Fatigue Risk Management Systems

2011 Edition

Manual for Regulators

Doc 9966 - UNEDITED VERSION
Overview

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ii Contents

CONTENTS

FRMS Manual for Regulators.................................................................................................................. 1

Chapter 1: Introduction to fatigue risk management systems (FRMS) .................................................... 1‐1

1.1 What is a fatigue risk management system?..................................................................................... 1‐1

1.2  Why the aviation industry is introducing FRMS................................................................................. 1‐1

1.3 ICAO Standards and Recommended Practices for fatigue management.......................................... 1‐3

    1.3.1   Section 4.10 of Annex 6, Part I.............................................................................................. 1‐5

     4.10.1 .................................................................................................................................... 1‐5

     4.10.2 .................................................................................................................................... 1‐5

     4.10.3 .................................................................................................................................... 1‐5

     4.10.4 .................................................................................................................................... 1‐6

     4.10.5 .................................................................................................................................... 1‐6

     4.10.6 .................................................................................................................................... 1‐6

     4.10.7 .................................................................................................................................... 1‐7

     4.10.8 .................................................................................................................................... 1‐7

    1.3.2   Appendix 8, Annex 6, Part I................................................................................................... 1‐8

1.4 Structure of this manual..................................................................................................................... 1‐8

Chapter 2: Science for FRMS .................................................................................................................. 2‐1

2.1 Introduction to science for FRMS....................................................................................................... 2‐1

2.2 Essential sleep science ....................................................................................................................... 2‐1

    2.2.1 What is happening in the brain during sleep............................................................................ 2‐1

    2.2.2 The issue of sleep quality.......................................................................................................... 2‐5

    2.2.3 Consequences of not getting enough sleep.............................................................................. 2‐6

2.3 Introduction to circadian rhythms...................................................................................................... 2‐9

    2.3.1 Examples of circadian rhythm................................................................................................... 2‐9

    2.3.2 The circadian body clock and sleep .......................................................................................... 2‐10

    2.3.3 Sensitivity of the circadian body clock to light ......................................................................... 2‐12

    2.3.4 Shift work.................................................................................................................................. 2‐13

    2.3.5 Jet lag  ........................................................................................................................................ 2‐14

2.4 Summary of essential science for FRMS............................................................................................. 2‐17

Chapter 3: FRMS policy and documentation........................................................................................... 3‐1

3.1 Introduction to FRMS policy and documentation .............................................................................. 3‐1
Contents iii

3.2 Appendix 8, 1.1:  FRMS policy............................................................................................................ 3‐3

    3.2.1 Scope of the FRMS .................................................................................................................... 3‐3

3.3 Examples of FRMS policy statements................................................................................................ 3‐5

    3.3.1 FRMS policy statement for a major air carrier.......................................................................... 3‐5

    3.3.2 FRMS policy statement for a smaller operator

    providing medical evacuation services ....................................................................................... 3‐6

3.4 Appendix 8, 1.2: FRMS documentation ............................................................................................. 3‐7

    3.4.1 Example of Terms of Reference for a Fatigue Safety Action Group ......................................... 3‐8

Chapter 4: Fatigue Risk Management (FRM) Processes .......................................................................... 4‐1

4.1 Introduction to FRM processes.......................................................................................................... 4‐1

4.2 FRM Processes Step 1: Identify the operations covered.................................................................... 4‐4

4.3 FRM Processes Step 2: Gather data and information ........................................................................ 4‐4

4.4 FRM Processes Step 3: Hazard identification..................................................................................... 4‐6

    4.4.1 Predictive hazard identification processes............................................................................... 4‐6

    4.4.2 Proactive hazard identification processes................................................................................ 4‐9

    4.4.3 Reactive hazard identification processes.................................................................................. 4‐13

4.5 FRM Processes Step 4: Risk assessment............................................................................................. 4‐14

4.6 FRM Processes Step 5: Risk mitigation............................................................................................... 4‐16

4.7 Example: Setting up FRM processes for a new ULR route ................................................................. 4‐18

    4.7.1: Step 1 – Identify the operation................................................................................................ 4‐19

    4.7.2: Step 2 – Gather data and information..................................................................................... 4‐19

    4.7.3: Step 3 – Identify hazards.......................................................................................................... 4‐21

    4.7.4: Step 4 – Assess safety risk........................................................................................................ 4‐22

    4.7.5: Step 5 – Select and implement controls and mitigations........................................................ 4‐22

    4.7.5: Step 6 – Monitor effectiveness of controls and mitigations ................................................... 4‐22

    4.7.6: Linking to FRMS safety assurance processes........................................................................... 4‐23

Chapter 5: FRMS safety assurance processes.......................................................................................... 5‐1

5.1 Introduction to FRMS safety assurance processes............................................................................. 5‐1

5.2 FRMS Safety Assurance Processes Step 1: Collect and review data .................................................. 5‐4

5.3 FRMS Safety Assurance Processes Step 2: Evaluate FRMS performance .......................................... 5‐5

5.4 FRMS Safety Assurance Processes Step 3: Identify emerging hazards .............................................. 5‐6

5.5 FRMS Safety Assurance Processes Step 4: Identify changes affecting FRMS..................................... 5‐6

5.6 FRMS Safety Assurance Processes Step 5: Improve effectiveness of FRMS ...................................... 5‐7

5.7 Assigning Responsibility for FRMS Safety Assurance processes ........................................................ 5‐7

5.8 Examples of FRMS safety assurance processes interacting with FRM processes.............................. 5‐8
iv Contents

Chapter 6: FRMS promotion processes................................................................................................... 6‐1

6.1 Introduction to FRMS promotion processes...................................................................................... 6‐1

6.2 FRMS training programmes............................................................................................................... 6‐2

    6.2.1 Who needs to be trained ...................................................................................................... 6‐2

    6.2.2 Curriculum ............................................................................................................................ 6‐2

    6.2.3 FRMS training formats and frequency.................................................................................. 6‐6

    6.2.4 FRMS training evaluation...................................................................................................... 6‐6

    6.2.5   FRMS training documentation.............................................................................................. 6‐7

6.3 FRMS Communications plan .............................................................................................................. 6‐7

Chapter 7: Deciding to offer FRMS regulations....................................................................................... 7‐1

7.1 Is the State’s safety oversight system mature enough?.................................................................... 7‐1

7.2 Do we have adequate resources?...................................................................................................... 7‐2

7.3 If we offer FRMS, can we pay less attention to our prescriptive regulations?.................................. 7‐3

7.4 What if the State already has a process to approve

    an FRMS and/or operators with an approved FRMS? ....................................................................... 7‐3

7.5 When should the operator apply for a variation and

    when should they be required to implement an FRMS?................................................................... 7‐4

7.6 How will we assess the acceptability of the operator‐proposed outer limits of their FRMS? .......... 7‐4

7.7 What are the aspects of an operation for which FRMS outer limits have to be determined? ......... 7‐5

7.8 Why don’t we develop regulations that require FRMS to be a component of SMS?........................ 7‐6

7.9 The FRMS provisions require that significant deviations in scheduled and

    actual flight times, duty periods and rest periods, and reasons for those

    significant deviations, be recorded by operators. How do we monitor that? .................................. 7‐6

Chapter 8: The FRMS approval process .................................................................................................. 8‐1

8.1 A Phased approach to FRMS implementation................................................................................... 8‐1

    8.1.1 Phase I: Planning................................................................................................................... 8‐1

    8.1.2 Phase II: Implement reactive FRM processes....................................................................... 8‐3

    8.1.3 Phase III: Implement proactive and predictive FRM processes............................................ 8‐3

    8.1.4 Phase IV: Implement FRMS safety assurance processes...................................................... 8‐3

    8.1.5 Operational Example of staged FRMS implementation ....................................................... 8‐4

8.2 FRMS Approval process ..................................................................................................................... 8‐6

    8.2.1 Regulatory Milestone 1 – Notification by the operator ....................................................... 8‐7

    8.2.2 Regulatory Milestone 2 – Review of FRMS plan, policy and documentation....................... 8‐7

    Regulatory documentation – ............................................................................................................. 8‐7

    1. Review of FRMS plan................................................................................................................... 8‐7

    2. Review of the initial FRMS policy and documentation proposal ................................................ 8‐8
Contents v

    8.2.3 Regulatory Milestone 3 – Review of initial FRM processes.................................................. 8‐9

    8.2.4 Regulatory Milestone 4 – Approval of FRMS........................................................................ 8‐10

Chapter 9:  Oversight of an FRMS........................................................................................................... 9‐1

9.1 Regulatory planning functions........................................................................................................... 9‐1

9.2 Special requirements for FRMS oversight ......................................................................................... 9‐1

9.3 Enforcement ...................................................................................................................................... 9‐2

Appendix A: Glossary ............................................................................................................................. A‐1

Appendix B: Measuring crewmember fatigue ........................................................................................ B‐1

B1 Crewmembers’ recall of fatigue......................................................................................................... B‐1

    B1.1 Fatigue reporting forms........................................................................................................ B‐1

    B1.2 Retrospective surveys........................................................................................................... B‐3

B2 Monitoring crewmember fatigue during flight operations ............................................................... B‐4

    B2.1 Subjective fatigue and sleepiness ratings............................................................................. B‐4

    B2.2 Objective performance measurement ................................................................................. B‐7

    B2.3 Monitoring sleep................................................................................................................... B‐8

    B2.4 Monitoring the circadian body clock cycle ........................................................................... B‐13

   

B3 Evaluating the contribution of fatigue to safety events.................................................................... B‐16

Appendix C: Procedures for Controlled Rest on the Flight Deck .............................................................. C‐1

Appendix D: Example of an FRMS Evaluation Form ................................................................................ D‐1
Chapter 1. Introduction to FRMS 1‐1

Unedited version

Chapter 1. Introduction to fatigue risk management systems (FRMS)

1.1 What is a fatigue risk

management system?

ICAO has defined fatigue as:

A physiological state of reduced mental or

physical performance capability resulting from

sleep loss or extended wakefulness, circadian

phase, or workload (mental and/or physical

activity) that can impair a crew member’s

alertness and ability to safely operate an

aircraft or perform safety related duties.

Fatigue is a major human factors hazard because it

affects most aspects of a crewmember’s ability to

do their job. It therefore has implications for safety.

A Fatigue Risk Management System (FRMS) is

defined as:  

A data‐driven means of continuously

monitoring and managing fatigue‐related

safety risks, based upon scientific principles and

knowledge as well as operational experience

that aims to ensure relevant personnel are

performing at adequate levels of alertness.

An FRMS aims to ensure that flight and cabin crew

members are sufficiently alert so they can operate

to a satisfactory level of performance. It applies

principles and processes from Safety Management

Systems (SMS) to manage the risks associated with

crewmember fatigue. Like SMS, FRMS seeks to

achieve a realistic balance between safety,

productivity, and costs. It seeks to proactively

identify opportunities to improve operational

processes and reduce risk, as well as identifying

deficiencies after adverse events. The structure of

an FRMS as described here is modelled on the SMS

framework. The core activities are safety risk

management (described in the SARPS as FRM

processes) and safety assurance (described in the

SARPs as FRMS safety assurance processes). These

core activities are governed by an FRMS policy and

supported by FRMS promotion processes. The

entire system must be documented to the

satisfaction of the State of the Operator.

Both SMS and FRMS rely on the concept of an

‘effective safety reporting culture1

, where personnel

have been trained and are constantly encouraged to

report hazards whenever observed in the operating

environment. To encourage the reporting of fatigue

hazards by all personnel involved in an FRMS, an

operator must clearly distinguish between:

• unintentional human errors, which are

accepted as a normal part of human behaviour

and are recognized and managed within the

FRMS; and  

• deliberate violations of rules and established

procedures. An operator should have

processes independent of the FRMS to deal

with intentional non‐compliance.  

To encourage an ongoing commitment by personnel

to reporting fatigue hazards, the organization must

take appropriate action in response to those reports.

When an effective safety reporting system exists, a

large percentage of safety reports from operational

personnel relate to identified or perceived hazards,

instead of errors or adverse events.  

1.2   Why the Aviation Industry is

Introducing FRMS

The traditional regulatory approach to managing

crewmember fatigue has been to prescribe limits on

maximum daily, monthly, and yearly flight and duty

hours, and require minimum breaks within and

between duty periods. This approach comes from a

long history of limits on working hours dating back

to the industrial revolution. It entered the

transportation sector in the early 20th century in a

series of regulations that limited working hours in

rail, road and aviation operations . The approach

                                                      

1 See ICAO Safety Management Manual (Doc 9859).
1‐2 Introduction to FRMS

Unedited version

reflects early understanding that long unbroken

periods of work could produce fatigue (now known

as ‘time‐on‐task’ fatigue), and that sufficient time is

needed to recover from work demands and to

attend to non‐work aspects of life.

In the second half of the 20th century, scientific

evidence began accumulating that implicated other

causes of fatigue in addition to time‐on‐task,

particularly in 24/7 operations. The most significant

new understanding concerns:

• the vital importance of adequate sleep (not

just rest) for restoring and maintaining all

aspects of waking function; and  

• daily rhythms in the ability to perform mental

and physical work, and in sleep propensity (the

ability to fall asleep and stay asleep), that are

driven by the daily cycle of the circadian

biological clock in the brain.

This new knowledge is particularly relevant in the

aviation industry which is unique in combining 24/7

operations with trans‐meridian flight.  

In parallel, understanding of human error and its

role in accident causation has increased. Typically,

accidents and incidents result from interactions

between organizational processes (i.e. workplace

conditions that lead crewmembers to commit active

failures), and latent conditions that can penetrate

current defenses and have adverse effects on

safety2

. The FRMS approach is designed to apply

this new knowledge from fatigue science and safety

science. It is intended to provide an equivalent, or

enhanced level of safety while also offering greater

operational flexibility.  

Prescriptive flight and duty time limits represent a

somewhat simplistic view of safety – being inside

the limits is safe while being outside the limits is

unsafe – and they represent a single defensive

strategy. While they are adequate for some types of

operations, they are a one‐size‐fits‐all approach that

                                                      

2 Gander, P.H., Hartley, L., Powell, D., Cabon, P.,

Hitchcock, E., Mills, A., Popkin, S. (2011). Fatigue risk

management I: organizational factors. Accident Analysis

and Prevention 43:573‐590.

does not take into account operational differences

or differences among crewmembers.  

In contrast, an FRMS employs multi‐layered

defensive strategies to manage fatigue‐related risks

regardless of their source. It includes data‐driven,

ongoing adaptive processes that can identify fatigue

hazards and then develop, implement and evaluate

controls and mitigation strategies. These include

both organizational and personal mitigation

strategies. While an FRMS is based on scientific

principles, its application within various aviation

contexts requires operational experience and

knowledge. An FRMS should not be provided to an

operator by a consultant; it needs to be developed,

understood and managed by people who have

comprehensive experience in the complex

operational environment to which it will apply. In

this way, meaningful interpretations can be made of

what various data analyses may mean in particular

contexts, and workable operational strategies can

be developed.

The cost and complexity of an FRMS may not be

justified for operations that remain inside the flight

and duty time limits and where fatigue‐related risk

is low. Some operators may therefore choose to

place only certain parts of their operations under an

FRMS or not implement an FRMS at all. Nonetheless,

where an FRMS is not implemented, it remains the

operator’s responsibility to manage fatigue risks

through their existing safety management processes.

It would be a misconception to think of an operator

with an FRMS as having no flight and duty time

limitations. In fact, an operator continues to have

flight and duty time limitations but these are

identified through their own FRMS processes,

specific to a defined operational context, and are

continually evaluated and updated in response to

their own risk assessments and the data the

operator is collecting. It is up to the regulator to

assess whether the risk assessments, mitigations

and the data collected are appropriate, and that the

flight and duty time limitations identified are

reasonable responses as evidenced in safety

performance indicators. This means that FRMS

necessitates performance‐based regulation.  
Introduction to FRMS 1‐3

Unedited version

In essence, FRMS regulations will define a process

for operators and regulators to manage fatigue risk,

rather than prescribing limits that cannot consider

aspects specific to the organization or operating

environment.  

1.3 ICAO Standards and

Recommended Practices for Fatigue

Management  

This section describes the Standards and

Recommended Practices (SARPs) relating to the

management of fatigue experienced by flight and

cabin crew. These SARPs provide a high‐level

regulatory framework for both prescriptive flight

and duty limitations and FRMS as methods for

managing fatigue risk. Both methods share two

important basic features:

1. They are required to take into consideration the

dynamics of transient and cumulative sleep loss

and recovery, the circadian biological clock, and

the impact of workload on fatigue, along with

operational requirements.  

  

2. Because fatigue is affected by all waking activities

not only work demands, regulations for both are

necessarily predicated on the need for shared

responsibility between the operator and

individual crewmembers for its management. So,

whether complying with prescriptive flight and

duty limitations or using and FRMS, operators are

responsible for providing schedules that allow

crewmembers to perform at adequate levels of

alertness and crewmembers are responsible for

using that time to start work well‐rested. The

requirement for shared responsibility in relation

to FRMS is discussed further in Chapter 3.

FRMS also shares the building blocks of SMS. This

means that an FRMS is predicated on: effective

safety reporting; senior management commitment;

a process of continuous monitoring; a process for

investigation of safety occurrences that aims to

identify safety deficiencies rather than apportioning

blame; the sharing of information and best

practices; integrated training for operational

personnel; effective implementation of standard

operating procedures (SOPs); and a commitment to

continuous improvement. So, together, the

foundations of prescriptive flight and duty time

limitations and SMS form the building blocks of

FRMS (see Table 1).

Prescriptive flight

and duty time

limitations

• Addresses transient and

cumulative fatigue

• Shared operator‐individual

responsibility  

SMS • Effective safety reporting

• Senior management commitment

• Continuous monitoring process

• Investigation of safety occurrences

• Sharing of information

• Integrated training

• Effective implementation of SOPs

• Continuous improvement

Table 1: FRMS building blocks

However, an FRMS, as a management system

focused on fatigue, also has added requirements

beyond that which would be expected of an

operator complying with prescriptive flight and duty

time limitations and managing their fatigue risks

through their SMS. In meeting these additional

FRMS‐specific requirements, an operator with an

approved FRMS may move outside the prescribed

limits. Therefore, the fatigue management SARPs in

Section 4.10, Annex 6, Part I, include particular

Standards that enable the effective regulation of

FRMS. These are, in turn, supported by Appendix 8,

which details the requirements for an FRMS.  

1.3.1   Section 4.10 of Annex 6, Part I:

The SARPs related to fatigue management of flight

and cabin crew are as follows:
1‐4 Introduction to FRMS

Unedited version

Annex 6, Part I

4.10 Fatigue Management

4.10.1   The State of the Operator shall establish regulations for the purpose of managing fatigue. These

regulations shall be based upon scientific principles and knowledge, with the aim of ensuring that flight and cabin

crew members are performing at an adequate level of alertness. Accordingly, the State of the Operator shall

establish:

a)   regulations for flight time, flight duty period, duty period and rest period limitations; and

b)   where authorizing an operator to use a Fatigue Risk Management System (FRMS) to manage fatigue,

FRMS regulations.

4.10.2   The State of the Operator shall require that the operator, in compliance with 4.10.1 and for the purposes

of managing its fatigue‐related safety risks, establish either:

a)   flight time, flight duty period, duty period and rest period limitation that are within the prescriptive

fatigue management regulations established by the State of the Operator; or

b)   a Fatigue Risk Management System (FRMS) in compliance with 4.10.6 for all operations; or

c)   an FRMS in compliance with 4.10.6 for part of its operations and the requirements of 4.10.2 a) for the

remainder of its operations.

4.10.3   Where the operator adopts prescriptive fatigue management regulations for part or all of its operations,

the State of the Operator may approve, in exceptional circumstances, variations to these regulations on the basis

of a risk assessment provided by the operator. Approved variations shall provide a level of safety equivalent to, or

better than, that achieved through the prescriptive fatigue management regulations.

4.10.4   The State of the Operator shall approve an operator’s FRMS before it may take the place of any or all of

the prescriptive fatigue management regulations. An approved FRMS shall provide a level of safety equivalent to,

or better than, the prescriptive fatigue management regulations.

4.10.5   States that approve an operator’s FRMS shall establish a process to ensure that an FRMS provides a level

of safety equivalent to, or better than, the prescriptive fatigue management regulations. As part of this process,

the State of the Operator shall:

a)   require that the operator establish maximum values for flight times and/or flight duty periods(s) and duty

period(s), and minimum values for rest periods. These values shall be based upon scientific principles and

knowledge, subject to safety assurance processes, and acceptable to the State of the Operator;

b) mandate a decrease in maximum values and an increase in minimum values in the event that the operator’s

data indicates these values are too high or too low, respectively; and

c)   approve any increase in maximum values or decrease in minimum values only after evaluating the

operator’s justification for such changes, based on accumulated FRMS experience and fatigue‐related

data.

4.10.6   Where an operator implements an FRMS to manage fatigue‐related safety risks, the operator shall, as a

minimum:

a)   incorporate scientific principles and knowledge within the FRMS;

b)   identify fatigue‐related safety hazards and the resulting risks on an ongoing basis;

c)   ensure that remedial actions, necessary to effectively mitigate the risks associated with the hazards, are

implemented promptly;

d)   provide for continuous monitoring and regular assessment of the mitigation of fatigue risks achieved by

such actions; and

e)   provide for continuous improvement to the overall performance of the FRMS.
Introduction to FRMS 1‐5

Unedited version

4.10.7   Recommendation.— States should require that, where an operator has an FRMS, it is integrated with the

operator’s SMS.

4.10.8   An operator shall maintain records for all its flight and cabin crew members of flight time, flight duty

periods, duty periods, and rest periods for a period of time specified by the State of the Operator.

The intent of each of these SARPs is discussed below.

STANDARD INTENT

4.10.1 Standard 4.10.1 stipulates the State’s responsibilities for establishing regulations for fatigue

management. The establishment of regulations for prescriptive limitations remains mandatory,

while the establishment of regulations for FRMS is optional for the State. Both types of regulations

need to address the known scientific principles, including the dynamics of transient and

cumulative sleep loss and recovery, the circadian biological clock, and the impact of workload on

fatigue, along with knowledge gained from specific research and operational experience and

requirements. Further, both types of regulations need to emphasize that within an operation, the

responsibility for managing fatigue risks is shared between management and individual

crewmembers (discussed in Chapter 3).

4.10.2 Standard 4.10.2 aims to make clear that, where the State has established regulations for FRMS,

operators then have three options for managing their fatigue risks:  a) they can do so solely within

their State’s flight and duty time limitations regulations; b) they can choose to implement an FRMS

for all operations; or c) they can implement an FRMS in part of their operations and use

prescriptive flight and duty time limitations in other operations. Therefore, this Standard intends

to allow the operator to decide which method of fatigue management is most appropriate for

their specific types of operations. Given this choice, it is likely that many operators will embrace

the safety and operational benefits offered through an FRMS approach

Where the State does not have FRMS regulations, operators must manage their fatigue‐related

risks within the constraints of their State’s prescriptive flight and duty time limitations or State‐

approved variations to those limitations. Many will choose to do so through their existing safety

management processes. However, an FRMS approach, as described here with its added

requirements, can also be applied within prescriptive flight and duty period limitations.

4.10.3 It is recognised that prior to the FRMS Standards, many States had approved variations to the

prescribed flight and duty time limitations for operators. In some cases, these variations relate to

very minor extensions and Standard 4.10.3 allows an operator to continue to have minor

extensions to scheduled operations without having to develop and implement a full FRMS.

Approval of the variation is subject to the provision of a risk assessment acceptable to the

regulator.  

The intent of Standard 4.10.3 is to minimize “regulation through variations” and to avoid the

approval of variations that meet operational imperatives in the absence of a risk assessment. It is

not intended to offer a quick and easy alternative to an FRMS when a more comprehensive fatigue

risk management approach is required. Nor is it intended to be used to address deficiencies due to

inadequate prescriptive regulations. Importantly, it only applies in “exceptional circumstances”.
1‐6 Introduction to FRMS

Unedited version

STANDARD INTENT

4.10.4 Standard 4.10.4 means that approval is given when the operator can clearly demonstrate that all

FRMS processes are functioning effectively. It is not simply given based on a documented plan to

put an FRMS in place or a desk top review of an FRMS manual. Standard 4.10.4 also means that

operators need to support an iterative approach to developing an FRMS (also described in

Chapter 8).  

Approval for the overall FRMS can only be given once all four component processes (discussed in

Chapters 3, 4, 5 and 6 respectively) are developed and the State has confidence that the operator

can adjust flight and duty times appropriately (i.e. both over and under prescriptive limitations),

can put mitigations in place in accordance with evidence provided through their FRMS, and the

effectiveness of the FRMS has been proven over time using the safety assurance processes. During

the last phase of development, and prior to gaining approval, the operator will be working to

agreed‐upon limits determined through the fatigue risk management processes. These limits may

be outside prescriptive flight and duty regulations for the particular operations on which its initial

FRMS efforts are focused. This last phase of development is necessary in order to validate the

FRMS safety assurance processes and is essentially a defined trial period for the entire FRMS.  

Once approval has been given, and in the operations to which the FRMS applies, the operator is

able to use its FRMS to move away from flight and duty time limitations to a new limit that can be

supported by data within the State‐approved upper boundary of the FRMS (see 4.10.5).

Should an operator seek to misuse an FRMS to benefit from duty times that cannot be supported

by scientific principles, collected data and other FRMS processes (i.e. that does not meet the

minimum requirements of an FRMS as identified in Appendix 8 of Annex 6, Part I), the State would

have to withdraw its approval of the FRMS. The operator would then be required to comply with

prescriptive limitations.

4.10.5 4.10.5 is a “change management” SARP, aiming to assist the regulator in the successful

introduction of the performance‐based regulations that FRMS requires.

4.10.5 a) requires the operator to identify an upper boundary which flight and duty times will not

exceed, and a lower boundary under which no rest period will be shortened, even when using

mitigations and processes within an FRMS. It aims to offer an extra layer of insurance and sets

clear expectations amongst all stakeholders.    

4.10.5 b) provides regulators with a less drastic alternative to withdrawing approval for an FRMS

when an adjustment will suffice to ensure that an equivalent level of safety is maintained. It

intends to be proactive, in that it addresses less serious situations where an operator’s data

indicates a trend that suggests the values may be too high or too low.

4.10.5 c) ensures that operators who have demonstrated the responsible and comprehensive

management of their fatigue‐related risks through a mature FRMS are not prevented from gaining

its full benefits by unnecessarily restrictive constraints.

4.10.6 4.10.6 provides high‐level minimum requirements for an FRMS and notes more detailed minimum

requirements not appropriate for the main body of the Annex, in Appendix 8. Essentially, 4.10.6

provides the “broad brushstrokes” of what an FRMS must have, while Appendix 8 fills in the
Introduction to FRMS 1‐7

Unedited version

STANDARD INTENT

components in more of detail. This Standard is presented in a similar format as SMS Standard 3.3.4

(Annex 6, Part I) to reflect the similarities and consistencies in approaches between FRMS and

SMS.

For the regulator, 4.10.6 means that it will be necessary to provide adequate assessment and

oversight of a) to e). Processes and documentation will have to be developed that outline the

State’s approval and oversight criteria in line with the regulations that are developed. This manual

aims to provide detailed information to assist the regulator in achieving this.

4.10.7 4.10.7 recognises the relationship between FRMS and SMS. Because FRMS has a safety function, it

should be complementary to existing safety management processes within an operator’s SMS.

Ideally, where multiple systems are utilised to identify hazards and manage risk they should be

integrated to maximise their combined effectiveness, to ensure resources are being distributed

appropriately across the systems and, where possible, to reduce duplicated processes for greater

system efficiency. So, an operator wishing to implement an FRMS and who already has sufficiently

mature SMS processes in place should be able to readily adopt and understand the fundamental

processes of an FRMS. Examples of such maturity would include the routine use of hazard

identification, risk assessment and mitigation tools, and the existence of an effective reporting

culture (refer SMM, 2‐27). Where such systems are already in place, it should not be necessary for

an operator to develop entirely new processes to implement FRMS. Rather, FRMS can build upon

the organisation’s existing risk management and training processes.  

The importance of coordinating FRMS and existing safety management processes cannot be

overemphasised in order to avoid overlooking or prioritising risks inappropriately. For example,

from an SMS viewpoint, a succession of ground proximity warnings at the same point, on the same

approach, and on the same flight number, may well be attributed to inadequate pilot training in

altitude management and maintenance of the localizer and glide slope. Without the particular

focus and methods of measurement associated with an FRMS, it may not be as obvious that the

succession of ground proximity warnings occurred on flights that were part of a particularly

fatiguing sequence which resulted in tired pilots not paying enough attention. Both possibilities

need to be considered and therefore the two systems designed to do this cannot work in isolation.

However, the degree of integration between an operator’s SMS and its FRMS will depend on many

factors, including the relative maturity of the two systems, and operational, organisational and

regulatory considerations. Further, given that the level of maturity for each operator’s SMS will

vary significantly, the operator is not required to have an SMS accepted by the State before

establishing an FRMS. Thus, 4.10.7 is a Recommended Practice rather than a Standard.  

Where an operator does not wish to implement an FRMS or has had its FRMS approval revoked,

the regulator should require the operator to use their SMS to manage fatigue‐related risks within

prescriptive limitations.

4.10.8 Irrespective of which method of fatigue management is used (i.e. compliance with prescriptive

flight and duty limitations or implementation of an approved FRMS), all operators are required to

maintain records of working periods, with or without flight duties, for flight and cabin crew. It is up

to each regulator to stipulate the period of time which these records much be kept.
1‐8 Introduction to FRMS

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1.3.2   Appendix 8, Annex 6, Part I

Appendix 8 gives detailed requirements for an

FRMS which must include, at a minimum, the

following components:

1. FRMS policy and documentation;

2. Fatigue risk management processes;

3. FRMS safety assurance processes; and  

4. FRMS promotion processes.

Table 1.1 shows how these components map to the

requirements of SMS.

SMS

Framework FRMS

1.  Safety policy

and

objectives

1. FRMS policy and documentation

2. Safety risk

management

2. FRM processes

• Identification of hazards

• Risk assessment

• Risk mitigation

3. Safety

assurance

3. FRMS safety assurance processes

• FRMS performance monitoring

• Management of operational

and organizational change

• Continuous FRMS improvement

4. Safety

promotion

4. FRMS promotion processes

• Training programs

• FRMS communication plan

Table 1.1:  Comparing SMS and FRMS Components

The core operational activities of the FRMS are the

FRM processes and the FRMS safety assurance

processes. They are supported by organizational

arrangements defined in the FRMS policy and

documentation, and by the FRMS promotion

processes.

1.4 Structure of this manual

Figure 1.1 shows a basic framework linking the

required components of an FRMS. For ease of

explanation, Figure 1.1 presents a single, central,

functional group, designated as the “Fatigue Safety

Action Group”, responsible for all of these FRMS

components. The Fatigue Safety Action Group

includes representatives of all stakeholder groups

(management, scheduling, and crewmembers) and

other individuals as needed to ensure that it has

appropriate access to scientific and medical

expertise. However, depending on the

organizational structure, some of the Fatigue Safety

Action Group functions as described in this manual

may be undertaken by other groups within the

organization (discussed further in Chapter 3). The

important thing is that, irrespective of who does

them, all of the component functions required

under an FRMS be performed.  
Introduction to FRMS 1‐9

Unedited version

Figure 1.1: Linking the required components of an FRMS

Communication between the FRMS and the SMS (in

both directions) is necessary to integrate the

management of the fatigue risks into the broader

risk management activities of the SMS. Even so, the

regulator will need to be able to distinguish the

FRMS activities from the SMS functions to allow

adequate monitoring.

The detailed structure of an FRMS, and the specific

ways in which it links to an operator’s SMS, will vary

according to:  

• the size of the organization;

• the type and complexity of the operations

being managed;  

• the relative maturity of the FRMS and the SMS;

and

• the relative importance of the fatigue risks.  

The FRMS approach is based on applying scientific

principles and knowledge to manage crewmember

fatigue. Chapter 2 introduces the essential scientific

concepts that are needed to provide adequate

oversight of an FRMS. Chapters 3, 4, 5, and 6 each

deal with one of the required FRMS components.

Chapter 7 discusses considerations for the State

prior to making the decision whether to offer FRMS

regulations. Chapter 8 steps though the approval

process of an FRMS, while the continued oversight

of an FRMS is discussed in Chapter 9.

Appendices A, B and C provide extra information to

support the concepts that are provided in the

preceding chapters. For ease of reference, Appendix

A provides a glossary of terms used in this manual.

Appendix B provides more detailed information on

methods of measuring fatigue as part of the FRM

processes presented in Chapter 8, Appendix C also

supports Chapter 3 by providing further information

on using controlled rest on the flight deck as a

mitigator of fatigue risk. Finally, Appendix D

provides an example of an FRMS evaluation form

for use in the regulatory oversight of an FRMS.
Chapter 2. Science for FRMS 2‐1

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Chapter 2: Science for FRMS

2.1 Introduction to science for FRMS

The FRMS approach represents an opportunity for

operators to use advances in scientific knowledge to

improve safety and increase operational flexibility. To

provide effective oversight, States should be aware of

the scientific principles on which the FRMS approach

is based. These are reviewed in this chapter.  

In Chapter 1, the ICAO definition of crewmember

fatigue was given as:

A physiological state of reduced mental or

physical performance capability resulting

from sleep loss or extended wakefulness,

circadian phase, or workload (mental and/or

physical activity) that can impair a crew

member’s alertness and ability to safely

operate an aircraft or perform safety related

duties.

In flight operations, fatigue can be measured either

subjectively by having crewmembers rate how they

feel, or objectively by measuring crewmembers’

performance (Chapter 4 and Appendix B).  

Another way of thinking about this is that fatigue is a

state that results from an imbalance between:

• the physical and mental exertion of all waking

activities (not only duty demands); and  

• recovery from that exertion, which (except for

recovery from muscle fatigue) requires sleep.  

Following this line of thinking, to reduce

crewmember fatigue requires reducing the exertion

of waking activities and/or improving sleep. Two

areas of science are central to this and are the focus

of this chapter.  

1. Sleep science – particularly the effects of not

getting enough sleep (on one night or across

multiple nights), and how to recover from them;

and  

2. Circadian rhythms – the study of innate rhythms

driven by the daily cycle of the circadian

biological clock (a pacemaker in the brain).

These include:  

‐ rhythms in subjective feelings of fatigue and

sleepiness; and

‐ rhythms in the ability to perform mental and

physical work, which affect the effort required

to reach an acceptable level of performance

(exertion); and

‐ rhythms in sleep propensity (the ability to fall

asleep and stay asleep), which affect recovery.

2.2 Essential sleep science

There is a widespread belief that sleep time can be

traded off to increase the amount of time available

for waking activities in a busy lifestyle. Sleep science

makes it very clear that sleep is not a tradable

commodity.

2.2.1 What is happening in the brain during sleep

There are a variety of ways of looking at what is

happening in the sleeping brain, from reflecting on

dreams to using advanced medical imaging

techniques. Currently, the most common research

method is known as polysomnography (see Appendix

B for details). This involves sticking removable

electrodes to the scalp and face and connecting them

to a recording device, to measure three different

types of electrical activity: 1) brainwaves

(electroencephalogram or EEG); 2) eye movements

(electroculogram or EOG); and 3) muscle tone

(electromyogram or EMG). Using polysomnography,

it is possible to identify two very different kinds of

sleep.  

Non‐rapid eye movement sleep

Compared to waking brain activity, non‐Rapid Eye

Movement sleep (non‐REM sleep) involves gradual

slowing of the brainwaves. The amplitude (height) of

the brainwaves also becomes larger as the electrical
2‐2 Science for FRMS

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activity of large numbers of brain cells (neurons)

becomes synchronized so that they fire in unison.

Heart rate and breathing tend to be slow and regular.

People woken from non‐REM sleep do not usually

recall much mental activity. However, it is still

possible for the body to move in response to

instructions from the brain. Because of these

features, non‐REM sleep is sometimes described as ‘a

relatively inactive brain in a movable body’.

Non‐REM sleep is usually divided into 4 stages, based

on the characteristics of the brainwaves.

Stages 1 and 2 represent lighter sleep (it is not very

difficult to wake someone up). It is usual to enter

sleep through Stage 1 and then Stage 2 non‐REM.

Stages 3 and 4 represent deeper sleep (it can be very

hard to wake someone up). Stages 3 and 4 are

characterized by high amplitude slow brainwaves,

and are together often described as slow‐wave sleep

(or deep sleep).

Slow‐wave sleep has a number of important

properties. Pressure for slow‐wave sleep builds up

across waking and discharges across sleep. In other

words:

the longer you are awake, the more slow‐wave sleep

you will have in your next sleep period; and

across a sleep period, the proportion of time spent in

slow‐wave sleep decreases.

This rising and falling of pressure for slow wave sleep

is sometimes called the sleep homeostatic process,

and it is a component in most of the bio‐

mathematical models that are used to predict

crewmember fatigue levels (see Chapter 4).  

Even in slow‐wave sleep, the brain is still about 80%

activated and capable of active cognitive processing.

There is growing evidence that slow‐wave sleep is

essential for the consolidation of some types of

memory, and is therefore necessary for learning.

   

OPERATIONAL NOTE:

Mitigation strategies for sleep inertia

Operationally, slow‐wave sleep may be important because the brain can have difficulty transitioning out of it

when someone is woken up suddenly. This is known as sleep inertia – feelings of grogginess and disorientation,

with impaired short‐term memory and decision‐making. Sleep inertia can occur coming out of lighter sleep, but

it tends to be longer and more disorienting when someone is woken abruptly out of slow‐wave sleep.

This is sometimes used as an argument against the use of flight deck napping or in‐flight sleep. It would not be

desirable to have a crewmember who is woken up because of an emergency, but who is impaired by sleep

inertia. This argument is based on the effects of sleep inertia seen in laboratory studies.

However, studies of napping on the flight deck and of sleep in onboard crew rest facilities show that sleep in

flight contains very little slow‐wave sleep. (It is lighter and more fragmented than sleep on the ground). This

means that sleep inertia is much less likely to occur waking up from sleep in flight than would be predicted from

laboratory sleep studies. The risk of sleep inertia can also be reduced by having a protocol for returning to active

duty that allows time for sleep inertia to wear off.

Overall, the demonstrated benefits of controlled napping and in‐flight sleep greatly out‐weigh the potential risks

associated with sleep inertia. To reduce the risk of sleep inertia after flight deck napping, the recommendation is

to limit the time available for the nap to 40 minutes. Given the time taken to fall asleep, a 40‐minute

opportunity is too short for most people to enter slow‐wave sleep. Refer to Appendix C for suggested Flight

Operations Manual procedures for controlled napping.
Science for FRMS 2‐3

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Rapid eye movement sleep  

During Rapid Eye Movement sleep (REM sleep), brain

activity measured by polysomnography looks similar

to brain activity during waking. However    in REM

sleep, from time to time the eyes move around under

the closed eyelids – the so‐called ‘rapid eye

movements’ –and this is often accompanied by

muscle twitches and irregular heart rate and

breathing.  

People woken from REM sleep can typically recall

vivid dreaming. At the same time, the body cannot

move in response to signals from the brain so dreams

cannot be ‘acted out’. (The signals effectively get

blocked in the brain stem and cannot get through to

the spinal cord.) People sometimes experience brief

paralysis when they wake up out of a dream, when

reversal of this ‘REM block’ is slightly delayed.

