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Fatigue Risk Management System in Aviation

Conference Paper · November 2016

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Šárka Hulínská Jakub Kraus

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 FATIGUE RISK MANAGEMENT SYSTEM IN AVIATION

Šárka Hulínská1, Jakub Kraus 2

1
Laboratory of Aviation Safety and Security (Department of Air Transport, Faculty of
Transportation Sciences, Czech technical University in Prague, [email protected])
2
ATM Systems Laboratory (Department of Air Transport, Faculty of Transportation
Sciences, Czech technical University in Prague)

ABSTRACT
The objective of this article is to introduce the concept of Fatigue Risk Management
supported by ICAO and EASA and an analysis of current issues in this area. The FRM
System has become a closely watched management system mainly due to a fact that lack of
knowledge about fatigue and related dangers has led to several aviation accidents and
incidents. The article addresses main definitions related to issues of fatigue with regard to air
transport, describes the main elements of FRM and describes approaches to risk management
in aviation. Later it is dealt with the matters of non-introduction of the FRM into the
operation, on which basis it might be possible to implement the basis of FRMS into the
operational processes of airlines.
KEY WORDS
Fatigue, impact, management, model, risk
JEL classification: L930, R410, M140

1 INTRODUCTION
At first, it is important to explain why fatigue is being discussed. In recent years, fatigue has
become a real concern for most of the air operators. Due to the estimated doubling of air
transport by 2020, a lot of focus is being given to fatigue. Fatigue is a state caused by
performing comprehensive and highly responsible tasks that should be seen as a clear
operational risk, because it reduces both attention and performance. Management of risks
caused by fatigue of flight crews can contribute to increasing the level of aviation safety.
In recent years, management systems have been implemented to areas of safety, but also to
other areas that could negatively affect operations of aviation organizations. Using safety
management systems, risks are being mitigated, however new threats emerge. That applies to
fatigue as well, as it had not been understood well and had been hard to measure until
recently. Employed strategies for fatigue management begin to provide solution for individual
employees and organizations to better deal with this threat and related risks.
Fatigue has been mentioned as a factor for several accidents and serious incidents. For
example, Colgan Air flight in 2009, Air India Express in 2010 or Air Berlin in 2012, when the
crew requested emergency landing in Munich due to extreme fatigue of pilots. In 2007, an
aircraft with 288 passengers on board came off the runway in Iceland when landing. The
investigation showed that fatigue was to blame. All these accidents and incidents set
requirements for a new way of thinking in regard to safety management. One of the main
features of such new approach in aviation is that all organizations involved share
responsibility for minimizing risks and increasing safety. Each organization and each
employee contributes to increasing safety by sharing information about safety events. Wise
stakeholders can then learn not only from their own mistakes, but also from the mistakes of
others. [1]
2 DEFINITION OF THE PROBLEM OF FATIGUE IN AVIATION
The danger associated with an aircraft comes out of its own nature: it is dangerous simply
because it is flying. Pilots cannot just stop in mid-air, they are not able to change (not
counting doubled or boosted crews), they are responsible for every single passenger travelling
on board and in case of long-distance flights they are influenced by changes of time zones (jet
lag). Furthermore, the pilots are under great pressure from their employers, which try to
maximize their profits by applying maximum possible workload on their fleets and crews
while keeping the costs down. During the boom of aviation, pilots’ work was highly rated and
respected. [9] Nowadays, the pilot is considered as a simple “mean” for making money for
aviation organisations. Due to all those facts the workload is increasing inadequately thereby
increasing the risk of fatigue. [10]

3 FATIGUE RISK MANAGEMENT SYSTEM

ICAO defines a Fatigue Risk Management System (FRMS) as:
“A data-driven means of continuously monitoring and managing fatigue-related safety risks,
based on scientific principles and knowledge as well as operational experience, which aim to
ensure relevant personnel are performing at adequate levels of alertness.” [2]
Functioning of the whole FRMS describes the picture below. The FRMS is a cycle, which
involves processes of measurement and assessment of the current conditions, modelling and
analysing of fatigue risk, managing and mitigating the risks of fatigue and assessment and
feedback.

