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Fatigue Risk Management System

for the Canadian Aviation Industry

Developing and

Implementing a Fatigue

Risk Management System

TP 14575E

April 2007

edu.au

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ii

Project Team

Edu.au Transport Canada

Kirsty McCulloch Isabelle Marcil, Transportation Development Centre (TDC)

Angela Baker Jacqueline Booth-Bourdeau, Civil Aviation

Sally Ferguson Mark Laurence, Civil Aviation

Adam Fletcher TDC Communications Unit

Drew Dawson

Notices

© Her Majesty the Queen in Right of Canada, as represented by the Minister of Transport 2008

All rights reserved. This document may be reproduced in part or in whole and by any means only in the

context of personal or public non-commercial use only. Any other use or any modification of this document

is strictly forbidden under the applicable copyrights law without prior written permission of Transport

Canada. Please contact the Civil Aviation Communications Centre at 1-800-305-2059 (EST) for assistance.

The information in this publication is to be considered solely as a guide and should not be quoted as or

considered to be a legal authority. It may become obsolete in whole or in part at any time without notice.

Transport Canada does not endorse products or manufacturers. Trade or manufacturers’ names appear in

this report only because they are essential to its objectives.

Une traduction de ce document est également disponible en français : «Système de gestion des risques liés à la

fatigue pour le milieu aéronautique canadien : Élaboration et mise en oeuvre d’un système de gestion des risques liés

à la fatigue», TP 14575F.

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iii

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

Adeliade, 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: 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 toa 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 www.tc.gc.ca

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v

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1

The Aim of This Guide . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1

Your Role . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1

How to Use This Guide . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1

1. Overview of Fatigue Risk Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3

Causes and Consequences of Fatigue . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .4Managing Fatigue Levels . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .5

A Risk-Based Approach . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .8

An FRMS Working Group . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .11

2. Responsibility for Managing Fatigue under an FRMS . . . . . . . . . . . . . . . . . . . . . . .13

3. Policies and Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .17

FRMS Policy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .18

Developing FRMS Policies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .18

4. Training and Education . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .21Determining Training Needs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .22

Fatigue Management Education and Training . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .23

The Training Environment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .24

Fatigue Management Training and Education Outcomes . . . . . . . . . . . . . . . . . . . . . .24

5. Level 1 Controls: Providing Sufficient Sleep Opportunity . . . . . . . . . . . . . . . . . . . .27

Assessing Schedules for Adequate Sleep Opportunity . . . . . . . . . . . . . . . . . . . . . . . . .29

Fatigue Modelling . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .31

Designing the Ideal Shift System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .32

Considerations to Maximize Sleep Opportunity in Designing Work Schedules . . . .32

6. Level 2 Controls: Assessng Actual Sleep . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .35

Assessing Adequacy of Level 1 Controls . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .39

Contents

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Your Role

As an individual in a managerial or

supervisory role you are accountable notonly for managing your own fatigue lev-els but also the fatigue risk of employeeswithin your organization and/or workunit. The tools and strategies presented inthis guide have been developed to helpyou manage fatigue risk at various levels,ranging from ensuring compliance withlegal and regulatory requirements toinvestigating and learning from accidentsand incidents in the workplace. Managingfatigue-related risk in the organization isachieved using a fatigue risk manage-ment system (FRMS).

How to Use This Guide

This guide describes how an FRMS is bestemployed within an organization's safetymanagement system. This allows the risksassociated with fatigue to be managed ina way similar to other hazards such asdangerous goods. An FRMS should be based on an internal risk assessment ofthe organization. This ensures that anyfatigue management strategies beingimplemented are measured, appropriate,

Developing and Implementing a Fatigue Risk Management System 1

The Aim of This Guide

This guide is designed for individuals

who are responsible for managing fatiguerisk at an operational level. You shouldalready have completed the Fatigue Management Strategies for Employees(TP 14573E) workbook or equivalent,which provided information about thecauses and consequences of fatigue, andincluded practical strategies for manag-ing the impact of fatigue. Fatigue Management Strategies for Employeesfocussed on reducing fatigue risk at theindividual level. You should now befamiliar with the risks associated withfatigue and the major contributors toincreased fatigue levels (i.e., inadequatequality and/or quantity of sleep, time ofday, and length of time awake). Thisguide explains how the risks associatedwith fatigue can be managed at the orga-nizational level within a safety manage-ment system framework. You will learnhow to implement fatigue risk manage-ment controls systematically within yourorganization.

Introduction

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3. Risk Assessment/Management• Scheduled versus actual hours of

work• Individual sleep patterns

• Symptom checklists• Error/incident reporting

4. Training• Promote knowledge in the work-

place about risks, causes, and con-sequences of fatigue

• Ensure employees understandand can apply fatigue manage-ment strategies

5. Controls and Action Plans• Toolbox of methods used within

the FRMS, including error reduc-tion techniques (“fatigue proof-ing”)

• Clear decision trees for managersand employees to use whenfatigue has been identified as arisk

6. Audit and Review

• Documentation and data collec-tion at regular intervals of how theFRMS works

• Review of the FRMS based onaudit results

and targeted. There are several Canadiannational standards for risk assessment,all of which clearly outline acceptableguidelines for risk management

(e.g., CAN/CSA-Q850-971 , CAN/CSA-Q634-912 ).

The fatigue risk management systemdescribed in this guide provides yourcompany and employees with a recog-nized process based on likelihood andconsequence and the need to identify,understand, and control the workplacehazard. The resources and time requiredfor implementing a fatigue risk manage-

ment system will be determined by therelative risk identified during your riskassessment process.

There are six major aspects to an FRMS:

1. Policies and Procedures• Outline the commitment of orga-

nizational management to managefatigue-related risk

• Detail the required procedures formanaging fatigue at the opera-tional level

2. Responsibilities• List personnel responsible for

FRMS design, implementation,and maintenance

• Document responsibilities of indi-vidual employees and workgroups

Fatigue Risk Management System for the Canadian Aviation Industry2

1 Canadian Standards Association (1991). CAN/CSA-Q634-91 Risk Analysis Requirements andGuidelines, Quality Management – A National Standard of Canada. Rexdale (Toronto).

2 Canadian Standards Association (1997). CAN/CSA-Q850-97 Risk Management: Guideline forDecision-Makers. Rexdale (Toronto).

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Learning Outcomes

On completing this chapter, you will beable to:

• Explain reasons underlying the needfor organizations to implement

fatigue risk management systems.• Explain the limitations of prescriptivehours of work for managing fatigue-related risk.

• Name the major components of afatigue risk management system(FRMS).


CHAPTER 1

Overview of Fatigue

Risk Management

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In recent years, organizations have become better at managing workplacerisks including issues such as materials

handling, use of seatbelts and safety har-nesses, as well as exposure to harmfulchemicals. As these risks have beenreduced, other threats have become moreapparent. This is particularly true offatigue, which until recently was not wellunderstood or easy to measure. Recentresearch and applied management strate-gies are beginning to provide solutionsfor individual employees and organiza-tions to better manage fatigue-related

risk. This chapter of the guide providesinformation about managing fatigue-related risk within a safety managementsystem (SMS) framework. This incorpo-rates a formal risk assessment and willlikely fit within existing organizationalsafety management structures. Therationale for the development of a fatiguerisk management system is also providedin this chapter.

Causes and Consequencesof Fatigue

Fatigue is an experience of physical and/ormental tiredness that results in reduced


alertness and negatively impacts perform-ance. The major cause of fatigue is not hav-ing obtained adequate rest or recovery

from previous activities. In simple terms,fatigue largely results from inadequatequantity or quality of sleep. As discussedin Fatigue Management Strategies forEmployees , there are many consequences offatigue and they fall into three major cate-gories – physical (e.g., abruptly noddingoff for a few seconds, called a microsleep),mental (e.g., lapses in attention) and emo-tional (e.g., irritability).

The fatigue associated with tiredness andreduced alertness is different from physi-cal fatigue or weariness that is caused bylong and/or hard physical work. In thiscase, fatigue may be more accuratelydefined as mental fatigue although it cer-tainly affects physical performance aswell – especially tasks that require mental-physical interactions like hand-eye coor-dination, reaction time, and fine motorskills. Other skills that are impaired byfatigue include attention, vigilance, con-centration, ability to communicate infor-mation clearly and accurately, anddecision-making. Impairment can lead tofatigue-related errors, which in turn canlead to incidents or accidents. Evidence

CHAPTER 1

Overview of FatigueRisk Management

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from industrial and government investi-gations as well as industrial risk datademonstrates that fatigue and sleepinessare major contributors to incidents and

accidents across the entire transportationindustry. Incidents and accidents thatresult from fatigue can be severe and mayinclude fatalities but are most often asso-ciated with employee injury and/orequipment damage.

Managing Fatigue Levels

An understanding of both the causes and

consequences of fatigue enables us to

design more effective systems to managefatigue-related risk. Fatigue is sometimesmanaged indirectly by organizations (andregulators) through prescriptive limits on

work hours, often because it is seen as theonly available option. There is an assump-tion that prescribing maximum limits forthe length of work shifts and minimumthresholds for breaks between shiftsensures that employees achieve adequaterest and recovery. This assumption mostlikely evolved from information about theway in which humans recover from phys-ical fatigue. Physical fatigue accumulatesand diminishes in a predictable way over

time, as shown in the figure below.


