AC 120-103A

AdvisoryU.S. Department of Transportation Federal Aviation Administration Circular Subject: Fatigue Risk Management Systems Date: 5/6/13 AC No: 120-103A for Aviation Safety Initiated by: AFS-220 Change:

1. PURPOSE.

a. Contents. This advisory circular (AC):

(1) Describes the basic concepts of Fatigue Risk Management Systems (FRMS), as prescribed in Title 14 of the Code of Federal Regulations (14 CFR) part 117, § 117.7, and how they relate to aviation industry employees safely performing their duties.

(2) Provides information on the components of an FRMS as applied to aviation, and on how to implement an FRMS within an aviation operation.

(3) Defines an FRMS as an operator-specific process; therefore, while all FRMSs will have common elements, the specifics will be tailored to a certificate holder’s particular conditions.

(4) Provides (in Appendix 2, Fatigue Risk Management System Development) the certificate holder with the necessary detailed guidance to prepare for the FRMS approval process, develop the required documentation, develop and apply fatigue risk management (FRM) and Safety Assurance (SA) processes, collect and analyze data, develop flightcrew FRMS operations procedures and a step-by-step process required for Federal Aviation Administration (FAA) evaluation and validation of the proposed FRMS application.

b. Parts of an FRMS. This AC describes the essential processes and elements for an effective FRMS.

c. Not Mandatory. This AC is not mandatory and does not constitute a regulation.

However, this AC provides an acceptable method for developing an FRMS application.

2. CANCELLATION. This AC cancels AC 120-103, Fatigue Risk Management Systems for Aviation Safety, dated August 3, 2010.

3. INTRODUCTION TO FRMS. An FRMS is an optional approach to prescriptive regulations. A certificate holder seeking to exceed a limitation in part 117 or in 14 CFR part 121 subparts Q, R, or S, would do so under an FAA authorization. An FRMS is largely developed as an alternative method of compliance (AMOC) to prescriptive limitations based upon objective performance standards. A certificate holder may be authorized to apply an FRMS to any part or all of its operation, provided that the certificate holder demonstrates an effective AMOC that

meets or exceeds the safety standards afforded by the prescriptive limitations. Unlike a Fatigue Risk Management Plan (FRMP) that is required for each certificate holder conducting operations under part 121, the FRMS is an AMOC to prescriptive limitations that the certificate holder may implement for fatigue management and mitigation.

4. WHAT IS AN FRMS? An FRMS is a management system for a certificate holder to use to mitigate the effects of fatigue in its particular operations. An FRMS is a data-driven system, based largely upon scientific principles and operational knowledge, that allows for continuous monitoring and management of safety risks associated with fatigue-related error. An FRMS is a fatigue mitigation tool that minimizes the acute and chronic sources of fatigue and manages the potential risks associated with fatigue. The FRMS is part of a repetitive performance improvement process that leads to continuous safety enhancements by identifying and addressing fatigue factors across time and changing physiological and operational circumstances. The objective of the FRMS is to manage, monitor, and mitigate the effects of fatigue to improve flightcrew member alertness and reduce performance errors.

5. CREWMEMBER ALERTNESS AND PERFORMANCE. A certificate holder’s FRMS will be designed to demonstrate that flightcrew members are sufficiently alert so they can operate to a satisfactory level of performance. Additionally, the FRMS should be designed to achieve a realistic balance between safety and productivity. It should proactively identify opportunities to improve operational processes and reduce risk, as well as to identify deficiencies after adverse events or reports of excessive fatigue.

6. DEFINITIONS.

a. Acute Fatigue. Acute fatigue is closely related to recent sleep (i.e., sleep within the last 24 hours), time since last sleep, and current time of day. Less than 8 hours of sleep in the last 24 hours, being awake longer than 17 hours, and working between midnight and 0600 are associated with acute fatigue in the average person.

b. Biomarkers. Biomarkers are characteristic biological properties that can be detected and measured in the body, such as in the blood or tissue. Biomarkers may indicate either normal, abnormal, or diseased processes in the body. Currently, there are no easily obtainable biomarkers of fatigue. However, several biomarkers of the circadian rhythm exist, such as core body temperature and melatonin levels. In the absence of biomarkers to identify fatigue, we can measure fatigue effects directly, in performance variables, or indirectly, by using measures of sleep and time of day and by modeling the effects of these conditions on performance.

