Canada Develop & Implement FRM System PDF

TP 14575E
April 2007
Fatigue Risk Management System

for the Canadian Aviation Industry
Developing and
Implementing a Fatigue
Risk Management System
edu.au
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 galement disponible en franais : Systme de gestion des risques lis la
fatigue pour le milieu aronautique canadien : laboration et mise en oeuvre dun systme de gestion des risques lis
la fatigue, TP 14575F.
ii
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 to
a training presentation on fatigue, fatigue management systems, and individual
fatigue management strategies, the package includes background information for
delivery of the workshop, learning outcomes, and questions frequently asked by
participants
These documents are available on the Transport Canada web site at www.tc.gc.ca
iii
Contents
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 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .4
Managing 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 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .21

Determining 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
v
7. Level 3 Controls: Assessing Symptoms of Fatigue . . . . . . . . . . . . . . . . . . . . . . . . . . .41
Identifying At-Risk Individuals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .43
Insomnia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .46
Sleep Apnea . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .46
Restless Leg Syndrome and Periodic Limb Movement . . . . . . . . . . . . . . . . . . . . . . . . .46
Narcolepsy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .47
Sleep Clinics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .47
Assessing the effectiveness of other levels of control . . . . . . . . . . . . . . . . . . . . . . . . . .47
8. Level 4 and 5 Controls: Fatigue Proofing and . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .49

Reporting Incidents and Accidents
Level 4: Fatigue-Proofing Strategies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .50
Level 5: Incident Investigation Asking the Right Questions . . . . . . . . . . . . . . . . . . .52
9. Internal FRMS Audit . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .55
Resources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .61
vi
Introduction
The Aim of This Guide Your Role
This guide is designed for individuals As an individual in a managerial or

who are responsible for managing fatigue supervisory role you are accountable not
risk at an operational level. You should only for managing your own fatigue lev-
already have completed the Fatigue els but also the fatigue risk of employees
Management Strategies for Employees within your organization and/or work
(TP 14573E) workbook or equivalent, unit. The tools and strategies presented in
which provided information about the this guide have been developed to help
causes and consequences of fatigue, and you manage fatigue risk at various levels,
included practical strategies for manag- ranging from ensuring compliance with
ing the impact of fatigue. Fatigue legal and regulatory requirements to
Management Strategies for Employees investigating and learning from accidents
focussed on reducing fatigue risk at the and incidents in the workplace. Managing
individual level. You should now be fatigue-related risk in the organization is
familiar with the risks associated with achieved using a fatigue risk manage-
fatigue and the major contributors to ment system (FRMS).
increased fatigue levels (i.e., inadequate
quality and/or quantity of sleep, time of
day, and length of time awake). This How to Use This Guide
guide explains how the risks associated
with fatigue can be managed at the orga- This guide describes how an FRMS is best
nizational level within a safety manage- employed within an organization's safety
ment system framework. You will learn management system. This allows the risks
how to implement fatigue risk manage- associated with fatigue to be managed in
ment controls systematically within your a way similar to other hazards such as
organization. dangerous goods. An FRMS should be
based on an internal risk assessment of
the organization. This ensures that any
fatigue management strategies being
implemented are measured, appropriate,
Developing and Implementing a Fatigue Risk Management System 1

and targeted. There are several Canadian 3. Risk Assessment/Management
national standards for risk assessment, Scheduled versus actual hours of
all of which clearly outline acceptable work
guidelines for risk management Individual sleep patterns
(e.g., CAN/CSA-Q850-971, CAN/CSA- Symptom checklists
Q634-912 ). Error/incident reporting
The fatigue risk management system 4. Training

described in this guide provides your Promote knowledge in the work-
company and employees with a recog- place about risks, causes, and con-
nized process based on likelihood and sequences of fatigue
consequence and the need to identify, Ensure employees understand
understand, and control the workplace and can apply fatigue manage-
hazard. The resources and time required ment strategies
for implementing a fatigue risk manage-
ment system will be determined by the 5. Controls and Action Plans
relative risk identified during your risk Toolbox of methods used within
assessment process. the FRMS, including error reduc-
tion techniques (fatigue proof-
There are six major aspects to an FRMS: ing)
Clear decision trees for managers
1. Policies and Procedures and employees to use when
Outline the commitment of orga- fatigue has been identified as a
nizational management to manage risk
fatigue-related risk
Detail the required procedures for 6. Audit and Review
managing fatigue at the opera- Documentation and data collec-
tional level tion at regular intervals of how the
FRMS works
2. Responsibilities Review of the FRMS based on
List personnel responsible for audit results
FRMS design, implementation,
and maintenance
Document responsibilities of indi-
vidual employees and work
groups
1
Canadian Standards Association (1991). CAN/CSA-Q634-91 Risk Analysis Requirements and
Guidelines, Quality Management A National Standard of Canada. Rexdale (Toronto).
2
Canadian Standards Association (1997). CAN/CSA-Q850-97 Risk Management: Guideline for
Decision-Makers. Rexdale (Toronto).
2 Fatigue Risk Management System for the Canadian Aviation Industry

CHAPTER 1
Overview of Fatigue
Risk Management
Learning Outcomes
On completing this chapter, you will be

able to:
Explain reasons underlying the need

for organizations to implement
fatigue risk management systems.
Explain the limitations of prescriptive
hours of work for managing fatigue-
related risk.
Name the major components of a
fatigue risk management system
(FRMS).

CHAPTER 1
Overview of Fatigue
Risk Management
In recent years, organizations have alertness and negatively impacts perform-

become better at managing workplace ance. The major cause of fatigue is not hav-
risks including issues such as materials ing obtained adequate rest or recovery
handling, use of seatbelts and safety har- from previous activities. In simple terms,
nesses, as well as exposure to harmful fatigue largely results from inadequate
chemicals. As these risks have been quantity or quality of sleep. As discussed
reduced, other threats have become more in Fatigue Management Strategies for
apparent. This is particularly true of Employees, there are many consequences of
fatigue, which until recently was not well fatigue and they fall into three major cate-
understood or easy to measure. Recent gories physical (e.g., abruptly nodding
research and applied management strate- off for a few seconds, called a microsleep),
gies are beginning to provide solutions mental (e.g., lapses in attention) and emo-
for individual employees and organizational (e.g., irritability).
tions to better manage fatigue-related
risk. This chapter of the guide provides The fatigue associated with tiredness and
information about managing fatigue- reduced alertness is different from physi-
related risk within a safety management cal fatigue or weariness that is caused by
system (SMS) framework. This incorpo- long and/or hard physical work. In this
rates a formal risk assessment and will case, fatigue may be more accurately
likely fit within existing organizational defined as mental fatigue although it cer-
safety management structures. The tainly affects physical performance as
rationale for the development of a fatigue well especially tasks that require mental-
risk management system is also provided physical interactions like hand-eye coor-
in this chapter. dination, reaction time, and fine motor
skills. Other skills that are impaired by
fatigue include attention, vigilance, con-
Causes and Consequences centration, ability to communicate infor-
of Fatigue mation clearly and accurately, and
decision-making. Impairment can lead to
Fatigue is an experience of physical and/or fatigue-related errors, which in turn can
mental tiredness that results in reduced lead to incidents or accidents. Evidence

from industrial and government investi- design more effective systems to manage
gations as well as industrial risk data fatigue-related risk. Fatigue is sometimes
demonstrates that fatigue and sleepiness managed indirectly by organizations (and
are major contributors to incidents and regulators) through prescriptive limits on
accidents across the entire transportation work hours, often because it is seen as the
industry. Incidents and accidents that only available option. There is an assump-
result from fatigue can be severe and may tion that prescribing maximum limits for
include fatalities but are most often asso- the length of work shifts and minimum
ciated with employee injury and/or thresholds for breaks between shifts
equipment damage. ensures that employees achieve adequate
rest and recovery. This assumption most
likely evolved from information about the
Managing Fatigue Levels way in which humans recover from phys-
ical fatigue. Physical fatigue accumulates
An understanding of both the causes and and diminishes in a predictable way over
consequences of fatigue enables us to time, as shown in the figure below.
The manner in which physical fatigue accumulates

and dissipates in relation to work and rest

Based on this assumption, the manage- due to biological (or circadian)
ment of physical fatigue by limiting work rhythms. Sleepiness levels are natu-
hours and managing break periods is log- rally higher and alertness levels are
ical and practical. However, the same may lower at 3 a.m. than at 3 p.m.
not be assumed for mental fatigue. Circadian rhythms also influence
Common approaches for managing this sleep quality and quantity. For
type of fatigue often assume that the fac- instance, sleep obtained during the
tors that cause mental fatigue are similar day is poorer in quality compared to
to those that cause physical fatigue. And night sleep, when the body is pro-
while it is true that mental fatigue does, in grammed to sleep.
part, increase in a relatively predictable
way over time during waking hours and It is not correct to assume that a given
dissipate over a period of recovery, time is break from work will provide a given
not the only factor that needs to be con- level of recovery; the length of the break is
sidered. The most important factors not the key factor. It is the amount and
affecting mental fatigue levels are: quality of sleep obtained in the period of
time away from work that determines
Sleep quantity and quality insuffi- recovery from fatigue. The timing of a
cient or poor quality sleep results in work period within the 24-hour day will
increased fatigue levels. This is also determine fatigue risk.
because both how much and how well
one sleeps are important for recovery Both work and non-work factors can
from fatigue and for maintaining nor- affect sleep. Work-related factors length
mal alertness and performance. This of shifts, the type of work being per-
applies not only to a single sleep peri- formed, workload, work environment
od, but to consecutive sleep periods. If (e.g., heat, humidity, noise, vibration,
an individual gets inadequate sleep lighting levels) and breaks within a shift
(quality or quantity) over a series of can all influence the amount of sleep and
nights, this also causes increased time awake obtained in a 24-hour period.
fatigue.
Time awake how long an individual Non work-related factors sleep disor-
is awake affects fatigue levels. ders, family responsibilities, social and
Research indicates that alertness and leisure engagements, and emotional
performance levels begin to decrease stress can all affect the amount and
after a certain number of hours quality of sleep people obtain. These
awake. factors can also affect the length of time
Circadian rhythms fatigue levels are individuals are awake, which can also
also affected by the time of day. For affect fatigue. The figure below shows the
example, fatigue can be a bigger prob- relationship between each of these fac-
lem in the early hours of the morning tors.