The manner in which physical fatigue accumulates

and dissipates in relation to work and rest

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Based on this assumption, the manage-ment of physical fatigue by limiting workhours and managing break periods is log-ical and practical. However, the same may

not be assumed for mental fatigue.Common approaches for managing thistype of fatigue often assume that the fac-tors that cause mental fatigue are similarto those that cause physical fatigue. Andwhile it is true that mental fatigue does, inpart, increase in a relatively predictableway over time during waking hours anddissipate over a period of recovery, time isnot the only factor that needs to be con-sidered. The most important factors

affecting mental fatigue levels are:

• Sleep quantity and quality – insuffi-cient or poor quality sleep results inincreased fatigue levels. This is because both how much and how wellone sleeps are important for recoveryfrom fatigue and for maintaining nor-mal alertness and performance. Thisapplies not only to a single sleep peri-od, but to consecutive sleep periods. If

an individual gets inadequate sleep(quality or quantity) over a series ofnights, this also causes increasedfatigue.

• Time awake – how long an individualis awake affects fatigue levels.Research indicates that alertness andperformance levels begin to decreaseafter a certain number of hoursawake.

• Circadian rhythms – fatigue levels arealso affected by the time of day. Forexample, fatigue can be a bigger prob-lem in the early hours of the morning

due to biological (or circadian)rhythms. Sleepiness levels are natu-rally higher and alertness levels arelower at 3 a.m. than at 3 p.m.

Circadian rhythms also influencesleep quality and quantity. Forinstance, sleep obtained during theday is poorer in quality compared tonight sleep, when the body is pro-grammed to sleep.

It is not correct to assume that a given break from work will provide a givenlevel of recovery; the length of the break isnot the key factor. It is the amount and

quality of sleep obtained in the period oftime away from work that determinesrecovery from fatigue. The timing of awork period within the 24-hour day willalso determine fatigue risk.

Both work and non-work factors canaffect sleep. Work-related factors – lengthof shifts, the type of work being per-formed, workload, work environment(e.g., heat, humidity, noise, vibration,

lighting levels) and breaks within a shift –can all influence the amount of sleep andtime awake obtained in a 24-hour period.

Non work-related factors – sleep disor-ders, family responsibilities, social andleisure engagements, and emotionalstress – can all affect the amount andquality of sleep people obtain. These factors can also affect the length of timeindividuals are awake, which can alsoaffect fatigue. The figure below shows therelationship between each of these fac-tors.

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The relationship between sleep, time awake, circadian rhythms,

and fatigue, as well as the effect of work and non-work factors

on sleep and time awake.

With all of the contributing factors inmind, it is easy to understand why pre-scriptive limits on work hours may not,on their own, be adequate for managingfatigue-related risk. Prescriptive limita-

tions on shift length generally assumethat a break of a given length has a pre-dictable recovery value; for example, thata 10-hour break will allow the samerecovery to take place regardless of whenthe break occurs. While this may be rela-tively true for physical fatigue, it is defi-nitely not the case for mental fatigue.Providing the same time off during theday, as opposed to night, may result inless recovery due to the effect on sleep.

Factors such as this must be taken intoaccount when developing an FRMS.

The FRMS should be embedded withinthe existing SMS framework to allowfatigue to be managed within existingorganizational safety structures. This alsoensures that responsibility for managing

fatigue risk is shared between employerand employee. It may also allow safetyprofessionals or other stakeholders in thecompany to develop a cost-effectiveFRMS without needing to call in outsidefatigue expertise. However, it is impor-tant to have an understanding and appre-ciation of fatigue-related risk within aworkplace.The figure below illustrateshow fatigue can be incorporated into anoverarching SMS.

Fatigue risk management systems work best within the framework

of a larger safety management system.

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An incident trajectory demonstrates how weaknesses or "holes"

in management systems can provide opportunity for incidents

A Risk-Based Approach

Managing fatigue-related risk under anSMS framework involves developingcomprehensive defences against the haz-ard of fatigue based on a formal assess-ment of risk. Organizations can decide todo as much or as little as necessary tomanage their own levels of risk.

An important theorist in the area of orga-nizational risk management, JamesReason, describes the "normal" environ-ment in organizations that generally pre-cedes a workplace incident. Reasonsuggests that there is no 100% effectivesafety control for any hazard (such asfatigue). The inherent weaknesses or"holes" in a given safety defence provideopportunities for incident "trajectories" –the series of events and conditions lead-ing to an incident – to penetrate thedefence.

An effective safety management systemor, in this case, fatigue risk management

system, should use multiple, overlapping,and redundant defences against a givenhazard. In a multi-layered system, an inci-dent can only occur when all the defen-sive systems fail. That is, in circumstanceswhere the incident trajectory passesthrough the holes in each of the defensivelayers. The effectiveness of the safetymanagement system can therefore beimproved by (1) the appropriate selectionof supplementary layers, and/or (2)strengthening individual layers (shrink-ing the holes).

Reason's principles for the developmentof an SMS can be easily applied to afatigue risk management system. The fig-ure below shows a hazard control dia-gram for fatigue. Vulnerabilities along thefatigue-related incident trajectory should be identified so that supplementarydefensive layers can be introduced and/orexisting defensive layers can be strength-ened. Investigating incidents also ensuresthat appropriate hazard controls are putin place at each level of potential risk.

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In general, fatigue has traditionally beenmanaged using a single layer of defence(i.e., limits on work hours). The assump-tion is that compliance with the limits on

working hours is evidence that anemployee is adequately rested and fit forwork and will not make any fatigue- related errors. This may not always be thecase. Without supplementary defensive

layers it is entirely possible for anemployee to comply with working hourlimits but to be too tired to work safely(e.g., had a 12-hour break from work but

didn't get enough sleep due to a sick childor a night out on the town). Each of thefive levels of control is discussed in sepa-rate chapters, but a brief description ofthe theory is provided below.

Hazard-Control Model for Fatigue Risk Management

The hazard control model illustrated inthe figure above shows the controls inplace for reducing fatigue-related risk. Intheory, if each level of control is in place,

the “holes” in the management systemalong the incident trajectory should become smaller, minimizing the likeli-hood of a fatigue-related incident.


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Briefly, a fatigue-related incident is pre-ceded by a fatigue-related error. In turn, afatigue-related error is generally preced-ed by fatigue-related behaviours. Fatigue-

related behaviours or symptoms in turnindicate that an employee has either nothad adequate sleep (not enough or notenough good sleep), or has been awakefor an excessive period of time. Finally,inadequate sleep or excessive time awakemay occur as a result of inadequate sleepopportunity (i.e., too short a break between work shifts).

There are five major levels of control for

managing fatigue risk:

• Level 1 (organizational): making surescheduling gives employees adequateopportunity to sleep

• Level 2 (individual): making sureemployees actually get sufficient sleep

• Level 3 (behavioural): monitoring forsymptoms that indicate employeesare fatigued

• Level 4 (error): stategies to ensure that

fatigue in the workplace does notresult in errors or incidents

• Level 5 incident: determining the roleof fatigue in workplace errors or inci-dents

A successful fatigue risk management sys-tem addresses each of these levels byorganizing defence systems around theselayers. Most fatigue countermeasures(either formal or informal) can be assignedto one of the five defensive layers.

The FRMS should be developed andimplemented using a risk-basedapproach. Organizations should deter-mine the specific level of fatigue-related

risk associated with their operations.Organizational risk should be assessed interms of the type of work being conductedas well as the environment in which thework takes place. After identifying high-risk areas for fatigue within the workplace(by work group or by specific tasks), sys-tems can be put in place to either reduce oreliminate fatigue through processes suchas schedule reform (fatigue reduction) orthrough the implementation of mitigating

strategies such as napping and task rota-tion (fatigue proofing).

Implementation Map

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This increases the range of opinions andensures that information is received fromall levels of the organization. Workinggroup members should also have the

opportunity to consult with other opera-tional personnel, bringing an even widerrange of perspectives to the process ofFRMS design, implementation, andreview. This is best achieved through two-way communication of program objec-tives, milestones, progress, and theinvolvement of all employees in thedevelopment and review processes.

Working Group Training

Members of the working group mayrequire some training about the causesand consequences of fatigue and how tomanage the risks. Training for the work-ing group should:

• outline fatigue, its associated risks,and management strategies at theindividual level

• provide strategic information on the

daily management of fatigue from anorganizational perspective

• detail effective FRMS design andimplementation processes

• provide information about how toevaluate and audit the FRMS overtime.

This type of training can be obtained fromFatigue Management Strategies forEmployees (TP 14573E) and this guide.Further reading on these issues can befound in the list of resources included atthe end of this guide.


The figure above provides a plan, orroadmap, for organizations implement-ing an FRMS. The individual componentsof an FRMS are designed to complement

each other to ensure the best possible out-comes for fatigue risk management andsafety. This guide details each of the com-ponents recommended for an effectiveFRMS, and provides information on therelevant implementation process. No sin-gle component should be consideredmore important than another – all compo-nents should be examined and integratedinto the FRMS to achieve the ultimategoal of safety.

