Fatigue Risk Managing Systems

Richard Jones
Fatigue Risk Management System

Introduction into a Long-haul Airline
Submitted as part of the requirement for the award of MSc in Air

Transport Management at City University London
I certify that this project is wholly my own work, that all material
that has been extracted from others has been clearly referenced,
that it is in accordance with the project guidelines and that I have
read the Project Guidelines in full.
Signed: R M G Jones
Supervisor: Professor Roger Wootton
Date: 10 October 2009
Word count: 14,952
Unrestricted circulation
Executive Summary
Today’s UK pilot fatigue management Flight Time Limitations (FTL) regulations

were set out in the 1970s and, as research into fatigue was in its infancy, were
based more on operational practices developed since the 1950s rather than on
scientific or medical understanding such as it was at the time. These regulations
have remained substantially unchanged to the present day and, it has to be said,
served the industry well, but with the introduction of the low cost carrier (LCC)
business model of intensive short haul operations and the ultra long range
operations now being conducted, the robustness of these regulations is being
pressure tested to breaking point particularly now in light of the commercial
challenges brought about by the downturn in the world economy.
International bodies and regulators are recognising that FTLs in their present
form are outliving their usefulness, indeed being used to regulate, probably, a
much wider spectrum of activity than was ever originally intended. In its place
they are now embracing the idea of moving towards fatigue management
schemes that are a more credible means of preventing the insidious and
debilitating effects of fatigue on flight operations due to being formulated by
reference to medical and scientific knowledge.
Recently it has been reported that the International Civil Aviation Organisation
(ICAO), in response to at least 10 serious fatal, fatigue related accidents to
commercial operations since 1993, is to mandate the requirement for states to
have scientifically based FTLs as well as dedicated, operationally tailored fatigue
risk management systems (FRMS). In response the rulemaking directorate of the
European Aviation Safety Agency (EASA) is proposing to compel European
operators to adopt the use of FRMS for managing pilot fatigue.
This project, through a study of fatigue theory and discussion of UK flight crew
FTL schemes’ history, development and employment, highlights the
disadvantages of the continued use of prescriptive FTLs and describes how an
holistic FRMS specifically adapted to each operators’ operational circumstances
and integral to their safety management system can not only satisfy the
regulatory requirements but also bring about direct and diverse tangible benefits
to the company whilst paving the way for introducing the latest scientifically
backed approach to pilot fatigue management.
FRMS Introduction ii R M G Jones

The main conclusions drawn from this project are:
- A substantial body of evidence exists to cast doubt on the

effectiveness of current, prescriptive FTLs and their
suitability for continued use in the future;
- A FRMS that either enhances current FTL schemes or

replaces them entirely is essential for the diverse types of
operations that are likely to prevail in the future;
- Successful FRMS implementation relies on:
o A comprehensive change management process

that promotes:
 A major cultural shift in organisational,
safety management thinking which requires
a strong focus on education;
 Whole hearted acceptance of FRMS
philosophy by all stakeholders in the
operation;
 A company culture that is receptive to and
embraces the “shared ownership” and “just
culture” doctrines.
o Close regulator monitoring during implementation

phase of FRMS.
- Computer fatigue modeling can play a proactive role in a

long-haul airline’s FRMS.
- Significant benefits can be derived from FRMS

introduction.
FRMS Introduction iii R M G Jones

Table of Contents
Section Title Page

Executive Summary ii
Table of Contents iv
List of Figures vi
List of Tables vii
Glossary viii
1.0 Introduction 1
2.0 Project Aim 3
3.0 Method 3
4.0 Fatigue in Aviation 5
4.1 Theory 5
4.2 Consequences of Fatigue 9
4.3 Fatigue Counter Measures 9
5.0 Flight Time Limitations 11
5.1 History 11
5.2 Development 11
5.3 Current Operations 11
5.4 Commercial Challenges 12
5.5 Effectiveness 14
5.5.1 Accident/Incident Reports 16
5.5.2 Confidential Reporting 17
5.5.3 Survey 18
6.0 Fatigue Risk Management Systems 18
6.1 Definition and Theory 18

6.1.1 Human Factors Perspective 20
6.1.2 Legal Perspective 21
6.2 System Description 21
6.2.1 Risk Assessment/Management 25
6.2.2 Physiological Monitoring and Alertness Testing 26
6.2.3 Computer Fatigue Modelling 27
6.2.4 Operational Introduction 28
6.2.5 Operational Benefits 30
6.3 FRMS in Operation 31
FRMS Introduction iv R M G Jones

7.0 Introduction of FRMS into a Long-haul Operation 32
7.1 Regulatory Background 35

7.2 Safety Case 36
7.3 FRMS Integration into Airline SMS 37
7.4 System Ownership 38
7.5 Education and Training 38
7.6 Risk Assessment/Management 39
7.7 Company FRMS Policy 40
7.8 Regulator Oversight 41
7.9 Pros and Cons of FRMS Adoption 42
7.10 Acceptance Issues – Union/Employer 43
8.0 Future Applications of FRMS 44
9.0 Conclusions 45
10.0 Recommendations 47
11.0 Future Potential Areas of Study 48
12.0 References 49
13.0 Bibliography 53
Appendices
A Mechanism of Sleep 54
B UK Flight Time Limitation Schemes’ History
and Development
History 55
Avoidance Of Excessive Fatigue In Aircrews 56
Development 58
C VAA Pilot Fatigue Survey 60
Fatigue Survey Questionnaire 64
Epworth Sleepiness Scale 70
Samn-Perelli Seven-Point Fatigue Scale 70
D Sample FRMS Policy Statement 71
E Analysis of FRMS in Operation
Civil Aviation Authority, New Zealand 72
Civil Aviation Safety Authority, Australia 72
Air New Zealand 73
Ultra Long Range Flights, Singapore Airlines 74
easyJet 78
F Example of SAFE Analysis of Trip Rotations 80
FRMS Introduction v R M G Jones

List of Figures
Figure Title Page
1. Change in Alertness with Increasing Wakefulness due to 7

Homeostatic Process
2. Diurnal Variation of Alertness due to Circadian Rhythm 7
3. Typical Nocturnal Pattern of Sleep of Young Adult as 54

indicated by Electroencephalogram (EEG) Recording
4. Survey Indication of Annual Pilot Sickness by Fleet 61

(Virgin Atlantic Airways)
5. Samn-Perelli Seven Point Fatigue Scale Survey Results 63

FL2 HKG/SYD
6. An Incident Trajectory 19
7. Risk Reduction Process 19
8. Effective Fatigue Risk Management Systems 20
9. Hazard-Control Model for Fatigue Risk Management 23
10. An FRMS Organisational Chart 24
11. The Risk Management Process 26
12. Actiwatch, Palm Pilot and PVT Computer 27
13. FRMS Change Management Process 29
14. FRMS Organisational Implementation Map 30
15. easyJet’s Risk Assessment/Management Model – SIRA 79
16. Overview of FRMS Introduction and Time Line 35
17. Relationship Envisioned Between Regulator and Airline 42

with SMS
18. SAFE Analysis of Current LHR-HKG-SYD Schedule 80
19. SAFE Analysis of Current LHR-HKG-SYD Schedule 81

Modified by Inclusion of Pilot on Last Sector
20. SAFE Analysis of Current LHR-LGW-MCO Schedule 82
FRMS Introduction vi R M G Jones

21. SAFE Analysis of Current LHR-LGW-MCO Schedule 83
Modified by Inclusion of Third Pilot on All Sectors
Allowing In-flight Relief on Return Sector
List of Tables
Table Title Page
1. Mechanism of Sleep 54
2. Fatigue Related UK Registered Aircraft Accident/Incidents 16
3. Fatigue Related Non UK Registered Aircraft Accidents 16
4. Accident/Incidents where Fatigue Being Investigated as 17

Possible Cause
5. Responsibilities for Fatigue Risk Management 21
6. Sequence of Events – FRMS Introduction 34
7. LHR-HKG-SYD Trip Rotation Schedule 80
8. LHR-MCO Trip Rotation Schedule 82
9. SMS Principles Embedded in FRMS 37
10. FRMS Departmental Policy Guidance 41
FRMS Introduction vii R M G Jones

Glossary
AAIB - Air Accident Investigation Board (UK)

AME - Aviation Medical Examiner
ANO - Air Navigation Order (UK)
ANZ - Air New Zealand
AS - Australia Standard
ASR - Air Safety Report
ATSB - Australian Transport Safety Board
BALPA - British Air Lines Pilot Association
CAA - Civil Aviation Authority (UK)
CAANZ - Civil Aviation Authority, New Zealand
CAAS - Civil Aviation Authority of Singapore
CAO - Civil Aviation Order (Australia)
CAP - Civil Aviation Publication (UK)
CAR - Civil Aviation Regulations (Canada)
CASA - Civil Aviation Safety Authority (Australia)
CHIRP - Confidential HF Incident Reporting Programme (UK)
CRR - Controlled Rest Recovery
EASA - European Aviation Safety Authority
EEG - Electroencephalogram
EMG - Electromyogram
EOG - Electrooculogram
EU - European Union
FAA - Federal Aviation Administration (USA)
FAID - Fatigue Audit InterDyne (Centre for Sleep Research)
FAST - Fatigue Avoidance Scheduling Tool (USAF)
FCFSG - Flight Crew Fatigue Study Group (ANZ)
FDM - Flight Data Monitoring
FDP - Flight Duty Period
FDT - Flight Duty Times
FL2 - Florida 2 Variation (UK CAA FTL Dispensation)
FMS - Fatigue Management System
FMSC - Fatigue Management Steering Committee
FOQA - Flight Operations Quality Assurance
FRAM - Functional Resonance Accident Model
FRMS - Fatigue Risk Management System
FSF - Flight Safety Foundation
FTL - Flight Time Limitation
HFMP - Human Factors Monitoring Programme
HILAS - Human Interaction in Lifecycle of Aviation Systems
HoW - Hours of Work
IATA - International Air Transport Association
ICAO - International Civil Aviation Organisation
JAA - Joint Aviation Authorities (Europe)
LCC - Low Cost Carrier
LOSA - Line Orientated Safety Audit
MBTR - Minimum Base Turn Round
MEL - Minimum Equipment List
FRMS Introduction viii R M G Jones

MSLT - Multiple Sleep Latency Test
NAA - National Aviation Authority
NASA - National Aeronautics and Space Agency (USA)
NTSB - National Transportation Safety Agency (USA)
NZS - New Zealand Standard
PACTS - Parliamentary Advisory Committee on Trnspt Safety
PATANZ - Pilot Alertness Test, Air New Zealand
PF - Pilot Flying
PNF - Pilot Not Flying
PVT - Psychomotor Vigilance Task
SAFE - System for Aircrew Fatigue Evaluation (QinetiQ)
SARP - Standards And Recommended Practices (ICAO)
SIA - Singapore Airlines
SIRA - System for Integrated Risk Assessment (easyJet)
SMS - Safety Management System
SP - Samn-Perelli
SWS - Slow Wave Sleep
TC - Transport Canada
TLX - Task Load Index (NASA)
TOD - Top Of Drop
ULR - Ultra Long Range
VAA - Virgin Atlantic Airlines
WOCL - Window Of Circadian Low
IATA Airfield Decodes
LHR - London, Heathrow

LGW - London, Gatwick
HKG - Hong Kong
SYD - Sydney
MCO - Orlando
FRMS Introduction ix R M G Jones

1.0 Introduction
In the United Kingdom, since the early 1950s control over commercial aviation
pilots’ hours of duty, for the purpose of avoiding fatigue, has been exercised via
means of prescriptive flight time limitation (FTL) schemes. These Civil Aviation
Authority (CAA) approved schemes have set hours of work (HoW) limitations on
flight duties, rest periods, cumulative duty hours and length of duty cycle (Bader,
1973). To cater for the burgeoning variety and complexity of commercial air
transport operations, these schemes have become ever more complicated to the
point where their ability to protect pilots from risk-inducing levels of fatigue has
become questionable.
Exacerbating this situation has been the move by the European Aviation Safety
Authority (EASA) the former European Joint Aviation Authorities (JAA), to
harmonise all European countries’ FTLs under one standard set of rules for flight
time limitation known as “EU-OPS, Subpart Q” which became effective in July
2008. As the UK’s approved schemes legislate to stricter limits than those set out
by EU-OPS these have been allowed to continue in force. However in April 2012
European operators will be required to adopt either EU-OPS, Subpart Q rules or
adopt “alternative schemes” (EASA, 2009).
A further level of complication has arisen as the International Civil Aviation

Organisation (ICAO) has given notice that it is to recommend that operators
employ a fatigue management scheme that is “…based upon scientific principles
and knowledge where available…”(CAA, 2009c) acting upon which EASA has
mandated that operators implement fatigue risk management systems (FRMS)
by April 2012.
As a scientific and medical evaluation of Subpart Q rules commissioned by EASA

has criticised their effectiveness in regulating fatigue (Moebus, 2008), at present
the only viable option for European airlines, to comply with ICAO
recommendations, is to adopt an FRMS fatigue management scheme as an
“alternative scheme”.
This project sets out the case for FRMS introduction. It begins with a discussion
on the theory of fatigue and how it impacts on the safety of airline operations.
This leads on to a review of the history of UK FTLs, showing how they have
developed through the years to the present day and examines the challenges that
the current schemes face. An assessment of the effectiveness of FTLs is made by
way of a study of accident and incident reports, pilot confidential reporting and a
fatigue survey of Virgin Atlantic Airways (VAA) pilots. The reports and results
suggest that there is substantial evidence of the prevalence of unacceptable
fatigue risk in current operations although it is acknowledge that this evidence
can only ever be circumstantial.
There follows a description of FRMS, explaining the definition and theory, legal
and human factors background and structure of the system and how it interacts
with a company’s safety management system (SMS). Emphasis is made of the
holistic, safety performance driven nature of the system, its philosophy of
FRMS Introduction 1 R M G Jones

“shared ownership” and “just culture” reporting. Also explained is the risk
assessment/management function which lies at the heart of FRMS and the
physiological monitoring and alertness testing tools and computer fatigue
modelling programmes that are key elements in that process. It is suggested how
FRMS might be implemented into an airline through a process of change
management. The operational benefits that accrue from its introduction as they
apply to the employee, flight operations department, company and regulator, are
highlighted.
An appraisal of FRMSs already in operation is made by analysis of company

schemes at Singapore Airlines (SIA) and easyJet and fatigue management system
regulation put in place or trialled by the New Zealand Civil Aviation Authority
(CAANZ) and the Australian Civil Aviation Safety Authority (CASA). Critical
reviews of these first examples of FRMS point to the enormity of the cultural
change and task of education required to bring about this new concept of safety
management and that thorough planning is needed prior to implementation.
The detail, sequence and timeline of FRMS introduction are contemplated by

learning the lessons of previous operators’ findings and adopting best practice.
An appreciation of the regulatory environment is described that explains the
legislative imperative for adoption. The process of implementation is proposed
with reference to the easyJet and SIA examples. The purpose and objectives of a
safety case are outlined and examples are provided of trip rotation analysis by
QinetiQ’s System for Aircrew Fatigue Evaluation (SAFE) computer fatigue
modelling programme, to demonstrate the results of fatigue mitigating measures.
Subsequent sections cover FRMS integration into a company’s SMS

organisational structure, system ownership, the importance of education and
training, and a proposal for how the SAFE programme could be incorporated into
a risk assessment/management process. Company FRMS policy is laid out with a
depiction of how policy guidance might be drawn up for key operational areas of
the airline.
Crucially, a case is advanced for regulators to step up their oversight function

during a company’s FRMS implementation phase.
An appreciation of the pros and cons of FRMS introduction and an anticipation of

union/employer acceptance issues are considered and a suggestion is advanced
as to how universal flight crew physiological monitoring could enhance FRMS in
the future.
FRMS is recommended as the most appropriate pilot fatigue management system

to accommodate the increasing complexity of present and future long-haul
airline operations. Other recommendations are made for the airline industry and
regulators to encourage and facilitate FRMS adoption.
Finally future potential areas of study are proposed particularly with respect to
the relationship between fatigue and safety.

The 5 objectives of the project are:
- Establish the case for replacing current FTLs.
- Explain the theory and development of FRMS.
- Envisage how an FRMS can be introduced into a long-haul

operation as an integral part of the SMS.
- Examine the arguments for and against FRMS acceptance

with respect to airline employers and pilot unions.
- Explore how an FRMS could be developed to accommodate

fatigue modeling systems that accurately predict pilot
fatigue levels over the course of a roster period resulting
in “smarter” rostering and daily (dynamic) crewing.
.
2.0 Project Aim
The aim of this project is to state the case for introduction of a Fatigue Risk
Management System (FRMS) into a long-haul airline.
3.0 Method
Information for this project has come from a variety of sources including reports,
publications and articles in the aviation media. With a background knowledge
gained as a result of a career in commercial aviation and with first hand
experience of the issues, the author has a professional interest and concern for
the matters discussed.
An appreciation of the theory of fatigue, the historical context of FTLs and data
on accident/incident reports as well as confidential reporting has all been
sourced from commercially available literature, ICAO, EASA, CAA and other
industry body produced publications and project reports researched from the
internet and fellow students.
To add relevance and applicability to this project a fatigue survey of VAA’s pilots
was conducted using an online questionnaire via the facility of
surveymonkey.com.
Information on FRMS was gleaned principally from papers written by the main
proponents of FRMS, transcripts of presentations made to workshops and
conferences on crew management, through direct contact with the speakers, as
well as information already in the public domain on the internet and in trade
journals.