Because of these features, REM sleep is sometimes

described as ‘a highly activated brain in a paralysed

body’.  

Dreams have always been a source of fascination, but

are difficult to study using quantitative scientific

methods. They have been interpreted as everything

from spiritual visitations to fulfillment of instinctual

drives, to being a meaningless by‐product of activity

in various parts of the brain during REM sleep. The

current neuro‐cognitive view of dreaming argues that

it results from brief moments of consciousness when

we become aware of all the processing that our

brains normally do ‘off‐line’, i.e. when they are not

busy dealing with information coming in from the

environment through the senses, and are not being

directed by our conscious control. This ‘off‐line’

processing includes reactivating memories and

emotions from previous experiences, and integrating

them with experiences from the latest period of

waking. Dreams in this view are a glimpse into your

brain reshaping itself so that you can wake up in the

morning still yourself, but a slightly revised version as

a result of your experiences yesterday, and ready to

start interacting with the world again.  

People vary greatly in their ability to recall dreams,

and we generally only recall them when we wake

spontaneously out of REM sleep (and then only

fleetingly unless we write them down or talk about

them). Nevertheless, most adults normally spend

about a quarter of their sleep time in REM sleep.

Non‐REM/REM Cycles

Across a normal night of sleep, non‐REM sleep and

REM sleep alternate in a cycle that lasts roughly 90

minutes (but is very variable in length, depending on

a number of factors). Figure 2.1 is a diagram

describing the non‐REM/REM cycle across the night

in a healthy young adult. Real sleep is not as tidy as

this  ‐ it includes more arousals (transitions to lighter

sleep) and brief awakenings. Sleep stages are

indicated on the vertical axis and time is represented

across horizontal axis1

.  

Figure 2.1: Diagram of the non‐REM/REM cycle across

the night in a young adult

Sleep is entered through Stage 1 non‐REM and then

progresses deeper and deeper into non‐REM. About

80‐90 minutes into sleep, there is a shift out of slow‐

wave sleep (non‐REM stages 3 and 4). This is often

marked by body movements, as the sleeper

transitions briefly through Stage 2 non‐REM and into

the first REM period of the night. (REM periods are

indicated as shaded boxes in Figure 2.1). After a fairly

short period of REM, the sleeper progresses back

                                                           

1 Gander PH (2003) Sleep in the 24‐Hour Society.

Wellington, New Zealand: Open Mind Publishing. ISBN 0‐

909009‐59‐7
2‐4 Science for FRMS

Unedited version

down again through lighter non‐REM sleep and into

slow‐wave sleep, and so the cycle repeats.  

The amount of slow‐wave sleep in each non‐

REM/REM cycle decreases across the night, and there

may be none at all in the later cycles. In contrast, the

amount of REM sleep in each non‐REM/REM cycle

increases across the night. The sleeper depicted in

Figure 2.1 wakes up directly out of the final REM

period of the night, and so would probably recall

dreaming.  

Interestingly, slow‐wave sleep always predominates

at the beginning of a sleep period, regardless of when

sleep occurs in the day/night cycle or in the circadian

body clock cycle. There seems to be a priority to

discharge the homeostatic sleep pressure first. In

contrast, the time from sleep onset to the first bout

of REM (the REM latency) and the duration of each

REM bout varies markedly across the circadian body

clock cycle. The circadian drive for REM sleep is

strongest a few hours before normal wakeup time.

These two processes – the homeostatic sleep process

and the circadian body clock are the main

components in most of the bio‐mathematical models

that are used to predict crewmember fatigue levels

(see Chapter 4).  

Operational Note:

Mitigation Strategies for Sleep Loss

Restoration of a normal non‐REM/REM cycle is one measure of recovery from the effects of sleep loss. Lost

sleep is not recovered hour‐for‐hour, although recovery sleep may be slightly longer than usual.  

• On the first recovery night, there is more slow‐wave sleep than usual. Indeed, there can be so much slow‐

wave sleep that there is not enough time to make up REM sleep.

  

• On the second recovery night, there is often more REM sleep than usual.  

• By the third recovery night, the non‐REM/REM cycle is usually back to normal.

Operationally, this means that schedules need to periodically include an opportunity for at least two consecutive

nights of unrestricted sleep, to enable crewmembers to recover from the effects of sleep loss.

  

This does not equate to 48 hours off. For example, 48 hours off duty starting at 02:00 would only give most

people the opportunity for one full night of unrestricted sleep. On the other hand, 40 hours off starting at 21:00

would give most people the opportunity for two full nights of unrestricted sleep.  

Additional nights may be needed for recovery if a crewmembers’ circadian body clock is not already adapted to

the local time zone (see Section 2.3).
Science for FRMS 2‐5

Unedited version

2.2.2 The issue of sleep quality

Sleep quality (its restorative value) depends on going

through unbroken non‐REM/REM cycles (which

suggests that both types of sleep are necessary and

one is not more important than the other). The more

the non‐REM/REM cycle is fragmented by waking up,

or by arousals that move the brain to a lighter stage

of sleep without actually waking up, the less

restorative value sleep has in terms of how you feel

and function the next day.

Operational Note:

Mitigation Strategies to Minimize Sleep Interruptions

Because uninterrupted non‐REM/REM cycles are the key to good quality sleep, operators should develop

procedures that minimize interruptions to crewmembers’ sleep.

Rest periods should include defined blocks of time (sleep opportunities) during which crewmembers are not

contacted except in emergencies. These protected sleep opportunities need to be known to flight crews and all

other relevant personnel. For example, calls from crew scheduling should not occur during a rest period as they

can be extremely disruptive.

Operators should also develop procedures to protect crewmember sleep at layover and napping facilities. For

example, if a rest period occurs during the day at a layover hotel, the operator could make arrangements with

the hotel to restrict access to the section of the hotel where crewmembers are trying to sleep (such as no

children, crewmembers only) and instruct their staff to honor the necessary quiet periods (for example, no

maintenance work or routine cleaning).
2‐6 Science for FRMS

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Quality of in‐flight sleep

As mentioned above, polysomnography studies show

that crewmembers’ sleep in onboard crew rest

facilities is lighter and more fragmented than sleep

on the ground2

. Sleep during flight deck naps is also

lighter and more fragmented than would be

predicted from laboratory studies3

. Nevertheless,

there is good evidence that in‐flight sleep improves

subsequent alertness and reaction speed and is a

valuable mitigation strategy in an FRMS.

Studies of sleep in hypobaric chambers at pressures

equivalent to cabin pressure at cruising altitude

indicate that the fragmented quality of in‐flight sleep

is not due to altitude4

. Several studies have asked

crewmembers what disturbs their sleep on board.

The factors most commonly identified are random

noise, thoughts, not feeling tired, turbulence,

ambient aircraft noise, inadequate bedding, low

humidity, and going to the toilet.

Sleep quality and aging

Across adulthood, the proportion of sleep time spent

in slow‐wave sleep declines, particularly among men.

In addition, sleep becomes more fragmented. For

example, one study with 2,685 participants aged 37–

92 yrs found that the average number of arousals

(transitions to lighter sleep and awakenings) rose

from 16 per hour of sleep for 30‐54 year‐olds to 20

per hour of sleep for 61‐70 year‐olds5.  

                                                           

2 Signal, T.L., Gale, J., and Gander, P.H. (2005) Sleep

Measurement in Flight Crew: Comparing Actigraphic and

Subjective Estimates of Sleep with Polysomnography. Aviation

Space and Environmental Medicine 76(11):1058‐1063 3 Rosekind, M.R., Graeber, R.C., Dinges, D.F., et al., (1994)

Crew Factors in Flight Operations IX: Effects of planned

cockpit rest on crew performance and alertness in long

haul operations. NASA Technical Memorandum 108839,

Moffett Field: NASA Ames Research Center. 4 Mumm, J.M., Signal, T.L., Rock, P.B., Jones, S.P., O’Keeffe, K.M.,

Weaver, M. R., Zhu, S., Gander, P.H., Belenky, G. (2009) Sleep at

simulated 2438 m: effects on oxygenation, sleep quality, and

post‐sleep performance. Aviation, Space, and Environmental

Medicine 80 (8):691‐697. 5 Redline, S., Kirchner, H.L., Quan, S.F., Gottlieb, D.J., Kapur, V.,

Newman, A. (2004). The effects of age, sex, ethnicity, and sleep‐

disordered breathing on sleep architecture. Archives of Internal

Medicine 164:406–418.

These age‐related trends are seen in the sleep of

flight crewmembers, both on the ground and in the

air2,6. A study of in‐flight sleep on delivery flights of B‐

777 aircraft (from Seattle to Singapore or Kuala

Lumpur) found that age was the factor that most

consistently predicted the quality and duration of

bunk sleep. Older pilots took longer to fall asleep,

obtained less sleep overall, and had more fragmented

sleep.  

It is not yet clear whether these age‐related changes

in sleep reduce its effectiveness for restoring waking

function. Laboratory studies that experimentally

fragment sleep are typically conducted with young

adults. On the flight deck, experience (both in terms

of flying skills and knowing how to manage sleep on

trips) could help reduce potential fatigue risk

associated with age‐related changes in sleep.  

Sleep disorders

The quality of sleep can also be disrupted by a wide

variety of sleep disorders, which make it impossible

to obtain restorative sleep, even when people spend

enough time trying to sleep. Sleep disorders pose a

particular risk for flight crewmembers because, in

addition, they often have restricted time available for

sleep. It is recommended that FRMS training (Chapter

6) should include basic information on sleep

disorders and their treatment, where to seek help if

needed, and any requirements relating to fitness to

fly.  

2.2.3 Consequences of not getting enough sleep

Even for people who have good quality sleep, the

amount of sleep they obtain is very important for

restoring their waking function. An increasing

number of laboratory studies are looking at the

effects of ‘trimming’ sleep at night by an hour or two

(known as sleep restriction). There are several key

findings from these studies that are important for

FRMS.

  

                                                           

6 Signal, T.L., Gander, P.H., van den Berg, M. (2004) Sleep in flight

during long rest opportunities. Internal Medicine Journal 34(3):

A38.
Science for FRMS 2‐7

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The effects of restricting sleep night after night

accumulate, so that people become progressively less

alert and less functional day after day. This is

sometimes described as accumulating a sleep debt.

This is a common occurrence for crewmembers (see

below), for example when minimum rest periods are

scheduled for several days in a row.

The shorter the time allowed for sleep each night, the

faster alertness and performance decline. For

example, one laboratory study found that spending 7

hours in bed for 7 consecutive nights was not enough

to prevent a progressive slowing down in reaction

time7

. The decline was more rapid for a group of

participants who spent only 5 hours in bed each

night, and even more rapid for a group who spent

only 3 hours in bed each night. This is described as a

dose‐dependent effect of sleep restriction.

The pressure for sleep increases progressively across

successive days of sleep restriction. Eventually, it

becomes overwhelming and people begin falling

asleep uncontrollably for brief periods, known as

micro‐sleeps. During a micro‐sleep, the brain

disengages from the environment (it stops processing

visual information and sounds). In the laboratory, this

can result in missing a stimulus in a performance test.

Driving a motor vehicle, it can result in failing to take

a corner. Similar events have been recorded on the

flight deck during descent into major airports5

.  

Full recovery of waking function after sleep

restriction can take longer than two nights of

recovery sleep (i.e., longer than it takes the non‐

REM/REM cycle to recover). Indeed, chronic sleep

restriction may have effects on the brain that can

affect alertness and performance days to weeks

later8

.  

For the first few days of severe sleep restriction (for

example, 3 hours in bed), people are aware that they

are getting progressively sleepier. However, after

                                                           

7 Belenky, G., Wesensten, N.J., Thorne, D.R., et al. (2003). Patterns of

performance degradation and restoration during sleep restriction and

subsequent recovery: a sleep dose‐response study. Journal of Sleep

Research 12:1‐12. 8 Rupp, T.L., Wesensten, N.J, Bliese, P.D. et al. (2009). Banking

sleep: realization of benefits during subsequent sleep restriction

and recovery. Sleep 32 (3): 311‐321

several days they no longer notice any difference in

themselves, even although their alertness and

performance continues to decline. In other words, as

sleep restriction continues, people become

increasingly unreliable at assessing their own

functional status. This finding raises a question about

the reliability of subjective ratings of fatigue and

sleepiness as measures of a crewmember’s level of

fatigue‐related impairment (see Appendix B).  

At least in the laboratory, some people are more

resilient to the effects of sleep restriction than

others. Currently, there is a lot of research effort

aimed at trying to understand why this is, but it is still

too early for this to be applied in an FRMS (for

example, by recommending different personal

mitigation strategies for people who are more or less

affected by sleep restriction).  

In general, more complex mental tasks such as

decision making and communication seem to be

more severely affected by sleep loss than simpler

tasks. Brain imaging studies also suggest that the

brain regions involved in more complex mental tasks

are the most affected by sleep deprivation and have

the greatest need for sleep to recover their normal

function.

Laboratory sleep restriction studies are currently the

main source of information on the effects of sleep

restriction. However, they have some obvious

limitations. The consequences of reduced alertness

and poor task performance are quite different in the

laboratory than for crewmembers on duty.

Laboratory studies usually look at the effects of

restricting sleep at night and participants sleep in a

dark, quiet bedroom. This may mean that current

understanding is based on a ‘best case scenario’.

More research is needed on the effects of restricting

sleep during the day, and on the combination of

restricted sleep and poor quality sleep. Laboratory

studies also focus on the performance of individuals,

not people working together as a crew.  

One simulation study with 67 experienced B747‐400

crews has demonstrated that sleep loss increased the
2‐8 Science for FRMS

Unedited version

total number of errors made by the crew9

. The study

design was set up so that the pilot in command was

always the pilot flying. Paradoxically, greater sleep

loss among first officers improved the rate of error

detection. On the other hand, greater sleep loss

among pilots in command led to a higher likelihood of

failure to resolve errors that had been detected.

Greater sleep loss was also associated with changes

in decision making, including a tendency to choose

lower risk options, which would help mitigate the

potential fatigue risk. Simulator studies like this are

expensive and logistically complex to conduct

properly, but they provide vital insights on the links

between crewmember sleep and operational fatigue

risk.

Sleep restriction in flight operations

The idea of sleep restriction implies that there is an

optimum amount of sleep that people need to obtain

each night. The concept of individual sleep need is an

area of active debate in sleep research. One way to

measure sleep restriction that avoids this problem is

to look at how much sleep crewmembers obtain

when they are at home between trips, compared to

how much sleep they obtain during trips.

Table 2.1 summarizes data on sleep restriction across

different flight operations that were monitored by

the NASA Fatigue Program in the 1980s. 10 In these

studies, crewmembers completed sleep and duty

diaries before, during, and after a scheduled

commercial trip. For each crewmember, his average

sleep duration per 24 hours at home before the trip

was compared with his average sleep duration per 24

hours on the study trip. During night cargo and long

haul trips, crewmembers often had split sleep (slept

more than once in 24 hours).  

Scheduling has undoubtedly changed since these

studies, so the data in Table 2.1 are likely to be

                                                           

9 Thomas, M.J.W., Petrilli, R.M., Lamond, N.A., et al. (2006).

Australian Long Haul Fatigue Study. In: Enhancing Safety

Worldwide: Proceedings of the 59th Annual International Air

Safety Seminar. Alexandria, USA, Flight Safety Foundation. 10 Gander, P.H., Rosekind, M.R., and Gregory, K.B. (1998) Flight

crew fatigue VI: an integrated overview. Aviation, Space, and

Environmental Medicine 69: B49‐B60

unrepresentative of the current situation in many

cases. However, they indicate that sleep restriction is

very common across different types of flight

operations.  

Short

Haul

Night

Cargo

Long

Haul

crewmembers

averaging at least 1

hour of sleep

restriction per trip

day

67% 54% 43%

crewmembers

averaging at least 2

hours of sleep

restriction per trip

day

30% 29% 21%

length of trip 3‐4

days

8

days

4‐9

days

time zones crossed

per day 0‐1 0‐1 0‐8

number of

crewmembers

studied

44 34 28

Note: the night cargo trips included a 1‐2 night break in the

sequence of night shifts. Splitting long haul trips into 24 hours

days is rather arbitrary because the average duty day lasted 10.2

hours and the average layover lasted 24.3 hours.

Table 2.1: Sleep restriction during

commercial flight operations

A growing amount of evidence, from both laboratory

studies and from epidemiological studies that track

the sleep and health of large numbers of people

across time, indicates that chronic short sleep may

have negative effects on health in the long term. This

research suggests that short sleepers are at greater

risk of becoming obese and developing type‐2

diabetes and cardiovascular disease. There is still

debate about whether habitual short sleep actually

contributes to these health problems, or is just

associated with them. In addition, flight

crewmembers as a group are exceptionally healthy

compared to the general population. What is clear is

that good health depends not only on good diet and
Science for FRMS 2‐9

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regular exercise, but also on getting enough sleep on

a regular basis. Sleep is definitely not a tradable

commodity.  

   

Operational Note:

Mitigation Strategies for Managing Sleep Debt

Sleep restriction is common across different types of flight operations. Because the effects of sleep restriction

are cumulative, schedules must be designed to allow periodic opportunities for recovery. Recovery

opportunities need to occur more frequently when daily sleep restriction is greater, because of the more rapid

accumulation of fatigue.

The usual recommendation for a recovery opportunity is for a minimum of two consecutive nights of

unrestricted sleep. Some recent laboratory studies of sleep restriction suggest that this may not be enough to

bring crewmembers back up to their optimal level of functioning. There is evidence that the sleep‐restricted

brain can stabilize at a lower level of functioning for long periods of time (days to weeks).  

Especially in irregular operations, procedures that allow a crewmember to continue sleeping until needed can

reduce the rate of accumulation of sleep debt. For example, if an aircraft with an anticipated repair time of 0730

will not actually be ready until 11:30, then a reliable procedure that allows the crew member to continue

sleeping would be beneficial. One airline has a system where the operator contacts the layover hotel to update

the report time by slipping a message under the crewmember’s door. The hotel provides a wakeup call one hour

before pick up time.

2.3 Introduction to circadian rhythms

Sleeping at night is not just a social convention. It is

programmed into the brain by the circadian body

clock, which is an ancient adaptation to life on our

24‐hour rotating planet. Even very ancient types of

living organisms have something equivalent, which

means that circadian biological clocks have been

around for several billion years.  

A feature of circadian clocks is that they are light

sensitive. The human circadian clock monitors light

intensity through a special network of cells in the

retina of the eye (this special light input pathway to

the circadian clock is not involved in vision). The clock

itself resides in a fairly small cluster of cells (neurons)

deeper in the brain (in the suprachiasmatic nuclei

(SCN) of the hypothalamus). The cells that make up

the clock are intrinsically rhythmic, generating

electrical signals faster during the day than during the

night. However, they have a tendency to produce an

overall cycle that is a bit slow – for most people the

‘biological day’ generated by the circadian body clock

is slightly longer than 24 hours. The sensitivity of the

circadian body clock to light enables it to stay in step

with the day/night cycle. However, that same

sensitivity to light also creates problems for

crewmembers who have to sleep out of step with the

day/night cycle (for example on domestic night cargo

operations), or who have to fly across time zones and

experience sudden shifts in the day/night cycle.  

2.3.1 Examples of circadian rhythm

It is not possible to directly measure the electrical

activity of the circadian body clock in human beings.

However, almost every aspect of human functioning

(physical or mental) undergoes daily cycles that are

influenced by the circadian body clock. Measuring

overt rhythms in physiology and behaviour is like

watching the hands of an (analogue) wrist watch. The

hands move around the watch face because they are

driven by the time‐keeping mechanism inside the

watch, but they are not part of the time‐keeping

mechanism itself. Similarly, most circadian rhythms

that can be measured, such as rhythms in core body
2‐10 Science for FRMS

Unedited version

temperature or self‐rated fatigue, are driven by the

circadian body clock, but they are not part of the

biological time‐keeping mechanism.  

Figure 2.2 shows an example of circadian rhythms in

core body temperature and self‐rated fatigue of a 46‐

year old short haul crewmember monitored before,

during, and after a 3‐day pattern of flying on the east

coast of the USA (staying in the same time zone)11.

The crewmember had his core temperature

monitored continuously and kept a sleep and duty

diary, in which he noted his sleep times and rated the

quality of his sleep, as well as rating his fatigue every

2 hours while he was awake (on a scale from 0 = most

alert to 100 = most drowsy).  

Core body temperature typically fluctuates by about

1  0C across the 24‐hour day. Note that the

crewmember's core temperature starts to rise each

morning before he wakes up. In effect, his body is

beginning to prepare ahead of time for the greater

energy demands of being more physically active. (If

body temperature only began to rise after he started

to be more physically active, it would be a lot harder

to get up in the morning).

Looking at his self‐rated fatigue, this crewmember did

not feel at his best first thing in the morning. He

tended to feel least fatigued about 2‐4 hours after he

woke up, after which his fatigue climbed steadily

across the day. The dashed line across the sleep

period indicates that he was not asked to wake up

every 2 hours to rate his fatigue across this time.  

Core body temperature is often use as a marker

rhythm to track the cycle of the circadian body clock

because it is relatively stable and easy to monitor.

However, no measurable rhythm is a perfect marker

of the circadian body clock cycle. For example,

changes in the level of physical activity also cause

changes in core temperature, which explains the

small peaks and dips in temperature in Figure 2.2.  

                                                           

11 Gander, P.H., Graeber , R.C., Foushee, H.C., Lauber, J.K.,

Connell, L.J. (1994). Crew Factors in Flight Operations II:

Psychophysiological Responses to Short‐Haul Air Transport

Operations. NASA Technical Memorandum #108856. Moffett

Field: NASA Ames Research Center.

The daily minimum in core body temperature

corresponds to the time in the circadian body clock

cycle when people generally feel most sleepy and are

least able to perform mental and physical tasks. This

is sometimes described as the Window of Circadian

Low (WOCL).

Figure 2.2: Circadian rhythms of a short haul pilot

2.3.2 The circadian body clock and sleep

As mentioned in Section 2.2, the circadian body clock

influences sleep in a number of ways. (It has

connections to centers in the brain that promote

wakefulness and to opposing centers that promote

sleep, as well as to the system that controls REM

sleep.)    Figure 2.3 is a diagram that summarizes the

effects of the circadian clock on sleep. It is based on

data collected from 18 night cargo pilots on their

days off, i.e., when they were sleeping at night12. Like

the crewmember in Figure 2.2, they also had their

core temperature monitored continuously, and kept

sleep and duty diaries.  

                                                           

12 Gander, P.H., Rosekind, M.R., and Gregory, K.B.

(1998) Flight crew fatigue VI: an integrated overview.

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2‐12 Science for FRMS

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Operational Note:

The Circadian Body Clock, Sleep, and FRMS

• The daily minimum in core body temperature corresponds to the time in the circadian body clock cycle when

people feel most sleepy and are least able to perform mental and physical tasks. This is sometimes called the

Window of Circadian Low (WOCL) and it is a time of high risk for fatigue‐related error. In FRMS incident

investigations, it is important to estimate the time that errors occur relative to the expected time of the

WOCL.

The WOCL can occur in flight during domestic night operations and during long haul and ULR operations when

the duty/rest cycle is out of step with crewmembers’ circadian body clock cycles.

• The evening wake maintenance zone occurs in the few hours before usual bedtime. This makes it very difficult

to fall asleep early the night before an early duty report time. This has been identified a cause of restricted

sleep and increased fatigue risk in short haul operations that require early starts.  

• The increasing drive for wake that accompanies the increase in core body temperature in the morning makes

it difficult to fall asleep or stay asleep later in the morning and in the early afternoon. This has been identified

as a cause of restricted sleep and increased fatigue risk in night cargo operations, which require

crewmembers to delay their main sleep period until the morning.

• The internal alarm clock and the evening wake maintenance zone can also interfere with the in‐flight sleep

and layover sleep of long haul and ULR crewmembers when the duty/rest cycle is out of step with

crewmembers’ circadian body clock cycles.

2.3.3 Sensitivity of the circadian body clock to

light

At the beginning of this chapter, there was a brief

description of how the circadian body clock is able to

track light intensity in the environment. This enables

it to stay in step with the day/night cycle, even

although it has a tendency to generate a ‘biological

day’ that is slightly longer than 24 hours.

The effect of light on the circadian body clock

changes according to when in the clock cycle the light

exposure occurs. For a crewmember adapted to local

time and sleeping at night:

• light exposure in the morning (after the

temperature minimum) causes the circadian

clock to speed up temporarily, resulting in a

phase advance (equivalent to crossing time

zones in an eastward direction);

• light exposure in the middle of the day has very

little effect; and

• light exposure in the evening (before the

temperature minimum) causes the circadian

clock to slow down temporarily, resulting in a

phase delay (equivalent to crossing time zones in

a westward direction).

Bright light causes bigger shifts in the circadian body

clock cycle than dim light, and the clock is particularly

sensitive to blue light.

In theory, this means that just the right amount of

light exposure at the same time every morning would

speed up a 24.5‐hour circadian clock cycle just

enough to synchronize it to exactly 24 hours. In

practise, staying in step with the day/night cycle is

more complex than this. In modern industrialised

societies, people have very haphazard exposures to

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2‐14 Science for FRMS

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observed on these flights (all crews were

accompanied by a flight deck observer). However, all

flights were routine, i.e., there were no operational

events that tested the capacity of these

crewmembers to respond to non‐routine situations.  

   

Operational Note:

Mitigation Strategies for Night Duty

• Night duty forces crewmembers to sleep later than normal in their circadian body clock cycle. This means that

they have a limited amount of time to sleep before the circadian body clock wakes them up. Consequently,

they need to get to sleep as soon as possible after coming off duty.  

• Getting off duty earlier increases the time available for sleep in the morning, before the circadian body clock

makes it difficult for crewmembers to stay asleep.

• Napping before going on duty is beneficial to help maintain alertness and performance through to the end of

the night  

• Napping during the duty period (for example, on the ground while aircraft are being loaded and unloaded) is

beneficial to help maintain alertness and performance through to the end of the night. The napping

opportunity should be limited to 40‐45 minutes, with an additional 10‐15 minutes allowed to ensure that

sleep inertia (if any) has dissipated.

• In some operations, it may be possible to schedule a longer sleep opportunity during the night, for example

during loading and unloading of freight, or during continuous duty overnight periods. Providing a sleeping

room away from the aircraft and protected time to sleep would increase the amount of sleep that

crewmembers are able to obtain. Once again, and additional 10‐15 minutes should be allowed, to ensure that

sleep inertia (if any) has dissipated.

2.3.5 Jet lag  

Flying across time zones exposes the circadian body

clock to sudden shifts in the day/night cycle. Because

of its sensitivity to light and (to a lesser extent) social

time cues, the circadian body clock will eventually

adapt to a new time zone. Studies with participants

flown as passengers have identified a number of

factors that affect the rate of adaptation to a new

time zone. These factors include the following.

The number of time zones crossed  ‐  adaptation

generally takes longer when more time zones are

crossed.

The direction of travel  ‐  adaptation is usually faster

after westward travel than after eastward travel

across the same number of time zones.  

This probably reflects the fact that most people have

a circadian body clock that has an innate cycle slightly

longer than 24 hours, which makes it easier to

lengthen the cycle to adapt to a westward shift (a

phase delay).

After eastward flights across 6 or more time zones,

the circadian body clock may adapt by shifting in the

opposite direction, for example shifting 18 time zones

west rather than 6 time zones east. When this

happens some rhythms shift eastward and others

westward (known as resynchronization by partition)

and adaptation can be particularly slow.  

Rhythms in different functions can adapt at different

rates, depending on how strongly they are influenced

by the circadian body clock.
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2‐16 Science for FRMS

Unedited version

performance. This would be an ideal time to take an

in‐flight nap (crewmembers did not have in‐flight

sleep opportunities on this trip).  

Another consequence was that when crewmembers

returned home, their circadian body clocks were on

average 4.5 hours delayed with respect to local time

and took several days to readapt.  

Layover sleep patterns on long‐haul and ULR trips

The fact that long haul and ULR crewmembers

seldom stay long enough in any destination time zone

to become adapted to local time has effects on their

layover sleep. Often, crewmembers split their sleep,

having one sleep period on local night and another

corresponding to local night in their home time zone,

which overlaps the preferred part of the circadian

body clock cycle for sleep (at least for the first 24‐48

hours in a new time zone).  

Another factor affecting layover sleep, particularly for

unaugmented crews who do not have the

opportunity for in‐flight sleep, is that long haul duty

days are often associated with extended periods of

waking. For example, in a series of long haul trips

studied by the NASA Fatigue Program the average

period of waking associated with a duty day was

20.6 hours (the average length of a duty period was

9.8 hours)13. Across these long periods of waking, the

homeostatic pressure for sleep builds so that

crewmembers tend to sleep, at least for a short time,

soon after arrival at the destination layover hotel. For

example, this is a common pattern after eastward

night flights across multiple time zones. A short sleep

is taken soon after arrival, during the local afternoon,

and then the main sleep period is then taken during

local night.

FRMS training for long haul and ULR crewmembers

needs to include discussion of the effects of trans‐

meridian flights on the circadian body clock and

sleep. One way to reduce the complexity of this

material is to develop specific guidance for sleep and

the use of personal fatigue mitigation strategies on

different routes.

Operational Note:

Effects of Different Types of Long Haul Trip Patterns on the Circadian Body Clock

Relatively few studies have tracked the circadian body clock across long haul trip patterns, and many are over 20

years old. The available studies suggest that different types of trip patterns affect the circadian body clock in

different ways.  

• Sequences of back‐to‐back trans‐meridian flights (separated by 24 hour layovers) that do not return to the

domicile time zone for long periods of time (such as the pattern illustrated in Figure 2.5) tend to cause the

circadian body clock to drift on its innate cycle, which is typically slightly longer than 24 hours. This is probably

because these trips contain no regular 24‐hour pattern to which the circadian body clock can synchronize.

When they arrive back in their home time zone, crewmembers need additional days to readapt to local time.  

• Sequences of out‐and‐back transmeridan flights (separated by 24 hour layovers) that return to the home time

zone on alternate layovers seem to enable the circadian body clock to remain synchronized to the home time

zone. For example, a trip pattern studied by the NASA Fatigue Program  involved three back‐to‐back return

flights between the US West Coast and London (6 flights in total) with 24‐hour layovers between each flight.

Returning to their home time zone on every second layover appeared to keep crewmembers’ circadian body

clocks (monitored by the core temperature rhythm) synchronized to West Coast time. As a result,

crewmembers obtained relatively good sleep on the West Coast layovers and did not need additional days to

readapt to West Coast time at the end of the trip.
Science for FRMS 2‐17

Unedited version

• There is some evidence that when crewmembers stay longer in the destination region, for example doing

several days of local flying with minimal time zone changes before flying the long haul trip home, their

circadian body clocks begin to adapt to the destination time zone. This may improve layover sleep. On the

other hand, when they arrive back in their home time zone, they need additional days to readapt to local

time.  

The scarcity of data on what happens to the circadian body clock across different long haul trip patterns is one

reason most current bio‐mathematical models do not have a validated approach for simulating what happens to

the circadian clock across sequences of trans‐meridian flights (see Chapter 4).

2.4 Summary of essential science for

FRMS

Discoveries in sleep science and circadian rhythms

provide a strong scientific basis for FRMS. The science

does not address every detailed operational question

and it never will. In other words, there will always be

a need to combine operational experience and

scientific knowledge to come up with workable

controls and mitigations to manage fatigue risk in an

FRMS.

The scientific basis for FRMS can be continuously

improved if data that are routinely collected as part

of FRM processes (Chapter 4) and FRMS Assurance

processes (Chapter 5) can be shared in appropriate

ways in the public domain.

Operational Note:

Key facts about sleep

Sleep is vital for recovery from fatigue. Two aspects of sleep are important – the amount of sleep and the quality

of sleep.

Amount of sleep

• Sleep restriction is common in flight operations.

• Not getting enough sleep leads to: feeling sleepier, difficulty staying alert, getting irritable, slower reactions,

poorer coordination, slower thinking, getting fixated on part of a problem and losing the big picture (loss of

situation awareness), less creative problem solving, and reduced memory consolidation (impaired learning).

• The effects of restricted sleep accumulate:

‐  the rate of accumulation of fatigue is related to the rate of sleep loss (less sleep per day = more rapid

accumulation of fatigue);

‐  sleep pressure eventually becomes uncontrollable, which results in unintentional   sleep (microsleeps or

unintended naps).

• Lost hours of sleep do not need to be recovered hour‐for‐hour.

• At least two consecutive nights of unrestricted sleep are required to recover from the cumulative effects of

multiple nights of restricted sleep. Unrestricted sleep means being free to fall asleep when tired and wake up

spontaneously, with sleep occurring at the appropriate time in the cycle of the circadian body clock. In some
2‐18 Science for FRMS

Unedited version

cases, this recovery period can be built into schedules (for example with short day time duty periods).  

• Controlled napping can temporarily relieve the symptoms of sleep loss. It is a valuable personal mitigation

strategy, for example prior to a night duty period or on long haul flights.

‐  A NASA study of flight deck napping showed improved alertness at the end of unaugmented long haul

flights (8‐9 hrs) when flight crew members were given a 40‐min nap opportunity in their flight deck seat.    

Quality of sleep

• Good quality sleep involves regular cycles through two different types of sleep – Rapid Eye Movement sleep

(REM sleep) and non‐REM sleep. A full non‐REM/REM sleep cycle takes roughly 90 minutes.

• Sleep that is fragmented by multiple awakenings, or arousals into lighter stages of sleep, breaks up the non‐

REM/REM cycle and is less restorative than continuous sleep.  

‐  Sleep in onboard crew rest facilities is lighter and more fragmented than sleep in hotels or at home. This

does not appear to be an effect of altitude.

• Both flight deck naps and in‐flight sleep in crew rest facilities contain very little deep non‐REM sleep (known

as slow‐wave sleep), so sleep inertia is less likely after in‐flight sleep than is predicted by laboratory studies.

Two main physiological processes interact to regulate sleep:

• The homeostatic sleep process is evident in the pressure for slow‐wave sleep that builds up across waking and

discharges across sleep.  

• The circadian body clock regulates the timing of REM sleep and dictates the preference for sleep at night.

The interaction between the homeostatic pressure for sleep and the circadian body clock  results in two times of

peak sleepiness in 24 hours:

‐  a peak in the early afternoon (the afternoon nap window) that occurs around 3‐5 pm for most people; and

‐  a peak in the early hours of the morning (the window of circadian low or WOCL) that occurs around 3‐5 am

for most people.

Note: these two processes are the main components in most of the bio‐mathematical models that are used to

predict crewmember fatigue levels (see Chapter 4).

Operational Note:

Key facts about the circadian body clock

• The circadian body clock is a pacemaker in the brain that is sensitive to light through a specialized input

pathway from the eyes (separate from vision).  

• The circadian biological clock generates an innate ‘biological day’ that is slightly longer than 24 hours for most

people. Its sensitivity to light enables it to stay in step with the 24‐hour day/night cycle.
Science for FRMS 2‐19

Unedited version

• Almost every aspect of human functioning (physical or mental) undergoes daily cycles that are influenced by

the circadian body clock.  

• The daily minimum in core body temperature corresponds to the time in the circadian body clock cycle when

people feel most sleepy and are least able to perform mental and physical tasks. This is sometimes called the

Window of Circadian Low (WOCL) and it is a time of high risk for fatigue‐related error.  

Shift work

• Shift work can be defined as any duty pattern that requires a crewmember to be awake during the time in the

circadian body clock cycle that they would normally be asleep.  

• The ability of the circadian clock to ’lock on’ to the 24‐hour day/night cycle makes it resist adaptation to any

pattern other than sleep at night.  

• The fact that the circadian body clock does not adapt fully to altered sleep/wake patterns has two main

consequences:

‐  duty days that overlap crewmembers’ usual sleep times (particularly all‐night operations) tend to cause

sleep restriction; and

‐  crewmembers who are working through the window of circadian low (WOCL) can be expected to be sleepy

and have to make additional effort to maintain their performance.

• The further sleep is displaced from the optimum part of the circadian body clock cycle, the more difficult it

becomes for crewmembers to get adequate sleep.  

• In scheduling, the frequency of recovery breaks (at least 2 consecutive nights of unrestricted sleep) needs to

reflect the rate of accumulation of sleep debt.

Jet lag

• Flying across time zones exposes the circadian body clock to sudden shifts in the day/night cycle. Because of

its sensitivity to light and (to a lesser extent) social time cues, the circadian body clock will eventually adapt to

a new time zone.  

• The rate of adaptation depends on the number of time zones crossed, the direction of travel (faster after

westward flights) and the extent to which the circadian body clock is exposed to the 24‐hour cues in the new

time zone (outdoor light, sleeping and eating on local time, etc).

• Layovers of 24‐48 hours are not long enough to allow the circadian body clock to adapt to local time.  

• Different types of long haul trip patterns affect the circadian body clock in different ways.  

‐  Sequences of back‐to‐back trans‐meridian flights that do not return to the domicile time zone for long

periods of time tend to cause the circadian body clock to drift on its innate cycle. On return to the home

time zone, additional days are needed to readapt to local time.
2‐20 Science for FRMS

Unedited version

‐  Sequences of out‐and‐back transmeridan flights that return to the home time zone on alternate layovers

seem to enable the circadian body clock to remain synchronized to the home time zone.  

‐  On trips that include longer periods in the destination region, for example several days of local flying before

the return flight home, the circadian body clock begins to adapt to the destination time zone. This may

improve layover sleep. On the other hand, on return to the home time zone, additional days are needed to

readapt to local time.

• On long haul layovers, sleep is affected by competition between physiological processes (the homeostatic

sleep drive and the circadian biological clock) and a preference for sleeping during the local night.

• Route‐specific recommendations for personal fatigue mitigation strategies may be useful in FRMS training for

long haul and ULR crewmembers.

Operational Note:

How much sleep in 24 hours is enough?