An FRMS Working Group

The design, implementation, and day-to-day operation of any management systemrequire structure and leadership. A work-ing group should be formed to assumeresponsibility for the FRMS in the organi-zation. In smaller operations, the role of aworking group may be performed by one

or two employees – the size and makeupof the group will be dictated by the levelof fatigue-related risk the organizationcarries and the size of the organizationitself. It is also possible that an existingsafety-oriented committee could take onthe role of the FRMS working group.

The working group is responsible for thedesign, implementation, and ongoingreview of the FRMS. The working groupshould be composed of a representativesample of employees likely to be affected by the FRMS. Ideally, it also includesmanagement and operational personnel.

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Learning Outcomes


• Define specific responsibilities for both employers and employees forfatigue risk management.


CHAPTER 2

Responsibility for

Managing Fatigue

under an FRMS

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One of the key features of risk-basedapproaches to safety management is thatall stakeholders share responsibility for

minimizing risk and increasing safety.This approach works particularly well formanaging fatigue. Management has aresponsibility to create a work environ-ment that minimizes fatigue-related risk,and employees have an obligation toensure that time away from work is usedappropriately. Spreading responsibilityfor fatigue risk management across theentire organization represents a signifi-cant shift in thinking.

In the past, responsibility for safety hasgenerally been mandated by the regula-tor, who prescribed the level of safetymanagement required and audited theorganization to determine compliance. Ifsafety was found to be poorly managedand resulted in an accident or incident,the organization could be held legallyliable and face fines or a jail sentence.Thus, if an employee fell asleep at workand caused an accident, the organizationcould potentially be held responsible.

As our understanding of the hazards offatigue has increased, we have begun to

recognize the many different contributorsto the risk. It is now accepted that the reg-ulator, the organization, and employees

each have certain responsibilities forfatigue risk management. The mainresponsibilities are summarized in thetable below.

In the context of an FRMS, both employ-ers and employees have responsibilitiesfor the management of fatigue. Theemployees' responsibility is first, to obtainsufficient sleep; second, to report whenthey have been unable to do so or feel at

risk of making a fatigue-related error; andfinally, to report any situation observedthat may present fatigue-related risk. Theemployer has the responsibility of provid-ing adequate sleep opportunity, mitigat-ing fatigue-related risk, and taking actionif an employee is not fit for work.Managers and supervisors are responsible for taking prompt, consistent, andappropriate action whenever they believean employee is not fit for duty. Theaction(s) to be taken should be set outclearly and consistently in all documenta-tion, including policies and procedures.The aim of all actions should be to main-tain and promote safety.

CHAPTER 2

Responsibility for ManagingFatigue under an FRMS

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being unable to maintain fitness forwork.

6. Determining whether prescriptionmedication, alcohol, or drugs may beinvolved or have contributed to thesituation.

7. Determining whether a similar set ofcircumstances is likely to recur, and ifso, how could it be satisfactorilyaddressed by either the employeeand/or manager for a mutuallyacceptable outcome.

8. Providing alternative transport home,if warranted.

9. Assisting the employee to access sup-port and assistance where available(e.g., employee assistance programs).

Actions to be considered when anemployee is considered potentially unfit

for work may include:

1. Assessing the employee using asymptom checklist as a guide to phys-ical, mental, and emotional signs offatigue (see Chapter 7).

2. Providing closer regular supervisionof the employee by peers, work team,or supervisor.

3. Giving the employee lower-risk tasks.4. Providing the employee with an

opportunity to rest/nap and to bereassessed within a determined timeframe.

5. Discussing with the employee whatthe employee thinks were factors in

Responsibilities for Fatigue Risk Management

Government/

Regulatory

Responsibilities

• Prescribe requirements/framework for FRMS

• Assess compliance• Audit non-compliance• Where appropriate,

investigateaccidents/incidents

Organizational

Responsibilities

• Provide support:- Compliance with

legislation- Policy development- Training and

education- Error/incident

reporting systems• Ensure work schedules

provide adequate oppor-tunity for rest and recov-ery between shifts

• Assess specific worktasks for fatigue-relatedrisk

Individual

Responsibilities

• Use time away fromwork appropriately toobtain adequate rest andrecovery, and ensure fit-ness for work

• Report any potentialrisks to manager if expe-riencing fatigue-relatedsymptoms

• Report any situation thatmay present fatigue-related risk

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members (i.e., current spouse and chil-dren). Referrals can be made by anemployee, supervisor, manager, or med-ical officer. Service providers can be inter-

nal or external to the organization withservices varying in scope, range, andintensity.

Employee assistance programs (EAPs) areconfidential services funded by compa-nies and provided to any employee whomay require assistance for personal,

work, and/or family-related concerns orproblems. In some organizations, theservice is extended to immediate family


• Detail who is responsible for each FRMS component within your

organization.

E X E R C I S E

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Learning Outcomes


• Describe the importance of develop-

ing an FRMS policies and proceduresmanual.• Write a mission statement, outlining

the scope, objectives and purpose ofthe FRMS and design subsections ofan operationally specific policies andprocedures manual.


CHAPTER 3

Policies and Procedures

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As discussed in Chapter 1, it is theresponsibility of company management,or a fatigue risk management working

group, to produce a policies and proce-dures manual. This includes ensuring thatemployees are consulted and have theopportunity to provide feedback through-out the policy development process. Thegoals, objectives, implementation, andday-to-day operation of the FRMS should be clearly documented and communicat-ed to all stakeholders.

FRMS Policy

The policies and procedures manualdefines fatigue and its associated risksand creates a common understandingwithin the organization about the princi-ples and standards for dealing withfatigue-related risks. The FRMS policyhelps align all organizational effortstoward the ultimate goal of improvedsafety. If employees are consultedthroughout the development of the policyand are supportive of the process, it ismore likely they will take a positive,proactive approach to fatigue risk man-agement at the individual as well as orga-nizational levels.


FRMS policies and procedures should:

• meet existing legal/regulatory/indus-

trial requirements for fatigue riskmanagement

• suit specific operational needs• allow intra-organizational flexibility

(i.e., the rules for one work group maynot necessarily be the same as anotherwithin the same company)

• not place unnecessary economic bur-dens on organizations

Developing FRMS Policies

Studies have found that many organiza-tions need guidance in designing FRMSpolicies that are both specifically suited totheir operational needs and that meet reg-ulatory approval. Transport Canada haspublished a companion document to thisguide that offers guidelines for the devel-opment of policies and procedures (seePolicies and Procedures Development

Guidelines , TP 14576E).

CHAPTER 3

Policies and Procedures

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(for more information on developing thepolicy and mission statement, see Section3.2 of Policies and Procedures DevelopmentGuidelines). In addition to stating manage-

ment support, the mission statementshould outline the scope, purpose, andobjectives of the FRMS. The documentneed not be any longer than a page. Anexample is provided below.

FRMS policies are often developed over aperiod of several months. Many organiza-tions begin by releasing an over-archingmission statement to set the framework

and to underscore the backing of seniormanagement of the organization (e.g.,CEO, general manager, board members).The mission statement should also beincorporated as a single paragraph intothe organization's existing SMS policy

Sample FRMS Mission Statement

ABC CompanyFatigue Risk Management Mission Statement

ABC Company is committed to protecting all employees, clients, and visitorsfrom fatigue-related risk.

ABC's fatigue risk management system aims to continually improve thesafety of its flight operations by managing fatigue-related risk and byensuring that staff consider at all times the safety implications of theirown fatigue, and that of their colleagues.

ABC Company's fatigue risk management policy is backed by the strongest commitment at the highest level.(signed by managing director)

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hood that the goals and action plans setout in the policies are based on the truecapability of the organization and itsemployees.

The detailed FRMS policies and proce-dures manual should describe the variouslevels of fatigue hazard controls to be putin place at the company and the relatedprocedures for each. Usually the manualcovers:

• responsibilities of employees underthe FRMS

• communication and consultation

processes• hours of service and scheduling• verification of actual sleep• monitoring of fatigue-related symp-

toms• fatigue-proofing strategies• reporting protocols• training and education• review and improvement process

After announcing the support of seniormanagement through the mission state-ment, the detailed design of the FRMSpolicies and procedures manual can

begin. The responsibility for developing,implementing, and maintaining theFRMS manual should ultimately rest withthe individual responsible for safety orwith a more formal fatigue workinggroup (also known as the FRMS commit-tee). However, there should be opportuni-ties for employees to provide input. It isimportant that employees understand thepurpose as well as the required elementsof the FRMS policy. The consultation

should be undertaken by the person orcommittee responsible for the develop-ment, implementation, and operation ofthe FRMS policy.

Studies have underscored the benefits ofensuring that employees are involved inall new and ongoing policy initiatives.This not only ensures buy-in fromemployees, but also improves the likeli-

• Describe the importance of developing an FRMS policies and proce-

dures manual.

• Write the scope, purpose, objectives and definitions for your organi-

zation's FRMS.

E X E R C I S E

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Learning Outcomes

On completing this chapter, you will be

able to:

• Determine the fatigue training needsof your organization.

• List the resources required to supporta fatigue management training pro-gram.