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 in The FRMS should be embedded within
mind, it is easy to understand why pre- the existing SMS framework to allow
scriptive limits on work hours may not, fatigue to be managed within existing
on their own, be adequate for managing organizational safety structures. This also
fatigue-related risk. Prescriptive limita- ensures that responsibility for managing
tions on shift length generally assume fatigue risk is shared between employer
that a break of a given length has a pre- and employee. It may also allow safety
dictable recovery value; for example, that professionals or other stakeholders in the
a 10-hour break will allow the same company to develop a cost-effective
recovery to take place regardless of when FRMS without needing to call in outside
the break occurs. While this may be rela- fatigue expertise. However, it is impor-
tively true for physical fatigue, it is defi- tant to have an understanding and appre-
nitely not the case for mental fatigue. ciation of fatigue-related risk within a
Providing the same time off during the workplace.The figure below illustrates
day, as opposed to night, may result in how fatigue can be incorporated into an
less recovery due to the effect on sleep. overarching SMS.
Factors such as this must be taken into
account when developing an FRMS.
Fatigue risk management systems work best within the framework

of a larger safety management system.

An incident trajectory demonstrates how weaknesses or "holes"
in management systems can provide opportunity for incidents
A Risk-Based Approach system, should use multiple, overlapping,

and redundant defences against a given
Managing fatigue-related risk under an hazard. In a multi-layered system, an inci-
SMS framework involves developing dent can only occur when all the defen-
comprehensive defences against the haz- sive systems fail. That is, in circumstances
ard of fatigue based on a formal assess- where the incident trajectory passes
ment of risk. Organizations can decide to through the holes in each of the defensive
do as much or as little as necessary to layers. The effectiveness of the safety
manage their own levels of risk. management system can therefore be
improved by (1) the appropriate selection
An important theorist in the area of orga- of supplementary layers, and/or (2)
nizational risk management, James strengthening individual layers (shrink-
Reason, describes the "normal" environ- ing the holes).
ment in organizations that generally pre-
cedes a workplace incident. Reason Reason's principles for the development
suggests that there is no 100% effective of an SMS can be easily applied to a
safety control for any hazard (such as fatigue risk management system. The fig-
fatigue). The inherent weaknesses or ure below shows a hazard control dia-
"holes" in a given safety defence provide gram for fatigue. Vulnerabilities along the
opportunities for incident "trajectories" fatigue-related incident trajectory should
the series of events and conditions lead- be identified so that supplementary
ing to an incident to penetrate the defensive layers can be introduced and/or
defence. existing defensive layers can be strength-
ened. Investigating incidents also ensures
An effective safety management system that appropriate hazard controls are put
or, in this case, fatigue risk management in place at each level of potential risk.

In general, fatigue has traditionally been layers it is entirely possible for an
managed using a single layer of defence employee to comply with working hour
(i.e., limits on work hours). The assump- limits but to be too tired to work safely
tion is that compliance with the limits on (e.g., had a 12-hour break from work but
working hours is evidence that an didn't get enough sleep due to a sick child
employee is adequately rested and fit for or a night out on the town). Each of the
work and will not make any fatigue- five levels of control is discussed in sepa-
related errors. This may not always be the rate chapters, but a brief description of
case. Without supplementary defensive the theory is provided below.
Hazard-Control Model for Fatigue Risk Management
The hazard control model illustrated in the holes in the management system
the figure above shows the controls in along the incident trajectory should
place for reducing fatigue-related risk. In become smaller, minimizing the likeli-
theory, if each level of control is in place, hood of a fatigue-related incident.

Briefly, a fatigue-related incident is pre- Level 5 incident: determining the role
ceded by a fatigue-related error. In turn, a of fatigue in workplace errors or inci-
fatigue-related error is generally preced- dents
ed by fatigue-related behaviours. Fatigue-
related behaviours or symptoms in turn A successful fatigue risk management sys-
indicate that an employee has either not tem addresses each of these levels by
had adequate sleep (not enough or not organizing defence systems around these
enough good sleep), or has been awake layers. Most fatigue countermeasures
for an excessive period of time. Finally, (either formal or informal) can be assigned
inadequate sleep or excessive time awake to one of the five defensive layers.
may occur as a result of inadequate sleep
opportunity (i.e., too short a break The FRMS should be developed and
between work shifts). implemented using a risk-based
approach. Organizations should deter-
There are five major levels of control for mine the specific level of fatigue-related
managing fatigue risk: risk associated with their operations.
Organizational risk should be assessed in
Level 1 (organizational): making sure terms of the type of work being conducted
scheduling gives employees adequate as well as the environment in which the
opportunity to sleep work takes place. After identifying high-
Level 2 (individual): making sure risk areas for fatigue within the workplace
employees actually get sufficient sleep (by work group or by specific tasks), sys-
Level 3 (behavioural): monitoring for tems can be put in place to either reduce or
symptoms that indicate employees eliminate fatigue through processes such
are fatigued as schedule reform (fatigue reduction) or
Level 4 (error): stategies to ensure that through the implementation of mitigating
fatigue in the workplace does not strategies such as napping and task rota-
result in errors or incidents tion (fatigue proofing).
Implementation Map

The figure above provides a plan, or This increases the range of opinions and
roadmap, for organizations implement- ensures that information is received from
ing an FRMS. The individual components all levels of the organization. Working
of an FRMS are designed to complement group members should also have the
each other to ensure the best possible out- opportunity to consult with other opera-
comes for fatigue risk management and tional personnel, bringing an even wider
safety. This guide details each of the com- range of perspectives to the process of
ponents recommended for an effective FRMS design, implementation, and
FRMS, and provides information on the review. This is best achieved through two-
relevant implementation process. No sin- way communication of program objec-
gle component should be considered tives, milestones, progress, and the
more important than another all compo- involvement of all employees in the
nents should be examined and integrated development and review processes.
into the FRMS to achieve the ultimate
goal of safety. Working Group Training
Members of the working group may

An FRMS Working Group require some training about the causes
and consequences of fatigue and how to
The design, implementation, and day-to- manage the risks. Training for the work-
day operation of any management system ing group should:
require structure and leadership. A work-
ing group should be formed to assume outline fatigue, its associated risks,
responsibility for the FRMS in the organi- and management strategies at the
zation. In smaller operations, the role of a individual level
working group may be performed by one provide strategic information on the
or two employees the size and makeup daily management of fatigue from an
of the group will be dictated by the level organizational perspective
of fatigue-related risk the organization detail effective FRMS design and
carries and the size of the organization implementation processes
itself. It is also possible that an existing provide information about how to
safety-oriented committee could take on evaluate and audit the FRMS over
the role of the FRMS working group. time.
The working group is responsible for the This type of training can be obtained from
design, implementation, and ongoing Fatigue Management Strategies for
review of the FRMS. The working group Employees (TP 14573E) and this guide.
should be composed of a representative Further reading on these issues can be
sample of employees likely to be affected found in the list of resources included at
by the FRMS. Ideally, it also includes the end of this guide.
management and operational personnel.

CHAPTER 2
Responsibility for
Managing Fatigue
under an FRMS
Learning Outcomes

able to:
Define specific responsibilities for

both employers and employees for
fatigue risk management.

CHAPTER 2
Responsibility for Managing

Fatigue under an FRMS
One of the key features of risk-based recognize the many different contributors
approaches to safety management is that to the risk. It is now accepted that the reg-
all stakeholders share responsibility for ulator, the organization, and employees
minimizing risk and increasing safety. each have certain responsibilities for
This approach works particularly well for fatigue risk management. The main
managing fatigue. Management has a responsibilities are summarized in the
responsibility to create a work environ- table below.
ment that minimizes fatigue-related risk,
and employees have an obligation to In the context of an FRMS, both employ-
ensure that time away from work is used ers and employees have responsibilities
appropriately. Spreading responsibility for the management of fatigue. The
for fatigue risk management across the employees' responsibility is first, to obtain
entire organization represents a signifi- sufficient sleep; second, to report when
cant shift in thinking. they have been unable to do so or feel at
risk of making a fatigue-related error; and
In the past, responsibility for safety has finally, to report any situation observed
generally been mandated by the regula- that may present fatigue-related risk. The
tor, who prescribed the level of safety employer has the responsibility of provid-
management required and audited the ing adequate sleep opportunity, mitigat-
organization to determine compliance. If ing fatigue-related risk, and taking action
safety was found to be poorly managed if an employee is not fit for work.
and resulted in an accident or incident, Managers and supervisors are responsi-
the organization could be held legally ble for taking prompt, consistent, and
liable and face fines or a jail sentence. appropriate action whenever they believe
Thus, if an employee fell asleep at work an employee is not fit for duty. The
and caused an accident, the organization action(s) to be taken should be set out
could potentially be held responsible. clearly and consistently in all documenta-
tion, including policies and procedures.
As our understanding of the hazards of The aim of all actions should be to main-
fatigue has increased, we have begun to tain and promote safety.

