Fatigue Risk Management System for the Canadian Aviation Industry - Policies and Procedures Development Guidelines - TP 14576

April 2007

ProjectTeam 

Preface

Table of Content

• How to Use this Guide
• 1. Introduction
  • 1.1  Preamble (Mandatory)
  • 1.2  Document Control (Mandatory)
  • 1.3  Definitions and Abbreviations (Mandatory)
  • 1.4  Relevant Operational Publications (Mandatory)
• 2. Manual Control and Organization
  • 2.1  Company Operations (Mandatory)
  • 2.2  Outline of Organizational Structure (Mandatory)
  • 2.3  Responsibilities of Company Personnel (Mandatory)
• 3. Fatigue Risk Management System
  • 3.1  Preface (Mandatory)
  • 3.2  FRMS Policy (Mandatory)
  • 3.3  Hours of Service and Scheduling (Mandatory)
  • 3.4  Verification of Actual Sleep (Mandatory)
  • 3.5  Fatigue-Related Symptoms (Mandatory)
  • 3.6  Fatigue-Proofing Strategies (Recommended)
  • 3.7  Reporting Protocols (Mandatory)
• 4. Training and Education (Mandatory)
• 5. Review and Improvement Process
• 6. Appendices
• 7. Further Reading

Project Team

Edu.au

Kirsty McCulloch
Angela Baker
Sally Ferguson
Adam Fletcher
Drew Dawson

Transport Canada

Isabelle Marcil, Transportation Development Centre (TDC)
Jacqueline Booth-Bourdeau, Civil Aviation 
Mark Laurence, Civil Aviation 
TDC Communications Unit

Preface

This document is part of the Fatigue Risk Management System (FRMS) Toolbox for Canadian Aviation developed by Transport Canada and fatigue consultants edu.au of Adelaide, Australia.

The FRMS toolbox includes the following components:

1. FRMS for the Canadian Aviation Industry: An Introduction to Managing Fatigue, TP 14572E: introductory material intended to raise awareness about fatigue

2. FRMS for the Canadian Aviation Industry: Fatigue Management Strategies for Employees, TP 14573E: provides the knowledge and skills required to apply appropriate fatigue management strategies at the individual level

3. FRMS for the Canadian Aviation Industry: Employee Training Assessment, TP 14574E: an optional module intended to assess employee competence in topics covered in the Fatigue Management Strategies for Employees workbook

4. FRMS for the Canadian Aviation Industry: Developing and Implementing a Fatigue Risk Management System, TP 14575E: explains how to manage the risks associated with fatigue at the organizational level within a safety management system framework

5. FRMS for the Canadian Aviation Industry: Policies and Procedures Development Guidelines, TP 14576E: proposes a policy structure while providing examples and guidelines to help organizations through the process of designing fatigue risk management policies and procedures

6. FRMS for the Canadian Aviation Industry: Introduction to Fatigue Audit Tools, TP 14577E: provides an overview of tools available to employers to help determine whether scheduling provides employees with adequate opportunities to get sufficient sleep

7. FRMS for the Canadian Aviation Industry: Trainer’s Handbook, TP 14578E: in addition to a training presentation on fatigue, fatigue management systems, and individual fatigue management strategies, the package includes background information for delivery of the workshop, learning outcomes, and questions frequently asked by participants

These documents are available on the Transport Canada web site at https://tc.canada.ca/en.

How to Use this Guide

A fatigue risk management system (FRMS) is an integrated set of management policies, procedures, and practices for monitoring and improving the safety and health aspects related to fatigue within your organization. This guide is intended to help you to build an effective fatigue risk management policies and procedures manual tailored to your specific operational requirements. Such a manual should provide both the overall governance policy for fatigue risk management, as well as a detailed framework for how fatigue will be managed on a day-to-day basis within the workplace.

Implementing an FRMS does not mean you need to create another set of documents. Some aspects of the policy may already be covered in your safety management system (SMS) manual. If this is the case, just cross-reference or copy the information in your FRMS manual.

In accordance with Canadian Aviation Regulations (CARs), the FRMS manual must clearly define:

• the level of senior management commitment
• the purpose and goals of the FRMS
• responsibilities of all employees for managing fatigue risk
• training requirements
• reporting procedures for fatiguerelated hazards
• the fatigue reporting policy (any punitive actions that may be taken as a result of non-compliance, for example)
• a procedure for evaluation and continuous improvement of the FRMS.

This approach is in line with Transport Canada’s guide to implementing a safety management system: Safety Management Systems for Flight Operations And Aircraft Maintenance Organizations — A Guide to Implementation (TP13881E).

NOTE: Advisory Circular 107-001 replaces TP 13881, Revision 1, dated 2002-03-01 Safety Management Systems for Flight Operations and Aircraft Maintenance Organizations.

Each section of this guide has three components:

• Introduction — information about the purpose, theory and framework of the given FRMS policy component

• Points to consider — a summary of the main points to be covered in that section of the manual. These have been framed as questions, which can be used as a framework for discussing the core components of an FRMS in consultation workshops.

• Sample text — examples of what might be included in the given policy component section. These examples have been provided so that organizations can see the style of phrasing and content acceptable to Transport Canada. Each section of your policy manual should be tailored to the specific needs of your organization.

Each section of this FRMS guide is labelled as either mandatory or recommended:

• mandatory sections must be included in your document. The sample text provided in this guide should be reviewed and modified appropriately to suit your operation.

• recommended sections should be discussed with employees or your FRMS committee to determine whether they are appropriate and how they should be adapted to meet your operational requirements.

This guide follows the same organizational structure recommended for the FRMS policies and procedures manual.

1. Introduction

• 1.1 Preamble (Mandatory)
• 1.2 Document Control (Mandatory)
• 1.3 Definitions and Abbreviations (Mandatory)
• 1.4 Relevant Operational Publications (Mandatory)

1.1 Preamble (Mandatory)

The FRMS manual should include clearly defined policies, procedures, and practices to ensure that the risk of fatigue-related error is reduced as much as possible. The FRMS should be tailored to your operation. To ensure maximum effectiveness of your FRMS, the manual must reflect what you actually do.

