FATIGUE-THE

RULES_ARE
CHANGING
Disclaimer
This booklet is for information purposes only. It should not be relied on as the sole source of
information, and should always be used in the context of other authoritative sources and the relevant
regulations.
2013 Civil Aviation Safety Authority
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Direct any requests for further authorisation to: Safety Promotion, Civil Aviation Safety Authority,
GPO Box 2005 Canberra ACT 2601 (Australia), or email: safetypromotion@casa.gov.au
1209.1725
CASA is changing the fatigue management
regulations. This booklet relates to ight crew,
but legislation applicable to cabin crew members
and air trafc control is in the pipeline.
Managing fatigueCAO 48.1 timetable
April 2013 New CAO 48.1 rule made ight crew members and operators
2013 April 2016 Operators will be expected to commence transition to the new rule set.
Operators may apply for an FRMS
April 2016 Standard industry exemptions no longer available after April 2016
April 2016 Transition to the new ight crew member fatigue rules complete
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CIVIL AVIATION SAFETY AUTHORITY
Contents
What is happening? 02
Why are the fatigue regulations changing? 03
What is fatigue? 04
What causes fatigue?
Sleep debt
Circadian rhythms
04
04
05
Factors in fatigue 07
What are the effects of fatigue? 08
Are we the best judges of fatigue? 10
Warning signs of fatigue 11
What about fatigue-related accidents and incidents? 12
Flight crew rest and ying duties 14
What does the new CAO 48.1 look like? 16
Benets of fatigue management and FRMS 17
Managing fatigue
How will FM and FRMS affect operators?
What are the operators responsibilities?
What are the individuals responsibilities?
18
18
20
20
Fatigue management within an existing SMS 21
Strategies for managing fatigue in the avitation environment
Risk control
Work-related fatigue factors
Non work-related fatigue factors
Hierarchy of fatigue controls
23
23
23
23
23
Fatigue-ghting tips 24
Fatigue case study 26
Fit to y? The ner points of fatigue 27
Glossary 28
Managing fatigueCAO 48.1 timetable
April 2013 New CAO 48.1 rule made ight crew members and operators
2013 April 2016 Operators will be expected to commence transition to the new rule set.
Operators may apply for an FRMS
April 2016 Standard industry exemptions no longer available after April 2016
April 2016 Transition to the new ight crew member fatigue rules complete
FATIGUETHE RULES ARE CHANGING
2
What_is_happening?
Under the CAO 48.1, introduced in April 2013, operators and ight crew will have
shared responsibility to manage fatigue. The new CAO adopts a tiered approach to
managing fatigue, ranging from prescriptive requirements to a mix of prescription and
risk management to a fully developed fatigue risk management system.
Having a tiered system allows operators to choose an appendix based on operational
requirements and with an overlying fatigue risk management strategy appropriate for
their organisation. A tiered system also allows for improvements in the light of current
sleep and fatigue research.
International evidence suggests the changes will generate safety benets and
signicant operational efciencies, without imposing undue cost or time burdens
on operators.
FRMS
FATIGUE
MANAGEMENT
BASIC
Limitations
Customisable
Data-driven
Operator obligations
Policy and documentation
Risk management processes
Safety assurance processes
Safety promotion processes
Prescriptive
Type-of-operation specific
More flexible
Less restrictive
Prescriptive
Somewhat restrictive
Hazard identification
Limitations taking into account
identified hazards
Continuous monitoring
Transitional procedures
Training for FCMs
No additional obligations
The three-tier approach to fatigue management
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CIVIL AVIATION SAFETY AUTHORITY
Why_are_the_fatigue_
regulations_changing?
Fatigue increases the likelihood of poor decision making, a greater rate of error and
generally impaired performance. In the safety-critical aviation environment any or all
of these could result in tragedy.
Current ight crew fatigue regulations have been in place for more than 50 years
without signicant review. Over those years, the industry has signicantly changed.
Flying in the era of Constellations was very different to todays global ultra long-haul
operations, with rapid transit of multiple time zones
(up to eight time zones in 24 hours). Advances in
technology, and scientic understanding of human
performance limitations, and of sleep, mean the
old regulations are out of step with contemporary
practice and knowledge. They do not properly address transient and cumulative
fatigue, operator and individual responsibilities, the impact of circadian rhythms, and
crossing of multiple time zones.
They are also not in accordance with a recent change to Annex 6 by the International
Civil Aviation Organization.
CASAs updates to these regulations will better address the changing, 24-hour nature
of the aviation industry, advances in fatigue research, and evidence from accidents
and near misses in Australia and overseas. They will therefore better manage
alertness levels of ight crew.