CHAPTER 4

Training and Education

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Determining Training Needs

There are three main factors to consider

when designing and implementing anFRMS training program:

1. Level of existing knowledge withinthe organization

2. The level of fatigue-related risk withinthe organization

3. Requirement of resources for trainingwithin the organization

Training is an essential component of afatigue risk management system. Beforedesigning and implementing a trainingprogram, an organization should deter-mine the level and method of trainingrequired. For example, if fatigue riskmanagement is relatively new to anorganization, it may need to start with a basic training program about fatigue andhow to manage it at a personal level (i.e., An Introduction to Managing Fatigue (TP14572E). An organization that under-stands the risk of fatigue may choose togo directly to more detailed instructionabout applied management strategies(i.e., Fatigue Management Strategies forEmployees , TP 14573).


A risk assessment of the various worktasks and the work environment alsohelps in developing a training program.

Companies with low fatigue-related riskmay decide to launch a basic workplaceawareness program. Companies wherefatigue-related risk is high or extrememay require employees to follow compe-tency-based training with regular refresh-er courses.

Another factor to take into account is thesize of the organization. A small companywith only 20 employees in a single loca-tion may choose to hire an external train-er to present the training package to allemployees at the same time. A companywith several locations may choose to use aweb-based package that employees cancomplete in their own time and at theirown location. If an organization alreadyhas an in-house safety training program,it can train its own trainers to deliver afatigue management training program.The Fatigue Risk Management for the

Canadian Aviation Industry: Trainer'sHandbook (TP 14578E) may be useful forcompanies that choose this option.

CHAPTER 4

Training and Education

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Factors to consider when designing afatigue risk management training program

Level of Fatigue Risk

• Working hours• Work tasks• Work environment• Frequency of fatigue-

related accidents• Likelihood and conse-

quences of fatigue- related error

• Regulatory requirement

Resources

• Financial commitment• Time for development• Time for implementation• Workplace culture –

most effective methodsof training

• Availability of in-housetrainers

• Training materials

Employee Characteristics

• Geographic location• Literacy skills• Venue• Rates and reasons for

sickness/absenteeism• Current knowledge• Existing competencies

The table above provides a summary ofvarious things to take into considerationin implementing a training program.

When the training needs and levels have been identified, it will be necessary to:

• determine the content of the training

package• determine the time frame and sched-

ule for completion of training• allocate the necessary resources to

ensure the successful roll-out and follow-up of the course

Fatigue ManagementEducation and Training

Fatigue training is most efficient when itprovides both knowledge and know-how.

The aims of any fatigue training should be clearly stated in the course outline. Thetime devoted to the course should reflect

the priority and importance of fatigueissues for the organization. Typically,face-to-face training can run from 60 min-utes to eight hours.

In the past, organizations typically pro-vided short educational sessions aboutfatigue. While such sessions are impor-

tant for raising awareness, there is often alow rate of knowledge retention with thistype of training. Employees may takesome information away but since detailsare quickly forgotten, they are unlikely toalter any of their habits at work or away.

More recently, organizations have begunusing competency-based training tech-niques, which require employees to applywhat they have learned to their individ-ual situations. This approach promotes better knowledge retention amongtrainees. In addition, formal competency- based assessments can assure an organi-zation that employees understand theconcepts presented and can apply them to

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• assessment process outlined, conduct-ed, and recorded (e.g., oral and writ-ten assessment, log book, etc.)

• support of trainees (e.g., time,

resources, follow up, mentoring, etc.)• skilled trainers and their contact infor-

mation

Fatigue Management Trainingand Education Outcomes

On completion of training, it is expectedthat:

• Employees know and understand theorganization's fatigue managementpolicies and procedures.

• Managers and employees know andunderstand their responsibilities inmanaging fatigue.

• Personnel know how to identify andmanage risks associated with fatigueat both a personal and organizationallevel.

• Those responsible for decisions influ-

encing sleep opportunities foremployees know and understandtheir responsibilities and implementappropriate fatigue-reduction strate-gies where necessary.

• Training records have been made andstored in an appropriate place.

their work situation. Refresher trainingshould be given annually for the first twoyears, and every two years after that.Refresher courses also provide an oppor-

tunity to disseminate new informationfrom the evolving field of fatigue man-agement and allow employees to consoli-date prior learning.

The Training Environment

Investment in training can be wasted if itis not framed by a real learning environ-ment. Employees who attend training

courses may not actually know why theyare there or how they will be followed up.Some managers may show little interestin helping or encouraging employees toimplement changes based on their train-ing. It is important to develop a trainingenvironment as well as a training course.An environment that promotes learningprovides:

• appropriate notice for course atten-

dance (i.e., several weeks compared toseveral hours)

• any prior reading required (i.e.,refresher course materials, back-ground information, etc.)

• course location and aims• facilities for training (i.e., training

room rather than lunch room, air- conditioned environment, quiet, etc.)

• training support materials and facili-ties (e.g., printed materials, audio-visual presentations, white board,paper, pens, etc.)

• appropriate record keeping of courseattendance and future coursesrequired

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• Determine the need for fatigue training within your organization.

• Develop a training program for the organization.

• Develop a training report that you would present to senior manage-

ment; within this report, identify (1) resources required, (2) trainingtimes, and (3) trainer to conduct the fatigue training course for

employees. E X E R C I S E

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Learning Outcomes


• Describe the characteristics of a sched-ule that would increase the likelihoodof work-related fatigue.

• Assess the scheduling practices ofyour organization with respect tomental fatigue.


CHAPTER 5

Level 1 Controls:

Providing Sufficient

Sleep Opportunity

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In the past, fatigue has been largely man-aged through scheduling regimes, usual-ly through rules governing hours of workimposed by regulators, organizations, orunion bodies. In a fatigue-risk manage-ment system, however, there are fivemajor levels of control: organizational,

individual, behavioural, error, and inci-dent level. A successful fatigue risk man-agement system addresses each of theselevels by organizing defence systemsaround these layers. This chapteraddresses Level 1 of the hazard controlmodel.

28

CHAPTER 5

Level 1 Controls: ProvidingSufficient Sleep Opportunity

Fatigue Risk Management System for the Canadian Aviation Industry


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Level 1 controls are aimed at ensuringthat the work schedule provides employ-ees with sufficient sleep opportunity. Toachieve this, the following factors should

be considered:

• length and timing of shifts• length and timing of breaks• number of shifts worked in a row• number of days off between shifts

Using factors such as these, an organiza-tion can predict, on average, how muchsleep an employee will obtain. This chap-ter provides an overview of some strate-

gies for assessing work schedules andtheir impact on sleep, alertness, andfatigue.

Assessing Schedules forAdequate Sleep Opportunity

The major reason for assessing workschedules, apart from ensuring that theycomply with industry requirements and

other rules, is to understand the likelyimpact that specific hours of work haveon sleep opportunity. Sleep is the onlycure for fatigue. In the context of anFRMS, the employer has the responsibili-ty to ensure that adequate opportunity isprovided for sleep between work shifts. Itis the employee's responsibility to use theopportunities given to obtain recoverysleep.

Most people need between seven andnine hours sleep to maintain safe per-formance and alertness levels. Dependingon the time of day that a break is provid-ed, the amount of time off needed to getadequate sleep could be as little as

10 hours and as much as 20 or more. Thisreflects the fact that employees do notsimply fall asleep as soon as they leavework and wake just before they return.

People have many activities and responsibilities to manage between shifts such ascommuting to and from work, eating,showering, socializing, relaxing, spend-ing time with family and friends, etc. Toensure adequate rest, sleep opportunityneeds to include time for employees forrecovery sleep and other activities.

Work schedules may be assessed byexamining specific aspects of the hours of

work. The questions provided below can be used as a guide, but they should not beseen as a complete list for all circum-stances. Sleep opportunity alone shouldnot determine appropriate schedules,even though it is generally the mostimportant factor. For example, earlymorning start times generally producehigher levels of fatigue, but a 5 a.m. startmay be more appropriate than workingunder extremely hot and humid condi-

tions in the afternoon. This reflects therisk-based approach of safety manage-ment systems (as discussed in Chapter 3).

The following are some questions thatcould be asked to assess sleep opportuni-ty and potential fatigue:

a. How many hours are worked perseven-day period? Not surprisingly,as total hours worked increase, sleepopportunity decreases.

b. What is the maximum shift length? Asthe length of a given shift increases,the subsequent sleep opportunitydecreases.

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e. How often do employees get a long break from work? A long break isdefined as a period of two night sleepswith a non-working day in between.

Long breaks typically provide a sig-nificant opportunity to recover fromsleep loss accumulated over a series ofshifts.

The table below provides an example ofhow questions like those above can bequantified into a rule system.

c. What is the minimum length of timeoff between shifts? A short break isdefined as a single sleep opportunity between subsequent work periods. It

is typically a period of less than 32hours. Not surprisingly, as the break between subsequent shifts decreasesso does the sleep opportunity.

d. How many hours are worked between 9 p.m. and 9 a.m.? This ques-tion considers late finishes, earlystarts and night work. All of these willreduce night sleep opportunity andresult in a significant reduction intotal sleep opportunity.