The aim of implementing an FRMS is to institute a change in organizational culture that results in enhanced flight safety and a safer working environment. It is essential that organizations do not simply paraphrase generic FRMS policy statements but take the time to write their own. The FRMS manual should be used as the primary means of communicating to employees the FRMS policies and procedures to be followed as part of regular operations.

You should review and update the FRMS manual one year after implementation, and on a set schedule thereafter (e.g., every two years). You will need to include a control process for amending documentation as per CAR documentation requirements.

Points to Consider

• Why is the organization implementing an FRMS?
• Who will be affected by implementation of the FRMS?
• What are the basic responsibilities of employees within the FRMS?
• How often will the FRMS policy be reviewed and updated?

Sample Text

1.2 Document Control (Mandatory)

All Canadian civil aviation certificate holders are required by the CARs to amend the FRMS manual whenever it is necessary to do so. You should systematically create, circulate, and record any amendments to the FRMS policy. You may choose to use your current procedure for this or the one described in the sample text below. This text provides a basic amendment process for a simple FRMS manual. You may wish to add extra controls suitable for the size or complexity of your operation.

Points to Consider

• How will amendments to the FRMS policy be recorded?
• How will employees be informed about FRMS policy amendments?
• How will employee understanding of FRMS policy amendments be recorded?

Sample Text

1.3 Definitions and Abbreviations (Mandatory)

It is important to provide employees with clear definitions of key concepts in the FRMS policy. This helps the organization to avoid confusion and function with clear goals. If the content of this section is covered in your SMS manual, you may chose to simply cross-reference it here rather than repeating the information.

Define the meaning of words and phrases unique to the FRMS policy only. For example, you may want to define the terms “management,” “competent person,” and “responsible person.” Any terms or titles that you introduce in the manual should be defined here.

You must define “company” (operator/ organization) as the legal entity referred to throughout the manual.

You may wish to include references or other information sources in this section.

Points to Consider

• What terms used in the FRMS policy could be ambiguous or unknown to the user?
• What words are likely to recur throughout the document as acronyms?

Sample Text

1.4 Relevant Operational Publications (Mandatory)

This section is required when additional documents are relevant to your FRMS. You may wish to include references to regulatory material cited in this manual.

NOTE: If data such as accident statistics are included, they must be kept up to date.

Points to Consider

• Does the FRMS manual refer to any existing regulatory material or company documents?

Sample Text

2. Manual Control and Organization

• 2.1 Company Operations (Mandatory)
• 2.2 Outline of Organizational Structure (Mandatory)
• 2.3 Responsibilities of Company Personnel (Mandatory)

2.1 Company Operations (Mandatory)

You must provide details of the legal entity (as shown on your Civil Aviation Document) and its trading name (if applicable) in the opening paragraph. A copy of this FRMS policy manual must be placed at each location identified in the distribution list (see Section 1.2).

If the content of this section is already covered in your SMS documentation, you may chose to simply cross-reference it here rather than repeating the information.

Points to Consider

• What is the legal and contact information of the company referred to in this FRMS policy (i.e., address, telephone, fax, e-mail, website, operating certificate, operating licence number)?

Sample Text

2.2 Outline of Organizational Structure (Mandatory)

You must provide an outline of your organizational structure. If you have provided this information in your operations or SMS manual, you may refer to it here, remembering that you must add the position of “person responsible for the FRMS” and/or “FRMS Committee.” The information may be provided in text or table format.

You must also include a reference to the legal entity named in Section 2.1 who holds the CAD to which this FRMS policy applies. The name of the legal entity should be the same as listed on the CAD.

Note: if any information changes, such as the company address, you are required to amend your SMS manual and notify Transport Canada accordingly.

You must state that this manual is available for Transport Canada’s inspection at the location specified in Section 1.2.

Points to Consider

• How many layers of management are there in the hierarchy of the organization?
• Who is directly responsible for each group of employees?
• Where does fatigue risk management fit within the organizational structure?
• How is the accountable executive notified of fatigue-related issues?

Sample Text

Section 2.2    Outline of Organizational Structure (Mandatory)

This organization operates with the positions described below. A reporting structure is implied by the arrangement of the names in this structure, i.e., each position reports to and is accountable to the position immediately above.

 

2.3 Responsibilities of Company Personnel (Mandatory)

You must ensure that responsibilities for fatigue risk management are specified in the organizational structure. This is likely to include:

• Safety Manager
• Person responsible for the FRMS
• The SMS/FRMS Committee
• Employees

If there are other positions in the organization with responsibilities related to the FRMS, they should be included here. You may choose to define the roles and responsibilities of those positions here or elsewhere in the document, cross referencing them to this section.

The person responsible for FRMS may be the Accountable Executive, the person responsible for maintenance, or — in a small organization — the director of flight operations. In larger organizations, responsibility is likely delegated to a specific position, individual, or committee. It is important, however, to designate one person as having primary responsibility for directing the FRMS.

The responsibilities of each position under the FRMS should be outlined here. You can add the responsibilities of employees to the organization chart, or you can add them in point form below the chart.

Points to Consider

• What are the specific duties and responsibilities of each subgroup of employees for managing fatigue within the context of the FRMS?
• How do those responsibilities fit within the organizational structure?