c. Chronic Fatigue. The average person needs about 8 hours of sleep per day. If the average person gets less than the required amount of sleep each day for multiple days, then a state of chronic fatigue can occur. With chronic fatigue, performance is degraded and recovery tends to be relatively slow. A person can hasten recovery by attempting to sleep longer than the normal amount for several days.

d. Circadian Fatigue. Circadian fatigue refers to the reduced performance during nighttime hours, particularly during an individual’s Window of Circadian Low (WOCL) (typically between 0200 and 0600 hours).

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e. Circadian Rhythm. In humans, the circadian rhythm is a daily alteration in a person’s behavior and physiology. These behavioral and physiological alterations are controlled by an internal biological clock located in the brain (i.e., the circadian clock). Examples of circadian rhythms include body temperature, melatonin levels, cognitive performance, alertness levels, and sleep patterns.

f. Cumulative Fatigue. Cumulative fatigue is fatigue brought on by repeated mild sleep restriction or extended hours awake across a series of days.

g. Fatigue. Fatigue is a complex state characterized by a lack of alertness and reduced mental and physical performance, often accompanied by drowsiness. Fatigue is objectively observed as changes in many aspects of performance, including increased reaction time, lapses in attention (e.g., reaction times greater than 500 milliseconds), reduced speed of cognitive tasks, reduced situational awareness, and reduced motivation. A person’s perceived fatigue levels are often lower than observed decrements in performance.

h. Fatigue Risk Management System (FRMS). A management system that certificate holders may use to mitigate the effects of fatigue in their operations where the FRMS is applied. Specifically, an FRMS is the method by which a certificate holder may exceed a flightcrew member flight, duty, or rest limitation, provided the FRMS demonstrates an AMOC and is approved by the FAA. Essentially, an FRMS is a nonprescriptive fatigue mitigation tool.

i. Transient Fatigue. Transient fatigue is acute fatigue brought on by extreme sleep restriction or extended hours awake within 1 or 2 days.

j. Window of Circadian Low (WOCL). Individuals living on a regular 24-hour routine with sleep at night have two periods of maximum sleepiness, also known as WOCLs. One WOCL occurs at night, roughly from 0200 to 0600, a time when physiological sleepiness is greatest and performance capabilities are lowest. The other WOCL is in the afternoon, roughly from 1500 to 1700, and is less severe than the nighttime WOCL.

7. RELATED READING MATERIAL (current editions).

 Proceedings of the “Aviation Fatigue Management Symposium: Partnerships for Solutions,” June 17-19, 2008.

 AC 120-100, Basics of Aviation Fatigue.

 International Civil Aviation Organization (ICAO) Fatigue Risk Management Systems Implementation Guide for Operators.

 ICAO Document 9966, FRMS Manual for Regulators.

 Mahon, G. & Cross, T. The Fatigue Management Program: Alternatives to Prescription.

Queensland Transport: Queensland, Australia, 1999.

 Mallis M.M., Banks S., & Dinges D.F. Aircrew fatigue, sleep need and circadian rhythmicity (Chapter). In Elsevier, E. Salas, T. Allard, & D. Maurino, (Eds), Human Factors in Aviation (2nd edition), in press; 2010.

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8. BACKGROUND.

a. Causes of Fatigue. Generally speaking, the main causes of fatigue in aviation are:

 Amount, timing, and quality of sleep each day (sleep/wake schedule),

 Amount of time since last sleep period (continuous hours awake),  Time of day (circadian rhythm),  Operations through multiple time zones, and

 Workload and time on task.

b. Fatigue Management. The traditional ways to manage fatigue associated with aviation operations have been prescriptive flight and duty time limitations and rest requirements.

Conventional regulations following this model reduce, but do not eliminate, the conditions that contribute to fatigue. They are primarily based on “time on task” theories and on the assumption that fatigue accumulates in a linear manner. Conventional regulations on fatigue management do not consider the interactions of sleep loss and circadian rhythms. Additionally, conventional regulations cannot address operational complexities on a case-by-case basis.

