13 cases, medical treatment. These interventions are described in detail in the following paragraphs.
8.1 HOS Limits. In the United States, the only regulatory HOS limit that currently applies to aviation maintenance is § 121.377. HOS limits are also instituted by non-government agencies (including airlines, certified repair stations (CRS) and other maintenance, repair, and overall companies). These limits are primarily used to restrict the length of duty days as well as provide designated sleep or break opportunities to reduce fatigue.
8.2 Scientific Scheduling Models. In recent years, software modelling systems have been incorporated into many FRMS. Software models have advantages over HOS limits as they can take into account circadian variations in alertness and sleep obtained to produce an estimate of the fatigue level that may result from a particular shift pattern. When used as scheduling tools, software models have the advantage of offering greater flexibility than hard HOS limits. However, they can also be implemented in conjunction with hard limits. To utilize scheduling models, the user inputs an employee’s work and break times over a 7-day period. The system then produces fatigue scores which express the level of fatigue likely to be experienced by the person. Thresholds are set to inform whether the fatigue level represents an unacceptable risk. Software modelling can be a useful tool as part of a comprehensive FRMS, but must be used cautiously, with an awareness of the capabilities and limitations of computerized models (Independent Transport Safety Regulator, 2010). For a comprehensive review of fatigue modelling systems, refer to Mallis et al. (2004). There can be a reasonable, scientific scheduling agreement between management and labor. It is a good situation for all.
8.3 Napping Strategies. Naps can be helpful either as a preventative measure, as when taken before reporting for a night of shift work, or as a way of improving alertness during a night shift. Controlled studies have shown that even a brief sleep episode can result in performance improvements. For instance, Purnell, Feyer, and Herbison (2002) found that the vigilance performance of aircraft maintenance personnel on the first of two consecutive 12-hour night shifts (7:00 p.m. to 7:00 a.m.) was improved by a 20-minute nap taken at around 3:00 a.m. No improvement was found on the second of the two night shifts. The reason for this is unclear. Other studies have found that brief, controlled sleeps of less than 40-minute duration have been shown to significantly increase the alertness of airline pilots, resulting in reduced lapses and reduced response time to stimuli (Rosekind et al., 1994). Similar benefits have been found for air traffic controllers (Della Rocco, Comperatore, Caldwell, and Cruz, 2000) and truck drivers (Macchi, Boulos, Ranney, Simmons, and Campbell, 2002).
8.4 Training and Educational Material. The provision of educational material to employees is one of the few steps the organization can take to address the personal lifestyle factors that contribute to fatigue. The FAA provides extensive educational material on fatigue for maintenance personnel, including training material, video material, and posters. This material can be accessed at http://www.faa.gov/about/initiativ es/maintenance_hf/. Aviation Maintenance Technicians (AMT), inspectors, maintenance planners, task schedulers, and the families of shift workers will benefit from information on fatigue issues and steps they can take to help the shift worker obtain sleep. It is
14 important to note that time worked, time awake, time asleep, and time of day are critical in considering fatigue risk. It is also important to consider all factors associated with sleep quality. The FAA training material addresses these factors.
8.5 Excused Absences. Some FRMS enable employees to take unplanned leave if they believe their level of fatigue would prevent them from performing their duties (Cook, 2008). While sick leave is a generally accepted aspect of personnel management, “fatigue leave” may be less readily accepted. Organizations need to weigh the potential disruption caused by an unplanned absence against the potential harm that could result when an employee reports for duty impaired.
8.6 Medical Treatment. In some cases, a maintainer’s fatigue at work may be a consequence of an underlying medical condition, such as insomnia or sleep apnea (Kryger, Roth, and Dement, 2005). In these situations, medical attention will be required to address the root cause of the problem. A comprehensive FRMS must include measures to ensure that at-risk employees receive appropriate medical treatment.
9 HOW TO REDUCE FATIGUE-RELATED ERRORS. Despite efforts to ensure that employees are well-rested and alert when they report for duty, it is not possible to completely eliminate fatigue from the workplace. Therefore, it is appropriate to have a second line of defense with the objective of reducing the probability of error among fatigued workers. The plain language slogan of this approach could be: “We know that people are going to be fatigued. How can we manage the risk when a fatigued maintainer is at work?” These interventions can involve one of two approaches: measures directed towards individuals, or measures directed towards tasks.
9.1 Measures Directed Towards Individuals. Several methods are available to help fatigued individuals recognize their level of fatigue and take steps to obtain temporary relief.