Responsibilities for Fatigue Risk Management
Government/ Organizational Individual

Regulatory Responsibilities Responsibilities
Responsibilities
Prescribe requirements/ Provide support: Use time away from

framework for FRMS - Compliance with work appropriately to
Assess compliance legislation obtain adequate rest and
Audit non-compliance - Policy development recovery, and ensure fit-
Where appropriate, - Training and ness for work
investigate education Report any potential
accidents/incidents - Error/incident risks to manager if expe-
reporting systems riencing fatigue-related
Ensure work schedules symptoms
provide adequate oppor- Report any situation that
tunity for rest and recov- may present fatigue-
ery between shifts related risk
Assess specific work
tasks for fatigue-related
risk
Actions to be considered when an being unable to maintain fitness for

employee is considered potentially unfit work.
for work may include: 6. Determining whether prescription
medication, alcohol, or drugs may be
1. Assessing the employee using a involved or have contributed to the
symptom checklist as a guide to phys- situation.
ical, mental, and emotional signs of 7. Determining whether a similar set of
fatigue (see Chapter 7). circumstances is likely to recur, and if
2. Providing closer regular supervision so, how could it be satisfactorily
of the employee by peers, work team, addressed by either the employee
or supervisor. and/or manager for a mutually
3. Giving the employee lower-risk tasks. acceptable outcome.
4. Providing the employee with an 8. Providing alternative transport home,
opportunity to rest/nap and to be if warranted.
reassessed within a determined time 9. Assisting the employee to access sup-
frame. port and assistance where available
5. Discussing with the employee what (e.g., employee assistance programs).
the employee thinks were factors in

Employee assistance programs (EAPs) are members (i.e., current spouse and chil-
confidential services funded by compa- dren). Referrals can be made by an
nies and provided to any employee who employee, supervisor, manager, or med-
may require assistance for personal, ical officer. Service providers can be inter-
work, and/or family-related concerns or nal or external to the organization with
problems. In some organizations, the services varying in scope, range, and
service is extended to immediate family intensity.
EXERCISE
Detail who is responsible for each FRMS component within your

organization.

CHAPTER 3
Policies and Procedures
Learning Outcomes

able to:
Describe the importance of develop-

ing an FRMS policies and procedures
manual.
Write a mission statement, outlining
the scope, objectives and purpose of
the FRMS and design subsections of
an operationally specific policies and
procedures manual.

CHAPTER 3
Policies and Procedures
As discussed in Chapter 1, it is the FRMS policies and procedures should:

responsibility of company management,
or a fatigue risk management working meet existing legal/regulatory/indus-
group, to produce a policies and proce- trial requirements for fatigue risk
dures manual. This includes ensuring that management
employees are consulted and have the suit specific operational needs
opportunity to provide feedback through- allow intra-organizational flexibility
out the policy development process. The (i.e., the rules for one work group may
goals, objectives, implementation, and not necessarily be the same as another
day-to-day operation of the FRMS should within the same company)
be clearly documented and communicat- not place unnecessary economic bur-
ed to all stakeholders. dens on organizations
FRMS Policy Developing FRMS Policies
The policies and procedures manual Studies have found that many organiza-
defines fatigue and its associated risks tions need guidance in designing FRMS
and creates a common understanding policies that are both specifically suited to
within the organization about the princi- their operational needs and that meet reg-
ples and standards for dealing with ulatory approval. Transport Canada has
fatigue-related risks. The FRMS policy published a companion document to this
helps align all organizational efforts guide that offers guidelines for the devel-
toward the ultimate goal of improved opment of policies and procedures (see
safety. If employees are consulted Policies and Procedures Development
throughout the development of the policy Guidelines, TP 14576E).
and are supportive of the process, it is
more likely they will take a positive,
proactive approach to fatigue risk man-
agement at the individual as well as orga-
nizational levels.

FRMS policies are often developed over a (for more information on developing the
period of several months. Many organiza- policy and mission statement, see Section
tions begin by releasing an over-arching 3.2 of Policies and Procedures Development
mission statement to set the framework Guidelines). In addition to stating manage-
and to underscore the backing of senior ment support, the mission statement
management of the organization (e.g., should outline the scope, purpose, and
CEO, general manager, board members). objectives of the FRMS. The document
The mission statement should also be need not be any longer than a page. An
incorporated as a single paragraph into example is provided below.
the organization's existing SMS policy
ABC Company
Fatigue Risk Management Mission Statement
ABC Company is committed to protecting all employees, clients, and visitors

from fatigue-related risk.
ABC's fatigue risk management system aims to continually improve the

safety of its flight operations by managing fatigue-related risk and by
ensuring that staff consider at all times the safety implications of their
own 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)
Sample FRMS Mission Statement

After announcing the support of senior hood that the goals and action plans set
management through the mission state- out in the policies are based on the true
ment, the detailed design of the FRMS capability of the organization and its
policies and procedures manual can employees.
begin. The responsibility for developing,
implementing, and maintaining the The detailed FRMS policies and proce-
FRMS manual should ultimately rest with dures manual should describe the various
the individual responsible for safety or levels of fatigue hazard controls to be put
with a more formal fatigue working in place at the company and the related
group (also known as the FRMS commit- procedures for each. Usually the manual
tee). However, there should be opportuni- covers:
ties for employees to provide input. It is
important that employees understand the responsibilities of employees under
purpose as well as the required elements the FRMS
of the FRMS policy. The consultation communication and consultation
should be undertaken by the person or processes
committee responsible for the develop- hours of service and scheduling
ment, implementation, and operation of verification of actual sleep
the FRMS policy. monitoring of fatigue-related symp-
toms
Studies have underscored the benefits of fatigue-proofing strategies
ensuring that employees are involved in reporting protocols
all new and ongoing policy initiatives. training and education
This not only ensures buy-in from review and improvement process
employees, but also improves the likeli-
EXERCISE
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.

CHAPTER 4
Training and Education
Learning Outcomes

able to:
Determine the fatigue training needs

of your organization.
List the resources required to support
a fatigue management training pro-
gram.

CHAPTER 4
Training and Education
Determining Training Needs A risk assessment of the various work

tasks and the work environment also
There are three main factors to consider helps in developing a training program.
when designing and implementing an Companies with low fatigue-related risk
FRMS training program: may decide to launch a basic workplace
awareness program. Companies where
1. Level of existing knowledge within fatigue-related risk is high or extreme
the organization may require employees to follow compe-
2. The level of fatigue-related risk within tency-based training with regular refresh-
the organization er courses.
3. Requirement of resources for training
within the organization Another factor to take into account is the
size of the organization. A small company
Training is an essential component of a with only 20 employees in a single loca-
fatigue risk management system. Before tion may choose to hire an external train-
designing and implementing a training er to present the training package to all
program, an organization should deter- employees at the same time. A company
mine the level and method of training with several locations may choose to use a
required. For example, if fatigue risk web-based package that employees can
management is relatively new to an complete in their own time and at their
organization, it may need to start with a own location. If an organization already
basic training program about fatigue and has an in-house safety training program,
how to manage it at a personal level (i.e., it can train its own trainers to deliver a
An Introduction to Managing Fatigue (TP fatigue management training program.
14572E). An organization that under- The Fatigue Risk Management for the
stands the risk of fatigue may choose to Canadian Aviation Industry: Trainer's
go directly to more detailed instruction Handbook (TP 14578E) may be useful for
about applied management strategies companies that choose this option.
(i.e., Fatigue Management Strategies for
Employees, TP 14573).