The Australian Civil Aviation Safety Agency (CASA), Australian Transport Safety
Board (ATSB), the New Zealand Civil Aviation Authority, Transport Canada,
Clockwork Research Limited, Flight Safety Foundation (FSF) and The Centre for
Sleep Research at The University of Southern Australia in Adelaide all have a
considerable wealth of data and material readily available on the internet
detailing past and current thinking on FRMS and this has been a valuable
resource.
Particularly helpful have been the papers written by Simon Stewart detailing the
introduction of FRMS into the easyJet operation.
Finally, Dr. Karen Robertson of QinetiQ has been of invaluable assistance in

providing advice and SAFE computer modeling analysis of specific trip patterns.

4.0 Fatigue in Aviation
4.1 Theory
Definitions abound for what fatigue is. In 1972 the Bader Commission considered
fatigue to be:
“…a markedly reduced ability to carry out a task. It is a condition of reduced

performance from which there is no certainty that a person can be aroused
in an emergency, even when considerable stimulus is present.”
(Bader, 1973)
Today the European Aviation Safety Authority (EASA) and the International Civil
Aviation Organisation (ICAO) FRMS subgroup, describe fatigue as:
“A physiological state of reduced mental or physical performance capability

resulting from sleep loss or extended wakefulness and/or physical activity
that can impair a crew member’s alertness and ability to safely operate an
aircraft or perform safety related duties”
(EASA, 2009)
Fatigue can either be physical, with an inability to continue functioning at the

level of one’s normal abilities due to a lack of strength usually as a consequence
of heavy exercise; or mental, which manifests itself either in somnolence, a state
between wakefulness and sleep including microlapses or micorsleeps, or just as a
general decreased level of concentration not necessarily connected with
sleepiness. This latter condition, most commonly associated with flight crews,
has implications for the operation of vehicles and is the main area of concern
with regard to fatigue in aviation.
The symptoms of mental fatigue can take the form of:
- Difficulty concentrating on task;

- Lapses in attention;
- Difficulty remembering what you are doing;
- Failure to communicate important information;
- Failure to anticipate events or actions; and
- Accidentally doing the wrong thing or not doing the right thing.
Also, in terms of work place interaction with colleagues, mental fatigue can make
one:
- More quiet or withdrawn;
- Lacking in energy;
- Lacking in motivation to do the task well; and
- Irritable or grumpy.
(Transport Canada, 2007c)

Ninety five percent of reported fatigue cases are as a result of inadequate
amounts of sleep (Caldwell et al, 2003). Other causes of mental fatigue include
mental stress, over/under stimulation, disease, dietary deficiencies, obesity and
jet lag. Whatever the causes, the drive for sleep emanating from fatigue cannot be
consciously controlled. It is as basic a physiological need as eating or drinking.
No amount of commitment to the task can counteract the effects of fatigue
induced decrements in alertness and progressive onset of sleep.
Several factors combine to influence an individual’s state of fatigue. These are:
- Homeostatic process; the amount of time spent awake since the last
sleep period;
- Circadian rhythm; the phase of the internal body clock;
- Sleep inertia; the initial period of consciousness while recovering from
deep sleep;
- Sleep debt; the accumulation of fatigue due to prior inadequate rest
periods either through inappropriate timing or length of rest;
- Task load; the rate of working since the last sleep period;
- Personal sleep physiology;
 Tolerance to above factors;
 Whether one is a “morning” or “afternoon”
person;
 Ability to adapt to restricted sleep.
The first 2 of these factors in combination, homeostatic process and circadian

rhythm, are considered to have the greatest influence on alertness levels. The
former can be thought of as an internal drive for sleep, which increases across a
normal day of wakefulness and contributes to maintaining sleep at night. The
latter is a function of the brain that controls the diurnal peaks and troughs of a
range of physiological and behavioural variables, including temperature,
hormone levels, the sleep wake cycle and intellectual performance (Dijk, 1997).
It is the variation of body temperature that is used as a proxy for the biological
clock in circadian rhythm studies. These studies have shown that the body uses
external environmental cues or zeitgebers such as daylight, meal times and
work/rest schedules to keep the body synchronised to the local time zone. It is
recognised that the desynchronistion of this process leads to fatigue, malaise,
sleepiness, lack of motivation, confusion, insomnia and digestive disorders
(Caldwell et al, 2003).
The graphs that follow show how homeostatic process and circadian rhythm
effect alertness in isolation:

Figure 1. Change in Alertness with Increasing Wakefulness due to
Homeostatic Process
(CAA, 2005b)
Figure 2. Diurnal Variation of Alertness due to Circadian Rhythm
(CAA, 2005b)
By taking the example of shift workers awaking at 8am and finding difficulty
obtaining further sleep during the day prior to going on night shift in the evening,
the amplitude of their combined alertness values, represented by these 2 graphs,
reaches a nadir in the early morning between 3 and 5am; the window of
circadian low (WOCL). Interestingly, this period has been the local time window
when several major disasters in recent history have occurred such as the Three
Mile Island and Chernobyl nuclear power station accidents, the grounding of the

Exxon Valdez supertanker off Alaska and was the timing of the decision making
process that led to the Challenger Space Shuttle explosion.
A description of the mechanism and structure of sleep can be found at Appendix

A.
Another important contributor to fatigue is sleep inertia, the sensation of

grogginess experienced after awakening from a deep, slow wave sleep (SWS).
This can last for several minutes and dramatically impair a pilot’s performance
particularly in the context of the working environment of a flight deck
The normal requirement for sleep is around 8 hours per night varying between
individuals from 7 to 9 hours. If this is not achieved due to shift patterns or trans
meridian time shifts disrupting the restorative quality of sleep then a sleep debt
accumulates which cannot be dismissed as a physiological weakness that can be
overridden. This cumulative sleep loss can become substantial overtime leading
to degraded performance and increased risk exacerbated by an individual’s
inability to gauge their own level of impairment (Caldwell et al, 2003).
With regard to long-haul crews’ work routine, early studies found that, to offset
the effects of cumulative fatigue, transient sleep loss over a period of consecutive
duty days would be unlikely to occur if the rate of working reduced in a
logarithmic manner in relation to the increase in days of the schedule. This
relationship became known as the Nicholson Curve and informs the regulations
of present day FTL schemes (CAA, 2005b).
The fatiguing effects of work orientated task load are complex with wide
variations in perceptions of ease or difficulty of a particular duty and the actual
contribution it makes to overall fatigue depending on the individual’s training,
experience, personal outlook and, the organisation’s culture. A NASA paper
concerning the development of the NASA Task Load Index (TLX) discusses these
factors (NASA, 1988).
Every individual has different tolerances to the many factors influencing fatigue
and succumb to their effects at varying rates and degrees. An important aspect of
fatigue management, discussed later, is an individual’s awareness of their
susceptibility to fatigue and the characteristics of their physiological propensity
for sleep such as whether they are a “morning” or an “afternoon” person and how
well they can function with reduced rest.
Unfortunately for the long-haul airline the nature of the operation is predisposed
to creating fatigue. The task is characterised by long periods of sometimes
continuous duty involving crossing several time zones, opportunities for rest that
are out of synch with the internal body clock and flights conducted at times when
the body is more normally expecting to be asleep.

4.2 Consequences of Fatigue
In a safety critical, risk-averse industry that thrives on defining and quantifying

every component feature of its existence the imprecise, diverse and insidious
nature of fatigue is an anathema. Yet the industry has been able to recognise the
many characteristics of fatigue which impair the cognitive skills of memory,
decision making, and communication and that compromise the effective
functioning of individuals performing complex tasks such as operating aircraft.
Some of the threats that fatigue presents are:
- Unconscious acceptance of lower standards of performance as

accuracy and timing degrade;
- Inability to make sense of and integrate information;
- Narrowing of attention accompanied by forgetfulness and
absentmindedness;
- Inconsistent performance particularly during night hours;
- Slower problem solving and reasoning;
- Degraded psychomotor skills;
- Increased rate of false responding;
- Poorer risk awareness and less risk aversion;
- Reduced social interaction accentuated by a highly automated
environment; and,
- Loss of task resource prioritisation.
Increased incidences of irritability, impatience and reduced social inhibitions

have been manifestations of reduced ability to control mood and behaviour due
to sleep deprivation and that these symptoms have been magnified when the
tasks being performed have been more demanding and complex. Significantly,
the biological effects of fatigue will impair even the most highly skilled and
motivated individuals irrespective of their training and experience and cannot be
overridden by inducements (ATSB, 2006).
Examples of embedded fatigue risk in regulation, systems and procedures that

have developed into incidents and accidents are recorded later in this project.
4.3 Fatigue Counter Measures
In commercial aviation the responsibility for fatigue avoidance is shared

between the operator and the flight crew member. The airline is bound by
regulation and law to adopt practices and procedures that prevent the onset of
fatigue and the crew member has a duty to arrive for duty in a fit and rested
state.
From the perspective of the individual, the counter measures that can be
employed to offset fatigue are, in the main, lifestyle type choices that reduce
stress through promoting regimes such as:

- Maintaining a healthy diet and taking regular exercise;
- Keeping to a regular sleep routine at home:
- Adopting good “sleep hygiene” i.e. measures that make sleep more
conducive when preparing for sleep:
 Ensuring no noise disturbance and interruptions,
wearing ear plugs if necessary and placing “Do Not
Disturb” signs;
 Blocking out daylight, if sleeping in daytime;
 Setting room temperature to a colder setting than
normal (16-20C);
 Preventing drafts from windows, fans and air
conditioning units;
 Limiting alcohol consumption before sleep;
 Avoiding heavy meals before turning in; and,
 Trying to obtain a comfortable bed.
If sleep deprivation does lead to fatigue the pilot should seek aviation medical
examiner (AME) advice on possible sleep disorders and/or use of medication.
For the long-haul pilot contending with sleep pattern and circadian rhythm
disruption, a good knowledge of sleep physiology and awareness of their own
personal physiological traits are important to predict the best times to take rest
periods when sleep can be achieved and, if the facility is available, bid for the
roster patterns that most appropriately conform to the diurnal variations of their
metabolism.
For the airline some alleviation from fatigue risk is achieved through
sympathetic and preferential rostering where pilots can influence their
allocation of trips. Scheduling and rostering department staff should be trained
in company procedures that protect pilots from trip pairings and the
juxtapositioning of consecutive trips which can induce considerable fatigue
despite being “legal”.
The traditional method of fatigue counter measure for the organisation has been
compliance with a regulator approved FTL scheme. These schemes have relied
more on preventing fatigue by limiting HoW than providing opportunities for
rest. Indeed, for the long-haul airline, the minimum periods set out for recovery
from duty do not respect the body’s time dictated biological propensity for sleep
and are more closely aligned with recovery from physical fatigue, possibly
reflecting the heritage of FTLs dating back to the 1950s when the distinction
between physical and mental fatigue was less appreciated.
Alternative means of fatigue management are starting to be introduced into the

industry that take a more holistic, multi-faceted and flexible approach based on
scientific findings. The main features of this approach comprise of; clear
workplace policies and procedures, good rostering practices, an informed work
group, active management involvement and effective monitoring of safety-
related outcomes (ATSB, 2006). These are the elements that make up what has
generally become known as a fatigue risk management system (FRMS).

5.0 Flight Time Limitations
5.1 History and Development
The catalyst for the start of UK FTL regulation was the statement in both the
accident reports of 2 passenger aircraft crashes in the early 1950s, that pilot
fatigue may have been a contributory cause. From their beginning the schemes
have had to define a delicate balance between commercial interests and safety. In
designing the Civil Aviation Authority’s (CAA) Civil Aviation Publication (CAP)
371 document, “The Avoidance of Excessive Fatigue In Aircrews”, it was
acknowledged that much weight had been put on industry best practice which
had little medical foundation. The small concession made for the effects of
circadian rhythm disturbance of long-haul operations was also criticised.
The development of CAP 371 to its present day form has been driven by events
in the aviation industry. Over the years the intent of the regulation has frequently
been open to poor interpretation and abuse resulting in a high oversight
commitment from the regulator. Appendix B charts the history and development
of UK FTLs.
5.3 Current Operations
As the fourth edition of CAP 371 matches or exceeds the commonly established
procedures under European legislation it continues in force as the UK’s national
provision on FTLs until such time that the Community rules based on scientific
knowledge and best practise are established (CAA 2009a). These new rules,
EASA EU Ops Subpart Q, have been constructed with the intention of
harmonising all European national FTLs into one legislative document but as
Captain R Williams of the Air Safety Group that advises the Parliamentary
Advisory Council for Transport Safety (PACTS) commented in June 2007 “… the
way Subpart Q is currently written will allow all sorts of excesses, the intent in
places is unclear and it is anticipated that fatigue in crews will become evident
within a relatively short time following its introduction…”(Williams, 2007). Indeed
a recent scientific and medical evaluation, commissioned by EASA, conducted by
a team of internationally recognised experts in the field of human factors study
drew the same conclusions in their report (Moebus, 2008).
Presently the responsibility for management of fatigue risk is still placed on both
operators and crew members and is mitigated by the adoption of an approved
FTL scheme which is properly owned, implemented and monitored by the
operator and provides for good rostering and other best practice
recommendations of CAP371. The CAA oversees FTL compliance through audits
of operator’s Quality System and Safety Management System/Fatigue Risk
Management System as appropriate (CAA, 2009a).
Apart from the ANO, CAP 371 and EASA EU Ops Subpart Q other legislation has
appeared in recent times which also sets limits on a crew member’s flight and

duty time such as the Civil Aviation (Working Time) Regulations and Health and
Safety at Work Regulations. Very much akin to the state of affairs leading to the
“Bader Report” there is now a plethora of sometimes conflicting, ambiguous and
inconsistent regulation waiting in the wings and uncertainty as to which
authority will ultimately be responsible for oversight of aircrew fatigue
management (Williams, 2007).
Meanwhile developments over the last 10 years have seen regulator approval of
in seat, in-flight napping strategies recognising NASA research that showed that a
short “power nap” during a quiet period of the cruise could temporarily increase
alertness and performance for the more demanding phases of approach and
landing with particular relevance for the long range sector, 2 pilot crew aircraft
operation (CAA, 2003).
The results of other research carried out by QinetiQ and its predecessor
organisations dating back to the early 80s into the sleep and wakefulness of
aircrew are now starting to be applied in the form of a complex fatigue modelling
programme, SAFE, which is being employed to predict the fatigue levels
associated with operating new trip rotations especially those that fall outside
normal FTL schemes and require variations to the schemes (CAA, 2005b and
CAA, 2009b).
These are amongst the first examples of the outcome of dedicated

scientific/medical research having a baring on pilot fatigue management
whereas in the past changes have come about through a process of industrial
negotiation necessitated by the demands of the prevailing commercial
environment which have not always been sympathetic to the best physiological
interests of crew. Indeed many of the revisions in edition 3 of CAP 371 were
instigated as a direct result of AMEs detecting signs of fatigue amongst pilots
whilst undergoing their aircrew medical renewals (Williams, 2007).
In other jurisdictions, that comply with an FTL regime similar to the UK’s CAP
371, ultra long range (ULR), scheduled flights lasting over 16 hours have entered
into regular service under special ULR operations rules that use human factor
and FRMS strategies that ensure that the fatigue risk encountered is equivalent
to that of a shorter flight operated within the existing FTL scheme. These rules
were formulated through consultation between ICAO and the participating
aviation authorities including the JAA and the US Federal Aviation
Administration (FAA). Amongst other industry body consultees, scientific advice
was taken from QinetiQ resulting in the first case of FRMS principles being used
in the construction of a long-haul trip roster pattern (Singh, 2003).
5.4 Commercial Challenges
Throughout the history of FTL regulation the commercial environment that

airlines have operated in, very often using the same equipment on similar route
structures under common regulatory supervision, has become evermore