9.1.1 Self-Assessment. The most obvious way to detect fatigue is self-assessment by the employee. Several quick assessment guides are available to assist with this judgment, although they should be used with caution as individuals are not always accurate judges of their own level of fatigue (Dinges, Mallis, Maislin, and Powell, 1998).
9.1.2 Technologies. Several technologies offer the possibility of detecting a dangerous level of fatigue at the start of a shift, or continuously throughout task performance. For the most part, psychomotor performance tests have been used widely in research studies and have been shown to be effective indicators of a person’s vigilance performance when fatigued.
Such tests require a period of performance monitoring to establish a baseline for each individual. Changes in that baseline performance can be indicative of fatigue. The tests are usually installed on a handheld device or even a smartphone, and typically measure the person’s speed of response to a stimulus (Dinges and Powell, 1985; Thorne et al., 2005). It must be understood that one-time use of a Psychomotor Vigilance Test (PVT) and other such tests are not a tactical means to establish a fatigue level. However, organized, established integration of PVT, and like devices/tests, can be a strategic tool for an FRMS. Other technologies, such as eye movements, blink rate, performance
15 measures, and voice analysis, also show promise as methods to detect fatigue in operational personnel. Again, such devices are a strategic part of an FRMS. Alertness monitoring systems are not likely to be adopted in maintenance in the near future; it is conceivable that they may eventually play a part in an overall FRMS.
9.1.3 Exercise. Research shows that a period of exercise, such as a brief walk, can increase alertness and temporarily reverse the impact of fatigue on some psychomotor tasks (Bonnet, 2005; Bonnet and Arand, 1998; Wilkinson, 1965). However, the results appear to be temporary, only lasting a matter of minutes. A maintenance technician experiencing extreme fatigue may be able to call “time out” and put down their tools for a moment, or perform a part of a task that requires physical activity, such as walking to a storeroom.
However, such breaks provide only temporary relief lasting a matter of minutes, and are not feasible strategies for managing fatigue over long periods of time.
9.1.4 Environment. Certain aspects of the work environment can exacerbate or mask the effects of fatigue. In some cases, improvements to the work environment may help maintainers cope with fatigue. There is evidence that bright light can increase attentiveness and reduce errors among otherwise fatigued individuals (Cajochen, 2007; Caldwell et al., 2009; Campbell and Dawson, 1990; Dawson, Encel, and Lushington, 1995; Moore-Ede, 1993). These findings are a reminder that tasks performed in a dark environment, such as fluorescent penetrant inspections, will be particularly challenging for a fatigued individual. Exposure to fresh air or cool, dry air may also provide relief from fatigue, although the benefit is temporary and may be slight (Bonnet, 2005; Moore-Ede, 1993).
Posture may also have an impact on fatigue susceptibility. An activity that is carried out while standing or walking is less likely to be affected by fatigue than an activity performed in a prone or seated position (Bonnet, 2005).
9.1.5 Caffeine. Caffeine is one of the most widely used stimulants, and if used carefully and in moderation, can be part of an overall FRM strategy in maintenance. Caffeine has a half-life in the body of around 5 hours, and shift workers should be careful to avoid caffeine in the hours leading up to sleep. An exception is where caffeine is intentionally taken immediately prior to a brief nap. The alertness-enhancing effects of caffeine do not occur until approximately 30 minutes after the caffeine has been consumed, leaving a brief window in which a useful nap may be taken. This combination of caffeine followed immediately by a brief nap has been shown to significantly reduce fatigue during the 2 hours following the nap (Reyner and Horne, 1997). When caffeine is used as a fatigue countermeasure, it is generally recommended that the person avoids the routine consumption of caffeinated drinks, as caffeine is less effective as an alerting agent for people who have developed caffeine dependence (Mitler and O’Malley, 2005).
9.2 Measures Directed Towards At-Risk Tasks. In addition to managing fatigue at the level of the individual, it is also possible to break the link between fatigue and maintenance error by changing aspects of the task assigned to the maintainer. Because much of the worldwide work on FRM has been directed at pilots or vehicle operators, the task-based approach has received relatively little attention. The task-based approach is based on the idea that maintenance tasks vary along a continuum, from tasks that are highly susceptible to fatigue, to those that are less susceptible. This approach is based
16 upon the probability that an error will occur on a task, not necessarily the severity of the consequences of the error. Task-based approaches to harm minimization can involve two complimentary approaches: changing when the task is performed, and changing how it is performed.