This common question is usually aimed at trying to get a ‘magic number’ for the minimum amount of sleep that

a crewmember needs, or the minimum rest period that needs to be scheduled. From a sleep science

perspective, the answer is ‘it depends on many factors, including individual differences’. Some of the things it

depends on are:

• Recent sleep history  ‐ one restricted sleep period is a smaller fatigue risk for a crewmember who is starting

out well‐rested than for a crewmember who has already accumulated a sleep debt;

• The amount of sleep a crewmember needs to be fully‐rested (which varies among crewmembers);

• Whether the crewmember is likely to obtain good quality sleep during the restricted sleep period. (For

example, is sleep at home, in an onboard crew rest facility, in a layover hotel? Does the sleep opportunity

occur at an appropriate time in the circadian body clock cycle?);

• Whether sleep is shortened because a crewmember has to stay awake for an extended time beforehand

(increasing the homeostatic pressure for sleep and the risk of micro‐sleeps prior to the sleep period);

• Whether sleep is shortened because a crewmember has to stay awake for an extended time afterwards

(increasing the homeostatic pressure for sleep and the risk of micro‐sleeps prior to the next sleep period);

• Whether the crewmember will be trying to work through times of increased circadian sleep drive (the early

hours of the morning and mid‐afternoon when the circadian body clock is adapted to  local time);  

• The criticality of the tasks that a crewmember will be undertaking after the restricted sleep period;

• Other defensive strategies that are in place to manage the safety risk if that crewmember is fatigue‐impaired

as a result of the restricted  sleep period; and

• When the opportunity will occur for recovery from the effects of the restricted sleep period (for example, is it

the first in a series of restricted sleep periods, or is it followed by two unrestricted nights of recovery sleep?).
Science for FRMS 2‐21

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From a safety perspective, the answer is that no single defensive strategy is 100% sure. (The same desire for

simplicity is a risk with bio‐mathematical models that define a ‘safety threshold’ for crewmember fatigue. For

example, there is a tendency to believe that an operation is safe if it is predicted to be below the threshold, but

unsafe if it is predicted to be above it.) In an FRMS, safety comes from having a data‐driven multi‐layered system

of defenses to manage fatigue risk, not from a reliance on simple thresholds. The FRMS answer is – measure

crewmember fatigue levels, do a risk assessment and implement controls and mitigations as needed. These

processes are the subject of Chapters 5 and 6.
Chapter 3. FRMS policy and documentation 3‐1

Unedited version

Chapter 3. FRMS policy and documentation

3.1  Introduction to FRMS policy and

documentation

This Chapter describes what should be included in an

FRMS policy, and other documentation required to  

record its activities. The policy and documentation

define organizational arrangements that support the

core operational activities of the FRMS (the FRM

processes and the FRMS safety assurance processes).

The linkages between policy and documentation and

other FRMS components are outlined in Figure 3.1.

The FRMS policy specifies the operator’s commitment

and approach to the management of fatigue risk. If

acceptable to the State, it may be appropriate in

some cases for the operator to incorporate its FRMS

policy in its SMS policy. However, it should be noted

that ICAO Annex 6, Part I, Appendix 8 requires an

operator to clearly define all elements of the FRMS in

its policy. The operator’s FRMS policy must be able to

be distinguishable from the general SMS policy to

allow separate review.

The FRMS documentation describes the components

and activities of the entire FRMS. It makes it possible

for the effectiveness of the FRMS to be audited

(internally and externally) to check whether it is

meeting the safety objectives defined in the FRMS

policy. Maintaining the required documentation is

one of the recommended functions of the Fatigue

Safety Action Group.

Figure 3.1: Linkages between FRMS policy and documentation and other FRMS components
3‐2 FRMS policy and documentation

Unedited version

The ICAO requirements for FRMS policy and documentation are as follows (Appendix 8, Annex 6, Part I).

Annex 6, Part I, Appendix 8

1. FRMS policy and documentation

1.1 FRMS policy

1.1.1 The operator shall define its FRMS policy, with all elements of the FRMS clearly identified.

1.1.2   The policy shall require that the scope of the FRMS operations be clearly defined in the

Operations Manual.

1.1.3 The policy shall:

a)  reflect the shared responsibility of management, flight and cabin crews, and other involved

personnel;

b)  clearly state the safety objectives of the FRMS;

c)  be signed by the accountable executive of the organization;

d) be communicated, with visible endorsement, to all the relevant areas and levels of the

organization;

e)  declare management commitment to effective safety reporting;

f)  declare management commitment to the provision of adequate resources for the FRMS;

g)  declare management commitment to continuous improvement of the FRMS;

h)  require that clear lines of accountability for management, flight and cabin crews, and all

other involved personnel are identified; and  

i) require periodic reviews to ensure it remains relevant and appropriate.

Note.— Effective safety reporting is described in Doc 9859, Safety Management Manual (SMM).

1.2 FRMS documentation

An operator shall develop and keep current FRMS documentation that describes and records:

a)  FRMS policy and objectives;

b)  FRMS processes and procedures;

c)  accountabilities, responsibilities and authorities for these processes and procedures;

d)  mechanisms for ongoing involvement of management, flight and cabin crew members, and

all other involved personnel;

e)  FRMS training programs, training requirements and attendance records;

f)  scheduled and actual flight times, duty periods and rest periods with significant deviations

and reasons for deviations noted; and

g)  FRMS outputs including findings from collected data, recommendations, and actions taken.
FRMS policy and documentation 3‐3

Unedited version

3.2  Appendix 8, paragraph 1.1: FRMS

policy

1.1.1   The operator shall define its FRMS policy,

with all elements of the FRMS clearly identified.

The FRMS policy provides the umbrella under which

the FRMS operates. While an FRMS may be an

integral part of an operator’s SMS, SMS and FRMS

require two separate approval processes.

Consequently, whether the operator’s FRMS Policy

has been written as a stand‐alone document, as a

component of its SMS Policy, or as part of its overall

Safety Policy, any aspects of the FRMS policy must be

easily identifiable as such. This means that the FRMS

policy can be reviewed in its entirety and is clearly

distinguishable from other safety policy statements.

3.2.1 Scope of the FRMS

1.1.2   The policy shall require that the scope of

FRMS operations be clearly defined in the Operations

Manual.

ICAO Standard 4.10.2 (Annex 6, Part I) requires that,

where FRMS regulations are provided, States allow

an operator to choose whether it will use the FRMS

to manage fatigue risk in all its operations, or only in

designated specific types of operations (for example,

a particular fleet, a particular route, only ULR

operations, etc.). All operations not covered by the

FRMS must operate under the applicable prescriptive

flight and duty time limits.  

Because a policy statement is typically a short and

stable document, it does not have to detail the scope

of the operations to which the FRMS applies, but it

does have to identify where these are detailed. For

example, an operator policy statement may indicate

that the scope of the FRMS is defined in the Flight

Operations Manual. This means that State‐approved

changes in scope do not require a rewrite of the

initial FRMS policy statement.

As an operator’s familiarity and experience with

FRMS builds, they may wish to expand the scope of

the FRMS. This could be viewed as a natural evolution

of the FRMS, and the regulator will need to give

consideration to the requirements that would govern

expanding the scope of an FRMS.  

The following text boxes show examples of

statements of the scope of an FRMS.

Example 1

Airline A ‐ large international carrier

with 11 different fleet types

‘The FRMS for Airline A will apply to all operations as

specifically identified in the Flight Operations Manual

(FOM). All other operations will be conducted under

the prescriptive flight and duty time regulations.’

In Example 1, the Flight Operations Manual initially

lists the entire B‐777 fleet and Ultra‐Long Range

(ULR) flights on the B‐787, and only includes pilots.

Subsequently, Airline A decides that it wants to add

its A‐330 fleet to the FRMS.  

With approval from the regulator, the A‐330 fleet can

be added to the list in the Flight Operations Manual

that identifies operations covered by the FRMS,

without requiring a change to the FRMS policy

statement. This change makes the Fatigue Safety

Action Group responsible for establishing FRMS

processes to identify fatigue hazards in the A‐330

operations, assess the risks, and develop and

implement controls and mitigations. FRMS safety

assurance processes also need to be established to

monitor the effectiveness of the FRMS in managing

fatigue risk in the A‐330 operations.

The addition of cabin crewmembers to the FRMS

would require an amended policy statement, as

follows.

‘The FRMS for Airline A will apply to all operations as

specifically identified in the Flight Operations Manual

(FOM) and Cabin Operations Manual (COM). All other

operations will be conducted under the prescriptive

flight and duty time regulations.’
3‐4 FRMS policy and documentation

Unedited version

Example 2

Airline B – domestic carrier operating both scheduled

and charter operations with 3 fleet types. Airline B

chooses to operate its charter operations under

FRMS and to operate its scheduled operations under

the prescriptive flight and duty time regulations.

‘The FRMS for Airline B will apply to all flight crew

members in all charter aircraft operations.’

Example 3

Airline C – Two airplane on‐demand carrier

that chooses to cover all its operations under FRMS

‘The FRMS for Airline C will apply to all flight crew

members in all operations.’

1.1.3 The policy shall:

a) reflect the shared responsibility of management,

flight and cabin crews, and other involved

personnel;

b) clearly state the safety objectives of the FRMS;

c) be signed by the accountable executive of the

organization;

d) be communicated, with visible endorsement, to

all the relevant areas and levels of the

organization;

e) declare management commitment to effective

safety reporting;

f) declare management commitment to the

provision of adequate resources for the FRMS;

g) declare management commitment to continuous

improvement of the FRMS;

h) require that clear lines of accountability for

management, flight and cabin crews, and all other

involved personnel are identified; and  

i) require periodic reviews to ensure it remains

relevant and appropriate.

Note.— Effective safety reporting is described in Doc

9859, Safety Management Manual (SMM).

Appendix 8, Section 1.1.3 identifies the minimum

requirements that must be addressed in the FRMS

policy. Essentially, these identify the prerequisites of

an FRMS. As for the management of fatigue‐related

risks within prescriptive flight and duty limitations,

FRMS necessitates shared responsibility between the

operator and individual crew members, because of

the particular nature of fatigue.  

Fatigue is affected by all waking activities, not only

work demands ‐ sometimes described as a ‘whole‐of‐

life issue’. For example, crewmembers have personal

responsibility because they can choose the amount of

time they spend trying to sleep during available rest

breaks, and choose when to use personal fatigue

mitigation strategies (Chapter Four). They have a

responsibility to use rest periods effectively prior to

duty periods to enable them to start work fit for duty.

In addition, their cooperation is vital for voluntary

reporting of fatigue hazards, and when fatigue levels

need to be measured for FRM processes (Chapter

Four) and FRMS safety assurance processes (Chapter

Five). Crewmembers’ willingness to cooperate will

depend on their confidence that the operator is

committed to the principles of an effective safety

reporting culture1 (Chapter One).  

However, management is also, and primarily,

responsible for the management of fatigue risk

because it schedules the work activities of personnel

and the distribution of resources in the organization2

.

The FRMS is an organizational system that enables

management to meet that responsibility.

  

Like SMS, the Accountable Executive when signing

the FRMS policy accepts accountability for the FRMS,

either directly or through supervision and

management of others, including those to whom the

Accountable Executive has delegated responsibility.  

The safety objectives in the FRMS policy specify what

the operator wants the FRMS to achieve. To track

whether the FRMS is meeting these objectives, its

performance needs to be monitored. Examples of

                                                           

1 ICAO Safety Management Manual (Doc 9859) 2 ICAO Safety Management Manual (Doc 9859)
FRMS policy and documentation 3‐5

Unedited version

safety performance indicators and targets that can be

used to measure how well the FRMS is meeting the

safety objectives can be found in Chapters Four and

Five.  

The FRMS policy needs to be reviewed periodically by

the operator, to ensure that it is adequate to meet

changing operational demands. In addition, it should

be subject to periodic review by the regulator.

3.3  Examples of FRMS policy

statements

The following examples are intended to be used as

guidance, not templates. Each operator needs to

develop an FRMS appropriate their specific

organizational context and operational needs.

3.3.1 FRMS policy statement for a major air

carrier

[Insert Company Name] Fatigue Risk Management Policy

As a commitment to the continuous improvement of safety, X Company has an FRMS to manage fatigue‐related risks.

This Fatigue Risk Management System (FRMS) applies to the operations as defined in the Flight Operations and Cabin Operations

Manuals. All other operations will operate under the prescriptive flight and duty time regulations. The FRMS Manual describes the

processes used for identifying fatigue hazards, assessing the associated risks, and developing, implementing, and monitoring controls and

mitigations. The FRMS Manual also describes the safety assurance processes used to ensure that the FRMS meets its safety objectives,

and how the FRMS is integrated with our industry‐leading SMS programs.  

Under this policy:

Management is responsible for:  

• Providing adequate resources for the FRMS;

• providing adequate crewing levels to support rosters that minimize fatigue risk;

• providing flight and cabin crew with adequate opportunity for recovery sleep between duties;

• creating an environment that promotes open and honest reporting of fatigue related hazards and incidents;

• providing fatigue risk management training to flight, cabin crew and other FRMS support staff;  

• demonstrating active involvement in and understanding of the FRMS;

• ensuring that the fatigue risks within their area(s) of responsibility are managed appropriately;  

• regularly consulting with flight and cabin crew regarding the effectiveness of the FRMS; and  

• demonstrating continuous improvement and providing annual review of the FRMS.

Flight and cabin crew are required to:  

• make appropriate use of their rest periods (between shifts or periods of duty) to obtain sleep;   

• participate in fatigue risk management education and training;  

• report fatigue‐related hazards and incidents as described in the FRMS Manual;  

• comply with the Fatigue Risk Management Policy;

• inform their manager or supervisor immediately prior to or during work if:

o they know or suspect they or another crew member are suffering from unacceptable levels of fatigue; or  

o they have any doubt about their or another crew member’s capability to accomplish their duties.

Fatigue Risk Management must be considered a core part of our business as it provides a significant opportunity to improve the safety

and efficiency of our operation and to maximize the well being of our staff.

Policy authorized by:

(Signed) ___________________________________

Insert Title (Accountable Executive)

Date:  ___________________________
3‐6 FRMS policy and documentation

Unedited version

3.3.2 FRMS policy statement for a smaller operator providing medical evacuation services

[Insert Company Name] Fatigue Risk Management Policy

The unique challenges that we face in our international medical evacuation operations here at [Insert Company] include 24 hour on‐

call schedules, a need for immediate response in all weather conditions, and many flights landing at unprepared locations. These

challenges require our flight crews to perform at the highest levels of competence and professionalism at all times.  They also mean

that we are exposed on a regular basis to elevated fatigue risks, which are best managed through a Fatigue Risk Management System

(FRMS).

We need to manage these risks carefully in order to make consistently sound decisions, particularly to balance the critical needs of

patients with the requirement for safe operations. This can only be achieved through the shared responsibility and commitment of

management, crew members (pilots, doctors and nurses) and our support staff (e.g. crew schedulers) to ensure our fatigue risks

remain acceptable.

[Insert Company Name] will ensure that management, crew and support staff, and all other relevant personnel are aware of:

• the potential consequences of fatigue within our company;

• the unique challenges and fatigue risks confronting our staff due to the nature of our operations;

• the importance of reporting fatigue‐related hazards; and

• how to best manage fatigue.

To achieve this we have developed specific policies and procedures within our Safety Management System (SMS) for the

management of fatigue risks. These are documented in the FRMS sections of our SMS Manual and apply to all operational staff.  

Management are responsible for:  

• appropriately resourcing the SMS;

• providing adequate crewing levels to support rosters that minimise fatigue risk;

• providing crew with adequate opportunity for recovery sleep between duties;

• creating an environment that promotes open and honest reporting of fatigue related hazards and incidents;

• providing fatigue risk management training to crew and other support staff;  

• demonstrating active involvement in and understanding of our fatigue risks;

• regularly consulting with crew regarding the effectiveness of fatigue management; and  

• demonstrating continuous improvement and providing annual review of fatigue management.

Crew and support staff are required to:  

• make appropriate use of their rest periods (between shifts or periods of duty) to sleep;

• participate in fatigue risk management education and training;  

• report fatigue‐related hazards and incidents;  

• comply with the Fatigue Risk Management Policy and Practices as contained within our SMS;

• inform their manager or supervisor immediately prior to or during work if:

o they know or suspect they or another crew member are suffering from unacceptable levels of fatigue; or

o they have any doubt about their or another crew members capability to accomplish their duties.

• seek external support in accordance with our company policies and procedures to ensure, whenever possible, that third parties

(e.g. Chief Pilot, Operations Manager) who are not part of your crew are used to support crew decision making. Whenever

crewmembers have doubts about their fatigue risk they are requested to use the company’s 24‐hour hotline.

The effective management of fatigue is critical to ensuring that our company can deliver a quality service to our customers.  

Policy authorized by:

(Signed) ___________________________________

Insert Title (Accountable Executive)

Date:  ___________________________
FRMS policy and documentation 3‐7

Unedited version

3.4  Appendix 8, paragraph  1.2 – FRMS

documentation

1.2      An operator shall develop and keep current

FRMS documentation that describes and records:

a) FRMS policy and objectives;

b) FRMS processes and procedures;

c) accountabilities, responsibilities and authorities for

these processes and procedures;

d)mechanisms for ongoing involvement of

management, flight and cabin crew members, and

all other involved personnel;

e) FRMS training programs, training requirements and

attendance records;

f) scheduled and actual flight times, duty periods and

rest periods with significant deviations and reasons

for deviations noted; and

g) FRMS outputs including findings from collected

data, recommendations, and actions taken.

The documentation describes all the elements of the

FRMS and provides a record of FRMS activities and

any changes to the FRMS. The documentation can be

centralized in an FRMS Manual, or the required

information may be integrated into an operator’s

SMS Manual. However, it needs to be accessible to all

personnel who may need to consult it, and to the

regulator for audit.

As a way of meeting these requirements, it is

expected that an operator create a functional group

that is responsible for coordinating the fatigue

management activities within the organisation. Such

a group is referred to here as the Fatigue Safety

Action Group. The principle functions of the Fatigue

Safety Action Group are to:

• develop and maintain the FRMS documentation;

• manage the FRM processes (Chapter Four);

• contribute to the FRMS safety assurance

processes (Chapter Five); and

• be responsible for the FRMS promotion

processes (Chapter Six).

However, in order to ensure that the focused

management of fatigue risks does not result in

unintended consequences in overall risk

management, some of the functions of the Fatigue

Safety Action Group as described here may in fact be

undertaken by the SMS team or other functional

groups. Regardless of who undertakes these

functions, the regulator will need to observe and

monitor all of the functions required under an FRMS.

The composition of the Fatigue Safety Action Group

should reflect the shared responsibility of individuals

and management by including representatives of all

stakeholder groups (management, scheduling staff,

and crewmembers and/or their representatives) and

other individuals as needed to ensure that it has

appropriate access to scientific and medical

expertise. It should operate under Terms of

Reference that are included in the FRMS

documentation and which specify the lines of

accountability between the Fatigue Safety Action

Group and the operator’s SMS.  

The size and composition of the Fatigue Safety Action

Group will vary for different operators, but should be

related to the size and complexity of the operations

covered by the FRMS, and to the level of fatigue risk

in those operations. In small operators, a single

individual may represent more than one stakeholder

group, for example the chief pilot may also be the

primary scheduler. In very small operators, there may

not even be a designated Fatigue Safety Action

Group, simply extra items on the Safety Meetings

agenda, as long as long as all fatigue risk

management activities are documented. Larger

airlines will have specialised departments that

interact with the Fatigue Safety Action Group.  

While the regulator may wish to observe Fatigue

Safety Action Group meetings as part of its oversight

activities, the regulator is not a required part of this

group. The regulator may also wish to review the

minutes and outputs of such meetings as part of their

continuous oversight activities (see Chapter 9).

Appendix 8, paragraph 1.2 f) also requires that

significant deviations in scheduled and actual flight

times, duty periods and rest periods, and reasons for
3‐8 FRMS policy and documentation

Unedited version

those significant deviations be recorded by operators.

As an initial step, the Fatigue Safety Action Group, or

other appropriate entity within the organisation, will

need to identify through a risk assessment process,

differences between scheduled and actual flight

times, duty periods and rest periods that will be

considered significant within the context of their

specific operations.  

For example, identified significant differences may

include:

• for a particular city pair, any occasion where

actual flight time exceeds planned flight time by

30 minutes;

• for a particular trip, any occasion where actual

duty time exceeds planned duty time by 60

minutes;

• for a particular layover, any occasion where the

rest period is reduced from the planned rest

period by 60 minutes.  

As a result, the significant deviations should be used

as indicators to help identify potential fatigue hazards

(discussed in Chapter Four) and may also be used to

monitor the performance of the FRMS itself (Chapter

Five). Further, the Fatigue Safety Action Group will

also be responsible for establishing a process for

monitoring such significant deviations and

documenting any subsequent actions taken.  

Such definitions will need to be provided to the

regulator for their acceptance and it will be important

that there is a clear understanding between the

regulator and the operator as to what constitutes a

significant deviation. The regulator may also use

these to identify criteria for reporting requirements.

3.4.1 Example of terms of reference for a fatigue

safety action group

This example is designed to cover the needs of a large

operator. This is not a template. Not all the items

suggested here will be needed by every operator. The

regulator needs to be confident that the operator has

considered its operational and organizational profile

in deciding the composition of the fatigue safety

action group, its activities, and its interactions with

other parts of the operator’s organization.
FRMS policy and documentation 3‐9

Unedited version

[Insert Company Name] Terms of Reference: Fatigue Safety Action Group (FSAG)

Purpose

The Fatigue Safety Action Group (FSAG) is responsible for coordinating all fatigue risk management activities at [insert Company name].

This includes responsibility for gathering, analyzing, and reporting on data that facilitates the assessment of fatigue‐related among flight

crewmembers. The FSAG is also responsible for ensuring that the FRMS meets the safety objectives defined in the FRMS Policy, that it

meets regulatory requirements, and that the FRMS informs the SMS to facilitate the management of safety risks in general. The FSAG

exists to improve safety, and does not get involved in industrial issues.  

Terms of Reference

The FSAG is directly responsible to the Senior VP Flight Operations and reports through the Departmental Safety organization. Its

membership will include at least one representative of each of the following groups: management, scheduling, and crewmembers, with

other specialists as required.  

The tasks of the FSAG are to:

• develop, implement, and monitor processes for the identification of fatigue hazards;

• ensure that comprehensive risk assessment is undertaken for fatigue hazards;

• develop, implement, and monitor controls and mitigations as needed to manage identified fatigue hazards;

• develop, implement, and monitor effective FRMS performance metrics;

• cooperate with the Safety Department to develop, implement and monitor FRMS safety assurance processes, based on agreed

safety performance indicators and targets;

• be responsible for the design, analysis, and reporting of studies that measure crewmember fatigue, when such studies are needed

for the identification of hazards, or for monitoring the effectiveness of controls and mitigations (such studies may be contracted out

but the FSAG is responsible for ensuring that they are conducted with the highest ethical standards, meet the requirements of the

FRMS, and are cost‐effective);  

• be responsible for the development, updating, and delivery of    FRMS education and training materials (these activities may be

contracted out but the FSAG is responsible for ensuring that they meet the requirements of the FRMS and are cost‐effective);

• ensure that all relevant personnel receive appropriate FRMS education and training, and that training records are kept as part of

the FRMS documentation;

• develop and maintain strategies for effective communication with all stakeholders;

• ensure that crewmembers and others receive response to their fatigue reports;

• communicate fatigue risks and the performance of the FRMS to senior management;

• develop and maintain the FRMS intranet site;

• develop and maintain the FRMS documentation;

• ensure that it has adequate access to scientific and medical expertise as needed, and that it documents recommendations made by

these specialist advisors and the corresponding actions taken;

• keeps informed of scientific and operational advances in fatigue risk management principles and practice;

• cooperate fully with the regulator in relation to FRMS auditing; and

• manage effectively and be accountable for  FRMS resources.  

The FSAG will meet monthly. Minutes will be taken during meetings and distributed within 10 working days after each meeting. The FSAG

will present an annual budget request in [designated part of the financial cycle] and an annual report of all expenditures.
Chapter 4. FRM processes 4‐1

Unedited version

Chapter 4. Fatigue risk management (FRM) processes

4.1 Introduction to FRM processes

This Chapter works through the basic steps for setting

up FRM safety risk management processes, which are

very similar to SMS safety risk management

processes1

.    The main difference is that SMS

processes are designed to address all types of risks.

FRM processes within an FRMS are specifically

designed to manage the risks related to crewmember

fatigue.

FRM processes (represented in the blue box in Figure

4.1 below) are one part of the day‐to‐day operations

of the FRMS. They are designed to enable the

operator to achieve the safety objectives defined in

its FRMS Policy, and are managed by the Fatigue

Safety Action Group.  

FRM processes

• identify where fatigue is a hazard; and

                                                           

1

  See ICAO Safety Management Manual (SMM), 2nd Edition

‐ 2009, Doc 9859.

• assess the level of risk that a given fatigue hazard

represents; and  

• if necessary, put in place controls and mitigation

strategies, and monitor to make sure that they

manage the risk at an acceptable level.

To do this, FRM processes require different sorts of

data, including: a) measures of the fatigue levels of

crewmembers; and b) measures of operational

performance. Examples of these types of measures

are described later in this Chapter. The key is

choosing the right combination of measures for each

operation that is covered by the FRMS. However, just

collecting data is not enough. Data analysis needs to

be used to inform decisions made by the Fatigue

Safety Action Group and others accountable for the

FRM processes and for FRMS safety performance

(Chapter 5). The ICAO requirements for FRM

processes are as follows (Annex 6, Part I, Appendix 8).

Figure 4.1:  Linkages between FRM

processes and other FRMS components
4‐2 FRM processes

Unedited version

Annex 6, Part I, Appendix 8

2. Fatigue risk management processes

2.1 Identification of hazards

An operator shall develop and maintain three fundamental and documented processes for fatigue hazard identification:

2.1.1 Predictive. The predictive process shall identify fatigue hazards by examining crew scheduling and taking into account

factors known to affect sleep and fatigue and their effects on performance. Methods of examination may include but are

not limited to:

a) operator or industry operational experience and data collected on similar types of operations;

b) evidence‐based scheduling practices; and

c) bio‐mathematical models.

2.1.2 Proactive The proactive process shall identify fatigue hazards within current flight operations. Methods of

examination may include but are not limited to:

a) self‐reporting of fatigue risks;

b) crew fatigue surveys;

c) relevant flight and cabin crew performance data;

d) available safety databases and scientific studies; and

e) analysis of planned versus actual time worked.

2.1.3 Reactive. The reactive process shall identify the contribution of fatigue hazards to reports and events associated with

potential negative safety consequences in order to determine how the impact of fatigue could have been minimized. At a

minimum, the process may be triggered by any of the following:

a) fatigue reports;

b) confidential reports;

c) audit reports;

d) incidents; and

e) flight data analysis events.

2.2 Risk assessment

An operator shall develop and implement risk assessment procedures that determine the probability and potential severity

of fatigue‐related events and identify when the associated risks require mitigation.

2.2.1 The risk assessment procedures shall review identified hazards and link them to:

a) operational processes;

b) their probability;

c) possible consequences; and

d) the effectiveness of existing safety barriers and controls.

2.3 Risk mitigation

2.3.1 An operator shall develop and implement risk mitigation procedures that:

a) select the appropriate mitigation strategies;

b) implement the mitigation strategies; and

c) monitor the strategies’ implementation and effectiveness.

Figure 4.2 summarizes the steps in FRM processes. Each step is described in more detail below.
FRM processes 4‐3

Unedited version

   

1.

Different operations (e.g., ULR operations, night

flights, charter operations, or particular fleets,

routes, crew bases, etc) have different causes of

fatigue and may need different mitigations.   

2.

Collect and analyze data, and use available

information on potential fatigue hazards.  

Decide how this applies to your operation.  

Gather additional data on your operation if

necessary.

3. Identify the specific nature of the fatigue

hazard(s) that may need to be managed.

4.

Conduct a safety risk assessment for each

identified hazard.  

Decide which risks require mitigation.

5.

Implement appropriate mitigation strategies

and communicate them to all relevant

personnel.   

Set safety performance indicator(s), to be able

to assess whether the mitigation strategies are

delivering the required level of risk reduction.

6.

If mitigation strategies perform to an

acceptable standard, they become part of

normal operations and are monitored by the

FRMS safety assurance processes.

If mitigation strategies do not perform to an

acceptable standard, then re‐enter the FRM

processes at the appropriate step.

Figure 4.2: FRM Processes

FRMS assurance processes

Not

Effective Effective

FRM PROCESSES

1. Identify operation(s) to

which FRM processes apply

2. Gather and analyze data

3. Identify hazards

4. Assess safety risk

5a. Select and implement

controls and mitigations

5b. Set safety performance

indicators

6. Monitor effectiveness of

mitigations
4‐4 FRM processes

Unedited version

4.2 FRM Processes Step 1: Identify

the operations covered

To meet ICAO FRMS Standards, States should allow

an operator to choose whether it will use the FRMS

to manage fatigue risk in all its operations, or only

in specific types of operations (for example, only a

particular fleet, only ULR operations, etc.). It is

important that the operator clearly identifies to

which operations the FRMS pertains.  

Further, as described in Chapter 2, different types

of flight operations can involve different causes of

crewmember fatigue and may require different

controls and strategies to mitigate the associated

risks. Within its FRMS, an organization may need to

develop multiple sets of different FRM processes for

different operations. These should be clearly

identifiable. On the other hand, in some cases it will

be possible to include multiple types of operations

under one set of FRM processes.  

4.3 FRM Processes Step 2: Gather

data and information  

In Step 2, the Fatigue Safety Action Group gathers

required data and information to be confident that

they can identify the likely fatigue hazards in

operations that are covered by the FRM processes.

To do this, the group needs to have a good

understanding of the operational factors that are

likely to cause crewmember fatigue.

To illustrate some of the considerations in different

operations, Figure 4.3 compares flight and duty

times in daytime short haul, domestic night cargo,

and long haul operations studied by the NASA

Fatigue Program2

.  

                                                           

2

Gander PH, Rosekind MR, Gregory KB (1998). Flight

crew fatigue IV: a synthesis. Aviation, Space and

Environmental Medicine 69 (9): B49‐B60.

Figure 4.3: Average flight, duty, and rest periods in a

sample of daytime short haul, domestic night cargo,

and long haul operations

The daytime short haul operations (2‐person crews)

had the longest daily duty hours, averaged 5 flights

per day, and had the shortest rest periods.

However, they crossed a maximum of 1 time zone

per 24 hours and the rest breaks occurred at night,

during the optimal part of crewmembers’ circadian

body clock cycle for sleep. The main causes of

fatigue identified in this scientific study were:

• restricted sleep caused by short rest periods and

early duty report times; and  

• high workload, flying multiple sectors in high

density airspace across long duty days.

The domestic night cargo operations (2 pilots, 1

flight engineer) had the shortest duty periods,

averaged 3 flights per duty period, and had longer

rest periods than the short haul operations. They

also crossed a maximum of 1 time zone per 24

hours. However, the night cargo crewmembers’ rest

periods occurred during the day and their circadian

body clocks (tracked by their core body

temperature rhythms) did not adapt to this pattern.

The main causes of fatigue identified in this

scientific study were:

• shorter, less restorative sleep during the day; and

• being required to work at night, at the time in the

circadian body clock cycle when self‐rated fatigue

and mood were worst, and when additional

effort would be required to maintain alertness

and performance.  

0 10 20 30

Average duration of rest

breaks (hours)

Average duty hours per

24 hours

Average flight hours per

24 hours

Short Haul

Night Cargo

Long Haul
FRM processes 4‐5

Unedited version

The long haul operations (2 pilots, 1 flight engineer)

had long duty periods, but averaged only 1 flight

per duty period and had the longest rest periods.

However, every layover was in a different time

zone, with a maximum of 8 time zones crossed per

24 hours. The crewmembers’ circadian body clocks

(tracked by their core body temperature rhythms)

did not adapt to the time zone changes or to the

non‐24‐hour duty/rest pattern (averaging 10 hours

of duty and 25 hours of rest). The main causes of

fatigue identified in this scientific study were:

• long periods of wakefulness (average 20.6 hrs)

associated with duty days (there were no

onboard crew rest facilities);  

• on some flights, having to operate the aircraft at

the time in the circadian body clock cycle when

self‐rated fatigue and mood were worst, and

additional effort was    required to maintain

alertness and performance;  

• split sleep patterns and short sleep episodes on

layovers (usually some sleep at local night and

some at body clock night); and

• on some trip patterns, the circadian body clock

drifted away from crewmembers’ domicile time

zone. As a result, additional time for circadian re‐

adaptation was needed for full recovery after the

trip.  

These examples illustrate a fundamental principle in

FRMS  ‐ that flight and duty time limitations do not

capture all the causes of fatigue, which are different

in different types of operations.  

Table 4.1 summarizes the different duty‐related

causes of fatigue identified in these studies , all of

which pre‐dated ULR flights and involved scheduled

operations. The very long duty days in ULR

operations might be expected to cause fatigue, but

the use of augmented crews and the availability of

onboard crew rest facilities for in‐flight sleep are

important mitigation strategies. Unscheduled

operations pose particular challenges, because it is

hard to plan sleep when you do not know when you

have to work, or for how long.  

Cause of Fatigue Hazard

TYPE OF  OPERATIONS

Domestic

short haul

Domestic

night

cargo

Long

haul

Restricted sleep due to short rest

periods

X

Restricted sleep due to early duty

report times

X

Multiple high workload periods

across the duty day

X

Multiple sectors X X

High density airspace X

Long duty days X X

Extended wakefulness on duty

days

X

High workload during circadian

low

X X

Shorter sleep periods at wrong

times in the circadian cycle

X X

Circadian disruption (due to night

work)

X X

Split sleep patterns and short sleep

episodes on layovers

X X

Circadian disruption (due to

crossing multiple time zones)

X

Circadian drift (changes in

circadian pattern) following

extended patterns

X

Note.— These are the causes of fatigue identified in these

particular studies, not an exhaustive list.

Table 4.1: Summary of identified work‐related

fatigue causes (from NASA field studies 18)

Other potential causes of work‐related fatigue

include:

• additional tasks that are performed immediately

prior to a flight or at intermediate points during a

series of flights;

• high total duty time and flight time over specified

periods (per month, per year), which increases

the risk of cumulative fatigue;

• not having the opportunity for    adequate

recovery sleep after one trip (or set of

consecutive duties) before starting the next trip;

and

• other related tasks that crew members may be

required to perform before or after flight duty,
4‐6 FRM processes

Unedited version

for example training activities, administrative

duties, or baggage loading and unloading.

When FRM processes are being set up, it is not

always necessary for the operator to gather new

data for Step 2. It may be possible to identify

potential fatigue hazards based on information and

operational experience from similar types of

operations flown by the operator or other carriers,

or from published scientific studies of fatigue in

similar operations. This is illustrated at the end of

the Chapter, in the example on how to set up FRM

processes for a new ULR route.  

For existing routes being moved into the FRMS,

data that is already routinely collected by the

operator can be analyzed to help identify fatigue

hazards, for example the use of captain’s discretion,

on‐time performance, violations of prescriptive

flight and duty time rules, level of sickness

absences, and standby usage, or Aviation Safety

Reports (ASR’s) that mention fatigue. It should be

noted that it is a requirement of the FRMS SARPs

(Annex 6, Part I, Appendix 8, 1.2 g) that the

operator collects data on significant deviations to

scheduled and actual flight times and duty periods,

with the reasons for these significant deviations

(previously discussed in Chapter 3).  

Once the FRM processes become fully operational,

data collection and analysis are part of the

operator’s day‐to‐day function, so a range of data

will be available routinely for Step 2. In addition, the

Fatigue Safety Action Group may sometimes decide

to undertake non‐routine data collection to better

understand specific fatigue hazards (for example, a

one‐off fatigue survey at a crew base, or a targeted

monitoring study on a route where fatigue is

identified as a concern). The different types of

information and data that can be collected are

described in the following sections and in

Appendix B.  

4.4 FRM Processes Step 3: Hazard

Identification

ICAO Annex 6, Part I, Appendix 8 requires that an

operator develop, maintain, and document three

types of processes for fatigue hazard identification:

1. predictive processes;

2. proactive processes; and  

3. reactive processes.  

All of these processes gather various kinds of

information and data to continuously monitor the

levels of fatigue risk in the operation(s) covered by

the FRMS. These processes enable the Fatigue

Safety Action Group to make data‐driven decisions

‘based upon scientifically valid principles and

measurements’ as stated in the ICAO definition of

FRMS.  

As already mentioned, various types of data are

involved including measures of operational

performance, which operators are familiar with,

and measures of the fatigue levels of

crewmembers, which will be less familiar to most

operators. The following sections and Appendix B

provide guidance about measuring crewmember

fatigue. Interpreting crew fatigue data also requires

expertise. On some occasions, it may be

appropriate for the Fatigue Safety Action Group to

seek external scientific advice in this area. However,

it is also possible for an operator to develop in‐

house expertise in fatigue data collection and

analysis. This usually involves a ‘fatigue champion’

who is interested and motivated to develop skills as

required. The complexity of operations and the

level of fatigue risk need to be considered when

evaluating the need for, and level of, expert advice.  

4.4.1 Predictive hazard identification processes

In an FRMS, predictive hazard identification focuses

on establishing crew schedules and conditions that

consider factors known to affect sleep and fatigue

in order to minimise their potential future effects.

ICAO Annex 6, Part I, Appendix 8 lists three possible

ways of doing this: a) previous experience (of the

operator or others in the industry); b) evidence‐

based scheduling practices; and c) bio‐mathematical

models.

a) Previous experience

The collective experience of managers, schedulers,

and crewmembers is an important source of
FRM processes 4‐7

Unedited version

information for identifying aspects of a proposed

schedule that may be associated with increased

fatigue. For example, crewmembers may recognize

a particular destination within a proposed schedule

as generating a high level of fatigue because of their

past experience of regular delays there caused by

heavy traffic. Schedulers may know that a particular

city pairing regularly exceeds planned flying time.

Management may organize for crew to stay in

another hotel where noise is a known problem.

Various information sources should be used. For

existing operations, information about schedules

may already be available that could be analyzed to

check for potential fatigue hazards. Examples

include the use of captain’s discretion, on‐time

performance, violations of prescriptive flight and

duty time rules, standby usage, Aviation Safety

Reports (ASR’s), and level of fatigue reports.

When operational demands are changing, reliance

on previous experience can have some limitations.

Scheduling based only on previous experience may

not give the most robust or innovative solutions for

new situations. It may also be important to collect

data on actual levels of crew fatigue, to check

whether the lessons from previous experience are

still valid in the new context.  

Another way to identify fatigue hazards related to

scheduling, for existing or new routes, is to look for

information on similar routes. This could include

incident reports and crew fatigue reports, or

published scientific research and other information

available on similar routes flown by other

operators. The amount of confidence that can be

placed in this approach depends directly on how

similar these other operations really are to the

operation in which you are trying to identify fatigue

hazards (see the ULR example at the end of this

Chapter).  

b) Evidence‐based scheduling practices

The value of experience can be enhanced when

fatigue science is also applied in the building of

schedules. This means considering factors such as

the dynamics of sleep loss and recovery, the

circadian biological clock, and the impact of

workload on fatigue, along with operational

requirements. Since the effects of sleep loss and

fatigue are cumulative, evidence‐based scheduling

needs to address both individual trips (multiple,

successive duty periods without extended time off),

and successive trips across rosters or monthly bid‐

lines. The following are examples of general

scheduling principles based on fatigue science.  

• The perfect schedule for the human body is

daytime duties with unrestricted sleep at night.

Anything else is a compromise.

• The circadian body clock does not adapt fully

to altered schedules such as night work. It does

adapt progressively to a new time zone, but

full adaptation usually takes longer than the

24‐48 hours of most layovers.

• Whenever a duty period overlaps a

crewmember’s usual sleep time, it can be

expected to restrict sleep. Examples include

early duty start times, late duty end times, and

night work.

• The more that a duty period overlaps a

crewmember’s usual sleep time, the less sleep

the crewmember is likely to obtain. Working

right through the usual night time sleep period

is the worst case scenario.

• Night duty also requires working through the

time in the circadian body clock cycle when

self‐rated fatigue and mood are worst and

additional effort is required to maintain

alertness and performance.

• Across consecutive duties with restricted sleep,

crewmembers will accumulate a sleep debt

and fatigue‐related impairment will increase.  

• To recover from sleep debt, crewmembers

need a minimum of two full nights of sleep in a

row, when they are fully adapted to the local

time zone. The frequency of rest periods

should be related to the rate of accumulation

of sleep debt.  