Fatigue is not a
sign of weakness
FATIGUETHE RULES ARE CHANGING
4
What_is_fatigue?
We use the word fatigue all the time, but what exactly is it? It has several different
origins, some of which are:
hard physical work
intense emotions
heightened concentration on a task
lack of sleep.
We can distinguish between two types of sleep-related fatigue:
acute (transient)this is generally only short term, resulting from an extended
period of being awake, and can normally be remedied by a single adequate
period of sleep
chronic (cumulative)can occur after delayed or incomplete recovery from
transient fatigue, or a series of days with insufcient sleep. This tends to be a
longer-term problem as there is usually a build-up of sleep debt.
Fatigue can act like a toxin accumulating in our body. We can generally deal with
a small amount of it, and work it out of our system by catching up on a nights
sleep. However, a continuous accumulation of fatigue can lead to potentially
dangerous effects.
What_causes_fatigue?
Fatigue is caused by two processessleep debt and circadian rhythms.
Sleep debt
Adults generally sleep between seven and eight hours a night, although the need
for sleep varies between people. A century ago, before the widespread use of
electric lighting, people typically slept around nine hours per night. Today, family
demands, work commitments and even television viewing habits combine to limit the
opportunities for night-time sleep. In our busy world, many people are suffering from
sleep deprivation without being aware of it. Extreme sleep deprivation has severe health
effects, but even mild sleep deprivation can affect health and our ability to perform
tasks in our work and personal lives.
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If we obtain less sleep than we need, we build up a sleep debt. Each successive night
of inadequate sleep adds to the debt. Even reducing our sleep by just one hour each
night over several nights (e.g. getting seven hours when we really need eight) can
reduce our mental capability.
Shift workers, who sleep during daylight hours, can build up a sleep debt because
daytime sleep tends to be briefer and of poorer quality than sleep obtained at night.
A sleep debt may build up when a persons work and family commitments do not allow
them to sleep as long as their body needs. But sleep debts can also occur when sleep
is disrupted by alcohol, other drugs, and medical conditions. Medical conditions that
can cause sleep disruption include the following:
Insomnia An inability to get to sleep, or difculty in staying asleep. In many
cases, insomnia is a symptom of another problem, such as a medical condition,
side effect of medication, or a sleep disorder. Insomnia can also be caused by
worry, stress or other emotional upset.
Restless legs syndrome (RLS) A disorder that causes a strong urge to
move your legs, making it difcult to fall asleep. This urge to move often occurs
with strange and unpleasant feelings such as creeping, tingling or burning.
Moving your legs relieves the urge and the unpleasant feelings.
Periodic limb movements (PLM) Involuntary leg movements while asleep.
The movements often disrupt sleep and may cause the person or their partner
to wake up.
Sleep apnoea A disorder characterised by abnormal pauses in breathing or
instances of abnormally shallow breathing.
If you think you may be experiencing any of these conditions, see your doctor.
Circadian rhythms
Our bodies have steady 24-hour physiological, biochemical and behavioural rhythms.
Alertness, body temperature, sleep tendency and human error have been shown to
follow a 24-hour pattern.
These rhythms are known as circadian rhythms, the word circadian being Latin for
about a day. The human body clock is affected by exposure to light, particularly early
morning light. Humans are basically diurnal creaturesin other words, we are awake
during the day and sleep at night, as distinct from nocturnal creatures such as owls.
FATIGUETHE RULES ARE CHANGING
6
Our circadian rhythms are so reliable that even if we were removed from the 24-hour
rhythm of night and day (such as spending winter in Antarctica), the rhythms continue
to run.
Circadian rhythms have an important role in regulating sleep patterns. Chemical
changes occur in the body as it prepares for sleep, typically between 8pm and
midnight. Body temperature reaches a low point at around 3am and then begins
rising steadily as our
body gets ready for
the day ahead, even
before most people are
naturally awake.
One especially critical time for shift workers is from 02000500, also known as the
window of circadian low. At this time our body temperature is at its lowest, and
our mental alertness can be at its poorest. (There is another peak in sleepiness
sometimes called the afternoon nap window [around 15001700 for most people].
Restricted sleep at night, or disturbed sleep, may make it harder to stay awake during
the next afternoon nap window.)
