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(5) Customization. The certificate holder can tailor an FRMS to the size of the organization. For a large organization with an entire department dedicated to each primary function, it will be necessary to have a Fatigue Safety Action Group (FSAG) to coordinate the fatigue-related initiatives across departmental boundaries. Within a smaller organization, it may only require that a single person be assigned the responsibilities to oversee the program.
Likewise, within a large organization, there may be multiple sources available to support the data requirements of the FRMS, while, in a small organization, data may be limited to reports of fatigue from pilots and occasional reports of procedural errors.
b. Employees/Crew. For the employees/crew there are three main responsibilities:
(1) Get Enough Sleep. The only remedy for sleep deprivation is sleep and it is the employee’s responsibility to use the facilities and sleep opportunities to obtain rest, sleep, and meals. Each person has a unique requirement for sleep and only the individual can decide how much sleep is adequate to maintain alertness and performance. As a general guide, the average person is thought to require about 8 hours of sleep per day, although individual differences exist in sleep need, ranging from 7-9 hours. In general, it is the employee’s responsibility to get as much sleep as they need and to take additional sleep when they feel fatigued or unfit for duty.
(2) Plan Sleep Ahead of Time. Getting adequate sleep requires planning with future duty times in mind. For example, if duty will require an early morning awakening, then the employee should plan to go to bed early the night before so as to be fully rested for the next duty.
If the next duty will commence in the evening, the employee is responsible for taking an afternoon or evening nap so that they do not start work with eight or more hours of continuous wakefulness before the start of duty.
(3) Report Fatigue. If circumstances preclude sufficient sleep for the employee to be adequately alert and rested and to perform duty, whether they are the result of the schedule, delays, illness, life events, or personal actions, it is the employee’s responsibility to report their state of fatigue to the certificate holder. The employee should not accept the responsibilities of duty when fatigued or feeling unfit to perform assigned duties to the extent that the safety of the flight may be jeopardized.
c. Regulator. A regulator needs to be able to see that a certificate holder has a well-defined FRMS plan that provides for at least an AMOC to that provided by the applicable prescriptive flight, duty, and rest regulations. Beyond evaluation of the plan, the regulator has the responsibility to monitor the application of the FRMS plan and evaluate measures of outcomes to ensure that an AMOC is, in fact, provided by the FRMS. Both of these steps are critical to the success and public acceptance of an FRMS. The assessment requires evaluation of both the FRMS plan and the FRMS process and outcomes. The following are the regulator’s responsibilities for guiding and assessing a certificate holder’s FRMS:
(1) The regulator has the responsibility to provide descriptions of the essential components and guidance for the steps required to implement an acceptable FRMS. Given the complexity of the aviation industry, such guidance will necessarily be general in nature to allow for adaptation to the size of the organization. This AC provides useful guidance for the regulator and certificate holder.
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(2) For each certificate holder, the regulator reviews the components of the system (structures, policies, and process) and assesses whether those components are implemented on an ongoing basis.
(3) Prior to implementation, the regulator evaluates whether the FRMS, as planned, would be expected to establish an AMOC (forecasting function) to that provided by compliance with established flight time/duty time regulations.
(4) Once implemented, the regulator periodically evaluates if the FRMS, in practice, is meeting safety goals (auditing function).
(5) The regulator must evaluate if the FRMS process itself is responsive to feedback for continuous improvement (tracking progress).
14. IMPLEMENTATION. Details of implementation will depend greatly on the complexity of the organization and the demands of the operational conditions confronted by flightcrew. This AC does not provide a step-by-step implementation guide, but rather details the general progression of the implementation process and several potential implementation pitfalls.
a. Resources. In order to implement an effective FRMS, the organization must commit resources to acquire and develop the four basic building blocks (refer to Figure 2, Building Blocks of a Fatigue Risk Management System):
FIGURE 2. BUILDING BLOCKS OF A FATIGUE RISK MANAGEMENT SYSTEM Building Blocks of an FRMS Organization and Personnel Training and Publicity Policies and Procedures Tools and Methods
(1) P olicies and Procedures. The foundation of the FRMS is documentation that defines the policies and procedures that guide FRM, representing the commitment of the organization to the process and clear statements defining how the system will function. The basic elements of that documentation have been outlined in this AC, but the detail and complexity of the system will depend on the size and diversity of the organization and its operation.