Factors to consider when designing a
fatigue risk management training program
Level of Fatigue Risk Resources Employee Characteristics
Working hours Financial commitment Geographic location

Work tasks Time for development Literacy skills
Work environment Time for implementation Venue
Frequency of fatigue- Workplace culture Rates and reasons for
related accidents most effective methods sickness/absenteeism
Likelihood and conse- of training Current knowledge
quences of fatigue- Availability of in-house Existing competencies
related error trainers
Regulatory requirement Training materials
The table above provides a summary of the priority and importance of fatigue
various things to take into consideration issues for the organization. Typically,
in implementing a training program. face-to-face training can run from 60 min-
utes to eight hours.
When the training needs and levels have
been identified, it will be necessary to: In the past, organizations typically pro-
vided short educational sessions about
determine the content of the training fatigue. While such sessions are impor-
package tant for raising awareness, there is often a
determine the time frame and sched- low rate of knowledge retention with this
ule for completion of training type of training. Employees may take
allocate the necessary resources to some information away but since details
ensure the successful roll-out and are quickly forgotten, they are unlikely to
follow-up of the course alter any of their habits at work or away.
More recently, organizations have begun

Fatigue Management using competency-based training tech-
Education and Training niques, which require employees to apply
what they have learned to their individ-
Fatigue training is most efficient when it ual situations. This approach promotes
provides both knowledge and know-how. better knowledge retention among
trainees. In addition, formal competency-
The aims of any fatigue training should based assessments can assure an organi-
be clearly stated in the course outline. The zation that employees understand the
time devoted to the course should reflect concepts presented and can apply them to

their work situation. Refresher training assessment process outlined, conduct-
should be given annually for the first two ed, and recorded (e.g., oral and writ-
years, and every two years after that. ten assessment, log book, etc.)
Refresher courses also provide an oppor- support of trainees (e.g., time,
tunity to disseminate new information resources, follow up, mentoring, etc.)
from the evolving field of fatigue man- skilled trainers and their contact infor-
agement and allow employees to consoli- mation
date prior learning.
Fatigue Management Training

The Training Environment and Education Outcomes
Investment in training can be wasted if it On completion of training, it is expected

is not framed by a real learning environ- that:
ment. Employees who attend training
courses may not actually know why they Employees know and understand the
are there or how they will be followed up. organization's fatigue management
Some managers may show little interest policies and procedures.
in helping or encouraging employees to Managers and employees know and
implement changes based on their train- understand their responsibilities in
ing. It is important to develop a training managing fatigue.
environment as well as a training course. Personnel know how to identify and
An environment that promotes learning manage risks associated with fatigue
provides: at both a personal and organizational
level.
appropriate notice for course atten- Those responsible for decisions influ-
dance (i.e., several weeks compared to encing sleep opportunities for
several hours) employees know and understand
any prior reading required (i.e., their responsibilities and implement
refresher course materials, back- appropriate fatigue-reduction strate-
ground information, etc.) gies where necessary.
course location and aims Training records have been made and
facilities for training (i.e., training stored in an appropriate place.
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 course
attendance and future courses
required

EXERCISE 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) training
times, and (3) trainer to conduct the fatigue training course for
employees.

CHAPTER 5
Level 1 Controls:
Providing Sufficient
Sleep Opportunity
Learning Outcomes

able to:
Describe the characteristics of a sched-

ule that would increase the likelihood
of work-related fatigue.
Assess the scheduling practices of
your organization with respect to
mental fatigue.

CHAPTER 5
Level 1 Controls: Providing

Sufficient Sleep Opportunity
In the past, fatigue has been largely man- individual, behavioural, error, and inci-
aged through scheduling regimes, usual- dent level. A successful fatigue risk man-
ly through rules governing hours of work agement system addresses each of these
imposed by regulators, organizations, or levels by organizing defence systems
union bodies. In a fatigue-risk manage- around these layers. This chapter
ment system, however, there are five addresses Level 1 of the hazard control
major levels of control: organizational, model.

Level 1 controls are aimed at ensuring 10 hours and as much as 20 or more. This
that the work schedule provides employ- reflects the fact that employees do not
ees with sufficient sleep opportunity. To simply fall asleep as soon as they leave
achieve this, the following factors should work and wake just before they return.
be considered: People have many activities and responsi-
bilities to manage between shifts such as
length and timing of shifts commuting to and from work, eating,
length and timing of breaks showering, socializing, relaxing, spend-
number of shifts worked in a row ing time with family and friends, etc. To
number of days off between shifts ensure adequate rest, sleep opportunity
needs to include time for employees for
Using factors such as these, an organiza- recovery sleep and other activities.
tion can predict, on average, how much
sleep an employee will obtain. This chap- Work schedules may be assessed by
ter provides an overview of some strate- examining specific aspects of the hours of
gies for assessing work schedules and work. The questions provided below can
their impact on sleep, alertness, and be used as a guide, but they should not be
fatigue. seen as a complete list for all circum-
stances. Sleep opportunity alone should
not determine appropriate schedules,
Assessing Schedules for even though it is generally the most
Adequate Sleep Opportunity important factor. For example, early
morning start times generally produce
The major reason for assessing work higher levels of fatigue, but a 5 a.m. start
schedules, apart from ensuring that they may be more appropriate than working
comply with industry requirements and under extremely hot and humid condi-
other rules, is to understand the likely tions in the afternoon. This reflects the
impact that specific hours of work have risk-based approach of safety manage-
on sleep opportunity. Sleep is the only ment systems (as discussed in Chapter 3).
cure for fatigue. In the context of an
FRMS, the employer has the responsibili- The following are some questions that
ty to ensure that adequate opportunity is could be asked to assess sleep opportuni-
provided for sleep between work shifts. It ty and potential fatigue:
is the employee's responsibility to use the
opportunities given to obtain recovery a. How many hours are worked per
sleep. seven-day period? Not surprisingly,
as total hours worked increase, sleep
Most people need between seven and opportunity decreases.
nine hours sleep to maintain safe per- b. What is the maximum shift length? As
formance and alertness levels. Depending the length of a given shift increases,
on the time of day that a break is provid- the subsequent sleep opportunity
ed, the amount of time off needed to get decreases.
adequate sleep could be as little as

c. What is the minimum length of time e. How often do employees get a long
off between shifts? A short break is break from work? A long break is
defined as a single sleep opportunity defined as a period of two night sleeps
between subsequent work periods. It with a non-working day in between.
is typically a period of less than 32 Long breaks typically provide a sig-
hours. Not surprisingly, as the break nificant opportunity to recover from
between subsequent shifts decreases sleep loss accumulated over a series of
so does the sleep opportunity. shifts.
d. How many hours are worked
between 9 p.m. and 9 a.m.? This ques- The table below provides an example of
tion considers late finishes, early how questions like those above can be
starts and night work. All of these will quantified into a rule system.
reduce night sleep opportunity and
result in a significant reduction in
total sleep opportunity.
Fatigue Likelihood Scoring Matrix for Work Schedules
Score 0 1 2 4 8
a) Total hours < 36 hours 36.1 43.9 44 47.9 48 54.9 55+

per 7 days
b) Maximum < 8 hours 8.1 9.9 10 11.9 12 13.9 14+

shift duration
c) Minimum short > 16 hours 15.9 13 12.9 10 9.9 8 <8

break duration
d) Maximum night 0 hours 0.1 8 8.1 16 16.1 24 > 24

work per 7 days
e) Long break > 1 in < 1 in < 1 in <1 in < 1 in

frequency 7 days 7 days 14 days 21 days 28 days

In the table above, a 9 a.m. to 5 p.m. work duce a score of 21, which would be con-
week (5 days in a row) would produce a sidered high. The figure below shows
score of zero. On the other hand, a work examples of schedules scored using this
schedule of seven 12-hour night shifts, approach.
followed by seven days off would pro-
Examples of different schedules scored using the

Fatigue Likelihood Scoring Matrix
Calculating a score for a schedule allows ed errors, it should reassess scores that
companies to quantify what they deem to show signs of providing insufficient sleep
be acceptable or unacceptable. The cutoff opportunity.
score for an acceptable schedule will be
determined by the specific characteristics
of the organization. For example, an Fatigue Modelling
organization could choose to assign a
lower cutoff score for highly complex or Although fatigue cannot be measured like
safety-critical work, or for a high-stress alcohol or drug impairment, there are
work environment (e.g., high humidity) ways it can be assessed. Work schedules
than for less critical work in an air condi- can be used to predict fatigue based on
tioned environment. the likely sleep loss caused by a specific
shift pattern. Predictive software models
In the beginning, cutoff scores will be best can provide fatigue likelihood scores on
estimates. However, as an organization's the basis of a schedule.
understanding of its own fatigue hazard
improves through collecting data on actu- Many models predict fatigue based on
al sleep (see Chapter 7) and fatigue-relat- planned or actual hours of work. In doing

so, they consider a number of factors supply, companies often require employ-
known to be relevant for work-related ees to work outside these hours.
fatigue. These factors include the timing
and duration of all previous work shifts A fatigue-friendly schedule would ensure
(with more weight given to the most that all shifts are finished between nine
recent shifts). Most models also allow and ten oclock at night so employees
comparison of the fatigue scores that var- could go home and easily get eight hours
ious schedules may impose on an of sleep without having to wake up too
employee population. In addition, organ- early. However, such a schedule leaves lit-
izations can set different threshold values tle time for socializing or spending time
for fatigue likelihood scores, based on a with family, and could lead to feelings of
risk assessment of tasks within their oper- social isolation and depression.
ation. In other words, a score may be des-
ignated acceptable for low-risk tasks, but A social-friendly schedule, on the other
unacceptable for tasks that involve a hand, would have employees starting
much higher potential safety risk. One work in the early hours of the morning
limitation of such a system, however, is and finishing mid-afternoon to enable
that it does not tailor predictions for every them to spend time with family and
single employee. friends. However, since it is unlikely that
an employee would go to bed before ten
As with any fatigue management tool, or eleven o'clock at night, this type of
testing devices and models should form schedule significantly limits the opportu-
part of an integrated system, not replace nity for sleep before the next shift.
it. Each organization should understand
the likely impact of fatigue in the context The ideal shift for one employee is not
of the work tasks that its employees per- likely to satisfy all employees. For exam-
form. ple, a schedule that suits an employee
with two young children would be
unlikely to suit another employee who
Designing the Ideal likes to sleep in and stay up late. While
Shift System sleep should be the primary concern,
other factors (such as family and social
It is important to understand that there is life) should also be considered when
no such thing as a perfect work sched- designing new shift systems.
ule. There are always a multitude of fac-
tors to consider. For example, while
managing fatigue and providing suffi- Considerations to Maximize
cient sleep opportunity is important, it is Sleep Opportunity in
also important to ensure employees Designing Work Schedules
receive sufficient family and social time
away from work. The ideal schedule As discussed in Chapter 1, prescriptive
would be from 9 a.m. to 5 p.m. However, rules based solely on schedule design
in today's world of 24-hour demand and may be appropriate for ensuring recovery

