Fatigue Risk Management

Transcription

1 Fatigue Risk Management Capt. Robert Johnson Senior Pilot, Beijing, China and R. Curtis Graeber, Ph.D. Chief Engineer, Human Factors Chair, ICAO FRM Subteam Boeing Commercial Airplanes 1st ASIA RAST and 9th SEARAST Meeting Flight Operations and Air Traffic Management Component November Bangkok, Thailand

2 Fatigue Risk Management Agenda Today s Situation Some Basic Facts Enabling Fatigue Risk Management Integrating FRM into SMS Alertness Management Conclusions

3 Today s Situation Fatigue related accidents and incidents Most flight time limitations lack a scientific basis Unsuccessful attempts to set new limits Inability to address key alertness factors Exemptions for unanticipated operational situations No worldwide standards enabling fair competition Over 25 years of scientific results awaiting application Fatigue Risk Management applies scientific knowledge and offers a new comprehensive approach

4 Alone, Prescriptive Duty Times Do Not Manage Fatigue Risk Key Alertness Factors; - Multiple time zones - Night work/shift work - Sleep at inappropriate circadian times - Effects of sunlight, caffeine, drugs, etc. Operational Factors: - Unexpected ops demands - Novel ops not fitting within existing prescriptions Do not assess fatigue related safety risk levels Performance Factors: - Differing ability to adapt to sleep/wake changes - Poor ability to assess own alertness & performance - Differences in susceptibility to fatigue

5 Fatigue Risk Management Agenda Today s Situation Some Basic Facts Enabling Fatigue Risk Management Integrating FRM into SMS Alertness Management Conclusions

6 Sleep loss, hrs Basic Fact: Sleep Differs Among Pilots 20 Sleep Loss on a Polar Route

7 Basic Fact: Sleep Restriction Degrades Performance Increasing sleep restriction degrades performance in a dose dependent manner Even mild sleep loss (40 min/night) can degrade performance over time Psychomotor Vigilance Task

8 Speed on PVT Basic Fact: Individuals Perform Differently When Sleepy Baseline 3 Hours Sleep/Night X 7 Days Recovery Days Mean +/- SEM (n = 18) Resistant Subject Sensitive Subjet #1 Sensitive Subject #2 Belenky et al, J. Sleep Res. 2003

9 Basic Fact: Pilots Are Poor Estimators of Own Alertness SSS Tense/Alert scale (mm) A SSS Alert Tense 1 15 MSLT score (min) 10 B 5 major sleep episode MSLT (mean = 10.51) Sasaki et al., 1986 Local Time (hr)

10 What the Basic Facts Tell Us Current prescriptive limits do not adequately address the core physiological factors underlying fatigue risk. Pilots differ in their ability to sleep, assess their alertness and to perform when sleep deprived. The industry and states can capitalize on the recent scientific gains to manage the issue better from a data driven perspective that addresses specific risk.

11 Fatigue Risk Management Agenda Today s Situation Some Basic Facts Enabling Fatigue Risk Management Integrating FRM into SMS Alertness Management Conclusions

12 What Has Enabled Fatigue Risk Management? Two Decades of Evolutionary Change Worldwide adoption of SMS Commitment to just culture enabling: Non-jeopardy incident reporting (e.g., ASAP) Flight Data Monitoring (FOQA) Scientific studies on sleep, fatigue and performance Computer modeling capability Digital, portable technology to collect data Recent development of ULR operations

13 Miniaturized Portable Digital Recording Devices Psychomotor Vigilance Task Solid State EEG Actigraph Flight Data Recorders

14 ULR Initiative: A Precursor to FRMS SME Operational Model Amend Task Force/ Steering Committee(Operator, Regulator Pilot group) Goals & Protocol (Outcome Measures) Select Independent Scientific Organization Validation Plan Data Collection & Analysis Validation Process for Operational Model Ongoing Monitoring & Evaluation

15 Fatigue Risk Management Agenda Today s Situation Some Basic Facts Enabling Fatigue Risk Management Integrating FRM into SMS Alertness Management Conclusions

16 Why Implement an FRM System? Provides an equivalent safety with greater operational flexibility than prescriptive Flight/Duty Time Limitations. Enables an enhanced level of safety based upon identifying and managing fatigue risk relevant to specific circumstances. Is based upon the latest scientific knowledge about sleep, circadian rhythms, alertness levels, and performance. Takes into account known variables that affect sleep and alertness which prescriptive flight/duty limits cannot address. Is data driven and thereby reflects unique airline factors. Incorporates the management of operational fatigue risk into a proactive SMS framework.

17 Fatigue Risk Management Draft Definitions Fatigue Risk Management The management of fatigue in a manner appropriate to the level of risk exposure and the nature of the operation, in order to minimize the adverse effects of fatigue on the safety of operations. Fatigue Risk Management System A scientifically-based, data-driven flexible alternative to prescriptive flight and duty time limitations that forms part of an operator s Safety Management System and involves a continuous process of monitoring and managing fatigue risk.