Pic. 1 The FRMS process [7]

Apart from mitigating the risks of fatigue the advantages of the FRMS are:
a) Reduction of number of incidents and accidents related to mistakes caused by fatigue,
which might be connected to the financial costs or impact on the operator’s reputation.
b) Reduction of insurance costs, since some insurance companies might lower the
insurance premium in cases where the operator proves the existence of functional
FRMS in their organisation.
c) Reduction of number of crew absences connected to fatigue.
 d) Recruiting and keeping crew members through the use of ”fatigue friendly” lists,
providing better working conditions.

4 SPECIFICATION OF RESPONSIBILITIES WITHIN THE FRMS

Fatigue risk management system is an organizational system, which allows management of
responsibilities of all participating parties (pilots and their employers), which are then well
aware of their duties and commitments. The aviation industry embraced regulatory approach
to prevention fatigue by restricting the length of flight service – so called flight time
limitations.
One of the main attributes of the FRMS approach is, that all involved parties share the
responsibility for minimizing risks and increasing safety. That is in compliance with the new
approach to safety. It is therefore the management’s duty to create working conditions, which
minimalize the risks of fatigue. Simultaneously, employees have a responsibility to ensure,
that they get the most out of their free time. This whole idea introduces great advance in
thinking about fatigue. In the past, the above mentioned responsibility lied upon a regulator,
who prescribed the level of safety based on flight time limitations.
Every participating party – regulator, as well as the operator and the employees of the
operator – have their own duties in FRM.
The duties of the employees are:
a) Getting a sufficient amount of sleep;
b) Reporting occurrences, when they did not have enough sleep or they felt tired; [2]
The matters of self-management are closely connected to these points. Each pilot should
create such conditions that have a positive effect on his fatigue, i.e. lower it or do not increase
it steeply. Should he fail to define such conditions on his own, the operator should help him in
defining these conditions, for example through personality or psychological training.
The duties of the employer (operator) are:
a) Providing adequate opportunities to sleep (allowing employees enough time to rest).
b) Embracing actions whenever the employee is unfit for work or exhausted. Such
actions should be clearly specified in every operator’s manual along with proper
principles and actions. [2]
The connection between fatigue and safety is highly challenging to define. The biggest
challenge is assessment of risk, because definition of “acceptable” or “safe” level is
complicated. The acceptability of such risk depends on concrete type of operation, therefore
differs for each organisation and each person.