9. THE FRMS CONCEPT. An FRMS consists of organizational processes and procedures to control fatigue risk in aviation operations. An FRMS is a data-driven and scientifically based process that allows for continuous monitoring and management of safety risks associated with fatigue-related error. It is part of a repeating performance improvement process. This process leads to continuous safety enhancements, by identifying and addressing fatigue factors across time and changing physiological and operational circumstances. Structurally, an FRMS is composed of processes and procedures for measuring, modeling, managing, mitigating, and reassessing fatigue risk in a specific operational setting. An FRMS is an effective fatigue mitigation strategy when the organization bases it on valid scientific principles. An FRMS combines schedule assessment, operational data collection, continuous and systematic analysis, and both proactive and reactive fatigue mitigations, guided by information provided by scientific studies of fatigue. Overall, an FRMS offers a way to more safely conduct flights by offering flexibility not available within regulatory limits. An FRMS complements prescriptive flight time, duty time, and rest period requirements.

a. Operational Demands. An FRMS addresses the complexity of operational demands and the inherent fatigue-related challenges associated with aviation operations. The FRMS approach is to apply risk management (RM) techniques to identify and reduce the risk of fatigue relevant to specific operational circumstances. An FRMS aims to ensure high levels of alertness in personnel to maintain acceptable levels of performance and safety.

b. Adaptability. An FRMS provides an interactive and collaborative approach to operation performance and safety levels on a case-by-case basis. Therefore, an FRMS permits a certificate holder to adapt policies, procedures, and practices to the specific conditions that create fatigue in a particular aviation operation. Certificate holders may tailor their FRMSs to unique operational demands and focus on mitigations of fatigue that are practical within the specific operational environment.

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c. Assessment. An FRMS relies on assessments to project and confirm the fatigue effects of an operation on crewmember sleep and alertness. This permits continuous assessment of fatigue levels associated with ever-changing operational conditions. The common tool for this assessment is a biomathematical model of fatigue and alertness levels.

d. Risk Management Process (RMP). The FRMS applies the RMP to identify fatigue risks through the use of data-driven systems. An FRMS includes documented processes for collecting and analyzing fatigue-related safety data and implementing corrective actions, always allowing for continuous improvement. A “just” or “safety” culture is integral to a successful FRMS, and it requires a shared responsibility among all levels of the organization, as well as the involvement of regulatory agencies.

10. TOOLS FOR AN EFFECTIVE FRMS. There are four basic tools for an FRMS to be effective. These basic tools are fatigue-related data, fatigue analysis methods, identification and management of fatigue drivers, and application of fatigue mitigation procedures.

a. Fatigue-Related Data. An effective FRMS is data-driven, meaning that it relies on the use of reports, studies, etc., rather than on speculation. An FRMS is based on scientific principles and involves continuous monitoring. Fatigue effects on performance and safety have been documented and are well recognized (Bonnet, 2000; Carskadon and Dement, 1987; Dinges, 1992; Dinges and Kribbs, 1991; Horne, 1993; Naitoh, 1975). It is difficult to detect fatigue in operational settings because there are no biomarkers for fatigue or simple tests of how an individual will respond to sleep loss. However, the environmental conditions that promote fatigue are well known and continue to contribute to performance deficits during operations. The challenge is that aviation operators cannot totally eliminate fatigue from 24/7 aviation operations, so certificate holders need to apply proactive and adaptive mitigation for fatigue.

Managing fatigue risk depends on two types of operational evidence available to certificate holders:

(1) The duty schedule directly affects crewmembers’ opportunities to obtain restorative recovery sleep. Monitoring work schedules provides indirect evidence of potential fatigue resulting from inadequate or poorly timed opportunities to obtain sleep.

(2) A nonpunitive reporting system permits crewmembers and other employees to report subjective fatigue and, from time to time, request relief from duties because of chronic fatigue.

These reports contain valuable data, especially when coupled with information about the conditions that contributed to fatigue, such as the work schedule for the week prior to the report.

Subjective reports of fatigue can underestimate the true extent of performance impairment, especially when an individual is already suffering from acute or chronic fatigue due to sleep loss or circadian disruption (Dinges, 1989; Horne, 1985; Rosekind et al., 1994; Wylie et al., 1996).