Fatigue Likelihood Scoring Matrix for Work Schedules

Score

a) Total hoursper 7 days

b) Maximum

shift duration

c) Minimum short break duration

d) Maximum nightwork per 7 days

e) Long breakfrequency

0

< 36 hours

< 8 hours

> 16 hours

0 hours

> 1 in7 days

1

36.1 – 43.9

8.1 – 9.9

15.9 – 13

0.1 – 8

< 1 in7 days

2

44 – 47.9

10 – 11.9

12.9 – 10

8.1 – 16

< 1 in14 days

4

48 – 54.9

12 – 13.9

9.9 – 8

16.1 – 24

<1 in21 days

8

55+

14+

< 8

> 24

< 1 in28 days

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duce a score of 21, which would be con-sidered high. The figure below showsexamples of schedules scored using thisapproach.

In the table above, a 9 a.m. to 5 p.m. workweek (5 days in a row) would produce ascore of zero. On the other hand, a workschedule of seven 12-hour night shifts,

followed by seven days off would pro-

Examples of different schedules scored using theFatigue Likelihood Scoring Matrix

ed errors, it should reassess scores that

show signs of providing insufficient sleepopportunity.

Fatigue Modelling

Although fatigue cannot be measured likealcohol or drug impairment, there areways it can be assessed. Work schedulescan be used to predict fatigue based onthe likely sleep loss caused by a specificshift pattern. Predictive software modelscan provide fatigue likelihood scores onthe basis of a schedule.

Many models predict fatigue based onplanned or actual hours of work. In doing

Calculating a score for a schedule allows

companies to quantify what they deem to be acceptable or unacceptable. The cutoffscore for an acceptable schedule will bedetermined by the specific characteristicsof the organization. For example, anorganization could choose to assign alower cutoff score for highly complex orsafety-critical work, or for a high-stresswork environment (e.g., high humidity)than for less critical work in an air condi-tioned environment.

In the beginning, cutoff scores will be bestestimates. However, as an organization'sunderstanding of its own fatigue hazardimproves through collecting data on actu-al sleep (see Chapter 7) and fatigue-relat-

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from physical exhaustion. However, theyare of limited benefit in managing mentalfatigue. More effective strategies forreducing physical and metal fatigue focus

instead on the time available for sleep (orsleep opportunity) and actual sleepobtained (see next chapter).

Things to consider in designing workschedules include, but are not restrictedto:

• limiting night shifts• reducing shift length to 12 hours or

less

• limiting early morning starts

• limiting extended duty hours/over-time

• recording and controlling overtime• ensuring appropriate breaks during

shifts (coffee, meals, etc.)• providing sufficient time off between

shifts to allow for minimum sleeprequirements

• limiting long blocks of work (i.e., mul-tiple days worked one after the other)

• planning as much of the actual hoursof work as possible

• creating a napping policy and facili-ties, including a process for managingsleep inertia

• List some of the main characteristics of a work schedule that increas-es the likelihood of obtaining sufficient sleep between shifts.

• What score would your typical work schedule produce on the Fatigue

Likelihood Scoring Matrix?

• Explain why you might choose a computer-based modelling tool over

prescriptive hours-of-work rules. E X E R C I S E

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Learning Outcomes


• Identify employees who are at risk for

fatigue-related impairment.• Identify some of the reasons whyemployees may not obtain sufficientsleep.

• Describe potential processes for deal-ing with employees who have hadinsufficient sleep.

CHAPTER 6

Level 2 Controls:

Assessing Actual Sleep

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Level 1 controls presented in the previouschapter are intended to provide adequatesleep opportunities to employees.However, the organization has little con-trol over what employees actually do or,specifically, how much sleep they actuallyobtain after they leave the workplace.


Level 2 controls are aimed at ensuringthat employees get adequate sleep when-ever they are provided sufficient sleepopportunity. This level of control is aimedat the individual level rather than at theorganizational level.

CHAPTER 6

Level 2 Controls:Assessing Actual Sleep


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optimally varies – in general it is betweenseven and nine hours. Research has foundthat a person can maintain alertness andperformance for a single day on approxi-

mately six hours sleep. However, moresleep is needed on average over twoor more nights, or performance – andsafety – are likely to decline significantly.Even a few nights of five or six hours ofsleep is likely to result in poorer perform-ance, communication, and functioning inmost individuals.

Another factor that should be consideredin addition to total sleep time is the time

since an employee last had a sleep or nap(i.e., length of time awake). Considerablescientific evidence suggests that thelonger an individual has been awake thepoorer their capacity. This is especiallytrue if the total time since the last sleep ornap extends beyond 16 or 18 hours.

There are various ways to assess the sleepemployees obtain. With the agreement ofemployees – and any other stakeholders,

such as unions – companies may decide toset up a system where employees calcu-late for themselves how much sleep theyhave had and how long it has been sincetheir last sleep period or nap. Employeesmay be required to report when theirsleep or time awake doesn’t meet therequirements. For example, in a high-riskoperation it might be agreed that anyemployee who has had less than 6 hoursof sleep in 24 hours, or 12 hours of sleepin 48 hours, or has been awake for longerthan 18 hours, must report to the supervi-sor. A simple method of calculatingwhether an employee is likely to befatigued based on sleep and time awake isillustrated below.

Level 2 controls play two main roles with-in the fatigue risk management frame-work:

• They identify employees who, evengiven sufficient sleep opportunity, failto obtain sufficient sleep.

• They can be used to assess the effec-tiveness of Level 1 controls.

While Level 1 controls provide an indica-tion of the quantity of sleep likely to beobtained, it is important to know whetherthere is still a risk of fatigue at the individ-ual level.

There are a number of reasons whyemployees may not get sufficient or suffi-cient quality sleep. Some may not be with-in the employee’s control. For example,parents with a newborn baby are likely toget reduced amounts of sleep. An employ-ee with a partner who is a chronic snorermay be awakened periodically through-out the night. An employee with a busi-ness on the side may suffer from reduced

sleep opportunity. Insomnia or life stressmay keep an employee awake at night. Anemployee working night shift may simply be unable to sleep during the day. Or, anemployee may be irresponsible and putsocial time and partying ahead of obtain-ing sufficient sleep to ensure fitness forduty. Regardless of the circumstancescausing insufficient sleep, fatiguedemployees should be identified and treat-ed as a potential workplace hazard.

Before discussing different kinds of actionto take when employees do not getenough sleep, it is important to quantify“sufficient” sleep. How much sleep eachperson needs every 24 hours to perform

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On reporting:

• Six hours sleep in the previous

24 hours, and 12 hours sleep in the

previous 48: the employee might beinstructed to go to work as normal.

• Five hours sleep in the previous

24 hours, and 11 hours sleep in the

previous 48 hours: the employee

might be instructed to continue work, but to closely monitor fatigue-related behaviours or symptoms.

• Five hours sleep in the previous

24 hours, 11 hours sleep in the previ-

ous 48 hours, and 18 hours awake:the employee might be instructed totake a nap and have a strong cup ofcoffee on waking up to minimize therisk of fatigue.

• Four hours sleep in the previous

24 hours and ten hours sleep in theprevious 48 hours: the employeemight be instructed to have a strongcup of coffee, and work under closesupervision of colleagues and managers.

This calculation tool can be printed on awallet-sized card for easy reference byemployees and managers.

A company may also decide that employ-ees can, within reasonable limits, assesstheir own requirements for sleep andreport to their supervisor when they donot meet minimum limits. This simple

and practical process can flag sleepinessand fatigue issues before they lead to anincident.

When employees report to a supervisorthat they have had insufficient sleep, it isimportant that clear procedures be inplace to manage the risk in a consistentmanner. This helps managers performtheir duties and ensure that decision-making is based on clearly understoodrules. The countermeasures to adoptshould take into account the level of riskinherent in the tasks involved. The exam-ple below illustrates six possible scenariosof insufficient sleep that would requiredifferent actions by management.


Individual Fatigue Likelihood

Step 1. Sleep in prior 24 hoursSleep <2h 3h 4h 5+h

Points 12 8 4 0

Step 2. Sleep in prior 48 hoursSleep <8h 9h 10h 11h 12+hPoints 8 6 4 2 0

Step 3. Hours awake since last sleepAdd one point per hour awake greaterthan sleep in step 2.

Individual Fatigue Likelihood

Step 4.Add all points together to determine

your score

Refer to FRMS policy for detailedexplanation of controls

Score Control Level

1-4 Self-monitoring

5-8 Supervisor monitoring

9+ Don’t start shift until fit for work

Individual fatigue likelihood score (IFLS) is a calculation

based on time asleep and awake

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• Four hours sleep in the previous

24 hours, and eight hours sleep in the

previous 48: the employee might beassigned to less critical tasks to mini-

mize the consequence of potentialerrors.

• Two hours sleep in the previous

24 hours and five hours sleep in the

previous 48 hours: employees might be told to stop work, and either gohome to sleep (if they live close by) ortake a nap on the premises becausethey are unfit to drive.

Sleep thresholds are likely to vary from

organization to organization, task to task,and individual to individual. If thethreshold is set too low, it will be pickedup by the subsequent levels of the hazardcontrol system. For example, if employeesare getting the recommended minimumamount of sleep (e.g., six hours per night), but still exhibit fatigue behaviours andsymptoms (see Chapter 7), and if they arenot suffering from a sleep disorder, it islikely that the minimum level of sleep is

insufficient. Each organization – or evenwork group – should establish its ownsleep thresholds and decision trees forwhen employees have not met the sleeprequirements.