Sample Text

3. Fatigue Risk Management System

Five-Level Fatigue Hazard Control Model

Click on image to enlarge

• 3.1 Preface1.1 Preamble (Mandatory)
• 3.2 FRMS Policy
  • 3.2.1 Senior Management Commitment to Managing Fatigue (Mandatory)
  • 3.2.2 Fatigue-related Safety Objectives (Mandatory)
  • 3.2.3 Communication and Consultation (Mandatory)
• 3.3 Hours of Service and Scheduling (Mandatory)
• 3.4 Verification of Actual Sleep (Mandatory)
• 3.5 Fatigue-related Symptoms (Mandatory)
• 3.6 Fatigue-Proofing Strategies (Recommended)
• 3.7 Reporting Protocols (Mandatory)

3.1 Preface (Mandatory)

An effective fatigue risk management plan should take a systems approach to minimizing fatigue-related incidents. The FRMS section of this policy tool is based on the five-level error trajectory (see Developing and Implementing a Fatigue Risk Management System (TP 14575E) for more detailed discussion). At Level 1, organizations must provide sufficient sleep opportunity to all employees. This can be achieved either through prescriptive hours of service rules or computerbased fatigue modelling (see Section 3.3). At Level 2, organizations should encourage employees so that, when provided with sufficient sleep opportunity, they strive to obtain sufficient sleep. This can be done in a number of different ways, as outlined in Section 3.4. At Level 3, organizations should monitor the frequency that employees exhibit fatigue-related symptoms, regardless of sleep opportunity and actual sleep obtained. If employees appear to be exhibiting fatigue-related symptoms, their ability to perform high-risk tasks should be examined by an appropriate manager. This process is outlined in more detail in Section 3.5. Level 4 deals with fatigue proofing situations that may involve higher levels of fatigue-related risk, such as emergency overtime or extreme weather. See Section 3.6. The final level in the error trajectory is concerned with reporting errors and incidents that may be fatigue-related. Details of this process are given in Section 3.7.

The information presented under each of the following sections is not intended as a prescriptive formula for the development of a Fatigue Risk Management System. You should use this material to tailor an FRMS to suit the size and nature of your operation. This will ensure a level of owner ship by both management and operational personnel.

As with any Safety Management System, commitment from management and clear consultation with employees ensures a positive safety culture that is the foundation for success.

An FRMS should be part of your wider SMS as an integrated set of work practices and procedures for monitoring and improving the safety of all aspects of your organization. It recognizes the potential for fatigue-related errors and establishes robust defences to minimize the likelihood of incidents or accidents.

As with all safety management systems, fatigue risk management involves goal setting, planning, documentation, and measuring performance against goals. An FRMS should be a comprehensive, integrated tool for managing fatigue in operational settings.

This section should include general information about the FRMS and provide a framework for the remainder of the manual. It should say why the FRMS has been implemented and list the basic components that it covers.

Points to Consider

• What is the basic structure of the FRMS?

Sample Text

Section 3.1    Preface (Mandatory)

The FRMS incorporates fatigue hazard control mechanisms to ensure:

• sufficient sleep opportunity is given to employees (see Section 3.3)
• actual sleep obtained is verified (see Section 3.4)
• procedures for monitoring and dealing with fatigue-related symptoms (see Section 3.5)
• fatigue-proofing strategies are implemented to reduce fatigue-related risk (see Section 3.6)
• fatigue-related accident/incident investigation procedures are in place (see Section 3.7)

The FRMS is based on the five-level error trajectory shown below.

 

Five-Level Fatigue Hazard Control Model

3.2 FRMS Policy

3.2.1 Senior Management Commitment to Managing Fatigue (Mandatory)

Every organization is unique in terms of the size of its operation, layout of its facilities, frequency of aircraft movements, and maintenance and flight operations. The FRMS you develop needs to be tailored to meet the needs of your specific operation.

This section must contain a clear commitment to the FRMS from the organization’s senior management. This is an overall statement about the management of fatigue hazard (see Developing and Implementing a Fatigue Risk Management System (TP 14575E) for an example of such a mission statement). The statement outlines the corporate philosophy of fatigue risk management and clearly identifies the person(s) responsible for oversight of the FRMS within the company. FRMS policies and procedures must be communicated to all employees with a clear endorsement by senior management.

Your policy statement should clearly state:

• commitment of senior management to the FRMS
• responsibilities and accountability of the accountable executive, managers, committees, and employees
• how the organization will achieve its safety objectives
• resources allocated
• fatigue-related safety outcomes expected of managers, employees, and contractors

You should also include a statement explaining how the FRMS interacts with your SMS.

Points to Consider

• Has senior management given support and commitment to FRMS implementation?
• What is the overall purpose of the FRMS?
• What resources are allocated for the FRMS?

Sample Text

3.2.2 Fatigue-related Safety Objectives (Mandatory)

Fatigue-related safety objectives form the basis for measuring the success of the FRMS components. Safety objectives need to be specific, measurable, realistic, and have the backing of those who have to deliver them. Both short- and long-term objectives should be set and prioritized, and balanced with business requirements.

Fatigue risk management objectives are outcome-based to meet the organization’s safety policies. They should be transparent to employees and customers and clearly outline expectations and intent to ensure a safe work environment for everyone.

It is essential that employees know how these objectives affect their job functions and roles. Simply informing employees that they need to manage fatigue-related risk is not sufficient. They should be given operational roles or responsibilities that ensure fatigue-related risk is managed appropriately.

Points to Consider

• What does the organization aim to achieve with FRMS implementation? (This may extend beyond the reduction of fatigue-related risk to aspects such as increased employee morale or increased performance capacity)
• How does the organization plan to achieve that?

Sample Text

3.2.3 Communication and Consultation (Mandatory)

As with the wider SMS, information on FRMS policies, objectives, and responsibilities must be clearly communicated to staff, consultants, customers, and other appropriate individuals.

Where possible, the communication process should be recorded and filed for future reference by management and/or a Transport Canada audit team. Methods of communication could include memos, e-mail, or posters. Employees may be invited to submit agenda items to the FRMS Committee.

Whatever the method, communication needs to be clear and unambiguous, specific, and easily transferred and recorded by some means. An important step in this communication process is feedback.

Feedback can be formal and informal. Formal communication may take the form of minutes from the FRMS committee meetings or newsletters. Informal communication may be verbal. For example, a supervisor may update employees on the outcome of a fatigue-related issue during a lunch break.

In this section, you need to describe how you will distribute FRMS-related information, throughout the organization. What method will you use? How is the information to be distributed? Who is responsible? What is the time frame?

You also need to describe the methods of communication between the person/committee responsible for the FRMS and senior management. For example, regular, scheduled meetings with a set agenda or e-mail updates following each FRMS committee meeting.