from physical exhaustion. However, they limiting extended duty hours/over-
are of limited benefit in managing mental time
fatigue. More effective strategies for recording and controlling overtime
reducing physical and metal fatigue focus ensuring appropriate breaks during
instead on the time available for sleep (or shifts (coffee, meals, etc.)
sleep opportunity) and actual sleep providing sufficient time off between
obtained (see next chapter). shifts to allow for minimum sleep
requirements
Things to consider in designing work limiting long blocks of work (i.e., mul-
schedules include, but are not restricted tiple days worked one after the other)
to: planning as much of the actual hours
of work as possible
limiting night shifts creating a napping policy and facili-
reducing shift length to 12 hours or ties, including a process for managing
less sleep inertia
limiting early morning starts
List some of the main characteristics of a work schedule that increas-

EXERCISE
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.

CHAPTER 6
Level 2 Controls:
Assessing Actual Sleep
Learning Outcomes

able to:
Identify employees who are at risk for

fatigue-related impairment.
Identify some of the reasons why
employees may not obtain sufficient
sleep.
Describe potential processes for deal-
ing with employees who have had
insufficient sleep.

CHAPTER 6
Level 2 Controls:
Assessing Actual Sleep
Level 1 controls presented in the previous Level 2 controls are aimed at ensuring
chapter are intended to provide adequate that employees get adequate sleep when-
sleep opportunities to employees. ever they are provided sufficient sleep
However, the organization has little con- opportunity. This level of control is aimed
trol over what employees actually do or, at the individual level rather than at the
specifically, how much sleep they actually organizational level.
obtain after they leave the workplace.

Level 2 controls play two main roles with- optimally varies in general it is between
in the fatigue risk management frame- seven and nine hours. Research has found
work: that a person can maintain alertness and
performance for a single day on approxi-
They identify employees who, even mately six hours sleep. However, more
given sufficient sleep opportunity, fail sleep is needed on average over two
to obtain sufficient sleep. or more nights, or performance and
They can be used to assess the effec- safety are likely to decline significantly.
tiveness of Level 1 controls. Even a few nights of five or six hours of
sleep is likely to result in poorer perform-
While Level 1 controls provide an indica- ance, communication, and functioning in
tion of the quantity of sleep likely to be most individuals.
obtained, it is important to know whether
there is still a risk of fatigue at the individ- Another factor that should be considered
ual level. in addition to total sleep time is the time
since an employee last had a sleep or nap
There are a number of reasons why (i.e., length of time awake). Considerable
employees may not get sufficient or suffi- scientific evidence suggests that the
cient quality sleep. Some may not be with- longer an individual has been awake the
in the employees control. For example, poorer their capacity. This is especially
parents with a newborn baby are likely to true if the total time since the last sleep or
get reduced amounts of sleep. An employ- nap extends beyond 16 or 18 hours.
ee with a partner who is a chronic snorer
may be awakened periodically through- There are various ways to assess the sleep
out the night. An employee with a busi- employees obtain. With the agreement of
ness on the side may suffer from reduced employees and any other stakeholders,
sleep opportunity. Insomnia or life stress such as unions companies may decide to
may keep an employee awake at night. An set up a system where employees calcu-
employee working night shift may simply late for themselves how much sleep they
be unable to sleep during the day. Or, an have had and how long it has been since
employee may be irresponsible and put their last sleep period or nap. Employees
social time and partying ahead of obtain- may be required to report when their
ing sufficient sleep to ensure fitness for sleep or time awake doesnt meet the
duty. Regardless of the circumstances requirements. For example, in a high-risk
causing insufficient sleep, fatigued operation it might be agreed that any
employees should be identified and treat- employee who has had less than 6 hours
ed as a potential workplace hazard. of sleep in 24 hours, or 12 hours of sleep
in 48 hours, or has been awake for longer
Before discussing different kinds of action than 18 hours, must report to the supervi-
to take when employees do not get sor. A simple method of calculating
enough sleep, it is important to quantify whether an employee is likely to be
sufficient sleep. How much sleep each fatigued based on sleep and time awake is
person needs every 24 hours to perform illustrated below.

Individual Fatigue Likelihood Individual Fatigue Likelihood
Step 1. Sleep in prior 24 hours Step 4.
Sleep <2h 3h 4h 5+h Add all points together to determine
Points 12 8 4 0 your score
Step 2. Sleep in prior 48 hours Score Control Level

Sleep <8h 9h 10h 11h 12+h 1-4 Self-monitoring
Points 8 6 4 2 0
5-8 Supervisor monitoring
Step 3. Hours awake since last sleep 9+ Dont start shift until fit for work
Add one point per hour awake greater
than sleep in step 2. Refer to FRMS policy for detailed
explanation of controls
Individual fatigue likelihood score (IFLS) is a calculation

based on time asleep and awake
This calculation tool can be printed on a On reporting:

wallet-sized card for easy reference by
employees and managers. Six hours sleep in the previous
24 hours, and 12 hours sleep in the
A company may also decide that employ- previous 48: the employee might be
ees can, within reasonable limits, assess instructed to go to work as normal.
their own requirements for sleep and Five hours sleep in the previous
report to their supervisor when they do 24 hours, and 11 hours sleep in the
not meet minimum limits. This simple previous 48 hours: the employee
and practical process can flag sleepiness might be instructed to continue work,
and fatigue issues before they lead to an but to closely monitor fatigue-related
incident. behaviours or symptoms.
Five hours sleep in the previous
When employees report to a supervisor 24 hours, 11 hours sleep in the previ-
that they have had insufficient sleep, it is ous 48 hours, and 18 hours awake:
important that clear procedures be in the employee might be instructed to
place to manage the risk in a consistent take a nap and have a strong cup of
manner. This helps managers perform coffee on waking up to minimize the
their duties and ensure that decision- risk of fatigue.
making is based on clearly understood Four hours sleep in the previous
rules. The countermeasures to adopt 24 hours and ten hours sleep in the
should take into account the level of risk previous 48 hours: the employee
inherent in the tasks involved. The exam- might be instructed to have a strong
ple below illustrates six possible scenarios cup of coffee, and work under close
of insufficient sleep that would require supervision of colleagues and
different actions by management. managers.

Four hours sleep in the previous schedules. On the other hand, if only a
24 hours, and eight hours sleep in the few fail to obtain a sufficient sleep, it may
previous 48: the employee might be be because of non-work related reasons,
assigned to less critical tasks to mini- rather than an issue with the sleep oppor-
mize the consequence of potential tunity provided by the work schedule.
errors. With appropriate record-keeping proce-
Two hours sleep in the previous dures, reporting insufficient sleep can
24 hours and five hours sleep in the help organizations take a performance
previous 48 hours: employees might management approach to employees who
be told to stop work, and either go consistently report difficulties in this area.
home to sleep (if they live close by) or The underlying reasons for each case
take a nap on the premises because should be investigated. It might be that
they are unfit to drive. the employee has a medical problem (e.g.,
insomnia, physical injury, or a bad cold)
Sleep thresholds are likely to vary from or that some life circumstance is negative-
organization to organization, task to task, ly affecting sleep (e.g., personal stress,
and individual to individual. If the sickness in the family, noisy neighbour-
threshold is set too low, it will be picked hood).
up by the subsequent levels of the hazard
control system. For example, if employees If an employee repeatedly does not take
are getting the recommended minimum the necessary measures to obtain suffi-
amount of sleep (e.g., six hours per night), cient sleep, further action may be
but still exhibit fatigue behaviours and required. An organization may choose to
symptoms (see Chapter 7), and if they are address the issue using an approach sim-
not suffering from a sleep disorder, it is ilar to that used for any other problem
likely that the minimum level of sleep is that may affect performance, such as drug
insufficient. Each organization or even or alcohol abuse. This can be dealt with
work group should establish its own through discussions with the employee,
sleep thresholds and decision trees for agreements on measures to be taken, and
when employees have not met the sleep a series of warnings that could even even-
requirements. tually lead to dismissal.
Assessing Adequacy of
Level 1 Controls
Level 2 controls allow an organization to

verify whether Level 1 controls for pro-
viding sufficient sleep opportunity are
adequate. For instance, if numerous
employees report insufficient sleep, the
organization should reassess the sleep
opportunity provided by the work

How much sleep is required by most people to maintain alertness
EXERCISE 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?