These sorts of principles can be used by an expert

reviewer, for example by a scheduler trained in

fatigue hazard identification, or by the Fatigue

Safety Action Group, to develop evidence‐based

scheduling rules. The scientific basis for the

scheduling rules should be recorded in the FRMS

documentation. This approach can be validated, by
4‐8 FRM processes

Unedited version

monitoring the reported or estimated levels of

fatigue across the schedules, using the tools

described below and in Appendix B. Validation data

can be used, in turn, to refine and improve

evidence‐based scheduling rules for an operation.

c) Bio‐mathematical models

Bio‐mathematical models begin life as computer

programs used by scientists to test their current

understanding of how factors like sleep loss,

circadian rhythms, and workload interact to affect

human alertness and performance. The modeling

process begins by trying to write a program that can

simulate a ‘developmental data set’ – for example

self‐rated fatigue and performance measured

during a sleep loss experiment in the laboratory. If

this works, then the model is used to predict a

different situation. Data are then collected in this

new situation (a ‘validation data set’) and model

predictions are tested against the new data.  

Scientific modeling is a continuous improvement

process. As scientific tools, bio‐mathematical

models are accepted as being incomplete and

transient. In scientific best practice, scientists

continue designing new experiments to try to find

out where their models fail. In this way, they find

out where their current understanding is

incomplete or possibly wrong. (This is a much more

efficient way of increasing scientific knowledge than

just doing random experiments.)

A range of bio‐mathematical models have been

commercialized and are marketed as tools for

predicting fatigue hazards relating to scheduling.

There are also several models available in the public

domain. Used properly, these models can be helpful

tools in FRMS, because it is hard to visualize the

dynamic interactions of processes like sleep loss

and recovery, or the circadian biological clock. To

use models properly requires some understanding

of what they can and cannot predict. An important

question to ask about any model is whether it has

been validated against fatigue data from operations

similar to those that you are interested in.  

Currently available models:  

• predict group average fatigue levels, not the

fatigue levels of individual crewmembers;

• do not take into account the impact of

workload or personal and work‐related

stressors that may affect fatigue levels;

• cannot take into account the effects of

personal or operational mitigation strategies

that may or may not be used by crewmembers

(caffeine consumption, exercise, improved rest

facilities, etc.);   

• do not predict the safety risk that fatigued

crewmembers represent in a particular

operation, i.e., they are not a substitute for risk

assessment (Step 4 in FRM processes– see

below). Several available models try to predict

safety risk by merging safety data from a range

of operations in different industries, but their

applicability to flight operations has not yet

been validated.  

The most reliable use of currently available models

is probably for predicting relative fatigue levels – is

the fatigue hazard likely to be greater on this

schedule versus that schedule? However, model

predictions should not be used without reference to

operational experience, when making decisions

about schedule design. On the other hand, data

collected in the course of FRM processes could be a

rich resource for improving the performance of bio‐

mathematical models, if model designers follow a

continuous improvement philosophy.

Note that Appendix 8, Annex 6, Part I states that

methods for predictive fatigue hazard identification

may include but are not limited to: operator or

industry operational experience and data collected

on similar types of operations, evidence‐based

scheduling practices, and bio‐mathematical models.

In other words, none of these methods are

required, and other methods may be used.  
FRM processes 4‐9

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4.4.2 Proactive hazard identification processes

In an FRMS, proactive hazard identification

processes focus on monitoring fatigue levels in an

operation. Because fatigue‐related impairment

affects many skills and has multiple causes, there is

no single measurement that gives a total picture of

a crewmember’s current fatigue level. and multiple

sources of data are required.  

To decide on which types of data to collect, the

most important thing to consider is the expected

level of fatigue risk. In other words, it is not a good

use of limited resources to undertake intensive data

collection with multiple measures on a route where

the fatigue‐related risk is expected to be minimal.

Resources should be targeted towards operations

where the risk is expected to be higher.  

The importance of collaboration

Appendix 8, Annex 6, Part I, requires that an

operator’s FRMS Policy ‘reflect the shared

responsibility of management, flight and cabin

crews, and other involved personnel’. Regulators

will need to find evidence of this sharing of

responsibility.

The success of proactive processes (and of the

FRMS) depends on the willingness of crewmembers

to continue participating in data collection. This

makes it important to consider the demands placed

on crewmembers by different types of fatigue‐

related data collection (for example, measures such

as filling out a questionnaire once, keeping a

sleep/duty diary and wearing a simple device to

monitor sleep every day before during and after a

trip, doing multiple performance tests and fatigue

ratings across flights, etc).  

The willingness of crewmembers to participate will

also reflect their level of understanding of their

roles and responsibilities in FRMS, and their

confidence that the purpose of the data collection is

to improve safety. Gathering fatigue‐related data

may involve monitoring crewmembers both on duty

and off duty, because fatigue levels on duty are

affected by prior sleep patterns and by waking

activities outside of duty hours. There are ethical

considerations around issues such as the privacy of

crewmembers, confidentiality of data, and whether

crewmembers are really free to refuse to

participate (voluntary participation is a requirement

in scientific studies involving human participants).

Many countries have specific legislation around

privacy and workplace responsibilities for safety

that may need to be considered, in addition to

conditions specified in industrial agreements.

Appendix 8 lists five possible methods of proactive

fatigue hazard identification:  

a) self‐reporting of fatigue risks;

b) crew fatigue surveys;

c) relevant flight crew performance data;

d) available safety databases and scientific

studies; and

e) analysis of planned versus actual time worked.  

The following sections describe each of these

methods in some detail. It should be noted that

these are options  ‐ they are not all required all of

the time.

a) Self‐reporting of fatigue risks

Crewmembers’ reports about high fatigue levels or

fatigue‐related performance issues are vital to keep

the Fatigue Safety Action Group informed about

fatigue hazards in day‐to‐day operations. A series of

fatigue reports on a particular route can be a trigger

for further investigation by the Fatigue Safety

Action Group.

An effective fatigue reporting system requires an

effective reporting culture3

. It needs to:

• use forms that are easy to access, complete,

and submit;  

• have clearly understood rules about

confidentiality of reported information;

• have clearly understandable voluntary

reporting protection limits;

• include regular analysis of the reports; and  

                                                           

3 See ICAO Doc 9859 Safety Management Manual.
4‐10 FRM processes

Unedited version

• provide regular feedback to crewmembers

about decisions or actions taken based on the

reports, and lessons learned.  

A fatigue report form (either paper‐based or

electronic) should include information on recent

sleep and duty history (minimum last 3 days), time

of day of the event, and measures of different

aspects of fatigue‐related impairment (for example,

validated alertness or sleepiness scales). It should

also provide space for written commentary so that

the person reporting can explain the context of the

event and give their view of why it happened. An

example of a fatigue report form can be found in

Appendix B.

b) Crew fatigue surveys

Crew fatigue surveys are of two basic types:  

1. retrospective surveys that ask crewmembers

about their sleep and fatigue in the past. These

can be relatively long and are usually

completed only once, or at long time intervals

(for example, once a year); and  

2. prospective surveys that ask crewmembers

about their sleep and fatigue right now. These

are typically short and are often completed

multiple times to monitor fatigue across a duty

period, trip, or roster. They usually include

measures such as sleepiness, fatigue, and

mood ratings.

Appendix B describes some standard fatigue and

sleepiness measures (rating scales) that can be used

for retrospective surveys, and others that can be

used for prospective monitoring. These scales have

been validated and are widely used in aviation

operations. Using standard scales enables the

Fatigue Safety Action Group to compare fatigue

levels between operations (run by their own

operator or others), across time, and with data from

scientific studies. This can be helpful in making

decisions about where controls and mitigations are

most needed.  

Crew fatigue surveys can be focused on a particular

operation or issue. For example, a series of fatigue

reports about a particular trip might trigger the

Fatigue Safety Action Group to undertake a survey

of all crewmembers flying that trip (retrospective or

prospective), to see how widespread the problem

is. The Fatigue Safety Action Group might also

undertake a survey (retrospective or prospective) to

get crewmember feedback about the effects of a

schedule change.  

Surveys can also be more general, for example

providing an overview of fatigue across a particular

aircraft fleet or operation type. Figure 4.4 shows an

analysis of the effects of time of day and duty

length on fatigue ratings at top of descent (using

the Samn‐Perelli fatigue scale  ‐  see Appendix B).

These data come from the Air New Zealand FRMS

and include 3181 ratings made across a 3‐month

period, at the end of 1‐2 sector short haul duty days

that stayed in the crewmembers’ domicile time

zone (two‐person crews)4

. For short duty periods (2‐

4 hours) there is a clear time‐of‐day variation in

how fatigued crewmembers feel at the top of

descent, with highest average ratings between

03:00 and 06:00, and lowest average ratings

between 15:00 and 18:00. In contrast, at the end of

long duty periods (10‐12 hours), fatigue ratings

remain high from 00:00 to 09:00 and there is a

second peak in fatigue between 12:00‐15:00. These

ratings show an interaction between time‐on‐task

fatigue (duty duration) and the daily cycle of the

circadian body clock. In addition, crew members

who are at the end of a 10‐12 hour duty period

between 12:00 and 15:00 will have had their sleep

restricted by an early duty report time.

                                                           

4 Powell D, Spencer MB, Holland D, Petrie KJ (2008).

Fatigue in two‐pilot operations: implications for flight

and duty time limitations. Aviation, Space and

Environmental Medicine 79: 1047‐1050.
FRM processes 4‐11

Unedited version

Figure 4.4: Effects of time of day and duty length on

fatigue ratings at top of descent in short‐haul

operations across a 3‐month period

Compared to some other types of fatigue

monitoring, crew fatigue surveys can be conducted

relatively quickly and inexpensively to provide a

“snapshot” of subjective fatigue levels and their

potential causes. If a high proportion of

crewmembers participate in a survey (ideally more

than 70%), it gives a more representative picture of

the range of subjective fatigue levels and opinions

across the whole group. Since the information

gathered in surveys is subjective (crewmembers’

personal recall and views), getting a representative

picture can be important for guiding the decisions

and actions of the Fatigue Safety Action Group.  

c) Crew performance data

Performance measurements provide objective data

that can be used to supplement the subjective data

collected in fatigue reports and survey responses.

Currently, there are three main approaches to

monitoring crewmember performance: 1) simple

tests developed in the laboratory, which measure

aspects of an individual’s performance (for

example, reaction time, vigilance, short‐term

memory, etc.); 2) flight data analysis (FDA), which

examines the relationship between identified

elements of aircraft performance and pilot

performance; and 3) having trained flight deck

observers rating the performance of crewmembers

on the flight deck (for example, Line‐Oriented

Safety Audit).

For monitoring crewmember fatigue levels during

an operation, the first approach is currently the

most practical. A range of objective performance

tests are used in scientific research. Things to

consider when choosing a performance test for

measuring crewmember fatigue include the

following.

1. How long does the test last? Can it be

completed at multiple time points (for

example, in the operations room during pre‐

flight preparations, near top of climb, near top

of descent, and post‐flight before disembarking

from the aircraft), without compromising a

crewmember’s ability to meet duty

requirements?

2. Has it been validated?    For example, has it

been shown to be sensitive to the effects of

sleep loss and the circadian body clock cycle

under controlled experimental conditions?   

3. Is the test predictive of more complex tasks,

e.g., crew performance in a flight simulator?

(Unfortunately, there is very little research

addressing this question at present.)

4. Has it been used in other aviation operations,

and are the data available to compare fatigue

levels between operations?   

Appendix B describes a performance test that is

commonly used to measure crewmember fatigue –

the Psychomotor Vigilance Task or PVT5

.  

There is considerable interest in finding ways to link

crew member fatigue levels to FDA data particularly

during approach and landing. FDA data has the

advantages that it is routinely collected and is

relevant to flight safety. The difficulty is that a

multitude of factors contribute to deviations from

planned flight parameters. To use FDA data as an

indicator of crewmember fatigue would require

demonstrating consistent changes in FDA data that

are reliably linked to other indicators of

crewmember fatigue (for example sleep loss in the

last 24 hours, time in the circadian body clock cycle,

etc). Research in this area is ongoing.

Using trained flight deck observers to rate the

performance of crewmembers on the flight deck is

very labor‐intensive and expensive. Having the

observer present may also have an alerting effect

and place additional demands on crewmembers.

These factors currently limit the usefulness of this

approach for proactive fatigue hazard identification

in an FRMS.  

                                                           

5 Balkin TJ,  Bliese PD, Belenky G, Sing H, Thorne DR, Thomas M,

Redmond DP, Russo M, Wesensten NJ (2004). Comparative

utility of instruments for monitoring sleepiness‐related

performance decrements in the operational environment.

Journal of Sleep Research, 13: 219‐227.
4‐12 FRM processes

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d) Available safety databases and scientific studies

More general guidance about fatigue hazards may

be available from external safety databases, such as

Aviation Safety Reports (ASRs) and Mandatory

Occurrence Reports (MORs) maintained by safety

authorities, or databases maintained by airline

organizations or research institutions. Because

safety events are relatively rare, databases that

collect and analyse them are an important

additional source of information that complements

direct assessment of fatigue levels in the

operation(s) covered by the FRMS.  

A fairly large amount of scientific research has been

undertaken on crewmember fatigue in flight

operations. Some of this is available on the web, for

example many studies from the NASA Fatigue

Countermeasures Program can be downloaded free

from  

http://human‐

factors.arc.nasa.gov/zteam/fcp/FCP.pubs.html  

This type of research tends to be costly and labour‐

intensive and not all types of aviation operations

have been studied in depth. The particular value of

these studies is in their use of more rigorous

scientific approaches, which increases the reliability

of their findings. The level of detail in some studies

may be more than is needed for proactive

identification of fatigue hazards. However, most

reports and published papers have executive

summaries or abstracts that outline the key

findings.  

e) Analysis of planned versus actual time worked

The planning of schedules and rosters based on

fatigue science as well as operational requirements

permits predictive identification of fatigue hazards

(Section 4.4.1 above). However, numerous

unforeseen circumstances can cause changes to

planned schedules, for example weather conditions,

volcanic ash, unexpected technical problems, or

crewmember illness. Crewmember fatigue relates

to what is actually flown, not what is planned. Thus

another proactive approach for identifying fatigue

hazards is to analyze actual schedules and rosters

for factors such as on‐time performance,

exceedances of the flight and duty time limits

specified in the FRMS, and schedule manipulation

by individual crewmembers.

Monitoring crewmembers’ sleep

Given the primary importance of sleep loss and

recovery in the dynamics of crewmember fatigue,

another valuable and commonly used method for

proactive fatigue hazard identification is sleep

monitoring.  

Sleep can be monitored in a variety of ways, all of

which have advantages and disadvantages (for

details, see Appendix B).

• The simplest and cheapest method of

monitoring sleep is to have crewmembers

complete a daily sleep diary before, during,

and after the trip(s) being studied. They are

typically asked to record when they sleep, and

to rate the quality of their sleep, as soon as

possible after waking up. This can be done

using a paper diary or an electronic device such

as a Personal Data Assistant (PDA).  

• A more objective measure of sleep/wake

patterns can be obtained by continuously

monitoring movement, using an “actigraph”.

This is a wristwatch‐like device that is worn

continuously (except when showering or

bathing). Data on the amount of movement is

recorded regularly (typically every minute) and

is downloaded to a computer after several

weeks, for subsequent analysis. Because

actigraphs are not cheap (yet), usually only a

sample of crewmembers on a given trip would

have their sleep monitored in this way. Current

systems also require a trained person to

process and analyze the data.  

• In rare cases, where the expected fatigue risk is

high or uncertain (for example in new types of

operations), portable polysomnographic

recordings may be used to monitor sleep both

in‐flight and during layovers. This involves

applying electrodes to the scalp and face to

record electrical signals coming from the brain

(electroencephalogram or EEG), eye
FRM processes 4‐13

Unedited version

movements (electro‐oculogram or EOG) and

chin muscles (electromyogram or EMG).

Polysomnography is the “gold standard”

method for evaluating sleep quality and

quantity, but it is relatively invasive for

participants and expensive both in terms of

equipment and because it requires manual

scoring and analysis by a trained technician.

Selecting measures of crewmember fatigue  

Several options have just been described for

assessing crewmember fatigue levels in order to

identify fatigue hazards. Appendix 8 is clear that the

five methods it lists can be used – it does not say

that they must be used, or that other methods

cannot be used. The following general points are

intended to help regulators in determining whether

operators are using appropriate measures for the

appropriate purpose.

1. Fatigue‐related impairment affects many skills

and has multiple causes, so there is no single

measurement that gives a total picture of a

crewmember’s current fatigue level.

2. The most important thing to consider in choosing

fatigue measures is the expected level of fatigue

risk. All measures require resources (financial and

personnel) for data collection and analysis.

Limited resources need to be used effectively to

identify fatigue hazards and to help the Fatigue

Safety Action Group prioritize where controls and

mitigations are most needed.

3. A core set of measures can be selected for

routine monitoring. For example, crew fatigue

reports and regular analyses of scheduling and

rostering variations could be used for ongoing

monitoring of fatigue hazards.

4. An additional range of measures can be available

to be used if a potential hazard is indentified and

the Fatigue Safety Action Group decides that it

needs more information about that hazard.

Again, the measures selected need to reflect the

expected level of risk. For example:

• A series of complaints about a particular

layover hotel prompts a brief on‐line survey of

crewmembers using that hotel, to see how

widespread the problem is and whether it

merits action.

  

• A series of fatigue reports is received about a

tag flight on the end of a particular trip. This

prompts monitoring of the sleep, sleepiness,

and fatigue ratings of crewmembers flying that

trip, using sleep dairies and subjective rating

scales. Data collection continues for a month,

followed by data analysis, so that within 3

months the Flight Safety Action Group will

have the information it needs to reach a

decision and plan any necessary controls and

interventions (for example, having another

crew take the tag flight).

• An operator with limited long haul experience

gets the regulators’ agreement to begin

developing an FRMS in order to undertake ULR

operations on a specified city pair. As part of

gaining regulatory approval for the overall

FRMS, the operator is required to undertake

intensive monitoring of crewmember fatigue

during the first 4 months of the operation. This

includes monitoring sleep before, during, and

after the trip using actigraphs and sleep

diaries, as well as ratings of sleepiness and

fatigue and PVT performance tests pre‐flight,

within 30 minutes of top of climb, before each

in‐flight rest period, within 30 minutes of top

of descent, and post flight before leaving the

aircraft. The regulator requires a report on the

findings no later than 6 months after the

launch of the operation.

5. Balance needs to be maintained between

gathering enough data for the Fatigue Safety

Action Group to be confident about its decisions

and actions and the additional demands that data

collection can place on crewmembers.

4.4.3 Reactive Hazard Identification Processes

In an FRMS, reactive processes are designed to

identify the contribution of crewmember fatigue to

safety reports and events. The aim is to identify

how the effects of fatigue could have been

mitigated, and to reduce the likelihood of similar
4‐14 FRM processes

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occurrences in the future. Appendix 8 lists five

examples of triggers for reactive processes:  

a) fatigue reports;

b) confidential reports;

c) audit reports;  

d) incidents; and  

e) Flight Data Analysis (FDA) events (also known as

Flight Operations Quality Assurance or FOQA).  

Depending on the severity of the event, a fatigue

analysis could be undertaken by the Fatigue Safety

Action Group, the operator’s safety department, or

an external fatigue expert. The findings of any

fatigue investigation should be recorded as part of

the FRMS documentation.  

There is no simple test (such as a blood test) for

fatigue‐related impairment. To establish that

fatigue was a contributing factor in an event, it has

to be shown that;

1. the person or crew was probably in a fatigued

state;  

2. the person or crew took particular actions or

decisions that were causal in what went wrong;

and

3. those actions or decisions are consistent with the

type of behavior expected of a fatigued person or

crew.

To show that the person or crew were likely to be in

a fatigued state, ideally you would have information

about:

• how much sleep they need to feel fully rested;  

• how much sleep they had in the 24 hours before

the accident (acute sleep loss);  

• how much sleep they had in the 72 hours before

the accident (cumulative sleep debt);  

• how long they had been awake at the time of the

event (extended wakefulness);  

• whether their workload was unusually heavy or

light leading up to and during the event;  

• whether they were in a sleepy part of the

circadian body clock cycle at the time of the

event (early morning or mid‐afternoon, body

time); and

• when they last had the opportunity for full

recovery from sleep debt (at least two nights of

unrestricted sleep in a row, fully adapted to the

local time zone).  

This information generally has to be gathered after

the event, based on the recall of the people

involved, and should be confirmed where possible

by anyone with whom they spent time leading up to

the event. Where it is not possible to get this

information, the duty history can give an idea of

what opportunities the person or crew had for

sleep.  

There are no simple rules for interpreting this

information (how much acute sleep loss do you

need to be fatigue‐impaired? how much cumulative

sleep debt?). Transport Canada has proposed a

method for fatigue investigation that provides

useful guidance for answering these questions, and

for deciding if the crewmember’s actions or

decisions are consistent with the type of behavior

expected of a fatigued person or crew, although it

has not yet been validated in aviation operations.

This method is summarized in Appendix B.  

4.5 FRM Processes Step 4: Risk

assessment

Once a fatigue hazard has been identified, the level

of risk that it poses has to be assessed and a

decision made about whether or not that risk needs

to be mitigated. Fatigue risk assessment follows

SMS principles (combining risk probability and risk

severity). It evaluates the potential for injury,

equipment damage, or loss due to a fatigue hazard,

and provides recommendations about management

of that risk, as summarized in the following tables6

.

                                                           

6

  ICAO SMM (Doc 9859).
FRM processes 4‐15

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Fatigue Risk Probability

Meaning Value

Frequent Likely to occur many times (has occurred frequently) 5

Occasional Likely to occur sometimes (has occurred infrequently) 4

Remote Unlikely to occur, but possible (has occurred rarely) 3

Improbable Very unlikely to occur (not known to have occurred) 2

Extremely improbable Almost inconceivable that the event will occur 1

Table 4.2a: Defining Fatigue Risk Probability

Fatigue Risk Severity

Meaning Value

Catastrophic ‐ Multiple deaths

‐ Equipment destroyed

A

Hazardous ‐ A large reduction in safety margins, physical distress or a workload such

that crewmembers cannot be relied upon to perform their tasks accurately

or completely

‐ Serious injury

‐ Major equipment damage

B

Major ‐ A significant reduction in safety margins, a reduction in the ability of

crewmembers to cope with adverse operating conditions as a result of

increase in workload, or as a result of conditions impairing their efficiency

‐ Serious incident

‐ Injury to persons

C

Minor ‐ Nuisance

‐ Operating limitations

‐ Use of emergency procedures

‐ Minor incident

D

Negligible ‐ No significant consequences E

Table 4.2b: Defining Fatigue Risk Severity
4‐16 FRM processes

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Fatigue risk

Risk probability

Risk severity

Catastrophic

A

Hazardous

B

Major

C

Minor

D

Negligible

E

Frequent 5 5A 5B 5C 5D 5E

Occasional 4 4A 4B 4C 4D 4E

Remote 3 3A 3B 3C 3D 3E

Improbable 2 2A 2B 2C 2D 2E

Extremely 1

Improbable

1A 1B 1C 1D 1E

Table 4.2c: Fatigue Risk Assessment Matrix

Suggested Criteria Assessment Risk Index Suggested Criteria

Intolerable

Region

5A, 5B, 5C

4A, 4B, 3A Unacceptable under the existing circumstances

Tolerable

Region

5D, 5E, 4C, 4D

4E, 3B, 3C, 3D

2A, 2B, 2C

Acceptable based on risk mitigation. May

require management decision

Acceptable

Region

3E, 2D, 2E, 1A

1B, 1C, 1D, 1E Acceptable

Table 4.2d: ICAO Risk Tolerability Matrix

However, it should be noted that these tables are

provided as general examples only. In reality, each

operator must develop their own criteria for levels

of severity and probability. There are no right and

wrong criteria, but whatever criteria are identified,

they must be agreed upon and widely understood

by the people who will then use them to make risk

assessments. Depending on an operator’s safety

management structure, the Fatigue Safety Action

Group may identify the severity and probability

criteria, and then use these to assess the fatigue‐

related risks and the need for mitigation in an

FRMS.  

4.6 FRM Processes Step 5: Risk

mitigation

When it is decided that a particular fatigue hazard

requires action, then controls and mitigations must

be identified and implemented. The specific

expertise of the Fatigue Safety Action Group should

be used in the selection of these controls and

mitigations. All involved personnel should clearly

understand the hazard and the controls and

mitigations designed to reduce the associated risk.  

Table 4.3 provides some examples of

organizational‐level mitigations for managing

fatigue hazards. These are examples only, not

exhaustive lists.
FRM processes 

Unedited version

Fatigue Hazard Controls Mitigation

Back‐to‐back night flights Scheduling rules do not permit back to‐back

night flights.

Software is programmed to prohibit sch

night flights.

Reserve crew available to cover excepti

Lack of ULR crew in departure city base All flights scheduled >12 hours require

evaluation of staffing levels at crew base in

departure city.

Established crew staffing policies to support

operation and

monitor staffing levels to ensure that policy

requirements are being met.

Relocate additional crewmembers to de

Ensure that sufficient reserve crew are 

flight schedules

Lack of ULR crew in en‐route divert base Establish reserve crew staffing at en‐route base

to support diversions

Reserve crew call‐out

Reports of inadvertent crew napping on

the flight deck

Scheduling rules, trip construction, rostering ,

crew augmentation policies to enable in‐flight

rest, improved onboard crew rest facilities

Scheduling changes to improve layover 

Flight Operations Manual procedure fo

napping developed.

Crewmembers not getting enough sleep

in onboard rest facilities

Pay attention to design of crew rest facilities

when ordering aircraft. Retro‐fit problemaircraft.Flight ops manual contains rules for organizing

in‐flight rest

Provide crewmembers with education o

flight sleep

Captain’s discretion on the day allowed 

rest.

Interrupted sleep periods in crew hotels Scheduling rules, trip construction, rostering. Internal procedures to restrict crew con

Hotels required to provide segregated c

minimizing noise

Landings at a confluence of circadian low,

extended work period, and high work

demands.

Scheduling rules, trip construction, rostering. Protocols for in‐flight rest and controlle

Table 4.3: Examples of Fatigue Hazards and Operator Controls

and Mitigations (not an exhaustive list)
4‐18 FRM processes

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The effectiveness of implemented mitigations must

be assessed, which requires setting safety

performance indicators such as the following.

Schedule‐related indicators:

• Number of flight deviations (or flight completion

not accomplished) on specific city pairings, due to

fatigue, lack of staff, medical emergencies, etc.

• Number of bids for pairings identified as high

fatigue risk (e.g. back‐to‐back night flights).

• Number of crew duty day exceedances into

allowable excesses (as determined through risk

assessment. For example, longer than 14 hours.)  

• Number of flight duty periods determined to be

“significantly” later than scheduled*. .

• Number of flight duty periods longer than a

specified number of hours without a rest break

within the duty.

• Number of flight times more than a specified

number of minutes longer than planned (e.g., 30 or

60 minutes).  

• Number of flight duty periods starting within

window of circadian low (WOCL).

• Number of landings within the WOCL.

• Number of duty periods with more than a specified

number of flight sectors.

• Number of duty periods with more than a specified

number of aircraft changes.

• Number of successive early wakeups, especially

combined with long “sits” between flights or long

duty days.

• Number of reduced rest breaks within duties (by

more than a specified number of minutes

determined to be “significant”)*.  

• Number of reduced rest breaks between duties (by

more than a specified number of minutes

determined to be “significant”)*.  

• Number of reserve crew call‐outs (on particular

flights, at a particular crew base, etc).  

* This indicator is a specific requirement of an FRMS,

(Section 1.2 f), Appendix 8, Annex 6, Part I), and is

discussed in Chapter 3.

  

Proactive/reactive fatigue indicators

• Measured data outside acceptable thresholds (e.g.,

sleepiness ratings, PVT scores, or inadequate

layover sleep duration).

• Numbers of fatigue reports (sorted in many ways

such as by crew base, seat, augmented flights, fleet

types, operational types, etc).

• Number of fatigue‐related incidents.

• Number of fatigue‐related FOQA events associated

with a particular schedule for which fatigue reports

have been received.

• Absenteeism/fatigue calls.

The implications of such safety performance

indicators should be considered within the context of

the entire operation, to distinguish between

acceptable and unacceptable risk.   

If the controls and mitigations perform to an

acceptable standard (i.e., they bring the risk into the

tolerable region – see Table 4.2d), they become part

of normal operations and are monitored by the FRMS

safety assurance processes. If the controls and

mitigations do not perform to an acceptable

standard, then it will be necessary to re‐enter the

FRM processes at the appropriate step. As indicated

in Figure 4.2, this could require:    gathering of

additional information and data; and/or re‐evaluation

of the fatigue hazard and the associated risks; and/or

identification, implementation, and evaluation of

new or revised controls and mitigations.

4.7 Example: Setting up FRM processes

for a new ULR route

In 2005, recommended guidelines for ULR operations

were developed by a Flight Safety Foundation

consortium group– the Ultra Long Range Crew

Alertness Steering Committee. This group identified

ULR operations as scheduled operations that exceed

16 hours. This 16‐hour distinction for ULR operations

has since become broadly accepted.  

This example works through FRMS processes that

could be used for establishing a new ULR operation. It

is developed from an actual safety case for a new ULR

route that received regulatory approval, but it is an
FRM processes 4‐19

Unedited version

example not a recipe. The accepted approach for ULR

operations is to evaluate each city pair to be flown7

.

Figure 4.5 summarizes the FRM processes, which are

explained in more detail in the text.  

4.7.1 Step 1 – Identify the operation

The operation to which these FRM processes apply is

a new ULR route between City A and City B

(described here as the A‐B‐A route).

4.7.2 Step 2 – Gather data and information  

Information and data are potentially available from

two types of existing operations: long‐haul

operations that are similar but have flight times

under 16 hours; and ULR operations already being

flown by other operators. The relevance of the

available information depends on how closely the

existing operations resemble the proposed new ULR

operation. The following factors need to be

considered.

• Crew complement and facilities for in‐flight rest.

• Crew domicile (if crewmembers are domiciled in

the departure city and they have had sufficient

time off since their last trans‐meridian flight, it can

be assumed that their circadian body clocks are

adapted to domicile time).

• Departure time of the outbound flight (local time

and likely body clock time).

• Outbound flight duration and time zones crossed.

• Arrival time of the outbound flight (local time and

likely body clock time).

• Duration of the layover.

• Departure time of the return flight (local time and

likely body clock time).

• Return flight duration and time zones crossed.

                                                           

7 Flight Safety Foundation (2005). Flight Safety Digest

26.

• Arrival time of the return flight (local time and

likely body clock time).

• Depending on the actual city pairs being served, it

may also be relevant to compare winter and

summer schedules for take‐off and landing times

and flight durations.  

In this case, another operator has been flying a ULR

trip between City C and City D. This existing operation

has the same crew complement and similar

departure times, flight durations, layover durations,

and patterns of time zone crossings as the A‐B‐A

route. As part of the regulatory approval process for

the C‐D‐C route, the operator was required to

conduct a 6‐month operational validation, which

included intensive monitoring of crewmember sleep

and fatigue. The operator generously makes these

findings available for use in the A‐B‐A safety case,

through an independent scientific team who were

involved in the C‐D‐C data collection and analysis.

(The expertise of the scientific team ensures that the

findings are interpreted and applied to the A‐B‐A

route in an appropriate manner.)
4‐20 FRM processes

Unedited version

Figure 4.5: FRM processes in setting up a new ULR route

1. New ULR route City A‐City B‐City A   

2.

Route is very similar to an existing ULR route flown

by another operator (City C‐City D‐City C) who

collected and analysed data.    The other operator

agrees to share information.

3.

Proactive: bio‐mathematical model predictions are

tested against the data from City C‐City D‐City C.

Most reliable model is used to predict fatigue levels

on City A‐City B‐City A route.  

Proactive: existing fatigue surveillance methods plus

enhanced monitoring during the first 4 months of the

City A‐City B‐City A route.

Reactive: systems are in place for analysis of fatigue

contribution to any safety events.

4.

Bio‐mathematical model simulations predict that,

with two crews and in‐flight sleep, fatigue risk is less

than on some existing long haul routes.

City C‐City D‐City C ULR has flown daily for 4 years

without fatigue‐related incident.

5.

Multiple controls and mitigation strategies

implemented (see text).

Data collection during first 4 months of operation to

check bio‐mathematical model predictions of fatigue

levels.

Performance indicator – by 4th month of operation,

no more fatigue reports per month than existing long

haul routes.

6.

Intensive fatigue monitoring during first 4 months of

operation. Revert to routine monitoring if

performance indicators are acceptable.

FRM ASSURANCE PROCESSES

FRM PROCESSES

Not

Effective Effective

1. Identify operation(s) to

which FRM processes apply

2. Gather and analyze data

3. Identify hazards

4. Assess safety risk

5a. Select and implement

controls and mitigations

5b. Set safety performance

indicators

6. Monitor effectiveness of

mitigations
FRM processes 4‐21

Unedited version

4.7.3 Step 3 – Identify hazards

Predictive processes

The operator already has experience with several

long haul routes using the same aircraft and crew

complement and with similar departure times and

time zone crossings to the A‐B‐A route, but that

remain under the 16‐hour flight time limit that is

used to define ULR. This experience has guided

development of the operational plan for the A‐B‐A

ULR route.

Two bio‐mathematical models are available that can

be used to predict the likely levels of crewmember

fatigue or alertness on the A‐B‐A route. The data

collected on the C‐D‐C route are used to test how

well these models can predict the sleep and fatigue

of crewmembers before, during, and after ULR

operations.  

One model makes the following predictions for the C‐

D‐C route:  that crewmember fatigue levels increase

significantly across both the outbound and return

flights; that layover sleep is too short to enable

recovery before the return flight; and that fatigue

levels are potentially unsafe by the end of both

flights. These predictions are directly contradicted by

PVT performance data and subjective sleepiness and

fatigue ratings collected during the first 6 months of

the C‐D‐C operation, which has flown daily without

major incident for four years. The operational data

and experience are considered more reliable than

these bio‐mathematical model predictions.  

On the other hand, the second model reliably

predicts the duration of in‐flight sleep on the C‐D‐C

route (to within the range of variability seen among

the crewmembers monitored). This model is chosen

to predict crewmember alertness on the A‐B‐A route.  

Proactive processes

The following proactive processes for identifying

fatigue hazards are proposed for intensive monitoring

during the first 4 months of the new operation, to

validate the predictions about fatigue levels and fine

tune the mitigation strategies, as needed.  

• Crewmembers are reminded about and

encouraged to use existing fatigue reporting forms.  

• For the first month of the operation, a senior flight

crewmember will be present in the Flight

Operations Centre for the first and last few hours

of every flight on the A‐B‐A route, to ensure rapid

and appropriate management response to any

fatigue‐related issues arising.

• For the first month of the A‐B‐A operation, a subset

of crewmember volunteers is asked to complete a

sleep and duty diary (with fatigue and sleepiness

ratings) before, during, and after an A‐B‐A trip.

These data will be compared with the same

measures collected during the C‐D‐C operational

validation.  

Other proactive fatigue monitoring processes that

could be used include:

• Asking all crewmembers to complete fatigue and

sleepiness ratings at the top of descent on each

flight, for the first month of the A‐B‐A operation.  

• Surveying all crewmembers after the A‐B‐A

operation has been flown for 3 months, to obtain

an overview of their experience of fatigue and the

effectiveness of different mitigation strategies

(scheduling, in‐flight rest facilities, layover hotels,

etc).  

• Having a subset of crewmember volunteers who

wear actiwatches and complete sleep diaries

before, during, and after a complete trip on the A‐

B‐A route. In addition they would complete fatigue

and sleepiness scales and undertake PVT

performance tests at key times across each flight.

These data would be compared with the same

measures from the C‐D‐C operational validation.

Reactive processes

The operator has systems in place for analyzing the

contribution of fatigue to safety reports and events,

and for determining how to reduce the likelihood of

similar events occurring in future. Special attention

will be paid to ensuring that any fatigue reports or

incidents from the A‐B‐A operation are analyzed

quickly and appropriate action taken.  

   
4‐22 FRM processes

Unedited version

4.7.4 Step 4 – Assess safety risk

The bio‐mathematical model used to predict

crewmember alertness on the A‐B‐A route has

previously been used to predict alertness on a range

of 2‐person and 3‐person long haul routes. These

predictions indicate that minimum alertness levels on

the A‐B‐A route are likely to be higher than on some

existing long haul routes, notably 3‐person westward

return night flights with duty periods of about 14

hours, and long overnight flights with 2‐person crews.

Two sets of operational experience support the

prediction that the A‐B‐A route does not pose

excessive fatigue hazards: 1) the safety record of the

C‐D‐C operation which has flown daily for four years;

and 2) the A‐B‐A operator’s experience with similar

long haul routes using the same aircraft and crew

complement, but remaining under the 16‐hour flight

time limit.

4.7.5 Step 5 – Select and implement controls and

mitigations  

In this example, the following controls and mitigation

strategies are proposed for the A‐B‐A operation.  

• The aircraft chosen for the route has the best

available on‐board crew rest facilities.  

• All crewmembers flying the new operation are

domiciled in the departure city.  

• All crewmembers flying the new operation receive

specific education on personal and organizational

strategies for managing fatigue on the A‐B‐A

operation. This includes discussion on how to make

best use of in‐flight and layover sleep

opportunities.

• All crewmembers have protected time off duty to

enable two full nights of sleep in the departure city

time zone, so that they have the opportunity to

begin the A‐B‐A operation fully rested.

• There is a clear policy defining on‐call

arrangements and the provisioning of relief crew.  

• The flight crew includes 2 captains and 2 first

officers, so that a single captain does not have sole

command responsibility for entire ULR flights. This

is in accordance with the Flight Safety Foundation

ULR recommendations.

• There is a clear policy on the distribution of in‐

flight rest opportunities, so that crewmembers can

plan how best to use them.  

• Each crewmember has two rest opportunities per

flight, to ensure that they have at least some rest

time overlapping their normal sleep time and that

they have a second opportunity to get some sleep

if, for any reason, they are unable to sleep during

their first in‐flight rest period.  

• Meals may be taken by the flight crew on the flight

deck, in order to maximize the amount of time for

sleep during in‐flight rest periods.

• The layover hotel has been carefully vetted to

ensure that it provides adequate facilities for sleep,

eating, and exercise.

• A procedure is implemented between Flight

Operations and the layover hotel to provide

notification of delays without having to wake

crewmembers.  

• There are clear procedures on the management of

flight delays.

• There are clear procedures on the management of

flight diversions.

The following safety performance indicators are

identified:

• Data collected during the first 4 months of the A‐B‐

A operation will be compared with model

predictions and with the same measures from the

C‐D‐C validation, to establish whether

crewmember fatigue and alertness levels are in the

range predicted.

• By the fourth month of the A‐B‐A operation, the

fatigue reporting rate (reports/flight segment) and

average fatigue report risk level should be

comparable to existing long haul routes. No

‘’intolerable” fatigue reports should be received

(see Table 4.2.d).  