competitive and one of the main levers companies have had at their disposal to
gain commercial advantage has been the manipulation of aircrew FTLs. Their
sometimes cynical interpretation was noted by Captain D Quilley, CAA head of
flight operations when he commented, in 1989, on the liberties that many British
airlines were taking at the time, stating “… some rosters obviously assumed the
commander’s discretion was available to be used (at the planning stage). While the
hours were not planned to run over maximum duty time, they were close to the
maxima during operating periods when delay was normal.” (Flight International,
1989).
The hard monthly and annual limits set down in the first edition of CAP 371, that
remain in force today, were stipulated in a much gentler commercial
environment where the average line pilot was stated to be achieving about 500
hours a year and the highest annual average flying hours for any company was
745 hours (Bader, 1973) whereas now some data analysis suggests these figures,
in recent years, could have approached 650 hours (enhanced by suggested 20%
to reflect average line pilot hours) with some pilots averaging “…in excess of 800
hours per annum.” (Paton, 2009). These restrictions were set out to be absolute
limits, enforced by statute of the Air Navigation Order (ANO, 2005), which were
intended to be approached on an occasional basis yet monthly limits are now
regularly tested by seasonal operators and the annual limit has become
commonly regarded in scheduling agreements as a target to be achieved year in
year out. Highly efficient computer driven rostering processes ensure that these
targets are consistently achieved.
With advances in technology allowing aircraft to travel further distances and for
longer durations by ensuring the integrity of onboard systems (and thereby
reducing the likelihood of diversion) the limiting constraint has become the
endurance of the operating crew and the provisions of the conventional FTL
scheme under which they work (Flight International 2004).
Further commercial challenges for the regulation of FTLs are materialising now
through the onset of the world economic downturn and many airlines’ struggle
for survival by trimming all aspects of their operations to the minimum and
squeezing the remaining assets to achieve the maximum advantage. As the
second most expensive resource cost (to fuel) pilots are an obvious target for
more effective “resource management” especially as, in comparison to the
employment groups they work alongside, pilots are perceived to enjoy high pay
for undemanding work routines.
The relatively short term economic imperative is used as argument to impose

ever more punitive industrial work agreements, with respect to FTLs and
scheduling practices, that then outlast the current crisis and go on to have a
lasting impact on future working practises and associated fatigue.
An example of this is the situation that VAA pilots faced during the restructuring
of the airline in the wake of the 9/11 terrorist attacks. The company, having
decided to retire the 3 crew (2 pilots and an engineer) Classic B742 and replace
it on the Florida route with the 2 pilot crew B744, succeeded in getting

temporary approval to invoke the Florida 2 variation to CAP 371 in order to be
able to operate these routes with unaugmented, 2 pilot crews. This variation had
been designed to allow occasional flights to Florida and the Caribbean by holiday
charter airlines that would otherwise have been restricted by CAP 371 FTLs.
With the consent of the pilot union and the CAA, due to the extraordinary
commercial conditions prevailing at the time, VAA was allowed to use this
variation to run a daily schedule. Some 8 years of operation later the temporary
nature of this arrangement has developed a permanency, and in the mean time,
the company has reaped the commercial benefit of being the only scheduled
operator to use this variation and in the process accepted the associated risk of
increased fatigue amongst the pilot workforce.
The arrival of the 2 pilot long-haul flight deck and the demise of the flight
engineer is further example of where CAP 371 has not kept pace with changes in
the industry (Flight International, 1980). The issue concerns the rostering of a
third pilot on a 2 crew flight deck to take advantage of longer permitted flight
duty periods (FDPs) that were originally specified for a 3 crew (including
engineer) operation. Theoretically, the third pilot, sat on the jump seat, can play
no part in the conduct of the flight because the procedures are designed for 2
pilots and yet individual sector times, particularly on multi sector flights, are
often not long enough to allow proper use of in-flight relief where a third pilot
can enhance the FDP by taking the place of an operating pilot during the cruise
(CHIRP, 2008).
For the post “credit crunch” future the whole landscape of the aviation industry
is likely to undergo seismic changes. Present airline business models will be
severely tested with long-haul airlines feeling the economic effects most keenly.
It is conceivable that they will have to increasingly adopt the practices that, up to
now, have been the sole preserve of short haul low cost carrier operations in
order to survive. These new practices will undoubtedly impact on pilot work
routines with inevitable, further challenges to fatigue management.
5.5 Effectiveness
The insidious nature of fatigue is such that it makes it enormously difficult for
anybody to accurately assess their own state of fatigue and most methods of self
evaluation will be prone to wide variations of subjectivity according to the
environment, circumstances and mood that the individual is experiencing.
Clinical, objective testing is also problematic outside of the laboratory; there is
no simple breath or blood test for fatigue as there is for alcohol intoxication and,
indeed, it is not fatigue itself that can be measured but only decrements in
alertness. These facts considered in combination with an industry that has
inherited, from the earliest days of wartime military aviation, a “macho” attitude
which tends to turn a blind eye towards the subject means that any discussion of
fatigue does not benefit from a wealth of reports of solid, empirical data.
Accident investigators, until quite recently, would not attribute fatigue as a
causal factor in their reports relying on the presumption that, if FTLs had been

complied with, fatigue could not have been a contributory factor, preferring to
state “pilot error” instead. Furthermore, given the hitherto poor understanding
of the subject and its somewhat intangible relationship with operational safety
pitted against an acute awareness of how fatigue countermeasures are perceived
to directly impact on an operation’s productivity (and commercial viability), any
debate on fatigue has necessarily been contentious.
To date, commercial aviation culture has not condoned fatigue reporting by

pilots and traditional prescriptive fatigue management systems have not
specified any requirements for systematic monitoring of fatigue risks. It is
reasonable to comment that fatigue is and has always been present in
commercial aviation; the question is at what level has fatigue become a risk and
at what level has that risk become unacceptable? It is therefore hard to
definitively gauge the effectiveness of prescriptive FTL schemes in contributing
to the avoidance of fatigue risk and whether or not the right balance between
productivity and safety has and is being achieved.
It is unlikely that an FTL scheme devised in the early 1970’s, when much less was
known about the science of fatigue, and which has largely evolved through a
process of industrially negotiated trade offs to arrive at its present day
manifestation, would be as valid today for regulating an industry where working
routines and demands on aircrew have changed out of all recognition through
the embracing of huge advances in both technological and commercial practices.
Perhaps the proliferation of variations (exemptions in other regulatory regimes)
to FTLs, new ULR rules and the condoning of in-seat napping strategies, all
introduced to cater for the more extreme areas of present day airline activity, are
symptoms of the increasing inadequacy of traditional, one size fits all,
prescriptive FTLs to regulate fatigue in the modern industry.
It is also valid to argue, in as much as historic poor understanding of the causes

of fatigue has contributed to ineffective FTLs, then the very same lack of
understanding will have, in some instances, lead to overly restrictive FTLs
limiting operations that are indeed safe. One result of a recent fatigue survey
suggests that present regulations might be too focused on limiting hours of duty
rather than maximising sleep opportunities (Roach et al, 2006).

5.5.1 Accident/Incident Reports
Inspection of the UK’s Air Accident Investigation Branch (AAIB) online accident
report database reveals that in the period 1980 to the present day only 2 reports
indicate that fatigue was a contributory cause to accidents or incidents occurring
to fixed wing pilots operating under a CAA approved FTL scheme. These were:
Date Event Aircraft Registration Flight Location

Phase
6 Jun Incident HS748-2A G-BIUV and approach Ronaldsway, Isle
1998 G-BGMO of Man
15 Accident BN2B-26 G-BOMG approach Campbeltown,
Mar (Islander) Argyll, Scotland
2005
Table 2. Fatigue Related UK Registered Aircraft Accident/Incidents
(AAIB, 2009)
However, one of most deserving incidents in recent times for a AAIB human
factors investigation was that which befell the crew of the British Airways B747-
136 aircraft, G-AWNO on 21 November 1989 who, at the end of an operationally
difficult flight from Bahrain with problems compounded by crew sickness,
mishandled a go-around from an approach in thick fog to runway 27R at London
Heathrow and in doing so came very close to the nearby Penta Hotel. With on
going investigations into the Pan Am Lockerbie disaster and the British Midland,
Kegworth accident, AAIB resources were already stretched and so an
opportunity to learn valuable lessons about how systemic short comings can lead
to the possibility of fatigue induced hazards was lost (Wilkinson, 1993).
The first accident in history to have fatigue cited as a primary cause was the
crash of the Kalitta International DC-8-61F at Guantanamo Bay in 1993. Since
then the following accidents, to aircraft operated by crews regulated by
prescriptive FTLs of other National Aviation Authorities (NAAs), have had fatigue
recorded as a cause:
Year Company Aircraft Location

1994 Air Algerie B737-200F Coventry, UK
1997 Korean Air B747-300 Guam, Pacific Ocean
1999 American Airlines MD-82 Little Rock, TX, USA
2001 Crossair BAe146 Zurich, Switzerland
2002 AgcoCorp Challenger 604 Birmingham, UK
2004 MK Airlines B747-200F Halifax, Nova Scotia
2004 Corporate Airlines BAe Jetstream 31 Kirksville, USA
2004 Med Air Learjet 35A San Bernadino, CA, USA
Table 3. Fatigue Related Non UK Registered Aircraft Accidents

(Learmont, 2009a)
In the following more recent events fatigue is being investigated as a possible
cause:
Date Company Aircraft Event Location

27 Aug Comair CRJ100 Crashed on Take off Lexington, KY, USA
2006
12 Jun Cathay B747- Ground Collision on Stockholm
2007 Pacific 400F Start Up Arlanda, Sweden
16 Sep One-Two- MD-82 Overran Runway on Phuket, Thailand
2007 Go Landing
12 Feb Colgan Dash 8- Crashed on Approach Buffalo, NY, USA
2009 Q400 in Icing
20 Mar Emirates A340-500 TODC Error – Melbourne,
2009 Tailstrike on Take off Australia
Table 4. Accidents/Incidents where Fatigue Being Investigated as a a

Possible Cause
(Learmont, 2009a)
Currently, the US National Safety Transportation Board (NTSB), in its August

2009 report into the Go! Airlines incident where both pilots fell asleep at the
controls of their CRJ200 aircraft on a short haul flight between Honolulu and
Hilo, Hawaii on 13 February 2008 and could not be raised by air traffic control
for some 25 minutes as they flew 26 nautical miles past their destination at
cruise altitude, has made 6 recommendations to the FAA. All relate to pilot
fatigue, 3 of which urge that research should be carried out with a view to
implementing FRMS into short haul carriers’ operating procedures (Ranson,
2009).
5.5.2 Confidential Reporting
The UK’s Confidential Human Factors Incident Reporting Programme’s (CHIRP)

states that “Duty related issues are one of the most frequently reported topics by
flight crew in confidential reports” with alleged fatigue contributing 11, 39 and
20% respectively of the total reports filed in years 2006, 2007 and 2008 (CHIRP,
2008). A review of the 19 CHIRP Feedback magazines between January 2003 and
June 2009 reveals that duty related reports topped the league of issues on all but
3 occasions.
A similar confidential aircrew reporting programme for commercial aviation in

the USA recorded 227 schedule related, fatigue incident reports made by pilots
between 1994 and 1998 amounting to an average of 45 reports a year (NASA,
1999). Indeed the Safety Board of the NTSB has had “fatigue” on its most wanted
list since 1990 and made 32 aviation fatigue recommendations since 1972, most
concerning flight and duty time regulations and policies (NTSB, 2008).

5.5.3 Survey
In order to gauge the effectiveness of VAA’s FTL scheme and lend weight to the
argument for introducing FRMS a fatigue survey was conducted amongst the
pilot workforce (Appendix B).
The results of the survey did indicate that sickness rates for pilots on the Airbus
fleet were 22.6% higher than those on the Boeing fleet (differences in general
levels of sickness between the fleets might suggest a route structure that is more
prone to cause fatigue). The data also showed a consensus on each fleet as to
which respective trip rotation was considered to be the most tiring and that
Samn-Perelli Seven Point Fatigue Scale (Appendix C) scores for these trips
recorded levels of fatigue that were not commensurate with the safe operation of
an aircraft, particularly so for the Airbus rotation to Hong Kong and Sydney. On
one trip pattern there was some evidence to suggest an aspect of cumulative
fatigue.
6.0 Fatigue Risk Management System
6.1 Definition and Theory
ICAO has defined FRMS as a “scientifically based, data driven, addition/alternative

to prescriptive flight and duty time limitations which manages crew fatigue in a
flexible manner appropriate to the level of risk exposure and the nature of the
operation” (ICAO, 2008).
Essentially, through an integrated set of management policies, procedures and

practices, it moves away from the traditional, scientifically doubtful, hours of
work limits as a means of controlling fatigue in the work place and takes a much
broader, holistic perspective of the causes of fatigue on duty with respect to
organisational, environmental, physiological and other factors.
FRMS principles should prevail from roster design through all stages to crew rest
and recovery. The philosophy recognises that different influences will affect
levels of fatigue on otherwise similar duties and that a “one size fits all”
prescriptive hours limitation scheme cannot effectively regulate for this. In an
FRMS every duty will have its own bespoke hours limitations formulated
through a process of multi faceted monitoring and reporting, evaluation, timely
modification of limits and procedures, and integral, systematic feedback loop for
continuous fatigue risk assessment for that particular operation. It is a
performance outcome driven system relying on a “just” culture reporting,
intended to be as much proactive as it is reactive.
FRMS is a risk management function which is allied to and designed to be an

integral part of an organisation’s SMS. Akin to SMS, FRMS requires the
implementation of multiple defences against fatigue at various organisational
levels according to James Reason’s “Swiss cheese” model. This suggests that such

multiple defences must be put in place to prevent alignment of failures (holes) in
the layers of the organisation (slices of the cheese) which may result in an
incident (Reason, 1997).
Figure 6. An incident trajectory demonstrates how failures or “holes” in

management systems can provide opportunity for incidents
(Transport Canada, 2007a)
A major element of an FRMS is the identification of fatigue hazard, evaluation of

its severity and likelihood of occurring, assessment of the risk that it posses and
implementation of mitigating risk reduction measures. Figure 7 summarise the
risk reduction process.
Figure 7. Risk Reduction Process
(VAA, 2009)
An important concept of FRMS is shared ownership. Figure 8 represents how

consultation and communication among all involved parties influences and
shapes the principle functions of the system in a dynamic process of continual
development.

Figure 8. Effective Fatigue Risk Management Systems
(McCulloch, 2003)
6.1.1 Human Factors Perspective
Improved understanding of fatigue risk hazards has lead to the realisation that
all stakeholders (regulators, employers, employees) share responsibility for
minimising risk and increasing the safety of the operation. In the past human
error, considered the primary cause of accidents and incidents, had been
associated with operations personnel (pilots, engineers, dispatchers, controllers
etc). Analysis of recent major accidents in aviation and other industries has
revealed that managerial decision making failures, primarily related to latent
risk embedded in an organisation’s procedures or structure, have also been a
contributory factor. Table 5 illustrates how this new thinking translates into the
allocation of FRMS responsibilities.
The integrity of this system relies upon an open, honest and non-punitive
reporting culture, appropriate regulatory oversight and confidence that an
organisation’s management will not be tempted to abuse the FRMS process for
commercial advantage and similarly that employees do not overstate fatigue
issues for lighter work schedules. Ideally this moves the fatigue management
process out of the labour/management negotiation regime into the domain of
safety management where lifestyle issues are respected and where all
operational, ancillary and directing staff have a stake and are able to contribute
to the process.