This section should also detail the level of consultation with levels of management and employees during the FRMS design and review process. All employees should have the opportunity to participate in the FRMS design and review. There are many ways of achieving this. For example, focus naires, or employees may be asked to e-mail feedback.

Finally, you need to describe how you will distribute non-critical information related to fatigue. This might include educational information related to personal fatiguerisk management strategies. Examples might include memos, website, company newsletter, and safety notice boards.

Points to Consider

• How will information related to the FRMS be distributed and recorded?
• Who needs to receive FRMS related information?
• What level of consultation will be conducted among employees during the FRMS design and review process?
• Who will be involved in the FRMS consultation process?
• How will the FRMS consultation process be conducted?

Sample Text

3.3 Hours of Service and Scheduling (Mandatory)

The degree of work-related fatigue associated with a given task on a given schedule is linked to the degree a schedule precludes sleep of sufficient quality and duration to ensure employees are fit for work. A schedule produces higher levels of work-related fatigue if it requires an employee to work more often at times when one is socially and biologically predisposed to sleeping.

It is important that schedules provide employees with sufficient sleep opportunity to ensure they are fit for work. The factors that affect sleep opportunity are the length and timing of shifts, time away from work, long blocks of shifts, and biological limits on recovery.

There are a number of ways to ensure employees have been provided with sufficient sleep opportunity within a schedule:

• operate within federal or provincial hours-of-work rules
• use a computer-based fatigue modelling package
• use a fatigue likelihood scoring matrix

Biomathematical modelling

Many models predict fatigue based on planned or actual hours of work. They consider a number of factors including the timing and duration of all shifts in the previous days (with more weight given to more recent shifts). Most models also allow comparison of various schedules and the fatigue “scores” that each may produce in an employee population.

Using a “fatigue score” as an index of average sleep opportunity, organizations can determine whether sleep opportunity is adequate by comparing the estimated fatigue score to a threshold value established by the organization in advance. Schedules that produce a score over this threshold value may be considered to provide inadequate sleep opportunity. Any organization that chooses to use a biomathematical model should set threshold values for fatigue scores based on a risk assessment of the tasks found in the workplace. The risk assessment process may identify different task categories that require different threshold values based on their susceptibility to fatigue impairment. These threshold values are used to establish compliance tables for the schedules of various workgroups. To keep compliance tables convenient to manage, task categorization should be broad and based on criticality and susceptibility to fatigue risks.

The most effective way to use biomathematical models for scheduling is to set risk-based limits and restrict how much of the schedule exceeds them. Using this approach, the company defines acceptable, questionable, and unacceptable zones. Fatigue (sleep opportunity) scores (based on a task-defined risk assessment) are assigned to the acceptable/questionable and questionable/unacceptable thresholds.

Organizations should not intentionally schedule work with scores in the unacceptable zone and 95% of actual work hours must fall within the acceptable zone. A small percentage of total hours are permitted for scheduled work in the questionable zone. Circumstances may sometimes dictate that actual hours worked fall in the unacceptable zone. All work in zones other than acceptable must be investigated and appropriate corrective action taken. An example of a compliance table that shows threshold values, percentages of planned and actual hours of work, and corrective actions is shown below.

Create a compliance table or a list of threshold values as needed for each task category defined in the risk assessment process. The FRMS manual could also contain a list of corrective actions to be taken when necessary.

Example of a compliance table used with biomathematical modelling

Fatigue Likelihood Scoring Matrix for Work Schedules

An alternative assessment tool to the biomathematical model is a fatigue likelihood scoring matrix. There are five key elements that make up this matrix:

1. The total number of hours worked in a seven-day period. As total hours worked increases, sleep opportunity decreases.

2. The maximum length of an individual shift. As the length of a given shift increases, the subsequent sleep opportunity decreases.

3. The minimum length of a short break. A short break is defined as a single sleep opportunity between work periods. It is typically a period shorter than 32 hours. As the break between shifts decreases, so does the sleep opportunity.

4. The total number of hours worked between 9 p.m. and 9 a.m. in a seven-day period. This element captures late finishes, early starts, and night work. All of these will reduce the night sleep opportunity and result in a significant reduction in total sleep opportunity.

5. The frequency of long breaks. A long break is defined as a period of two night sleeps with a non-working day in between. Long breaks typically provide a significant opportunity to recover from sleep loss accumulated over a sequence of work periods.

A schedule can then be scored on each of the five elements using the following table.

Fatigue Likelihood Scoring Matrix for Work Schedules

Organizations should consider consulting with employees, the regulator, researchers, and others in the industry to establish some initial standards for how sleep opportunity can be assessed using each of these approaches and appropriate threshold values for adequate sleep opportunity for various categories of employees in the Canadian aviation industry.

Points to Consider

• How likely are employees to be fatigued due to lack of sleep opportunity in their work schedule (night work, early morning starts, extended shifts, overtime, long blocks of shifts, amount of time away from work, commute time, etc.)?
• How will the work schedules be assessed for fatigue-related risk?
• What is the level of fatigue-related risk associated with work tasks within the organization?
• What benchmark is the organization using to define fatigue-related risk as acceptable, questionable, or unacceptable?
• What procedures are in place for when work schedules fall within the questionable zone?

Sample Text

3.4 Verification of Actual Sleep (Mandatory)

The primary physiological determinants of fatigue for a given employee carrying out a given task are the timing and duration of prior sleep and time awake. These factors are the most appropriate criteria for judging whether an employee is likely to be fit for work. The hours of service and scheduling rules outlined in the preceding section are effective in predicting how much sleep an employee is likely to obtain in a given break from work. Level 2 control, however, aims to ensure that individual employees actually obtained sufficient sleep.

The focus of this level of control is setting minimum and maximum thresholds for sleep and time awake for employees to ensure that they are fit for duty. These minimum and maximum thresholds may vary for a specific task category or work group, according to the risk profile, but they can provide a simple, practical, and easily measurable yardstick to determine whether an employee has obtained sufficient sleep and is, by inference, fit for work.