Assessing Adequacy of Level 1 Controls

Level 2 controls allow an organization toverify whether Level 1 controls for pro-viding sufficient sleep opportunity areadequate. For instance, if numerousemployees report insufficient sleep, theorganization should reassess the sleepopportunity provided by the work

schedules. On the other hand, if only afew fail to obtain a sufficient sleep, it may be because of non-work related reasons,rather than an issue with the sleep oppor-

tunity provided by the work schedule.With appropriate record-keeping proce-dures, reporting insufficient sleep canhelp organizations take a performancemanagement approach to employees whoconsistently report difficulties in this area.The underlying reasons for each caseshould be investigated. It might be thatthe employee has a medical problem (e.g.,insomnia, physical injury, or a bad cold)or that some life circumstance is negative-

ly affecting sleep (e.g., personal stress,sickness in the family, noisy neighbour-hood).

If an employee repeatedly does not takethe necessary measures to obtain suffi-cient sleep, further action may berequired. An organization may choose toaddress the issue using an approach sim-ilar to that used for any other problemthat may affect performance, such as drug

or alcohol abuse. This can be dealt withthrough discussions with the employee,agreements on measures to be taken, anda series of warnings that could even even-tually lead to dismissal.

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• How much sleep is required by most people to maintain alertness

during a work period?

• List two questions you would ask an employee whom you think may

not be getting enough sleep. What information would you seek with

these questions?• What actions would you take if an employee has had insufficient

sleep? E X E R C I S E

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Learning Outcomes


• Explain the purpose of includingfatigue-related symptom checklistswithin an FRMS.

• Recognize symptoms of fatigue-

related impairment.• Describe some of the major sleep disorders.

• Outline appropriate action to be taken by a company if an employee isthought to suffer from a sleep disorder.

CHAPTER 7

Level 3 Controls:

Assessing Symptoms

of Fatigue

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Level 3 controls play two main roles:

1. Identify employees who continue toexhibit fatigue-related symptoms,despite getting sufficient sleep.

2. Assess the effectiveness of Level 1 and2 controls. For example, whereemployees fail to report they did not


CHAPTER 7

Level 3 Controls:Assessing Symptoms of Fatigue

Even when sufficient sleep opportunityhas been provided (Level 1 controls) andemployees feel they have obtained suffi-cient sleep (Level 2 controls), they maystill show fatigue-related symptoms.Level 3 controls assess individualemployees for symptoms that could leadto fatigue-related error.


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get enough sleep, monitoring forfatigue-related symptoms adds anadditional layer of defence.

Identifying At-RiskIndividuals

Fatigue-related symptoms can be dividedinto three categories: physical, mental,

and emotional. The table below outlinessome of the major symptoms under eachcategory. If employees experience three ormore of the symptoms outlined below,

they may be experiencing some level offatigue or reduced alertness. Fatigue isnot the only cause of the symptoms pre-sented below, but when they occurtogether it likely indicates fatigue-relatedimpairment.

An employee who presents three or more symptoms in a short period

of time is likely to be experiencing fatigue-related impairment.

Physical Symptoms

• Yawning• Heavy eyelids• Eye-rubbing• Head drooping• Microsleeps

Mental Symptoms

• Difficulty concentratingon tasks

• Lapses in attention• Difficulty remembering

what you are doing• Failure to communicate

important information

• Failure to anticipateevents or actions

• Accidentally doing thewrong thing

• Accidentally not doingthe right thing

Emotional Symptoms

• More quiet or with-drawn than normal

• Lacking in energy• Lacking in motivation to

do the task well• Irritable or grumpy with

colleagues, family or

friends

To further reinforce the importance ofmonitoring fatigue-related symptoms,employees can be provided with aids,such as a checklist to be filled out at thestart of every shift, or a wallet-sized cardlisting the most common symptoms towatch out for.

Many companies teach employees how toidentify symptoms, both in themselvesand others, that may indicate an increasedrisk of making a fatigue-related error.Raising awareness about the signs andsymptoms of fatigue can be an effectivestrategy to reduce the number and sever-ity of fatigue-related errors and incidents.

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Another way to check how fatiguedemployees feel is to ask them to rate theiralertness at various intervals within a shift.The Karolinska Sleepiness Scale3 can be

used to determine whether fatigue is aproblem for an individual without deter-mining the root cause for the lack of sleep.As shown below, the scale requiresemployees to select the statement that bestdescribes them at the time. The scale can beused as an assessment of sleepiness/fatigueat any point in time: at work, while driv-ing, on waking in the morning, etc.

If employees consistently exhibit fatigue-related behaviour, potential reasonsshould be investigated. It may simply bethat the employee has a personal problem

(e.g., sickness in the family, new child orconcern, or poor sleeping environment).Employees who say they get enough sleepand cannot explain their fatigue-relatedsymptoms should undergo screening for asleep disorder. The first step is some kindof paper-based screening, such as a ques-tionnaire, to determine whether they areat risk. At-risk employees should then bereferred to a sleep clinic.

3 Åkersted, T., & Gillberg, M. (1990). Subjective and objective sleepiness in the active individ-ual. International Journal of Neuroscience , 52 (1-2), 29-37.

Karolinska Sleepiness Scale

1. Extremely alert

2. Very alert

3. Alert

4. Rather alert

5. Neither alert nor sleepy

6. Some signs of sleepiness

7. Sleepy, but no effort to keep awake

8. Sleepy, some effort to stay awake

9. Very sleepy, great effort to keep awake, fighting sleep

Screening for Sleep Disorders

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Employees who report fatigue-relatedsymptoms on a regular basis may have asleep disorder. An example of a paper- based test to identify the severity of

fatigue is the Epworth Sleepiness Scale4 ,which asks individuals to determine howlikely they are to fall asleep or doze offduring a variety of activities. Subjects areinstructed to provide answers based on

their usual way of life over the past sever-al months. Even if they have not donesome of these things recently, they areinstructed to try and work out how they

might have been affected in each situa-tion. Employees who score above 10 arelikely to have problems with their sleeppatterns and should be referred to a sleepspecialist.

4 Johns, M. W. (1991). A new method for measuring daytime sleepiness: the Epworth sleepinessscale. Sleep , 14 (6), 540-545.

SituationChance

of dozing

Sitting & Reading

Watching TV

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

As a passenger for an hourwithout a break

Lying down to rest in the afternoonSitting & talking to someone

Sitting quietly after lunch withoutalcohol

In a car, while stopping for a fewminutes in traffic

Total Score

Epworth Sleepiness Scale

0 = would never doze1 = slight chance

of dozing2 = moderate chance

of dozing3 = high chance

of dozing

A score of less than 8

indicates normal sleepfunction

8-10 = mild sleepiness11-15 = moderate

sleepiness16-20 =severe sleepiness21-24 = excessive

sleepiness

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ages and both genders, but it is most com-mon in men and is particularly prevalentin obese people. The disorder exists intwo forms:

1. Obstructive sleep apnea is the mostcommon and occurs when the airwaysclose while a person is sleeping, blocking the flow of air and prevent-ing adequate oxygen flow to the body.This awakens the sleeper many timesa night, disrupting the normal struc-ture of sleep, and resulting in sleepi-ness and reduced alertness at work.

2. Central sleep apnea is less common and

occurs when muscles required for breathing do not receive a signal fromthe brain, causing the sleeper to stop breathing.

Untreated sleep apnea can lead to cardio-vascular tissue damage caused byreduced oxygen levels and can lead toexcessive sleepiness when a person isawake. Excessive sleepiness can lead toaccidents and injuries, particularly while

driving or operating safety sensitive sys-tems.

Restless Leg Syndrome andPeriodic Limb Movement

Restless Leg Syndrome and Periodic LimbMovement are sleep disorders that arecharacterized by involuntary limb move-ments, usually a leg, many times over thecourse of a night. Movements can occur asoften as every 10 seconds, disruptingsleep and leaving the individual sufferingsignificant daytime sleepiness.

There are several types of sleep disorderthat affect daytime functioning. Apolysomnographic (PSG) recording ofsleep at a sleep clinic can help determine

the root cause of the fatigue. This processincludes analysis of electrical brain activi-ty, eye movements, and breathingthroughout the sleep period.

Some of the major sleep disorders are out-lined below. Any of these conditions canresult in bouts of daytime sleepiness,reduced alertness, and overall lack ofenergy. Physicians trained in sleep medi-cine are best equipped to diagnose and

treat these problems. A primary carephysician should be able to refer clients toa sleep specialist for evaluation, diagno-sis, and treatment.