Government/Regulatory Organisational Individual
Responsibilities Responsibilities Responsibilities
* Prescribe requirements/ * Provide support * Use time away from
framework for FRMS. - Compliance with work appropriately to
legislation. obtain adequate rest and
- Policy development. recovery, and ensure
- Training and fitness for work.
education.
- Error/incident
reporting systems.
* Assess compliance. * Ensure work * Report any potential
schedules provide risks to manager if
adequate opportunities experiencing fatigue-
for rest and recovery related symptoms.
between shifts.
* Audit non-compliance. * Assess specific work * Report any situation

tasks for fatigue- related that may present fatigue-
risk. related risk.
* Where appropriate,
Investigate accidents/incident
Table 5. Responsibilities for Fatigue Risk Management
6.1.2 The Legal Perspective
With changes in the law concerned with corporate governance and duty of care
brought about as a result of the Zeebrugge Ferry sinking, Clapham Rail crash and
Piper Alpha Oil Platform fire disasters, ignorance of risk is now not a defence
against the new charge of corporate manslaughter (Ministry of Justice UK, 2007).
It cannot necessarily be assumed that adherence to legal duty hour limits will
prevent fatigue risk and, in the event of a fatigue induced accident, the operator
could be found responsible and accountable for such a risk (CAA, 2007). A
properly run FRMS mitigates the liability to such a charge.
6.2 System Description
The Transport Canada FRMS Toolbox publication lays out the components parts
of an FRMS under 6 headings which are closely aligned with the ICAO draft
proposals. These headings with their associated elements are as follows:

Policies and Procedures
- Outline the commitment of organisational management to manage
fatigue-related risk
- Detail the required procedures for managing fatigue at the
operational level
Responsibilities
- List personnel responsible for FRMS design, implementation and
maintenance
- Document responsibilities of individual employees and work
groups
Risk Assessment/Management
- Scheduled versus actual hours of work
- Individual sleep patterns
- Symptom checklists
- Error/incident reporting
Training
- Promote knowledge in the workplace about risks, causes and
consequences of fatigue
- Ensure employees understand and can apply FMRS strategies
Controls and Action Plans

- Toolbox of methods used within FRMS, including error reduction
techniques (“fatigue proofing” rather than “fatigue reduction”)
- Clear decision trees for managers and employees to use when
fatigue has been identified as a risk
Audit and Review
- Documentation and data collection at regular intervals monitoring
how FRMS is working
- Review of FRMS based on audit results
This format replicates the typical structure of an airline’s SMS allowing an FRMS
to be superimposed as an extra safety related dimension onto the functioning of
an already operating organisational system and thereby facilitating its
introduction, reducing duplication of effort and benefiting from a common
human factors philosophy of a “just safety culture” and shared system ownership
and responsibilities.
Furthermore the Transport Canada guidance identifies 5 defensive layers (or

levels of control in managing fatigue risk) against an error trajectory analogous
to Reason’s “Swiss cheese” model. The 5 levels are:

Level 1 (organisational): making sure that scheduling gives employees
adequate opportunity to sleep:
Level 2 (individual): ensuring employees actually get sufficient sleep:
Level 3 (behavioural): monitoring for symptoms that indicate employee

fatigue:
Level 4 (error): strategies to prevent workplace fatigue resulting in errors

or incidents:
Level 5 (incident): determining the role of fatigue in workplace errors or

incidents.
These are represented in Figure 9.
Figure 9. Hazard-Control Model for Fatigue Risk Management
By comparison, FTL schemes just have the one defensive layer, that of duty hours
limitation.
Overseeing and acting as a focal point for all the FRMS processes in an
organisation is the Fatigue Management Steering Committee (FMSC). The FSF
lists the functions of this body as follows:

- monitoring fatigue information sources;
- investigating fatigue-related issues;
- requesting internal audit of specific issues;
- proposing solutions to fatigue related issues;
- recommending priorities for targeting fatigue management
resources;
- providing transparent and timely feedback to management and
workforce;
- cooperating with internal and external audits; and,
- overseeing the quality assurance of FRMS training in whole
organisation.
It goes on to recommend that this group is made up of representatives drawn

from:
- pilots and cabin crew

- medical staff
- establishment planners/rostering staff
- commercial/marketing departments
- training establishment
- engineering
- safety services
- flight operations,
achieving a balance of company and employee staff with access to

scientific/specialist advice as required (FSF, 2005a).
The organisational structure of an FRMS is represented in Figure 10.
Figure 10. An FRMS Organisational Chart

(FSF, 2005a)

6.2.1 Risk Assessment/Management
Fatigue risk is difficult to predict and quantify with any accuracy within a risk
management system. Indeed the relationship of fatigue and risk is non linear and
poorly understood (Roach et al, 2006)(Folkard et al, 2007). However the
Functional Resonance Accident Model (FRAM) of risk suggests that increased
fatigue does lead to increased risk and this is an assumption common to both
FRMS and FTL schemes (Hollnagel, 2004).
With FTL schemes the risk assessment and management has been a
predominantly reactive process, adopting a compromise between best practice
and commercial imperative. In a FRMS this process is a central function which
binds the system together using reactive and proactive components. The reactive
part comprises a “risk radar” that senses fatigue hazard via 4 layers of reporting
chains:
- Routine reports;
i.e. Flight Data Monitoring (FDM), Flight Reports, Roster Stability
Data, Sickness Rates, Aviation Medical Examiners’ Reports, etc.,
- Ad hoc reports;
i.e. FRMS Audits, Crew Surveys, Safety Walks, Line Orientated
Safety Audits (LOSA), Flight Operations Quality Assurance (FOQA),
etc.,
- Incident (Accident)/Risk driven reports;

i.e. Air Safety Reports (ASRs), CHIRP, Fatigue Incident Report
Forms, Crew Welfare Report Forms, Fatigue Investigations,
Discretion Reports, etc.,
- Long term fatigue studies;

i.e. Human Factors Monitoring Programmes (HFMP), Human
Interaction in the Lifecycle of Aviation Systems (HILAS) project,
etc.
(Stewart, 2008)
Far greater and immediate relevance is given to these sources of information

than is the case with FTL schemes. The data is processed in relation to a series of
functions that investigate, analyse, assess and rate according to the context of the
operation. This establishes a defined risk for the reported hazard and, if the
metrics of the risk exceed a set threshold, this leads to a process of operational
change and risk mitigation, the level of which is dictated by the severity of the
risk. The system is, therefore, procedurally and dynamically adapted to mitigate
fatigue risk.
The output of this process can be either immediate, tactical modifications to, say,
a specific trip rotation or long-term strategic changes to, for example, rostering

policy, both of which are informed by organisational learning processes and/or
feedback loops (Stewart, 2008).
Figure 11 is a diagrammatic representation of the risk management process

promoted by International Risk Management Standard 4360 (AS/NZS, 2004).
Figure 11. The Risk Management Process
(AS/NZS, 2004)
The complexity of modern day air transport operations and higher expectations
of safety demands a system with a greater proactive emphasis. This can be
provided by computer fatigue modelling programmes that can predict generic
fatigue levels at any point of an FDP and can be instrumental in the assessment of
the fatigue risk associated with new trip patterns. This, then, can influence the
risk management process resulting in the deployment of proactive fatigue risk
mitigating measures.
6.2.2 Physiological Monitoring and Alertness Testing
Fatigue studies have employed a range of methods to collect data about flight
crew’s quality of sleep, susceptibility for sleep (multiple sleep latency tests -
MSLT) and state of alertness. In controlled scientific studies polysomnographic
monitoring, which uses electroencephalograms (EEG), electrooculograms (EOG)
and electromyograms (EMG) to record brain activity, eye movement and chin
muscles tension respectively, has been used to assess the structure of sleep

following disturbed rest associated with shift work or time zone change. In other
scientific tests measures have included; the readings of individual’s body
temperature (using Biorhythm watches) and salivary melatonin to establish
phase of the internal body clock and rate of adaptation to new time zones, the
wearing of Actilumes and Actiwatches (watch like devices that detect light and
movement respectively) to record when sleep was likely to have occurred, and
Psychomotor Vigilance Task (PVT) and Palm Pilot computer alertness tests. To
compliment these objective tests, subjective assessment has usually been
conducted in tandem for comparison and validation purposes and these have
taken the form of sleep diaries and alertness report forms.
The 3 most practical and commonly used means for targeted FRMS data retrieval
have been the Actiwatch, Palm Pilot and PVT computer tests, as depicted in
Figure 12, together with alertness report forms.
Figure 12. Actiwatch, Palm Pilot and PVT Computer

(courtesy Air New Zealand)
6.2.3 Computer Fatigue Modelling
The principle method for proactively predicting fatigue levels associated with
proposed duties and therefore a key component of an FRMS is the computer
fatigue modelling programme. There are several programmes in widespread use
today, not just in the aviation industry, such as the UK Health and Safety

Executive’s Fatigue and Risk Index Calculator, the NASA – TLX (Task Load Index),
the USAF’s FAST (Fatigue Avoidance Scheduling Tool) and the FAID (Fatigue
Audit InterDyne) risk management tool used by easyJet for their FRMS.
The programme most appropriate for assessing the fatigue generated by the long
duty hours, irregular patterns of work and rest, and time zone shifts common
place in long-haul rosters is the UK’s QinetiQ developed SAFE.
Developed from research conducted on behalf of the UK’s CAA into sleep and
wakefulness of airline pilots, SAFE incorporates the QinetiQ alertness model
based on basic physiological factors derived from laboratory studies, the 2
principle components of which being the effects of circadian rhythm and
proceeding patterns of sleep and wakefulness. Through a series of studies of
aircrew alertness conducted over several years the fatigue model has been
refined, enhanced and validated to the point where it is now a valuable aid for
the appraisal of aircrew rosters, capable of illuminating potential areas of fatigue
risk. It is this aspect that makes SAFE ideally suited to play an integral part in a
long-haul operation’s FRMS (QinetiQ, 2004).
Data entry for SAFE includes information about crew composition, in-flight rest
and time zone transition as well as schedule, duty time and sectors operated.
Computed analysis output takes several forms listed as follows:
- Workload and Alertness Summary; indicating problem

areas/transgressions within a particular duty;
- Cumulative Workload; successive duty workload comparison with
Nicholson Curve; (as explained in Section 4.1);
- Body Clock Desynchronisation;
- Duty Hours;
- Blood Alcohol Concentration;
- Equivalent Alertness Scales; including Samn-Perelli Seven-point Scale
and Karolinska Sleepiness Scale,
- Estimated Sleep Period; prediction of time when sleep may be
achieved.
(QinetiQ, 2009)
Several examples of SAFE trip rotation analyses are produced in Appendix F.
6.2.4 Operational Introduction
Implementation of FRMS will be a change management process that will need to

be a continuous process to reflect the dynamic, ever adapting nature of this
safety management function.

1. 2.
Awareness; of Commitment;
the need to to participate in
change and support
change
5. 3.
Reinforcement; Knowledge;
to sustain change on how to change
4.
Ability;
to implement
required skills
and behaviours
Figure 13. FRMS Change Management Process
(Stewart, 2009)
Awareness of a need to change must be created within the organization, starting

with a diagnosis of the prevailing situation and then identification and evaluation
of methods to address it.
Management, Union and the FMSC need to show strong leadership in “selling”
FRMS so that it is a process that is “owned” and potential benefits recognized
company wide. To encourage workforce engagement, a strong signal of senior
management commitment to the FRMS philosophy is the policy statement a
generic example of which is found at Appendix D.
Courses on policies and procedures training are required for managers and
employees alike to understand the behavioral and cultural traits of FRMS so that
the relevant skill sets can be deployed to create, develop and maintain such a
system.
An organisational framework must be established, within the structure of the

SMS, and informed by an open and transparent company FRMS policy which
should include the following elements:

- commitment from the highest levels of the organization;
- a specified line of accountability for fatigue risk management;
- definition of company management and employee responsibilities;
- identification of work groups covered by the FRMS;
- FMSC terms of reference;
- identification of fatigue reporting mechanisms;
- policies for the identification and managing of fatigue risk;
- FRMS training and resources commitment;
- Responsibility to act on FRMS internal audit recommendations.
(FSF, 2005)
Through a process of human factors monitoring programme (HFMP) reports,

internal and external FRMS audits and reviews of the reactive reporting
elements of the fatigue “risk radar” a running assessment of the efficiency of the
system can be maintained and a variety of tactical or strategic modifications can
be introduced to reinforce the process. Figure 13, summarises the stages of the
FRMS change management process.
Figure 14 describes how the change management process might translate into a
company’s organisational process chart.
Figure 14. FRMS Organisational Implementation Map
6.2.5 Operational Benefits
The overarching benefit of FRMS is enhanced flight safety. In some quarters this
is perceived as being achieved at the expense of commercial viability as many of
the FRMS “levers” of change represent increased direct operating costs. This
assumes that current operations are safe enough i.e. if FTLs are complied with,
then as well as being legal, the operation must be safe; and that FRMS is a
handicap in terms of commercial competitiveness. The first assumption has
already been addressed, the second is dealt with here.

The derived advantages of FRMS implementation can be categorised as accruing
in 4 distinct areas; the individual employee, the flight operations department, the
company and the regulator.
For the pilot employee every duty, planned or otherwise, will be assessed by the
FRMS and the sometimes highly contentious decision of whether or not a flying
duty can be safely carried out with respect to fatigue is left to the integrity of the
system, removing from the pilot a weight of responsibility and releasing
intellectual resources that can be focused on other areas of the operation. Other
advantages include better welfare and lifestyles less blighted by continuous
fatigue leading to possible long term health benefits.
For flight operations, although some aspects of the roster may be more
restricted, FRMS will quite possibly open up opportunities where traditional
FTLs have been unnecessarily punitive on the programme. Safety cases based on
FRMS principles may be made for increasing absolute monthly and yearly limits
of flying duty. More physiologically sympathetic rostering will result in lower
absenteeism with a better balance of work and time off; a feature that will play
out well as a recruitment incentive and benefit employee retention. Fewer
incidents as a consequence of FRMS policies will mean less disruption to the
flying programme and a reduced engineering and administrative task. The
computerised rostering tools required of an FRMS system will lead to a much
simpler and transparent roster production process and also increased flexibility
and efficiency.
The company, beyond the flight operations department, can capitalise on the
cache of operating FRMS as an enhanced safety feature that contributes to
commercial interests via brand protection. Furthermore the reduction in
frequency of medium and high risk events will result in a lower risk signature
that will qualify for lower insurance premiums (Stewart, 2009). Data from other
transport sectors indicate that companies with accredited FRMS/SMS suffer 50
to 75% less crashes (Jackson, 2008). Crucially it might be the case that duty
limitations will no longer be decided by typically protracted management/union
negotiation but rather on purely scientific grounds.
From a regulator’s point of view an organisation running an FRMS, as an integral

part of an SMS, will be much easier to oversee as the built in reporting and
operational control functions of the system will endow the operation with far
greater transparency. As FRMS/SMS is intended to apply to every operational
aspect of an airlines activity, then an external audit of FRMS/SMS should reveal a
complete operational assessment of the organisation.
6.3 FRMS in Operation
The first application of an FRMS philosophy to an aviation environment was in

1995 when the CAA of New Zealand (CAANZ) introduced an “alternative
compliance scheme” to their existing FTL scheme. Following on from this the

Australian Civil Aviation Safety Authority (CASA) began trialling FRMS in 2001.
Both of these initiatives were prompted by the geographical remoteness of these
2 countries and particular demands on their aviation industry leading to a
realisation by the NAAs that the conventional FTL schemes in place were not
sufficiently broad enough in their scope to regulate all aviation activities.
With the arrival of the Airbus A340-500 extended range aircraft airlines were
able to introduce scheduled ULR services of 16 hours and over. In 2004
Singapore Airlines (SIA) started services from Changi to Los Angeles and New
York whilst Emirates began flying directly to Sydney and New York from Dubai.
These operations could not be catered for within these organisations’ normal
FTLs so special, dedicated ULR procedures were devised for these flights based
on FRMS principles which are now a universally accepted reference for long-haul
FRMS operations.
Elsewhere, in the intensive, short haul environment of the low cost carrier,
easyJet found that the roster routine allowed by their existing FTL scheme was
contributing to undesirable levels of fatigue risk and incidences of flight deck
errors. After conducting a trail of an FRMS designed roster, easyJet was able to
present to the regulator, a safety case for alleviation from their FTLs by virtue of
employing FRMS techniques which ensured an equivalent or better level of
safety. This was accepted and easyJet rolled out their FRMS programme in April
2005.
Also in Europe, to date, Jetairfly (TUI) and DHL Air have begun development of
their own FRMS systems (Jackson, 2008).
A review of FRMS introduction into the regulatory regimes of the CAANZ and
CASA together with a description of FRMS in operation with ANZ, SIA and easyJet
is contained in Appendix E.
7.0 Introduction of FRMS into Long-haul Operations
As the Australian regulator CASA discovered, the introduction of FRMS involves

such a cultural shift in thinking about how fatigue is managed that the ground
has to be thoroughly prepared before institutional change is initiated.
In the first instance the impetus has to come from the regulator as no established
commercial operator is going to change such a fundamental aspect of its
operation without an element of regulatory coercion. This, however, must
represent the least of the reasons for change. The rationale for FRMS adoption
must rest firmly on the merits of the argument for moving towards a dynamic,
safety driven, risk management system. Everyone involved in the operational
activity of an organisation has to “buy in” to the philosophy. General acceptance
of the idea is the first major hurdle and this has to be achieved through a
company wide campaign of education at all levels through studies of theory,
industry best practice and company FRMS safety case analysis.