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(2) Organization and Personnel. An FRMS is more than documentation; it is an active process that is implemented by members of the organization who regularly meet to review data on fatigue indicators, analyze contributing factors to fatigue, take reactive and proactive actions to mitigate fatigue, audit the effectiveness of the system, and take corrective action to continuously improve the system. Most organizations can form a defined FSAG to implement the system. The committee should include representatives of all departments and groups that have a role in reporting, managing, and mitigating fatigue.
(3) Tools and Methods. A variety of tools and methods are instrumental in aiding the activities of the FRMS organization, such as fatigue modeling, statistical analysis software, performance and sleep measurement systems, and reporting forms and databases. The tools do not constitute the FRMS, but they are essential for the system to function effectively. The organization must be willing to commit resources to procure the necessary supporting tools if the FRMS is to be effective.
(4) Training and Publicity. Training operational personnel and managers about the physiological and behavioral foundations of fatigue, the operational and environmental drivers of fatigue, and effective fatigue mitigations is essential to managing fatigue risk. Furthermore, all personnel must know the corporate policies that are the foundation of the corporate FRMS process, including policies and procedures that govern fatigue reporting, fitness for duty, absence for fatigue, incident reporting, employee privacy, and prevention of coercion to perform duties while fatigued. Finally, an effective FRMS includes feedback and publicity about the system to all affected employees to encourage cooperative participation in the corporate FRM strategy.
b. Extending Processes. The building blocks of the FRMS will be an extension of existing processes to manage overall operational safety. For example, incident report forms may already exist and need only be expanded to collect information relevant to a fatigue analysis. An organizational structure may already exist to implement safety management, and the addition of an FSAG might be the only change in the organization.
c. Developing an FRMS. The initial development of an FRMS will start with a certificate holder assembling the building blocks described above, starting with developing the policies and procedures and establishing the FRMS organization. The organization will then acquire the necessary tools and methods, and develop supporting training and publicity programs. There are several pitfalls to avoid in this complex process.
(1) The FRMS organization, such as the FSAG, should include representatives of all the key departments and groups that have a role in identifying, managing and mitigating fatigue in operations. FRM is a collaborative process and will require the commitment of key leaders of the organization and the cooperative participation of relevant groups. An example would be the marketing department, which plays a key role in defining trips and schedules. While their primary responsibility is to advance the business interests of the corporation and provide service to customers, marketing also has a key role in defining the requirements of schedules that may be causing excessive fatigue. Its participation in finding acceptable alternatives that reduce fatigue is essential to a successful FRMS. At the same time, employee groups (e.g., union representatives) should also participate in the process because managing and mitigating fatigue is a shared responsibility between the organization and the employees. Ensuring that employees
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(2) There is a danger that the FSAG may adopt a reactive approach to fatigue management, taking constructive action only in response to reports of fatigue or fatigue-related adverse events. The more effective approach is to minimize fatigue by using available tools to forecast potential fatigue well in advance of actual operations, and taking corrective action to proactively eliminate potentially fatiguing schedules or conditions prior to their occurrence. An indicator of a highly effective FRMS is the frequency of such proactive corrective actions.
(3) The FRMS should include a methodology for evaluating the success of the program and make changes in the program for process improvement. Two equally important parts of the evaluation and validation process are necessary. The first is self-evaluation using established metrics that reflect the degree of fatigue in the organization. The FSAG should monitor those metrics regularly, looking for trends over time that suggest the need for change or validate the effectiveness of actions already taken. The second is an occasional independent audit of the program by an outside agency or consultant.
(4) An outside observer familiar with FRMS principles and cognizance of best practices developed by other organizations can be an invaluable aid to improving the effectiveness and efficiency of the FRMS process.
15. FRMS APPLICATION PROCESS. For a full description of the FRMS approval process, see Appendix 2, Section 7. The FRMS approval process consists of five steps that must be satisfactorily completed in succession. Each step is referred to as a phase. Within each phase are specific tasks that must be completed before the certificate holder may move to the next phase.