A can-do attitude We are paid
to do our job, so we can handle it
can be very dangerous
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Factors_in_fatigue
Overwork
Stress
Poor_diet
Medications
Pain
Inactivity
Grief
Burnout
Alcohol_and_other_drugs
Sleep_difficulties
Anxiety
Depression Illness
Circadian_rhythms
Excess_weight
Shift_work
Social_life
Age
Water_intake
FATIGUETHE RULES ARE CHANGING
8
What_are_the_effects
of_fatigue?
Some in the industry see fatigue as a normal and unavoidable part of aviation.
They consider that with enough effort, tired workers can continue to perform their
jobs effectively. While increased effort or concentration might help for a few minutes,
it certainly cannot compensate for fatigue over an entire shift. Fatigue has a very real
detrimental impact on safety in aviation and in many other industries.
To continue to perform safety-critical tasks appropriately, there has to be the right
balance between work, rest and play. Fatigue can reduce ight crews ability to
y safely.
Physical signs of fatigue
yawning
heavy eyelids
eye-rubbing
head drooping
inappropriate or unintentional sleep onsetfalling asleep while ying or
performing other safety-critical tasks
poor coordinationslowed reaction times
headache, lightheadedness
Other fatigue effects include:
reduced vigilance
reduced mental abilities, including impaired problem solving
forgetfulness
increased risk taking
poor communication
reduced alertness and concentration
poor decision making
xation on a single task
errors of expectancy e.g. descending to a certain altitude out of routine when a
different altitude has been cleared
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CIVIL AVIATION SAFETY AUTHORITY
lack of motivation
inefciency
lowered morale and sense of wellbeing
irritability, moodiness, short temperedness
Effects of fatigue
Performance category Effects
Attention: reduced Leave out steps in tasks
Preoccupation with single tasks or steps
Tunnel vision, less likely to notice the unexpected
Less aware of poor performance
Concentration requires more effort
Memory: diminished Poor memory for tasks completed or underway
Forget to perform task steps
Revert to old habits
More likely to forget to return to interrupted tasks
Mood: withdrawn Reduced communication
More irritable, frustrated by minor difculties
Temptation to shortcut tasks
Reaction time: increased Slower to notice problems
Less smooth control of equipment or vehicles
Many of the skills required in emergency situations are sensitive to sleep debt,
including:
being able to lter out distractions and attend to complex information
keeping track of a situation as it evolves and recognising when it is necessary
to update your strategy
being able to think laterally and innovatively
assessing risk
maintaining your interest/concentration
controlling your mood and behaviour
monitoring your own performance and knowing your safety capability limits
decision making, which can be impaired or delayed
communicating effectively
FATIGUETHE RULES ARE CHANGING
10
One obvious hazard of fatigue is that the fatigued ight crew member falls asleep while
on duty. This was the scenario in 2008. Air-trafc controllers frantically radioed go! Flight
1002 for 18 minutes on 13 February 2008. According to the National Transportation
Safety Board (NTSB), the two go! airline pilots fell asleep while ying from Honolulu to
Hilo, cruising past their destination for 18 minutes before waking up and returning for a
safe landing.
This falling asleep can also take the form of a microsleep, which is a brief moment
(generally between two and thirty seconds) when a person starts to enter the rst
stage of sleep, possibly with their eyes still open,
sometimes for less than a few seconds before
regaining consciousness. The person is typically
unaware that they have experienced a microsleep and
may continue to perform simple repetitive tasks while asleep. For someone performing
a routine low-risk task this is not critical. However, for ight crew it is very different. An
aircraft travelling at 250 knots on a glide path can cover over 400 feet in one second
the duration of a microsleep.
The safety implications of fatigue in aviation are reinforced by ndings in other transport
industries. When truck drivers volunteered to wear sleep-monitoring equipment while
they worked, researchers were amazed to nd that some drivers were showing signs of
the rst stage of sleep while driving on interstate highways.
Sleep deprivation impairs the brains effectiveness, with research showing it can
produce effects very similar to alcohol consumption. On-the-job performance loss
for every hour of wakefulness between 10 and 26 hours is equivalent to about a .004
per cent rise in blood alcohol concentration. Seventeen to 18 hours of wakefulness is
usually considered to be equivalent to a blood alcohol concentration of about .05
per cent. In the safety-critical aviation environment, this could result in tragedy.
Are_we_the_best_judges
of_fatigue?
People are notoriously poor judges of their own level of fatigue. Asking a fatigued
person if they are OK to keep working is a bit like asking someone who is drunk if they
are OK to drive.
Even if we are not good judges of how tired we are, we can still keep track of how
long we have been awake, how much sleep we have had recently, and the quality
of that sleep.