These thresholds are equivalent to the simple formula used by people to determine whether they are alcohol impaired. For example, in counting number of drinks they have had over a period of time. While counting sleep and time awake is not a perfect indicator of the level of fatigue for all individuals on all occasions, it can provide employees with a simple measure for determining the relative likelihood that they are fatigued.

Calculating an Individual Fatigue Likelihood Score (IFLS)

Most evidence suggests that to maintain optimum performance, health, and wellbeing, individuals should get between seven and nine hours sleep per 24-hour period.

Many studies have investigated how decreasing levels of sleep and increasing time awake affects performance (see references in Section 7). In general, research has found that performance begins to become impaired after less than five hours sleep over a 24-hour period. Performance also becomes impaired if sleep consistently falls below six hours per night on an ongoing basis (over the period of a week).

A measure of fitness-for-duty related to fatigue can be calculated using the following table.

As prior sleep decreases and time awake increases, the likelihood of fatigue-related symptoms, errors, and incidents also increases. In general, X should be greater than 5, Y should be greater than 12 and Z should be less than Y. Each of the factors (X, Y, and Z) are added to provide an overall score of individual fatigue likelihood. Employees who obtain an elevated score should inform the appropriate supervisor or manager, and appropriate action should be taken. It is useful to establish a decision tree for employees and managers that provides clear information about appropriate action at various levels of fatigue. The table below shows an example.

How to calculate the Individual Fatigue Likelihood Score

* Partial hours should be pro-rated or scored proportionally. For example, if the scoring calls for 4 points for every hour below the threshold, give 2 points for a half-hour, or 1 point for 15 minutes.

Decision tree based on Individual Fatigue Likelihood Score

Potential Applications of the Individual Fatigue Likelihood Score (IFLS)

One way to use the IFLS as a Level 2 control is to apply the minimum sleep and maximum time awake rules as a simple self-assessment tool embedded in the training program. Employees would determine their own risk of fatigue and be required to manage their own fatigue with countermeasures such as sleep planning, strategic napping, caffeine, breaks, task rotation, etc.

Or employees might be required to report actual sleep obtained on a daily basis to the employer and to engage in clearly defined and documented risk mitigation strategies. In this case, the organization should design specific decision trees for designated tasks or work groups indicating what should be done at specified IFLSs. Levels of risk mitigation should increase with higher IFLSs. Examples of fatigue control measures for the various levels of risk are presented below.

Minor increase in risk: At this level, individual fatigue controls implemented by the employee are most common. Employees should report the level of fatigue-related risk to the appropriate supervisor according to the organizational reporting structure. The use of symptom checklists prior to starting work would be appropriate as would an increased level of supervision by the employee and/or by co-workers. Appropriate use of caffeine may be recommended, particularly during hours when an employee would typically be asleep. It would also be reasonable for the employee and/or co-workers to restructure work tasks and/or breaks to minimize any additional risk.

Moderate increase in risk: No employee should begin work with an IFLS in this range without completing a symptom checklist and indicating in writing that they consider themselves fit to work. Supervisors should discuss the work assignment with the employee and ensure that the number of safety-critical tasks are minimized and that all reasonable efforts are made to reallocate the workload safely. Employees with an IFLS in this range would receive priority for napping, where possible. The use of caffeine or other strategies to stay awake (bright lights, exercise, cool air, noise or upbeat music, etc.) would be common.

Significant increase in risk: An employee with an IFLS in this range would typically be considered unfit for work. This level of impairment is broadly comparable to drug or alcohol intoxication. It is unlikely that an employee would be permitted to undertake any safety-critical task and would probably not be allowed to drive to or from the workplace. Activities should not require employees to be responsible for the safety of themselves or others and should be limited to simple tasks in a relatively hazard-free environment. Before returning to work, all employees should be given adequate opportunity to obtain sufficient sleep. In general, employees should not be required to return until their fatigue likelihood score is zero.

When an employee notifies a supervisor or line manager of an elevated fatigue score, the reasons for the score need not to be discussed unless the employee reports such a score more than three times in 90 days. Discussions about the cause of multiple reports should typically involve the employee assistance program in the first instance (where applicable) and can subsequently involve line managers and supervisors where appropriate.

Using the Individual Fatigue Likelihood Score (IFLS) to Improve Work Scheduling Practices

Level 2 controls are designed to ensure adequate sleep at the individual level. They use relatively objective measures that are intuitively meaningful, observable, and easily recorded at the individual and group levels.

If an organization emphasizes Level 2 controls and they are reliably reported and documented, they can also be used to collect valuable data on fatigue in the organization. The data could be aggregated across an entire organization or even industry to provide the basis of a statistically sound approach to evaluating the amount of sleep and time awake provided by a schedule and form the basis for evaluating the effectiveness of scheduling factors set out in Section 3.3.

Points to Consider

• What is the minimum amount of sleep required to be considered fit for work:
  • on a one-time basis?
  • on a continual basis?
  • for high-risk work?
  • for low-risk work?
• What are the measures or procedures to follow when an employee has not obtained sufficient sleep?
• What should be done when this happens repeatedly?
• What policies or procedures are in place for contractors working on site?

Sample Text

3.5 Fatigue-related Symptoms (Mandatory)

Level 3 controls are concerned with reducing the likelihood that employees exhibit fatigue-related symptoms – and reducing the consequences. There are many reasons that an employee may appear to be or act fatigued. If the FRMS is operating effectively, the main cause – insufficient sleep – should be screened out by Level 1 or 2 controls.

The type of work performed may be particularly physically or mentally demanding, which can exacerbate fatigue and lead to fatigue-related symptoms. External factors such as weather can also affect fatigue. These factors should all be considered in the risk assessment of work tasks so that scheduling parameters can be set for different work groups or work tasks where warranted. The appearance of fatigue-related symptoms during certain work periods or tasks can be an indication that risk profiles need to be reassessed.