4.7.6 Step 6 – Monitor effectiveness of controls

and mitigations  

There is a defined validation period for the first four

months of the operation that involves more intensive

monitoring. The Fatigue Safety Action Group will have

regular oversight of all data and fatigue reports

coming in and will act in a timely manner when issues

arise.
FRM processes 4‐23

Unedited version

At the end of the validation period, a report will be

compiled and routine processes will be defined for

fatigue risk monitoring and management on the A‐B‐

A route. This report will be available to all interested

parties. If the performance indicators are acceptable,

the A‐B‐A operation will revert to routine monitoring.  

4.7.7 Linking to FRMS safety assurance processes

Normally, the FRM processes do not operate in

isolation from the FRMS safety assurance processes

(described in detail in the next Chapter). However,

when setting up FRMS in an organization, or for a

new type of operation, the data needed for FRMS

safety assurance processes are not available before

the operation(s) begin flying. This means that it is

necessary to have a staged approach to FRMS

implementation, which is described in Chapter 7.
Chapter 5. FRMS safety assurance processes 5‐1

Unedited version

Chapter 5: FRMS safety assurance processes

5.1  Introduction to FRMS safety

assurance processes

The FRM processes described in Chapter 4 are the

part of the day‐to‐day FRMS operations that focuses

on identifying fatigue hazards, assessing safety risks,

putting in place controls and mitigation strategies,

and monitoring their effectiveness.  

This Chapter works through the basic steps in FRMS

safety assurance processes, which form another layer

in an operator’s defenses against fatigue‐related risk.

FRMS safety assurance processes are also part of the

routine operation of the FRMS, and they monitor

how well the entire FRMS is functioning. They:

• check that the FRMS is functioning as intended;

• check that it is meeting the safety objectives

defined in the FRMS policy;

• check that it is meeting regulatory requirements;

• identify where changes in the operating

environment have the potential to increase fatigue

risk; and  

• identify areas for improvement in the management

of fatigue risk (continuous improvement of the

FRMS).  

• To do this, FRMS safety assurance processes use a

variety of data and information as safety

performance indicators that can be measured and

monitored over time.    Having a variety of safety

performance indicators, plus a safety target for

each, is expected to give better insight into the

overall performance of the FRMS than having a

single measure.    Safety performance targets must

fall in the tolerable region defined in the risk

assessment process (see Section 4.5), and they

may need to be revised as operational

circumstances change.

Figure 5.1 outlines the linkages between the FRMS

safety assurance processes and other components of

the FRMS. The information, data, and safety

performance indicators from the FRM processes

provide a source of information for the FRMS safety

assurance processes. In addition, the FRMS safety

assurance processes:

• use information and expertise from other sources,

both from within the operator’s organization and

external to it, to evaluate the functioning of the

FRMS;  

• evaluate trends in safety performance indicators to

identify emerging or changed hazards and refer

these back to the FRM processes;  

• identify changes in the operating environment that

could affect fatigue risk and refer these back to the

FRM processes; and  

• provide input about ways to improve the operation

of the FRMS.  

Figure5.1:  Linkages between FRMS assurance processes and other FRMS components
5‐2 FRMS safety assurance processes

Unedited version

Some of the FRMS safety assurance processes can be

undertaken by the Fatigue Safety Action Group, while

others (for example audits of the FRMS) would

normally be undertaken by other units within the

operator’s organization. The responsibility for

different FRMS safety assurance activities may be

distributed differently, depending on the size of the

organization. For example, larger operators may have

a separate FRMS safety assurance team and/or a

designated FRMS safety assurance manager.

Communication (in both directions) between the

FRMS safety assurance processes and the SMS is

necessary, since the safety performance of the FRMS

will impact on the overall safety performance of the

operator.

The ICAO requirements for FRMS safety assurance

processes are as follows.

Figure 5.2 summarizes the steps in FRMS safety

assurance processes. Each step is described in more

detail below.

Appendix 8:

3. FRMS Safety Assurance Processes

3.1  The operator shall develop and maintain FRMS safety assurance processes to:

a) provide for continuous FRMS performance monitoring, analysis of trends, and measurement to validate the

effectiveness of the fatigue safety risk controls. The sources of data may include, but are not limited to:

1)  hazard reporting and investigations;

2)  audits and surveys; and

3)  reviews and fatigue studies;

b) provide a formal process for the management of change which shall include but is not limited to:

1)  identification of changes in the operational environment that may affect FRMS;

2)  identification of changes within the organization that may affect FRMS; and

3)  consideration of available tools which could be used to maintain or improve FRMS performance prior to

implementing changes; and

c)  provide for the continuous improvement of the FRMS. This shall include but is not limited to:

1) the elimination and/or modification of risk controls have had unintended consequences or that are no

longer needed due to changes in the operational or organizational environment;

2)routine evaluations of facilities, equipment, documentation and procedures; and

3) the determination of the need to introduce new processes and procedures to mitigate emerging fatigue‐

related risks.
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5‐4 FRMS safety assurance processes

Unedited version

5.2  FRMS safety assurance processes

    Step 1: Collect and Review Data

Step 1 involves bringing together and reviewing

information gained through the FRM processes to

examine the overall performance of the FRMS.  

Performance of the FRMS should be examined

through indentifying a variety of safety performance

indicators.  These should include those specific to the

FRMS as well as SMS safety performance indicators.  

Examples of safety performance indicators specific to

an FRMS will include measures obtained through the

FRM processes, such as:   

• The number of exceeded maximum duty days in

operations covered by the FRMS;

• The number of voluntary fatigue reports per

month;

• The average “fatigue call” rate by flight crews on a

specific pairing (trip);

• The ratio of fatigue reports from ULR operations

covered by the FRMS to fatigue reports from the

long haul operations covered by the prescriptive

flight and duty time regulations.

• Attendance at FRMS training sessions;  

• Results on FRMS training assessments;

• The level of crew member participation in fatigue‐

related data collection;

• The number times fatigue is identified as an

organizational factor contributing to an event.

ICAO Annex 6, Part I, Appendix 8 indicates that

identification of safety performance indicators may

result through examination of:

1. hazard reporting and investigations;

2. audits and surveys; and

3. reviews and fatigue studies.

1. Hazard reporting and investigations

Trends in voluntary fatigue reports by crewmembers

and others can provide valuable insights into the

effectiveness of the FRMS. Safety events in which

crewmember fatigue has been identified as a

contributing factor will be less common than fatigue

reports. However, regular review of these events may

also highlight areas where functioning of the FRMS

could be improved. The value of both these sources

of information depends on using appropriate

methods for analyzing for the role of fatigue (see

Chapter 4 and Appendix B).

2. Audits and surveys

Audits and surveys can provide measures of the

effectiveness of the FRMS without having to rely on

fatigue levels being high enough to trigger fatigue

reports or fatigue‐related safety events (both of

which are relatively rare events).

Audits focus on the integrity of, and adherence to,

the FRM processes. These audits should answer

questions such as:

• are all departments implementing the

recommendations of the Fatigue Safety Action

Group?  

• are crewmembers using mitigation strategies as

recommended by the Fatigue Safety Action group?  

• is the Fatigue Safety Action Group maintaining the

required documentation of its activities?  

Audits can also periodically assess the effectiveness

of the FRMS, for example by looking at the status of

FRMS safety performance indicators and targets.  

Audits are external to the Fatigue Safety Action

Group, but may still be internal to the operator, i.e.,

conducted by other units within the organization. In

addition, feedback from regulatory audits can provide

useful information for FRMS safety performance

monitoring. Another type of audit that can be used in

this context is to have an independent scientific

review panel that periodically reviews the activities of

the Fatigue Safety Action Group, and the scientific

integrity of their decisions. A scientific review panel

can also provide the Fatigue Safety Action Group with

periodic updates on new scientific developments

relevant to the FRMS.

Surveys can provide information on the effectiveness

of the FRMS. For example they can document how

schedules and rosters are affecting crewmembers,

either by asking about their recent experiences
FRMS safety assurance processes 5‐5

Unedited version

(retrospective) or tracking them across time

(prospective). Surveys for this purpose should include

validated measures, such as standard rating scales for

fatigue and sleepiness, and standard measures of

sleep timing and quality (see Chapter 4 and Appendix

B).   A high response rate (ideally more than 70%) is

needed for survey results to be considered

representative of the entire group, and response

rates tend to decline when people are surveyed too

frequently (‘participant fatigue’).

3. Reviews and fatigue studies

In general, safety reviews are used to ensure that

safety performance is adequate during times of

change, for example during the introduction of a new

type of operation or a significant change to an

existing operation covered by the FRMS.  

A review would start by identifying the change (for

example, moving a trip to a crew base in a different

time zone, changes in on‐board crew rest facilities,

significant changes in the total trip, a change of

equipment being used for the trip, etc). It would then

evaluate the appropriateness and effectiveness of the

FRMS activities relating to the change (for example,

proposed methods for fatigue hazard identification,

the risk assessment process, proposed controls and

mitigations to address the fatigue hazard(s), and

measures of their effectiveness to be used during the

implementation of the change).

Fatigue studies as part of FRMS safety assurance

processes are undertaken when an operator is

concerned about a broad fatigue‐related issue for

which it is appropriate to look at external sources of

information. These could include the experience of

other operators, industry‐wide or State‐wide studies,

and scientific studies. These sources of information

can contribute in situations when safety arguments

based on the limited experience and knowledge

within that operator may not be enough. Fatigue

studies in this context are mainly used for gathering

information about large‐scale issues in FRMS, rather

than for identifying specific fatigue hazards.

5.3  FRMS safety assurance processes

    Step 2: Evaluate FRMS

Performance

The aim of Step 2 is to validate the effectiveness of

the fatigue controls and mitigations (ICAO Annex 6,

Part I, Appendix 8).    It involves analyzing the

information gathered in Step 1 to check whether:

• all specified FRMS safety performance targets are

being met;  

• all specified FRMS safety performance indicators

remain in the tolerable region defined in the risk

assessment process (see Section 4.5);  

• the FRMS is meeting the safety objectives defined

in the FRMS policy; and

• the FRMS is meeting all regulatory requirements.

The following are examples of safety performance

targets that could be used in FRMS safety assurance

processes and that correspond with the safety

performance indicators identified above (for

additional examples see Section 5.8 below).

• The length of the maximum duty days in

operations covered by the FRMS does not exceed

the limits defined in the FRMS policy. This is

reviewed monthly by a computer algorithm and

trends across time are evaluated every 3 months.

• By the fourth month after the introduction of a

new operation, there should be a stable low

number of voluntary fatigue reports per month, or

a clear downward trend in the number per month

(allowing time for crewmembers and other

affected personnel to adjust to the new operation).

The Fatigue Safety Action Group should provide a

written report on the validation phase of the new

operation, including analysis of all fatigue‐related

events and voluntary fatigue reports, and

documentation of the corresponding adjustments

made in fatigue controls and mitigations.  

• No specific pairing (trip) exceeds the average

fatigue call rate by flight crews by more than 25%.

• ULR operations covered by the FRMS do not attract

any more fatigue reports than the long haul

operations covered by the prescriptive flight and

duty time regulations.
5‐6 FRMS safety assurance processes

Unedited version

• In the last quarter, the Fatigue Safety Action Group

has met as often as is required in the FRMS policy

and has maintained all the documentation of its

activities that is required for internal and

regulatory auditing.

   

• All personnel responsible for schedule design and

rostering have met annual FRMS training

requirements as specified in the FRMS promotion

processes.  

• Measures of the effectiveness of FRM training and

education programs (see Chapter 6 for examples).  

• Quarterly levels of absenteeism are below the

target specified for each operation covered by the

FRMS.

When FRMS safety performance targets are not met

or when safety performance indicators are not at an

acceptable level, the controls and mitigations in use

may need to be modified by re‐entering the FRM

processes at Step 2 or beyond (see Figure 4.2).  

Regulators should require that operators notify them

when values for specific safety performance

indicators reach particular values.  The regulator can

then assess how the operator intends to address this

problem and monitor their progress.

For the operator, it may be appropriate to seek

additional information from outside the organization

(for example, by looking at fatigue studies). It may be

necessary to undertake a review of compliance of

crewmembers and other departments with the

recommendations of the Fatigue Safety Action

Group. It may also sometimes be necessary to review

the functioning of the Fatigue Safety Action Group

itself, to find out why the FRMS is not working as

intended.

Figure 5.3 tracks a measure of the effectiveness of

the Air New Zealand FRMS across time1

.    It shows

that the percentage of pilots reporting duty‐related

fatigue occurring at least once a week has declined

across a series of surveys conducted between 1993

and 2006.

                                                           

1 Figure 5.3 is used by kind permission of Dr David Powell.

Figure 5.3: Declining reports of crewmember fatigue

across successive Air New Zealand surveys

5.4  FRMS safety assurance processes

    Step 3: Identify emerging hazards

Analysis of trends in safety performance indicators

may indicate the emergence of fatigue hazards that

have not previously been recognized through the

FRM processes. For example, changes in one part of

the organization may increase workload and fatigue‐

related risk in another part of the organization.

Identifying emerging fatigue risks is an important

function of FRMS safety performance processes,

which take a broader system perspective than FRM

processes. Any newly identified fatigue risk, or

combination of existing risks for which current

controls are ineffective, should be referred back to

the Fatigue Safety Action Group for evaluation and

management using FRM processes (risk assessment,

design and implementation of effective controls and

mitigations).

5.5  FRMS safety assurance processes

    Step 4: Identify changes affecting

FRMS

In our dynamic aviation environment changes are a

normal part of flight operations. They may be driven

by external factors (for example, new regulatory

requirements, changing security requirements, or
FRMS safety assurance processes 5‐7

Unedited version

changes to air traffic control) or by internal factors

(for example, management changes, new routes,

aircraft, equipment, or procedures).    Changes can

introduce new fatigue hazards into an operation,

which need to be managed. Changes may also reduce

the effectiveness of controls and mitigations that

have been implemented to manage existing fatigue

hazards.    Step 4 of the FRMS safety assurance

processes aims to identify when new hazards may be

a result of change.

ICAO Annex 6, Part I, Appendix 8 requires that an

operator has FRMS safety assurance processes that

provide a formal methodology for the management

of change. These must include (but are not limited

to):

1. identification of changes in the operational

environment that may affect FRMS;

2. identification of changes within the organization

that may affect FRMS; and

3. consideration of available tools which could be

used to maintain or improve FRMS performance

prior to implementing changes.

A change management process is a documented

strategy to proactively identify and manage the

safety risks that can accompany significant change in

an airline1

. When a change is planned, the following

steps can be followed.

Use the FRM processes to identify fatigue hazards,

assess the associated risk, and propose controls and

mitigations.  

Obtain appropriate management and/or regulatory

sign‐off that the level of residual risk is acceptable.  

During the period of implementation of the change,

use the FRMS safety assurance processes to provide

periodic feedback to line managers that the FRMS is

functioning as intended in the new conditions. An

example would be having a validation period for a

new ULR route, during which additional monitoring of

crewmember fatigue is undertaken, together with

more frequent assessment of FRMS safety

performance targets and indicators. Documentation

of the change management strategy in relation to

fatigue management is also the responsibility of the

Fatigue Safety Action Group.

Changes in the operational environment may also

necessitate changes in the FRMS itself.    Examples

include bringing new operations under the scope of

the FRMS, collecting different types of data,

adjustments to training programs, etc. The Fatigue

Safety Action Group should propose such changes

and obtain approval for them from appropriate

management.  

5.6  FRMS safety assurance processes

    Step 5: Improve effectiveness of

FRMS

Ongoing evaluation by the FRMS safety assurance

processes not only enables the FRMS to be adapted

to meet changing operational needs, it also allows

the FRMS to continuously improve the management

of fatigue risk.    In doing so, risk controls that have

unintended consequences or that are no longer

needed due to changes in the operational or

organizational environment can be identified, then

modified or eliminated through the FRM processes.  

Examples include:

1. routine evaluations of facilities, equipment,

documentation and procedures; and

2. the determination of the need to introduce new

processes and procedures to mitigate emerging

fatigue‐related risks.

It is important that changes made to the FRMS are

documented by the Fatigue Safety Action Group so

that they are available for internal and regulatory

audit.

5.7  Assigning responsibility for FRMS

safety assurance processes

To deliver effective oversight of the functioning of the

FRMS, and to examine its functioning in relation to

the SMS, the FRMS safety assurance processes need

to operate in close communication with the Fatigue

Safety Action Group, but with a degree of

independence from it.  The aim is to avoid the Fatigue
5‐8 FRMS safety assurance processes

Unedited version

Safety Action Group reviewing its own performance.  

Figure 5.4 describes an example of how responsibility

for the FRMS safety assurance processes might be

assigned in a large organization.

In this example, the Fatigue Safety Action Group is

accountable to the Safety Team for Flight Operations.

The Safety Team for Flight Operations is accountable

in turn to the Executive Safety Team. In Figure 5.4,

these lines of accountability are indicated by heavy

arrows. (In a large organization, there might

eventually be separate FRMSs and Fatigue Safety

Action Groups for flight operations, maintenance,

ground operations, and in‐flight services.) The thin

lines represent information flows.

Primary responsibility for the FRMS safety assurance

processes is assigned to a Quality Assurance person

or team that is accountable to the Executive Safety

Team and:

• maintains close communication with the Fatigue

Safety Action Group;  

• makes recommendations to the Safety Team for

Flight Operations, as needed to improve the

functioning of the FRMS;

• makes recommendations to the Safety Team for

Maintenance, as needed to improve the

functioning of the FRMS;

• makes recommendations to the Safety Team for

Ground Operations, as needed to improve the

functioning of the FRMS;

• makes recommendations to the Safety Team for In‐

Flight Services, as needed to improve the

functioning of the FRMS; and

• monitors changes in the regulatory environment

and the operating environment that may affect the

functioning of the FRMS.

In a smaller operator, responsibility for the FRMS

safety assurance processes might reside with an

individual rather than a team. This individual may

also have a variety of other quality assurance

responsibilities. A single safety team might be

responsible for flight operations, in‐flight services,

ground operations and maintenance.

Figure 5.4: Example of assignment of responsibility for

FRMS safety assurance processes in the flight

operations department of a large organization

5.8  Examples of FRMS safety

assurance processes interacting

with FRM processes

Figure 5.5 summarizes interactions between the FRM

processes and the FRMS safety assurance processes.

Together, these two sets of processes form the

“engine” of the FRMS.    Both function in a dynamic

way in response to the information and data

collected and each is responsive to changes in the

other.   

The following examples illustrate some FRMS safety

assurance processes and describe the specific ways in

which they interact with the FRM processes.
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5‐10 FRMS safety assurance processes

Unedited version

Figure 5.6: FRMS Safety Assurance Processes

Example 1  

1.  Collect and review

information

2.  Evaluate overall FRMS

performance

3. Identify emerging

fatigue hazards

4.  Identify changes

affecting FRMS

5.  Improve effectiveness

of FRMS

FRMS Performance Indicator ‐ 

Exceedence of Rostering Parameters

1. Collect and evaluate monthly exceedances

of the 13‐hour scheduled duty limit.

2.

Monthly reviews by the Fatigue Safety

Action Group indicate that duties exceeding

13 hours have been trending upwards for 3

months in B‐747 operations.  

3.

Further analysis shows that most of the

trend is due to one hub where crews are

frequently positioned (dead head) before

outbound flights or after inbound flights.  

4.

Due to a change in marketing strategy, the

total number of B‐747 flights in and out of the

hub has been steadily increasing for 6 months.

The the Fatigue Safety Action Group

recommends an increase in the size of the

crew base at the hub.

5.

An improvement to the FRM processes is

introduced. Monthly data are collected and

analyzed to monitor the number of flights

from all crew bases.   
FRMS safety assurance processes 5‐11

Unedited version

In the example in Figure 5.6, as the result of a risk

assessment (FRM processes Step 4), the Fatigue

Safety Action Group sets a duty length of 13 hours as

one of its FRMS safety performance indicators (SPIs).  

The target is to have no more than two instances of

duties in excess of 13 hours per week in B‐747

operations.  It collects and assesses monthly data on

scheduled and actual exceedances of the 13‐hour

duty limit across all its B‐747 flights in and out of the

hub. For 3 consecutive months, there is an increasing

trend in exceedances.  

A short haul example is described in Figure 5.7. Here,

the use of captain’s discretion is tracked as an FRMS

safety performance indicator.  Most State regulations

allow for flight duty periods to be increased on the

day of operation at the discretion of the relevant

captain.  

In this example, in the FRMS processes, the Fatigue

Safety Action Group has conducted a risk assessment

(see Table 4.2 d) and decided to set the following

thresholds for short haul flights:

• intolerable region ‐ discretion used on at least 25 %

of flight duty periods in a two month period;  

• tolerable region  ‐  discretion used on 10‐25 % of

flight duty periods in a two month period;  

• acceptable region  ‐  discretion used on less than

10% of flight duty periods in a two month period.

In addition, delays of more 2 hours must be logged

and presented to the Fatigue Safety Action Group.

Data on use of discretion are collected in a log

generated by the operator’s crew management

system. The Fatigue Safety Action Group analyzes this

data monthly, to ensure that the trips being created

by the scheduling software are realistic, given the

usual operating conditions. The data are sorted by

trip (sequence of consecutive flight duty periods),

distinguishing between regular scheduled trips (that

recur for several roster periods, e.g., monthly bid

lines) and trips that are introduced temporarily to

cover variations in scheduling or crewmember

availability at a particular crew base. Data are also

analyzed by crewmember rank, category, and

qualifications to see, for example, if trips with more

frequent use of discretion are avoided by more senior

crewmembers).   
5‐12 FRMS safety assurance processes

Unedited version

Figure 5.7: FRMS Safety Assurance Processes

Example 2  

1.  Collect and review

information

2.  Evaluate overall FRMS

performance

3. Identify emerging

fatigue hazards

4.  Identify changes

affecting FRMS

5.  Improve effectiveness

of FRMS

FRMS Performance Indicator – Use of

Captain’s Discretion

1. Use of captain’s discretion recorded in the

Operations ́ Log and analyzed monthly

2.

An out‐and‐back daily short‐haul trip has

had an ‘unacceptable’ level of use of

captain’s discretion (at least 25% of flights)

for 3 consecutive months, averaging 30

minutes delay beyond the planned buffer of

40 minutes for all flights.

3.

Further analyses identify the main causal

factors as air traffic control en route and

ground handling, especially of late

passengers to the gate.  

Schedule Planning and Ground Operations

are notified. They had not previously

identified the issue.

4. Not applicable

5.

Schedule Planning and Navigation Services file

a different route that delivers time and fuel

savings. Ground Operations management

negotiate a new Service Level Agreement with

the handling agent that reduces turnaround

times and improves passenger satisfaction

ratings. Average length of duty periods

reduced, use of captain’s discretion returns to

the acceptable region.
FRMS safety assurance processes 5‐13

Unedited version

The next example (Figure 5.8) looks at an operator

whose FRMS uses scheduled maximum values for

planning purposes that are well within the

established risk‐assessed, regulator‐approved, outer

boundaries of the FRMS.    In this example, on a

particular day at a particular crew base, the

maximum value of scheduled duty time periods

defined in the FRMS have been exceeded multiple

times

Every exceedance of the scheduled duty times

requires submission of a report to the Fatigue Safety

Action Group, which is added to the FRMS

documentation for regulatory audit. In addition, the

FRMS safety assurance processes require that the

reasons for each exceedance are investigated and

that, if required, corrective action is taken. In this

example, the functions of FRMS safety assurance are

undertaken by the SMS team as part of their broader

SMS safety assurance functions.    This is to ensure

that the management of fatigue risks does not result

in unintended consequences in overall risk

management, that the actions taken by the Fatigue

Safety Action Group are not self‐monitored, and that

there is appropriate distribution of resources across

both the FRMS and the SMS.

In this example, the monthly review of exceedances

by the SMS team responsible for FRMS safety

assurance processes identifies a cluster of

exceedences that occurred on the same day in the

same place. They notify the Fatigue Safety Action

Group. The Fatigue Safety Action Group contacts the

line manager responsible for crewing resources on

the day and asks him to interview the staff on duty on

that day. The investigation reveals that there were a

series of problems that coincided on that particular

day, which combined to produce the outcome of

multiple exceedances of the scheduled duty time

limits. It is unlikely that this same combination of

problems would recur. However, the effectiveness of

the FRMS is improved by a series of measures that

improves the management of staff in the crew office

in times of unexpected high workload.

Monthly analyses of exceedances of the scheduled

duty time limits specified in the FRMS could consider:

  

• the total number of Level 1 and Level 2

exceedances;

• the areas of the organization involved in

exceedances;

• causes and extenuating circumstances; and

• patterns of overdue submission of reports on

exceedances.

The Fatigue Safety Action Group is responsible for

developing and implementing any recommended

mitigations, in consultation with the team responsible

for the FRMS safety assurance processes.
5‐14 FRMS safety assurance processes

Unedited version

Figure 5.8: FRMS Safety Assurance Processes

Example 3  

1.  Collect and review

information

2.  Evaluate overall FRMS

performance

3. Identify emerging

fatigue hazards

4.  Identify changes

affecting FRMS

5.  Improve effectiveness

of FRMS

FRMS Performance Indicator –

Exceedances of scheduled duty time

limits specified in the FRMS

1.

The SMS team responsible for FRMS safety

assurance processes identifies multiple

exceedances of FRMS scheduled duty time

limits on a specific day at a particular

location.   

2.

The SMS team asks the Fatigue Safety Action

Group    to conduct an investigation in

conjunction with staff members who were

working on that day.

3.

Causal factors identified were:

aircraft technical problems at the location;  

temporary shortage of standby flight

crewmembers due to a peak in sickness

levels;  

lack of staff on duty in the Crewing

Department due to a departmental meeting;

and  

absence of any contingency plan to manage

the situation when workload of crewing staff

becomes excessive.

4. Not applicable.

5.

Staffing levels in the Crewing Department are

reviewed and increased, and a contingency

plan is developed and implemented for

managing extreme workload.  

Subsequently, this enables the operation to

withstand significant winter weather

disruption, resulting in safety and financial

benefits. 
FRMS safety assurance processes 5‐15

Unedited version

Figure 5.9 describes an example that uses another

type of FRMS safety performance indicator  ‐  a code

incorporated in the rostering software that indicates

when a crewmember is approaching the limit for

maximum allowable monthly flight hours. If the code

is set to trigger below the flight hours limit defined in

the FRMS policy, then this provides a buffer that

enables some flexibility and reduces the risk of

exceedances.  In effect, it acts as an alert level.

Each month, the Fatigue Safety Action Group

analyses how often the code is activated, i.e., how

often crewmembers are approaching the maximum

monthly flight hours, and where this is happening. An

increasing trend in code indicates increasing

workload for flight crewmembers, and can be due to

an increasing number of flights being scheduled, or a

reduced number of crewmembers available to fly

them, or both. Seasonal analyses are also undertaken

to indicate whether this is a normal cyclical pattern

that requires short‐term remedial action, or a

separate upward trend that requires long term

remedial action.

In this example, monthly analyses by the Fatigue

Safety Action Group have revealed that occurrences

of scheduled and actual flight hours triggering the

code have increased in July compared with June, for

Captains at a particular crew base.

Note:

It is possible to incorporate a variety of codes in the

rostering software to track when different rostering

parameters are approaching limits specified in the

FRMS. These codes can be separated into categories,

for example by fleet, crewmember rank and crew

base, and analyzed in a variety of ways, including:

• number of times that codes occur for actual versus

rostered schedules;

• analysis of which duty or flight hours limit is most

frequently approached, and in which part of the

operation this is most likely to occur;

• month‐by‐month trends in numbers of codes

occurring;

• rolling 13‐month trends (recalculated each month

for the last 13 months, to cover a full cycle of

seasonal changes);

• longer‐term trends, for example 3‐yearly trends by

crewmember rank.
5‐16 FRMS safety assurance processes

Unedited version

Figure 5.9: FRMS Safety Assurance Processes

Example 4  

1.  Collect and review

information

2.  Evaluate overall FRMS

performance

3. Identify emerging

fatigue hazards

4.  Identify changes

affecting FRMS

5.  Improve effectiveness

of FRMS

FRMS Performance Indicator – Code

Tracking High Monthly Flight Hours

1.

Code (scheduled and actual) is triggered for

Captains at Crew Base A more frequently in

July than in June.

   

2.

Code relates to the limit of 100 hours of

flight time in 28 consecutive days.  

3.

Further analyses show that the number of

Captains available at Crew Base A has been

stable for the last 3 months. However,  

Captains from  Crew Base A are increasingly

being positioned to cover a shortage of

Captains at Crew Base B.

4. Not applicable.

5.

Captains from Crew Base C are added to the

roster to help cover shortages at Crew Base B. 

Captains from Crew Base A that are assigned

flights serviced by Crew Base B are limited to

operating shorter flights to help reduce their

total flight hours.  

In August, the number of times the code is

triggered decreases for rostered duties for

Captains at Crew Base A. Subsequent analyses

indicate that this change has reduced the use

of standby and increased roster stability.
Chapter 6. FRMS promotion processes 6‐1

Unedited version

Chapter 6: FRMS promotion processes

6.1   Introduction to FRMS promotion

processes

This Chapter details the requirements for FRMS

promotion processes that include training programs

and a communication plan. Figure 6.1 outlines the

linkages between the FRMS promotion processes and

other FRMS components. Along with the FRMS policy

and documentation, the FRMS promotion processes

support the core operational activities of the FRMS

(FRM processes and FRMS safety assurance

processes).  

Like SMS, FRMS relies on effective communication

throughout the operator’s organization1

. On the one

hand, there needs to be regular communication

about the activities and safety performance of the

FRMS to all stakeholders. Depending on the structure

of the organization, this may come from the Fatigue

Safety Action Group, the SMS, or from an

accountable executive responsible for the FRMS

communication plan. On the other hand,

crewmembers and other stakeholders need to

communicate promptly and clearly about fatigue

hazards to the Fatigue Safety Action Group or other

relevant management.

                                                           

1 ICAO Safety Management Manual (Doc 9859), Section 9.1

All involved personal should be trained and

competent to undertake their responsibilities in the

FRMS, and standards for initial and recurrent training

should be specified in the FRMS documentation. A

special feature of FRMS training is that key principles

of fatigue science – managing sleep and

understanding the effects of the circadian body clock

– are relevant not only to individuals’ roles in the

FRMS at work but also to their lives outside of work,

for example in safe motor vehicle driving and in

staying healthy. Thus FRMS training covers issues that

everyone can identify with personally, and this can

help promote the concept of shared responsibility in

an FRMS.

Figure 6.1: Linkages between FRMS promotion processes and other FRMS components
6‐2 FRMS promotion processes

Unedited version

The ICAO requirements for FRMS promotion

processes are as follows (Annex 6, Part I, Appendix 8).

Annex 6, Part I, Appendix 8

4. FRMS promotion processes

4.1   FRMS promotion processes support the ongoing

development of the FRMS, the continuous

improvement of its overall performance, and

attainment of optimum safety levels. The following

shall be established and implemented by the

operator as part of its FRMS:

a) training programs to ensure competency

commensurate with the roles and

responsibilities of management, flight and cabin

crew, and all other involved personnel under the

planned FRMS; and

b) an effective FRMS communication plan that:

1)   explains FRMS policies, procedures and

responsibilities to all relevant stakeholders;

and

2)   describes communication channels used to

gather and disseminate FRMS‐related

information.

6.2   FRMS training programmes

In addition to the above requirements, ICAO Annex 6,

Part I, Appendix 8 requires that an operator maintain

documentation that describes and records FRMS

training programs, training requirements, and

attendance records. It further recommends that

regulators have competency requirements for FRMS

training instructors, who may be part of an operator’s

internal training department or external contractors.   

6.2.1 Who needs to be trained

For an FRMS to be effective, all personnel who

contribute to FRMS safety performance need to have

appropriate training. This includes crewmembers,

crew schedulers, dispatchers, operational decision‐

makers, all members of the Fatigue Safety Action

Group, and personnel involved in overall operational

risk assessment and resource allocation. It also

includes senior management, in particular the

executive accountable for the FRMS and senior

leadership in any department managing operations

within the FRMS.

6.2.2 Curriculum

The content of training programs should be adapted

according to the knowledge and skills required for

each group to play their part effectively in the FRMS.

All groups require basic education about the

dynamics of sleep loss and recovery, the effects of

the daily cycle of the circadian body clock, the

influence of workload, and the ways in which these

factors interact with operational demands to produce

fatigue (see Chapter 2). In addition, it is useful for all

groups to have information on how to manage their

personal fatigue and sleep issues.  

The ICAO SMS guidance (Doc 9859) recommends a

‘building‐block’ approach to training. Applying this

approach to FRMS, training for crewmembers could

address the following areas.

• An overview of the FRMS structure and how it

works in the operator’s organization;

• Their responsibilities and those of the operator, in

the FRMS, including effective safety reporting;

• Causes and consequences of fatigue in the

operation(s) in which they work;

• FRM processes in which they play a vital role,

particularly in the use of fatigue reporting systems

and implementing mitigations;

• The importance of accurate fatigue data (both

subjective and objective);

• How to identify fatigue in themselves and others;

• Personal strategies that they can use to improve

their sleep at home and to minimize their own

fatigue risk and that of others, while they are on

duty; and
FRMS promotion processes 6‐3

Unedited version

• Basic information on sleep disorders and their

treatment, where to seek help if needed, and any

requirements relating to fitness to fly.  

FRMS training for personnel involved in crew

scheduling could address the following areas.

• An overview of the FRMS structure and how it

works in the operator’s organization, including the

concepts of shared responsibility and an effective

reporting culture;

• A robust understanding of how scheduling affects

sleep opportunities and can disrupt the circadian

biological clock cycle, the fatigue risk that this

creates, and how it can be mitigated through

scheduling;  

• Comprehensive training in the use and limitations

of any scheduling tools and bio‐mathematical

models or other algorithms that may be used to

predict the levels of crewmember fatigue across

schedules and rosters;

• Their role in the FRMS in relation to fatigue hazard

identification and risk assessment;

• Processes and procedures for assessing the

potential fatigue impact of planned scheduling

changes, and for ensuring that the Fatigue Safety

Action Group is engaged early in the planning of

changes with significant potential to increase

fatigue risk;  

• Processes and procedures for implementing

scheduling changes recommended by the Fatigue

Safety Action Group;

• How to identify fatigue in themselves and others;

• Personal strategies that they can use to improve

their sleep at home and to minimize their own

fatigue risk, and that of others, while they are at

work; and  

• Basic information on sleep disorders and their

treatment, and where to seek help if needed.

FRMS training for members of the Fatigue Safety

Action Group, and for others with responsibility for

safety decision‐making that affects FRMS

performance, could address (at least) the following

areas.

• A full understanding of all FRMS components and

elements (policy and documentation; processes for

hazard identification, risk assessment, mitigation,

and monitoring; safety assurance processes for

monitoring FRMS performance, managing change,

and for continuous improvement of the FRMS; and

FRMS promotion processes, including training and

communication);  

• The responsibilities and accountabilities of

different stakeholders in the FRMS;

• Linkages between the FRMS and parts of the

operator’s overall safety management system;

• Linkages between the FRMS and other parts of the

organization, for example the scheduling

department, flight operations, medical

department, etc.;

• Regulatory requirements for the FRMS;

• How to identify fatigue in themselves and others;

• Personal strategies that they can use to improve

their sleep at home and to minimize their own

fatigue risk, and that of others, while they are at

work; and  

• Basic information on sleep disorders and their

treatment, and where to seek help if needed.

FRMS training for senior management could address

the following areas.

• An overall understanding of crewmember fatigue

and the safety risk that it represents to the

organization;

• An overview of the FRMS structure and how it

works, including the concepts of shared

responsibility and an effective reporting culture,

and the role of the Fatigue Safety Action Group;

• The responsibilities and accountabilities of

different stakeholders in the FRMS, including

themselves;

• An overview of the types of fatigue mitigation

strategies being used by the organization;

• FRMS safety assurance metrics used by the

organization;

• Linkages between the FRMS and other parts of the

operator’s safety management system;

• Linkages between the FRMS and other parts of the

organization, for example the scheduling
6‐4 FRMS promotion processes

Unedited version

department, flight operations, medical

department, etc.;

• Regulatory requirements for the FRMS;

• How to identify fatigue in themselves and others;

• Personal strategies that they can use to improve

their sleep at home and to minimize their own

fatigue risk, and that of others, while they are at

work; and  

• Basic information on sleep disorders and their

treatment, and where to seek help if needed.

Examples of training materials developed by the

NASA Fatigue Countermeasures Program for flight

crew in different types of operations are freely

available on the internet. 2

• The original generic training package ‘Crew Factors

in Flight Operations X: Alertness Management in

Flight Operations Education Module’ is available at:  

• http://ntrs.nasa.gov/archive/nasa/casi.ntrs.nasa.go

v/20020078410_2002126547.pdf

• The training package ‘Crew Factors in Flight

Operations XIV: Alertness Management in Regional

Flight Operations Education Module’ is available at:  

• http://human‐

factors.arc.nasa.gov/zteam/PDF_pubs/REGETM_XI

V.pdf

• The training package ‘Crew Factors in Flight

Operations XV: Alertness Management in General

Aviation Education Module’ is available at:  

http://humanfactors.arc.nasa.gov/publications/B_

Flight_Ops_XV_GAETM1.pdf

These training packages draw on fatigue‐related

safety data and scientific research. Each package

includes a slide presentation with explanatory text.

They are designed to be used as a personal resource

by crewmembers, and/or as a live presentation that

lasts at least an hour. In addition, the Regional and

General Aviation Modules include summaries from a

number of NASA studies and safety reports. It should

be noted that these materials date from 2001‐2002

and need to be updated to include more recent

                                                           

2 Web addresses accurate as of August 2, 2010

safety and scientific data, and to reflect current

operating conditions. Nevertheless, they provide

useful examples of the type and level of information

that can be used in initial FRMS training, particularly

for flight crew. They are useful examples, but each

operator will need to look at how relevant the

training materials are for their particular operational

needs.  

Table 6.1 provides some examples of personal fatigue

mitigation strategies that might be covered in FRMS

training for flight crew.  
FRMS promotion processes 6‐5

Unedited version

Table 6.1: Examples of fatigue hazards and personal mitigation strategies (not an exhaustive list)

Fatigue Hazard Personal Mitigation Strategies

Sleep at home disturbed by

new baby

Move to a quiet part of the house for final sleep before departure.  

Maximize sleep in 24 hours before departure.

Controlled flight deck napping, maximize sleep during in‐flight rest periods (if

available).

Strategic use of caffeine in flight.

In‐flight sleepiness on non‐

augmented flights

Maximize sleep in 24 hours before departure.

Controlled flight deck napping, strategic use of caffeine in flight.

Difficulty sleeping in onboard

crew rest facilities

Maximize sleep in 24 hours before departure.

Use eye mask, ear plugs, arrange a suitable wakeup call.  

Avoid caffeine for 3‐4 hours before trying to sleep.  

Strategic use of caffeine after in‐flight rest period.

Difficulty sleeping in noisy,

poorly‐curtained rooms in

layover hotel

Submit a fatigue report to the Fatigue Safety Action Group.

Use eye mask, ear plugs, arrange a suitable wakeup call.  

Avoid caffeine for 3‐4 hours before trying to sleep.

Non‐restorative sleep See a sleep disorders specialist.

Comply fully with recommended treatment.

Unpredictable call‐outs   Ensure that sleep environment is dark and quiet, and use sleep hygiene

measures to maximize sleep quality.  