Insomnia

Insomnia is a disorder characterized bydifficulty falling or staying asleep, and/orfrequent awakenings during the sleep

period. There are a number of factors thatmay contribute to insomnia, including(but not limited to):

• short-term or long-term stress such astrauma or chronic illness

• psychological condition• the presence of another sleep disorder• poor sleep hygiene (i.e., not following

good sleep practices)

Sleep Apnea

Sleep apnea causes a person to stop breathing for brief periods several timesduring sleep. This condition can affect all

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Narcolepsy

Narcolepsy is characterized by a suddenirresistible desire to go to sleep that lasts

from minutes to hours at a time. It is asso-ciated with cataplexy (the sudden loss oftone in one or more muscle groups) andwith vivid auditory or visual hallucina-tions when falling asleep. This is under-stood to be a malfunction of themechanism that controls rapid eye move-ment (dreaming) sleep. Excessive daytimesleepiness and the tendency to fall asleepuncontrollably may render individualsunable to carry on working, and may put

themselves or others at risk.

Sleep Clinics

An employee suspected of having a sleepdisorder should be encouraged to consulta sleep specialist. Usually, the employeewill need a doctor’s referral. TheCanadian Sleep Society offers a list ofsleep medicine clinics in Canada:www.css.to/sleep/centers.htm.

Assessing the effectivenessof other levels of control

In Chapter 6, we discussed Level 2 con-trols (i.e., obtaining sufficient sleep) asthey related to Level 1 controls (providingsufficient sleep opportunity). We estab-lished that assessing the actual amount ofsleep obtained provides a measure of howeffective the Level 1 controls are in pro-viding sufficient sleep opportunity. In thesame way, Level 3 controls offer a way to

measure the effectiveness of the two pre-vious levels of control.

In Chapter 2 we discussed organizational

and individual responsibilities in manag-ing fatigue. The organizational responsibilities included two subcomponents:

1. Fatigue related to hours of work2. Fatigue related to workload and

environment

Fatigue related to hours of work should be managed by providing employeeswith sufficient sleep opportunity between

shifts (Level 1 controls). Assessing actualhours of sleep (Level 2 controls) lets youdouble-check that sleep opportunity issufficient.

Some employees may find it difficult toquantify how much sleep they actuallyget, particularly if sleep is disturbed.Some may also choose to be dishonestabout the actual amount of sleep theyobtain and fail to report when they may be at risk of fatigue-related error. Level 3controls (monitoring for fatigue-related behaviours or symptoms) provide a fur-ther check to ensure that sufficient sleepopportunity has been provided (Level 1)and that employees are obtaining suffi-cient sleep (Level 2).

The tasks involved in a job can signifi-cantly affect fatigue. Some tasks are morefatiguing than others. As shown in the fig-ure below, this can occur at both ends ofthe spectrum – mundane tasks can be justas fatiguing as highly complex, demanding tasks.

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Similarly, some aspects of the work envi-ronment can affect fatigue more than others. For example, fatigue-related behaviour tends to be more prevalent in

workplaces that have high levels of vibra-tion or noise, or high temperatures. Thelevel of lighting (lux) in a workplace canalso affect fatigue. Since these factorswould not be identified in the Level 1 or 2controls, watching for specific fatigue-related symptoms in the workplace pro-vides an additional level of control tofurther enhance the safety managementsystem.

• Describe the role of Level 3 controls in an FRMS.

• List seven signs or symptoms of fatigue.

• Describe two of the major sleep disorders.

E X E R C I S E

Relationship between Task

Complexity and Fatigue

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Learning Outcomes


• Choose fatigue-proofing strategiesthat would be useful for your organi-zation.

• Understand the reasons why mostorganizations’ incident and accidentinvestigation procedures do not prop-erly identify fatigue as a contributingfactor in a specific event.

• Identify the two necessary conditionsthat define an event as a fatigue- related incident or accident

• Outline specific trends that can beassessed to identify potential patterns between incident and accident dataand fatigue factors.

CHAPTER 8

Level 4 and 5 Controls:

Fatigue Proofing

and Reporting Incidentsand Accidents

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Even with strict controls in place, it is stillpossible that fatigue-related errors couldoccur and result in incidents or accidents.Level 4 and 5 controls are designed to fur-ther reduce fatigue-related risk.

Level 4: Fatigue-Proofing

Strategies

The goal of an FRMS should be to reducefatigue levels as much as reasonably pos-sible. Achieving this goal involvesfocussing on the time available for sleep

CHAPTER 8

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


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More specific examples of fatigue- proofing 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 experi-

enced personnel• self-reporting systems

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

Work Environment

• self-selected break times• interaction with peers• provision of appropriate facilities for

break time: lunch room, access tovending machines with healthysnacks, caffeinated drinks, etc.

• napping facility in a quiet environ-ment

• appropriate lighting• control over temperature• vibration management• car pooling (minimize driving alone

on commute)• provision of transport (bus, taxi, etc.)

for personnel for commutes afterovertime (longer or extended shifts;call-ins, etc.)

(or sleep opportunity) and actual sleepobtained. However, it is important toacknowledge that it is not possible tocompletely eliminate fatigue from all

workplaces all of the time. Employees andmanagers should also understand that acertain amount of fatigue in the work-place may be acceptable, provided therisks are managed.

Many organizations supplement fatiguereduction strategies with fatigue-proofingstrategies. Both types of countermeasuresare important defences against latent fail-ures – a series of breakdowns in the sys-

tem that build up to create the conditionsfor an incident. They also act to furtherreduce the risk of active failures – thedirect causes of an incident.

Once an analysis of the work schedule has been completed using work design princi-ples, computer-modelling techniques,assessment of sleep patterns, or otherapproaches, the organization can targetthe areas of highest fatigue in the sched-

ule with fatigue-proofing strategies. Thisapproach encompasses four main compo-nents, including:

• “double-checking” to increase thelikelihood of detecting errors

• improving the work environment toreduce risk

• scheduling less complex or less safety-critical tasks at times of highestfatigue risk

• training employees about personallimitations and strategies to increasealertness

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A better understanding of fatigue risksand how they contribute to hazards inoperational environments now makes itpossible to include an assessment of

fatigue and shift work as part of the inves-tigation process.

It is now generally held that for an inci-dent or accident to be defined as fatigue-related, it must have both:

• occurred in the presence of fatigueand

• been consistent with fatigue-relatederror (i.e., caused by falling asleep,

inattention, delayed reaction time,error in judgement, etc.)

Defining an event as fatigue-relatedshould involve a review of the first threelevels of fatigue risk control. This permitsdetermining whether:

• the work schedule provided sufficientsleep opportunity for the employee

• the employee actually obtained suffi-

cient sleep• fatigue-related symptoms were

observed prior to the event

The results of this review should allowyou to determine whether fatigue mayhave been involved and to identify weak-nesses in the fatigue-risk control meas-ures in place in the organization.

Many companies analyse information

from individual incident reports as wellas other company sources. For example,the incident investigation process mightrequire asking employees whether theyhave recently used medications known tohave an effect on alertness. Or they may

Scheduling Less Complex or

Less Safety-Critical Tasks

• ensure high-risk activities are con-

ducted during the day, rather than atnight, where possible

• rotate tasks• avoid boring and mundane tasks at

times of higher risk for fatigue• maintain 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: IncidentInvestigation – Askingthe Right Questions

Incidents and accidents that an organiza-tion records for safety audits may includeerrors, near-hits (or near-misses), lost-

time injuries, medically treated injuries, breaches of policy or procedure, etc.While error and incident reporting iscommon, until recently few reportingprocedures systematically examinedwhether fatigue was a contributing factor.


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

4. What were the reasons for any addi-tional hours worked beyond theplanned hours during this period?Specifically, was the extra work orovertime foreseeable in advance andhow was it allocated among all eligi- ble employees? [Level 2 controls]

5. How many hours sleep did eachemployee involved in theincident/accident recall havingobtained 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 theincident/accident? [Level 2 controls]

7. Were any of the employees observedfalling asleep or otherwise strugglingto remain alert in the week prior to theincident/accident? If yes, documentdetails. [Level 3 controls]

8. Does anyone involved in the incidentrecall having unexpectedly fallen

asleep or otherwise struggling toremain alert during the week prior tothe incident/accident? If yes, docu-ment details. [Level 3 controls]

9. Did anyone involved in theincident/accident take medications ordrugs (prescription or non-prescrip-tion) in the week prior to the event? Ifyes, then document details and noteany effect the medication or drug isknown to have on sleep, alertness,and/or fatigue. [Level 3 controls]

10. Was any employee involved aware ofany sleep or other medical disorderthat might have affected sleep, alertness, and/or fatigue? If yes, docu-ment details. [Level 3 controls]

be asked about the most recent break dur-ing the shift – how long was it and whendid it occur? Other organizational infor-mation might include hours worked on

the day of the incident and during theprevious week.

The questions asked during an investiga-tion can help determine whether a specif-ic factor contributed to an incident. To geta clear understanding of whether fatiguecontributed to an incident or accident,investigators must ask sufficient ques-tions, and specific questions. By collectingpertinent information about fatigue, the

company can improve understanding ofits own fatigue risk and adjust its proce-dures to reduce that risk.

The list below provides a range of gener-al questions that might be included. Thisis not intended to be an exhaustive list forall organizations. Each question is linkedto the various levels of FRMS control,which can allow an organization to iden-tify where corrective measures may be

needed. Bear in mind that even if no evi-dence of fatigue is found in the answers tothe questions, fatigue may still have beena factor – there are many contributors tofatigue and further probing may be necessary.