5 RISK-BASED APPROACH – PILOT MANAGES THE OPERATIONAL RISKS

BETTER WITHOUT FATIGUE
Definitions of acceptability and safety are in the area of operational safety addressed by the
Safety management system (SMS), which might be seen as a “package” of defined relations,
responsibilities and set procedures, which is used by the aviation organisations to assess
hazard effects and manage risks. These tools are connected to two basic processes of safety
management – hazard identification and management of risks, and provide them with
complex support. SMS is focused on constant improvement of the safety level and it
introduces the process of hazard identification into operator’s everyday operations, together
with collection of safety data and their analysis, risk assessment and implementation of
mitigating strategies. [11]
Management of risks according to the SMS includes development of complex protection
against the risk of fatigue based on formal evaluation of a risk. The scale of fatigue risk
management lies entirely on the organisation.
Risk-based approach is based on assessment of risks connected to fatigue. On the basis of
their concrete evaluation, the appropriate protections to avoid risks of fatigue are created. [12]
Compliance-based approach is a different approach, which constitutes of planning the crew
work in compliance with valid regulations, hoping it guarantees reaching a certain level of
safety. Risk-based approach presents a more thorough examination of conditions in the
organisation, which might contribute to the risks appearance.
The chronology of events is probably better evaluated by a rested pilot that embodies no signs
of fatigue, rather than exhausted one. Any signs of exhaustion worsen the risk management.
The risks of fatigue depend on crew planning and the health state of a pilot. Pilot’s part of risk
management lies in responsible attitude to sleep and resting, while the remaining factors
depend on the airline. [8]
Airlines manage the risk of fatigue in several ways. One of them is the approach to flight crew
planning, where crews are given sufficient amount of time for rest. Another way is creating an
internal system of voluntary reporting, which allows a pilot to not come to work for any
reason. However, this option can be easily abused by the employees. Therefore, they are
given only a limited number of days, which they can use in this way. Given that companies
exploit the concept of just culture, pilots are not being charged for announcing their state of
fatigue, but the company focuses on determining the causes and learns from it. Any such
information is very valuable for an operator, because it can easily obtain a feedback from
crews, therefore evaluate the level of utilization of crews.
Penetration of a barrier, in other words failure of a concrete protection layer, gives
opportunities for a complete system failure or manifests as a trigger of events that lead to the
system failure. Effective safety management system shall consist of several protective layers
and processes, redundant protective layers used to strengthen each layer against a given
hazard. Occurrence of an accident in such multi-layer system can happen only if all the
protective systems fail. FRMS is one of those protective layers.

6 PREDICTIVE METHODS OF RISK IDENTIFICATION

The above mentioned approach (risk-based) to functioning of FRMS identifies the risks by
using predictive, proactive and reactive methods, where the predictive methods are the best.
They consist of exploiting own experience while planning and an effort to predict a level of
fatigue, that will be brought by a new operation or planning. The predictive process has to
determine risks associated with fatigue through crew planning control and consideration of
known factors affecting sleep and fatigue and their effect on performance. Such control
methods might include, but are not limited to:
a) Operational experience of the operator or the industry and collection of data from
similar activities
b) Planning methods based on records
c) Biomathematical models [3]
The first two methods are a common approach, that can be used by anyone, as they are simple
to implement and depend on a type of data that is accessible to any operator.
On the other hand, biomathematical models are extension to those methods. They are used for
testing of current understanding of the matter how factors such as sleep deprivation; work
load or circadian rhythms affect human performance. The process of modelling starts with
simulation of so called ”development data set”, where factors such as self-evaluation of the
fatigue and data collected by fatigue measurement are used. After that, the data can be used
for prediction of different situations. Then, the modelled predictions are tested using newly
acquired data. Scientific modelling is a continual process of improvement. New experiments
take place in order to improve the predictive models. Scientists discover flaws of these models
through random experiments and these discoveries are then used to improve the models.
Many of the biomathematical models [5][6], which were and still are commercially
introduced to the market, are used as tools to predict fatigue risks and for planning. Correctly
used models might be also utilized as useful tools for FRMS, especially because they can
capture dynamic interactions of processes, such as restoration of vigilance. To use these
models correctly, it requires certain knowledge of the predictive possibilities of the models.
The current models are capable of predicting average amount of fatigue, however do not take
into account the individual factors. Some of the available models are designed to predict the
level of safety. The most trustworthy use of currently available models is comparison of
probabilities of relative level of fatigue. [5] The modelled predictions should not be used
without any links to operational experience. On the other hand, the data collected through
FRMS might be used as source of data for improvement of biomathematical models.

7 REASON FOR NOT IMPLEMENTING FRMS INTO THE OPERATION

FRMS introduces a framework, which helps to manage risks associated with fatigue. Its
implementation is, however, not simple and some operators are avoiding it. The reasons for
not implementing FRMS vary from operator to operator, but in principle they are based upon
these aspects:
a) insufficient preparedness;
b) uncertain safety policy;
c) “just culture” not used;
d) imbalanced use of research;
e) lack of resources; [4]