There is no blood
test for fatigue
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CIVIL AVIATION SAFETY AUTHORITY
Before starting work, you could ask yourself these questions:
How much sleep have I been getting over the last few nights?
How long have I been awake?
Will I be working at a time when I would rather be sleeping?
Have I had good quality sleep?
Your answers to these questions can help you to assess how likely you are to be at
risk because of fatigue.
Warning_signs_of_fatigue
How tired are you?
Epworth sleepiness scale developed by Dr Murray Johns of Epworth Hospital
in Melbourne
How likely are you to doze off or fall asleep in the following situations, in contrast to just
feeling tired? This refers to your usual way of life over recent times. Even if you have not
done some of these things recently, try to work out how they would have affected you.
Use the following scale to choose the most appropriate number for each situation:
Situation Chance of dozing
Sitting and reading _________________
Watching TV _________________
Sitting inactive in a public place (e.g. a theatre or a meeting) _________________
As a passenger in a car for an hour without a break _________________
Lying down to rest in the afternoon when circumstances permit _________________
Sitting and talking to someone _________________
Sitting quietly after a lunch without alcohol _________________
In a car, while stopped for a few minutes in trafc _________________
1 6. Congratulations, you are getting enough sleep!
7 8. Your score is average
9 and up. Seek the advice of a sleep specialist without delay!
no chance of dozing
slight chance of dozing
moderate chance of dozing
high chance of dozing
0
1
2
3
FATIGUETHE RULES ARE CHANGING
12
What_about_fatigue-
related_accidents_and
incidents?
Evidence shows that fatigue is a safety issue or contributing factor in a number of
Australian aviation accidents and near misses. The Australian Transport Safety Bureau
(ATSB) has identied 12 accidents and 64 near misses over the last 10 years in which
fatigue was considered relevant. There were two deaths as a result of these accidents.
International aviation accidents in which fatigue was implicated
Date Airline/location Description
21 December 1994 Air Algerie/
Warwickshire UK
Five people killed: ight crew and
passengers. The ight crew were fatigued
they had had 10 hours of ight duty,
with ve ight sectors which included six
approaches to land.
6 August 1997 Korean Air/Guam Boeing 747-300 crashed on approach to
Guams international airport, killing 223
passengers and crew at the crash site.
Captains fatigue was cited in the report
as a contributing factor.
18 August 1998 Kalitta DC-8-61F/
Guantanamo Bay
The Guantanamo Bay accident was the
rst in which pilot fatigue was cited as the
primary cause. The pilot stalled a perfectly
serviceable aircraft into the ground on
approach. His inability to monitor the
aircrafts safe ight was accepted as being
the direct result of fatigue. The ight crew
had been on duty for 18 hours, and ying
for nine hours, and were suffering from
circadian rhythm disturbance and lack
of sleep.
1 June 1999 American
Airlines/Little
Rock USA
Douglas MD-82 overran runway on landing
and crashed, killing the captain and
10 passengers. Knowing that they were
approaching their 14-hour duty limits, the
pilots might have exhibited get-there-itis.
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25 June 2007 Cathay Pacic
747F/ground
collision at
Stockholm
(Arlanda)
Swedish investigator said crews had been
awake for 18-20 hours; the time was 0330
local; and fatigue was a factor. Hong Kong
CAD dissented, saying the crew had been
given sufcient rest opportunity, so it was
not fatigue.
12 February 2009 Colgan Air/
Buffalo
Fifty people killed in the crash of a
Bombardier Dash 8-Q400. Fatigue was
cited as a factorthe young co-pilot
frequently commuted across the USA to
report for duty.
22 May 2010 Air India Express/
Mangalore
All six crew members and 152 passengers
killed when the Boeing 737-800 crashed at
Mangalore. The report found that the chief
cause of the accident was the captains
failure to discontinue the unstabilised
approach and his persistence in continuing
with the landing, despite three calls from
the rst ofcer to go around and a number
of EGPWS alerts. The report also identied
that in spite of the availability of adequate
rest before the ight, the captain slept for
a prolonged one hour and forty minutes
during ight, awakening just prior to
approach. This could have led to
sleep inertia, possibly causing impaired
judgement, accentuated because he was in
the window of circadian low.
14 January 2011 Air Canada/
Boeing 767-333/
North Atlantic
Approximately halfway across the Atlantic,
at night, the aircraft experienced a
46-second pitch excursion. This resulted in
an altitude deviation of minus 400ft to plus
400ft from the assigned altitude of 35,000ft
above sea level. Fourteen passengers and
two ight attendants were injured. The rst
ofcer had reported not feeling altogether
well. The father of young children, his home
sleep was frequently interrupted, and his
75-minute controlled rest (nap) on the
aircraft meant it was highly likely he was
suffering from sleep inertia. See case study
on page 26.