There may be situations where fatigue-related symptoms are not directly linked to work tasks or environmental conditions, and where the employee has been provided sufficient opportunity and actually obtained sufficient sleep. Nonwork factors are likely the cause. For example, the employee may be experiencing personal stress (e.g., sickness, newborn baby, financial issues, divorce) that is disturbing sleep.

Employees who say they get enough sleep and cannot explain their fatigue-related symptoms should undergo screening for a sleep disorder. Some of the more common sleep disorders are discussed in Developing and Implementing a Fatigue Risk Management System (TP 14575E). Employee Suspected of having a sleep disorder should be referred to a doctor or sleep specialist as soon as possible, particularly if they are performing high-risk tasks.

Level 3 controls – observing and reporting fatigue-related symptoms – are important in an effective FRMS to determine whether:

• minimum sleep requirements are appropriate
• task-scheduling processes are appropriate
• non-work activities are affecting the risk of workplace fatigue
• employees have a sleep disorder

The following table lists typical symptoms of fatigue. If employees have experienced more than three of the specified symptoms in a 15-minute-period, they are likely to be fatigued and should be considered at an elevated level of fatigue-related risk.

Symptoms of fatigue

When employees notice symptoms of fatigue in a co-worker, they should point it out to the co-worker. If the situation arises again, employees should encourage the coworker to report the fatigue and take the precautions outlined in the FRMS manual.

Employees repeatedly exhibiting fatigue-related symptoms should be encouraged to consult medical specialist to determine whether they suffer from a sleep disorder. This is particularly important for employees with a body mass index greater than 30 kg/m² and a neck size greater than 16 inches (40 cm) since they are at a greater risk for sleep apnea.

Some organizations are exploring performance testing technologies that could theoretically provide a more objective indication of fatigue-related impairment. Some of the main technologies currently available include the Occupational Safety Performance Assessment Test (OSPAT), psychomotor vigilance tests (PVT), Digit-Symbol Substitution Tests (DSST), pupillometry and blink tests. While some of these technologies are promising, they have not yet been shown to be sufficiently scientifically reliable to serve as a sole means to detect fatigue-related impairment.

Using Symptom Data to Assess Level 1 and 2 Controls

Documenting Level 3 controls can help double-check that Level 1 and 2 controls are appropriate. For example, if there is a high incidence of fatigue-related symptoms, and employees say they are complying with the organization’s minimum sleep requirements, the scoring system for sufficient sleep may need to be reviewed.

Fatigue-related symptoms can also flag employees who breach their responsibility of obtaining appropriate sleep in the time provided. For example, it is unlikely that employees who choose to engage in social activities rather than sleep will report their inadequate sleep to management. If employees regularly demonstrate fatigue-related symptoms, they may need to be reminded of their responsibility under the FRMS to arrive at work fit for duty.

Level 3 controls can also flag employees who experience disturbed sleep quality or quantity beyond their or their employer’s control, and who may be impaired by fatigue.

Points to Consider

• What are the main fatigue-related symptoms experienced by employees in the work environment?
• What symptoms are particularly indicative of being unfit for duty due to fatigue?
• How should fatigue-related symptoms be reported/used within the overall FRMS?

Sample Text

The main benefit of an FRMS is to provide organizations and employees with an increased level of safety management. The scheduling guidelines set out in Section 3.3 should be used for the majority of the company’s operations. However, there will be occasions when operational demands require extended hours of work. This may result in employees working through higher levels of fatigue than normal.

In these situations, there are a number of strategies that can be used to reduce the consequences of increased fatigue. For example, management may rely more heavily on Level 2 and 3 controls. This can help to determine which employees are most appropriate to complete the additional duties. To prevent fatigue-related errors, management should use Level 4 strategies, such as:

• napping
• supervisor and co-worker monitoring
• double-check systems
• task rotation and reallocation
• additional breaks and strategic use of caffeine

The organization should provide guidelines on how each of these can be used.

Napping: As a general rule, those with the highest risk should have the highest priority for napping. In general, the longer the nap the greater the recovery value. Naps should last at least 20 minutes and no more than two hours to be of maximum benefit. Shorter naps do not produce appreciable or lasting improvements in alertness. Sleeping more than two hours brings little additional benefit, particularly when that time could be used to provide another employee with a napping opportunity. Where controlled napping is allowed, the company should detail the circumstances under which it is permitted.

It is important to keep in mind that longer naps are associated with a longer period of sleepiness immediately following waking. This effect is known as sleep inertia. Employees should be given sufficient time to overcome the effects of sleep inertia before returning to work. Typically, this is at least 10 minutes during the day, and up to 20 minutes in the early hours of the morning.

Monitoring and double-check systems: Where an employee is at an elevated risk of fatigue-related error, increased monitoring by peers or supervisors for fatigue-related symptoms and/or impaired task performance can be an effective strategy. However, this can be a sensitive issue and it is important that the criteria for increased monitoring are clear in advance to minimize misunderstanding.

Increased monitoring can be achieved in a number of ways. It can be as simple and informal as more frequent or regular conversations with the employee over the course of the shift. Or it can involve more formal policies or procedures that call for additional, verified supervisory checks on safety-critical work by the fatigued impaired employee, co-workers, or a supervisor/line manager.

Task rotation and reallocation: Monotonous tasks with little variety are particularly susceptible to the effects of fatigue. In many cases, the workload can be made more engaging by varying the tasks during a shift. It is important to understand that the benefits of task rotation do not increase linearly. In general, the number of different tasks undertaken in a given shift should not exceed three or four, or the risk of error due to unfamiliarity with the job at hand may rise. Where task rotation forms part of the control system for fatigue-related risk, the number and types of tasks allocated should be determined in consultation with employees.

When an employee shows signs of fatigue, or when a self-assessment tool indicates impairment from fatigue is likely, the employer should make sure that the employee is not given certain tasks that may be high-risk to the employee, colleagues, the work flow, and/or the general public. Acceptable activities might include simple procedural tasks, word or data processing, quality checks, and basic communication. This reduces the risk of an incident, but does not mitigate the employee’s fatigue.