Management and unions alike will have important roles to play in
comprehensively endorsing the new thinking and showing leadership in
adapting to a new safety management culture. With the aim of casting the
system’s safety net over a much broader reach as its primary focus, the FRMS
should transcend the old industrial “tug-of-wars” contests fought over flight duty
times. The cultural philosophy of the system recognises that by catering to work
group safety/welfare needs the overall safety/commercial requirements of the
operation are also fulfilled. Fundamental to its unimpeded working will be
management/union agreement to wholeheartedly support and participate in the
programme.
Establishment changes to accommodate FRMS will be minor as the company’s

existing SMS will provide the appropriate organisational framework with
common system data and communication network requirements already in
place. However, the change management task will call for extensive and
thorough training as would befit the major cultural realignment exercise
involved with moving from a static fatigue limitation scheme to a dynamic, risk
focused scheme. Training will be an ongoing commitment, reinforcing the
realignment process through periodic refresher courses.
As is demonstrated by the easyJet experience, the operational heart of FRMS is

the Risk Assessment/Management process. This has to be uniquely designed to
meet with the specific characteristics of the airline’s activity and deliver
appropriate solutions that fit the airline’s operation to mitigate recognised risk.
Part of the function of this process is a feedback loop that will act to monitor the
working of the system and validate its effectiveness for internal/external audits
and regulatory oversight.
Responsibility for implementing, coordinating and supervising all aspects of the

company FRMS will rest with the FMSC, made up of representatives from all
operational areas of the organisation including, scheduling/rostering, as well as
commercial/marketing staff and establishment planners, and external
medical/scientific advisers. Their primary function will be to set out company
FRMS policy.

Event Organisation Notes
Regulatory ICAO, EASA, CAA FRMS as enhancement to
Requirement FTLs.
Policy Company Management Union agreement.
Statement
FMSC Company Management/Union Representation from all
establishment Operational areas of
Business.
- Policy Document
- Organisational Structure
- Education
-Risk
Assessment/Management
Educational Company/FMSC “Sell” FRMS to company staff.
campaign
Safety Case FMSC/Safety Specific Fatigue
Services/Operations Survey/Study of Problem
Trips with FRMS proposed
solution as change/approval
justification.
General Company wide
Fatigue Survey to act as
reference baseline pre FRMS
introduction.
FRMS CAA/Company FRMS Regulator Audit
Approval requirements established.
FRMS FMSC/Safety - Responsibilities
establishment Services/Operations/Training - Training
Department/HF Department - Reporting Chains/Nets
-Risk
Assessment/Management
goes live.
Transition FMSC/Safety Initially on a trip by trip basis
from FTLs to Services/Operations/Training starting with problem trips
FRMS Department/HF Department rolling out to other trips as
experience gained of process.
General FRMS Principles, not
associated with
organisational change can be
applied immediately.
Table 6. Sequence of Events – FRMS Introduction

Figure 16. Overview of FRMS Introduction and Time Line
(Dawson, 2004)
7.1 Regulatory Background
The International Civil Aviation Organisation (ICAO) sets out in its Standards and
Recommended Practices (SARP) document guidance for aviation authorities to
follow in formulating regulations. In the draft Annex 6, Part I of the SARP
proposed for issue in 2011, ICAO recommends that:
“Operators shall establish flight time and duty period limitations and a rest
scheme….. to manage fatigue.” and that these “Shall be based upon scientific
principles and knowledge where available…”.
(CAA, 2009c)
In response to this ICAO guidance EASA have signalled in a notice of proposed

amendment to EU.OPS proposed to be mandated in April 2012 (postponed from
October 2010), when EASA takes control of FTL regulation, that OR.OPS.025.FTL
will state (Learmount, 2009b):

“An operator shall establish and maintain an FRMS as an integral part of its
management system.” that “shall correspond to the roster system or flight
time specification scheme used by the operator…” and that the “Operator
shall take mitigating safety measures when the FRMS process shows that
the required safety performance is not maintained.”
(EASA, 2009)
7.2 Safety Case
The purpose of the safety case exercise is to verify the need for FRMS
incorporation, collect a baseline of fatigue risk data as a pre-FRMS
implementation reference, establish and refine the process for risk assessment
and management, trial “levers” for fatigue risk mitigation (to prove the system
and effectiveness of “levers”) and gain regulator approval.
The 2 trip rotations indicated by the VAA pilot fatigue survey to be the most
fatiguing should be the primary focus for an FRMS safety case i.e. for the Airbus
fleet, the LHR-HKG-SYD pattern and for the Boeing fleet, the LHR-LGW-MCO
pattern.
A comprehensive HFMP should be planned for at least 6 months to account for

seasonal changes in length of daylight and effects of weather. A campaign of
objective testing using Actiwatches and carrying out PVT and Palm Pilot
alertness tests together with subjective data achieved through sleep diaries and
fatigue report forms, completed at specified points, should be conducted.
The performance outcome of these surveyed trips could be analysed through

assessment of the various sources of data, listed in section 6.2.1, and already
collated by the SMS, filtered for those reported outcomes, the occurrences of
which, pilots had some influence over. By emulating easyJets methodology
(Appendix E), it should be possible to establish a linkage between rostering
practice and given working environment, measured flight crew alertness (and by
inference, fatigue) and the performance/safety outcome.
With the inclusion of a computer fatigue modelling programme such as QinetiQ’s

SAFE, tuned to the particular operating characteristics of the airline, validated by
the HFMP, areas of fatigue risk could be predicted and a proactive risk
assessment/management function could be employed for these safety case trips
and applied in future to all trips in the airline’s route structure.
FRMS strategies deployed by SIA for their ULR operations could be trialled to
gauge their effectiveness and reinforce the case for regulator approval.
Organisational “levers” to mitigate fatigue risk could be manipulations of the
schedule by changing departure times, or roster pattern by varying layover and
recovery times, or crewing establishment by increasing crew compliments.
Further measures might include studies into the best arrangement for crew in-

flight rest and the effects of cumulative fatigue built up over a series of rotations
(QinetiQ, 2008).
Appendix F shows an example of a SAFE analysis for both the LHR-HKG-SYD and
LHR-LGW-MCO trip rotations for the current schedules, as planned, and in each
case after the operation of a fatigue risk mitigating ”lever”.
7.3 FRMS Integration into Airline SMS
Organisational establishment changes to accommodate FRMS can be minimised

as the FRMS Organisational Chart, depicted in Figure 10 (Section 6.2), can
overlay the SMS structure. The “just culture”, holistic, shared ownership and
safety performance driven features are closely mirrored in both the related
systems which compliment each other’s purpose. Table 9 demonstrates how the
essential elements of FRMS are related to the 10 organisational functions of SMS
identified by ICAO.
ICAO’s 10 Steps to SMS Essential FRMS Elements

1. Planning - Non-punitive Fatigue Risk Management
Policy
- “Just Culture”
2. Senior Management
Commitment
3. Organisation - Fatigue Management Steering Group
4. Hazard Identification - Fatigue Risk Assessment Tools
- Crew Fatigue Reporting
- Employee Communication Channels for
Feedback
5. Risk Management - Strategic, Scientifically-Driven Crew
Scheduling
- Validated, Timely Fatigue Mitigation
Strategies
-Data driven processes for monitoring
alertness
6. Investigation Capability - Procedures to Investigate and Record
Fatigue-Related Incidents
7. Safety Analysis Capability - Data Collection & Assessment
8. Safety Promotion & Training - Education and Awareness Training
Programmes
9. Safety Management - Documented SOPs for FRMS Implementation
Documentation
10.Oversight and Performance - Operator Internal Audit Programme
Monitoring - FRMS Validation Programme
- Safety Performance Measurement
Table 9. SMS Principles Embedded in FRMS (Powell, 2009)

7.4 System Ownership
A core principle of FRMS philosophy is system ownership. All operational

stakeholders have a part to play in and are responsible and accountable for
FRMS implementation, operation, equitable administration, maintenance and
improvement of the system (CASA, 2004).
7.5 Education and Training
Compelling, comprehensive, coherent and credible education will be the key to

the success of introducing FRMS into an airline SMS. The ideas of shared
ownership, “just culture”, and collaborative and proactive safety management,
central pillars of the FRMS philosophy must be accepted into the lexicon of the
corporate culture for the theory to transform into efficient and productive
practice.
For such a cultural shift in fatigue management thinking, from prescriptive hours
of work limitations to safety/performance outcome influenced limits, and very
much dependant on company personnel active acceptance, the education process
needs to take place right at the beginning of the change management phase
reaching as many people in the airline as possible, from top management down.
The topics should cover:
- FRMS theory;
- Legal (Corporate) and Regulatory (NAA) requirement;
- Human Factors justification;
- Company FRMS Policy;
- Company Risk Assessment/Management Process;
- Company FRMS Organisational Structure;
- Individual FRMS Responsibilities
- FRMS Implementation Plan and
- Benefits of FRMS adoption.
After the FRMS education campaign has completed, then training of all staff
associated with flight operations should begin based on the curricula that the
FSF recommended for SIA ULR operations i.e.:

- Causes of fatigue in the airline environment
- Consequences of fatigue on aviation safety;
- Requirement for confidential feedback from incidents;
- Recognition of signs of fatigue and decreased alertness in
self and others;
- Physiology of sleep and understanding of one’s own sleep
physiology and how it should influence preferential
bidding;
- Circadian rhythms and homeostatic process;
- Sleep and alertness strategies including “sleep hygiene”;
- Diet and hydration including effects of alcohol and caffeine;
- Prescription and non-prescription medication and rules;
- In-flight environment and its effects;
- Work scheduling and,
- Crew coordination to address sleep inertia after in-flight
rest.
(FSF, 2005b)
This training should be reinforced through the normal routine of recurrent

training.
7.6 Risk Assessment/Management
The complexity of a long-haul operation with world wide destinations, round the
clock activity, and a variety of trip and layover lengths requires a modified risk
assessment/management process to that explained earlier (6.2.1).
By comparing the analysed output of the “risk radar” element of the reactive
component of the process with predicted fatigue levels from the SAFE
programme, the proactive component, a relationship can be established between
safety of the operation in terms of reported fatigue risk events and expected
fatigue. This relationship, which may be unique to each rotation, can be used to
aid trip planning with respect to schedule timings, number of pilots, length of
layover etc..
The starting point for this process would be a defined level of safety stipulated by
the regulator as an acceptable rate of fatigue risk event reporting which would
correspond (via the relationship) to a limit on the decrement to SAFE predicted
alertness. This limit would then inform the trip design process, using SAFE, and
continue to be a dynamic, systematic fatigue risk governing function. True to
FRMS principles, safety performance outcome would drive the process.
The transparency of the process could be ensured by publishing the latest

alertness level limits calculated for each trip. By making the SAFE programme
available to pilots it could be verified that predicted alertness levels for a
prospective trip rotation did not diminish below the limit promulgated. In setting

the limit, factors could be introduced to allow for individual physiological
differences in tolerances to fatigue and for variations in fatigue inducing aspects
of the operation such as coping with weather and technical problems. Delays and
diversions would necessitate a fresh SAFE evaluation with the facility to specify a
cut off time for creeping delays.
FRMS system ownership would be satisfied by pilots’ ability to directly monitor

and influence, by tactical fatigue risk mitigating measures, the risk
assessment/management process. The process’s working metrics would meet
the data needs of the regulator/operator for auditing/oversight requirements.
7.7 Company FRMS Policy
As a FRMS is a closely integrated feature of a company’s SMS much of the

documentary requirements of both systems will be common and therefore a
degree of FRMS policy can be referenced to the SMS policy manual.
Features that FRMS policy must define are:
- The level of senior management commitment;

- Responsibilities and accountability of the accountable executive,
managers, committees, and employees;
- The purpose and goals of the FRMS;
- How the organisation will achieve its safety objectives;
- Resources allocated to FRMS
- The responsibility of all employees to manage fatigue risk;
- Fatigue related safety outcomes expected of managers, employees and
contractors;
- Training requirements;
- Reporting procedures for fatigue related hazards;
- The fatigue reporting policy (“just culture”);
- A procedure for evaluation and continuous improvement of the FRMS.
(Transport Canada, 2007b)
Further expressions of FRMS policy will require statements on the

characteristics of FRMS integration within the company’s SMS, and means of
communication and consultation on policy. As FRMS is intended to be a dynamic,
constantly developing entity, explanation of how and when policy changes are
going to be promulgated will be crucial for the coordinated propagation of
procedures. It is envisaged that specific policy guidance will be formulated for
operational departments as indicated in Table 10.

Department Policy Guidance covering:
Rostering Trip pairing, roster build and juxtaposition of trip rotations do
not compromise FRMS principles.
Crewing FRMS principles preserved with operational changes.
Operations Rescheduling conducted according to FRMS criteria.
Engineering Understanding how technical unserviceabilities effect fatigue
levels. Minimum Equipment Lists amended to reflect FRMS
requirements.
Airport Influence of delays on fatigue and importance of OTP
Services
Fleet Evaluation of FRMS effectiveness on pilot workforce
Management
Training Ensuring FRMS policy understood and being followed.
Safety Services Monitoring and auditing of FRMS processes.
Crew Logistics Layover hotel arrangements respect FRMS requirement for
uninterrupted sleep opportunity (during daytime if necessary).
Table 10. FRMS Departmental Policy Guidance
7.8 Regulator Oversight
It is anticipated that FRMS implementation into a long-haul operation will be a

stepped process on a trip by trip basis. Many of the oversight requirements of the
prescriptive FTL scheme will remain as FRMS is initially operated as an
enhancement to the present scheme of fatigue management. Regulator
supervision of company SMS will include functions of the FRMS.
The metrics of the risk assessment/management process output will facilitate

the regulator’s auditing task. However, to gain company wide confidence and
acceptance of the new fatigue management system, to ensure that poor or
incorrect practices do not become entrenched and enshrined in company
procedure a strict regulator oversight commitment will be required in the early
stages of implementation. Moreover, as every airline’s FRMS will be different,
tailored to their particular operating circumstances, the regulator will have to
learn and understand each organisation’s system in order to validate and
monitor it. Bench marking and establishment of safety goals will be needed by
which the system can be assessed. The robustness of the system and company’s
management ability to oversee the correct functioning of the programme will be
the major issues to be considered.
The oversight task will be demanding and, indeed, involve a change management
process requiring new organisational structures for the regulator as well.
Once the FRMS/SMS are established the relationship envisaged between

regulator and airline is illustrated by the diagram in Figure 17.

Figure 17. Relationship Envisioned Between Regulator and Airline with
SMS
(FSF, 2005c)
7.9 Pros and Cons of FRMS Adoption
Some of the advantages and disadvantages listed by a 2004 Australian

Government discussion paper particularly applicable to a long-haul operation
are:

Advantages;
- Improved flexibility with operation not restricted by sometimes

inappropriate prescriptive FTLs;
- Increased safety through better awareness and understanding of
fatigue;
- Improved rostering efficiency through deployment of more
capable rostering tools and procedures required for FRMS;
- Clearer sharing of responsibilities for fatigue management;
- Credible, scientific basis for fatigue management;
- System not polluted by industrial issues;
- FRMS closely aligns with corporate governance and duty of care
legislation;
- Transparency, understanding and faith in method of operation;
and
- Shared ownership, “a problem shared is a problem halved”.
Disadvantages;
- Resource hungry implementation costs for cash strapped business;

- Temptation to over rely on the sexy fatigue management software
to the detriment of other FRMS components and strategies;
- Some fatigue management software can be cumbersome and
difficult to apply;
- Potential for FRMS abuse by either management or employees;
- High establish workload, particularly in implementation phase.
(CASA, 2004)
Previously mentioned benefits of a more engaged work force due better lifestyle,
lower rates of operational exceedances and incident/accident occurrences
resulting in lower insurance premiums and airline brand protection all combine
to make a strong corporate case for FRMS adoption beyond just complying with
forthcoming regulation.
7.10 Acceptance Issues – Union/Employer
FRMS has to be universally accepted within an organisation if it is to properly

function as an effective fatigue management system. Contest over prescriptive
FTLs has traditionally been the modus operandi of union and employer
engagement and removal of this industrial minefield of issues into the realms of
scientifically decreed best practice will present huge challenges for both sides of
the labour relations divide.
The union scepticism echoes natural pilot cautiousness which is characterised by

a deep seated suspicion of the additional role of FRMS in modifying hard won
prescriptive FTL rules and the potential for its exploitation by airlines to gain

increased productivity at the expense of fatigue risk. As a former British Airline
Pilots’ Association (BALPA) official commented:
“The culture of the company is crucial to the success of FRMS, which creates
one of the biggest challenges to its effective use.”
(Jones, 2007)
Similarly employer groups are wary that FRMS may be a charter for disaffected
employees to abuse the system by falsifying fatigue issues for their own ends and
prejudicing the airline’s operation. Other concerns focus on the difficulty of
implementing and regulating such an amorphous system which appears to set ill
defined boundaries that may have dubious legitimacy, to limit operations.
Substitution of the “hard rules” of FTL schemes, drawn up right at the outset of
FTL design to protect the lifestyle aspirations of flight crew, would be fiercely
opposed. Only through recognition of the underlying tenet of FRMS philosophy
which promotes a work/lifestyle balance that relies on equally satisfying both
the needs of the operational task and the employee, one reliant on the other, will
the change in culture occur.
Successful FRMS adoption requires a holistic company safety culture that is

complimented by a corporate culture of universal, mutual trust and respect.
8.0 Future Applications of FRMS
Complete objective recording of circadian rhythms and sleep profiles of the

whole flight crew workforce of an airline could be facilitated by technological
development of a combined mini Biorhythm and Actiwatch physiological
monitoring device that was made unobtrusive to wear. This would allow a
continuous monitoring process and be an integral part of the company’s FRMS.
The data from such a monitoring programme could enhance the “risk radar” of
the risk assessment/management process, contribute to a much more thorough
database of fatigue risk which could guide future research into the area, improve
computer fatigue modelling, and be a valuable aid for fatigue risk mitigation.
Benefits for the individual pilot might include; assessment of their personal
tolerance to fatigue, advice on lifestyle options to address areas where
monitoring identified fatigue susceptibility and informing the roster production
process to allocate trips that suited their physiological routine.
For crews on standby duty, continuous monitoring matched to computer fatigue

modelling could protect them from the excesses of dynamic, operational crewing
decisions and be a valuable tool for crewing staff to make best use of their
available standby crews.

