Not Just Fatigue - Operationally Ready and Fit for Duty

Imagine a moment in the Bernabeu Stadium in Madrid, Spain. Real Madrid are playing Atletico in the semi-final of the European Champions League. A place in the final against Liverpool or Bayern Munich awaits the winners of this epic football derby match.

This article from our fake airline "Safewings" talks about the aspects of effective fatigue risk management. 

Imagine Football Teams not Caring About their Players' Fitness

Imagine also that Real Madrid decide not to care about the preparation of their start striker Kylian Mbappe. They don’t care how much sleep he had the night before, or whether he
is rested properly since the last game. They don’t care what he’s eaten before the match, how he’s been looking after his physical and mental fitness or what he’s been doing in the
hours before the game. Get out there Kylian and just do the best you can.

Such a situation is impossible to consider. Football teams want their whole team to be able to perform like finely tuned machines, so they have the best chances of success. The same
is true of us here at Safewings, and this is particularly relevant as we approach the busy summer season. Our goal is to help everyone perform to their best - a team of who understand their individual roles and come together to deliver a safe and effective operation.

Not Just Compliant but “Operationally Ready and Fit for Duty”

Some of our staff, the pilots and cabin crew have specific flight time limitations (FTL), these are specific EASA rules that govern how long they can work in single duties, over specific
periods of time and in specific situations. Some people are of the impression that simple compliance to the flight time limitations is enough. Doing this, without any risk management or data collection, however, has not met compliance requirements since EASA’s Organisational Requirements (ORO FTL) was published. Instead, airlines sit on one of the three higher level steps in the image below.

Currently, at Safewings we have what is called an ‘Appropriate FRM’. We demonstrate effective management of fatigue through Operator Responsibilities, using the elements of our Safety Management System (SMS) to identify key contributors to fatigue and manage them appropriately. This is why fatigue reporting is so important. The next step is a ‘fully-fledged FRM’, where we can identify elevated risks and control them in a way that our aviation authority approves. We aim to continually increase the maturity of our system for managing fatigue. It is important to mention that other staff members don’t generally have specific rules governing/mandating how long they can work, other than what is required in the EU rules on working time.

The main point is that helping all staff perform to their best is vtial for the whole Safewings operation. 

Our Journey with Fatigue Risk Management

When working with fatigue it’s easy to get overwhelmed and lose track of the bigger picture. So, to ensure the aim was clear and that there was a consistency within the
FRM(S), four objectives were set at the beginning:

1. The company FRM should be practically oriented.
2. The company FRM should be built on core principles derived from the ICAO definitions of fatigue (in the Figure above).
3. The company FRM should work towards future FRMS approval.
4. The company FRM should be a shared responsibility between safety and operational departments.

The Core Principles of our FRM(S) 

The ICAO definition of fatigue contains a lot of information that was used when we built our FRM. Firstly, ICAO highlight that sleep, workload and circadian rhythm play a role.
Secondly, they specify fatigue as a physiological state of reduced mental or physical performance capability that can impair alertness and/or safety performance. From this we
created “Four Key Fatigue Factors”: sleep quantity, sleep quality, circadian rhythm and workload. We then decided that “sufficiently free from fatigue” would mean that crew
would be sufficiently alert and free from safety-related errors (we’ll get back to this later).

Structure & Plan

The next step of the process meant splitting the necessary FRM processes as stated in Doc 9966 into areas of responsibility and identifying what current processes were in place and what processes were missing. Smart-art and colour coding then gave us both a foundation to build on and the roadmap for the future (and now, nearly three years
later, also a bit of nostalgia).

At a later stage, we decided that reactive, proactive, and predictive processes should be identified for all four component levels - creating a red thread and continuous focus on mitigating, rather than simply managing, fatigue.

Metrics

“You can't manage what you don't measure” - Peter Drucker

Given the first objective, we quickly needed to figure out how to measure fatigue levels. As I guess you already know, this is sometimes easier said than done, particularly when you’re on a budget. Initially, we didn’t have any fancy fatigue models, very little reporting data and were still figuring out a lot of the functions of our rostering system.