Maximise recovery sleep on off‐duty days.  

When feeling sleepy while waiting for call‐out, attempt sleep (prioritise sleep

over other activities).  

Controlled flight deck napping, maximize sleep during in‐flight rest periods (if

available)  

Strategic use of caffeine in flight.

A specific city pairing results in

landing when extremely

fatigued.  

Submit a fatigue report to the Fatigue Safety Action Group.

Controlled flight deck napping.

Maximize sleep during in‐flight rest periods (if available).

Strategic use of caffeine in flight.

Extended commute prior to

scheduled flight duty period.

Arrive at duty location with sufficient time to allow adequate sleep, ensuring

fitness for duty.   
6‐6 FRMS promotion processes

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6.2.3 FRMS training formats and frequency

There are a variety of ways in which FRMS training

can be delivered, each of which has strengths and

limitations. Live training sessions with a trained

instructor have the advantage that crewmembers can

ask questions about their specific issues or concerns,

and can learn from each other’s experiences. Face‐to‐

face contact with different stakeholders in the FRMS

can facilitate relationships and information sharing,

and foster trust.    However, live training requires

coordinating a time and place that groups of

participants can attend, and involves time getting to

and from the venue, in addition to the time required

for the actual training session.  

Web‐based learning or distributed training (for

example, using DVDs) allows greater flexibility in the

time and place that training occurs. Individual

participation allows participants to proceed at their

own pace through the training materials. In web‐

based learning, sessions can be networked so that

multiple participants can join in with a tutor on‐line.

Material can also be made interactive (a task has to

be completed, for example a short quiz answered,

before the participant can move on to the next part

of the training). Participants and tutors can interact

via designated ‘chat rooms’. Web‐based learning

programs can also direct participants to explore a

variety of other resources available on the internet.

On the other hand, it is harder to eliminate ‘cheating’

when learning assessments are completed on‐line

than when they are completed in a classroom. This

may be important for training evaluation (see below).

Providing different materials and formats for

recurrent training can help to maintain interest. For

example, recent fatigue reports or Fatigue Safety

Action Group interventions can be used as case

studies to illustrate and revise concepts covered in

the initial training material. Recurrent training can

also cover changes to the operations or the FRMS,

and scientific and regulatory updates. The frequency

and nature of recurrent training needs to be decided

by the Fatigue Safety Action Group, in consultation

with professional trainers (internal or external to the

operator) as needed. Many regulators may also

prescribe requirements on the frequency of FRMS

training.

6.2.4 FRMS training evaluation

The effectiveness of FRMS training and education

programs should be periodically evaluated. Examples

of evaluation tools can include the following.  

• To evaluate immediate knowledge transfer from

a training session, participants can be given a

short quiz assessing fatigue knowledge, to be

completed before and after the training session

(for an example, see the text box below).  

• To evaluate the amount of knowledge retained,

crewmembers’ use of suggested

countermeasure strategies, and perceived

usefulness of training, a survey can be

conducted at a fixed time after training (for

example, 6 months).  

• Findings from the quiz and surveys can be used

to:

o revise the content of the training package, to

improve the training on topics which a

significant proportion of crewmembers have

not fully understood;

o provide feedback to trainers on areas where

they may need to change or improve their

teaching approaches; and

o identify areas that need to be reviewed or

added in recurrent training.
FRMS promotion processes 6‐7

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6.2.5   FRMS training documentation

ICAO Annex 6, Part I, Appendix 8 requires that an

operator keep documentation that describes and

records FRMS training programs, training

requirements, and attendance records.

6.3   FRMS communications plan

ICAO Annex 6, Part I, Appendix 8 requires an operator

to have an FRMS communication plan that:

• explains FRMS policies, procedures and

responsibilities to all stakeholders; and

• describes communication channels used to

gather and disseminate FRMS‐related

information.

The FRMS training programs are clearly an important

part of the communication plan. However, training

generally occurs at fairly long intervals (for example

annually). In addition, there needs to be ongoing

communication to stakeholders about the activities

and safety performance of the FRMS, to keep fatigue

‘on the radar’ and encourage the continuing

commitment of all stakeholders.  A variety of types of

communication can be used, including electronic

media (websites, on‐line forums, e‐mail), newsletters,

QUIZ (for use before and after initial training)

Are these ideas true or false? Please tick one box for each question.

1. Sleep is a time when your brain switches off.  True  False

2. Dreaming sleep is better for you than non‐dreaming sleep.  True  False

3. In the end, the only way to get rid of sleepiness is to get some sleep.  True  False

4. You can always beat sleepiness, if you try hard enough.  True  False

5. As you get sleepier, your reaction time slows down.  True  False

6. Napping is a sign of laziness.  True  False

7. The circadian body clock adapts easily to sleeping during the day.  True  False

8. There are two times of day when your circadian body clock makes you feel most sleepy,

around 3‐5 am and 3‐5 pm.

 True  False

9. Having a regular routine at bedtime can help you to fall asleep more easily.    True  False

10. A dark, quiet room helps you sleep better.  True  False

11. If you drink too much coffee and can’t sleep, you should drink some alcohol to help you relax.  True  False

12. Even if you are not sleepy, you should start each flight with a cup of coffee, to fight fatigue.  True  False

13. You are in the cockpit and you feel incredibly sleepy. The best thing to do is not to tell anyone,

and to try extra hard to stay focused.

 True  False

14. Fatigue would not be a problem if the schedules were properly designed.  True  False
6‐8 FRMS promotion processes

Unedited version

bulletins, seminars, periodic poster campaigns in

strategic locations, etc.

Communications about the activities and safety

performance of the FRMS (from the Fatigue Safety

Action Group or other designated management) need

to be clear, timely and credible, i.e., consistent with

the facts and with previous statements, The

information provided also needs to be tailored to the

needs and roles of different stakeholder groups, so

that people are not swamped by large quantities of

information that has little relevance to them.

Communications from crewmembers are vital for

fatigue hazard identification, for feedback on the

effectiveness of controls and mitigations, and in

providing information for FRMS safety performance

indicators (for example, by participating in surveys

and fatigue monitoring studies).    For these

communications to be open and honest, all FRMS

stakeholders need to have a clear understanding of

the policies governing data confidentiality and the

ethical use of information provided by crewmembers.

There also needs to be clarity about the thresholds

that separate non‐culpable fatigue‐related safety

events from deliberate violations that could attract

penalties.  

Timely feedback to crewmembers who submit fatigue

reports is vital. Feedback does not require

completion of a full investigation. Every crewmember

should receive a timely response to their report with

some indication of the planned follow‐up activity.  

For example  ‐  “To Capt Smyth; thank you for your

fatigue report yesterday regarding flight 123 from AA

to ZZ. This report has been forwarded to the Fatigue

Safety Action Group, which is currently investigating

an adverse trend in fatigue reports associated with

this trip and is evaluating a number of potential

mitigation strategies”.

The communication plan needs to be described in the

FRMS documentation and assessed periodically as

part of FRMS safety assurance processes.
Chapter 7. Deciding to offer FRMS regulations 7‐1

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Chapter 7: Deciding to offer FRMS regulations  

FRMS requires a performance‐based regulatory

approach and any performance‐based regulation

offers particular challenges to the regulator. Instead

of identifying and then monitoring compliance with

prescribed requirements, performance‐based

regulation requires the identification of acceptable

performance outcomes and validation of the system

by which the outcomes are achieved. This difference

in approach necessitates a change in the knowledge

base and skill sets of the various individuals involved

in developing the regulations and providing the

oversight of these systems. It also has implications for

the way in which the regulator and the operator

interact and on the regulator’s resources.

  

However, according to 4.10.1 (Annex 6, Part I), the

regulator does not have to develop FRMS regulations.

Only flight and duty time limitation regulations are

mandatory. This chapter discusses some of the issues

that should be considered in making the decision

whether to provide FRMS regulations and when

establishing FRMS regulations.

7.1  Is the State’s safety oversight

system mature enough?

FRMS has the potential of both improving safety

performance and allowing increased operational

flexibility. As a performance‐based approach

however, appropriate, experienced and

knowledgeable regulatory oversight is as essential as

effective implementation by the operators for these

benefits to be realized. Regulators who have not had

significant experience with performance‐based

regulations should consider very carefully whether

they have the resources to develop and oversee

FRMS regulations.  

  

The State’s Lack of Effective Implementation (LEI)

measurement, identified through participation in

ICAO’s Universal Safety Oversight Audit Programme

(USOAP), may provide some guidance to States as to

their capability to regulate and oversee an FRMS. The

USOAP audits focus on the State's capability for

providing safety oversight by assessing whether the

critical elements of a safety oversight system have

been implemented effectively (Refer to ICAO Doc

9734 for additional details).    Additionally, the LEI

measurement is based on the applicable USOAP

protocol questions that are not satisfactorily

addressed by the State for each critical element.

Consequently, the LEI can be used as a measurement

of the maturity of the States oversight system.

A State with a low LEI score (<30%) should already

have the following:

• Comprehensive regulation in conformity with

International Standards  

• Consistent regulatory oversight  

• An effective incident and accident investigation  

• Employment of a sufficient number of qualified

personnel  

• Consistent compliance with regulatory

requirements by the industry  

• Effective hazards and incidents reporting system

• Consistent coordination of Regional Programmes  

• Effective hazards and incidents reporting and

analysis in the industry

This means that a low LEI State is able to concentrate

on the following areas:  

• Full implementation of its State Safety Programme

(SSP)  

• Use of technology to enhance safety  

• Continuous improvement of the civil aviation

system  

• Consistent use of Safety Management Systems

(SMS) by the industry  

• Consistent adoption of industry best practices by

the industry  

• Alignment of industry safety strategies

  

These are the types of focus areas that effective

FRMS regulation demands. States with medium (30 –

50%) or high LEI (> 50%) scores do not have safety
7‐2 Deciding to offer FRMS regulations

Unedited version

oversight systems mature enough to allow them to

focus on these areas and are likely to have difficulty

in adequately regulating and overseeing FRMS.

7.2  Do we have adequate resources?

New regulatory approaches create an initial,

increased regulatory workload. For States, the

decision to allow their operators the option of using

FRMS will mean establishing performance‐based

regulations in accordance with the ICAO Standards

for FRMS, while continuing to maintain and oversee

prescriptive flight and duty limitations. State

employees designated to be responsible for the

development of FRMS regulations and for the

oversight of FRMS will require adequate knowledge,

experience and training with regards to fatigue

science and FRMS, and they may initially need the

support of fatigue scientists/specialists as advisors. A

thorough familiarization with this manual is a good

start, but further training and information gathering

might be necessary and may require consultation

with ICAO or other States with more advanced and

mature FRMS regulations and practices.  

Detailed planning to determine the tasks required to

support regulatory development of FRMS will

maximize the opportunity for a State to adopt

processes commensurate with resources. In most

cases this may warrant initial activity that adopts a

gradual and phased approach to developing FRMS

regulations, e.g. updating prescriptive flight and duty

time limitations and developing specialist fatigue

knowledge and skills of the inspectorate staff prior to

commencement of the FRMS regulatory process.

Detailed planning will provide a better understanding

of the workload and how the resources required can

best be used. For example, the State may need to

prioritize initial applications to use FRMS. Inadequate

planning of the States’ resources can lead to

inefficient regulatory processes due to lengthy delays

with operators gaining FRMS approval. To better

understand the resources required, States should

consider a number of areas to support the regulatory

development process. These include, but are not

limited to, the following:  

a) The maturity of existing prescriptive flight and duty

limitations and the resources required to enhance

these limitations to ensure that current scientific

principles and knowledge related to fatigue

underpin those regulations;

b) Development of specialist fatigue competency

requirements (knowledge, skills, experience) for

inspectorate staff who will oversee FRMS. This will

require development of competency based training

programmes and may also require on the job

training and instruction (OJTI) to ensure staff are

aware of the intricacies of an FRMS from an

operational perspective, particularly where staff

have had limited operational exposure to fatigue

management and/or SMS;

c) Knowledge in the development, design and

implementation of training programmes to allow

assessment of the efficacy of learning outcomes

developed by the operator within its own FRMS

training programmes;

d) The availability of fatigue scientists to provide

support with more technical elements of the FRMS

such as the limitations of various tools (e.g.

biomathematical models). Where limited

specialists are available, there may be a conflict of

interest if the same specialist is supporting the

development of State regulations and also

providing direct support with developing an

operators FRMS. Limited access to fatigue

specialists may also increase the time needed to

develop FRMS regulations, train inspectorate staff

and limit the number of FRMS applications the

State can handle at any given time;   

e) The resources and time required to develop clear

guidelines for operators to ensure they understand

the States regulatory processes, timelines (e.g.

how long it may take for approval), how the FRMS

will be assessed, costs, etc;

f) Development of tools to provide standardization

and support to FRMS surveillance activities e.g.
Deciding to offer FRMS regulations 7‐3

Unedited version

structured questionnaires for inspectorate staff to

use with crewmembers to elicit feedback on their

understanding and the effectiveness of the FRMS.

These can be useful in determining such things as

the level of understanding of fatigue science and

the limitations of various FRMS tools;

g) Assessment of the contribution of fatigue in

accident and incident investigations. States may

need to consider further training of inspectors or

rely on the expertise of the local accident

investigation agency;

h) The likely timeframes and resources for ongoing

surveillance e.g. reviewing and collating fatigue

data provided by the operator, conducting

observation flights, interviewing key staff within

the FRMS, reviewing previous State audits to

monitor the system over time to provide indicators

of system performance, etc.

i) Resources to ensure the State remains up to date

with emerging fatigue science, including updates to

the regulatory process, inspectorate training etc.

To meet their FRMS oversight obligations, States will

have to establish and maintain a database that

identifies what means of fatigue management each

operator is using and, where FRMS is being used, to

what part(s) of the operation it applies.  

7.3  If we offer FRMS, can we pay less

attention to our prescriptive regulations?

No. Prescriptive flight and duty time limitations

remain a mandatory ICAO requirement. Both flight

and duty time limitations and FRMS have their place

within the regulatory framework. It is the State’s

responsibility to develop scientifically‐based

prescriptive flight and duty time limitation

regulations. Guidance on developing scientifically‐

based prescriptive regulations are provided in

Attachment A, Annex 6, Part I.  

While FRMS offers significant benefits over

prescriptive regulations, both the regulator and

operator should not underestimate the workload

required with developing guidance material,

processing applications and providing suitable

oversight to the FRMS. If the prescriptive regulations

are not aligned with appropriate fatigue science or

they’re too restrictive, it could force larger numbers

of operators towards FRMS with a significant and

potentially unmanageable workload for all parties.

The regulator may not be able to process approvals in

adequate timeframes to the frustration and

commercial detriment of the operator and the

operators may not have access to adequate specialist

resources to support development. Robust

prescriptive regulations remain an essential element

of the regulatory framework.  

Further, prescriptive flight and duty time limitations

provide the baseline from which the FRMS is assessed

in terms of an equivalent level of safety. An FRMS

provides the evidence by which a regulator can

approve an alternative means of compliance to the

prescriptive limitations for managing fatigue.

The regulator must also consider fall‐back options

should an operator consistently fail to demonstrate

appropriate use of an FRMS (see Chapter 9). Well

developed prescriptive regulations remain a viable

option through which an operator can be returned

should they be unsuccessful in the use of their FRMS.

7.4  What if the State already has a

process to approve an FRMS and/or

operators with an approved FRMS?

It would be necessary for the State to conduct a

review of its existing regulations, guidance material,

procedures and processes to identify any gaps

between existing practices and the ICAO SARPs. It

would also be a requirement to review any approved

FRMS against the ICAO SARPs to determine whether

any critical gaps exist and whether this may be

exposing the operator to unacceptable fatigue risk.

For example, if there was no evidence the operator

had pro‐actively collected any fatigue data to further

understand the impact of fatigue on any operations

being managed by an already approved FRMS, it’s
7‐4 Deciding to offer FRMS regulations

Unedited version

possible the operator and the regulator are unaware

of the actual impact of fatigue and the potential

fatigue risk. Furthermore, without adequate data it

would be difficult to meet the requirements of

4.10.6(c)‐(d) in providing evidence to develop quality

assurance processes and to confirm that continuous

improvement of the FRMS has occurred.  

So, it will also be necessary for the State to identify a

process for the operator to amend their current

FRMS to comply with the new FRMS requirements.

There will also have to be an identified process for

managing operators back under prescriptive flight

and duty limitation regulations who cannot or will not

amend their FRMS as required.

7.5  When should the operator apply

for a variation and when should they be

required to implement an FRMS?

Standard 4.10.3, Annex 6, Part I allows for variations

to prescriptive flight and duty time limitations in

exceptional circumstances without full FRMS

requirements. When establishing its regulations, a

State will need to clearly identify what constitutes the

“exceptional circumstances” for application to a

variation, so that a distinction is made between when

variations to prescriptive flight and duty time

limitations may be sought by an operator and when

they are required to implement an FRMS. Variations

tend to be short term in nature, route‐specific, and

relate to very minor extensions beyond prescriptive

regulations. They are approved on the basis of a risk

assessment and use of mitigations acceptable to the

regulator.

As a minimum, for an individual operator seeking

variation without FRMS, the regulator must be

assured that:

a) there is an acceptable focal person(s) or fatigue

management subject matter expert within the

organization; and

b)the operator has proven high standards

demonstrated through their routine regulatory

oversight audits, so that the State has confidence

that the operator can correctly manage the

variation and the required mitigations.

Where there are pre‐existing approved variations, a

means for assessing their continued acceptability

needs to be identified. Where it is determined that an

FRMS is required rather than a variation, a process

for transition also needs to be identified.  

7.6  How will we assess the

acceptability of the operator‐proposed

outer limits of their FRMS?

States should require that the operator provide a

safety case to support the proposed values for outer

limits. The decision to accept or deny the proposed

outer limits will rely on a variety of factors including:

• Whether or not the operator’s safety case is

supported by well‐established scientific principles

and operating experience;

• Research findings from multiple studies and

different authors;

• Operational insights from multiple sources,

including all relevant stakeholders;

• Demonstrated maturity of the operator’s SMS

practices and/or demonstrated ability to manage

risk appropriately;

• Previous history of regulatory compliance of that

operator;

• Experience gained through regulatory oversight of

a variety of operators implementing an FRMS or

giving approval of variations to flight and duty time

limitation regulations.

Where the operator wishes to use the FRMS in

different types of operations (e.g. where they

operate long haul and separately operate short haul),

outer limits should be identified for each operation

type. For example, an operator’s ULR operations may

require a maximum value of 22 hours within which

the FRMS can function but this does not mean that

the same maximum value is an acceptable boundary

for their FRMS with regard to their short haul

operations.  
Deciding to offer FRMS regulations 7‐5

Unedited version

It should be kept in mind, however, that overly

restrictive outer limits may mean that an operator

achieves no extra operational flexibility in

implementing an FRMS.  There has to be some room

for movement to allow the FRMS to function

properly. On the other hand, because these values

are extreme limits, they cannot be considered as

targets. So, the identified maximum flight and duty

and minimum rest values should lean to the outer

limits of acceptability taking into consideration the

types of operations being undertaken, physiological

sleep requirements and circadian factors (following

Attachment A guidance), although these should be

rarely, if ever, reached. When reached or exceeded,

these should be documented, trended and reported

to the State. Based on these trends, more stringent

oversight of the FRMS may be adopted by the

regulator (see Chapter 9).  

7.7  What are the aspects of an

operation for which FRMS outer limits

have to be determined?

When identifying the aspects of an operation for

which the operator has to identify maximum values

for flight and duty periods and minimum values for

rest periods, both transient fatigue (fatigue that is

dispelled by a single sufficient period of rest or sleep)

and cumulative fatigue (incomplete recovery from

transient fatigue over a period of time) need to be

addressed.  

3.

4. This means that States should require that there are

identified outer limits for a day and across multiple

days (e.g. weekly, monthly, annually). The guidance

material for the development of prescriptive fatigue

management regulations in Attachment A of Annex 6,

Part I can be helpful here. For example, excerpts from

Attachment A indicate that limitations should be

specified for the following:

7.8  Why don’t we develop regulations

that require FRMS to be a component of

SMS?

On the face of it, FRMS is simply a clearly‐defined,

single‐focused management system, so it would

appear that the functions of an FRMS should just be

incorporated into the functions of an SMS. While the

....

4.7.1.1 The maximum flight time may not exceed:

a) (*) hours in any flight duty period;

b) (*) hours in any [7] consecutive days or (*) hours in any [28] consecutive days; and

c) (*) hours in any [365] consecutive days.

....

4.7.2.1 Duty hours may not exceed:

a) (*) hours in any [7] consecutive days or in a week; and

b) (*) hours in any [28] consecutive days or in a calendar month.

....

4.7.3.1 The maximum flight duty period should be (*) hours.

....

4.8.1 The minimum rest period immediately before commencing a flight duty period may not be less than

(*) hours.

....
7‐6 Deciding to offer FRMS regulations

Unedited version

SARPs do not preclude such an approach, there a

several complex issues that must be considered

before regulating for such an organizational

structure.  

First, despite first appearances, FRMS and SMS have a

different focus and functions. FRMS is an optional

management system which focuses only on fatigue‐

related risks. It allows an operator to establish their

own flight and duty time limitations as determined by

the FRMS risk management and safety assurance

processes. SMS is a required management system,

which covers mitigation of all operational risks with

no focus on one over the other. Unlike FRMS, an SMS

does not permit an operator to move outside of

prescriptive flight and duty time limitations. So, the

particular requirements of an FRMS far exceed what

would be expected of an SMS to manage fatigue‐

related risks. It is important that the focus and

functions of an SMS do not over‐ride those of an

FRMS and vice‐versa.  

Nevertheless, information from an FRMS should

inform an operator’s SMS, and vice versa (discussed

earlier in Chapter 1, under Standard 4.10.7).

Therefore, FRMS must be supported by an oversight

process that includes examination of the information

flow between the FRMS and the SMS. This is

discussed in Chapter 9.

Second, regardless of the similarities in framework

and their complementary nature, FRMS has an

approval process that differs from the process of

acceptance for SMS. Having an approved FRMS does

not mean that an operator’s SMS is automatically

accepted, and conversely, the withdrawal of approval

of an FRMS does not mean that an operator is

absolved of the responsibility of managing their

safety risks (including fatigue) through their SMS

processes.  

7.9  The FRMS provisions require that

significant deviations in scheduled and

actual flight times, duty periods and rest

periods, and reasons for those significant

deviations, be recorded by operators.

How do we monitor that?

Not every flight that exceeds a scheduled time by a

minute, or rest period that is cut short by two

minutes, needs to be recorded. The amount of data

collection that would require is not only onerous, but

unnecessary. The requirement is for the operator to

record “significant deviations” that can be used to

highlight when there might be increases in fatigue‐

related risk. This data can provide information that is

useful for both the operator and the regulator. The

operator can use information provided by analysis of

such data to help manage their fatigue‐related risks

and the regulator can use the information as a part of

their routine monitoring of an FRMS and as a means

to identify when an operator must immediately notify

the regulator.  
Chapter 8. FRMS approval process 8‐1

Unedited version

Chapter 8: The FRMS approval process  

Once the State has decided that it will offer FRMS

regulations, it will be necessary for the regulator to

identify exactly what they expect operators to do

throughout the implementation process to gain final

approval for an FRMS. The regulator needs to

document their requirements in detail. This chapter

deals with establishing a documented approval

process.  

8.1 A phased approach to FRMS

implementation

There is no ‘off‐the‐shelf’ version of an FRMS that will

suit all operators. Each operator needs to develop an

FRMS that is appropriate to its organization and

operations and the nature and level of the fatigue

risk(s). A fully functioning FRMS doesn’t happen

overnight. The FRMS processes take time to plan and

develop so the operator needs to implement their

FRMS in stages, as is recommended for SMS1

.  

                                                           

1

  ICAO Safety Management Manual (Doc 9859) Chapter 10

Figure 8.1 summarizes a phased approach to FRMS

implementation.

8.1.1 Phase I: Planning

The objective of Phase I is for the operator to arrive

at an overall plan to demonstrate to the regulator

how the FRMS will function, how it will be integrated

with other parts of the operator’s organization, who

will be accountable for the FRMS, and who will be

responsible for making sure that FRMS

implementation is successfully completed.  

It is recognised that some operators may wish to use

outside consultants to come in and “provide them

with an FRMS” as a quick and relatively painless way

of meeting their regulatory obligations. However, an

FRMS requires ownership and commitment by the

people who will be using it, and the regulator needs

to see evidence of that ownership and commitment

from the early stages of its inception. While experts

Figure 8.1: Phased approach to FRMS implementation
8‐2 FRMS approval process

Unedited version

can offer invaluable assistance within an FRMS at

certain times, they do not have the operational

knowledge and experience of the operator.  

They should not be the interface between the

regulator and the operator. The relationship between

the regulator and the operator concerning the use of

FRMS should be identical to their relationship

concerning the prescriptive flight and duty time

limitation regulations.  

Gap Analysis and Developing an Implementation Plan

Many elements needed for an FRMS may already be

in place in an operator’s organization. One of the first

steps in FRMS implementation is therefore for the

operator to undertake a gap analysis to:  

• identify elements of the FRMS that are already

available in existing systems and process;  

• identify existing systems and process that could be

modified to meet the needs of FRMS (to minimize

‘re‐inventing the wheel’); and

• identify where new systems and processes need to

be developed for the FRMS.

For example, an operator may already have a

confidential safety reporting system as part of its

SMS. Existing report forms may need to be modified

to include the information needed to analyze the role

of fatigue in safety events. Additional training may be

needed for the staff responsible for analysing safety

data, to ensure that they know how to analyze for the

role of fatigue in events. A procedure will need to be

added for information on fatigue‐related events to be

communicated on a regular basis to the Fatigue

Safety Action Group. Fatigue reports may also be

used as an FRMS safety performance indicator. In this

case, a procedure would need to be added for this

information to be evaluated regularly as part of the

FRMS safety assurance processes.

Data on scheduled and actual flight and duty times

are required to be collected under the prescriptive

flight and duty time regulations. An operator that is

moving some of its operations into an FRMS could

add a variable to the existing flight and duty time

databases to identify the operations covered by the

FRMS, so that this information can be analyzed

separately as required for the FRMS (4.10.8, Annex 6,

Part I). Procedures will need to be added for this

information to be communicated to the Fatigue

Safety Action Group and recorded as required in the

FRMS documentation.

Rostering‐related data may already be available for

FRMS performance indicators, for example monthly

exceedences on duty limits, use of captain’s

discretion, use of extended duties, or violation

occurrence reports. A procedure will need to be

added for this information to be evaluated regularly

as part of the FRMS safety assurance processes.

It may be efficient to schedule FRMS training to

coincide with other training activities that already

bring the target groups together.  

The results of the gap analysis are used as the basis

for the development of the operator’s FRMS

implementation plan. Essentially, this provides a road

map describing how the development of each of the

FRMS processes will proceed, with timelines.  

By the end of Phase I, the operator should have:

  

• completed a gap analysis.

• An FRMS Policy Statement signed by the

accountable executive. Developing the policy at

the beginning of the FRMS implementation process

will assist in defining the scope of the FRMS.

• An FRMS implementation plan.

• An FRMS documentation plan. This can be

expected to evolve as the FRMS becomes

operational.

• An FRMS communication plan. This can be

expected to evolve as the FRMS becomes

operational.

• Allocation of financial and human resources. The

Accountable Executive for the FRMS needs to have

the authority and control to ensure that this

happens.  

• A Fatigue Safety Action Group (or equivalent) is

established. The stage at which the Fatigue Safety

Action Group is established will vary, according to

the size and complexity of the organization and the
FRMS approval process 8‐3

Unedited version

FRMS, and whether there are suitably qualified

people in other parts of the organization who are

available to begin the Phase I activities.  

In order to move on to Phase II, the operator should

be required to provide their FRMS plan to the State

for review. This is an opportunity for the State to

assess and identify potential problem areas prior to

the State or the operator investing excessive time

and effort.

8.1.2 Phase II: Implement reactive FRM processes

Phase II requires the operator to implement the (first

version) of the FRM processes. It does this by

gathering and analyzing existing sources of

information and data that are relevant to the

operations covered by the FRMS. Types of

information that may be available include

confidential safety reports, accident reports and

incident investigations, audits, and historical

rostering data (for example, data on scheduled and

actual flight and duty times, exceedances, etc.). In

effect, Phase II activities consolidate existing fatigue

risk management processes and procedures in the

organization, and introduce controls and mitigations

to manage identified deficiencies in the existing

system.  

By the end of Phase II, the operator should have

accomplished the following steps:

• FRM processes based on reactive hazard

identification are operational, including risk

assessment and the development, implementation,

and monitoring of appropriate controls and

mitigations.  

• FRMS documentation processes are established to

support the current version of the FRMS.  

• FRMS training activities are established to support

the current version of the FRMS. (Stakeholders

need training to ensure that they are competent to

undertake their responsibilities in the FRMS as the

implementation plan rolls out).  

• FRMS communication processes are established to

support the current version of the FRMS.

• The operator is ready to undertake coordinated

safety analyses of this first version of the FRMS,

similar to the process used when implementing

SMS (ICAO SMM 10.4).  

8.1.3 Phase III: Implement Proactive and

Predictive FRM Processes

Phase III adds proactive and predictive fatigue hazard

identification processes (discussed in Chapter 4) into

the FRM processes established in Phase II.  

By the end of Phase III, the operator should have

accomplished the following steps:

• FRM processes based on reactive, proactive, and

predictive hazard identification are operational,

including risk assessment and the development,

implementation, and monitoring of appropriate

controls and mitigations.  

• FRMS documentation processes are established to

support the current version of the FRMS.  

• FRMS training activities are established to support

the current version of the FRMS. (A single

programme to the level required for the full FRMS

implementation may be more efficient than part‐

training at each Phase of the implementation.)  

• FRMS communication processes are established to

support the current version of the FRMS.

• The operator is ready to undertake coordinated

safety analyzes of this version of the FRMS (ICAO

SMM 10.4).  

8.1.4 Phase IV: Implement FRMS safety assurance

processes

Phase IV activates the FRMS safety assurance

processes (Chapter 5 of this manual). By the end of

Phase IV, the following steps need to be

accomplished.

• Roles and responsibilities for assuring the safety

performance of the FRMS are established.

• The necessary authorities and communication

channels are active.  

• FRMS safety performance indicators have been

developed and agreed on.
8‐4 FRMS approval process

Unedited version

• The procedures and processes for periodic

evaluation of the safety performance indicators are

established.

• Appropriate feedback is established between the

FRM processes and the FRMS safety assurance

processes.

• FRMS documentation processes are fully

implemented.

• FRMS training processes are fully implemented.

• FRMS communication processes are fully

implemented.

In other words, by the end of Phase IV, the FRMS

should be fully functional and integrated with the

operator’s SMS and other parts of the organization as

appropriate. It should be continuously improving and

able to respond to changes in the organization and

the operating environment.  

Regulatory approval for the full FRMS is sought at the

end of Phase IV.

8.1.5 Operational example of staged FRMS

implementation

Operator A is a major airline that flies primarily long

range, trans‐oceanic flights with multi‐national crews.

It has been flying for 20 years with an excellent safety

record. Operator A is interested in starting an FRMS

for both of its long range fleets. The CEO decides to

implement FRMS for the entire operation to enhance

safety and efficiency.

This example works through the steps that Operator

A could follow to establish a fully operational FRMS. It

assumes that management at Operator A are familiar

with information in the FRMS Implementation Guide

for Operators (2011, a joint publication by ICAO,

IATA, IFALPA) and are ready to start implementation.

Phase I

1. Responsibility for FRMS implementation assigned

to a designated FRMS manager.  

2. FRMS manager assembles an implementation

team, and organizes training for the team on

FRMS basics and fatigue science.

3. Accountable Executive for the FRMS allocates

resources and authority to support FRMS

development.

4. FRMS manager identifies internal stakeholders

(department representatives).

5. FRMS policy statement is drafted.

6. Gap analysis undertaken by FRMS manager and

implementation team.

7. FRMS documentation plan developed and first

draft established.

8. FRMS communication plan developed and first

draft established.

9. Implementation plan developed, with initial

timeline.  

10. Fatigue Safety Action Group established with

required stakeholder membership and meets

regularly with the implementation team (if

different employees) to discuss progress.

  

Phase II

11. Fatigue Safety Action Group works through the

FRM process diagram (Chapter 4), using existing

information and data for reactive fatigue hazard

identification.

a) Step 1  ‐ decide whether domestic, international

long haul and ULR operations require different

FRM processes. Carry out the following steps for

each set of FRM processes.

b) Step 2 –collect and analyze available data and

information (for example confidential safety

reports, accident reports and incident

investigations, audits, and historical rostering

data).  

c) Step 3 – Identify fatigue hazards(s)

d) Step 4 – establish risk assessment processes and

procedures. Clarify linkages to SMS risk

assessment and processes for prioritization of

risks to be mitigated. (In this large airline

example, the FRMS policy statement indicates

that the Fatigue Safety Action Group is

responsible for prioritizing fatigue risks, and for

developing, implementing, and monitoring

fatigue controls and mitigations. It is required to
FRMS approval process 8‐5

Unedited version

provide monthly reports of these activities to the

SMS Safety Review Board, with the intent that

this report will become part of the FRMS safety

assurance process in the overall FRMS.)

e) Step 5 – select and implement controls and

mitigations. Set safety performance

indicators.

f) Step 6 – set up processes for monitoring the

effectiveness of controls and mitigations.

12. Perform training to ensure that stakeholders are

competent to undertake their roles and

responsibilities in the FRMS. In this example, it is

decided to undertake training to support the full

FRMS. Communication channels are set up to

provide training updates and reminders when

Phases III and IV of the FRMS implementation

become active.

13. FRMS communication channels established.

14. Fatigue Safety Action Group provides a

coordinated safety analyses of the existing FRMS

to the SMS Safety Review Board. (The SMS Safety

Review Board are responsible for the FRMS safety

assurance functions, in this example).

Phase III

15. For each set of FRMS processes established in

Phase II, the Fatigue Safety Action Group

identifies appropriate tools for proactive and

predictive fatigue hazard identification.  

a) Proactive fatigue identification tools are used

for assessing routine and complex hazards.  

16. Proactive and predictive fatigue hazard

identification are integrated in to the FRM

processes established in Phase II.

17. All stakeholders have received suitable training

and are competent to undertake their roles and

responsibilities in the FRMS.  

18. FRMS communication channels are operational.

19. Fatigue Safety Action Group provides a

coordinated safety analyses of the existing FRMS

to the SMS Safety Review Board.

Phase IV

20. FRMS safety performance indicators are decided

collaboratively by the Fatigue Safety Action

Group and the SMS Safety Review Board and

approved by the Accountable Executive for the

FRMS.

21.

• Decide which information that will be

analyzed for trends (e.g., fatigue reporting

rates between similar city pairs, operations, or

fleets)

• Develop criteria for comparing performance

with safety objectives    (for example, is the

overall risk level increasing, is the number of

higher risk events increasing, are safety

objective in the FRMS policy being achieved,

are regulatory requirements being met).

• Decide how emerging fatigue hazards are

identified. For example, set triggers to identify

when action is needed (at what level do

adverse trends in performance indicators

trigger an investigation of the causes of the

trend).

24. Processes are established for identifying changes

that could impact the FRMS.

25. Processes are established for evaluating how well

Fatigue Safety Action Group recommendations

are implemented in other parts of the

organization, for example in scheduling and flight

operations.  

26. The following safety assurance processes are

established.  

• Monthly reporting by the Fatigue Safety Action

Group to the SMS Safety Review Board. To

include updates on fatigue hazards identified

and on the status of agreed safety

performance indicators.

• SMS Safety Review Board is able to call for

special reports from the Fatigue Safety Action

Group, for example after significant

operational changes such as a newly

established route.

• Quarterly review of trends in confidential crew

reports relating to fatigue, to be undertaken by
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FRMS approval process 8‐7

Unedited version

Suggested documentation to be completed by the

regulator during the course of the approval process is

highlighted in each of the sections below. All of the

information and evidence collected by the regulator

during the approval process contributes to the overall

assessment when deciding to grant final approval of

the FRMS.  

8.2.1 Regulatory Milestone 1 – Notification by the

operator

Throughout the progressive implementation of an

FRMS there should be contact between the regulator

and the operator, starting from the time the operator

begins the implementation process. Such early

interaction helps establish an open and informed

working relationship between the regulator and the

operator and allows the regulator to provide clear

indication of their expectations and requirements.  

One way the regulator can encourage early contact

with an operator planning to develop an FRMS is to

require written notification of intent. Some States

may simply require a letter from the operator stating

their intentions, while others may use a more formal

application such as a “Notice of Proposed

Amendment”. The regulator may also choose to meet

the operator face‐to‐face to discuss their plans.  

At this point, the regulator may expect that the

operator has already undertaken some preparatory

actions. These may include:

• Designation of a specific organizational

manager(s) with proper authority;

• Ensuring that a key person(s) has gained or are

gaining adequate knowledge;

• Allocation of resources to support FRMS

development.

Once initial contact has been established by the

operator, the regulator should then provide the

operator with a detailed checklist of their regulatory

requirements for an FRMS. While necessarily

detailed, this checklist should allow the operator

flexibility in the way they can meet these

requirements. Developing such a detailed checklist

takes time and effort but once this is achieved,

provides a key tool for both the operator and the

regulator. It will form the basis of the operator’s GAP

analysis, required as part of the development of their

FRMS implementation plan. For the regulator, it

forms the first part of the subsequent audit processes

for both approval and oversight purposes. An outline

of the checklist items for each of the subsequent

regulatory milestones is discussed below.

8.2.2 Regulatory Milestone 2 – Review of FRMS

Plan, Policy and Documentation

Based upon the FRMS checklist developed earlier, the

regulator can develop a more comprehensive tool

that can be used to record where each required

component of the FRMS has been documented in the

operator’s procedures, the method used by the

operator to demonstrate compliance with the

required FRMS components, and any regulator

comments on the operator’s proposal. Again,

development of such a tool (referred to here as the

FRMS evaluation form) takes time and effort but is a

worthwhile investment given that the resulting

document becomes the primary oversight tool. An

example of an FRMS evaluation form is provided in

Appendix D.

Regulatory Documentation

1. Review of FRMS plan

The regulator should review the operator’s

implementation plan, including the GAP analysis, the

operations to which the FRMS is intended to be

applied, the key personnel involved and expected

timelines, to allow early detection of any areas

needing improvement in the operator’s ability to

implement an FRMS prior to the State or the operator

investing excessive time and effort.  

A positive review of the FRMS implementation plan

means that the regulator has been provided with

evidence that the operator understands what is

required
8‐8 FRMS approval process

Unedited version

Regulatory Checklist:

Checklist for Review of FRMS Implementation Plan

• Reflects a commitment to an effective safety

reporting culture

• Defines the safety objectives of the FRMS;

• Defines roles and responsibilities for all

stakeholders in the FRMS, including identifying

the Accountable Executive;  

• Identifies to what specific operations the

implementation plans pertain;

• Identifies an overall timeline for seeking final

approval.