Therefore, data on procedural errors and flight exceedances, Aviation Safety Action Program (ASAP) or Aviation Safety Reporting System (ASRS) reports, and flight operations quality assurance (FOQA) data may help a certificate holder to objectively document fatigue.

Certificate holders may couple data sources with scheduling information or other event data reported by crewmembers that implicate the potential for fatigue (e.g., flight delays and irregular operations). A nonpunitive reporting system is essential to encouraging the reporting of fatiguerelated events as part of the overall safety system.

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b. Fatigue Analysis Methods. An FRMS should be part of the overall risk identification and management approach that employs both proactive and reactive processes to monitor, manage, and mitigate operational risk. Certificate holders can use commercially available computer models to assess average performance capability from sleep/wake history, placement within the circadian cycle, and duty schedule information (Hursh and Van Dongen, 2010).

Certificate holders can embed models within the FRMS process to help themselves to understand the likely effects on individual performance of sleep obtained before and during trip patterns.

Using these models (although it is not required) incorporates the latest scientific research on human circadian systems, sleep, and performance capability, and can be useful for rapidly estimating fatigue levels associated with proposed new routes or schedule changes. However, certain assumptions and limitations need to be taken into account. Models are not a substitute for a comprehensive FRMS; they are one useful component of an FRMS.

(1) Retrospective (Reactive) Processes for Oversight of Schedules. Certificate holders can use a science-based fatigue model to assess the estimated fatigue levels associated with current or past schedules and determine which schedules are more vulnerable to increased fatigue levels and reductions in performance. First, certificate holders identify those schedules (both trip sequences and monthly pilot schedules) that have been associated with the greatest levels of fatigue. Next, certificate holders can derive the fatigue factors present and examine the potential for schedule changes to reduce fatigue. Such changes might include additional layover days, additional recovery days, augmented crews to permit in-flight sleep opportunities, or rescheduled block times to avoid critical tasks at times during or near the WOCL.

(2) Prospective (Proactive) Processes for Oversight of Schedules. Certificate holders also can assess proposed schedules for potential fatigue impact by using the method described above. Trip sequences that have been identified as leading to acute and chronic fatigue can be removed or modified to prevent the accumulation of fatigue across a bid schedule. For scheduled operations, rules may be embedded into the schedule creation process to avoid those conditions that, according to the fatigue model, could lead to excessive fatigue risk.

(3) Identification and Management of Aviation Fatigue Drivers. Many operational drivers of fatigue occur in any aviation environment. Some of the common factors that certificate holders must manage to minimize fatigue risk in aviation operations are:

 Crew flight and duty periods, and rest breaks to reduce fatigue;

 Additional duties assigned to flightcrews that further reduce sleep opportunities;

 Schedule changes that extend duties beyond the published schedule;

 The duration and timing of layovers between successive flight segments;

 Recovery days, following a trip, that permit sufficient sleep to eliminate any accumulated sleep debt prior to scheduling or performing additional flight duties;

and  Optimal utilization of available rest opportunities.

c. Application of Fatigue Mitigation Procedures. An FRMS is part of a process that requires shared responsibility among management and flight/cabin crewmembers and builds on feedback and nonpunitive reporting within a “just culture.” Developing mitigation strategies and schedule adjustments should be part of a collaborative management process that includes all the Page 6 Par 10

stakeholders, such as crew schedulers, marketing, safety, and employee representatives.

An FRMS should employ multiple layers of defense to prevent fatigue and fatigue-induced errors from progressing to a level that enables incidents or accidents. Based on an analysis of the factors that lead to fatigue and practical mitigation alternatives, one or more of these mitigations may be applied to reduce fatigue associated with specific schedules or situations. The primary levels of defense and mitigations are:

(1) Viewed together, the flight duty schedule, additional tasks assigned to crewmembers, and schedule change provide recovery sleep opportunities. It may be necessary to adjust scheduling rules to reduce the occurrence of identified fatigue drivers.

(2) Maximizing use of available sleep opportunities reduces cumulative fatigue. This level of defense is largely the responsibility of the crewmember. Comprehensive fatigue training, adequate crew rest facilities at non-domicile locations, and efficient transportation to rest facilities aid crewmembers in fulfilling their responsibility.