What we did have was our SMS, where we set up the risk register for FRM to allow for monitoring using a common measure (i.e. a risk score), with a dedicated process for
continuous improvement.

Setting up the SMS

The way we went about it was to start with the four fatigue factors mentioned earlier. We then identified parts of the operation that would fall under each category that were specific for our operation (given rostering metrics would be covered by the rostering system). We also set up triggers and a process to identify more detailed sub-hazards.

Figuring out the Rostering Data

Whilst rostering systems do measure fatiguing rostering practices (as required by the regulations), the devil often lies in the details. Our operation is highly complex with night, alternating day/night, ACMI (Aircraft, Crew, Maintenance and Insurance)/charter and short and longhaul duties. Not to mention we also have multicultural crew bases spread halfway across the world. Based on the reporting we got and the newly created risk register, we soon noticed that there was more to fatigue than just rostering. We also recognised, however, that we’d need both systems to work together. This wasn’t an easy task, but we figured we’d take it back to the basics - block hours!

The good thing about this is that we can find out the trailing block hours of any crew at any date, meaning we could track it on a per-report basis (we’d argue this should be a common Safety Performance Indicator (SPI) for all of us, but that’s for a later discussion). For us, this gave us our first SPI showing output rather than input. We have since
then expanded on this and now track block hours over multiple different periods as well as compare it to averages to get an indication of efficiency (trailing block hours(BLH)/ average BLH per crew).

This isn’t the only thing we measure with the rostering system, but it’s one of the things we’d argue any operator can use regardless of size or resources. It’s also simple to
understand and is tied to cost - if someone calls “unfit due fatigue” at 50 block hours, you’re technically losing half of their potential…

Sufficiently Free From Fatigue

It’s useful to finish with an explanation of both what we consider as sufficiently free from fatigue and an example of how we turned a base from being insufficiently free from
fatigue to one of our most productive ones! 

Firstly, remember the part about alertness and performance? Remember also the SMS Competency Based Training (CBT) you had about “safety barriers” and “likelihood”? Well, we structured those two parts and merged them with the SMS Risk Matrix to create an “FRM Risk Matrix”, ensuring we get an objective measure of risk for every report.

Secondly, given that the definition states both performance and alertness impact, we use both within our report-templates and can cross-check them with the BFM to determine acceptable levels of fatigue (there’s no such thing as zero fatigue in aviation). Which brings us to what’s acceptable? Well, that’s for you to decide, but we used a mix of the Samn-Perelli scale (which contains more performance-oriented statements), and the Karolinska Sleepiness Scale (aimed more at sleepiness) to come up with our values.

From Insufficient to Sufficient

With the above processes in place, we noticed at one point that one of our bases were at increased risk levels (largely due to the type of flights they were doing), had increased sickness and reported fatigue more frequently and at higher severity than other bases. Unions were also starting to bring up the subject, meaning we were all agreeing that something had to be done. 

So, what did we do? We first used the risk register to figure out what the main hazards were. This was followed by a block-hour analysis (for different trailing periods) and finally a
biomathematical analysis. They all came out with more or less the same conclusion. Whilst the easy thing could have been to simply reduce frequency or change departure times, that wasn’t really an option - so we had to get a bit more creative. 

Together with crew planning, we created multiple versions of flight pairings, which we then reviewed with the BFM, resulting in a few restrictions but none that included reducing
efficiency. Total off-days, timing of duty and rest-times all stayed the same; we simply changed the order of trips and long-term structure of rostering. I even attended the union
meetings myself to explain how the whole process had been carried out, the alternatives we considered and the final conclusion. Then, we agreed to give it a go.

The following year, the base we had identified as being at increased risk levels flew the most hours of any base in the network, with less sickness, less reporting and happy unions. Showing that FRM will have an impact on your bottom line; it’s simply up to you to determine which way you want it to move it.

A Hazard That has a Shared Responsibility

Hopefully by now, its clear that we treat fatigue as simply another hazard that is managed through risk assessment, risk mitigation/management activities and safety assurance.
Fatigue is also something that can only be managed through joint responsibility. How we act in our personal lives impacts our safety due to fatigue at work and vice versa. So, both the individual and the organisation have critical roles to play in ensuring fatigue is managed appropriately.

