1. Safety Culture in the Aviation Industry:
- the example of Fatigue Risk Management
Highways England, 14th March 2017
Dr Paul Jackson

2. The Aviation Industry Safety-critical work, demanding work environment
Commercial pressures
Round-the-clock operations – circadian disruption
Heavy reliance upon shiftwork
Working when should be asleep, trying to sleep during day
Reluctance to report
Incentives to operate fatigued
Consequently, workforce fatigue is a significant hazard

3. Consequences of fatigue
Microsleeps while operating
More than 10 occasions in last 12 months:
Cabin Crew 42%
Flight Crew 25%
Microsleeps while driving home
More than 10 occasions in last 12 months:
Cabin Crew 30%
Flight Crew 24%

4. Traditional control: Hours of Work regulations
Simplistic illusion of safety management:
within the limits you are safe
outside the limits you are unsafe.
Hours of work regulations are not enough – you can work entirely ‘legal’ shifts, but prescriptive regulations are a blunt instrument, and can still lead to unsafe levels of fatigue
Fatigue Risk Management Systems (FRMS) use evidence- and data-based mitigations and controls to ensure that fatigue risk is kept as low as reasonably practicable.
Regulatory authorities now require a more scientific approach to the management of fatigue, based on analysis of data specific to the operation

5. Fatigue Risk Management
FRM POLICY
EFFECTIVE REPORTING SYSTEM
Fatigue Risk Management (FRM) Processes
FRM Safety Assurance Processes
Data Collection and
Hazard Identification
Performance Monitoring
SPIs
(Safety Performance Indicators)
Risk Assessment
Managing changes that may impact on the FRMS
As shown in the figure, FRMS can be broken into two principle processes, namely fatigue risk management (FRM) processes and FRMS safety assurance processes. These processes are supported by four additional constructs: FRMS policy, an effective reporting system, communication: safety promotion and feedback and a Fatigue Management Training Program (FMTP).
FRM processes facilitate the detection of fatigue hazards, the assessment of the associated risk and identification and implementation of the necessary mitigation strategies. When the mitigators are put in place a set of safety performance indicators (SPIs) are defined to enable the effectiveness of the mitigators to be tracked. The monitoring of SPIs is where the FRMS safety assurance processes take over.
The function of the FRMS safety assurance process is to monitor the SPIs and other information including FRMS roster metrics, FOR metrics and FOR investigation results on an ongoing basis and to ensure that the Complex Aviation operates within an acceptable level of fatigue risk exposure.
An effective reporting system is critical to the successful management of fatigue risk. The open and honest reporting of information by pilots enables current fatigue risks to be addressed and future potential hazards to be managed pro-actively before they pose a significant risk to the operation.
Safety culture can be defined as the extent to which the avoidance of harm is considered and determines the day-to-day actions and decisions of people at all levels of an organisation. Safety culture is vital to the day-to-day functioning of the FRMS and attainment of the FRMS safety objectives and safety performance goals and the continuing success of the FRMS.
Communication: safety promotion and feedback is essential to achieve and maintain an informed safety culture. This involves ensuring all employees understand the objectives and function of the FRMS and the FRMS policies, procedures, responsibilities and duties which apply to their role. It also involves maintaining communication channels via which flight crew members and management can exchange information pertaining to fatigue.
The Fatigue Management Training Program (FMTP) is designed to provide all management members and crew with the training required in order to competently manage fatigue in their role(s). The FMTP provides management, crew and operations staff with knowledge of the science related to sleep and fatigue, an understanding of the company FRMS and their responsibilities regarding fatigue management.
The FRMS is described and undertaken in accordance with the policy and procedures stated in this document and other relevant manuals.
Risk Management
Audit and review
COMMUNICATION: SAFETY PROMOTION AND FEEDBACK
FATIGUE MANAGEMENT TRAINING PROGRAMME

6. Preparing the organisation
Just culture: open, fair, equal
Top level endorsement/commitment
Union support and involvement
Consultation with workforce
Management Education Programme
Steering Group
Communication plan: raising awareness
“An atmosphere of trust in which people are encouraged, even rewarded, for providing essential safety-related information, but in which they are also clear about where the line must be drawn between acceptable and unacceptable behaviour.”
Its about accountability: mistakes are fair enough, but it is not a ‘no-blame’ culture where people can make wilful violations.
The rule of thumb to determine whether an incident was an honest mistake, or whether it was something more is the Substitution Test. Where an error has been made, or there is a report of fatigue – would another individual in the same circumstances have done the same thing?
Also need to consider whether there are organisational factors that set the individual up to fail – e.g. Inadequate training?

7. 5
COMMON MISTAKES MADE
WHEN IMPLEMENTING FRM

8. 1 Management don't demonstrate their commitment to FRM
For FRM to be implemented successfully it is essential that management take their responsibilities seriously, and demonstrate their commitment through actions as well as words.

9. 2 FRM is under-resourced
Successful FRM needs human and financial resources. As well as a budget to enable projects to be undertaken, individuals need to be allocated time to enable them to complete the various tasks required to introduce and manage FRM.

10. 3 Lack of a clear, credible, visible leader
FRM needs a figurehead or champion. An individual with credibility and authority, who the workforce trust and respect, and who management will listen to.

11. 4 Reporting is rolled out before the organisation is ready
Organisations looking to quickly gather data on fatigue sometimes make the mistake of introducing a fatigue report form before the company culture is ready for it. To ensure that a fatigue reporting system is accepted and used appropriately, procedures need to be put in place and publicised so that everyone understands how and what to report, what will happen to the data they submit, and the consequences of reporting fatigue.

12. 5 Fatigue training is not tailored to the organisation's risks
Generic off-the-shelf fatigue training that does not consider the specific risks faced by an individual operation will be of limited relevance to crew. To be of value, training should reflect the operation: the routes, rosters and operational practices of the organisation.

13. Summary All shiftworkers experience elevated levels of fatigue
Sleep loss, poor sleep quality, circadian disruption
Prescriptive regulations in isolation offer limited protection against fatigue risk
FRM - an alternative approach based on Safety Management System principles – just culture, data collection, feedback
Offers significant potential benefits but needs preparation, commitment and careful implementation to prevent abuse.

14. Thank you for your attention