18 A Data Driven Approach Relies on in-flight measures of sleep and alertness, and subjective crew reports, to monitor how scheduling affects alertness during flight duty. Computer models can be used to help understand the likely effects on performance of sleep obtained before and during trip patterns Models aim to predict average performance capability from sleep/wake history and circadian rhythm phase. Accuracy cannot be assumed, so outputs must be validated. Routinely collecting and analyzing operational flight performance data as well as crew alertness data provides a multi-layered defence to manage fatigue risk proactively.

19 FRMS and SMS Share Fundamental Concepts FRMS Characteristics Should be an integral part of an established SMS. Applies SMS principles and processes to proactively identify and continuously manage fatigue safety risk. Uses data driven systems designed to identify risks. Implements multi-layered defenses to manage risk. Requires shared responsibility among management and employees. Functions within a regulatory oversight framework. Can enhance safety within the envelope of prescriptive flight/duty time limits or as an alternative to prescriptive rules that provides at least an equivalent level of safety.

20 FRMS Major Structural Elements Fatigue Risk Management Policy (FRMP). Establishes commitment of senior management to the general philosophy and goals of the operator s FRMS. Defines management and employee responsibilities at all levels for the elements of the FRMS. Fatigue Management Steering Group (FMSG). Coordinates all fatigue management activities (e.g., SOP recommendations, rostering, data collection & analysis). Includes all stakeholders, including those with scientific, data analysis, operational and medical expertise. Sleep/Fatigue Awareness and Countermeasure Training Educates relevant staff about sleep and performance.

21 FRMS Structure 4th International Fatigue in ULR Workshop Flight Safety Digest 2005

22 SMS Principles Embedded in FRMS: ICAO s 10 Steps to SMS: Essential FRMS Elements: 1. Planning Non-punitive Fatigue Risk Management Policy 2. Senior Management Commitment Just Culture 3. Organization Fatigue Management Steering Group 4. Hazard Identification Fatigue Risk Assessment Tools Crew Fatigue Reporting Employee Communication Channels for Feedback 5. Risk Management Strategic, Scientifically-Driven Crew Scheduling Validated, Timely Fatigue Mitigation Strategies Data driven processes for monitoring alertness 6. Investigation Capability Procedures to Investigate and Record Fatigue Related Incidents 7. Safety Analysis Capability Data Collection & Assessment 8. Safety Promotion & Training Education and Awareness Training Programs 9. Safety Management Documentation Documented SOPs for FRMS Implementation 10. Oversight and Performance Monitoring Operator Internal Audit Program FRMS Validation Program Safety Performance Measurement

23 Some Recent FRMS Developments Regulators Transport Canada issued FRMS Toolbox April 2007 FAA Fatigue Risk Management Symposium, June Proceedings expected by Dec. 1. Draft Generic Op Spec A332 for ULR operations (flights > 16 hrs) based on FRM principles EASA is currently examining implementation of FRMS. Viewed as a safety management tool for any FTL scheme. Does not preclude mandating a prescriptive rules as the primary means of compliance until an alternative FRMS is established. CASA is currently drafting FRMS regulation. Operators EasyJet has implemented for short-haul ops Air New Zealand and Emirates have implemented for long-haul ops

24 Fatigue Risk Management within SMS Agenda Today s Situation Some Basic Facts Enabling Fatigue Risk Management Integrating FRM into SMS Alertness Management Conclusions

25 FRM = Alertness Management We cannot measure fatigue, we can only measure decrements in alertness FRMS Scheduling and Rostering tools are only one mitigation strategy FRM applies any mitigation tools that can help sustain alertness in support of safe operations Other mitigation techniques can include: Lifestyle behaviors exercise, diet, sleep habits, etc. Equipment design Use of mild stimulants Preplanned in-flight rest

26 Preplanned Cockpit Rest Improves Performance Non-Rested Median Reaction Time (msec) Flight Leg 1 Flight Leg 4 P <.02 P < % 14% 212 Rested Median Reaction Time (msec) Pre- Flight Flight Leg 1 Flight Leg 4 Rest In-Flight Post Flight

27 Cockpit Rest Improves EEG Indicated Alertness Number of micro-event occurrences No Rest Rest TOD Landing

28 Regulatory Approval of Preplanned Controlled Rest Cockpit napping is approved in AUS CASA and NZ CAA approved Flight Administration Manuals Controlled Rest in Use, Regulations Unclear

29 Conclusions Prescriptive limits are not based on science, are inadequate safeguards, and can be too restrictive. FRM is valid, scientifically based, and can manage fatigue risks for all critical aviation domains. FRMS can address variables not addressed by limits and can be readily integrated into SMS. FRMS is one of several tools for mitigating alertness decrements. ICAO is reviewing final FRMS draft guidance to be issued as a note to the recently revised FTL Annex 6 Part 1. We have the science, tools and systematic framework to better manage fatigue risk.