(3) Implementing error detection and corrective processes can prevent operational consequences of fatigue. Crew Resource Management (CRM) is a recognized and widely used process to encourage crewmembers to work together to detect and prevent operational errors.

(4) Conducting comprehensive and objective accident, incident, and error analyses can help in determining when fatigue has been a potential contributing factor, so that those conditions can be avoided in the future.

11. COMPONENTS OF AN FRMS. An FRMS is more than a collection of tools, it is a management process built on organizational policies and procedures that implement a systems approach to fatigue management. A “systems approach” means that FRMS is an integrated network of people and other resources performing activities designed to minimize fatigue in the operational environment. This network of people addressing potential fatigue uses the four basic tools described in paragraph 9. Below is a list of the six organizational components of the FRMS, as required under § 117.7. They will vary in complexity based on the size and diversity of the operational environment.

a. FRMS Policy. The first required component, as prescribed in § 117.7(b)(1), is an FRMS policy. The FRMS policy will be part of the overall fatigue management policy of the corporation. This policy defines the following:

(1) The organizational structure and composition of the FRMS in terms of people and job functions. This group may include individuals responsible for crew scheduling, operational safety, human resources, marketing, training, labor relations, and human factors research and analysis.

(2) At a minimum, scheduling policies assure that the organization adheres to all applicable FAA flight and duty time regulations. Beyond that minimum, the organization may develop additional scheduling constraints and rules that have proven to be useful in preventing fatigue under certain situations. Some of these limits and constraints may be formulated during collective bargaining agreements with labor organizations.

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(3) Individuals are expected to report fit for duty. In the case of fatigue, employees are expected to report for duty sufficiently well rested to be able to safely perform the duties of the job. Likewise, it is the responsibility of the individual to alert the organization when her or she is not sufficiently rested to perform safely, and the organization must have a policy for replacing that person with someone who is well rested. The “absent for fatigue” policy must be designed to ensure that the individual reporting fatigued is not coerced into performing duties.

(4) Fatigue is a complex topic. All crewmembers should have adequate training to understand the causes of fatigue, how an individual can maximize the benefits of rest opportunities, the use of various countermeasures to minimize the effects of fatigue, and the overall responsibilities of the individual to report for duty fit to safely perform duties.

(5) Policies should define mechanisms for reporting errors and events related to fatigue, including policies that define a nonpunitive fatigue reporting system (refer to “Just Culture;”

Reason, 1997).

(6) Depending on the size and complexity of the organization, this policy will define various methods utilized to collect objective data on fatigue and the effects of fatigue on performance.

(7) The overall FRMS is a Continual Improvement Process (CIP). This requires a set of policies that define how the data on fatigue are subsequently utilized to further improve the management of fatigue. In other words, these are procedures by which the system is self-corrective and adaptive to changing conditions that may cause fatigue.

(8) Policies should define manager and employee responsibilities relative to managing fatigue, both on the job and between assignments, including policies providing adequate rest opportunities between assignments and requiring individuals to report fit for duty (i.e., well rested).

b. Education and Awareness Training Program (§ 117.7(b)(2)). Comprehensive education and awareness training programs applicable to the certificate holder’s FRMS are essential in providing a foundation and understanding for managing and mitigating fatigue associated with operations where the FRMS authorization is applied. The certificate holder should develop their education and training program to focus on the specifics of the FRMS authorization and applicable flightcrew FRMS operation procedures. Each FRMS authorization will be different; therefore, the education and awareness training program for that FRMS will be specific to that FRMS authorization. If the certificate holder is issued multiple FRMS authorizations, the certificate holder should identify the training items associated with that authorization. For specific guidance in developing an education and awareness training program refer to Appendix 2, Section 3.

c. Fatigue Analysis and Reporting System (§ 117.7(b)(3)).

(1) This component defines the processes needed to detect, report, and investigate cases of fatigue risk from internal and external sources. It includes objective operational data and methods that enable the certificate holder to develop and evaluate reactive and proactive methods to reduce and manage fatigue risk, including:

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 Trip scheduling,  Crew scheduling (rostering), and  Rest periods.

(2) There are analysis methods, such as biomathematical models of fatigue, which can be used to evaluate the fatigue implications of specific city pairs or trips and monthly pilot schedules. This system includes two components: an analysis of the risk of fatigue associated with the trip/schedule and an analysis of the potential consequences of that fatigue risk. Based on this risk and consequence analysis, proactive corrective action can be taken to mitigate the risk.