• Plan for the development of documentation

(Chapter 3):

o Milestones

o Method

• Plan for the development of FRM processes

(Chapter 4)

o Milestones

o Method

• Plan for the development of FRMS safety

assurance processes (Chapter 5)

o Milestones

o Method

• Plan for the development of FRMS Training

(Chapter 6)

o Milestones

o Method

• Plan for the development of FRMS

Communication procedures and processes

(Chapter 6. 6.3)

o Milestones

o Method

2. Review of the initial FRMS policy and

documentation proposal

Using the FRMS evaluation form (mentioned above),

the regulator should conduct a desktop review of the

policy and documentation, to determine whether the

operator’s initial FRMS policy and documentation

proposal adequately addresses the regulatory

requirements. This will include evaluating:

• policy content;  

• the organizational structure;  

• the risk‐based deviation recording process that

will document the extent and reason for

significant exceedances of scheduled flight and

duty periods, significant reductions of rest

periods; and significant numbers of uses of the

captain’s authority to complete the flight

period);

• the proposed fatigue risk assessment process;

• the proposed safety assurance process;

• integration processes with the safety

department;  

• quality control audit procedures;  

• initial training plan, procedures (including

fatigue reporting);  

• terms of reference for the Fatigue Safety Action

Group;  

• details of the safety promotion activities; and  

• methods for monitoring and managing changes

to the FRMS.

The regulator may also wish to conduct some

documented interviews of key personnel involved

with the development of the implementation plan to

check the level of organizational knowledge and

commitment to the plan.  

A positive review of the FRMS policy and

documentation proposal means that the regulator

has been provided with evidence that the operator

has a commitment to meet these requirements of

implementing an FRMS.

Regulatory Checklist:

Checklist for review of the initial FRMS policy

and documentation

(Chapter 3)

• An FRMS policy is in place.

• The FRMS policy reflects organizational

commitments regarding fatigue risk management.

• The FRMS policy includes a clear statement about

the provision of the necessary resources for the

implementation of the policy.

• FRMS reporting procedures are identified.

• There is clear indication of which types of

operational behaviours are unacceptable within
FRMS approval process 8‐9

Unedited version

the context of the FRMS.

• The conditions under which disciplinary action

would apply are clearly identified in the context of

the FRMS.

• The policy is communicated, with visible

endorsement, throughout the organization.

• The Accountable Executive, who has ultimate

responsibility and accountability for the

implementation and maintenance of the FRMS

and full control of the necessary resources, is

identified.

• Deliver of initial documentation including:

o FRM processes  

o FRMS safety assurance processes

o FRMS Training

o FRMS Communication procedures and

processes

8.2.3 Regulatory Milestone 3 – Review of initial

FRM processes

Once the plan for the development of the FRMS and

the policy and documentation proposal has been

positively reviewed, the operator can begin

implementing the FRM processes. This incorporates

Phases II and III of the operator’s implementation

process and may take a significant period of time and

may require several meetings with the operator.  

To achieve the third milestone of the regulatory

process, the regulator:

1. reviews the operator’s reactive risk assessment

process, including the tools used, such as the

fatigue hazard log, how the risk matrix was

developed and the use of the agreed upon

severity and likelihood measures, the

methodology for the development of mitigation

strategies, fatigue report procedures, any crew

surveys, Fatigue Safety Action Group meeting

minutes;  

2. reviews the proactive and predictive hazard

identification processes, including assessment of

agreed fatigue roster metrics, any information

from biomathematical modeling, development

of FRMS performance indicators and their

targets, supporting scientific documentation,

Fatigue Safety Action Group meeting minutes,

other operational best practices, the fatigue

hazard log, and further proposed mitigations to

reduce the risk;

3. reviews the results of all the risk assessment

processes (reactive, proactive and predictive)

and agrees on initial FRMS performance

indicators and targets;  

4. directly sample some of the records quoted in

the risk assessment and assess the operators

procedures against supplied risk assessments;

5. conducts the final review of the initial training

programme and training records (and may

possibly attend one of the initial training

courses). The regulator will need to review the

training proposals for the operator’s employees

to check that they cover both generic fatigue

material and operation‐specific FRMS aspects.

Training will need to be given in a proportionate

manner to the employee groups’ involvement in

the FRMS. As part of the training programme, all

employees who are involved with the fatigue

reporting system need to be specifically trained

on how the system works, how they use the

system information, and at what point an

individual would need to be further assessed

due to trends in their filed fatigue reports. The

regulator may choose to attend a training

session rather than just review the training

material and or syllabus.

6. conducts documented interviews with a

selection of employees from all the areas

involved with the FRMS, and

7. may involve other regulator experts or resources

(both internal and external to the State) as part

of their review of the information;

8. reviews the outer limits for the proposed FRMS

operation and adjusts them accordingly if there

is insufficient evidence to support the case;

9. produces an audit report and where necessary a

list of corrective actions.  

If the operator is required by the regulator to make

corrective actions, the regulator should agree to an

action plan to make these corrections. Once the

operator has taken the corrective actions, the

regulator will need to go back into the above process
8‐10 FRMS approval process

Unedited version

at the relevant point and produce an audit closure

report.

Where no corrective actions are necessary, or once

corrective actions are complete, the regulator may

then permit the operator to trial the proposed FRMS

operations within the newly agreed outer limits. At

this point, the FRMS does not have final approval as

the safety assurance processes have not yet been

implemented.  

Regulatory Checklist:

General Requirements

• Establishment of FSAG

o Appointment of FSAG members.

o Appointment of a qualified person to manage

and oversee the functions of the FSAG.

o All FSAG members fulfil the required job

functions and responsibilities.

• Establishment of outer limits (maximum values

for flight times and/or flight duty period(s) and

duty period(s), and minimum values for rest

periods).

• Maintenance of records of flight time, flight duty

periods, duty periods, and rest periods.

Validation of initial FRM processes (Chapter 4)

• An effective fatigue reporting system is in place.

• The operations covered by each set of FRMS

processes is identified (4.2).

• Data and information is collected (4.3, 4.4).

• Hazards are identified (4.4).

• Risk assessments are undertaken and

documented. (4.5)

• Appropriate risk mitigation is undertaken (4.6).  

• There is a demonstrable information flow

between the FRMS and other safety systems (e.g.

their SMS through the Safety Action Group

meetings or their safety department).  

Validation of initial FRMS promotion processes

(Chapter 6)

• Training plan implemented (6.2) with personnel

involved in FRMS displaying required level of

knowledge of sleep and fatigue, and their

responsibilities and procedural requirements in

relation to the FRMS.

• Training records maintained (6.3).

• FRMS‐related information is disseminated in a

timely manner to all necessary stakeholders.

8.2.4 Regulatory Milestone 4 – Approval of FRMS

Before final approval of the FRMS can be given,

evidence is required to demonstrate that the FRMS is

delivering the required safety outcomes. The

operator now needs to validate the safety assurance

processes and demonstrate a fully functioning FRMS

within the agreed outer limits, which may be outside

of the prescriptive limitations. Validation of the safety

assurance processes will take time, and this will

require the regulator to conduct regular visits,

desktop reviews of sample data, analyses and

documentation and interviews of key personnel. All

of the components of an FRMS, including the safety

assurance processes, need to be functioning in a

coordinated way within the operator’s overall safety

processes. During this trial period, the regulator

needs to be closely monitoring all activities.

Importantly, a time limit needs to be identified by the

regulator for the course of this trial period. While

adequate time needs to be given to allow the

operator to demonstrate that all components of an

FRMS (including the safety assurance processes) are

functioning, an operator cannot be allowed to

operate outside of the prescriptive limits for an

indefinite period. Protracted trial periods diminish

the value of having an approved FRMS, if an operator

can continue using an “FRMS in progress” that is not

actively trying to meet approval requirements.  

The operator will need to demonstrate that their

FRMS safety assurance processes are used to review

the FRMS performance indicators against their

agreed targets and can identify and undertake any

necessary actions. Where trends demonstrate that

either the mitigations or the outer limits are not

appropriate to achieve the safety performance

targets, or where changes affecting the overall FRMS

are detected by the safety assurance processes, the

failing areas of the FRMS operation(s) are re‐assessed

through the FRM processes.  
FRMS approval process 8‐11

Unedited version

These processes are documented and form part of

the Fatigue Safety Action Group review of the system

and are recorded in the minutes. The functioning of

the Fatigue Safety Action Group must also

demonstrate the identification and management of

any new fatigue hazards and their subsequent risk

assessment and management. The assurance

functions monitor the effectiveness of the mitigations

and suitability of the outer limits of the FRMS. The

whole system will also be internally audited to check

the procedures are being correctly applied and the

effectiveness of risk mitigations and assumptions

made. These audits must be documented.

During the course of this trial period, the regulator

will have the opportunity to gain confidence in the

operator’s ability to respond appropriately to the

data being collected and should be supplied with

evidence that the operator is managing their fatigue

risk appropriately. This should include the monitoring

of the operator’s safety performance after any

changes. In some cases, the regulator may have

observed the operator lowering flight and duty times

that would otherwise be permitted using prescribed

limitations using their FRMS processes.  

In this final phase prior to approval, the operator will

also have demonstrated that they have added

effective recurrent training into their training

programme. Further, the regulator should ensure

that all initial training as identified in the accepted

implementation plan has been completed prior to

final approval of the FRMS.

Still using the FRMS evaluation form, the regulator

should then conduct the final audit of the operator’s

FRMS. By now, this evaluation form documents the

progress made by the operator throughout the

approval process. At the final approval audit, the

regulator should examine evidence of the operators

FRMS safety assurance functions by reviewing the

agreed FRMS performance targets and assesses any

trends. They should also check that the system has

been subject to internal auditing of the processes.

The regulator may choose to audit some of the

primary sources of input into the system (e.g. fatigue

reports). However, they will need to be mindful of

the confidential nature of some the methods of

reporting (such as fatigue reports) examining such

reports only to confirm the operator’s assessment of

trends. The integrity of the operator’s effective safety

reporting system, and the maintenance of reporter

confidentiality that is required to support it, should

be a priority for the regulator. The regulator should

expect the operator to have already documented

trends and re‐evaluated the fatigue‐related risk using

the risk assessment functions.  

The regulator should also conduct a review of the

operator’s final documentation and procedures to

ensure required corrections or additions have been

made. Finally, they should review the final training

package, including the recurrent training programme.

Once all the criteria in each of the steps have been

met, and all of the FRMS processes are functioning in

a cohesive manner with regards to the specific

operations to which they have been applied, approval

can be given. This means that the operator is no

longer on a trial period and may now use the FRMS to

adjust flight and duty hours within the approved

outer limits for the particular operations identified.

Any changes to the scope of the FRMS cannot be

implemented without regulatory approval for its

application to new operations.  

The following table provides a checklist of the general

requirements for validating the safety assurance

processes.  

Regulatory Checklist:

Validation of FRMS safety assurance processes

(Chapter 5)

• Safety performance indicators are identified and

acceptable to the regulator (5.2).

• The safety performance of the FRMS is monitored

through monitoring of trends in safety

performance indicators (5.2, 5.3).  

• Mitigations and controls are changed where

necessary in response to the findings (5.3, 5.4).

• There is an existing process for identifying and

managing changes that affect the FRMS (5.5).

• There is an existing process for continual

improvement of the FRMS.
8‐12 FRMS approval process

Unedited version

• Review final FRMS documentation, including:

o FRM processes  

o FRMS safety assurance processes

o FRMS Training (including recurrent training

programme)

o FRMS Communication procedures and

processes

The final part of the approval process will be for the

regulator to set up the ongoing audit requirements

and the audit calendar. As part of this, the regulator

may require that the operator sends monthly updates

(or another designated period of time) of trends on

all or some of the agreed FRMS performance

indicators.

In the same way that normal oversight audit

functions are recorded, regulators will need to ensure

that where an operator uses an FRMS, they have an

adequate record keeping process. These records will

store the outcomes, findings and rectification

notifications of the approval process and ongoing

oversight.
Chapter 9. Oversight of an FRMS 9‐1

Unedited version

Chapter 9:  Oversight of an FRMS

Once approval of an operator’s FRMS has been given,

it is the State’s responsibility to continue monitoring

the effectiveness of the FRMS, that it complies with

the regulations, and that it demonstrates an

acceptable level of performance. Organizational

conditions change, and many, such as external

pressures on the operator, economic issues, and the

overall performance of the operator, may have

consequences for the effectiveness of the FRMS.

Therefore, after final approval, the oversight of the

FRMS forms part of the regulator’s periodic

surveillance programme of the operator.

9.1  Regulatory planning functions

In order to ensure appropriate levels of oversight,

formal audits will need to be planned. Consideration

will need to be given to:

• Establishing an FRMS audit/inspection schedule as

part of the oversight programme.

The regulator will need to visit the operator at

least once a year. Ad hoc visits could also be made

and as part of the oversight, the regulator may also

wish to have more frequent documentation sent to

them by the operator.  

• Inspectorate resources:

Inspectors need to have knowledge of fatigue

science (see Chapter 6), experience in regulating

FRMS, as well as practical knowledge of the

operator.  

9.2  Special requirements for FRMS

oversight

In overseeing the operator’s FRMS, the regulator will

examine evidence of the operator’s FRMS safety

assurance functions by reviewing the agreed FRMS

performance targets and assess any trends. They will

also check that the system has been subject to

internal auditing of the processes. The regulator may

choose to audit some of the primary sources of input

into the system (e.g. fatigue reports). They will need

to confirm that the operator is documenting trends

and, where necessary, is identifying potentially

adverse trends and managing them appropriately as

part of the risk assessment functions. The regulator

will also conduct a review of the operator’s

documentation and procedures to assess any

corrections or additions that have been made post‐

approval. They will also review the current training

package, including all staff training records.  

As part of normal oversight, the regulator will

conduct interviews with a variety of people involved

with the FRMS, and monitor changes of key FRMS

personnel. Where key personnel have changed, the

regulator should seek to ensure the new personnel

are included in their list of interviewees. Occasionally,

a State inspector might also ask to attend an

operator’s Fatigue Safety Action Group meeting to

gain better insight in its FRMS processes, although

the inspector cannot be part of the Fatigue Safety

Action Group activities.  

The regulator is seeking to ensure that all of the

FRMS processes are functioning in a cohesive manner

with regards to the specific operations to which they

have been applied.    

Regulatory Checklist:

Oversight of an FRMS

• FRMS performance indicator and target review

• Targeted sampling of records and documentation

• Documented interviews

• Continuous reporting  

• Attendance at meetings, training sessions

• Evidence of information flow between SMS and

FRMS

• Fatigue Safety Action Group

o Review of hazard log

o Review of meeting minutes

• Collection of information from external sources,

e.g. scientific reviews, experience gained from

oversight of other operator’s FRMSs.

• Reviewing outer limits
9‐2 Oversight of an FRMS

Unedited version

• Reviewing FTLs identified within the FRMS

operations

• Assess management of changes, e.g.

o The operations to which the FRMS applies

o Key personnel

9.3  Enforcement

Regulators will need to establish a process for use

when deficiencies in an FRMS are identified.  

Enforcement actions should be commensurate to the

level of risk resulting from the deficiency. These

actions may range from administrative changes,

FRMS operational changes, to a withdrawal of FRMS

approval.

The following discusses various enforcement

alternatives in increasing severity:

• Operator on notice to improve FRMS processes:

Where the State’s oversight produces concerns

that the operator’s FRMS may not meet regulatory

requirements, then the operator should first be

given an opportunity to improve the specific

aspects of its FRMS so that it does meet regulatory

requirements. Based on the findings of the audit

process, the regulator will need to provide advice

to the operator and identify a mutually‐agreed

corrective action plan.

• Regulator‐mandated lowering of maximum values

(and/or increasing minimum values):

Where the State’s oversight produces concerns

that an element of an operator’s FRMS may be

ineffective, then the State may need to revise an

operator’s maximum and minimum values. These

regulator‐set limits should remain in place until the

operator can provide evidence that their FRMS

processes are effective and the State has regained

regulatory confidence in the operator.  

• Withdrawal of FRMS approval:

Where there is a significant safety concern that has

not been addressed by the above enforcement

alternatives, it is the State’s obligation to withdraw

the FRMS approval and require the operator to

operate within prescriptive flight and duty

limitations. While complying with the prescriptive

flight and duty limitations, the operator may

attempt to improve their FRMS processes and

other safety systems and SMS processes, in order

to re‐establish regulatory confidence and re‐apply

for FRMS approval. Should the State consider that

the operator’s FRMS meets their requirements at

this point, the State may approve the FRMS on

restricted conditions (e.g. decreased maximum

values for flight and duty periods and minimum

values for rest periods) until such time as they

were confident of the maturity and effectiveness of

the system.
Appendix A. Glossary A‐1

Unedited version

Appendix A: Glossary   * denotes an ICAO definition

Actiwatch. A wristwatch‐like device containing an

accelerometer to detect movement. Activity

counts are recorded per unit time, for example

every minute. The patterns of movement can be

analyzed using purpose‐built software to estimate

when the wearer of the actiwatch was asleep, and

to provide some indication of how restless a sleep

period was (i.e., sleep quality). Actiwatches are

designed to record continuously for several weeks

so they are valuable tools for monitoring sleep

patterns, for example before, during, and after a  

trip. Actiwatches provide graphs of movement as

output (actigraphs).

Actigraphy. Use of actiwatches to monitor sleep

patterns. For actigraphy to be a reliable measure of

sleep, the computer algorithm that estimates sleep

from activity counts must have been validated

against polysomnography, which is the gold

standard technology for measuring sleep duration

and quality. The main weakness of actigraphy is

that sleep and still wakefulness looks the same on

an actigraph (since an actiwatch measures

movement).

Afternoon nap window. A time of increased

sleepiness in the middle of the afternoon. The

precise timing varies, but for most people it is

usually around 15:00‐17:00. This is a good time to

try to nap. On the other hand, it is also a time

when it is more difficult to stay awake, so

unintentional micro‐sleeps are more likely,

especially if recent sleep has been restricted.    

Augmented flight crew. A flight crew that comprises

more than the minimum number required to

operate the aeroplane so that each crewmember

can leave his or her assigned post to obtain in‐flight

rest and be replaced by another appropriately

qualified crewmember.

Augmented long‐range operations. Flights where the

flight duty period is extended through the use of

augmented crews, allowing crewmembers the

opportunity for in‐flight rest.  

Bio‐mathematical model. A computer programme

designed to predict crewmember fatigue levels,

based on scientific understanding of the factors

contributing to fatigue. All bio‐mathematical

models have limitations that need to be

understood for their appropriate use in an FRMS.

An optional tool (not a requirement) for predictive

fatigue hazard identification (ICAO Annex 6, Part 1,

Appendix 8, Section 2.1.)

Chronic fatigue. In fatigue risk management, chronic

fatigue refers to the sleepiness and performance

impairment that accumulate when sleep is

restricted day after day. These effects can be

reversed by obtaining adequate recovery sleep

(also see cumulative sleep debt).

Chronic fatigue syndrome. A medical condition for

which the diagnosis requires a person must meet

two criteria:

1. Have severe chronic fatigue for at least 6 months

or longer that is not relieved by rest and not due

to medical or psychiatric conditions associated

with fatigue as excluded by clinical diagnosis;

and

2. Concurrently have four or more of the following

symptoms: self‐reported impairment in short‐

term memory or concentration severe enough to

cause substantial reduction in previous levels of

occupational, educational, social, or personal

activities; sore throat that is frequent or

recurring; tender lymph nodes in the neck or

armpits; muscle pain; multi‐joint pain without

swelling or redness; headaches of a new type,

pattern, or severity; unrefreshing sleep;    and

post‐exertional malaise (extreme, prolonged

exhaustion and sickness following physical or

mental activity) lasting more than 24 hours.  

The fatigue and impaired memory or

concentration must have impaired normal daily

activities, along with other symptoms that must

have persisted or recurred during 6 or more

consecutive months of illness and must not have
A‐2 Glossary

Unedited version

predated the fatigue.

(http://www.cdc.gov/cfs/general/case_definitio

n/index.html)

Circadian body clock. A neural pacemaker in the

brain that monitors the day/night cycle (via a

special light input pathway from the eyes) and

determines our preference for sleeping at night.

Shift work is problematic because it requires a shift

in the sleep/wake pattern that is resisted by the

circadian body clock, which remains ‘locked on’ to

the day/night cycle. Jet lag is problematic because

it involves a sudden shift in the day/night cycle to

which the circadian body clock will eventually

adapt, given enough time in the new time zone.  

Controls. System‐level defensive strategies designed

to minimize fatigue risk on an ongoing basis.

Examples include: scheduling rules, monitoring

staffing levels at crew bases, selection of

appropriate in‐flight crew rest facilities, and

protocols for in‐flight rest and controlled rest on

the flight deck.

Controlled flight deck napping. An effective

mitigation strategy to be used as needed in

response to fatigue experienced during flight

operations. Recommended procedures for

controlled flight deck napping can be found in

Appendix C. It should not be used as a scheduling

tool, i.e., as a planned strategy to enable extended

duty periods.  

Countermeasures. Personal mitigation strategies that

crewmembers can use to reduce their own fatigue

risk. Sometimes divided into strategic

countermeasures (for use at home and on

layovers, for example good sleep habits, napping

before night duty), and operational

countermeasures for use in flight, for example

controlled rest on the flight deck.

*Crewmember. A person assigned by an Operator to

duty on an aircraft during a flight duty period.

Crew pairing. A set of scheduled flights on which a

crewmember is rostered for one or more days.

Cumulative sleep debt. Sleep loss accumulated when

sleep is insufficient for multiple nights (or 24‐hr

days) in a row. As cumulative sleep debt builds up,

performance impairment and objective sleepiness

increase progressively, and people tend to become

less reliable at assessing their own level of

impairment.  

*Duty. Any task that crew members are required by

the Operator to perform, including, for example,

flight duty, administrative work, training,

positioning and standby when it is likely to induce

fatigue.   

*Duty period. A period which starts when a flight or

cabin crew member is required by an Operator to

report for or to commence a duty and ends when

that person is free from all duties.

Evening type. A person whose natural sleep time is

later than average as a result of the characteristics

of their circadian biological clock. There is also a

developmental trend to become more evening‐

type across puberty, which reverses for most

people in adulthood.

Evening wake maintenance zone. A period of several

hours in the circadian body clock cycle, just before

usual bedtime, when it is very difficult to fall

asleep. Consequently, going to bed extra early

usually results in taking a longer time to fall asleep,

rather than getting extra sleep. Can cause

restricted sleep and increased fatigue risk with

early duty start times.

*Fatigue. A physiological state of reduced mental or

physical performance capability resulting from

sleep loss or extended wakefulness, circadian

phase, or workload (mental and/or physical

activity) that can impair a crew member’s alertness

and ability to safely operate an aircraft or perform

safety related duties.

FRMS training. Competency‐based training

programmes designed to ensure that all

stakeholders are competent to undertake their

responsibilities in the FRMS.  
Glossary A‐3

Unedited version

Fatigue safety action group (FSAG). A group

comprised of representatives of all stakeholder

groups (management, scheduling, crew

representatives) together with specialist scientific,

data analysis, and medical expertise as required),

that is responsible for coordinating all fatigue

management activities in the organization.  

Fatigue risk management. The management of

fatigue in a manner appropriate to the level of risk

exposure and the nature of the operation, in order

to minimize the adverse effects of fatigue on the

safety of operations

Fatigue risk management system policy. A required

component of an FRMS (ICAO Annex 6, Part 1,

Appendix 8, Section 1.1). THE FRMS Policy must:

identify the elements of the FRMS and its scope;

reflect the shared responsibility of all stakeholders

in the FRMS; state the safety objectives of the

FRMS; be signed by the accountable executive of

the organization; be communicated throughout the

organization; declares management commitment

to effective safety reporting, to providing adequate

resourcing for the FRMS, and to continuous

improvement of the FRMS; identify clear lines of

accountability for the functioning of the FRMS; and

require periodic reviews of the FRMS.

*Fatigue risk management system (FRMS). A data‐

driven means of continuously monitoring and

managing fatigue‐related safety risks, based upon

scientific principles and knowledge as well as

operational experience that aims to ensure

relevant personnel are performing at adequate

levels of alertness.

Fatigue safety assurance. FRMS safety assurance

processes monitor the entire FRMS to check that it

is functioning as intended and meeting the safety

objectives in the FRMS policy and regulatory

requirements. FRMS safety assurance processes

also identify operational and organizational

changes that could potentially affect the FRMS,

and identify areas where the safety performance of

the FRMS could be improved (continuous

improvement).  

*Flight data analysis (FDA). A process of analyzing

recorded flight data in order to improve the safety

of operations.  

*Flight duty period. A period which commences

when a crew member is required to report for duty

that includes a flight or a series of flights and which

finishes when the aeroplane finally comes to rest

and the engines are shut down at the end of the

last flight on which he/she is a crew member.

*Flight time – aeroplanes. The total time from the

moment an aeroplane first moves for the purpose

of taking off until the moment it finally comes to

rest at the end of the flight.  

Homeostatic sleep pressure. See Sleep homeostatic

process.

Internal Alarm Clock. A time in the circadian body

clock cycle when there is a very strong drive for

waking and it is difficult to fall asleep or stay

asleep. Occurs about 6 hours after the window of

circadian low in the late morning to early

afternoon and can cause restricted sleep and

increased fatigue risk after night duty.  

Jet lag. Desynchronization between the circadian

body clock and the day/night cycle caused by

transmeridian flight (experienced as a sudden shift

in the day/night cycle). Also results in internal

desynchronization between rhythms in different

body functions. Common symptoms include

wanting to eat and sleep at times that are out of

step with the local routine, problems with

digestion, degraded performance on mental and

physical tasks, and mood changes. Resolves when

sufficient time is spent in the new time zone for

the circadian body clock to become fully adapted

to local time.

Micro‐sleep. A short period of time (seconds) when

the brain disengages from the environment (it

stops processing visual information and sounds)

and slips uncontrollably into light non‐REM sleep.

Micro‐sleeps are a sign of extreme physiological

sleepiness.
A‐4 Glossary

Unedited version

Mitigations. System‐level interventions designed to

reduce a specific identified fatigue risk. Examples

include:    increasing the number of crewmembers

at a base, use of reserve crew, educating

crewmembers on how to obtain optimal in‐flight

sleep, Captain’s discretion to re‐organize in‐flight

rest arrangements on the day of flight in response

to crewmembers’ fatigue levels and operational

conditions, etc.  

Morning type. A person whose natural sleep time is

earlier than average as a result of the

characteristics of their circadian biological clock.

There is also a developmental trend to become

more morning‐type across adulthood.  

Nap. A brief period of sleep, usually defined as less

than half of a full night time sleep period. Naps as

short as 5 minutes have been shown to provide

(temporary) relief from the cumulative effects of

sleep loss – also see controlled flight deck

napping.  

Non‐rapid eye movement sleep (Non‐REM Sleep). A

type of sleep associated with gradual slowing of

electrical activity in the brain (seen as brain waves

measured by electrodes stuck to the scalp, known

as EEG). As the brain waves slow down in non‐REM

sleep, they also increase in amplitude, with the

activity of large groups of brain cells (neurons)

becoming synchronized. Non‐REM sleep is usually

divided into 4 stages, based on the characteristics

of the brainwaves. Stages 1 and 2 represent lighter

sleep. Stages 3 and 4 represent deeper sleep and

are also known as slow‐wave sleep.  

Non‐REM/REM cycle. Regular alternation of non‐

REM sleep and REM sleep across a sleep period, in

a cycle lasting approximately 90 minutes.

Rapid eye movement sleep (REM Sleep) A type of

sleep during which electrical activity of the brain

resembles that during waking. However, from time

to time the eyes move around under the closed

eyelids – the  ‘rapid eye movements’ – and this is

often accompanied by muscle twitches and

irregular heart rate and breathing. People woken

from REM sleep can typically recall vivid dreaming.

At the same time, the body cannot move in

response to signals from the brain, so dreams

cannot be ‘acted out’. The state of paralysis during

REM sleep is sometimes known as the ‘REM block’.

Recovery sleep. Sleep required for recovery from the

effects of acute sleep loss (in one 24‐hour period)

or cumulative sleep debt (over multiple

consecutive 24‐hour periods). Recovery sleep may

be slightly longer than usual, but lost sleep is not

recovered hour‐for‐hour. Two nights of

unrestricted sleep (when a crewmember is fully

adapted to the local time zone) are typically

required for recovery of normal sleep structure

(non‐REM/REM cycles). Recent laboratory research

suggests that recovery of optimal waking function

may take more than two nights of recovery sleep.  

*Rest period. A continuous and defined period of

time subsequent to and/or prior to duty, during

which flight or cabin crew members are free of all

duties.  

Roster/rostering. Assignment of crewmembers to a

schedule.

Safety management. The systematic management of

the operational risks associated with flight,

engineering and ground activities in order to

achieve as high a level of safety performance as is

reasonably practicable.  

*Safety management system (SMS). A systematic

approach to managing safety, including the

necessary organizational structures,

accountabilities, policies and procedures.

Safety performance. The level of safety achieved in a

risk controlled environment measured against a

safety level deemed as low as reasonably

practicable.

Schedule.    Sequence of flights designed to meet

operational requirements and effectively manage

resources including crewmembers.  

Shift work. Any work pattern that requires a

crewmember to be awake at a time in the circadian
Glossary A‐5

Unedited version

body clock cycle that they would normally be

asleep. Problematic because the circadian body

clock is sensitive to light and tends to remain

‘locked on’ to the day/night cycle rather than

adapting to the work pattern. Shift work is usually

associated with sleep restriction, together with a

requirement to work during times in the circadian

body clock cycle when performance and alertness

are sub‐optimal (for example, through the window

of circadian low).

Sleep. A reversible state in which conscious control of

the brain is absent and processing of sensory

information from the environment is minimal. The

brain goes “off‐line” to sort and store the day’s

experiences and replenish essential systems

depleted by waking activities. A complex series of

processes characterized by alternation between

two different brain states: non‐REM sleep and

REM sleep.

Sleep debt. See Cumulative sleep debt.  

Sleep disorders. A range of problems that make it

impossible to obtain restorative sleep, even when

enough time is spent trying to sleep. More than 80

different sleep disorders have been identified, that

can cause varying amounts of sleep disruption.

Examples include obstructive sleep apnea, the

insomnias, narcolepsy, and periodic limb

movements during sleep.  

Sleep homeostatic process. The body’s need for

slow‐wave sleep (non‐REM stages 3 and 4), that

builds up across waking and discharges

exponentially across sleep.  

Sleep inertia. Transient disorientation, grogginess

and performance impairment that can occur as the

brain progresses through the process of waking up.

Sleep inertia can occur on waking from any stage of

sleep but may be longer and more intense on

waking from slow‐wave sleep (non‐REM stages 3

and 4), or after sleep periods or naps containing a

high proportion of slow‐wave sleep.  

Sleep need. The amount of sleep that is required on a

regular basis to maintain optimal levels of waking

alertness and performance. Very difficult to

measure in practice because of individual

differences. In addition, because many people live

with chronic sleep restriction, when they have the

opportunity for unrestricted sleep, their sleep may

be longer than their theoretical ‘sleep need’ due to

recovery sleep.

Sleep quality. Capacity of sleep to restore waking

function. Good quality sleep has minimal

disruption to the non‐REM/REM cycle.

Fragmentation of the non‐REM/REM cycle by

waking up, or by brief arousals that move the brain

to a lighter stage of sleep without actually waking

up, decreases the restorative value of sleep.  

Sleep restriction. Obtaining less sleep than needed

(‘trimming’ sleep) across at least two consecutive

nights. The effects of sleep restriction accumulate,

with performance impairment and objective

sleepiness increasing progressively. The need for

sleep will eventually build to the point where

people fall asleep uncontrollably (see micro‐sleep).  

Slow‐wave sleep. The two deepest stages of non‐

REM sleep (stages 3 and 4), characterized by high

amplitude slow brainwaves (EEG dominated by 0.5‐

4 Hz).  

Standby/standby duty. A defined period of time, at

the airport, at the hotel, or at home, during which

a flight or cabin crew member is required by the

Operator to be available to receive an assignment

for a specific duty without an intervening rest

period.  

Transient fatigue. Impairment accumulated across a

single duty period, from which complete recovery

is possible during the next rest period.

Trip. A scheduling expression describing the time

from when a crewmember initially reports for duty

until he/she returns home from the sequence of

flights and is released from duty. A trip may include

multiple flights and many days of travel.  

Ultra long range operations (ULR). Augmented long

range operations involving any sector between a
A‐6 Glossary

Unedited version

specific city pair in which the planned flight time

exceeds 16 hours, taking into account mean wind

conditions and seasonal changes (as defined by the

Ultra long range Crew Alertness Steering

Committee, Flight Safety Foundation (2005). Flight

Safety Digest 26.)

Unforeseen operational circumstance. An unplanned

event, such as unforecast weather, equipment

malfunction, or air traffic delay that is beyond the

control of the operator. In order to be considered

unforeseen, the circumstance would occur or

become known to the operator after the flight has

begun (after the moment the aeroplane first

moves for the purpose of taking off).

Unrestricted sleep. Sleep which is not restricted by

duty demands. Sleep can begin when a

crewmember feels sleepy, and does not have to be

delayed because of duty demands. In addition, the

crewmember can wake up spontaneously and does

not have to set the alarm to be up in time for duty.

Window of circadian low (WOCL) Time in the

circadian body clock cycle when subjective fatigue

and sleepiness are greatest and people are least

able to do mental or physical work. The WOCL

occurs around the time of the daily low point in

core body temperature  ‐  usually around 03:00‐

05:00 when a person is fully adapted to the local

time zone. However, there is individual variability

in the exact timing of the WOCL, which is earlier in

morning‐types (larks) and later in evening‐types

(owls), and may move a few hours later after

consecutive night shifts.  
Appendix B. Measuring crewmember fatigue B‐1

Unedited version

Appendix B: Measuring crewmember fatigue

FRM Processes (Chapter 4) and FRMS safety

assurance processes (Chapter Five) sometimes

require the measurement of crewmember fatigue.

There is no single measurement that is the ‘gold

standard’, because fatigue‐related impairment affects

many skills and has multiple causes. A wide variety of

fatigue measures are used in scientific research. The

measures described here are examples that have

been chosen because:

• they have been shown to be sensitive for

measuring what they claim to measure (i.e., they

have been scientifically validated);

• they do not jeopardize crewmembers’ ability to

perform their operational duties; and

• they have been widely used in aviation, so data

can be compared between different types of

operations.

   

New ways to measure fatigue and sleep are always

being developed and some will become valuable

tools to add to the list below, once they have been

validated for use in aviation operations.  Meanwhile,

in an FRMS it is important to use measures that are

accepted by regulators, operators, crewmembers,

and scientists as being meaningful and reliable. This

avoids the unnecessary cost and inconvenience of

collecting data that is of doubtful value.

Fatigue measurements can be based on

crewmembers’ recall or current impressions of

fatigue (subjective measures) or on objective

measurements, such as performance tests and

different types of physical monitoring. Each type of

measure has strengths and weaknesses. To decide

which types of data to collect, the most important

consideration should be the expected level of fatigue

risk.

B1. Crewmembers’ recall of fatigue

B1.1 Fatigue Reporting Forms

Fatigue reports allow individual crewmembers to give

vital feedback on fatigue risks where and when they

occur in an operation.    Crew members are

encouraged to do this through an effective reporting

system (ICAO Doc 9859, Safety Management

Manual).    It is necessary to provide a clear

understanding of the line between acceptable

performance (which can include unintended errors)

and unacceptable performance (such as negligence,

recklessness, violations or sabotage). This provides

fair protection to reporters but does exempt them

from punitive action where it is warranted.

Crewmembers also need to be confident that reports

will be acted on, which requires feedback from the

Fatigue Safety Action Group, and they need to be

assured that the intent of the reporting process is to

improve safety, not to attribute blame.    A series of

fatigue reports on a particular route can be a trigger

for further investigation by the Fatigue Safety Action

Group.

Fatigue report forms need to be easy to access,

complete, and submit.  Consideration should be given

to making fatigue report forms available for

completion electronically, for example on lap top

computers or smart phones (I‐Pod, Blackberry, etc).  

The following example is adapted from a form that

has been routinely used in an operator’s FRMS for

more than 10 years.
B‐2 Measuring crewmember fatigue

Unedited version

If confidentiality required tick here         ● Fatigue Report Form

Name Employee No. Pilot/CCM (circle)

WHEN DID IT HAPPEN? Local report date Time of event (local report time)

Duty description (trip pattern)

Sector on which fatigue

occurred

From To

Hours from report time to when fatigue occurred Disrupt? Yes / No

Aircraft type Number of crew

WHAT HAPPENED?

Describe how you felt (or what you observed)

Please circle how you felt

1 Fully alert, wide awake 5 Moderately let down, tired

2 Very lively, somewhat responsive, but not at peak

3 OK, somewhat fresh 6 Extremely tired, very difficult to concentrate

4 A little tired, less than fresh 7 Completely exhausted

Please mark the line below with an ‘X’ at the point that indicates how you felt

alert ‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐    drowsy

WHY DID IT HAPPEN?

Fatigue prior to duty? Yes  / No How long had you been awake when the        

Hotel Yes  / No event happened? hrs mins

Home Yes  / No How much sleep did you have in the 24 hrs

Duty itself Yes  / No before the event? hrs mins

In‐flight rest Yes  / No How much sleep did you have in the 72 hrs

Disrupt Yes  / No before the event? hrs mins

Personal Yes  / No flight deck nap? Yes / No If yes, when

start end

Other comments

WHAT DID YOU DO? Actions taken to manage or reduce fatigue (for example, flight deck nap)

WHAT COULD BE DONE? Suggested corrective actions
Measuring crewmember fatigue B‐3

Unedited version

When fatigue report forms are first introduced, or

other activities that raise fatigue awareness are

launched, there is likely to be an increase in fatigue

reporting. This ‘spike’ does not necessarily represent

an increase in fatigue occurrences or risk. It may

simply be due to people being more likely to report.

Other FRMS safety performance indicators may need

to be evaluated, to decide whether the increase in

reporting should trigger further action by the Fatigue

Safety Action Group.

B1.2 Retrospective surveys

Retrospective surveys are a comparatively cheap

way to obtain information from a group of

crewmembers on a range of topics such as:

• demographics (age, flying experience, gender,

etc);

• amount and quality of sleep at home and on

trips;

• experience of fatigue on duty; and

• views on the causes and consequences of

fatigue on duty.

Wherever possible, validated scales and standard

questions should be used for gathering information

on common topics such as sleep problems. This

enables the responses of crewmembers to be

compared across time, or with other groups. 1 For

example, the Epworth Sleepiness Scale is a validated

tool for measuring the impact of sleepiness on daily

life. It is widely used clinically, to evaluate whether an

individual is experiencing excessive sleepiness, 2 and

information is available on its distribution in large

community samples. 3 Figure B1 shows the Epworth

Sleepiness scale. The crewmember is asked to rate

                                                           

1 Note that some measures, for example the Karolinska

Sleepiness Scale and the Samn‐Perelli Crew Status Check

are not designed to be used retrospectively. They are

meant to be answered in relation to how you feel now. 2 Johns MW (1994). Sleepiness in different situations

measured by the Epworth Sleepiness Scale. Sleep 17:703‐

710.

3 Gander PH, Marshall NS, Harris R, Reid P (2005). The

Epworth sleepiness score: Influence of age, ethnicity and

socioeconomic deprivation. Sleep 28:249‐253

each situation from 0=’would never doze’ to 3 ‘high

chance of dozing’, for a total possible score of 24.

