Managing Fatiguerelated risk: An integral part of Safety Management Systems

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Managing Fatigue-related riskAn integral part
of Safety ManagementSystems
Drew DawsonCentre for Sleep Research, UniSA
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Why do we need a new approach

• Prescriptive regulations
• Historically rather than rationally derived
• Not scientifically defensible
• Operationally inflexible
• Not risk-based so can lead to paradoxical
  outcomes
• Non-prescriptive models
• Derived rationally at least in theory
• Scientifically defensible
• Operationally flexible
• Risk-based

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A New Paradigm

• Decision to move away from an industrially
  focused prescriptive model toward a Safety
  Management System SMS model of fatigue risk
  regulationGoals are to
• reduce fatigue-related accidents with acceptable
  impact on operational flexibility.
• Provide a scientifically and legally defensible
  framework and measurable outcomes
• Provide a a risk-based framework
• Provide a rational migration path from award
  compliance to an integrated SMS approach

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Performance-based definition for a Fatigue
RiskManagement System

• Where fatigue is a potential risk to the
  organisation it shall be managed as a hazard
  within their SMSe.g. AS/NZ 4360 4801
• an FRMS should at a minimum
• Be scientifically and legally defensible
• Discriminate between work and non-work related
  fatigue
• Be reported and auditable
• Address all reasonably foreseeable events
• Be appropriate to operator resource/risk profile

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Alternate compliance model
Prescriptive Zone(s)
SMS Zone
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Alternate compliance model
Acknowledges unique operational requirements
Ensures resource/risk profile is appropriate
Punishes poor SMS performance with return to the
minimum prescriptive zone or sin bin
Rewards appropriate use of SMS with flexibility
and competitive advantage
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The Key Elements of an FRMS

• There should be a written fatigue management
  plan/policy for all reasonably forseeable events
• There should be competency-based training and
  education programs for the identification and
  management of fatigue-related risk
• There should be a quantitative methodology for
  ensuring that employees are not fatigued at both
  the individual and organizational level
• There should be a quantitative methodology for
  determining compliance with 1-3

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1. Creating a Shared FRMS Policy

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FRMS policy frameworkmanagement

• The operator is responsible for providing staff
  with a work schedule that
• does not require excessive wakefulness and
• provides the opportunity to obtain sufficient
  sleep.
• In determining this, the employer shall take
  into account normal non-work activities and
  responsibilities of the employee.

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FRMS policy frameworkemployee

• The employee is responsible for using their
  allocated time away from work to obtain
  sufficient sleep in order to work safely.
• If this has not been possible, as a requirement
  of the FRMS, the employee must notify their
  employer that they may have had insufficient
  sleep.

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2. Competency-based Training

• Ensure that all relevant staff are aware of the
  organizational fatigue management policy and can
  identify and manage risks associated with fatigue
  at a personal and organizational level.
• Ensure that all relevant staff who are
  responsible for organizational decisions that
  impact on the length of wakefulness and/or the
  opportunity to obtain sufficient sleep know their
  responsibilities and understand how to use the
  appropriate risk mitigation strategies

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3. Ensuring employees arefit-for-work

• An effective SMS for fatigue should determine
  whether employees are FFW
• At the individual and organizational level
• Prospectively planned and retrospectively
  actual
• As a potential root cause of incidents and
  accidents
• SMS Models

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Incident Trajectory
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Prescriptive rules Aggregate PSW Model Fatigue
modeling
Adequate Sleep Opportunity
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Adequate Sleep Obtained
Personal PSW model
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Behavioural audit Symptom checklist
Fatigue-related behaviours?
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Error analysis addresses levels 1-3
Fatigue-related errors?
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Incident analysis addresses levels 1-4
Fatigue-related incidents?
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Level 1 ControlsEnsuring an adequate sleep
opportunity

• There may be a variety of ways that this can be
  achieved. Typical examples include
• Prescriptive Rules e.g. CAO 48
• Fatigue modeling
• FAID
• DERA
• Karolinska
• US Airforce SAFE-T
• Aggregate Sleep/Wake Models

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Level 1 ControlsEnsuring adequate opportunity

• The following five dimensions indicate the
  likelihood that a roster will provide an adequate
  opportunity for sleep
• Total number of hours worked per week
• Duration of individual shift
• Duration of short break Work-Sleep-Work
• Total hours of night work per 7 day
  periodi.e. total weekly hours worked between
  2100h-0900h
• frequency of long break Night sleep-Day
  off-Night sleep per 7 days