Additional breaks and strategic use of caffeine: When operational requirements call for longer hours of work, additional breaks should be provided to employees when fatigue may impair their performance. A break of 10 to 20 minutes may permit improvements in performance on a short-term basis. Employees assigned to tasks that require sustained attention over prolonged periods of time should take a break at least every two hours. Research shows that performance starts deteriorating after two hours on high-demand tasks. The breaks should be used to engage in strategies to improve alertness, e.g., walk outside to get some fresh air, exercise, have a coffee, etc.

Caffeine can provide a short-term improvement in alertness when it is used strategically. A typical dose of caffeine (75 to 150 mg) will provide an increase in alertness approximately 20 minutes after ingestion. The stimulating effects will vary in intensity and duration (up to four hours) depending on how often and how much caffeine the body is used to. However, the body can develop a tolerance, meaning the more caffeine the body gets on a daily basis, the less noticeable are the stimulating effects.

The best way to think about caffeine is that it has the capacity to “shift” fatigue and alertness to more appropriate times. However, there are significant disadvantages to prolonged regular caffeine use. Individuals differ enormously in their sensitivity to both the positive and negative effects of caffeine.

Points to Consider

• What strategies will be employed to avoid fatigue-related errors when employees need to work through high levels of fatigue?

Sample Text

3.7 Reporting Protocols (Mandatory)

Reporting protocols within the FRMS should be defined on two levels:

1. Reporting fatigue-related risk (insufficient sleep or sleep opportunity, fatigue-related symptoms)
2. Reporting errors and incidents that are fatigue related

Reporting fatigue-related risk (recommended)

Reporting risk is important for FRMS review and evaluation. Collect data on the frequency that employees are at risk of fatigue-related error or incident. How often did the work schedule provide insufficient sleep opportunity? How often did employees report getting insufficient sleep? How often did they report experiencing fatigue-related symptoms?

Employees may be reluctant to report this level of fatigue-related impairment on formal incident reporting forms, particularly in the early stages of FRMS implementation. The company should ensure that employees are aware of the fatigue reporting policy and that reports submitted to the system remain confidential. A special reporting form may be appropriate. The company could set up a reporting system and fatigue occurrence database on the company intranet to collect information such as:

• What schedule have you been working for the last week?
• How much sleep did you obtain in the last 24 hours?
• How much sleep did you obtain in the last 48 hours?
• What fatigue-related symptoms have you been experiencing?
• Have you notified a supervisor that you are at risk of making a fatigue-related error?
• Who have you notified that you are at risk of making a fatigue-related error?
• What countermeasures have you used?

Reporting fatigue-related errors and incidents (mandatory)

Most organizations have formal requirements to report errors and incidents as a part of their SMS. Few, however, systematically examine whether fatigue was a contributing factor. Industries that rely on shift work should develop standard reporting criteria that accurately reflect the occurrence of fatigue and sleepinessrelated errors and incidents.

For an error or incident to be defined as fatigue related, it must have:

1. occurred in the presence of fatigue
   and
2. been consistent with fatigue-related error (e.g., caused by employee falling asleep, inattention, delayed reaction time, complacency, etc.)

In order to define an event as fatigue related, the first three levels of control (see the figure in Section 3.1) must be reviewed:

1. Did the work schedule provide sufficient sleep opportunity for the employee?
2. Did the employee actually obtain sufficient sleep?
3. Was the event preceded by the presence of fatigue-related symptoms?

Examining planned and actual hours of work not only reveals whether changes led to insufficient sleep opportunity but can help the company better understand whether additional work hours were foreseeable and how to better allocate them in the future. Questions about the schedule could also include examining the commute to and from work for employees involved since this can also influence the sleep opportunity.

The second question allows the company to collect information on actual sleep obtained by the specific employee. How many hours of sleep did the employee obtain in the 24 and 48 hours before the event? How long was it since the employee had woken up from a sleep or a nap? If the employee had not obtained sufficient sleep, why not? Why was it not reported on arrival at work?

Since the reporting process relies heavily on the honesty of employees, it should be non-punitive. Incidents of insufficient sleep should be considered a learning experience for the organization and other employees, rather than as an incident that can affect an employee’s employment status.

The organization should also investigate whether the employee had been observed falling asleep or struggling to remain alert in the week before the event. This information could be collected either directly from the employee, or from co-workers or supervisors. Similarly, was the employee exhibiting any other fatigue-related symptoms directly before the event?

Additional questions that could be asked include:

• Did the employee take medications or drugs in the week prior to the event?
• Has the employee been diagnosed with or show symptoms of a medical problem or sleep disorder that may affect fatigue or alertness?
• Did the employee work at another job or have additional responsibilities during the two weeks before the event?

Assessing the information collected with these questions can provide organizations with a clearer understanding of when fatigue is a contributing factor to an error or incident.

Reporting non-critical errors also offers an opportunity to analyse the effectiveness of the FRMS. In any organization, there is a greater frequency of errors than incidents. An organization can determine the root causes of any fatigue-related risk and implement appropriate control strategies before an error becomes an incident.

Points to Consider

• What reporting structures are already in place within the organization?
• What is the process for reporting potential risk from fatigue (as opposed to an actual event)?
• What factors are to be investigated to determine whether fatigue was a contributing factor to an incident?
• How can fatigue be better reported within the organization?

Sample Text

4. Training and Education (Mandatory)

All staff should be trained to understand the purpose of the FRMS and their responsibilities within the system. The person responsible for the FRMS or the FRMS Committee should arrange fatigue-related safety training for all employees. The training program should highlight the risk of fatigue, how it will be managed within the organization’s operations, and how it fits within existing organizational policies and procedures. It is essential that records be kept that include dates, names, subjects covered, and course presenters. The company may seek the assistance of fatigue specialists in the development of a training program.

Training tools developed by Transport Canada include:

• an introductory booklet (TP 14572E)
• a workbook for employees on applied fatigue management strategies (TP 14573E)
• an employee competency assessment workbook (TP 14574E)
• a guide aimed at assisting the person/ committee responsible for the FRMS design and implement the FRMS (TP 14575E)
• a trainer’s handbook (14578E)

Use of these tools is not mandatory. They provide foundations and guidance material for the implementation of an FRMS. Organizations choosing to use the toolbox should tailor the contents to meet the requirements of their organization based on their own unique operating environment.