The Main Challenges Related to FRM

Looking at the whole FRM picture, here is a summary of the main challenges that most operators face (not just us):

• Concern that reducing fatigue levels may cause a significant increase in staffing levels, or prevent operations that are currently undertaken. 
• Balancing ‘subjective’ and ‘objective’ data and concern around “fitness for duty” being applied inappropriately.
• Ensuring appropriate competency across the organisation to support fatigue management.
• Identifying appropriate metrics and data, as fatigue is physiological and can be seen as difficult to measure.
• Having sufficient resource within operational and safety teams to support the additional data collection and informing operational decision-making to manage fatigue. 
• Identifying effective mitigations that can be implemented to reduce fatigue.

Some of these challenges may seem insurmountable, especially when taking first steps to manage fatigue through the SMS; however, as experience grows, solutions can be found. Moreover, the simplest solutions can often be the most effective; for example, skilled roster writers can adjust roster patterns to reduce fatigue without an increase in headcount, or a reduction in flights, one way this could be achieved is by simply changing the order of duty days. 

Learning from other operators and wider experience in the industry can also support you. An excellent resource is the EASA FTL/FRM Checklist for Inspectors, which provides a
series of checks for inspectors to undertake. In addition, the checklist can also be used by operators to audit their own system(s), identify checks that you cannot provide answers
to and allow gaps to be filled.

Fatigue at a Personal Level - Operational Readiness and Fitness for Duty

Whatever your role, we want you to be operationally ready and fit for duty. For pilots and cabin crew, this is a legal requirement and includes fitness for duty relating to sleep and fatigue. But what does this really mean?

Fitness for duty can be difficult to determine - particularly, if you are experiencing cumulative fatigue where fatigue slowly builds over weeks, months and even years. As individuals we can underestimate how much our performance is affected. When it comes to acute fatigue, we are more capable of identifying our fatigue levels. We provide all staff with training and useful ‘rules of thumb’ regularly, which help with your own decision making. Hopefully, organisational safety culture makes it more likely that you feel you can
make the right decisions about your fitness for duty. 

The Elephant in the Room (at Least for Some Managers…)

We know that some managers might be concerned that some crew will use the system for a ‘free’ day off. Yes, this could happen. In our experience and based on surveys, studies and the experience of our supporting consultants at Baines Simmons who have worked in fatigue management for over 10 years, however, the proportion of crew who will declare themselves unfit due to fatigue when they want a day off is significantly lower than the
proportion who continue to operate, when in hindsight it probably wasn’t a good idea.

Ultimately, this is a trust culture thing; but we like to assume that everyone is doing their best and doesn’t want to let their colleagues or passengers down.

If an individual feels unfit for duty, we would encourage them to declare themselves unfit to operate and remove themselves from the operation as early as possible - ideally before the start of a duty period. As a last line of defence, an individual might need to do this during a duty period; we appreciate that this is not an easy decision and, if this is the case, we must be there to support them. 

To increase the effectiveness of this mitigation, there aresome recommended additional steps:

• Submit a fatigue report identifying that you are not fit to operate. This is not to apportion blame, but to support work to identify the cause(s) and develop (and
  implement) corresponding mitigation(s).
  • If the cause was personal action (for example, due to coming back from holiday late before an early duty start, then it may be necessary to remind
    the individual of their responsibilities). We do acknowledge, however, that everyone’s lives are always changing, and - where practicable - we want to
    support people manage life’s challenges.
  • Just Culture approaches apply to fatigue reporting and, as such the goal is to identify fatigue risks just like any other in our operation.
• Removing oneself from duty due to fatigue must be seen as one of the responsibilities of a professional crew member. Whilst we welcome crew going the extra mile, continuing to operate and not wishing to let others down, if someone is not fit to fly safely, it is important they remove themselves from duty.
• As an organisation, we aim to provide you with the tools and means to identify signs of potential elevated fatigue, including how much sleep is not enough to
  perform as a safety critical member of the crew and signs of elevated fatigue.
  • FRM training is competency-based training. We continually improve and update the training using information we get from fatigue reports and other information sources such as surveys.