FATIGUETHE RULES ARE CHANGING
14
Aviation industry trends suggest fatigue-related accident risk may increase in the future.
As the airline industry becomes more competitive, operators are more likely to extend
pilot work period limits and utilise more shift work in order to improve productivity.
Aircraft are also becoming more sophisticated, and are capable of ying for longer
periods, therefore increasing the demands on ight crew.
Flight_crew_rest_and
flying_duties
Flight crew scheduling must consider various important factors, such as time of
sustained wakefulness, time on task, types of tasks, extensions of normal duty periods
and cumulative duty times.
Time since awakening is a signicant factor in building fatigue levels. It can be
prolonged before ying by issues such as:
the effects of crossing time zones
early waking due to disturbances in the sleep environment
the extra time needed to get up, check out of a hotel and travel to the airport
pre-ight delays, such as mechanical problems or inclement weather
A good nights sleep is the only cure for fatigue and its impact on performance.
An adequately restorative sleep will usually last for an average of seven to eight
hours and will include transition, light sleep, slow wave sleep (SWS), and rapid eye
movement (REM) sleep. If the balance between these phases is upset it can lead to
fatigue. Decits in REM or SWS can lead to decreased mental performance, impaired
psychological wellbeing, and increased complaints of fatigue.
Sleeping in the afternoon increases SWS and reduces
REM sleep. Morning sleep (perhaps after an overnight
ight) increases REM and reduces SWS. To avoid
fatigue the balance needs to be restored.
Fatigue problems are compounded when work/sleep routines do not allow for
acclimatisation. Our internal/biological clocks can take days to adjust to a novel
work/sleep pattern, so duty times that swap rapidly from night to day can cause
desynchronosis (a mismatch between the biological clock and environmental sleep/
wake cues such as daylight) and sleep loss.
There is no magic
anti-fatigue bullet
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CIVIL AVIATION SAFETY AUTHORITY

If you y aircraft, fatigue is just something both the operator
and individual have to manage. The worst of it is the long
overnight sectors. Your circadian rhythm is right out of
whack and to manage it you must strictly adhere to standard
operating procedures, plus slow it all down and err on the
conservative side. Fatigue is insidious and you may fail
to recognise it. The multi-crew environment helps in that
others are checking your actions. Never short-cut checklists
or procedures when youre tired because thats when errors
occur. Some aspects of the new CASA ight time limitations
are not popular and from a crew perspective have been
industry driven.
Our airline has conducted a fatigue management study but
little has changed and the problem is some crew through
personal greed will y anything without considering the risk.
Some years back we had some ridiculous ying patterns
over the Tasman and the rst ofcer and I hopped off rather
than struggle to stay awake. It wasnt well received by
management, but better than sticking out the side of a hill
with another 250 followers. Other crew did the same with
that ying pattern and it was changed. You have to be strong
with them sometimes for safetys sake.
International pilot for a major airline

FATIGUETHE RULES ARE CHANGING

16
WHAT_DOES_THE_NEW_
CAO 48.1_LOOK_LIKE?
The new fatigue rules will have three tiers, ranging from simple prescription to the
more complex and sophisticated fatigue risk management system (FRMS). These tiers
recognise that fatigue is a complex aviation safety issuethat there is no one-size-
ts-all solution.
The rst tier is the basic prescriptive level (basic limitations)
The second is fatigue management, This still uses prescriptive rules, but
improves safety through a greater emphasis on operator-managed risk control
and requirements for training and promotion of awareness regarding fatigue
The third and most sophisticated level is a fatigue risk management system
(FRMS).
FRMS
FATIGUE
MANAGEMENT
BASIC
Limitations
Customisable
Data-driven
Operator obligations
Policy and documentation
Risk management processes
Safety assurance processes
Safety promotion processes
Prescriptive
Type-of-operation specific
More flexible
Less restrictive
Prescriptive
Somewhat restrictive
Hazard identification
Limitations taking into account
identified hazards
Continuous monitoring
Transitional procedures
Training for FCMs
No additional obligations
The three-tier approach to fatigue management
17
CIVIL AVIATION SAFETY AUTHORITY
The rst tier, the basic duty periods and ight time limits, may well suit smaller operators
with few staff and simple operations.