9.0 Conclusions
The very nature of long-haul flying exposes pilots to fatigue risk through:
- Working long duty periods;

- Routinely operating over the WOCL period; and
- Accumulating sleep debt due to sleep pattern disturbance owing to
circadian rhythm disruption.
Traditional prescriptive FTLs as a means of fatigue management were originally

designed:
- Largely according to industry best practice;

- With little medical or scientific foundation;
- With minimal alleviation for effects of circadian disruption due to
trans meridian shift;
- To limit hours of duty rather than maximise opportunities for
sleep;
- Being better suited to aid recovery from physical rather than
mental fatigue; and,
- As a static form of regulation not able to adapt to a dynamic
environment.
Although modified over the years in reaction to changing industry conditions,

FTLs have:
- Suffered from poor interpretation and/or abuse;

- Been exercised to unintended degrees due to intense commercial
competition;
- Required extra allowances “bolted on” such as variations,
dispensations and exemptions to permit the extremes of airline
activity i.e. ULR flights;
- Insufficiently adapted to regulate 2 pilot long-haul and short-haul
LCC operations and other advances in the industry; and,
- Allowed “in seat napping”, to compensate for FTL shortcomings.
The lack of effectiveness of FTLs to regulate fatigue has been masked by:
- An accident reporting regime that was reluctant to assign fatigue

as a cause;
- “Macho” industry culture that considered fatigue management as a
threat to commercial competitiveness resulting in underreporting
of fatigue issues;
- Labour negotiations that traded FTL issues for employment
compensations;
- Perception that if the operation was “legal” then it must be safe:
and,
- Difficulty in measuring and assessing effects of fatigue.

More recent “enlightened” accident/incident reports, confidential reporting and
a subjective pilot survey suggest unacceptable levels of fatigue do occur under
prescriptive FTL schemes.
With increasing evidence of FTL deficiencies and the uncertainty over the future
of the European FTL regulatory environment the case for FRMS adoption
becomes ever stronger.
FRMS is a holistic, scientifically based, data driven fatigue management system

that can be an integral part of an airline’s SMS. The philosophy of the system is
based on:
- Multiple defensive layers to protect against fatigue;

- Shared ownership and responsibilities;
- “just” culture reporting;
- A risk assessment/management process that continuously, and
dynamically adapts the system to mitigate risks;
- Consultation and communication;
- Reactive and proactive risk mitigation; and,
- Open and transparent policy.
For a long-haul operation the SAFE, computer fatigue modelling programme can
play a key role as the proactive component in the FRMS risk
assessment/management process.
Early experience has shown that implementation of FRMS involves a major

change management task that must include:
- Comprehensive education to promote cultural shift in safety

thinking;
- Top Management (and union) commitment;
- Initial and recurrent training to reinforce knowledge;
- Establishment of organisational framework within SMS;
- Thorough planning of transition from FTLs to FRMS; and,
- Safety case “trials” with an HFMP.
Despite high start up costs and high establishment workload during

implementation phase, FRMS can bring about the following benefits:

- Improved safety leading to lower administration
/engineering/insurance costs;
- Increased operational flexibility and adaptability;
- Compliance with corporate governance and duty of care
legislation;
- Isolation of industrial issues from fatigue management:
- Corporate brand protection;
- Better regulator oversight;
- Engaged workforce due to:
o Improved rostering;
o Better lifestyles;
o Lower levels of fatigue;
o Transparent, scientifically credible system; and,
o Shared ownership.
The best outcome for FRMS introduction will only be achieved through a
partnership between management and union to promote a company culture that
fosters universal mutual trust and respect and is open to the “shared ownership”
and “just culture” doctrines.
During the implementation phase of FRMS it will be important that regulator

oversight is increased to ensure that the system is properly adopted. This
process may take 2 years or more.
With advances in physiological monitoring equipment, universal workforce sleep

and body clock data could be gathered contributing to a comprehensive database
of fatigue risk.
10.0 Recommendations
In light of proposed changes to European fatigue management regulations, the

best option for a UK long-haul airline is to implement an “alternative scheme”
governed by FRMS principles.
As part of their drive to mandate FRMS, regulators should be encouraging the

aviation industry to:

- Share fatigue management knowledge in a central database;
- Understand the philosophy and case for FRMS;
- Adopt FRMS best practice;
- Network with regulator and other organisations for rapid
dissemination of:
 New ideas;
 Guidance;
 Proposed regulation;
 Case studies;
 Presentations; and,
 Problem areas and solutions.
Regulators should also publish guidance documentation to educate organisations

about FRMS and aid them in implementing policy, procedures and practice. Such
guidance should take the form of:
- An FRMS toolset;
- Generic examples of FRMS policy and procedure to fit common
cases;
- Advice on regulation requirements;
- A manual authoring and assessment tool; and,
- Guidance on internal monitoring and audit of FRMS.
Regulator oversight commitment during an airline’s FRMS implementation phase

should be enhanced.
11.0 Future Potential Areas of Study
In the context of the aviation industry there is, as yet, no detailed understanding
of the relationship between fatigue and levels of safety (Dawson et al, 2005).
With widespread aviation industry implementation of FRMS resulting in greater

quantities of alertness testing data, physiological monitoring data and fatigue
related safety outcome data becoming available, studies could be undertaken to
establish the relationship of fatigue to safety; a relationship that would
fundamentally underpin the justification for FRMS.
Other studies might look into how task loads associated with specific trip
patterns effect fatigue, using the NASA Task Load Index (NASA, 1988) and the
effects of cumulative fatigue acquired over months and, indeed, years of long-
haul flying on general health.

12.0 References
Air Accident Investigation Branch (AAIB), UK, website 2009
ANO (2005), “Flight times – responsibilities of flight crew”, Air Navigation Order 2005,
Article 84
Australian Government, Civil Aviation Safety Authority (CASA), “Fatigue Management –

suggested alternatives to prescribed Flight and Duty Times”, Discussion Paper, DP 04040S,
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published by Standards Australia International Ltd and Standards New Zealand
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ATSB Research and Analysis Report, April 2006
Bader, D (1973), Report of the Committee on Flight Time Limitations, “The Bader Report”,
CAA, 4 June 1973
CAA (2003a), A Review of In-flight Napping Strategies – Updated 2003, CAA Paper 2003/8
CAA (2003b), Letter of Intent: Proposal to Amend CAP 371, CAA Flight Operations
Department Communication 29/2003
CAA (2005a), Flight Time Limitations (FTL) – CAP 371 Fourth Edition, CAA Flight Operations
Department Communication 16/2005
CAA (2005b), Aircrew Fatigue: A Review of Research Undertaken on Behalf of the UK Civil
Aviation Authority, CAA Paper 2005/04
CAA (2007), CAA presentation to Crew Management Conference, Brussels, 5-6 December
2007
CAA (2009a), Flight time Limitations (FTL) Schemes – Current Issues and Concerns, CAA
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CAA (2009b), “Supporting Pilot Performance” webpage, CAA, Safety Regulation Group (SRG),
Safety Plan, Safety Regulations, 2009
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OPS Workshop, “21-22 January 2009
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January 2009
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Ashgate Publishing, Aldershot, 2003
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“Duty/Rest/FTL Reporting Trends - 2006/2007/2008”, Feedback magazine, Issue 89
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Dawson, D., McCulloch, K., “Managing fatigue: It’s about sleep stupid” paper, Centre of Sleep
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January 2009
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magazine, 31 July 1982
Flight International (1989), “CAA modifies pilot duty rules”, article, Author Unknown, Flight
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Flight International (2004), “Test of Stamina” article, Kingsley Jones, M. and Francis, L., Flight
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Alertness, Performance”, Flight Safety Digest, Vol.24 No. 8-9, August-September 2005, p16-
19
Flight Safety Foundation (FSF, 2005b), “Early Ultra-long-range Flight Experience” Flight
Safety Digest, Vol. 24, No. 8-9, August-September 2005, p1-15
Flight Safety Foundation (FSF, 2005c), “Unlocking the Potential of a Safety Management
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published paper, Somnolgie 3, 2007
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Technical, Ashgate Publishing Group, Aldershot, 1991
Hollnagel, E., “Barriers and accident prevention.” Aldershot, UK: Ashgate. p226, 2006
International Civil Aviation Organisation (ICAO), OPSP Working Group, FRMS Sub
Committee, Draft Document, 2008
Jackson, P., “A Review of Fatigue Risk Management Systems” Clockwork Research Ltd
presentation, Dubai, 1-2 December 2008
Johns, M. W., “A New Method for Measuring Daytime Sleepiness: The Epworth Sleepiness
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Learmont, D., (2008), “ICAO to mandate pilot fatigue risk management” article, Flight
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Learmont, D., (2009a), “Proof that fatigue kills” presentation to FRMS Forum, QinetiQ,
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Learmont, D., (2009b), “EASA bends to industry pressure for evolutionary change” Air
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analysis of Part 121/135 duty schedule-related fatigue incidents.” Prepared for the Deputy
Associate Administrator for Regulation and Certification, Federal Aviation Administration,
Washington, DC: NASA, 30 June 1999
National Transportation Safety Board, (NTSB) “The Evolution of NTSB Fatigue Related
Recommendations” presentation by Dr. J M Price to FAA Fatigue Management Symposium:
Partnership for Solutions; Vienna, VA, USA, 17-19 June 2008
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Powell, D., Petrie, K., Norrie. M., “A Programme for Monitoring Fatigue in Long-Haul
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November 1998
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FRMS Forum Presentation, QinetiQ, Farnborough, 8 May 2009
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13.0 Bibliography
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J.A.,Caldwell, J.L., Ashgate 2003
2. The Introduction of Fatigue Management to an Airline Engineering

Department - Burgess, P. MSc Thesis 2007
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CAA - CAA Paper 2005/04
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Edition
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International System Safety Conference 2008, Singapore by Captain S
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Carrier - Presentation made to 59th International Air Safety Seminar
2006 by Captain S Stewart, Dr. A. Holmes, Dr. P. Jackson and R.
Abboud
10. Fatigue Management - Suggested Alternatives to prescribed Flight and

Duty Times - CASA Document DP 0404OS - August 2004
11. Fatigue Management in the New Zealand Aviation Industry - Australian

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the Circadian Cycle – Prepared for the Office of the Chief Scientific and
Technical Advisor for Human Factors, Federal Aviation
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Green, L.G., Avebury Technical, Ashgate Publishing Group, Aldershot,
1991
14. “Managing fatigue: It’s about sleep stupid”, Dawson, D., McCulloch, K.,

Appendix A
The Mechanism of Sleep

The mechanism of sleep itself comprises of several stages that are sequenced in
cycles lasting around 90 minutes throughout the period of sleep. The stages’
descriptions are laid out in Table 1 and the structure of sleep shown in Figure 3:
Stage Description Time of Occurrence Function

1 “drowsy sleep”, some Transition from Part of “sleep onset
awareness of waking to sleep, latency”
surroundings, microlapses usually 10 minutes
,microsleeps
2 Accounts for 50% of sleep, Between Stages 1 “True onset of sleep”
irregular brain wave and 3, usually 15
pattern, “spindles” minutes
3 Slow wave sleep (SWS) – Between Stages 2 Body restoration and
“deep sleep”, slower brain and 4 usually lasting immune system
activity 15 minutes regeneration.
4 Slow wave sleep –“deep Most Stage 4 sleep Decrease in
sleep”, slow brain activity occurs early in night metabolism
REM Rapid eye movement, 90 minutes after Strengthening and
desynchronous brain sleep onset in cycles organising of
activity, “paradoxical of increasing memory
sleep” amounts
Table 1. Mechanism of Sleep (Green et al, 1991 and Caldwell et al, 2003)
Figure 3. Typical Nocturnal Pattern of Sleep of Young Adult as

indicated by Electroencephalogram (EEG) Recording (CAA, 2005b)

Appendix B
UK Flight Time Limitations Schemes’ History and Development
History
The first time any means of flight time limitation was exercised in the UK was in
1927 when the authorities decreed that flight crew should undergo a complete
medical examination if they exceeded 125 flying hours in any 30 consecutive
days.
The first Standards and Recommended Practices (SARP) document produced in

1948 by the newly created Council of the International Civil Aviation
Organisation (ICAO), that became the basis for Part I of Annex 6 of the ICAO
convention, recommended that an operator should “formulate rules limiting the
flight time and flight duty periods of flight crew members.” and also called “for
adequate rest periods and shall be such as to ensure that fatigue, occurring either
in a flight or successive flights or accumulated over a period of time due to these or
other tasks, does not endanger the safety of a flight.” (Bader, 1973).
This requirement was incorporated as an article into the British Air Navigation
Order (ANO) in April 1950.
After the crashes of 2 British aircraft, the first a York aircraft (G-AHFA) into the
Andes mountain range of South America on 2 February 1953 and secondly a
BOAC Constellation aircraft (G-ALAM) on landing at Kallang Airport Singapore in
September 1954, pilot fatigue was cited in both accidents reports (Bader, 1973).
These reports prompted an amendment to the ANO, in May 1957, that required
operators to establish their own limits on flight time and duty periods within
amounts fixed by provisions of the Order. Additionally an absolute limit on crew
flying public transport aircraft was imposed of 125 hours in any 30 consecutive
days.
In January 1964 the UK Ministry of Aviation further restricted this limit to 115
flying hours in 28 consecutive days and constrained roster schedule planning to
one hour shorter than was actually allowed on the day by the ANO.
By January 1968, after earlier proposals for extensive restructuring of the

regulations could not be agreed to, a comprehensive guidance to help operators
discharge their responsibilities under the ANO was promulgated in Civil Aviation
Publication (CAP) 295 and as an appendix to Air Operators’ Certificates;
Information on Requirements to be met by Applicant and Holders (CAP 360). This
advised that a multi-pilot, single sector flight duty period should not extend
beyond 12 hours and again reduced the absolute limit on flying hours to 100 in
28 consecutive days. Again, the onus was put on operators to follow this
guidance material to set their own limits subject to the oversight of the
Department’s Flight Operations Inspectorate.