CHAPTER 7
Level 3 Controls:
Assessing Symptoms
of Fatigue
Learning Outcomes

able to:
Explain the purpose of including

fatigue-related symptom checklists
within 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 is
thought to suffer from a sleep
disorder.

CHAPTER 7
Level 3 Controls:
Assessing Symptoms of Fatigue
Even when sufficient sleep opportunity Level 3 controls play two main roles:
has been provided (Level 1 controls) and
employees feel they have obtained suffi- 1. Identify employees who continue to
cient sleep (Level 2 controls), they may exhibit fatigue-related symptoms,
still show fatigue-related symptoms. despite getting sufficient sleep.
Level 3 controls assess individual 2. Assess the effectiveness of Level 1 and
employees for symptoms that could lead 2 controls. For example, where
to fatigue-related error. employees fail to report they did not

get enough sleep, monitoring for and emotional. The table below outlines
fatigue-related symptoms adds an some of the major symptoms under each
additional layer of defence. category. If employees experience three or
more of the symptoms outlined below,
they may be experiencing some level of
Identifying At-Risk fatigue or reduced alertness. Fatigue is
Individuals not the only cause of the symptoms pre-
sented below, but when they occur
Fatigue-related symptoms can be divided together it likely indicates fatigue-related
into three categories: physical, mental, impairment.
An employee who presents three or more symptoms in a short period

of time is likely to be experiencing fatigue-related impairment.
Physical Symptoms Mental Symptoms Emotional Symptoms
Yawning Difficulty concentrating More quiet or with-

Heavy eyelids on tasks drawn than normal
Eye-rubbing Lapses in attention Lacking in energy
Head drooping Difficulty remembering Lacking in motivation to
Microsleeps what you are doing do the task well
Failure to communicate Irritable or grumpy with
important information colleagues, family or
Failure to anticipate friends
events or actions
Accidentally doing the
wrong thing
Accidentally not doing
the right thing
Many companies teach employees how to To further reinforce the importance of

identify symptoms, both in themselves monitoring fatigue-related symptoms,
and others, that may indicate an increased employees can be provided with aids,
risk of making a fatigue-related error. such as a checklist to be filled out at the
Raising awareness about the signs and start of every shift, or a wallet-sized card
symptoms of fatigue can be an effective listing the most common symptoms to
strategy to reduce the number and sever- watch out for.
ity of fatigue-related errors and incidents.

If employees consistently exhibit fatigue- Another way to check how fatigued
related behaviour, potential reasons employees feel is to ask them to rate their
should be investigated. It may simply be alertness at various intervals within a shift.
that the employee has a personal problem The Karolinska Sleepiness Scale3 can be
(e.g., sickness in the family, new child or used to determine whether fatigue is a
concern, or poor sleeping environment). problem for an individual without deter-
Employees who say they get enough sleep mining the root cause for the lack of sleep.
and cannot explain their fatigue-related As shown below, the scale requires
symptoms should undergo screening for a employees to select the statement that best
sleep disorder. The first step is some kind describes them at the time. The scale can be
of paper-based screening, such as a ques- used as an assessment of sleepiness/fatigue
tionnaire, to determine whether they are at any point in time: at work, while driv-
at risk. At-risk employees should then be ing, on waking in the morning, etc.
referred to a sleep clinic.
Screening for Sleep Disorders
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
3
kersted, T., & Gillberg, M. (1990). Subjective and objective sleepiness in the active individ-
ual. International Journal of Neuroscience, 52 (1-2), 29-37.

Employees who report fatigue-related their usual way of life over the past sever-
symptoms on a regular basis may have a al months. Even if they have not done
sleep disorder. An example of a paper- some of these things recently, they are
based test to identify the severity of instructed to try and work out how they
fatigue is the Epworth Sleepiness Scale4, might have been affected in each situa-
which asks individuals to determine how tion. Employees who score above 10 are
likely they are to fall asleep or doze off likely to have problems with their sleep
during a variety of activities. Subjects are patterns and should be referred to a sleep
instructed to provide answers based on specialist.
Epworth Sleepiness Scale
Chance 0= would never doze

Situation 1= slight chance
of dozing
of dozing
Sitting & Reading 2= moderate chance
Watching TV of dozing
3= high chance
Sitting inactive in a public place
of dozing
(e.g. theatre)
As a passenger for an hour
without a break A score of less than 8
Lying down to rest in the afternoon indicates normal sleep
function
Sitting & talking to someone
Sitting quietly after lunch without 8-10 = mild sleepiness
alcohol 11-15 = moderate
In a car, while stopping for a few sleepiness
minutes in traffic 16-20 = severe sleepiness
21-24 = excessive
Total Score sleepiness
4
Johns, M. W. (1991). A new method for measuring daytime sleepiness: the Epworth sleepiness
scale. Sleep, 14 (6), 540-545.

There are several types of sleep disorder ages and both genders, but it is most com-
that affect daytime functioning. A mon in men and is particularly prevalent
polysomnographic (PSG) recording of in obese people. The disorder exists in
sleep at a sleep clinic can help determine two forms:
the root cause of the fatigue. This process
includes analysis of electrical brain activi- 1. Obstructive sleep apnea is the most
ty, eye movements, and breathing common and occurs when the airways
throughout the sleep period. close while a person is sleeping,
blocking the flow of air and prevent-
Some of the major sleep disorders are out- ing adequate oxygen flow to the body.
lined below. Any of these conditions can This awakens the sleeper many times
result in bouts of daytime sleepiness, a night, disrupting the normal struc-
reduced alertness, and overall lack of ture of sleep, and resulting in sleepi-
energy. Physicians trained in sleep medi- ness and reduced alertness at work.
cine are best equipped to diagnose and 2. Central sleep apnea is less common and
treat these problems. A primary care occurs when muscles required for
physician should be able to refer clients to breathing do not receive a signal from
a sleep specialist for evaluation, diagno- the brain, causing the sleeper to stop
sis, and treatment. breathing.
Untreated sleep apnea can lead to cardio-

Insomnia vascular tissue damage caused by
reduced oxygen levels and can lead to
Insomnia is a disorder characterized by excessive sleepiness when a person is
difficulty falling or staying asleep, and/or awake. Excessive sleepiness can lead to
frequent awakenings during the sleep accidents and injuries, particularly while
period. There are a number of factors that driving or operating safety sensitive sys-
may contribute to insomnia, including tems.
(but not limited to):
short-term or long-term stress such as Restless Leg Syndrome and

trauma or chronic illness Periodic Limb Movement
psychological condition
the presence of another sleep disorder Restless Leg Syndrome and Periodic Limb
poor sleep hygiene (i.e., not following Movement are sleep disorders that are
good sleep practices) characterized by involuntary limb move-
ments, usually a leg, many times over the
course of a night. Movements can occur as
Sleep Apnea often as every 10 seconds, disrupting
sleep and leaving the individual suffering
Sleep apnea causes a person to stop significant daytime sleepiness.
breathing for brief periods several times
during sleep. This condition can affect all

Narcolepsy measure the effectiveness of the two pre-
vious levels of control.
Narcolepsy is characterized by a sudden
irresistible desire to go to sleep that lasts In Chapter 2 we discussed organizational
from minutes to hours at a time. It is asso- and individual responsibilities in manag-
ciated with cataplexy (the sudden loss of ing fatigue. The organizational responsi-
tone in one or more muscle groups) and bilities included two subcomponents:
with vivid auditory or visual hallucina-
tions when falling asleep. This is under- 1. Fatigue related to hours of work
stood to be a malfunction of the 2. Fatigue related to workload and
mechanism that controls rapid eye move- environment
ment (dreaming) sleep. Excessive daytime
sleepiness and the tendency to fall asleep Fatigue related to hours of work should
uncontrollably may render individuals be managed by providing employees
unable to carry on working, and may put with sufficient sleep opportunity between
themselves or others at risk. shifts (Level 1 controls). Assessing actual
hours of sleep (Level 2 controls) lets you
double-check that sleep opportunity is
Sleep Clinics sufficient.
An employee suspected of having a sleep Some employees may find it difficult to

disorder should be encouraged to consult quantify how much sleep they actually
a sleep specialist. Usually, the employee get, particularly if sleep is disturbed.
will need a doctors referral. The Some may also choose to be dishonest
Canadian Sleep Society offers a list of about the actual amount of sleep they
sleep medicine clinics in Canada: obtain and fail to report when they may
www.css.to/sleep/centers.htm. be at risk of fatigue-related error. Level 3
controls (monitoring for fatigue-related
behaviours or symptoms) provide a fur-
Assessing the effectiveness ther check to ensure that sufficient sleep
of other levels of control opportunity has been provided (Level 1)
and that employees are obtaining suffi-
In Chapter 6, we discussed Level 2 con- cient sleep (Level 2).
trols (i.e., obtaining sufficient sleep) as
they related to Level 1 controls (providing The tasks involved in a job can signifi-
sufficient sleep opportunity). We estab- cantly affect fatigue. Some tasks are more
lished that assessing the actual amount of fatiguing than others. As shown in the fig-
sleep obtained provides a measure of how ure below, this can occur at both ends of
effective the Level 1 controls are in pro- the spectrum mundane tasks can be just
viding sufficient sleep opportunity. In the as fatiguing as highly complex,
same way, Level 3 controls offer a way to demanding tasks.