The main reason for not implementing FRMS into the operation of aviation organisations is
the insufficient preparedness. Lack of understanding of the fatigue issues relate to that. Of
course it is necessary to evaluate the economic indicators, on which management bases its
decisions. Fatigue is commonly considered to be marginal risk, which is not necessary to be
managed, especially among low cost airlines.
Uncertain safety policy of the aviation organisations is closely related to the above mentioned.
Frequently, the whole concept of safety policy is unknown. An operator does not follow
regulations in because of uncertain safety policy and due to inadequate control, he is not
forced to follow them.
To the lack of feedback relates also the issue of not exploiting ”just culture”. Just culture is a
company policy, which encourages employees to report any situation, which had or possibly
could have had an effect on reduction of level of safety. Nobody is punished for such reports,
unless the reported event is caused by gross negligence, intentional misdeed or destructive
acts. It applies to operators as well.
Operator’s license revocation or imposition of a fine might discourage operators from
reporting any mistakes. Therefore, it is highly important to encourage development of an
environment, where the occurrences are reported. To support such approach, it might be
useful to introduce preventive measures. It is not easy to admit, that we made a mistake,
however if any such experience is shared, it might contribute to increase of safety of aviation.
People should communicate and share their experience, because each experience is unique.
Every single piece of information should be taken seriously and it should be used for the good
of the society. Incorporating such concept is, on the other hand, quite difficult, because
current way of thinking is still based on punishing the person responsible for the mistake. The
concept of ”just culture” is important for overall development of processes and general
understanding, where self-reports and feedback is used for improving the whole system. The
more we know, the safer the organisation is.
The next problem concerning not implementing FRMS in the organisations is imbalanced use
of science. In a scope of an organisation, there is either no research or too much of a research
that does not pursue any concrete goal. Outcomes are then based on too much theory or
insufficient understanding of the issue.
Final reason for not implementing FRMS is the lack of resources. FRMS requires initial
investments in areas such as conducting various studies, application of biomathematical
models or increasing the number of employees. On the other hand, introducing FRMS brings
along a lot of advantages (described in chapter 3). This increases prestige of the organisation
and enables the possibility of lowering the costs of insurance.

8 CONCLUSIONS
In general, it is difficult to assess one’s own level of fatigue. Human being can not very well
evaluate whether the situation, when he is unable to react safely, has already arisen. Human
body works in 24-hour cycle and it is programmed to sleep at night and being awake during
the day. Person who works at night is predetermined not to achieve good quality of sleep
during the day.
The aim of FRMS is to mitigate risks of fatigue at all observed levels. To achieve such goal,
we exploit knowledge about fatigue applied to concrete situations. It is however impossible to
entirely eliminate fatigue. There are a few different tools to eliminate risks of fatigue. The
basic one is sleep, but sleep cannot satisfy all parties concerned, especially the airlines.
Fatigue should be also treated as an operational risk. It is an extremely difficult task, mainly
because it is hard to manage something, what cannot be measured. Risks connected to fatigue
require special tools and methodologies that might determine productivity of the crew.
With the gradual development of science in the matter of fatigue, a new development within
the scope of FRMS and biomathematical models can be expected. Biomathematical models
bring information about the level of risk connected to fatigue. It is up to every single operator,
how they treat the information gained through modelling. The model outcomes might be used
to improve crew planning, to confirm accuracy of already prepared plan, to establish
predictions of individual fatigue, for performance measurement, for training and during
investigation. It also suggests using strategies, which help to manage risks. It is important to
realize, that using biomathematical models introduces certain financial demands. The results
of modelling usually bring information about the insufficient number of employees, who are
usually heavily occupied with workload. On the other hand, proper implementation of FRMS
into organisation might help to find out, how the fatigue affects performance and how to
eliminate fatigue. Such elimination can take form of, for example reduction of number of
accidents, i.e. increase in safety and decrease of additional costs related to accidents.

ACKNOWLEDGMENT
This paper was supported by the Grant Agency of the Czech Technical University in Prague,
grant No. SGS15/172/OHK2/2T/16.

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