9.2.1 Scheduling Tasks. Even if the task steps involved in a maintenance procedure cannot be modified, it may still be possible to reduce the susceptibility of a task to fatigue through careful task scheduling. Most maintenance organizations do not appear to take the fatigue susceptibility of a procedure into account when scheduling tasks. In some cases, individual maintainers have informal norms concerning the time of day at which tasks are performed. For example, when AMTs have discretion about the timing of tasks, they sometimes choose to perform the most challenging tasks at the beginning of their shift, leaving less complex tasks until the end of the shift, when they expect to be less alert. In most large organizations, AMTs have limited control over the timing of tasks throughout their shift, yet crew leads, foremen, or in some cases planning personnel may have some discretion in task scheduling to minimize the impact of fatigue. Therefore, it is critical that such personnel have an awareness of the impact of fatigue on human performance.
The following types of tasks have been identified as being most susceptible to fatigue-related errors:
• Inter-trade communications;
• In-depth supervision;
• Training;
• Troubleshooting;
• Testing;
• Calibration;
• Inspection;
• Job planning; and
• Documenting of work.
9.2.2 Modifying Tasks. In some cases, it is possible to modify task procedures to reduce the task’s susceptibility to fatigue-related errors, or to detect the presence of an error. Such task-based interventions are sometimes referred to as “fatigue proofing.” Task-based approaches to risk mitigation in maintenance can include:
• Close supervision;
• Working in pairs or teams, depending on the task;
• Task rotation;
• Checklists;
• Support for new personnel by experienced personnel;
• Communication/briefings at shift handover;
• Breaking lengthy repetitive tasks into smaller tasks with breaks in between;
• Independent inspections; and
• Operational, functional, or formalized self-checks.
10 HOW TO MINIMIZE IMPACT OF FATIGUE-RELATED ERRORS. After efforts have been made to reduce fatigue and to prevent or capture fatigue-related errors, a final line of defense is to minimize the operational consequences of fatigue-related errors.
Tasks vary along a continuum from the most safety-critical to tasks having limited or unlikely safety effect. Hazard prevention/reduction differs from the interventions described in the preceding sections, as the focus is on the severity of fatigue-related errors, rather than their probability. The plain language slogan of this approach could be:
“Despite our best efforts, fatigue-related errors will happen from time to time. How can we make sure these errors do not have serious consequences?”
10.1 Harm Minimization. Harm minimization in the context of maintenance fatigue involves keeping the most safety-critical tasks out of the hands of the most fatigued people. This approach does not prevent the maintainer from making a fatigue-related error, but reduces the likely consequences of the error. For example, if an overnight task involves a disassembly stage followed by an assembly stage, it may be appropriate, when feasible, to schedule the disassembly for the time of maximum fatigue, and the assembly for a time at which fatigue is less likely. This arrangement is based on the assumption that an error during assembly is likely to be more serious than an error during disassembly.
11 PROGRESSIVE RESTRICTIONS. The concept of progressive restrictions on work responsibilities has been proposed as a fatigue countermeasure. This involves progressively limiting the involvement of the individual in critical task steps as their level of fatigue increases. Some propose that the certification and inspection authority of maintenance personnel should be limited when they have been on duty for longer than 12 hours (Jauregui and Hosey, 2005). For example, a technician may be judged to be at “moderate” risk of fatigue once their shift has passed beyond 12 hours (if a day shift), or 8 hours (if a night shift), or when more than 48 hours have been worked in a 7-day period. These staff members are prohibited from carrying out secondary independent inspections, detailed inspections, or involvement with structurally significant items and critical systems. Technicians are judged to be at “extreme” risk of fatigue when a day shift is extended beyond 14 hours (beyond 12 hours for a night shift), or when they have worked more than 60 hours in a 7-day period. In addition to the above limitations, personnel at “extreme” risk of fatigue are not allowed to perform any critical tasks (including the performance or verification of Airworthiness Directives (AD)), are not permitted to be in charge of engine runs, must not be responsible for functional and operational checks on critical systems, and are not permitted to taxi aircraft.
“Unacceptable” fatigue risk is judged to commence when a person has been on duty for 16 hours (if their duty period started as a day shift) or 14 hours (if their duty period started as a night shift) or when they have worked more than 72 hours in a 7-day period.
18 A staff member with an “unacceptable” fatigue risk is not considered safe to perform any work activities.
11.1 Determination of Activity Complexity. This AC is not suggesting that every maintenance-related task must be assigned a level or risk, to include task complexity, with associated rating of probability and severity of an error. While such a large effort could be part of an FRMS, instead one could establish what a “reasonable person” would consider to be a complex activity requiring a rested maintenance worker.
11.2 Assessments. Fatigue’s most common assessments, as mentioned above, include amount of rest, number of hours awake, and time of day. However, organizations must be cognizant of factors such as type of physical/mental strain, environmental conditionals, industrial challenges, and more. Thus, HOS cannot be the sole determination of potential fatigue.