When proposed further changes to these guidelines were circulated by the
Director of Flight Safety (Department of Trade and Industry) in July 1971
difficulties once more arose in the consultation process with interested parties
and the proposals were not implemented.
This, then, was the background to the decision to set up a committee of inquiry
into the subject that, under the chairmanship of Douglas Bader, was called the
Committee on Flight Time Limitations (FTLs), the report of which, on 4 June
1973, led to the framework that all UK FTLs have since been based on and that
has remained largely unchanged to the present day (Bader, 1973).
The Avoidance of Excessive Fatigue in Aircrews
The “Bader Report”, as it became known, called for the consolidation of the
hitherto fragmented regulation of operators’ scheduling arrangements variously
contained in ANO 1972, CAPs 360 and 295 into a single, uniform “flight time
limitations requirements” document, the provisions of which would be
administered by a new, permanent body, the Flight Time Limitations Board. This
was constituted to advise the Civil Aviation Authority (CAA) on matters of
requirements and legislation but with the overriding remit of ensuring flight
safety. Of note here is that amongst the appointees to this board of operators and
“practising airline captains” there was to be an independent aeromedical
specialist (Flight International, 1973).
The prime objective of the report was to make recommendations to ensure “…..
that aircrew are rested at the beginning of each duty period.” For such a
technically complex matter it was considered that the emphasis should not be by
enforcement through legislation but rather by close supervision of the authority
through granting and maintaining of the Air Operators’ Certificate.
In producing its report the committee recognised the sensitivity of and effect that
their deliberations would have on “…. the economy of airline operations and on
the attractions or otherwise of the aircrews’ professions.” and also how
contentious a factor fatigue was in industrial negotiations (Bader, 1973). Of the 3
sources of evidence considered; aeromedical, accident reports and opinion based
on experience of operators and aircrews neither of the first 2 were thought to
“…provide a basis for establishing fatigue requirements in quantitative terms.”
although it did concede that future modification of the regulations should be
made “….in the light of experience and results of aeromedical and other research.”
(Bader,1973).
The report introduced the concept of the “duty cycle” as the most appropriate
framework for defining measures to prevent fatigue analogous to the normal
working patterns of other occupations. “Duty” was reclassified as; flying duty
periods (FDPs), positioning, ground training, ground duties and standby duties.
This cycle was to be constructed with reference to 4 separate but interrelated
operator set controls, limited by constraints of the requirement, on; cumulative

duty hours within a duty cycle, individual duty periods, individual rest periods,
and length of duty cycles related to time off.
In keeping with the “duty cycle” philosophy and to limit cumulative fatigue a
weekly and monthly limit on duty hours (flying plus other duties) was
recommended at 50 hours within any consecutive 7 day and 160 hours within
any 28 consecutive day period for all types of operation. The existing 100 flying
hours limit within 28 consecutive days was to be maintained. A further, annual
limit on flying hours was set at 900 hours in any consecutive 12 calendar
months. This was based on the assumption of a typical 1680 annual hours for
workers in business and industry occupations and relating this to flying hours
using a ratio of 1.87:1.
The FDP was redefined to include the post flight duties and was governed, in
most cases to values more restrictive than hitherto allowed. The calculation was
done according to a set of tables that took into account a number of factors that
influenced the duty such as; local start time, number of sectors operated,
whether the individual was acclimatised to local time and or the length of the
preceding rest period.
The rationale for the new FDP limits was based around an appreciation for the
normal human cycle of 16 hours wakefulness and 8 hours rest, reducing
available duty for later starts and setting limits for the amount of time spent on
standby and following duty. Although acknowledgement of the effects of
circadian rhythm disturbance (time zone shifts) were reflected in the proposals
it was observed at the time that “the maximum cutback of an FDP due to time-
zone effect is only one hour, and that that only covers morning departures.” (Flight
International, 1973). The overarching recommendation in this area was that
“Crews should make a conscious effort to plan their activities in accordance with
the requirements of their forthcoming duty period irrespective of local time.”
(Bader, 1973).
Other recommendations were made on limits of minimum rest, short breaks,

days off, split duties, in-flight relief, positioning, helicopter operations, single
pilot operations and, with respect to issues of crew lifestyles, on notification of
rostered duties. Notably, following the example of the Australian ANO, the report
suggested that the UK ANO should be amended to include the all encompassing
requirement “… that a flight crew member should not fly, and an operator should
not require him to fly if the crew member is suffering from fatigue.” (Bader, 1973).
At the time the “Bader Report” was recognised as a sincere attempt to reconcile
the various and often opposing views of interested parties, existing complex
regulations and the poorly understood study of fatigue into a comprehensive and
credible document. It was tacitly acknowledge as a good starting point and a
“work in progress” on the matter.
All the recommendations of the report were passed into regulation and came
into force as the first edition of CAP 371, “The Avoidance of Excessive Fatigue In
Aircrews”, on 1 May 1975.

Development
In July 1982 a second edition was published which simplified the details of the
regulation, accounted for time spent on standby and balanced increases in
permitted duty with increased requirements for time off (Flight International,
1982). A significant change was that FDP was redefined again to end at brakes on
and so as to not include the post flight activities.
By the end of the 80’s considerable changes to the FTL’s were required owing to
the greater prevalence of air ambulance operations, markedly increased
helicopter activity supporting the North Sea oil industry, the growth of intensive
holiday charter flights from the UK to Mediterranean destinations, increases in
night freighting flights and the impending introduction of long range, 2 pilot
crew aircraft such as the Boeing 747-400, the McDonnell Douglas MD-11 and the
Airbus A340.
The CAA were particularly concerned that British airlines were rostering
schedules which were technically within the requirements of CAP371 but
outside the document’s general principles and whilst not breaking existing pilot
duty hour regulations had “not applied the rules in the spirit in which they were
drawn up,” (Flight International, 1989).
The third edition of CAP371, that took effect on 1 May 1990, introduced
measures to combat disturbed sleep patterns resulting from roster disruptions
and uneven duty cycle work rates. Duty hour limits and minimum days off
requirements were increased as was the minimum allowed day off rest time.
Also introduced was a limit of not more than 3 consecutive night flight
operations with a compulsory extended rest period before the first flight.
Other new requirement to schedule not more than 4 early starts or late finishes
in any 7 days and rebanding of individual FDPs to limit early evening/late
afternoon departures were set. For the first time new limits were imposed
specifically on the flight duty periods that 2 pilot aircraft crew could operate to.
The maximum crew standby duty period was reduced from 20 hours to FDP plus
6 hours and all time spent positioning was now classed as duty.
Further measures to accommodate the new breed of long-haul aircraft which

were now coming into service included rules for augmented crew and revisions
to in-flight relief provisions for operations with more than 2 pilots.
Commenting on these changes the British Airline Pilot’s Association (BALPA)

said at the time that the CAA had “…. decided to accept arguments based on
commercial interests which prejudice the safety of pilots and passenger” (Flight
International, 1990). Nevertheless inclusive tour operators were contemplating
having to hire 5-10% more pilots to comply with the new regulations
highlighting the fundamental relationship between fatigue avoidance regulations
and airline commercial competitiveness.

Throughout the 1990’s, with the advent of new technology and commercial
pressure calling for 2 pilot crewed aircraft to reach increasingly more distant
destinations that required FDPs that went outside the template that the existing
regulations provided, new mechanisms to accommodate these extended FDPs
were devised and were known as variations to the standard FTL scheme. Still in
use today, these variations were strictly controlled, awarded after seeking
specific approval, recorded in the organisation’s operations manual, could not be
modified or amended without CAA permission and allowed extensions to normal
FDPs of up to one hour balanced by compensatory factors such that the overall
safety of the scheme was not compromised. To facilitate the burgeoning low cost
carrier airline sector other variations were adopted which included self-drive
positioning within an FDP and designation of alternate bases (CAA, 2005a).
In April 2006 the fourth edition of CAP 371 became effective and incorporated
the standard variations as annexes to the main body of the document.
Importantly the definitions of a week, 2 weeks and a month were tightened up to
mean a continuously rolling period of 7, 14 and 28 days respectively as was
originally intended but in subsequent interpretations had become open to abuse.
Other significant changes included the removal of the exemption from the “early
start” limits if crew were accommodated in a company provided hotel, as
scientific research showed that a night in hotel close to the airport did not
produce a more effective night’s sleep. Also steps were taken to stop the practice
of abusing the 18 – 30 hours rest period by inserting a short period of standby to
split the time into 2 rest periods of 18 hours or less so as to take benefit from the
more advantageous subsequent allowable FDP (CAA, 2003b).

Appendix C
VAA Pilot Fatigue Survey
The survey, in the form of an online questionnaire, sponsored by the author, was
run on a voluntary basis with respondents remaining anonymous. Out of a total
789 rostered pilot population at that time, 540 were surveyed with 131
responding, accounting for 17% of all VAA pilots. The responses achieved
represented a balanced, indicative cross section of the pilot body in that there
was an even spread of age and experience, almost exactly a 50/50 split between
captains and first officers, and appropriate distribution of the different annual,
contracted hours options. Notably, proportionally more Boeing pilots (53%) took
part than did Airbus pilots (47%) where as a more statistically correct sampling
would be around a 33/67 split, respectively. This possibly reflects better job
satisfaction levels on the Airbus due to more agreeable trip rotations.
In the first part of the survey, to gain an appreciation of general fatigue levels and
to investigate if any differences could be discerned between the Airbus and
Boeing fleets (and their different trip patterns), pilots were asked to asses their
clinical fatigue levels according to the Epworth Sleepiness Scale and record how
many days of sickness they had taken in the last year.
Following that, respondents were invited to nominate the trip pattern that they
found was the most fatiguing of all the trips that they did and rate their alertness
at 5 key points within the cycle of the trip with respect to the Samn-Perelli Seven
Point Fatigue Scale (SP). Comments were requested as to the reasons behind
why the chosen trip was found to be most tiring and, finally, statements were
sought of a more general nature about work related factors influencing fatigue.
It was accepted that, being highly subjective and retrospective in most aspects of
its execution, this survey had limited value as a definitive statement of fatigue
levels in the VAA pilot workforce. Rather its intended purpose was to point out
problem areas of the VAA operation with respect to fatigue that could then be
assessed from an FRMS perspective.
Analysis of the results of the Epworth Sleepiness tests indicated completely

normal levels of fatigue within the representative sample as a whole with the
Airbus pilots’ average rating of 7.16 coming out slightly nearer to the bottom end
of the “mild sleepiness” range (8-10) than did the Boeing pilots’ score of 6.79.
The responses to the sickness question did, however, highlight noticeable

differences between the 2 fleets. On the Airbus 28.6% of pilots said that they had
not taken any sick leave in the last year whereas for the Boeing the figure was
37.7% suggesting some 9.1% more pilots went sick on the Airbus. Pilots taking
over 2 week’s sick leave were proportionally more prevalent on the Airbus with
17.5% recording the longer absences to the Boeing’s 6.4% and embedded within
those results 7.9% of the former having over 6 weeks away with no participating
Boeing pilots falling into this category at all (Figure 4).

Survey Indication of Annual Pilot Sickness by Fleet over 6 weeks
40 days
29 days
28 days
21 days
80 19 days
17 days
70
15 days
60 14 days
50 12 days
Percentage of 11 days
Survey 40 10 days
respondents
30 8 days
7 days
20
6 days
10 5 days
4 days
0
Airbus Boeing 3 days
2 days
1 day
Figure 4
In terms of the number of sick days per pilot per year, according to those who
responded but excluding those Airbus pilots who had had over 6 weeks sick
leave, the rates were 3.97 for the Boeing fleet compared to 4.86 for the Airbus; a
22.6% higher rate for the Airbus fleet (specific data for sickness over 6 weeks
sick was not collected so it was not possible to include this in the calculation
however, in this case, its inclusion would have made the difference even more
pronounced).
With respect to which trip rotations were found to be most fatiguing it was
apparent that each fleet had their respective trip that stood out in this category.
On the Airbus 39.1% of pilots nominated the Hong Kong/Sidney (HKG/SYD)
rotation as their most tiring duty and 80.8% of Boeing pilots selected one of
several flights operating to either Orlando or Miami as their most exhausting
trip. This latter trip employed the Florida 2 (FL2) variation to the approved
company FTL scheme and, in most cases, required prior surface transport
positioning between Heathrow and Gatwick, It is appropriate to note here that
the Airbus fleet, that serves all East and South bound destinations as well as all
US destinations bar 2, has a far bigger route structure than does the Boeing
which only goes to the US, the Caribbean and very occasionally South Africa. This
partly explains why, with FL2 flights representing a much bigger proportion of
Boeing fleet’s overall flying, the FL2 trips were scored, in percentage terms,
significantly higher (64.9%) than the HKG-SYD flights on the Airbus (39.1%).
Interpretation of the coalesced SP Fatigue Scale survey results filtered to only

show the trips polled as being the most arduous did indeed reveal parts of the
trip cycle where the general feeling was of being “moderately tired; let down” and
in some instances, most notably on the commute home, after duty end, being
described as “extremely tired; very difficult to concentrate”. Interestingly even the
results from the non FL2 HKG/SYD trips, plotted for comparison, ranged into the
upper reaches of the fatigue scale.
In order to put these findings into some sort of context one of the few yardsticks
that is available to compare the results to more commonly held perceptions of
degrees of alertness is to relate the SP scale with Blood Alcohol Concentration
(BAC) levels. Research into this area suggests that the UK drink driving laws’ BAC
limit of 0.08 milligrams of alcohol per millilitre of blood is reached at around 4.8
on the SP scale (Dawson et al 1997). Plotted results for the SP scale survey,
shown in Figure 5 below, indicated that the HKG/SYD chart line was above this
level for a significant proportion of the last sector and that for the FL2, breached
the 4.8 level at the top of drop (TOD) point on the inbound UK sector and peaked
at a point markedly above this level for the commute home. Interestingly enough
the authors of the paper that introduced the SP scale considered that flight crews
with scores of 5 or above should not fly (Samn et al, 1982).
Of note for the FL2 line is that the indicated fatigue at check in for the next trip
after minimum base turn round (MBTR) was slightly higher than the first reading
in the cycle; possibly implying an aspect of accumulative fatigue with this
rotation.
Interestingly, these subjective survey results show a reasonable correlation with

the SAFE computer fatigue modelling predictions produced in Appendix F.

Samn Pirelli Seven Point Fatigue Scale Survey
Results - FL2 HKG/SYD
Non FL2 HKG/SYD FL2 HKG/SYD
7.00
6.00
5.00
Samn Pirelli Fatigue Scale
4.00
3.00
2.00
1.00
0.00
TOD Las t Pre Fl i ght TOD Inbound UK Commute Home Next Tri p Check-
Outbound Sector Inbound UK Sector In After MBTR
Sector
Selected Key Trip Points
Figure 5
Comments received in the survey broadly backed up the results achieved from
the analysed data with many respondents expressing the view that the current
FTL scheme was not succeeding in properly regulating the risk of fatigue in the
flying programme.
These survey results have to be qualified by reemphasising that respondents to

the survey were self selected and could participate without fear of disciplinary
retribution and so the pilots who did reply were most likely to be more
predisposed to highlighting the more fatiguing aspects of the operational routine.

Fatigue Survey Questionnaire

Epworth Sleepiness Scale (Johns, 1991)
How likely are you to doze off or fall asleep in the following situations, in
contrast to feeling just tired? This refers to your usual way of life in recent times.
Even if you have not been in some of these situations recently, try to imagine
how they would have affected you.
0 = would never doze

1 = slight chance of dozing
2 = moderate chance of dozing
3 = high 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 lunch without alcohol _________
- In a car, while stopped for a few minutes in traffic _________
Total Score _________

Scoring:
up to 8 - normal
8 – 10 - mild sleepiness
11 – 15 - moderate sleepiness
16 – 20 - severe sleepiness
21 – 24 - excessive sleepiness
Samn-Perelli Seven-point Fatigue Scale (Samn et al, 1982)
Individuals are requested to select one statement that describes how they feel:
1 Fully alert; wide awake; extremely energetic

2 Very lively; responsive; but not at peak
3 Okay; somewhat fresh
4 A little tired; less than fresh
5 Moderately tired; let down
6 Extremely tired; very difficult to concentrate
7 Completely exhausted; unable to function effectively

Appendix D
Sample FRMS Policy Statement
(Transport Canada, 2007b)

Appendix E.
Analysis of FRMS in Operation
Civil Aviation Authority, New Zealand
Although air transport operators in New Zealand have been allowed to choose
between complying with prescriptive flight and duty time (FDT) regulations and
applying for approval to operate under a potentially more flexible company
specific FDT scheme since 1995, a recent study found that there was no
appreciable difference in how fatigue was managed in terms of number and
frequency of use of fatigue management strategies between those sets of
companies opting for the different schemes. Moreover there was evidence of
discrepancies between managers and pilots of the effectiveness of some fatigue
strategies suggesting that there was an industry wide deficiency of knowledge of
fatigue and fatigue management processes. The report recommended that the
regulator and other industry groups should promote a more mature safety
culture and greater knowledge base as a prerequisite to support and oversee
company specific fatigue management schemes (Signal et al, 2008).
Civil Aviation Safety Authority, Australia
Instructed by a year 2000 Australian Government report entitled “Beyond the

Midnight Oil” recommending CASA to implement a FRMS to regulate flight and
duty times for aircrew, the Australian regulator commenced a trial of operator
developed safety cases based on, initially, 21 operators implementing fatigue
management systems (FMS). The impetus for this initiative came from the
recognition that the FTL system governed by CAO 48, the CASA equivalent of
CAP371, had become largely based on exemptions from the rules (variations in
UK CAA terms), was proving difficult to manage and was not science based. It
was also acknowledged that CAO48 had more to do with regulating work than
managing fatigue.
In 2001, as part of the process of FRMS introduction, CASA cancelled many of the
CAO 48 exemptions to encourage organisations to develop and implement FMS
comprising policy, training and education, risk management and compliance
audit mechanisms. CASA wanted to move the industry away from compliance to
an arbitrary rule set and make safety the primary focus through a performance
or outcome based model of regulation.
Although CASA’s intentions were well founded, the scale and complexity of the
task were underestimated. A 2003 CASA commissioned report observed that too
few resources had been devoted to educating the industry about the major
cultural shift to a safety-case approach to regulation. Many smaller operators,
predominant in the Australian aviation industry, did not have the time or funds
to invest in understanding the new system and crafting their own bespoke

version of it. They simply added the company name to the relevant boxes of the
guidance templates provided by Canberra as a means of complying, which
effectively, flew in the very face of FRMS philosophy. As well as recommending
more effort to be concentrated on education the report called for CASA to
develop an FRMS “toolbox” to assist in system development and suggested an
interim stage between CAO 48 and full FRMS compliance whereby, particularly
for smaller operators, a range of “off the peg” policies were made available that
could be “adapted” to the more commonly found, simpler operations (McCulloch,
2003).
Despite a poor implementation phase, CASA’s trial has gained acceptance for
FRMS and proved that it can be a successful FMS. Recent CASA announcements
state that it is preparing to roll out FRMS industry wide and that all of the
remaining CAO 48 exemptions will be withdrawn (Jackson, 2008).
Air New Zealand
Despite its, perhaps, uninspiring regulatory backdrop, Air New Zealand (ANZ)
has whole heartedly grasped the FRMS initiative and is today considered the
pioneer of FRMS adoption. Given its geographical location requiring long sectors
with night time departures to get to Northern Hemisphere destinations at
commercially appropriate times and with no overseas pilot basings resulting in
trip rotations lasting up to 13 days, circadian disruption and fatigue are ever
present hazards for ANZ pilots.
The airline’s fatigue management programme began with the setting up of the
Flight Crew Fatigue Study Group (FCFSG) to initially study the feasibility of
introducing a policy for controlled rest recovery (CRR) on the flight deck (in-seat
napping) as a means of temporarily enhancing alertness, based on research
conducted by NASA. Through a joint management and union initiative the
essential philosophy of the programme was that strategies would be “data driven
rather than industrially motivated”. The de-identified data, accessible to all
participants, had to support the recommendations of the FCFSG whose workings
were subjected to periodic, external, leading expert review and scrutiny. As a
result of this successful initiative ANZ became the first airline in the world to
introduce a CRR policy.
ANZ’s FCFSG is much the same as a Fatigue Management Steering Committee

discussed earlier but with the addition of a scientific advisor. It has set out the
model that has informed the generally accepted FRMS structures and practices of
today; monitoring, assessing and reporting fatigue risk; recommending
mitigating strategies; raising awareness of the subject through education and
training and carrying out fatigue surveys to identify problem areas and
increasing the knowledge base. One area of the FCFSG’s work has been the
development of a computerised pilot alertness test (PATANZ) based on a Palm
Pilot PDA that can be easily and inexpensively deployed for fatigue survey
programmes.