These tasks are compiled into number gates. Each gate must be completed in succession before that phase is considered completed. Appendix 2, Figure 2-6, Fatigue Risk Management System Approval Process, provides a graphic depiction of the FRMS approval process. The five phases of the approval process are:
• Phase 1: Preapplication, Planning, and Assessment (4 Gates).
• Phase 2: Formal Application (2 Gates).
• Phase 3: Documentation and Data Collection Plan (1 Gate).
• Phase 4: Demonstration and Validation (1 Gate).
• Phase 5: Authorization, Implementation, and Monitoring (1 Gate).
NOTE: Appendix 2 of this AC provides a complete, step-by-step process for applying for an FRMS authorization.
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16. AC FEEDBACK FORM. For your convenience, the AC Feedback Form is the last page of this AC. Note any deficiencies found, clarifications needed, or suggested improvements regarding the contents of this AC on the Feedback Form.
/s/ for John M . Al len, Director, Flight Standards Service
Appendix 1 APPENDIX 1. REFERENCES
1. Bonnet, MH. Sleep Deprivation. In M. H. Kryger, T. Roth, & W. C. Dement (Eds.), Principles and Practice of Sleep Medicine (3rd ed). Philadelphia: Saunders; 2000:53–71.
2. Carskadon, MA, Dement, WC. Daytime Sleepiness: Quantification of a Behavioral State.
Neuroscience Biobehavioral Review 1987; 11:307–17.
3. Dinges, DF. The Nature of Sleepiness: Causes, Contexts and Consequences. In A. Stunkard & A. Baum (Eds.), Perspectives in Behavioral Medicine: Eating, Sleeping and Sex. Hillsdale, NJ; 1989: Lawrence Erlbaum.
4. Dinges, DF. Probing the Limits of Functional Capability: the Effects of Sleep Loss on Short-Duration Tasks. In R. J. Broughton & R. D. Ogilvie (Eds.), Sleep, Arousal, and Performance. Boston: Birkhauser; 1992:177–88.
5. Dinges, DF, & Kribbs, NB. Performing While Sleepy: Effects of Experimentally-Induced Sleepiness. In T. Monk (Ed.), Sleep, Sleepiness, and Performance. Chichester, UK: John Wiley and Sons, Ltd; 1991:98–128.
6. Horne, JA. Human Sleep, Sleep Loss and Behaviour: Implications for Prefrontal Cortex and Psychiatric Disorder. British Journal of Psychiatry 1993; 162:413–9.
7. Horne, JA, Reyner, LA. Sleep Related Vehicle Accidents. Br Med Journal 1985; 310:565–7.
8. Hursh, SR & Van Dongen, HPA. Fatigue and Performance Modeling. In Meir H. Kryger, Thomas Roth, William C. Dement (Ed.), Principles and Practice of Sleep Medicine, 5th edition.
Saunders; 2010 (in press).
9. Naitoh, P. Sleep Deprivation in Humans. In P. H. Venables & M. J. Christie (Eds.), Research in Psychophysiology. London: John Wiley; 1975.
10. Reason, JT. Managing the Risks of Organizational Accidents. New York: Ashgate Publishing; 1997.
11. Rosekind MR, Graeber RC, Dinges DF, Connell LJ, Rountree MS, Spinweber CL, et al.
Crew Factors in Flight Operations IX: Effects of Planned Cockpit Rest on Crew Performance and Alertness in Long-haul Operations. Moffett Field, CA: NASA Ames Research Center; 1994 Report No: DOT/FAA/92/24.
12. Van Dongen, HPA & Hursh, SR. Fatigue, Performance, Errors and Accidents. In Meir H.
Kryger, Thomas Roth, William C. Dement (Ed.), Principles and Practice of Sleep Medicine, 5th edition. Saunders; 2010 (in press).
13. Wylie CD, Shultz T, Miller JC, Mitler MM, Mackie RR. Commercial Motor Vehicle Driver Fatigue and Alertness Study: Project Report (Report No.: FHWA-MC-97-002). Washington, DC: U.S. Department of Transportation; 1996.