Figure 2. Work Responsibility Restriction—Example E xample of the progressive restriction of work responsibilities as fatigue risk increases.
11.3 Implementation of Defensive Barriers for Fatigue. The concept of defensive barriers was developed to prevent human errors from becoming critical events. Organizations that are aware of fatigue and understand that personnel are fallible are then cognizant of fatigue as a latent organizational weakness. “About 80% of all events are attributed to human error… When the 80% human error is broken down further, it reveals that the majority of errors associated with events stem from latent organizational weaknesses.”
19 (DOE-HDBK-1028-2009, Human Performance Improvement Handbook, Volume 1, Concepts and Principles, pages 1-10, 1-15, 2-9.) Organizations should utilize human performance improvement tools to build defensive barriers into their administrative controls, policies, and procedures (DOE-HDBK-1028-2009, Volume 2, Human Performance Tools for Individuals, Work Teams, and Management). This can be done by identifying critical tasks associated with all disciplines and at all levels of the organization. Then, for each identified critical task, establish an administrative control that would halt the progression of human error into a critical event. In short, events will happen; however, those events will not become critical events unless a barrier has been side-stepped or is nonexsistent. Volumes 1 and 2 of the DOE-HDBK-1028-2009 can be found at https://www.standards.doe.gov/standards-documents/1000/1028-BHdbk-2009- v1/@@images/file and https://www.standards.doe.gov/files/doe-hdbk-1028-2009- human-performance-improvement-handbook-volume-2-human-performance-tools-forindividuals-work-teams-and-management.
12 FRM WITHIN SMS.
12.1 Objectives. The trend towards formal FRMSs in transport has been slow to reach aviation maintenance. An overall approach to FRM in maintenance can include interventions directed at three objectives: reducing fatigue, reducing or capturing fatigue-related errors, and minimizing the harm caused by fatigue-related errors. Most fatigue countermeasures can actually address more than one of these objectives. Because the FRMS approach was originally developed for pilots and vehicle drivers, most existing FRMS focus on objective one, the reduction of fatigue. However, maintenance organizations have greater opportunities to alter the scheduling and method of task performance in response to the threat of fatigue. Therefore, objectives two and three deserve special attention in maintenance operations.
12.2 Guiding Principles. FRMS is an application of the SMS model, through which hazards are identified and risk is managed with a comprehensive approach that extends beyond regulatory compliance, as described in AC 120-103. FRMS can be integrated within an existing SMS, or can be developed as a standalone system. The following principles guide FRM development:
• An FRMS requires a systemic approach, involving company policies; incident reporting and analysis systems; reactive, proactive, and predictive risk assessment;
and the other elements of a general SMS.
• Effective FRM requires a partnership between the employer and the employee, as each can contribute uniquely to solutions.
• It is unrealistic to aim for “zero fatigue” in all cases. An appropriate objective for FRM is to ensure that risks are managed to a level as low as reasonably practical.
12.3 Commitment. Whatever approach to FRM is applied, commitment from all levels of the organization is clearly essential. Upper management have a responsibility to state a clear policy on fatigue, including how fatigue-related incidents will be dealt with under a just safety culture. Supervisors and middle-level managers have a responsibility to ensure that
20 the FRM policy is applied in day-to-day operations. Supervisors, crew leads, and planners have a critical role in ensuring that fatigue and circadian factors are taken into account in task assignment and planning. Finally, individual AMTs and inspectors are ultimately responsible for the quality of their work. They must have a good understanding of fatigue and its effects, must strive to arrive for duty well-rested, and must have access to strategies to deal with workplace fatigue when it arises.
12.4 HOS Limits. In accordance with international best practices, HOS limits should be a central part of any FRMS. In the absence of national HOS regulations, companies can develop their own science-based policies. In addition to HOS limits, an FRMS for maintenance will include a range of interventions addressing the task, the work environment, and the fitness for duty of personnel, including organizational-level elements such as company policies, reporting and incident analysis systems, risk assessment, and mechanisms to periodically evaluate and improve the system.
Figure 3. Fatigue Risk Management (FRM) Elements Ele ments of an FRM for maintenance.
ORIGINAL SIGNED by /s/ John Barbagallo Deputy Director, Flight Standards Service
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Advisory Circular Feedback Form If you find an error in this AC, have recommendations for improving it, or have suggestions for new items/subjects to be added, you may let us know by contacting the Flight Standards Directives Management Officer at 9-AWA-AFB-120-Directives@faa.gov.
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