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. The
level of lighting (lux) in a workplace can
also affect fatigue. Since these factors
would not be identified in the Level 1 or 2
controls, watching for specific fatigue-
related symptoms in the workplace pro-
vides an additional level of control to
further enhance the safety management Relationship between Task
system. Complexity and Fatigue
EXERCISE
Describe the role of Level 3 controls in an FRMS.

List seven signs or symptoms of fatigue.
Describe two of the major sleep disorders.

CHAPTER 8
Level 4 and 5 Controls:

Fatigue Proofing
and Reporting Incidents
and Accidents
Learning Outcomes

able to:
Choose fatigue-proofing strategies

that would be useful for your organi-
zation.
Understand the reasons why most
organizations incident and accident
investigation procedures do not prop-
erly identify fatigue as a contributing
factor in a specific event.
Identify the two necessary conditions
that define an event as a fatigue-
related incident or accident
Outline specific trends that can be
assessed to identify potential patterns
between incident and accident data
and fatigue factors.

CHAPTER 8
Level 4 and 5 Controls:

Fatigue Proofing and
Reporting Incidents and Accidents
Even with strict controls in place, it is still Level 4: Fatigue-Proofing

possible that fatigue-related errors could Strategies
occur and result in incidents or accidents.
Level 4 and 5 controls are designed to fur- The goal of an FRMS should be to reduce
ther reduce fatigue-related risk. fatigue levels as much as reasonably pos-
sible. Achieving this goal involves
focussing on the time available for sleep

(or sleep opportunity) and actual sleep More specific examples of fatigue-
obtained. However, it is important to proofing strategies might include:
acknowledge that it is not possible to
completely eliminate fatigue from all Double-Checking
workplaces all of the time. Employees and
managers should also understand that a close supervision
certain amount of fatigue in the work- working in pairs or teams depending
place may be acceptable, provided the on the task
risks are managed. task rotation
checklists
Many organizations supplement fatigue self-assessment checklists for signs
reduction strategies with fatigue-proofing and symptoms of fatigue
strategies. Both types of countermeasures support for new personnel by experi-
are important defences against latent fail- enced personnel
ures a series of breakdowns in the sys- self-reporting systems
tem that build up to create the conditions communication/briefings at shift hand-
for an incident. They also act to further overs (written/verbal/face-to-face)
reduce the risk of active failures the
direct causes of an incident. Work Environment
Once an analysis of the work schedule has self-selected break times

been completed using work design princi- interaction with peers
ples, computer-modelling techniques, provision of appropriate facilities for
assessment of sleep patterns, or other break time: lunch room, access to
approaches, the organization can target vending machines with healthy
the areas of highest fatigue in the sched- snacks, caffeinated drinks, etc.
ule with fatigue-proofing strategies. This napping facility in a quiet environ-
approach encompasses four main compo- ment
nents, including: appropriate lighting
control over temperature
double-checking to increase the vibration management
likelihood of detecting errors car pooling (minimize driving alone
improving the work environment to on commute)
reduce risk provision of transport (bus, taxi, etc.)
scheduling less complex or less safety- for personnel for commutes after
critical tasks at times of highest overtime (longer or extended shifts;
fatigue risk call-ins, etc.)
training employees about personal
limitations and strategies to increase
alertness

Scheduling Less Complex or A better understanding of fatigue risks
Less Safety-Critical Tasks and how they contribute to hazards in
operational environments now makes it
ensure high-risk activities are con- possible to include an assessment of
ducted during the day, rather than at fatigue and shift work as part of the inves-
night, where possible tigation process.
rotate tasks
avoid boring and mundane tasks at It is now generally held that for an inci-
times of higher risk for fatigue dent or accident to be defined as fatigue-
maintain appropriate staffing levels related, it must have both:
avoid highly complex tasks at times of
higher risk for fatigue occurred in the presence of fatigue
and
Training Programs and Topics been consistent with fatigue-related
error (i.e., caused by falling asleep,
fatigue awareness/competency training inattention, delayed reaction time,
refresher training and capacity error in judgement, etc.)
building
training on maximizing sleep and Defining an event as fatigue-related
alertness should involve a review of the first three
information for families/housemates levels of fatigue risk control. This permits
on facilitating sleep at home determining whether:
awareness about the impact of food
and hydration on alertness the work schedule provided sufficient
physical activity sleep opportunity for the employee
appropriate use of stimulants such as the employee actually obtained suffi-
NoDoze cient sleep
availability of caffeine fatigue-related symptoms were
observed prior to the event
Level 5: Incident The results of this review should allow

Investigation Asking you to determine whether fatigue may
the Right Questions have been involved and to identify weak-
nesses in the fatigue-risk control meas-
Incidents and accidents that an organiza- ures in place in the organization.
tion records for safety audits may include
errors, near-hits (or near-misses), lost- Many companies analyse information
time injuries, medically treated injuries, from individual incident reports as well
breaches of policy or procedure, etc. as other company sources. For example,
While error and incident reporting is the incident investigation process might
common, until recently few reporting require asking employees whether they
procedures systematically examined have recently used medications known to
whether fatigue was a contributing factor. have an effect on alertness. Or they may

be asked about the most recent break dur- 3. What were the actual hours of work of
ing the shift how long was it and when employees involved in the incident/
did it occur? Other organizational infor- accident over the two weeks prior to
mation might include hours worked on the incident? [Level 2 controls]
the day of the incident and during the 4. What were the reasons for any addi-
previous week. tional hours worked beyond the
planned hours during this period?
The questions asked during an investiga- Specifically, was the extra work or
tion can help determine whether a specif- overtime foreseeable in advance and
ic factor contributed to an incident. To get how was it allocated among all eligi-
a clear understanding of whether fatigue ble employees? [Level 2 controls]
contributed to an incident or accident, 5. How many hours sleep did each
investigators must ask sufficient ques- employee involved in the
tions, and specific questions. By collecting incident/accident recall having
pertinent information about fatigue, the obtained in the 24 and 48 hours prior
company can improve understanding of to the event? [Level 2 controls]
its own fatigue risk and adjust its proce- 6. How long had each employee
dures to reduce that risk. involved been awake at the time of the
incident/accident? [Level 2 controls]
The list below provides a range of gener- 7. Were any of the employees observed
al questions that might be included. This falling asleep or otherwise struggling
is not intended to be an exhaustive list for to remain alert in the week prior to the
all organizations. Each question is linked incident/accident? If yes, document
to the various levels of FRMS control, details. [Level 3 controls]
which can allow an organization to iden- 8. Does anyone involved in the incident
tify where corrective measures may be recall having unexpectedly fallen
needed. Bear in mind that even if no evi- asleep or otherwise struggling to
dence of fatigue is found in the answers to remain alert during the week prior to
the questions, fatigue may still have been the incident/accident? If yes, docu-
a factor there are many contributors to ment details. [Level 3 controls]
fatigue and further probing may be 9. Did anyone involved in the
necessary. incident/accident take medications or
drugs (prescription or non-prescrip-
Sample questions: tion) in the week prior to the event? If
yes, then document details and note
1. What was the date and time of the any effect the medication or drug is
incident/accident? known to have on sleep, alertness,
2. What were the planned hours of work and/or fatigue. [Level 3 controls]
for each employee involved in the 10. Was any employee involved aware of
incident/accident over the two weeks any sleep or other medical disorder
prior to the incident? [Level 1 con- that might have affected sleep,
trols] alertness, and/or fatigue? If yes, docu-
ment details. [Level 3 controls]

11. Was any employee involved aware of measures that were taken to mitigate
any personal, financial, or other stress fatigue risk should be re-examined (as
that might have affected sleep, alert- discussed in Chapter 6).
ness, and/or fatigue? If yes, then is this
stress ongoing? Document details. By assessing the information collected
12. Did any employee involved have using such questions, companies can gain
another job or significant responsi- a much clearer understanding of whether
bility in the preceding two weeks? If fatigue contributed to an incident or acci-
yes, document details. dent. Over time, results of investigations
13. Approximately how many minutes is can be used to examine trends between
the commute to and from work for incidents/accidents and time of day, day
each employee involved in the inci- of week, time of year, amount of overtime,
dent or accident? commute distance, age of employee, pres-
ence of stressors, and other relevant fac-
Answers to some of these questions may tors. Properly collected incident and
identify areas that need to be probed fur- accident investigation data can permit the
ther. For instance, if the answers to ques- company to develop more stringent and
tions related to Level 2 controls indicate targeted controls to reduce the risk of
that insufficient sleep was obtained, any further accidents.
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.
EXERCISE
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.

CHAPTER 9
Internal FRMS Audit
Learning Outcomes

able to:
Detail the fatigue-risk management

factors that are assessed during
internal audits.