Sample questions:

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

2. What were the planned hours of workfor each employee involved in theincident/accident over the two weeksprior to the incident? [Level 1 con-trols]

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measures that were taken to mitigatefatigue risk should be re-examined (asdiscussed in Chapter 6).

By assessing the information collectedusing such questions, companies can gaina much clearer understanding of whetherfatigue contributed to an incident or acci-dent. Over time, results of investigationscan be used to examine trends betweenincidents/accidents and time of day, dayof week, time of year, amount of overtime,commute distance, age of employee, pres-ence of stressors, and other relevant fac-tors. Properly collected incident and

accident investigation data can permit thecompany to develop more stringent andtargeted controls to reduce the risk of further accidents.

11. Was any employee involved aware ofany personal, financial, or other stressthat might have affected sleep, alert-ness, 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? Ifyes, document details.

13. Approximately how many minutes isthe commute to and from work foreach employee involved in the inci-dent or accident?

Answers to some of these questions may

identify areas that need to be probed fur-ther. For instance, if the answers to ques-tions related to Level 2 controls indicatethat insufficient sleep was obtained, any

• 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 fatigue-

related incident or accident.

• List at least two incident or accident investigations in your organiza-

tion 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.

E

X E R C I S E

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Learning Outcomes


• Detail the fatigue-risk managementfactors that are assessed during internal audits.

CHAPTER 9

Internal FRMS Audit

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The components that make up a fatiguerisk management system will evolve overtime as additional information is collected

and assessed through normal operationsor through investigations into incidentsor events. This chapter outlines the kindsof information that can be useful for con-ducting an internal audit of the com-pany’s fatigue risk management system.Sample questions have been providedthat make it possible for individuals orgroups who are not necessarily fatiguerisk experts to perform the audit. Whileother stakeholders such as regulators may

require additional data for their own pur-poses, the questions provided below canact as a useful starting point.

Ideally, an internal FRMS audit should beconducted one year after the initial imple-mentation, and every two years after that.Internal audits are generally conducted by the safety manager or by an externalconsultant. However, it is essential thatemployees be involved in the auditprocess to obtain their perceptions of howthe FRMS is working. After the review,senior management and the FRMS com-mittee should meet to review and discussthe findings and plan any potentialchanges to the FRMS.


Policy

Used to define fatigue and to outline

responsibilities of the employer as well asemployees.

• Has a fatigue policy been developed?• Does the policy clearly detail individ-

ual responsibilities of the employerand employee (may also includeclients and contractors) in managingfatigue?

• Does the policy specifically helpemployees, supervisors and managers

understand (1) the significance offatigue management, and (2) their rolein keeping levels of fatigue withinacceptable levels in the workplace?Has the policy manual been sharedwith all relevant stakeholders forcomment and final approval?

• Has the policy implementation date been chosen or has the policy actually been implemented?

• Has the policy also been applied tocontractors who work on-site?

CHAPTER 9

Internal FRMS Audit

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assessed for effectiveness and cost benefit (for example, face-to-facetraining, e-mail, safety newsletters,posters in the workplace)?

• Have stakeholders been providedwith the policy, hours of work guide-lines, information about training andeducation, as well as sources of addi-tional information?

• Have stakeholders been consultedabout the implementation of theFRMS? What did the consultationprocess involve? How did the organi-zation consider each group’s point ofview in establishing the final FRMS?

Implementation Process

The step-by-step process and schedule forimplementation.

• Have supervisors, managers, andthose who supervise or manage on-site contractors been trained in theimplementation and use of the fatiguemanagement system? Do company

management, supervisors, andemployee representatives have theskills to implement and manage theFRMS?

• Have all parties received informationand procedures for managing fatigueaccording to the policies and guide-lines?

• Have training sessions or workshops been conducted to address any questions and to discuss possible

scenarios?• Has resource material been provided

to support these employees after thesession?

FRMS Committee (or person respon-

sible for the FRMS)

Tasked with the review and guidance of

company matters relating to fatigue.

• Has an FRMS committee been estab-lished? Or has it been incorporatedinto a more general safety committee?Or has a person been designated asresponsible for the FRMS?

• Does the committee represent all thekey stakeholders – for example, oper-ators, supervisors, managers, mainte-nance and safety personnel, union

representatives, as well as trainers?• Has the FRMS committee (or person

responsible for the FRMS) been pro-vided with the resources, information,and technical support to perform itsrequired role?

• Has the FRMS committee (or personresponsible for the FRMS) identifiedmajor fatigue-related issues, prob-lems, and strengths related to fatiguemanagement in the organization and

subsequently developed a fatiguemanagement plan?

• Does this plan deal specifically withtraining and education, schedulingguidelines, risk management, work-force planning, as well as manage-ment training and activities?

Communication and Consultation

To keep all stakeholders informed of the

fatigue management process and itsprogress (may be developed by the FRMScommittee or a pre-existing group).

• Have all reasonable methods for com-municating to stakeholders been

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• Has a system been developed to man-age reports of fatigue? What is thesystem?

• Was the workforce able to participate

in the planning and development ofthe self-disclosure system?

• Has the fatigue self-disclosure system been used? How many reports have been processed over the lastweek/month/six months/year? (Noreports of fatigue over a number ofmonths may indicate that the organi-zational culture does not yet supportthe system.)

• Has any employee reported fatigue on

so many occasions that it is consid-ered excessive? (It is important thatsuch cases be managed carefully andappropriately and that a clear defini-tion of excessive be in place.)

• Has the FRMS committee or other rel-evant pre-existing group developedprocedures to help supervisors dealwith employees who report that theyare fatigued?

Development of Training Program

To determine whether appropriate train-ing materials are developed.

• Who is responsible for developing/presenting training materials toemployees?

• What are the key components of thetraining?

• If training materials were developed

in-house, was the person or groupprovided with adequate referencematerial, financial resources, and sup-port to complete the job to an accept-able standard?

Schedules and Actual Hours of Work

Where “acceptable” balances safety, oper-ational, and general risk concerns with

social requirements.

• Has a scheduling guideline beendeveloped that meets both organiza-tional requirements and fatigue riskmanagement principles?

• Were stakeholders consulted andasked to provide feedback regardingthe FRMS scheduling guidelines?

• Were stakeholders provided with ade-quate information about the specific

fatigue implications of various shiftstructures?

• Has a date been set to implement thescheduling guidelines or have theyalready been implemented?

• Have specific criteria been developedto manage the effect of overtime, leaveand vacation, start and finish times ofshifts, and commuting to and fromwork?

• Has a fatigue assessment tool been

used to predict fatigue levels associat-ed with the hours of work? Have thescheduling guidelines been applied tocontractors work on site?

Assessment of Actual Sleep Obtained

To ensure that there is a process to be fol-lowed if an employee does not feel safe tostart or continue work. Ideally, thisshould be non-punitive.

• Has fatigue been formally recognizedas a legitimate reason for employeesto stop work and/or request a break?

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– Have adult learning principlesand competency-based trainingmethods been used?

– Were the people who developed

the training adequately qualifiedand/or experienced to develop afatigue-related program?

– Have the materials been testedand reviewed by groups ofemployees?

Delivery of Training

To ensure that specific and targeted train-ing occurs using suitably qualified and

experienced trainers.

• Are trainers appropriately qualifiedand experienced? (Experience withshiftwork is a significant advantage)

• Have trainers been involved, or atleast fully briefed, in the developmentof learning outcomes, lesson plans,and other aspects of the trainingrequirements? (For material devel-oped in-house)

• Have trainers been supplied with, orprovided access to, reference materi-als to help answer a wide range ofrelated questions?

• Have trainers been supplied withevaluation forms so that training can be improved?

• Is a training register kept as a recordthat employees have completed theirtraining?

Incident and Accident Investigation

To update procedures to ensure thatfatigue is included as a potential factor to be investigated.

• Has the existing incident and accidentinvestigation process been fullyreviewed to determine whether it ade-quately identifies potential fatigue-

related issues?• Does the process collect data relating

to work and non-work related factorsthat may contribute to fatigue?

• Have incident/accident investigationand training procedures been updated?

Internal Audits

To keep accurate records of implementa-tion for reporting purposes and audits by

any outside parties such as regulators.

• Does the internal audit system assessall relevant components of the fatiguemanagement system? (At a minimum,this should include policy, training,hazard control, and audit.)

• Are there additional assessments thatmight provide valuable informationfor the organization? If yes, providedetails.

• Has a survey or other consultation been conducted within the organiza-tion and with any relevant contractorsto consider the adequacy of theprocess and level of impact of thefatigue management system?

• Are follow-up assessments made oftraining delivery, compliance withscheduling guidelines, implementa-tion schedules, and other parts of thefatigue management implementation?

While the list above suggests that an auditconsists of a number of distinct and inde-pendent reviews, it should not be forgot-ten that each component is part of anoverall, interactive system.

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• Discuss the benefits of conducting fatigue management internal

audits.

• List six aspects of an FRMS that should be assessed during an audit.

• Provide at least three key questions for three of these aspects that

should be asked during a thorough internal audit assessment.• List the departments and/or individuals or groups that need to be

involved in the review and update of the incident and accident inves-

tigation system as well as the internal audit system.

E X E R

C I S E

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