However, mid- and larger-sized operators, whose businesses are more complex, with
changing 24-hour operational demands, are likely to work under the more exible rules
of the second tier. This introduces higher risk management requirements, including
hazard ID, and continuous monitoring and improvement of fatigue management, as
well as training and safety promotion.
It is likely that most operators will fall into this group, with only a small percentage
applying to operate under an FRMS.
Benefits_of_fatigue
management_and_FRMS
A fatigue risk management system is designed to create a exible operating
environment in which potential fatigue risks can be highlighted. Operators
must anticipate and address fatigue risks and amend their systems accordingly.
An FRMS can be implemented as part of an existing safety management system
(SMS), if one exists.
A well-implemented and supported FRMS should improve ight safety, efciency,
productivity and operational exibility, as well as satisfy the organisations duty of
care to its employees and the public. It can also offer health and wellbeing benets.
The elements of an FRMS can be grouped as follows:
Safety policy and objectives
Safety assurance
Safety risk management
Safety promotion
These are similar to the sections of the safety management system (SMS) that many
operators already have.
FATIGUETHE RULES ARE CHANGING
18
You cannot train yourself
to need less sleep and
you cannot store sleep
Managing_fatigue
Fatigue is a recognised potential safety and health risk factor and needs to be
managed and controlled as part of duty-of-care responsibilities of the operator/
employer and the FCM. Increasing scientic evidence supports the benets of recovery
on performance in a number of industries.
Ways of enhancing recovery include:
sleep and rest
nutrition
periodisation
stretching
massage
relaxation techniques
travel strategies
How will FM and FRMS affect operators?
Fatigue cannot be eliminated, but the
risks associated with it can be managed
through a partnership between the
operator and ight crew member. Some
of the causes of fatigue originate within
company policies and practices; for
example, length of shift, the extent to which work is performed during the night, and the
predictability of work schedules. Other causes originate from the employees personal
situation, including commuting time, family responsibilities, and the demands of
second jobs.
The diagram opposite shows some of the main sources of fatigue. Employer and
employee share responsibility for managing fatigue to the best of their abilities.
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CIVIL AVIATION SAFETY AUTHORITY
Employer and employee responsibilities for managing fatigue
Adapted from Australian National Transport Commission
Workload breaks
Organisational factors
Life away from work
Work demands
Work duration
Workload
breaks
Sleep quality
Work duration Stafng Team climate
Commuting
Regulations
Sleep duration
Circadian
rhythms
Type of work
Socio-economic
factors
Personal factors
FATIGUE
Family and
social life
FATIGUETHE RULES ARE CHANGING
20
What are the operators responsibilities?
Operators should:
schedule work hours and time off to give employees sufcient opportunity
for restorative sleep.
manage ight duty times and breaks.
ensure employees are informed of the risks associated with fatigue and
how to participate in controlling these risks.
ensure working hours, shift rosters and shift cycles are structured and
managed to avoid or minimise fatigue.
increase surveillance to ensure that exposure to workplace contaminants,
such as noise and hazardous substances, are controlled to within
acceptable limits.
provide conditions that are conducive to sleep where necessary.
if onsite accommodation is provided, ensure employees are offered a
balanced diet.
Operators may wish to conduct a risk assessment on each route and duty period,
taking into account the risk factors associated with fatigue.
Operators should document details of the assessment in their operations manual.
You can nd more information about the legislative framework in NPRM 1202OS.
CASA estimates there are currently 663 aviation operators that would potentially be
affected by changes to the fatigue regulations.
What are the individuals responsibilities?
Flight crew should:
manage their personal time to ensure they are rested and t for duty
inform the operator of factors that may mean they are not t for duty
not put other people in danger by performing a ight duty time when
excessively fatigued
when reporting incidents, note whether fatigue was a factor.
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CIVIL AVIATION SAFETY AUTHORITY
Fatigue management is not intended to control peoples lives. Its goal is that
employees understand that they need to arrive at work in a t state for duty. This
includes managing their time away from work so that they have adequate rest and
sleep. If, for whatever reason, ight crew are not able to get enough rest, it is their
responsibility to report this as a potential risk.
Fatigue_management_within
an_existing_SMS
Around the world, safety-critical industries such as railways, road transport and airlines
are beginning to introduce scientically-based risk management approaches to dealing
with fatigue-related hazards. These approaches are known as fatigue risk management
systems (FRMS), and are often part of an organisations overall safety management
system (SMS). If your organisation does not have an SMS, it can still have an FRMS.
A typical FRMS includes education and training for staff, incident reporting systems,
and work schedules that take into account knowledge of human fatigue.