Controlled Rest

Controlled Rest on the flight deck (also called in-seat napping) is an emergency mitigation for unexpected periods of high fatigue that might arise during a flight. Controlled rest cannot be relied upon. If, for example, there is excess turbulence, or the cruise period is not low workload, crew would not be able to take controlled rest. If, before a flight, any crew member suspects that they might need controlled rest, they should declare themselves too fatigued to operate (as described above).

Key elements of controlled rest include:

• It is an emergency countermeasure. 
• It can, however, be used proactively. If during cruise you experience high fatigue levels are likely to accumulate before approach and landing, taking a controlled rest
  at that point could be pragmatic to improve alertness during the most challenging parts of flight.
• The cruise period must be long enough to allow for preparation for the controlled rest, the rest period itself and a recovery from any post-rest inertia prior to rejoining operations.
• There must be a clear handover of roles around controlled rest, both before and after.
• Keep such rest periods shorter than 30 minutes to minimise the likelihood of entering deep sleep can reduce the intensity and duration of subsequent post-rest inertia.
  For more guidance on controlled rest, the flight safety foundation has produced a guidance document. 

Other Staff Groups?

As mentioned earlier, FRM outside flight and cabin crew is not as specifically legislated for; however, it’s as much a hazard for everyone else and must be managed.

As SMS is being introduced into Part-145 for maintenance organisations, there are specific requirements for the consideration of fatigue in organisations’ manpower plans.
Line maintenance organisations often conduct detailed and complex tasks during the middle of the night and could therefore be vulnerable to the effects of fatigue. Fatigue risk
assessments should be undertaken and identified controls and mitigations implemented.
The same will be true of ground handling organisations as the new EASA Ground Handling rules come into force in 3 years’ time.

It is important that we continually ask ourselves the following questions:

• Do our current shift patterns support adequate sleep opportunities between shifts
• What does working overtime mean for fatigue levels?
• Where is our highest likely fatigue level during a shift?
• What tasks are being done at that time?

There is a lot of focus on fatigue modelling, which may be available and could support identifying fatigue levels and timing; however, it is not mandatory.

Ultimately, that is why reporting is so important, so that staff can continually provide feedback to understand the situations that lead to problems, so we can adjust things as needed.

Shift Smarter Not Harder

For those of you who work on the ground side of things, jobs can often involve a lot of repetitive work that creates both physical and mental demands. We need to think about
the specific activities that might be highly repetitive, highly concentrated and even very physical. Where possible, we must look to identify control measures to help reduce the
risk of fatigue. These include:

• Consider where the work takes place and seek to improve that environment to help reduce fatigue. For example,working in a well-lit hangar requires less exertion than
  performing maintenance is near darkness with a grey floor. 
• Ensure that adequate machinery and equipment is installed so that it can be used in the workplace.
• Design tasks to reduce or eliminate repetitive or monotonous work, sustained mental or physical effort, and/or overly complex tasks.
• Introduce job rotation to limit the accumulation of mental and physical fatigue.

Nutrition  

Healthy eating and good nutrition are important for everyone, here are some useful tips:

• Prefer/favour protein-rich foods that promote alertness (stimulating effect): meat, eggs and fish in reasonable quantities and provided they are not fatty meats.
• Avoid snacks consisting solely of sugary foods like energy bars (fast-acting sugars and fast-burning carbohydrates induce sleep). 
• Remember to stay hydrated (drink plenty of water).
• While flights are in the cruise, alternate captains’ and first officers’ meals to avoid the risk of simultaneous drowsiness.

Summary

Managing fatigue seems complicated, but it is just another hazard. As an organisation, the amount of time, effort and resource that we invest depends on our risk exposure of the operation and our operational aims. This is where managing change in our management system is so important, so that we can identify (and mitigate) potential risks as early as
possible.

Managing fatigue through the SMS is the key requirement for us all - and not just in-flight operations. Fatigue is another hazard, so must be managed as we do any other hazard.

If you remember nothing else from this article, you are encouraged to be part of our FRM efforts and especially to report hazards whenever you identify something. It
is only with your reports that we can ensure that we are always operationally ready and able to help our passengers and cargo reach their destination safely.