CHAPTER 9
Internal FRMS Audit
The components that make up a fatigue Policy

risk management system will evolve over
time as additional information is collected Used to define fatigue and to outline
and assessed through normal operations responsibilities of the employer as well as
or through investigations into incidents employees.
or events. This chapter outlines the kinds
of information that can be useful for con- Has a fatigue policy been developed?
ducting an internal audit of the com- Does the policy clearly detail individ-
panys fatigue risk management system. ual responsibilities of the employer
Sample questions have been provided and employee (may also include
that make it possible for individuals or clients and contractors) in managing
groups who are not necessarily fatigue fatigue?
risk experts to perform the audit. While Does the policy specifically help
other stakeholders such as regulators may employees, supervisors and managers
require additional data for their own pur- understand (1) the significance of
poses, the questions provided below can fatigue management, and (2) their role
act as a useful starting point. in keeping levels of fatigue within
acceptable levels in the workplace?
Ideally, an internal FRMS audit should be Has the policy manual been shared
conducted one year after the initial imple- with all relevant stakeholders for
mentation, and every two years after that. comment and final approval?
Internal audits are generally conducted Has the policy implementation date
by the safety manager or by an external been chosen or has the policy actually
consultant. However, it is essential that been implemented?
employees be involved in the audit Has the policy also been applied to
process to obtain their perceptions of how contractors who work on-site?
the FRMS is working. After the review,
senior management and the FRMS com-
mittee should meet to review and discuss
the findings and plan any potential
changes to the FRMS.

FRMS Committee (or person respon- assessed for effectiveness and cost
sible for the FRMS) benefit (for example, face-to-face
training, e-mail, safety newsletters,
Tasked with the review and guidance of posters in the workplace)?
company matters relating to fatigue. Have stakeholders been provided
with the policy, hours of work guide-
Has an FRMS committee been estab- lines, information about training and
lished? Or has it been incorporated education, as well as sources of addi-
into a more general safety committee? tional information?
Or has a person been designated as Have stakeholders been consulted
responsible for the FRMS? about the implementation of the
Does the committee represent all the FRMS? What did the consultation
key stakeholders for example, oper- process involve? How did the organi-
ators, supervisors, managers, mainte- zation consider each groups point of
nance and safety personnel, union view in establishing the final FRMS?
representatives, as well as trainers?
Has the FRMS committee (or person Implementation Process
responsible for the FRMS) been pro-
vided with the resources, information, The step-by-step process and schedule for
and technical support to perform its implementation.
required role?
Has the FRMS committee (or person Have supervisors, managers, and
responsible for the FRMS) identified those who supervise or manage on-
major fatigue-related issues, prob- site contractors been trained in the
lems, and strengths related to fatigue implementation and use of the fatigue
management in the organization and management system? Do company
subsequently developed a fatigue management, supervisors, and
management plan? employee representatives have the
Does this plan deal specifically with skills to implement and manage the
training and education, scheduling FRMS?
guidelines, risk management, work- Have all parties received information
force planning, as well as manage- and procedures for managing fatigue
ment training and activities? according to the policies and guide-
lines?
Communication and Consultation Have training sessions or workshops
been conducted to address any
To keep all stakeholders informed of the questions and to discuss possible
fatigue management process and its scenarios?
progress (may be developed by the FRMS Has resource material been provided
committee or a pre-existing group). to support these employees after the
session?
Have all reasonable methods for com-
municating to stakeholders been

Schedules and Actual Hours of Work Has a system been developed to man-
age reports of fatigue? What is the
Where acceptable balances safety, oper- system?
ational, and general risk concerns with Was the workforce able to participate
social requirements. in the planning and development of
the self-disclosure system?
Has a scheduling guideline been Has the fatigue self-disclosure system
developed that meets both organiza- been used? How many reports have
tional requirements and fatigue risk been processed over the last
management principles? week/month/six months/year? (No
Were stakeholders consulted and reports of fatigue over a number of
asked to provide feedback regarding months may indicate that the organi-
the FRMS scheduling guidelines? zational culture does not yet support
Were stakeholders provided with ade- the system.)
quate information about the specific Has any employee reported fatigue on
fatigue implications of various shift so many occasions that it is consid-
structures? ered excessive? (It is important that
Has a date been set to implement the such cases be managed carefully and
scheduling guidelines or have they appropriately and that a clear defini-
already been implemented? tion of excessive be in place.)
Have specific criteria been developed Has the FRMS committee or other rel-
to manage the effect of overtime, leave evant pre-existing group developed
and vacation, start and finish times of procedures to help supervisors deal
shifts, and commuting to and from with employees who report that they
work? are fatigued?
Has a fatigue assessment tool been
used to predict fatigue levels associat- Development of Training Program
ed with the hours of work? Have the
scheduling guidelines been applied to To determine whether appropriate train-
contractors work on site? ing materials are developed.
Assessment of Actual Sleep Obtained Who is responsible for developing/

presenting training materials to
To ensure that there is a process to be fol- employees?
lowed if an employee does not feel safe to What are the key components of the
start or continue work. Ideally, this training?
should be non-punitive. If training materials were developed
in-house, was the person or group
Has fatigue been formally recognized provided with adequate reference
as a legitimate reason for employees material, financial resources, and sup-
to stop work and/or request a break? port to complete the job to an accept-
able standard?

Have adult learning principles Has the existing incident and accident
and competency-based training investigation process been fully
methods been used? reviewed to determine whether it ade-
Were the people who developed quately identifies potential fatigue-
the training adequately qualified related issues?
and/or experienced to develop a Does the process collect data relating
fatigue-related program? to work and non-work related factors
Have the materials been tested that may contribute to fatigue?
and reviewed by groups of Have incident/accident investigation
employees? and training procedures been updated?
Delivery of Training Internal Audits
To ensure that specific and targeted train- To keep accurate records of implementa-
ing occurs using suitably qualified and tion for reporting purposes and audits by
experienced trainers. any outside parties such as regulators.
Are trainers appropriately qualified Does the internal audit system assess
and experienced? (Experience with all relevant components of the fatigue
shiftwork is a significant advantage) management system? (At a minimum,
Have trainers been involved, or at this should include policy, training,
least fully briefed, in the development hazard control, and audit.)
of learning outcomes, lesson plans, Are there additional assessments that
and other aspects of the training might provide valuable information
requirements? (For material devel- for the organization? If yes, provide
oped in-house) details.
Have trainers been supplied with, or Has a survey or other consultation
provided access to, reference materi- been conducted within the organiza-
als to help answer a wide range of tion and with any relevant contractors
related questions? to consider the adequacy of the
Have trainers been supplied with process and level of impact of the
evaluation forms so that training can fatigue management system?
be improved? Are follow-up assessments made of
Is a training register kept as a record training delivery, compliance with
that employees have completed their scheduling guidelines, implementa-
training? tion schedules, and other parts of the
fatigue management implementation?
Incident and Accident Investigation
While the list above suggests that an audit
To update procedures to ensure that consists of a number of distinct and inde-
fatigue is included as a potential factor to pendent reviews, it should not be forgot-
be investigated. ten that each component is part of an
overall, interactive system.

Discuss the benefits of conducting fatigue management internal
audits.
EXERCISE
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.

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Trainer's Handbook (TP 13960E). Montreal: Transport Canada.
Talk about Sleep website: www.talkaboutsleep.com

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TP 14575E

Fatigue Risk Management System

Edu.au Transport Canada

The FRMS toolbox includes the following components:

1 FRMS for the Canadian Aviation Industry: An Introduction to Managing Fatigue,

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

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

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

4. Training and Education . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .21

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

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

8. Level 4 and 5 Controls: Fatigue Proofing and . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .49

9. Internal FRMS Audit . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .55

The Aim of This Guide Your Role

This guide is designed for individuals As an individual in a managerial or

Developing and Implementing a Fatigue Risk Management System 1

The fatigue risk management system 4. Training

2 Fatigue Risk Management System for the Canadian Aviation Industry

On completing this chapter, you will be

Explain reasons underlying the need

Developing and Implementing a Fatigue Risk Management System 3

In recent years, organizations have alertness and negatively impacts perform-

4 Fatigue Risk Management System for the Canadian Aviation Industry

The manner in which physical fatigue accumulates

Developing and Implementing a Fatigue Risk Management System 5

6 Fatigue Risk Management System for the Canadian Aviation Industry

Fatigue risk management systems work best within the framework

Developing and Implementing a Fatigue Risk Management System 7

A Risk-Based Approach system, should use multiple, overlapping,

8 Fatigue Risk Management System for the Canadian Aviation Industry

Hazard-Control Model for Fatigue Risk Management

Developing and Implementing a Fatigue Risk Management System 9

10 Fatigue Risk Management System for the Canadian Aviation Industry

Members of the working group may

Developing and Implementing a Fatigue Risk Management System 11

On completing this chapter, you will be

Define specific responsibilities for

Developing and Implementing a Fatigue Risk Management System 13

Responsibility for Managing

14 Fatigue Risk Management System for the Canadian Aviation Industry

Government/ Organizational Individual

Prescribe requirements/ Provide support: Use time away from

Actions to be considered when an being unable to maintain fitness for

Developing and Implementing a Fatigue Risk Management System 15

Detail who is responsible for each FRMS component within your

16 Fatigue Risk Management System for the Canadian Aviation Industry

Policies and Procedures

On completing this chapter, you will be

Describe the importance of develop-

Developing and Implementing a Fatigue Risk Management System 17

Policies and Procedures

As discussed in Chapter 1, it is the FRMS policies and procedures should:

FRMS Policy Developing FRMS Policies

18 Fatigue Risk Management System for the Canadian Aviation Industry

ABC Company is committed to protecting all employees, clients, and visitors

ABC's fatigue risk management system aims to continually improve the

ABC Company's fatigue risk management policy is backed by the

Sample FRMS Mission Statement