Appendix 2 APPENDIX 2: FATIGUE RISK MANAGEMENT SYSTEM DEVELOPMENT SECTION 1. INTRODUCTION
1. PRACTICAL APPLICATION OF A FATIGUE RISK MANAGEMENT SYSTEM (FRMS). An FRMS is as an alternative regulatory approach to providing a means of managing, monitoring, and mitigating fatigue to improve flightcrew member alertness and reduce performance errors. Under an FRMS, a certificate holder develops processes that manage and mitigate fatigue that serve as an alternate method of compliance (AMOC) to the prescriptive rule. Essentially, a certificate holder may apply an FRMS, which is an approved AMOC, to a specific limitations imposed by Title 14 of the Code of Federal Regulations (14 CFR) part 117.
However, before the certificate holder may conduct operations under a Federal Aviation Administration (FAA)-approved FRMS, the certificate holder must satisfactorily demonstrate to the FAA that their proposed FRMS satisfactorily demonstrates that the AMOC provides an equivalent level of safety to the safety standards set forth in part 117. At a minimum, the certificate holder’s proposed FRMS must include the following elements listed in part 117, § 117.7:
• A fatigue risk management (FRM) policy,
• An education and awareness training program,
• A fatigue reporting system,
• A system for monitoring flightcrew fatigue,
• An incident reporting process, and
• A performance evaluation.
2. FRMS STRUCTURE. An FRMS structure employs multilayered defensive strategies to manage fatigue-related risks, regardless of their source. It includes data-driven, ongoing adaptive processes that can identify fatigue hazards and then develop, implement, and evaluate controls and mitigation strategies. These include both organizational and personal mitigation strategies.
However, the cost and complexity of an FRMS may not be justified for operations that remain inside the flight and duty time limits and where fatigue-related risk is low. Some certificate holders, therefore, may choose to place only certain parts of their operations under an FRMS, or not to implement an FRMS at all. Nonetheless, where an FRMS is not implemented, it remains the certificate holder’s responsibility to manage fatigue-related risks through their existing safety management processes, the Fatigue Risk Management Plan (FRMP), and the prescriptive flight, duty, and rest limitations.
3. FRM AND SAFETY ASSURANCE (SA). FRM and SA are the core components of the FRMS. These core activities are governed by an FRMS policy and supported by FRMS promotion processes, and the system must be documented. The FRMS relies on the concept of an effective safety reporting culture, in which personnel have been trained and are constantly encouraged to report hazards whenever they observed them in the operating environment. To encourage the reporting of fatigue hazards by all personnel involved in an FRMS, a certificate holder must clearly distinguish between unintentional human errors, which are accepted as a normal part of human behavior and are recognized and managed within the FRMS, and deliberate violations of rules, policies, and established procedures. The certificate holder should have processes independent of the FRMS to deal with intentional noncompliance. Table 2-1,
Appendix 2 Components of Fatigue Risk Management Systems, describes the basic components of an FRMS.
TABLE 2-1. COMPONENTS OF FATIGUE RISK MANAGEMENT SYSTEMS.
Components Elements Fatigue Risk Management System (FRMS) policy and documentation
Fatigue risk management (FRM) processes • Identification of hazards
• Risk assessment
• Risk mitigation Safety Assurance (SA) processes • FRMS performance monitoring
• Management of operational and organizational change
• Continuous FRMS improvement FRMS promotion processes • Training programs
• FRMS communication plan
4. THE ADVANTAGE OF FRMS. Since an FAA-approved FRMS is applied to exceed a specific limitation, the potential exposure to a fatigue-related event must be mitigated, managed, and monitored. Typically, accidents and incidents result from interactions between organizational processes (i.e., workplace conditions that lead crewmembers to commit active failures) and latent conditions that can penetrate current defenses and have adverse effects on safety. The FRMS approach is designed to apply fatigue science and safety management. It is intended to provide an equivalent, or enhanced, level of safety, while also offering greater operational flexibility to that provided by the prescriptive limitation(s).
5. PERFORMANCE-BASED APPROACH. Essentially, an FRMS represents a performancebased regulatory approach. This means that the FRMS defines the requirements and processes required for certificate holders to measure, manage, mitigate, and monitor potential fatigue risk associated with the operation for which the FRMS is applied. Data collection and analysis are vital in determining the flightcrew members’ level of performance during that operation proposed by the certificate holder. The FRMS requirements and processes are derived from the data collection and analysis output. Applying the FRM and SA components, the FRMS requirements and processes are measured, managed, and monitored for continuous improvement of the FRMS.
