Chapter 8: Level 4 and 5 Controls: Fatigue Proofing and Reporting Incidents and Accidents

Learning Outcomes

On completing this chapter, you will be able to:

  • Choose fatigue-proofing strategies that would be useful for your organization.

  • Understand the reasons why most organizations’ incident and accident investigation procedures do not properly identify fatigue as a contributing factor in a specific event.

  • Identify the two necessary conditions that define an event as a fatiguerelated incident or accident

  • Outline specific trends that can be assessed to identify potential patterns between incident and accident data and fatigue factors.

Level 4 and 5 Controls: Fatigue Proofing and Reporting Incidents and Accidents

Hazard-Control Model for Fatigue Risk Management
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Hazard-Control Model for Fatigue Risk Management

Even with strict controls in place, it is still possible that fatigue-related errors could occur and result in incidents or accidents. Level 4 and 5 controls are designed to further reduce fatigue-related risk.

Level 4: Fatigue-Proofing Strategies

The goal of an FRMS should be to reduce fatigue levels as much as reasonably possible. Achieving this goal involves focussing on the time available for sleep or sleep opportunity) and actual sleep obtained. However, it is important to acknowledge that it is not possible to completely eliminate fatigue from all workplaces all of the time. Employees and managers should also understand that a certain amount of fatigue in the workplace may be acceptable, provided the risks are managed.

Many organizations supplement fatigue reduction strategies with fatigue-proofing strategies. Both types of countermeasures are important defences against latent failures – a series of breakdowns in the system that build up to create the conditions for an incident. They also act to further reduce the risk of active failures – the direct causes of an incident.

Once an analysis of the work schedule has been completed using work design principles, computer-modelling techniques, assessment of sleep patterns, or other approaches, the organization can target the areas of highest fatigue in the schedule with fatigue-proofing strategies. This approach encompasses four main components, including:

  • "double-checking" to increase the likelihood of detecting errors

  • improving the work environment to reduce risk

  • scheduling less complex or less safetycritical tasks at times of highest fatigue risk

  • training employees about personal limitations and strategies to increase alertness

More specific examples of fatigueproofing strategies might include:

Double-Checking

  • close supervision

  • working in pairs or teams depending on the task

  • task rotation

  • checklists

  • self-assessment checklists for signs and symptoms of fatigue

  • support for new personnel by experienced personnel

  • self-reporting systems

  • communication/briefings at shift handovers (written/verbal/face-to-face)

Work Environment

  • self-selected break times

  • interaction with peers

  • provision of appropriate facilities for break time: lunch room, access to vending machines with healthy snacks, caffeinated drinks, etc.

  • napping facility in a quiet environment

  • appropriate lighting

  • control over temperature

  • vibration management

  • car pooling (minimize driving alone on commute)

  • provision of transport (bus, taxi, etc.) for personnel for commutes after overtime (longer or extended shifts; call-ins, etc.)

Scheduling Less Complex or Less Safety-Critical Tasks

  • ensure high-risk activities are conducted during the day, rather than at night, where possible

  • rotate tasks

  • avoid boring and mundane tasks at times of higher risk for fatigue

  • aintain appropriate staffing levels

  • avoid highly complex tasks at times of higher risk for fatigue

Training Programs and Topics

  • fatigue awareness/competency training

  • refresher training and capacity building

  • training on maximizing sleep and alertness

  • information for families/housemates on facilitating sleep at home

  • awareness about the impact of food and hydration on alertness

  • physical activity

  • appropriate use of stimulants such as NoDoze

  • availability of caffeine

Level 5: Incident Investigation – Asking the Right Questions

Incidents and accidents that an organization records for safety audits may include errors, near-hits (or near-misses), losttime injuries, medically treated injuries, breaches of policy or procedure, etc. While error and incident reporting is common, until recently few reporting procedures systematically examined whether fatigue was a contributing factor.

A better understanding of fatigue risks and how they contribute to hazards in operational environments now makes it possible to include an assessment of fatigue and shift work as part of the investigation process.

It is now generally held that for an incident or accident to be defined as fatiguerelated, it must have both:

  • occurred in the presence of fatigue

    and

  • been consistent with fatigue-related error (i.e., caused by falling asleep, inattention, delayed reaction time, error in judgement, etc.)