ANZ’s FRMS has identified trip rotations where fatigue risk was not immediately
obvious due to comparison with similar rotations where there were no fatigue
issues. However owing to hotel and airport transfer arrangements prior to one
trip in question, the risk did become borderline significant. The finding lead to
the pre-positioning of slip crews in order to operate the last sector of the pattern
(Powell et al, 1998).
Other validation of subjective experiences of pilots by integrating knowledge

obtained from fatigue reports, operational studies and focused studies has led to
successful differentiation between effective and ineffective intervention
measures. This was so on the Auckland – Los Angeles – Auckland rotation where
the addition of a fourth pilot to the crew compliment was found to be more
effective at reducing fatigue than an extra 24 hours of layover in Los Angeles.
This strategy has now been adopted on other trip patterns (FSF, 2005b).
These examples highlighted some key characteristics of FRMS namely:
- Close correlation between subjective and objective data suggested

that subjective means of fatigue assessment can have validity in the
absence of objective testing due to impracticalities and/or costs;
- Management/union ownership of the FRMS process can bare fruit in
terms of a safer operation;
- A scientific approach pointed up problem areas on trip patterns
whereas a purely flight and duty time analysis would have compared
these patterns favourably with other similar patterns where no
problems existed.
Ultra Long Range Flights, Singapore Airlines
As regulator of one of the first airlines to conduct ULR flights, the Civil Aviation
Authority of Singapore prepared for this undertaking by setting up a ULR Task
Force which in turn took advice from the ULR Crew Alertness Steering
Committee, a global forum sponsored by Boeing, Airbus and the Flight Safety
Foundation consisting of representatives from medical research establishments,
airlines, aircraft manufacturers, regulators, safety groups and pilot associations.
Informed by earlier experience of FRMS, the steering committee recommended

that ULR flights should be approved on a case by case basis based on the
assumption that the rotation was an out-and–back flight between an approved
city pair using a specific aircraft type with a defined departure window and
treated as a variation to an airline’s FTL scheme rather than a broad based
blanket approval for such operations. In addressing crew alertness and
performance issues extensive guidelines were set out as to how a ULR flight
procedures and practices should be formulated. These were categorised under
the following headings:

- Crewing;
o Flight Crew Compliment

 Number of flight crew required assessed according to
scientific evidence and operational experience
 Initial FRMS validation of crew compliment
 Review of crew compliment according to validation
results
o Flight Crew Qualifications
 Operational experience of long-range flights
 Minimum of 4 pilots, 2 of which must hold pilot in
command qualification, 1 of which should be at the
controls at all times
- Education;
o Training of all staff associated with ULR operations;

management, pilots, cabin crew, scheduling and rostering staff,
dispatchers, operations staff and airline medics to include the
following curricula:
 Consequences of fatigue on aviation safety;

 Confidential feedback from incidents;
 Recognition of signs of fatigue and decreased alertness
in self and others;
 Physiology of sleep;
 Circadian rhythms and homeostatic process;
 Sleep and alertness strategies;
 Diet and Hydration;
 Prescription and non-prescription medication, plus
related regulatory policies;
 In-flight environment;
 Work scheduling and,
 Crew coordination to address sleep inertia after in-flight
rest.
- Delays and Disruptions;
o Specified maximum allowable departure delay dependant on

city pair and whether at home base or outstation to ensure
“creeping delay” does not compromise crew alertness
o Regulator approved delay, disruption and diversion
contingency plans
o Risk assessment of all factors associated with a diversion on a
ULR flight including reversion to long range flight FTLs
o Captain has final authority for the safe conduct of the flight
with respect to crew fatigue

- Standby;
o Standby crew must fulfil pre-ULR rest requirements

o Dedicated ULR standby system
o Early notification of in-flight rest allocation
- In-flight Environment;
o Rest
 Crew rest facilities are sufficient to ensure pilot
alertness is maintained at an acceptable level. Ideally
individual compartments separate from flight deck that
allow reclining or horizontal sleep and appropriately
designed to cater for the following factors:
 Noise levels;
 Changing space
 Reading lights
 Ventilation, temperature and humidity controls
 Alerting and communication systems to flight
deck and passenger cabin
 In-flight entertainment
o Lavatories
 Dedicated flight crew lavatory within flight deck secure
area
o Flight deck environment

 Ergonomic design to reduce stress and fatigue levels
such as:
 Comfortable seating;
 Suitable lighting and sunshades to limit sunlight
and heat;
 Noise management;
 Humidification control and
 Appropriate system alerting mechanisms.
- Rostering Practices:
o Operating patterns for flights and layovers should provide:

 Adequate pre-flight and layover rest preferably
affording 2 major sleep opportunities to ensure crew
member fully rested prior to flight departure;
 Adequate physiological recovery time after trip;
 Reasonable additional time off for normal social
interaction;
 Recovery time that does not infringe pre-ULR rest
requirements, and,
 Crews acclimatised to local base time before trip start.

o In-flight rest procedures should include:
 Responsible plan promulgated for in-flight rest
planning;
 In-flight rest planning guidance provided to crew;
 In-flight rest tailored to flight pattern;
 Adequate crew notification of in-flight rest period
allocation;
 A degree of flexibility towards rest allocation once flight
underway;
 Change/handover procedures particularly with respect
to sleep inertia following a rest period;
 Cockpit napping procedure advice (used as a
complimentary strategy)
o Scheduling of ULR trips:

 Not to include duty positioning as part of pre-ULR rest
period:
 Must be considered a “stand alone” duty and not
combined with any other.
- Go/No-go;
o Guidance material provided on go/no-go decision making with

respect to factors affecting crew alertness and performance
e.g.:
 Minimum equipment list (MEL) provisions i.e. for rest
facilities, inflight environment, degraded flight
automation etc.;
 Delays, disruptions, diversions, and,
 Any other aspects that may affect crew alertness.
(FSF, 2005b)
To achieve approval for ULR flights SIA had to show compliance with these
procedures and adopt FRMS styled practices such as mathematical computer
modelling using QinetiQ’s SAFE programme and create a company ULR
operational steering committee to validate and monitor these procedures and
outcomes in close cooperation with the CAAS.
Experience gained so far has shown that this cautious and consensual approach,
complying with FRMS principles, specifically allowing crew members 2 inflight
rest periods per sector and guidance on sleep management, has resulted in ULR
crew fatigue levels that are favourably comparable to crew fatigue levels of
conventional FTL regulated long range flights.

easyJet
In the early 2000s it became clear to easyJet management that, in following their
business model of focusing on minimising direct costs and maximising resource
utilisation, high flight crew utilisation, although within the boundaries of their
FTL scheme, led to decrements in crew alertness and performance, increased
absenteeism and attrition and an unacceptable risk of fatigue related accident
(Stewart, 2008). At the time they operated a roster pattern of 3 early duties, 3
late duties and 3 days off (6/3 roster) that, given the multi sector minimum crew
rest nature of the LCC working environment could, without sympathetic
rostering, lead to unacceptable levels of fatigue risk exposure.
To acquire a better understanding of this situation easyJet developed a Human

Factors Monitoring Programme (HFMP) that interrogated information from
Flight Data Monitoring (FDM), FAID predictive modelling and other data streams
from the company SMS to try to establish a link between flight crew fatigue,
rostering practices and human error. The programme identified that the short
time separating early and late duties on the 6/3 roster pattern presented a
fatigue risk and suggested a pattern of 5 early duties, 2 days off, 5 late duties and
4 days off (5/2/5/4 roster). This new pattern was trialled alongside the current
one and was found to more than halve the incidences of high to very high fatigue
risk duties. Line orientated safety audit (LOSA) results indicated that crew mean
error rates were aglso halved.
On the back of these results a safety case was presented to the UK CAA for
alleviation from the CAP371 stipulations on consecutive early and late starts to
allow implementation of the 5/2/5/4 roster. This was granted on the premise
that easyJet introduce an FRMS to actively manage, by way of an evidence based
system, fatigue risk (Stewart et al, 2006).
Much of the knowledge base of FRMS had previously come from the long-haul
sector of the aviation industry so easyJet has been a front runner in the
introduction of FMS into the European short haul arena. Consequently the
company have had to develop their own FRMS very much from first principles,
the latest human factors theory and other industries’ best practice. A key
element of the easyJet system is their bespoke risk assessment/management
model, System Integrated Risk Assessment (SIRA) (Figure 15) that has been
influenced in its design by the International Risk Management Standard 4360, a
respected standard in the world of organisational risk management.
In subsequent operation the 5/2/5/4 roster was the subject of 9% of all duty
related reports to the UK’s Confidential Human Factors Incident Reporting
(CHIRP) scheme in 2006 and indeed the roster was referenced in all reports
received from easyJet pilots that year. Significantly the following year only one
report was received after the roster routine was modified to allow 3 days off
between the early and late duties (CHIRP, 2008). This then is perhaps the perfect
example of an FRMS process in action; Reacting to a reported fatigue risk by
investigation, analysis, assessment, acceptance, evaluation, decision and
operational change management.

Figure 15. easyJet’s Risk Assessment/Management Model – SIRA
(Stewart et al, 2008)

Appendix F
Example of SAFE Analyses of Trip Rotations Before and After

Operation of Fatigue Risk Mitigating “Levers.”
Trip 1
LHR-HKG-SYD
Current roster schedule, operated by 3 pilot crew all sectors (all times GMT):
Day Report Departure GMT diff Destination GMT diff Duty Finish
2 20:00 LHR +1
3 HKG +8 10:20
4
5 10:00 HKG +8 SYD +11 21:05
6
7 03:05 SYD +11 HKG +8 14:25
8 09:40 HKG +8 LHR +1 19:20
Table 7. LHR-HKG-SYD Trip Rotation Schedule
Figure 18. SAFE Analysis of Current LHR-HKG-SYD Schedule (3 pilots all

sectors)
Samn Perelli Fatigue Scale prediction (above) for 1850Z on day 8 (time of
landing at LHR) is 4.8, i.e. equating to “moderately tired; let down”.

Figure 19. SAFE Analysis of LHR-HKG-SYD Schedule Modified by Inclusion
of Fourth Pilot on Last Sector
Samn Perelli Fatigue Scale prediction for 1850Z on day 6 (time of landing at LHR)
is 3.9, i.e. equating to “a little tired; less than fresh” – nearly a one point
improvement in alertness on the SP scale.
(Due to limitations of the computer programme schedule could only be represented

as starting from HKG outbound despite being a faithful analysis of whole trip
pattern starting from LHR, hence trip finishes on Day 6 rather than Day 8 as
previous analysis. Also LHR time is shown as local rather than as previously, GMT.)

Trip 2
LHR-LGW-MCO
Current roster schedule, operated by 2 pilot crew all sectors (all times GMT):
Day Report Departure GMT Destination GMT Duty Notes

diff diff Finish
2 0920 LHR +1 MCO -4 21:30 Surface
Positioning
LHR-LGW
3 22:10 MCO -4
4 LHR +1 09:15 Surface
Positioning
LGW-LHR
Table 8. LHR- MCO Trip Rotation Schedule
Figure 20. SAFE Analysis of Current LHR-LGW-MCO Schedule (2 pilots)
Samn Perelli Fatigue Scale prediction for 0730Z on day 4 (time of landing at
LGW) is 5.2, i.e. equating to “moderately tired; let down”.

Figure 21. SAFE Analysis of LHR-LGW-MCO Schedule Modified by Inclusion
of Third Pilot on All Sectors Allowing In-flight Relief on Return Sector
Samn Perelli Fatigue Scale prediction for 0730Z on day 4 (time of landing at
LGW) is 4.3, equating to “a little tired; less than fresh” – nearly a one point
improvement in alertness on the SP scale.
Notes:
- In the time line representation of the SAFE programme output the
colours indicate:
Mauve/Grey - Off Duty

Green/Yellow/Orange/Red - Increasing
Fatigue Levels during
Duty
Grey - In-flight Rest taken in
Bunk
- All analyses represent the most favourable case of the pilot flying
(PF). Other pilots, PNF and relief pilots may record higher
associated levels of fatigue.

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Richard Jones

Fatigue Risk Management System

Submitted as part of the requirement for the award of MSc in Air

Date: 10 October 2009

Word count: 14,952

Today’s UK pilot fatigue management Flight Time Limitations (FTL) regulations

FRMS Introduction ii R M G Jones

- A substantial body of evidence exists to cast doubt on the

- A FRMS that either enhances current FTL schemes or

- Successful FRMS implementation relies on:

o A comprehensive change management process

o Close regulator monitoring during implementation

- Computer fatigue modeling can play a proactive role in a

- Significant benefits can be derived from FRMS

FRMS Introduction iii R M G Jones

Section Title Page

2.0 Project Aim 3

4.0 Fatigue in Aviation 5

5.0 Flight Time Limitations 11

6.0 Fatigue Risk Management Systems 18

6.1 Definition and Theory 18

FRMS Introduction iv R M G Jones

7.1 Regulatory Background 35

8.0 Future Applications of FRMS 44

11.0 Future Potential Areas of Study 48

FRMS Introduction v R M G Jones

Figure Title Page

1. Change in Alertness with Increasing Wakefulness due to 7

2. Diurnal Variation of Alertness due to Circadian Rhythm 7

3. Typical Nocturnal Pattern of Sleep of Young Adult as 54

4. Survey Indication of Annual Pilot Sickness by Fleet 61

5. Samn-Perelli Seven Point Fatigue Scale Survey Results 63

7. Risk Reduction Process 19

8. Effective Fatigue Risk Management Systems 20

9. Hazard-Control Model for Fatigue Risk Management 23

10. An FRMS Organisational Chart 24

11. The Risk Management Process 26

12. Actiwatch, Palm Pilot and PVT Computer 27

13. FRMS Change Management Process 29

14. FRMS Organisational Implementation Map 30

15. easyJet’s Risk Assessment/Management Model – SIRA 79

16. Overview of FRMS Introduction and Time Line 35

17. Relationship Envisioned Between Regulator and Airline 42

18. SAFE Analysis of Current LHR-HKG-SYD Schedule 80

19. SAFE Analysis of Current LHR-HKG-SYD Schedule 81

20. SAFE Analysis of Current LHR-LGW-MCO Schedule 82

FRMS Introduction vi R M G Jones

Table Title Page

2. Fatigue Related UK Registered Aircraft Accident/Incidents 16

3. Fatigue Related Non UK Registered Aircraft Accidents 16

4. Accident/Incidents where Fatigue Being Investigated as 17

5. Responsibilities for Fatigue Risk Management 21

6. Sequence of Events – FRMS Introduction 34

7. LHR-HKG-SYD Trip Rotation Schedule 80

8. LHR-MCO Trip Rotation Schedule 82

9. SMS Principles Embedded in FRMS 37

10. FRMS Departmental Policy Guidance 41

FRMS Introduction vii R M G Jones

AAIB - Air Accident Investigation Board (UK)