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Assessing the likelihood of fatigue
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Prescriptive rule sets as a control
procedures Pros
Prescriptive approaches
Simple
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Prescriptive rule sets as a control
procedure Cons
Assumes that compliance ensures safety
Assigns no responsibility to an employee
Prescriptive approaches
Relies on subjective assessment of an internal
psychological state
Does not address risk
Does not provide explicit management strategies
for risk mitigation when a compliant individual
is fatigued
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Fatigue modeling as a control process Pros
More scientifically defensible
Software driven so unambiguous
Fatigue modeling systems
Enables large amount of data to managed
cost-effectively
Appeal to the techno lust gene in engineering
cultures
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Fatigue modeling as a control process Cons
Only indicate a potentially adequate opportunity
To be practical models need to predict fatigue
from work/rest not sleep wake data
Fatigue modeling systems
Current theoretical models are not evidence-based
Theoretical models are based on average data
rather than statistical distributions
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FAID as a level 1 control process
Estimates fatigue based on statistical
distrtibutions of prior sleep and wake
Does use real world data that includes social
activity
FAID
Only has specific sleep/wake data derived from
some workplace populations
Does not predict individual sleep/wake on a
specific occasion
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Level 2 Prior Sleep Wake Model
Wake-up
End-of-shift
Start of Shift
Sleep
Sleep
Work
Sleep
Sleep
X Sleep in prior 24 hours
Y Sleep in prior 48 hours
Z Prior wakefulness
Fatigue is unlikely to be a problem when X,Y and
Z are above task and/or occupationally defined
thresholds
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Prior Sleep Wake Rules

• sufficient sleep Must obtain X hrs sleep in the
  24hrs prior, and Y hrs sleep in the 48hr prior to
  commencing work
• excessive wake The period from wake-up to the
  end of shift should not exceed the amount of
  sleep obtained in the 48 hrs prior to commencing
  the shift
• hazard control Non-compliance indicates that
  fatigue is likely to be a potential problem. In
  this situation the individual should calculate a
  fatigue likelihood score and notify their line
  manager and the organization should engage in an
  auditable fatigue risk reduction process

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Risk-based Decision Tree

• Add 2 points for each hour of sleep below the 24h
  threshold
• Add 1 point for each hour of sleep below the 48h
  threshold
• 3. Add 1 point for each hour of wake beyond the
  48h threshold
• 4. Refer to organizational decision tree for
  predetermined response

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Sleep Loss - Single Night
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Sleep Loss - Multiple Nights
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Prior Sleep Wake Rules as Level 1 2 Control
Simple and practical to learn.
Deals with a specific individual on a specific
occasion
Prior Sleep-Wake Model
Is developed consultatively
Provides an unambiguous risk based framework for
decision making
Scientifically and legally defensible
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Prescriptive rules Aggregate PSW Model Fatigue
modeling
Adequate Sleep Opportunity
L
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Adequate Sleep Obtained
Personal PSW model
L
e
vel 2
Behavioural audit Symptom checklist
Fatigue-related behaviours?
L
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Error analysis addresses levels 1-3
Fatigue-related errors?
L
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Incident analysis addresses levels 1-4
Fatigue-related incidents?
L
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A
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Hazard Control Philosophy For Fatigue
The higher the likelihood of fatigue, the higher
level of control that is required
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Performance Management System

• Management to demonstrate a methodology that
  ensures
• All relevant employees are aware of relevant
  fatigue-related risk, know their responsibilities
  and have signed the FRMS policy
• All relevant employees have been appropriately
  trained and are competent to make decisions
  consistent with the fatigue management policy
• All relevant employees are sufficiently alert to
  operate safely within the workplace
  prospectively retrospectively.
• All relevant exceptions are documented and
  corrective action is undertaken in a timely
  manner

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Development of Fatigue Risk Management Systems
24 mo
6 mo
12 mo
18 mo
0 mo
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Questions?
drew.dawson_at_unisa.edu.auCentre for Sleep
Research, UniSA
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A minimum prescriptive framework

• Work-related fatigue is unlikely to be a problem
  in a work place for staff whose schedule or
  roster involves
• less than 48h at work and on call per week
• work periods less than 12h
• breaks between work periods of more than 12h
• less than 12h of night work per 7 day
  periodi.e. total weekly hours worked between
  2100h-0900h
• at least one break of 36h or more per 7 day
  period
• If any of the above are not true a FRMS is
  probably required
• For pilots additional limits for sectors and
  stick time would be required