Defining an event as fatigue-related should involve a review of the first three levels of fatigue risk control. This permits determining whether:

  • the work schedule provided sufficient sleep opportunity for the employee

  • the employee actually obtained sufficient sleep

  • fatigue-related symptoms were observed prior to the event

The results of this review should allow you to determine whether fatigue may have been involved and to identify weaknesses in the fatigue-risk control measures in place in the organization.

Many companies analyse information from individual incident reports as well as other company sources. For example, the incident investigation process might require asking employees whether they have recently used medications known to have an effect on alertness. Or they may be asked about the most recent break during the shift – how long was it and when did it occur? Other organizational information might include hours worked on the day of the incident and during the previous week.

The questions asked during an investigation can help determine whether a specific factor contributed to an incident. To get a clear understanding of whether fatigue contributed to an incident or accident, investigators must ask sufficient questions, and specific questions. By collecting pertinent information about fatigue, the company can improve understanding of its own fatigue risk and adjust its procedures to reduce that risk.

The list below provides a range of general questions that might be included. This is not intended to be an exhaustive list for all organizations. Each question is linked to the various levels of FRMS control, which can allow an organization to identify where corrective measures may be needed. Bear in mind that even if no evidence of fatigue is found in the answers to the questions, fatigue may still have been a factor – there are many contributors to fatigue and further probing may be necessary.

Sample questions:

  1. What was the date and time of the incident/accident?

  2. What were the planned hours of work for each employee involved in the incident/accident over the two weeks prior to the incident? [Level 1 controls]

  3. What were the actual hours of work of employees involved in the incident/ accident over the two weeks prior to the incident? [Level 2 controls]

  4. What were the reasons for any additional hours worked beyond the planned hours during this period? Specifically, was the extra work or overtime foreseeable in advance and how was it allocated among all eligible employees? [Level 2 controls]

  5. How many hours sleep did each employee involved in the incident/accident recall having obtained in the 24 and 48 hours prior to the event? [Level 2 controls]

  6. How long had each employee involved been awake at the time of the incident/accident? [Level 2 controls]

  7. Were any of the employees observed falling asleep or otherwise struggling to remain alert in the week prior to the incident/accident? If yes, document details. [Level 3 controls]

  8. Does anyone involved in the incident recall having unexpectedly fallen asleep or otherwise struggling to remain alert during the week prior to the incident/accident? If yes, document details. [Level 3 controls]

  9. Did anyone involved in the incident/accident take medications or drugs (prescription or non-prescription) in the week prior to the event? If yes, then document details and note any effect the medication or drug is known to have on sleep, alertness, and/or fatigue. [Level 3 controls]

  10. Was any employee involved aware of any sleep or other medical disorder that might have affected sleep, alertness, and/or fatigue? If yes, document details. [Level 3 controls]

  11. Was any employee involved aware of any personal, financial, or other stress that might have affected sleep, alertness, and/or fatigue? If yes, then is this stress ongoing? Document details.

  12. Did any employee involved have another job or significant responsibility in the preceding two weeks? If yes, document details.

  13. Approximately how many minutes is the commute to and from work for each employee involved in the incident or accident?

Answers to some of these questions may identify areas that need to be probed further. For instance, if the answers to questions related to Level 2 controls indicate that insufficient sleep was obtained, any measures that were taken to mitigate fatigue risk should be re-examined (as discussed in Chapter 6).

By assessing the information collected using such questions, companies can gain a much clearer understanding of whether fatigue contributed to an incident or accident. Over time, results of investigations can be used to examine trends between incidents/accidents and time of day, day of week, time of year, amount of overtime, commute distance, age of employee, presence of stressors, and other relevant factors. Properly collected incident and accident investigation data can permit the company to develop more stringent and targeted controls to reduce the risk of further accidents.

Exercise:
- List five fatigue-proofing strategies that would be practical for your organization.
- Discuss why many organizations’ incident and accident investigation processes are inadequate for assessing the contribution of fatigue.
- List the two necessary conditions to define an event as a fatiguerelated incident or accident.
- List at least two incident or accident investigations in your organization that identified fatigue as a possible contributor. Detail any specific fatigue-related factors, such as schedule, hours worked, and symptoms of fatigue observed. If there are no recorded events identified with fatigue, comment on the likely effectiveness of your organization's system to measure relevant fatigue factors.
- Given the nature of the operations on the site(s) where you work, discuss areas that you believe would be most susceptible to fatigue-related risks and why.
- Outline specific trends that could be investigated to identify potential patterns between incident and accident data and fatigue factors.

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