 HasaFatigueSafetyAction Grouporequivalentbeenestablished thatfulfilsthefunctionsdefinedinthe guidancematerial?

1.4FRMSDocumentation The organization shall develop and maintain FRMS documentation describing the FRMS policy and objectives, the FRMS requirements, the FRMS processes and procedures, the accountabilities, responsibilities and authorities for processes and procedures, and the FRMS outputs. The organization shall develop and maintain a FRMS manual to communicate its approachtothemanagementofsafetythroughouttheorganization,orshallincorporatetheFRMSdocumentationintoits existingSMSdocumentation.

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1.4.1 DoestheFRMSmanagement manualcontainalltheelementsas detailedintheguidancematerial? 1.4.2 Isitregularlyreviewed? 1.4.3 Isthereasystemforrecording scheduledandactualflighttimes,duty andrestperiodswithdeviationsand reasonsforanydeviations?

1.4.4 Isthereasystemforthe recordingandstorageofFRMSoutputs i.e.hazardlogs,riskassessments,fatigue reports,safetycases,rostermetrics, FSAGminutes,etc?

2. FATIGUERISKMANAGEMENT 2.1 HazardIdentification The organization shall develop and maintain a formal process that ensures that fatigue hazards are identified. This should includetheinvestigationofincidentsandaccidentstoidentifypotentialfatiguehazards.Fatiguehazardidentificationshallbe basedonacombinationofreactive,proactiveandpredictivemethodsofdatacollection.

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2.1.1 Isthereaprocessfor establishinghowfatiguehazardsare identifiedandfromwhatsources? 2.1.2 Isthereaconfidentialfatigue reportingschemethatencourages fatiguerelatedissuestobereportedby Uneditedversion

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staff?(Thisneedstobeopento proactiveandpredictiveaswellas reactiveinformation.) 2.1.3 Istherefeedbacktothe reporterandtherestofthe organization?

2.1.4 Doesfatiguehazard identificationincludereactive,proactive andpredictiveschemes? 2.1.5 Havethemajorfatiguehazards beenidentifiedandassessedforthe organizationanditscurrentactivities? 2.1.6 Dosafetyinvestigations throughouttheorganizationinclude fatiguehazardsaspossiblecausal factors? 2.1.7 Arethefatiguehazards identifiedfromfatigueinvestigations addressedandcommunicatedtotherest oftheorganization? 2.1.8 Arefatiguerelatederrors, hazardsandnearmissesbeingreported bystaff?

2.2 FatigueSafetyRiskassessmentandmitigationprocess The organization shall develop and implement formal risk assessment procedures that determine the probability and potentialseverityoffatiguerelatedeventsandidentifythosethatrequiremitigation.Theyshallalsodevelopandimplement riskmitigationprocedures.TheFatigueSafetyActionGroupisoftenusedtoassesstherisksanddevelopthemitigations.

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2.2.1 Isthereaprocesstoassessthe risksassociatedwithidentifiedfatigue hazards? 2.2.2 Isthereacriterion(e.g.risk tolerabilitymatrix)thatevaluatesrisk andthetolerablelevelsofriskan organizationiswillingtoaccept?Isthe criterionandprocessappropriateforthe operation?

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2.2.3 Arethemitigationactions, includingtimelinesandresponsibilities documented?

2.2.4 Isthereaclearprocesstoselect theappropriatemitigationactions?

3. FATIGUESAFETYASSURANCE 3.1 Fatiguesafetyperformancemonitoringandmeasurement Theorganizationshalldevelopandmaintainthemeanstoverifythefatiguesafetyperformanceoftheorganization,andto validatetheeffectivenessoffatigueriskcontrolsandmitigations.Thefatiguesafetyperformanceoftheorganizationshallbe verifiedinreferencetothefatiguesafetyperformanceindicatorsandfatiguesafetyperformancetargetsoftheFRMS. (Where the FRMS is incorporated into the SMS, the fatigue safety performance indicators and fatigue safety performance targetsmustbeclearlyidentified.)

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3.1.1 Arefatigueriskmitigationsand controlsbeingverified/auditedto confirmtheeffectiveness? 3.1.2 Arelessonslearntincorporated intothepolicyandprocedures? 3.1.3 Havefatiguesafety performanceindicatorsbeendefined, promulgatedandbeingmonitoredand analyzedfortrends?

3.1.4 IstheFRMSauditedtoassessits effectivenessandthattheregulations andstandardsarebeingfollowed?Are theseauditsdocumented? 3.1.5 Arefatiguesurveyscarriedout? 3.1.6 Arefatiguestudiescarriedout? (whereappropriate)

3.2TheManagementofChange Theorganizationshalldevelopandmaintainaformalprocesstoidentifychangeswithintheorganizationand/oroperation whichmayaffectestablishedprocessesinrelationtofatiguerisk.Theseprocessneedtoensurefatiguesafetyperformance beforeimplementingchangesandtoeliminateormodifyfatigueriskmitigationsthatarenolongerneededoreffectivedue tochangesintheoperationalenvironment.

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3.2.1 Isthereadocumentedchange managementprocesstoproactively identifyfatiguehazardsandtomitigate fatiguerisksduringorganizationaland operationalchanges? 3.2.2 Arethereperiodicalreviewsof thefatiguesafetyperformanceafter organizationaloroperationalchangesto assureassumptionsremainvalidandthe changewaseffective?

3.3ContinuousimprovementoftheFRMS The organization shall develop and maintain a formal process to review the performance of the FRMS, with the aim of continuousimprovementofthesystem.AlsotodeterminetheimplicationsofsubstandardperformanceoftheFRMS,and eliminateormitigatesuchcauses.

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3.3.1 Isthereameanstomonitorthe overallperformanceoftheFRMSto allowforcontinuousimprovementtobe achieved? 3.3.2 Isthereameanstoeliminate and/ormodifyriskcontrolsthathave unintendedconsequencesorareno longerneeded? 3.3.3 Isthereevidenceofcontinuous improvementbeingachieved?

4. FRMSPROMOTION 4.1 TrainingandEducation Theorganizationshalldevelopandmaintainafatigueawarenessandcountermeasurestrainingprogramthatensuresthat personnelaretrainedandcompetenttobothperformtheirFRMSdutiesandmanagefatiguerisksinactualoperations.The scopeofthetrainingshallbeappropriatetoeachindividualsinvolvementintheFRMS.

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4.1.1 Haveallstaffreceivedtraining ontheorganizationsFRMSandtheir rolesandresponsibilitiesinrespectof theFRMSincludingtheAccountable Manager,SeniorManagement, Managers,supervisorsandoperational

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staff? 4.1.2 Istheinitialandrecurrent trainingsyllabussuitableforthe organizationsFRMSoperations? 4.1.3 Istheeffectivenessofthe trainingmeasuredanddocumented?

4.2FRMScommunication TheorganizationshalldevelopandmaintainformalmeansforFRMScommunicationthatensuresthatallpersonnelarefully awareoftheFRMS,conveysfatiguerelatedsafetycriticalinformation,andexplainswhyparticularactionsaretakenandwhy proceduresareintroducedorchanged.

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4.2.1 DoesFRMScommunication reachalllevelsofstaffinthe organization? 4.2.2 DoestheFRMScommunication clearlyexplainthepolicies,procedures andresponsibilities?Doesitcomplement andenhancetheorganizationssafety culture? 4.2.3 IstheFRMSinformation disseminatedinasuitable communicationchannelsandisitand monitoredforitseffectiveness?

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