6. FRMS LIMITATIONS AND CONDITIONS. The certificate holder’s FAA-approved FRMS authorization will be based on analyzed and validated data applicable to the specific limitation to be exceeded under the FRMS. Therefore, the FAA will impose specific limitations and conditions applicable to the FRMS authorization. While conducting operations under an FRMS authorization, the certificate holder must comply with these limitations and conditions along with their FAA-approved FRMS processes and procedures.
Appendix 2
7. FRMS COMPLEXITY. The complexity of the FRMS structure will vary according to:
• The size of the organization;
• The scope of the FRMS;
• The type of operations where the FRMS will be applied;
• The type and complexity of the operations being managed;
• The relative maturity of the FRMS; and
• The relative importance of the fatigue hazards governed by the FRMS.
Appendix 2 SECTION 2. FRMS POLICY AND DOCUMENTATION
1. OVERVIEW OF FRMS POLICY AND DOCUMENTATION. The FRMS policy and documentation are instrumental in defining the organizational measures to support the core operational activities of the FRMS. While FRMS policy specifies the certificate holder’s commitment and approach to the management of fatigue risk, it should be noted that the certificate holder must clearly define all elements of their FRMS policy. The certificate holder’s FRMS policy must be distinguishable from the general safety policy to allow for a separate review. FRMS documentation describes the components and elements of the entire FRMS.
Additionally, the use of FRMS documentation makes it possible to audit the effectiveness of the FRMS (internally and externally) to verify that it is meeting the safety objectives defined in the FRMS policy.
2. FRMS DOCUMENTATION. The FRMS documentation describes all the elements of the FRMS and provides a record of FRMS activities and any changes to the FRMS. The documentation can be centralized in an FRMS manual. However, it needs to be accessible to all personnel who may need to refer to it and to the FAA for auditing purposes. The current edition of ICAO Annex 6, Part I, Appendix 7 requires that the certificate holder shall develop and keep current FRMS documentation that describes and records:
• FRMS policy and objectives;
• FRMS processes and procedures;
• Accountabilities, responsibilities and authorities for these processes and procedures;
• Mechanisms for ongoing involvement of management, flight and cabin crewmembers, and all other involved personnel;
• FRMS training programs, training requirements, and attendance records;
• Scheduled and actual flight times, duty periods, and rest periods with significant deviations and reasons for deviations noted; and
• FRMS outputs including findings from collected data, recommendations, and actions taken.
3. FATIGUE SAFETY ACTION GROUP (FSAG). As a way of meeting the ICAO requirements described in paragraph 2, it is expected that a certificate holder establish a functional group that is responsible for coordinating the fatigue management activities within the organization.
a. FSAG Role. This task should be the responsibility of the FSAG. The FSAG is a group comprised of representatives of all stakeholder groups (e.g., management, scheduling, and crewmembers) together with specialist scientific, data analysis, and medical expertise, as required), that is responsible for coordinating all fatigue management activities in the organization. The principle functions of the FSAG are to:
(1) Develop and maintain the FRMS documentation;
(2) Manage the FRM processes;
(3) Contribute to the FRMS SA processes;
Appendix 2
(4) Be responsible for the FRMS promotion processes; and
(5) Maintain the required documentation.
b. FSAG Composition. The composition of the FSAG should reflect the shared responsibility of individuals and management by including representatives of all stakeholder groups (management, scheduling staff, and crewmembers and/or their representatives) and other individuals as needed to ensure that it has appropriate access to scientific and medical expertise.
c. FSAG Scalability. The size and composition of the FSAG will vary for different certificate holders, but should be related to the size and complexity of the operations covered by the FRMS, and to the level of fatigue risk in those operations. Figure 2-1, Midsize and Large Air Carriers, illustrates midsize and large air carrier operations and Figure 2-2, Small Air Carriers, depicts operations for a small air carrier. In small certificate holders, a single individual may represent more than one stakeholder group; for example, the chief pilot may also be the primary scheduler. In very small operations, there may not even be a designated FSAG, but simply extra items on the safety meeting’s agenda, as long as long as all FRM activities are documented. Larger airlines will have specialized departments that interact with the FSAG.