All employees should be provided with the introductory booklet when the company decides to implement an FRMS. This booklet can also be provided to new employees in advance of scheduled training.

All employees should also complete a formal training course that includes face-to-face training and a competency-based workbook. Face-to-face training allows employees to ask questions about their responsibilities within the FRMS and how it affects the work environment. The competency-based workbook ensures that employees have understood the information and can apply the knowledge and skills to their own work environment. The training is also available online at www.shiftwork.com.au which features an automatic assessment tool.

Employees involved in the design, implementation, and/or evaluation of the FRMS (such as senior management staff, the person responsible for the FRMS or FRMS committee members) should follow a more advanced level of training. This should outline what an FRMS is, the specific elements that need to be included in an FRMS, and how to tailor the FRMS to suit operational needs. This is detailed in Developing and Implementing a Fatigue Risk Management System (TP 14575E).

A trainer’s handbook has been developed to help organizations who wish to maintain the in-house capacity to deliver face-to-face training on fatigue management for employees. It provides background information for delivery of the employee training workshop, including learning outcomes, questions frequently asked by participants, as well as additional reference material.

Points to Consider

• What level of fatigue-related training already exists within the organization?
• What are the major topics that should be covered in fatigue-related training?
• Do different work groups require different levels of fatigue-related training?
• How will fatigue-related training be delivered (e.g., posters, video, face-toface, readings, workbook, website)?
• How often should fatigue-related training be conducted?
• How will fatigue-related training be recorded and maintained?
• How will the training be given (i.e., process, people)?

Sample Text

5. Review and Improvement Process

Fatigue-related impairment is likely to change with operational demands, organizational culture, and employee turnover. It is important that the FRMS be continually reviewed and improved to ensure that it is operating effectively. All the major components of the FRMS and levels of control should be reviewed, including:

• Policy
• FRMS Committee
• Communication and consultation
• Implementation process
• Schedule and actual hours of work
• Assessment of actual sleep obtained
• Training and education
• Delivery of training and education
• Incident and accident investigation
• Internal audits

Among other aspects, the review process should consider the following:

• Is the FRMS manual clear and up to date?
• Has everyone been provided with fatigue-related information and received the appropriate training?
• Is the FRMS able to identify and deal with fatigue-related hazards before they result in an error or incident?
• Is the FRMS able to adapt to changing operational demands, scheduling changes, and contingency situations?
• Is the reporting system adequate for identifying fatigue-related hazards?
• Is there an internal investigation and auditing system in place, and is it working?
• What feedback has been obtained from safety audits and from error and incident reports?
• What feedback has been provided by employees, contractors, and clients about the system?

As part of the FRMS review, it is also useful to look at annual expenditures on the FRMS. In calculating the cost of FRMS, include factors such as person-hours devoted to implementing and maintaining the FRMS and absenteeism due to fatigue.

Major design and implementation expenses normally occur in the first year. It is possible that absenteeism due to fatigue will increase slightly at the beginning as employees become more aware of fatigue as a potential hazard. However, it is likely that employees who feel impaired by fatigue already call in sick under normal sick leave conditions – the FRMS will probably help highlight existing causes of absenteeism.

The review may find that employees need to be encourage to participate more actively in the FRMS. Employees who hold key leadership roles within the organization could be approached to promote the FRMS. Similarly, employees who have been proactive throughout the review period in FRMS (e.g., reporting events, involvement in the FRMS committee, promoting fatigue countermeasures) could be formally acknowledged in corporate newsletters.

Points to Consider

• How often will the FRMS be reviewed?
• Who will be responsible for collecting data and overseeing the review process?
• How will the FRMS be reviewed?
• What will be done with information obtained through the review process?
• How will results of the review be communicated to employees?

Sample Text

6. Appendices

Attach any supporting documents here. This may include:

• Relevant safety manuals
• Relevant CARs or guidance notes from Transport Canada
• Sleep diary form for collecting data
• Symptom checklist
• Description of the fatigue occurrence reporting form or database
• Additional reading material that may be of particular interest to employees

Points to Consider

• Is there any information that users of the FRMS manual will require easy access to?

7. Further Reading

Anthony, C. W., & Anthony, W. A. (1999). The Art of Napping at Work. Burdett, NY: Larson.

Blagrove, M., Alexander, C., & Horne, J. A. (1995). The effects of chronic sleep reduction on the performance of cognitive tasks sensitive to sleep deprivation. Applied Cognitive Psychology, 9: 21-40.

Dawson, D., & McCulloch, K. (2005). Managing Fatigue: It’s About Sleep. Sleep Medicine Reviews, 9 (5), 365-380.

Dinges, D. F., Pack, F., Williams, K., Gillen, K. A., Powell, J. W., Ott, G. E., Aptowicz, C., & Pack, A. I. (1997). Cumulative sleepiness, mood disturbance, and psychomotor vigilance performance decrements during a week of sleep restricted to 4-5 hours per night. Sleep, 20 (4), 267-277.

Ferrara, M., & De Gennaro, L. (2001). How much sleep do we need? Sleep Medicine Reviews, 5 (2), 155-179.

Harrison, Y., & Horne, J. A. (2000). The impact of sleep deprivation on decision making: A review. Journal of Experimental Psychology, 6 (3), 236-249.

Purnell, M. T., Feyer, A.-M., & Herbison, G. P. (2002). The impact of a nap opportunity during the night shift on the performance and alertness of 12-h shift workers. Journal of Sleep Research, 11 (3), 219-227.

Talk about Sleep website: www.talkaboutsleep.com

Van Dongen, H. P., Baynard, M. D., Maislin, G., & Dinges, D. F. (2004). Systematic individual differences in neurobehavioral impairment from sleep loss: evidence of trait-like differential vulnerability. Sleep, 27 (3), 423-433.