In addition, the fatigue reporting system may suggest that certain schedules are causing fatigue, and corrective steps can be taken to analyze the source of the fatigue and prevent a similar set of circumstances in the future.

d. Monitoring Fatigue in Flight and Cabin Crew (§ 117.7(b)(4)). Conceptually, this is similar to the fatigue analysis and reporting system component, but this component focuses on individual crewmember reports of fatigue. These reports provide feedback to the certificate holder about conditions perceived to contribute to fatigue.

(1) To maximize the utility of such reports, procedures must be arranged to capture all relevant information, such as the schedule leading up to the fatigue report, the actions of the employee to obtain rest, subjective and objective evidence of fatigue, environmental conditions that may have exaggerated or contributed to fatigue, relevant health or medical conditions, specific actions (commissions and/or omissions) related to the incident, and communications prior to and during the event. Corporate policy must provide protection of privacy and methods to protect the employee from adverse actions that would discourage reports of fatigue.

(2) Technologies developed to monitor sleep and performance in crewmembers can be used to supplement self-reports of fatigue. While it may not be practical to apply these technologies continuously, periodic studies of actual sleep (using actigraphs or logbooks) and fatigue (using performance measures and subjective ratings) can be highly valuable for objectively measuring the extent of fatigue across different kinds of operations and isolating key fatigue drivers (Hursh and Van Dongen, 2010). The certificate holder can use the results of these assessments to inform the analysis and forecasting functions of the FRMS to better assess potential fatigue in future operations (e.g., in a proposed new schedule).

e. Incident Reporting Process (§ 117.7(b)(5)). Reports of adverse events that may be attributable wholly or in part to fatigue are similar to crew reports, and can serve as a mechanism for obtaining all relevant information regarding fatigue contributions to the incident. Ideally, corporate policy would define how an adverse event is evaluated for potential fatigue involvement and also define a methodology for conducting a detailed Root Cause Analysis (RCA). Details of RCAs are available elsewhere (refer to the current edition of AC 120-59, Air Carrier Internal Evaluation Programs) but at a minimum, the incident investigation and reporting process must obtain all the necessary information to trace the root cause of the incident, especially the potential level of fatigue and the conditions that contributed to the fatigue-related event. The FRMS policy must provide for protection of privacy and methods to protect the employee from adverse actions that would discourage reporting events and conditions surrounding the events.

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f. Performance Evaluation (§ 117.7(b)(6)). An FRMS is a self-correcting process that includes evaluating the results of prior monitoring, analysis, training, and mitigation. Policies and procedures, based on the evaluation of results and the effectiveness of the FRMS in reducing fatigue, provide feedback to the system for continuous performance improvement.

(1) The CIP includes the following:

 A system for evaluating and reporting the effectiveness of the FRMS, including reporting that is available to the regulator.

 A process whereby the results of evaluations provide guidance to the FRMS program for self-correction and improvement.

 A system for periodic independent review of the FRMS for its effectiveness in managing fatigue-related risk.

(2) While not required, it may be desirable to have a process for capturing economic benefits and costs of the program.

12. THE CONTINUOUS FRMS PROCESS. This paragraph reviews four steps that comprise a typical continuous FRMS process (refer to Figure 1, Fatigue Risk Management System Process).

Calling an FRMS a “process” means that it consists of a series of actions that build on corporate policies, organizations, and procedures. An FRMS is not just a written set of rules, but a living system that envisions certificate holders detecting and adapting to fatigue impact on their operation and employees carrying out specific actions that implement the policies and procedures within an established organization. The specific actions that comprise the FRMS process break down into four general steps that repeat, leading to continuous performance improvement and reductions in fatigue-related risk. Each step in the process relies on one or more of the fatigue management tools.

FIGURE 1. THE FATIGUE RISK MANAGEMENT SYSTEM PROCESS The FRMS Process

a. Measure and Assess Current Conditions

b. Modeling and Analysis of Fatigue Risk

c. Manage and Mitigate Fatigue Risk

d. Assessment and Feedback

a. Measurement and Assessment of Current Conditions. The first step is to measure and assess the level of fatigue risk associated with current schedules and operations by collecting Page 10 Par 11

information on crewmember reports of fatigue or fatigue-related errors and incidents, and information on the schedules that led up to these reported fatigue-related errors and incidents.