Fatigue Risk
Management System
Safety Management System
A fatigue risk management system (FRMS) can be part of
a safety management system (SMS)
FATIGUETHE RULES ARE CHANGING
22
ICAO denes an FRMS as: A datadriven means of continuously monitoring and
managing fatiguerelated safety risks, based upon scientic principles and knowledge
as well as operational experience that aims to ensure relevant personnel are performing
at adequate levels of alertness.
An FRMS often includes the use of commercial computer software systems to design
shift rosters. Software models take into account the sleep the person is estimated to
have obtained, as well as circadian variations in alertness to produce an estimate of the
fatigue level that may result from a particular shift pattern.
The following elements are common to most formal FRMS:
Organisational policies
Commitment from management and staff
Safety reporting culture policy to enable staff to report incidents
Education and training
For front line staff, as well as managers, supervisors and scheduling
personnel
Risk assessment
Identifying tasks at greatest risk from fatigue
Developing strategies to reduce the risk to these tasks
Determining how much fatigue can be tolerated to get the job done
Changes to work schedules to reduce fatigue
Applying maximum duty time limits
If necessary, using software modelling to ne-tune schedules and estimate
fatigue levels
Continual monitoring and assessment of fatigue and fatigue-related events
Incident and event reporting system
Periodic evaluation and continuous improvement of the FRMS
Fatigue cannot be
overcome with coffee
and willpower
23
CIVIL AVIATION SAFETY AUTHORITY
Strategies_for_managing
fatigue_in_the_aviation
environment
Risk control
Shift length and roster design
Flight schedules
Commuting arrangements
Work-related fatigue factors
Hours employees are required to work (and the impact of these hours on
sleep opportunities)
Duration and time of day of duty periods
Time and duration of breaks within duty times
Complexity of tasks ight crew must perform
Work environment and conditions
Conditions and environment in the hotels used for overnights
Fluctuations in the bodys circadian rhythm due to shift work
Non work-related fatigue factors
Long commutes to and from work
Sleep disorders affecting quantity and/or quality of recovery sleep
Individual factors relating to family and social responsibilities
Hierarchy of fatigue controls
Organisational controls
Employee controls
Behavioural controls
Reactive controls
Documented policy on secondary employmentcommunicated to all employees
Personal minimums for safety-critical personalas an operating crew member
on overnight trips, my personal minimum would be to consume no alcohol to ensure
I am t for duty.
FATIGUETHE RULES ARE CHANGING
24
Fatigue-fighting_tips
Sleep baby, sleep
Aim for at least seven hours each night. If you really think you can manage
on less, do an experiment. Sleep for least seven hours a night for two weeks
and compare how you feel and perform.
2
3
4
1
Plan a power nap
Napping is better than falling asleep on the job. A 10 to 15-minute nap
has been shown to improve alertness for about an hour.
Flex those pecs
Aerobic exercise increases levels of the neurotransmitters dopamine,
noradrenalin and serotonin, all of which are good for mood and energy levels.
Water on the brain
Your brain is about 80 per cent water and it doesnt work as well if you
become dehydrated. The recommended daily amount is around two litres
per day; more if your work is physically demanding, or in hot conditions.
25
CIVIL AVIATION SAFETY AUTHORITY
Pigs cant y
Your diet can have a signicant impact on how you feel. Large meals require
energy to digest and a full stomach draws blood away from the brain, leaving
you feeling tired. Smaller meals, more often, can avoid this effect.
5
6
7
8
Begin with breakfast
Breakfast acts as an energy booster that defends against fatigue throughout
the day. A healthy breakfast should contain protein (from eggs, meat, or
other sources) and complex carbohydrates (as opposed to sugars).
Use caffeine strategically
The caffeine in coffee, soft drinks and tea has been proved to be useful
in increasing alertness, reaction speed and thinking ability for up to three
hours, but it is not the ultimate solution to fatigue. Too much can cause
restlessness and sleeping difculties. If ingested near the end of the day or
shift, caffeine can lead to sleeplessness which increases fatigue.
Do it in the dark
Sleeping in the day is unnatural our bodies are designed to react to light.
Therefore, try to limit your exposure to daylight after a night shift and keep
your bedroom as dark and quiet as possible.
FATIGUETHE RULES ARE CHANGING
26
A fatigued Air Canada rst ofcer on a transatlantic ight sent his plane into a dive after
mistaking the planet Venus for another plane, according to an ofcial report.
Fourteen passengers and two crew members were injured after the confused and
disorientated rst ofcer pushed the controls sharply downwards to avoid a U.S. plane
that he wrongly thought was on a collision course with the jet.