While the FAA may wish to observe FSAG meetings as part of its oversight activities, the FAA is not a required part of this group. However, the FAA may also wish to review the minutes and outputs of such meetings as part of their continuous oversight activities.
4. FRMS SCOPE. Within the FRMS manual, the certificate holder must identify the scope of the FRMS operations for which the FRMS is applied to their operations. Otherwise, all operations not covered by the FRMS must operate under the applicable prescriptive flight time, duty time, and rest limits. A certificate holder may choose to apply the FRMS to all its operations, or only to specific types of its operations (e.g., a particular fleet, a particular route, or only ultra-long-range (ULR) operations). Because the policy statement is typically short, it does not have to detail the scope of the operations to which the FRMS applies; however, the policy statement must identify where the scope of FRMS operations is detailed. As a certificate holder’s familiarity and experience with the FRMS builds, they may wish to expand the scope of the FRMS.
5. FRMS POLICY. The FRMS policy provides the umbrella under which the FRMS operates.
Within the FRMS policy, the certificate holder shall clearly define all elements of the FRMS.
The FRMS policy shall also require that the scope of the certificate holder’s FRMS operations be clearly defined in their FRMS manual.
a. Minimum Requirements. The FRMS policy must identify and address the minimum requirements of the FRMS, which are essentially the prerequisites of an FRMS. As with prescriptive flight and duty limitations, the management of fatigue-related risks associated with the FRMS is a joint responsibility between the certificate holder and individual crewmembers due to the particular nature of fatigue. The FRMS policy specifies the certificate holder’s commitment and approach to the management of fatigue risk. It is the responsibility of the certificate holder to clearly define all elements of the FRMS in its policy. Additionally, the certificate holder’s FRMS policy must be able to be distinguished from the general safety and operational policy to allow separate review. Minimum requirements for the FRMS policy shall:
Appendix 2
(1) Reflect the joint responsibility among the certificate holder’s management, flight and cabin crews, and other involved personnel;
(2) Clearly state the safety objectives of the FRMS;
(3) Be signed by the accountable executive of the organization;
(4) Be communicated, with visible endorsement, to all the relevant areas and levels of the organization;
(5) Declare management’s commitment to effective safety reporting;
(6) Declare management’s commitment to providing adequate resources for the FRMS;
(7) Declare management’s commitment to continuous improvement of the FRMS;
(8) Require that clear lines of accountability for management, flight and cabin crews, and all other involved personnel are identified; and
(9) Require periodic reviews of the FRMS policy to ensure that it remains applicable and appropriate.
b. Responsibility of Crewmembers. Fatigue is affected by all waking activities, not only work demands, sometimes described as “day-to-day life issues.” For example, crewmembers have personal responsibility because they can choose the amount of time they spend trying to sleep during available rest breaks, and choose when to use personal fatigue mitigation strategies.
They have a responsibility to use rest periods effectively to be properly rested and fit for duty.
Ultimately, as required in § 117.5(d), it is the responsibility of the flightcrew member to affirmatively state on the dispatch or flight release, prior to commencing a flight segment, that they are fit for duty. To that point, it is imperative that the flightcrew member obtain the proper amount of rest to safely perform their assigned duties during that flight. In addition, their cooperation is vital for voluntary reporting of fatigue hazards, and when fatigue levels need to be measured for FRM processes and FRMS SA processes. Crewmembers’ willingness to cooperate will depend on their confidence that the certificate holder is committed to promoting a “just” culture an effective safety reporting culture.
c. Responsibility of Management. Management is primarily responsible for the management and mitigation of fatigue risk because it schedules the work activities of personnel and the distribution of resources in the organization. The FRMS is an organizational system that enables management to meet that responsibility. The accountable executive, when signing the FRMS policy, accepts accountability for the FRMS, either directly or through supervision and management of others, including those to whom the accountable executive has delegated this responsibility. The safety objectives in the FRMS policy must specify what the certificate holder wants the FRMS to achieve. To track whether the FRMS is meeting these objectives, its performance needs to be monitored. The FRMS policy needs to be reviewed periodically by the certificate holder to ensure that it is adequate to meet changing operational demands. In addition, it will be subject to periodic review by the FAA.