Understanding the current conditions within the organization is critical for the development of a valid mitigation plan.

b. Modeling and Analysis. This second step helps to determine the root cause of fatigue by modeling the work schedules and analyzing fatigue risk associated with them. This step is crucial to the process because it uses scientific principles about fatigue, perhaps aided by computer modeling, to find the specific operational and crewmember factors that could contribute to significant performance changes due to fatigue (Hursh and Van Dongen, 2010). Managing and mitigating fatigue depends on this step because fatigue risk needs to be measured and connected to the conditions (fatigue drivers) that contribute to the risk. Analysis of the fatigue risk can be broken down into two components: likelihood of occurrence of a particular level of fatigue and the severity of the consequence of fatigue, should it occur (Van Dongen and Hursh, 2010). For example, flight time that occurs between midnight and 0600 will inevitably include the period identified as the WOCL. This low point in performance should be evaluated in relation to the duties to be performed at that time; an expected raised level of fatigue is of greater concern if it coincides with critical flight maneuvers.

c. Management and Mitigation of the Fatigue Risk. This third step is based on the measurement and analysis of the fatigue-causing conditions. It requires explicit and regular management activity to consider the information from the first two steps and engage all the stakeholders in a collaborative process to develop solutions to address the fatigue-causing factors.

d. Assessment and Feedback. The fourth step in the process is collection of evidence of success in the form of improved schedules, additional sleep opportunities, enhanced training, and revised policies combined with objective data that demonstrate that these changes have effectively reduced fatigue. Evidence of reduced fatigue includes fewer reports of fatigue and/or errors due to fatigue, evidence of increased sleep, or modeling of schedules that predicts improved performance and reductions in fatigue related risk. This step is important and essential for continuous process improvement. Some measures may not prove to be as effective in reducing fatigue as anticipated, leading to a need for further adjustments. Additionally, changes in schedules, turnover in the workforce, added demands for service, and the addition of new routes can lead to emerging pressures that contribute to increased fatigue risk. This step allows for further adjustments to improve current operations and correct for changes in future operations.

13. ROLES AND RESPONSIBILITIES. This paragraph describes the general roles and responsibilities of the three primary stakeholders in the FRMS process: the certificate holder, the employees, and the FAA. The stakeholders should regard the roles and responsibilities described here as a starting point. These general roles and responsibilities are not an exhaustive description of the various actions to be taken by each group during the development and execution of the FRMS. Many of the details left to be defined depend on the specifics of each operation.

a. Certificate Holder. For the certificate holder, there are five general responsibilities:

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(1) Initial Commitment. The certificate holder is responsible for taking the initiative to develop, document, and implement the scientifically based FRMS. First, the organization must understand what developing an FRMS entails and must garner the commitment of its leadership to support the process. Second, the organization must be willing to commit the resources of time and money to assign individuals in the organization to develop and sustain the FRMS.

(2) Assign FRMS Team. Once the certificate holder identifies a team to develop the FRMS, the certificate holder is responsible for tasking the team to develop policies, training, data acquisition processes, analysis methods, and management procedures to implement, audit, and guide the FRMS process.

(3) Commitment of Resources. An FRMS is not a one-time activity; an FRMS is a living system that requires a continuing commitment of resources to support the effectiveness and progressive improvement of the process. The size of the resource commitment will depend on the size and complexity of the operation, but it does not end once the certificate holder establishes the FRMS.

(4) Collaboration. An effective FRMS is a collaborative process that involves all the stakeholders in discussion and joint action to be successful. It is the certificate holder’s responsibility to provide the mechanisms for collaboration/consultation among managers, employees, and the regulator. The certificate holder is responsible for creating a “just culture” where managers and employees can share information about fatigue without threat of reprisal or disciplinary action. In keeping with the responsibility of each crewmember to only accept duty when he or she is adequately rested to safely perform his or her duties, it is the responsibility of the organization to develop a nonpunitive policy for responding to legitimate reports of fatigue and providing reserves to replace fatigue-impaired crewmembers.

(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.

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