____________
A report released by Canadas Transportation Safety Board (TSB) has shed light on the
January 2011 incident on the 767 jet which was half way over the Atlantic en route
from Toronto to Zurich, Switzerland at night.
____________
According to the report, the rst ofcer had just woken up after a 75-minute rest
more than the 40-minute maximum permitted by airline regulations when the captain
warned him there was a U.S. Air Force C-17 in the area.
The rst ofcer disorientated after falling into a deep sleep saw a bright object
ahead of the plane later believed to have been the planet Venus and mistook it for
the plane, the report read.
____________
The captain corrected him and advised that the plane was in fact at 12oclock and
passing in the opposite direction roughly 1000 feet below them.
____________
When the FO [rst ofcer] saw the oncoming aircraft, the FO interpreted its position as
being above and descending towards them, the report continued.
____________
The rst ofcer then pushed forward on the controls, forcing the plane to descend 400ft
and towards the C-17.
Fatigue_CASE_STUDY
27
CIVIL AVIATION SAFETY AUTHORITY
The captain immediately disconnected the autopilot and pulled back on the
control column to regain altitude. It was at this time the oncoming aircraft passed
beneath them.
None of the injured passengers were wearing seat belts, even though the seat belt
sign was switched on.
____________
After interviews with the ight crew, the safety board concluded that the crew did not
fully understand the risks of tiredness during night ights.
____________
It added that crew misunderstood why controlled rest was limited to 40 minutes
to avoid increasing the risks of sleep inertia (temporary grogginess and disorientation
felt when waking up).
____________
They were aware of the term (sleep inertia) but not of how signicantly impaired a
recently awakened pilot could be, the report said.
Fit_to_fly?_The_finer
points_of_fatigue
There is no magic anti-fatigue bullet
Fatigue is not a sign of weakness
Fatigue cannot be overcome with coffee and willpower
There is no blood test for fatigue
A can-do attitude We are paid to do our job, so we can handle it
can be very dangerous
You cannot train yourself to need less sleep and you cannot store sleep.
FATIGUETHE RULES ARE CHANGING
28
Glossary
AOC Air operators certicate
Augmented crew Comprises more crew members than the basic ight crew. Each crew
member can therefore be replaced by another suitably qualied crew
member for some part of the ight
ATSB Australian Transport Safety Bureau
CAAP Civil Aviation Advisory Publication
CAO Civil Aviation Order
CASA Civil Aviation Safety Authority
CASR Civil Aviation Safety Regulations 1998
Circadian low Time (02000500) when performance can be at its poorest, and body
temperature is at its lowest. [Also parallel afternoon nap window
(15001700 for most people) when sleepiness/fatigue peaks.]
Circadian rhythms Body functions (e.g. sleep/wakefulness, motor activity, hormonal
processes, temperature, and performance) that are controlled by
internal biological clocks and vary over a 24-hour cycle. As a result,
levels of human performance also vary signicantly during that
24-hour period.
FCM Flight crew member (pilot/ight engineer)
Flight duty period A period which starts when a ight crew member is required to report
for a duty period in which a ight as an operating crew member (OCM)
is undertaken, and nishes no fewer than 15 minutes after the end of
the scheduled time of the nal ight as an OCM.
FM Fatigue management
FRMS Fatigue risk management system
ICAO International Civil Aviation Organization
NFRM Notice of Final Rule Making
NPRM Notice of Proposed Rule Making
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CIVIL AVIATION SAFETY AUTHORITY
Off duty period Time during which a ight crew member is free of all employment
related duties and standby provisions
OH&S Occupational health and safety (also now workplace health and
safetyWHS)
Periodisation Strategies for bringing performance to peak at a predened point
in time
SARP Standards and recommended practice
SCC Standards consultative committee
Sector One segment of a ight, comprising one take-off and one landing
SIE Standard industry exemption
SMS Safety management system
Split duty Flight duty period which includes a rest period during which the ight
crew member is relieved of all duties.
Standby Time during which a ight crew member is required by an operator
to hold him/herself available for a ight duty period
WOCL Window of circadian low. See entry for circadian low
Further reading
For the latest information on fatigue, access to a fatigue management toolkit, and links to an
extensive number of fatigue resources from around the world, see www.casa.gov/fatigue
@CASABrieng Follow CASA at
GPO Box 2005 Canberra ACT 2601 T 131 757 E feedback@casa.gov.au W www.casa.gov.au
at www.youtube.com/CASABrieng