Scores above 10 are generally considered to indicate

excessive sleepiness. Scores above 15 are considered

to indicate extreme sleepiness.
B‐4 Measuring crewmember fatigue

Unedited version

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.                        PLEASE TICK ONE

BOX ON EACH LINE

     would never    slight     moderate    high

     doze     chance     chance    chance

Sitting and reading......0  .............1   ............ 2  .............3  

watching TV......0  .............1   ............ 2  .............3  

Sitting inactive in a public place (eg. theatre, meeting)...... 0  .............1   ............ 2  .............3  

As a passenger in a car for an hour without a break......0  .............1   ............ 2  .............3  

Lying down in the afternoon when circumstances permit..0  .............1   ............ 2  .............3  

Sitting and talking to someone......0  .............1   ............ 2  .............3  

Sitting quietly after a lunch without alcohol......0  .............1   ............ 2  .............3  

   In a car, while stopped for a few minutes in traffic......0  .............1   ............ 2  .............3  

Figure B1: The Epworth Sleepiness Scale

Retrospective surveys can also be used to track the

effectiveness of an FRMS across time (i.e., as an

FRMS safety assurance process – see Figure 5.3).

Strengths and weaknesses of retrospective surveys

Retrospective surveys are a comparatively cheap way

to gather a range of information. However, time and

costs are involved in developing and distributing the

survey questionnaire, entering the information into

databases and analyzing it.

A limitation of retrospective surveys is that the

information gathered is subjective, and therefore its

reliability is open to question. Reliability is a

particular issue when crewmembers are asked to

accurately recall details of past events, feelings, or

sleep patterns. This is not to question crewmembers’

integrity – inaccurate recall of past events is a

common and complex human problem. Concerns

about whether some crewmembers might exaggerate

in their responses, for personal or industrial reasons,

should be minimal in a just reporting culture as is

required for FRMS. In addition, extreme ratings are

obvious when compared with group averages.   

Crewmembers’ confidence in the confidentiality of

their data is likely to be a very important factor in

their willingness to participate in surveys and to

provide complete information on questionnaires.

Despite limitations, retrospective surveys from time‐

to‐time can be a useful source of information in an

FRMS.

B2. Monitoring crewmember fatigue

during flight operations

B2.1 Subjective fatigue and sleepiness ratings

The following things should be considered when

choosing rating scales for monitoring crewmember

fatigue and sleepiness during flight operations.

i. Is the scale quick and easy to complete?

ii. Is it designed to be completed at multiple time

points, e.g., across a flight?

iii. Has it been validated? For example, has it been

shown to be sensitive to the effects of sleep loss

and the circadian body clock cycle under

controlled experimental conditions?  

iv. Is it predictive of objective measures such as

performance or motor vehicle crash risk?

v. Has it been used in other aviation operations, and

are the data available to compare fatigue levels?   

The following two scales meet these criteria.  
Measuring crewmember fatigue B‐5

Unedited version

The Karolinska Sleepiness Scale (KSS)

This scale asks people to rate how sleepy they feel

right now. 4 Any of the values from 1‐9 can be ticked,

not only those with a verbal description.

Figure B3: The Karolinska Sleepiness Scale (KSS)

Figure B4 shows KSS ratings from 25 flight

crewmembers across ultra‐long range flights from

Singapore to Los Angeles5

.   

                                                           

4 Åkerstedt T, Gillberg M. Subjective and objective

sleepiness in the active individual. Int J Neurosci 52: 29‐37,

1990.

Gillberg M, Kecklund G, Åkerstedt T. Relations between

performance and subjective ratings of sleepiness during a

night awake. Sleep 17(3): 236‐241, 1994.

Harma M, Sallinen M, Ranta R, Mutanen P, Muller K. The

effect of an irregular shift system on sleepiness at work in

train drivers and railway traffic controllers. J Sleep Res

11(2):141‐151, 2002.

Gillberg M. Subjective alertness and sleep quality in

connection with permanent 12‐hour day and night shifts.

Scand J Work Environ Health 24 (Suppl 3): 76‐80, 1998.

Reyner LA, Horne JA. Evaluation of ‘in‐car’

countermeasures to sleepiness: cold air and radio. Sleep

21(1): 46‐50, 1998. 5 Flight Safety Foundation (2006). Flight Safety Digest 24

(8‐9).

Signal TL, van den Berg M, Travier N, Gander PH (2004).

Phase 3 ultra‐long range validation: in‐flight

polysomnographic sleep and psychomotor performance.

Wellington, New Zealand: Massey University, Sleep/Wake

Research Centre Report.

Figure B4: KSS sleepiness ratings on flights from

Singapore to Los Angeles

Solid line – data for the command crew

Dotted line – data for the relief crew

Each flight had two crews (two captains, two first

officers). The command crew (solid line) flew both

the take off and the landing and was allocated the 2nd

and 4th in‐flight rest periods. The relief crew (dotted

line) was allocated the 1st and 3rd in‐flight rest periods

(they became the command crew for the return

flight).  

Ratings were made at the following times:

• rating 1 ‐  pre‐flight;

• rating 2 ‐ at top of climb;

• rating 3 ‐ before each crewmember’s 1st  in‐flight

rest period;

• rating 4  ‐  after each crewmember’s 1st in‐flight

rest period;

• rating 5 ‐ before each crewmember’s 2nd  in‐flight

rest period;

• rating 6 – after each crewmember’s 2nd  in‐flight

rest period;   

• rating 7 ‐ at top of descent; and

• rating 8 ‐ post‐flight before departing the aircraft.

12345678

Rating Time

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4.00

6.00

8.00

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1 = extremely alert

2

3 = alert

4

5 = neither sleepy nor alert

6

7 = sleepy, but no difficulty remaining awake

8

9 = extremely sleepy, fighting sleep
B‐6 Measuring crewmember fatigue

Unedited version

The command and relief crews have different

patterns in their sleepiness ratings across the flight,

partly as a result of their different in‐flight rest

periods.

The Samn‐Perelli Crew Status Check  

This scale asks people to rate their level of fatigue

right now, and is a simplified version of the Samn‐

Perelli Checklist6

.  

Figure B5: The Samn‐Perelli Crew Status Check

Figure B6 shows Samn‐Perelli ratings for the same

ULR crewmembers on the same flights as in Figure

B4.  

                                                           

6 Samn SW, Perelli LP. Estimating aircrew fatigue: A

technique with implications to airlift operations. Brooks

AFB, TX: USAF School of Aerospace Medicine. Technical

Report No. SAM‐TR‐82‐21, 1982.

Samel A, Wegmann HM, Vejvoda M, Drescher J, Gundel A,

Manzey D, Wenzel J. Two‐crew operations: Stress and

fatigue during long‐haul night flights. Aviat Space Environ

Med 68: 679‐87, 1997.

Samel A, Wegmann HM, Vejvoda M. Aircrew fatigue in

long‐haul operations. Accid Anal & Prev 29(4); 439‐452,

1997.

Figure B6: Samn‐Perelli fatigue ratings on flights from

Singapore to Los Angeles

Solid line – data for the command crew

Dotted line – data for the relief crew

Strengths and weaknesses of subjective ratings

Subjective sleepiness and fatigue ratings are

relatively cheap and easy to collect and analyze.

Furthermore, how a crewmember feels is likely to

influence their decisions about when to use personal

fatigue countermeasure strategies. On the other

hand, subjective ratings do not always reliably reflect

objective measures of performance impairment or

sleep loss, particularly when a person has been

getting less sleep than they need (sleep restriction)

across several consecutive nights.  

Concerns about some crewmembers exaggerating on

subjective fatigue and sleepiness ratings, for personal

or industrial reasons, should be minimal in a just

reporting culture as is required for FRMS. In addition,

extreme ratings are obvious when compared with

group averages.   

In an FRMS, subjective sleepiness and fatigue ratings

are particularly useful for:

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Rating Time

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2.00

4.00

6.00

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1 = fully alert, wide awake

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
Measuring crewmember fatigue B‐7

Unedited version

• gathering information from large groups of

crewmembers;  

• where data are needed fairly quickly to decide

whether more in‐depth monitoring is warranted

or if additional fatigue risk mitigation strategies

are needed; and

• among a range of measures when more intensive

monitoring is undertaken in an FRMS (for

example during validation of a new route),

because they provide valuable insights on

crewmembers’ experience of fatigue.

Decision‐making by the Fatigue Safety Action Group

can be guided by comparing average (and/or

extreme) ratings with data gathered on other

operations.

B2.2 Objective performance measurement

A range of objective performance tests are used in

laboratory studies, but they usually measure very

specific aspects of performance (for example,

reaction time, vigilance, short‐term memory, etc), not

the complex combinations of skills needed by

crewmembers in the course of flight duties.  

Laboratory tests usually also measure the

performance of individuals, not the combined

performance of the crew.  Nevertheless, some simple

performance tests are considered ‘probes’ or

indicators of a crewmember’s capacity to carry out

his or her duties.  

The following things should be considered when

choosing performance tests for monitoring

crewmember fatigue and sleepiness during flight

operations.

I. How long does the test last?

II. Can it be completed at multiple time points,

(e.g., a number of times across a flight), without

compromising a crewmember’s ability to meet

duty requirements?

III. Has it been validated? For example, has it been

shown to be sensitive to the effects of sleep loss

and the circadian body clock cycle under

controlled experimental conditions?  

IV. Is it predictive of more complex tasks, e.g., crew

performance in the simulator or during an in‐

flight emergency? (Unfortunately, there is very

little research addressing this question at

present.)

V. Has it been used in other aviation operations,

and are the data available to compare fatigue

levels?   

One performance test that meets these criteria is the

Psychomotor Vigilance Task or PVT7

. In the most

widely used version of the PVT, the test lasts for 10

minutes and is carried out on a purpose‐built hand‐

held device.    However, some recent studies8 and

large aviation field studies currently in progress are

using a 5‐minute version of the PVT programmed on

a Personal Data Assistant (PDA) device.  

Figure B7 shows mean reaction times on the PVT for

the same ULR crewmembers on the same flights as in

Figures B4 and B6. In this study, the 10‐minute

version of the test was used. PVT tests were done at

the following times:

• test 1 ‐ close to top of climb;

• test 2  ‐  at the start of the second in‐flight rest

opportunity;

• test 3 ‐ close to top of descent; and  

• test 4 post‐flight,  before departing the aircraft.  

                                                           

7 Dinges, D. F. and Powell, J. P. (1985). Microcomputer analysis of

performance on a portable, simple visual RT task during sustained

operation. Behavior Research Methods, Instruments, and

Computing, 17: 652‐655

Balkin, T. J., Bliese, P. D., Belenky, G., Sing, H., Thorne, D. R.,

Thomas, M., Redmond, D. P., Russo, M. and Wesensten, N. J.

(2004). Comparative utility of instruments for monitoring

sleepiness‐related performance decrements in the operational

environment. Journal of Sleep Research, 13: 219‐227. 8 Lamond N, Petrelli, R, Dawson D, Roach GD. The impact of

layover length on the fatigue and recovery of long‐haul flight

crew. Proceedings of the Fatigue in Transportation Conference

(Session 13c), Seattle, September 11‐25, 2005. US Department of

Transport.  
B‐8 Measuring crewmember fatigue

Unedited version

Figure B7: Mean Reaction Time on the PVT Task on

Flights from Singapore to Los Angeles

Solid line – data for the command crew

Dotted line – data for the relief crew

Strengths and weaknesses of the PVT

The PVT requires a crewmember’s constant attention

during the test.    In the study in Figure B7, for

example, this meant that crewmembers were

required to be out of the operational control loop for

a total of 30 minutes during the flight. This is an even

greater challenge when crews are not augmented.  

In the study in Figure in B7, crewmembers were

asked to complete PVT tests on the flight deck and

there were clearly occasions when their attention

was distracted by operational events. This increased

the variability of performance on the PVT test across

the group and made it more difficult to find

statistically significant changes in PVT performance

across the flight. Only the post‐flight test (Test 4) in

Figure B7 is significantly different from any of the

others.

The PVT does not measure important skills such as

situation awareness and decision‐making. On the

other hand, more complex tests to measure these

types of skills usually require many practice trials

before they can be considered fully learnt and ready

to be used for measuring changes due to fatigue. The

PVT does not require practice trials, except to make

sure that crewmembers know how to operate the

testing device.   

B2.3 Monitoring Sleep

Sleep loss is a key contributing factor to fatigue. In

addition, crewmembers need to get recovery sleep to

return to their optimum level of waking function.

Sleep can be monitored during flight operations using

subjective sleep diaries and/or by objective measures

such as actigraphy or polysomnography. Each of

these is described in more detail below.

Sleep Diaries

Sleep diaries ask crewmembers to record the

following information about each sleep period:

• where they sleep (home, layover hotel, in flight in

a crew rest facility or a business class seat, etc);

• what time they go to bed and get up;

• how much sleep they think they get; and  

• how well they think they sleep.   

Crewmembers may also be asked to rate their

sleepiness and fatigue before and after planned sleep

periods. When sleep is being monitored during flight

operations, crewmembers are also asked to record

actual duty times.

Diaries can have different layouts and they are often

adapted to include specific information for a given

study (for example, reminders about when to do

performance tests or workload rating scales). Paper‐

based diaries are still more common, but electronic

versions are also used (e.g., programmed on a PDA).

Different layouts may be required for different parts

of a study, for example pre‐trip, during flights, and

during layovers.   

Figure B8 shows an example of an in‐flight sleep diary

designed to be used during ultra‐long range flight

when crews have multiple in‐flight rest periods

1234

Test Number

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250.00

275.00

300.00

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Measuring crewmember fatigue B‐9

Unedited version

(courtesy of the Sleep/Wake Research Centre). This

example includes Karolinska Sleepiness and Samn‐

Perelli ratings before and after each sleep period, as

well as a sleep quality rating scale for each sleep

period.

Figure B8: Example of an in‐flight sleep diary

for ULR operations

Strengths and weaknesses of sleep diaries

Sleep diaries are cheap compared to objective forms

of sleep monitoring. However, information from

paper diaries needs to be manually entered into

databases, which can slow down the process of

getting answers to a particular operational question,

and analysis of diary data has costs associated.

Sleep diaries are known to be less reliable than

objective sleep monitoring. One study has compared

sleep diaries and objective sleep measures from 21 B‐

777 flight crewmembers in a layover hotel and in

flight. 9 For in‐flight sleep:  

• average sleep durations from diaries were similar

to those recorded using polysomnography (the

accepted gold standard for recording sleep); but

• the variability among individuals was high. Some

crewmembers over‐estimated how long they

slept, and others underestimated; and

• crewmembers’ estimates of how long they took

to fall asleep, and their ratings of sleep quality

were not reliably related to polysomnography

measures.

Thus diaries alone may be useful for measuring the

sleep duration of groups but cannot be considered

accurate for estimating the sleep duration of any one

individual. In addition, diaries are not generally

considered reliable for measuring sleep quality.

(However, some very new research suggests that

people’s reports of their sleep quality may be related

to changes in parts of the brain that are not detected

by polysomnography, so scientific opinion about the

value of self‐reported sleep quality may change).

Despite these limitations, sleep diaries are a relatively

cheap way of gathering reasonable information on

the average amount of sleep obtained by groups of

crewmembers. They are also used to help interpret

objective sleep data, as described below.

Actigraphy

An actigraph is a small device worn on the wrist that

contains an accelerometer to measure movement

and a memory chip to store ‘activity counts’ at

regular intervals (for example every minute).

Depending on the amount of memory available, they

can be worn for weeks to months before the data

need to be down‐loaded to a computer for analysis.

Figure B9 shows an example of an older style

actigraph.  

                                                           

9 Signal, T.L., Gale, J., and Gander, P.H. (2005) Sleep

Measurement in Flight Crew: Comparing Actigraphic and

Subjective Estimates of Sleep with Polysomnography. Aviation

Space and Environmental Medicine 76(11):1058‐1063
B‐10 Measuring crewmember fatigue

Unedited version

There are a number of manufacturers of actigraph

devices, and each type comes with custom software

that scans through the activity record and decides

(based on a validated algorithm), whether the person

was asleep or awake in each recorded epoch (for

example every minute). Some devices have light

sensors and some also have a regular watch face so

that the wearer does not need to wear a normal

watch as well, to keep track of time.  

Figure B9: an example of an actigraph

Figure B10 shows an actigraphy record from a

crewmember before, during, and after a Singapore‐

Los Angeles‐Singapore ULR trip. Each vertical gray bar

indicates an hour, with 24 hours (from midnight to

midnight) plotted across the diagram. Consecutive

days are shown down the page. The vertical black

bars indicate the level of activity for each minute of

the recording (higher bars indicate more movement).

Periods with minimal movement (short, scattered

black bars) correspond to times when the

crewmember was asleep.  

On the first Thursday, the crewmember flew as a

relief crewmember on the SIN‐LAX segment, during

which he had three in‐flight rest opportunities (1 hr

30 mins, 4 hrs, and 2 hrs), but (according to his diary)

he only went to the crew rest facility for the 2nd of

these. The actigraphy scoring algorithm calculated

that he obtained 2hrs 55 mins of sleep during the 2nd

rest period, and 1 hr 12 mins of sleep during his 3rd

rest period, which he took in a passenger cabin. His

sleep diary indicated that he also spent 44 minutes

trying to sleep during his 1st rest period, but the

algorithm could not (at that time) score such a short

sleep period.

The following Sunday, he flew as a command

crewmember on the LAX‐SIN segment and had two

in‐flight rest opportunities (195 minutes and 300

minutes), both of which he took in the crew rest

facility. According to the actigraphy scoring

algorithm, he obtained 2 hrs 14 min of sleep in his 1st

rest period, and 4 hrs 3 min in his 2nd rest period.

Figure B10 : Actigraphy record of a crewmember

before, during, and after a Singapore‐Los Angeles‐

Singapore ULR trip

Strengths and weaknesses of actigraphy

As Figure B10 illustrates, actigraphy is very useful for

obtaining objective records of the sleep/wake

patterns of crewmembers across multiple days. This

is currently the most practical and reliable way to

look at whether a crewmember accumulates a sleep

debt across a line of flying, compared to the amount

of sleep they average when off duty. Actigraphy can
Measuring crewmember fatigue B‐11

Unedited version

also provide useful information on recovery sleep

after a trip.  

Actigraphs are small and unobtrusive to wear, and

actigraphy is cheap compared to polysomnography.

The main limitation of actigraphy is that it monitors

activity (not sleep) and it cannot distinguish between

someone being asleep versus being awake but not

moving.

The study described previously 9 also compared

actigraphy and polysomnographic sleep recordings

from the 21 B‐777 flight crewmembers. For both

hotel sleep and bunk sleep:

• average sleep durations calculated from

actigraphy were similar to those recorded using

polysomnography; but

• for individual crewmembers, actigraphy could

overestimate or underestimate polysomnographic

sleep duration by more than an hour. This

amount of inaccuracy is particularly problematic

for in‐flight sleep periods, which tend to be short;

and

• comparing actigraphy and polysomnography

minute‐by‐minute, the study concluded that

actigraphic estimates of how long crewmembers

took to fall asleep, and of how often they woke

up during a sleep period (sleep quality), were not

reliably related to polysomnographic measures.  

On the positive side, the study demonstrated that

actigraphy was not significantly contaminated by in‐

flight factors such as turbulence or aircraft

movement, and that it is reliable for estimating the

average sleep duration of groups of crewmembers,

both in the air and on the ground.   

Actigraphs are currently not particularly cheap,

although some manufacturers are working on new

generation devices that may push costs down. Not all

actigraphs on the market have been validated (by

comparing their algorithms for estimating sleep

quantity and quality with polysomnography), and

some have not yet been demonstrated to be robust

and reliable for sleep monitoring during flight

operations (battery life can be a problem in some

devices).  

At present, the accepted standard for analyzing

actigraphy records is to use a sleep diary to identify

when a crewmember was trying to sleep (as opposed

to just sitting still or not wearing the watch). The

sections of the record where the crewmember was

trying to sleep are then analyzed for sleep duration

and quality. This type of analysis requires a trained

person to work through actigraphy records manually,

which is time consuming and fairly costly. Several

manufacturers and research groups are looking at

ways to bypass the need for this manual scoring,

which would make actigraphy much cheaper and

faster to analyze. However, the reliability of these

new approaches for estimating sleep quantity and

quality (compared to polysomography) remains to be

demonstrated.   

Some operators may choose to develop the capacity

in‐house to collect and analyze actigraphy. As part of

the FRMS Assurance Processes, an external scientific

advisory group could be convened periodically to

review the actigraphy analyses and the resulting

decisions made by the Flight Safety Action Group.   

Polysomnography

Polysomnography is the accepted gold standard for

monitoring sleep and is currently the only method

that gives reliable information on the internal

structure of sleep and on sleep quality. It involves

sticking removable electrodes to the scalp and face

and connecting them to a recording device, to

measure three different types of electrical activity: 1)

brainwaves (electroencephalogram or EEG); 2) eye

movements (electroculogram or EOG); and 3) muscle

tone (electromyogram or EMG).   

In addition to monitoring sleep, polysomnography

can be used to monitor waking alertness, based on

the dominant frequencies in the brainwaves, and

patterns of involuntary slow rolling eye movements

that accompany sleep onset. Figure B11 shows a

flight crewmember on the flight deck wearing

polysomnography electrodes, which the researcher is

connecting to a portable recording device.
B‐12 Measuring crewmember fatigue

Unedited version

Figure B11: Polysomnographic recording in flight

Figure B12 shows an analysis of the polysomnography

record of the 1st in‐flight sleep period on the SIN‐LAX

flight for the same crewmember whose actigraphy

record is shown in Figure B10 (times in UTC).  Figure

B12 is a graph created by a trained sleep technician

who has gone through the entire polysomnographic

recording and, using an internationally agreed set of

rules, has decided for each 30 seconds whether the

crewmember was awake, or in which type of sleep he

spent most of that 30 seconds.    Figure B12 shows

that he took 13 minutes to fall asleep and then spent

a total of 17.5 minutes in light non‐REM sleep (S1 and

S2). However, he woke up 6 times across the sleep

period. He did not enter deep non‐REM sleep (S3 and

S4), or Rapid Eye Movement (REM) sleep.

Figure B12: Polysomnographic record for the

1st in‐flight rest period on the SIN‐LAX flight

(same crewmember as in Figure B10)

Figure B13: Polysomnographic record for the

2nd in‐flight rest period on the SIN‐LAX flight

(same crewmember as in Figure B10)
Measuring crewmember fatigue B‐13

Unedited version

Figure B13 shows the polysomnographic record for

the same crewmember during his 2nd in‐flight rest

period on the SIN‐LAX flight. In this rest period (in the

bunk), he  fell asleep in 19.5 minutes and then slept

for a total of 144.5 minutes, interrupted by numerous

brief periods of waking which totaled  52 minutes. He

spent 1.5 minutes in deep non‐REM sleep (S3), 2

minutes in REM sleep, and the rest of the time in light

non‐REM sleep (S1 and S2).   

Strengths and weaknesses of polysomnography

Figures B12 and B13 show the detailed information

about sleep quality that can only be obtained from

polysomnographic recordings. When it is important

to be certain about the amount and type of sleep that

crewmembers are obtaining, polysomnographic

monitoring is the most trusted method.  

On the other hand, polysomnography is relatively

obtrusive and time‐consuming. It takes a well‐trained

technician about 30 minutes to attach the recording

electrodes to a person’s scalp and face, and check

that all the electrical connections are working. For in‐

flight recordings, the electrical contacts need to be

checked periodically (for example before each in‐

flight rest period) to make sure that the signals are

still clean. Crewmembers can be shown how to

remove the electrodes themselves. However, the

equipment is expensive and fragile and a technician is

required to download the data from the recording

device to a computer, and to clean the equipment.

This means that it is usual for at least one technician

to accompany crewmembers throughout a trip during

which their sleep is recorded using polysomnography.

This is costly.

As previously mentioned, the currently accepted

standard for analyzing polysomnography is to have a

trained sleep scoring technician work through the

entire recording to decide    for each 30 seconds

whether the crewmember    was awake, or in which

type of sleep he/she spent most of that 30 seconds.

For quality assurance, it is usual to have a second

trained technician score at least some of the records

to check the reliability of scoring between the two

technicians. This is time consuming and relatively

expensive. A number of groups are working on

automated scoring systems for polysomnography,

but as yet none of these are widely accepted by the

sleep research and sleep medicine communities.

Beyond the scoring process, it is necessary to have a

qualified person to interpret that significance of

diagrams such as Figures B12 and B13.  

Despite these costs and inconveniences, there have

been a number of studies of flight crew sleep that

have used polysomnography and these have been

very informative. While it is unlikely that any airline

would need to develop in‐house capacity to record

and analyze polysomnography as a routine part of its

FRMS, there are situations where the detailed

information from polysomnography is needed. For

example, in launching the first commercial passenger

ULR flights, Singapore Airlines and the Singapore Civil

Aviation Authority agreed that a subgroup of

crewmembers would have their sleep monitored by

polysomnography during the operational validation

of the SIN‐LAX route. The data in Figures B4, B6, B7,

B10, B12, and B13 come from this validation and are

used with the kind permission of the Singapore Civil

Aviation Authority (Dr Jarnail Singh) and provided by

the Sleep/Wake Research Centre at Massey

University, New Zealand.

B2.4 Monitoring the circadian body clock cycle

The circadian body clock cycle is a key contributing

factor to crewmember fatigue, but it is difficult to

monitor during flight operations. In the laboratory,

the cycle of the body clock is usually monitored by

measuring two of the overt rhythms that it drives:

1. the daily rhythm in core body temperature; and

2. the daily rhythm in levels of the hormone

melatonin, which is secreted by the pineal gland

at night. Melatonin levels can be measured from

blood, saliva, or urine samples collected at

regular intervals.  

During the 1980s, a number of research teams

monitored the circadian body clocks of crewmembers

by tracking the rhythm of core body temperature.

Figure B14 shows the times of the daily temperature
B‐14 Measuring crewmember fatigue

Unedited version

minimum of one participating B‐747 crewmember

across an 8‐day long‐haul trip pattern10.

At home in SFO prior to the trip, his temperature

minimum (inverted triangle) occurred about 5 hours

into his sleep period (black horizontal bar). During the

trip, he repeatedly flew westward then back

eastward across multiple time zones, spending

around 24 hours in each location. The circadian

temperature minimum could not follow this

disrupted pattern (it shifted by no more than 2 hours

from one day to the next). Across the trip pattern, it

drifted progressively later, so that by the time the

crewmember arrived back in SFO at the end of the

trip, it had drifted about 6 hours later. Thus, when he

got home, the crewmember’s circadian body clock

was 6 hours out of step with his home time zone and

took several days to readapt.

Another interesting feature of this record is that the

temperature minimum (when physiological sleep

drive is highest), sometimes occurs in flight, for

example on the flight from NRT to HKG. At these

times, the crewmember is at greatest risk of falling

asleep unintentionally on the flight deck.

Alternatively, if he has the opportunity for a rest

break (which was not the case in this operation), this

would represent a very good time to try to get some

in‐flight sleep.

                                                           

10 Gander, P.H., Gregory, K.B., Miller, D.L., Rosekind, M.R., Connell,

L.J., and Graeber, R.C. (1998) Flight crew fatigue V: long‐haul air

transport operations. Aviation, Space, and Environmental Medicine

69:B37‐B48
Measuring crewmember fatigue B‐15

Unedited version

Clearly, Figure B14 provides valuable information that

can be related to the crewmember’s sleep, fatigue,

mood, and performance capacity. However, it has

been several decades since this type of monitoring

has been undertaken primarily because of the

logistics and cost of tracking circadian rhythms during

flight operations.  

There is ongoing research aimed at developing more

robust and less intrusive methods for continuously

monitoring circadian rhythms outside the laboratory,

including a new generation of temperature ‘pills’,

that are swallowed and transmit temperature

measurements as they transit through the digestive

system.  However, body temperature is also affected

by the level of physical activity, and it is complex to

separate out this ‘masking effect’ from the actual

circadian clock‐driven component of the temperature

rhythm (this was done mathematically in Figure B14).

The second rhythm that is commonly monitored in

the laboratory to track the cycle of the circadian body

clock is the level of the hormone melatonin.

Melatonin can be measured in blood or saliva

samples taken at regular intervals, and its

metabolites can be measured in urine samples. There

are obvious difficulties associated with collection and

frozen storage of body fluid samples during flight

operations. Another complicating factor is that

synthesis of melatonin is switched off by bright light.

Thus, if a crewmember is exposed to daylight during

his/her “biological night” (for example, a few hours

either side of the of the temperature minimum in

Figure B14), melatonin secretion will stop. This makes

it impossible to track its normal circadian cycle cross

Sleep (from diary)

Flight

Local night

Nap

Temperature minimum

Figure B14: Sleep times (diary data) and times of the circadian

temperature minimum

of a crewmember during a long haul trip pattern
B‐16 Measuring crewmember fatigue

Unedited version

a trip such as that in Figure B14. Analyzing for

hormone levels in body fluids is a highly skilled task

that needs to undertaken by a reputable laboratory.

Strengths and weaknesses of monitoring the circadian

body clock cycle

There is remarkably little information available on

how the circadian body clock is affected by any kind

of flight operations.  Where data have been collected,

there is evidence of considerable variability between

individuals on the same trip patterns. Better

information in this area would improve the predictive

power of bio‐mathematical models for fatigue hazard

identification, and might provide insights on how to

tailor personal mitigation strategies for

crewmembers who are morning‐types versus

evening‐types. A number of groups are actively

working on new technologies for monitoring the

circadian body clock cycle, but as yet none of these

has been validated or demonstrated to be robust

enough and practical for use during flight operations.

B3. Evaluating the contribution of

fatigue to safety events

There is no simple formula for evaluating the

contribution of crewmember fatigue to a safety

event. For the purposes of the FRMS, the aim is to

identify how the effects of fatigue could have been

mitigated, in order to reduce the likelihood of similar

occurrences in the future. Basic information can be

collected for all fatigue reports and safety events,

with more in‐depth analyses reserved for events

where it is more likely that fatigue was an important

factor and/or where the outcomes were more severe.  

To establish that fatigue was a contributing factor in

an event, it has to be shown that:

• the person or crew was in a fatigued state; and  

• the person or crew took particular actions or

decisions that were causal in what went wrong;

and

• those actions or decisions are consistent with the

type of behavior expected of a fatigued person or

crew.

In 1997, the Canadian Transportation Safety Board

produced guidelines for fatigue analysis. They suggest

four initial questions to decide whether or not fatigue

was a contributing factor to an event. 11

1. At what time of day did the occurrence take

place?

2. Was the crewmember’s normal circadian rhythm

disrupted?

3. How many hours had the crewmember been

awake at the time of the occurrence?

4. Does the 72‐hour sleep history suggest a sleep

debt?

If the answer to any one of these questions indicates

a problem, then fatigue should be investigated in

greater depth. This requires working through two

checklists (adapted from the Canadian Transportation

Safety Board guide).  

Checklist 1 is designed to establish whether the

person or crew were in a fatigued state, based on a

series of questions or probes that address key aspects

of fatigue. The answer to each question is compared

to the best case response, in order to build an overall

picture of the fatigue hazard. Any departure from the

best case response indicates increased risk of fatigue.

Checklist 2 is designed to establish whether the

unsafe action(s) or decision(s) were consistent with

the type of behavior expected of a fatigued person or

crew.

                                                           

11 Transportation Safety Board of Canada, 1997. A Guide

for Investigating for Fatigue. Transportation Safety Board

of Canada, Gatineau, Quebec.
Measuring crewmember fatigue 

Unedited version

Checklist 1: Establishing the fatigued state

QUESTIONS BEST CASE RESPONSES 

QUANTITY OF SLEEP

(Establish whether or not there was a sleep debt)

How long was last consolidated sleep period? 7.5 to 8.5 hoursStart time? Normal circadian rhythm, late eveningAwake Time? Normal circadian rhythm, early morningWas your sleep interrupted (for how long)? NoAny naps since your last consolidated sleep? yesDuration of naps? Had opportunity for restorative (1.5‐2 hrs) or strategic (20 min) nap prio

start of late shift

Describe your sleep patterns in the last 72 hours. (Applysleep credit system)

2 credits for each hour of sleep; loss of one credit for each hour awake ‐ shobe a positive value

QUALITY OF SLEEP

(Establish whether or not sleep was restorative)How did the sleep period relate to the individual normalsleep cycle i.e., start/finish time?

Normal circadian rhythm, late evening/early morning

Sleep disruptions? No awakeningsSleep environment? Proper environmental conditions (quiet, comfortable temperature, fresh 

own bed, dark room)

Sleep pathologies (disorders) None

WORK HISTORY

(Establish whether hours worked and type of duty or activities involved had an impact on sleep quantity and quality)Hours on duty and/or on call prior to the occurrence? Situation dependent  ‐ hours on duty and/or on call and type of duty t

ensure appropriate level of alertness for the task

Work history in preceding week? Number of hours on duty and/or on call and type of duty that do not lead t

cumulative fatigue
B‐18 Meas

Unedited version

Checklist 1: Establishing the fatigued state (continued)

QUESTIONS BEST CASE RESPONSES INV

IRREGULAR SCHEDULES

(Establish whether the scheduling was problematic with regards to its impact on quantity and quality of sleep)Was crewmember a shift worker (working through usualsleep times)?

No (The circadian body clocks and sleep of shift workers donot adapt fully)

If yes, was it a permanent shift? Yes ‐daysIf no, was it rotating (vs irregular) shift work? Yes  ‐ Rotating clockwise, rotation slow (1 day for each hour

delayed), night shift shorter, and at the end of cycle

How are overtime or double shifts scheduled? Scheduled when crewmembers are in the most alert parts of

the circadian body clock cycle (late morning, mid evening)

Scheduling of critical safety tasks? S Scheduled when crewmembers are in the most alert parts

of the circadian body clock cycle (late morning, mid evening)

Has crewmember had training on personal fatiguemitigation strategies?

Yes

JET LAG

(Establish the existence and impact of jet lag on quantity and quality of sleep)Number of time zones crossed? oneIf more than one, at what rate were they crossed? the slower the betterIn which direction was the flight? westward
Measuring crewmember fatigue B‐19

Unedited version

Checklist 2: Establishing the link between fatigue and the unsafe act(s)/decision(s)

PERFORMANCE INDICATORS INVESTIGATOR’S NOTES

Attention

Overlooked sequential task element

Incorrectly ordered sequential task element

Preoccupied with single tasks or elements

Exhibited lack of awareness of poor performance

Reverted to old habits

Focused on a minor problem despite risk of major one

Did not appreciate gravity of situation

Did not anticipate danger

Displayed decreased vigilance

Did not observe warning signs

Memory

Forgot a task or elements of a task

Forgot the sequence of task or task elements
B‐20 Measuring crewmember fatigue

Unedited version

Inaccurately recalled operational events

Alertness

Succumbed to uncontrollable sleep in form of microsleep,

nap, or long sleep episode

Displayed automatic behavior syndrome

Reaction Time

Responded slowly to normal, abnormal or emergency stimuli

Failed to respond altogether to normal, abnormal or

emergency stimuli

Problem‐Solving Ability

Displayed flawed logic

Displayed problems with arithmetic, geometric or other

cognitive processing tasks

Applied inappropriate corrective action

Did not accurately interpret situation

Displayed poor judgment of distance, speed, and/or time
Measuring crewmember fatigue B‐21

Unedited version

PERFORMANCE INDICATORS INVESTIGATOR’S NOTES

Mood

Was less conversant than normal

Did not perform low‐demand tasks

Was irritable

Distracted by discomfort

Attitude

Displayed a willingness to take risks

Ignored normal checks or procedures

Displayed a ‘don’t care’ attitude

Physiological Effects

Exhibited speech effects

Exhibited reduced manual dexterity  ‐  key‐punch entry

errors, switch selection
Appendix C. Procedures for controlled rest C‐1

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Appendix C: Procedures for controlled rest on the flight deck

Controlled rest on the flight deck is an effective

fatigue mitigation for flight crews. It should not be

used as a scheduling tool. It is not a substitute for

proper preflight sleep or for normal crew

augmentation, but is intended as a response to

unexpected fatigue experienced during operations.

Some basic principles:

• It should be considered a safety net.

• The Fatigue Safety Action Group should be able

to monitor the use of controlled rest on the

flight deck to evaluate whether existing

mitigation strategies are adequate.    Crew

reports are encouraged.

• It should only be used on flights of sufficient

length that it does not interfere with required

operational duties.

• It should only be used during low workload

phases of flight (e.g., during cruise flight).

• It should not be used as a method for extending

crew duty periods.

• Procedures for controlled rest on the flight deck

should be published and included in the

Operations Manual.

Recommended Procedures for Controlled Rest on

the Flight Deck

The following recommended procedures are based

on a survey of major air carriers. They represent

considerable experience in many regions of the

globe and include options reflecting variations

between different types of operations.

Note: this is not intended to be an all inclusive list,

nor are all of these procedures necessarily required.

Each operator should work with their regulator to

define appropriate procedures.

Planning  

 Only one pilot may take controlled rest at a time

in his/her seat.  The harness should be used and

the seat positioned to minimize unintentional

interference with the controls.

 The autopilot and auto‐thrust systems (if

available) should be operational.

 Any routine system or operational intervention

which would normally require a cross check,

should be planned to occur outside controlled

rest periods.

 Controlled rest on the flight deck may be used at

the discretion of the captain to manage both

unexpected fatigue and to reduce the risk of

fatigue during higher workload periods later in

the flight.  

 It should be clearly established who will take rest,

and when it will be taken.    If the pilot in

command requires, the rest may be terminated

at any time.

 The pilot in command should define criteria for

when his/her rest should be interrupted.   

 Hand‐over of duties and wake‐up arrangements

should be reviewed.  

 Flight crews should only use controlled rest if

they are familiar with the published procedures.

 Some operators involve a third crewmember (not

necessarily a pilot) to monitor controlled flight

deck rest. This may include a planned wake‐up

call, a visit to be scheduled just after the planned

rest period ends, or a third crewmember on the

flight deck throughout controlled rest.

 The controlled rest period should be no longer

than 40 minutes, to minimize the risk of sleep

inertia on awakening.     

 Controlled rest should only be utilized during the

cruise period from the top of climb to 20 minutes
C‐2 Procedures for controlled rest

Unedited version

before the planned top of descent. This is to

minimize the risk of sleep inertia.

 A short period of time should be allowed for rest

preparation. This should include an operational

briefing, completion of tasks in progress, and

attention to any physiological needs of either

crew member.  

 During controlled rest, the non‐resting pilot must

perform the duties of the pilot flying and the pilot

monitoring, be able to exercise control of the

aircraft at all times and maintain situational

awareness.    The non‐resting pilot cannot leave

his/her seat for any reason, including

physiological breaks.  

 Aids such as eye shades, neck supports, ear plugs,

etc., should be permitted for the resting pilot.
Appendix D. Example of an FRMS Evaluation Form D‐1

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Appendix D: Example of an FRMS Evaluation Form

TO BE COMPLETED AND SIGNED FOR BY THE SAFETY MANAGER OR ACCOUNTABLE MANAGER

Organization:    Approval

reference:

Signature:    Position:

Print name:    Date of

signing:

FRMS Manual revision:   

FOR AUTHORITY USE ONLY

Staff name:   

Signature:    Date of

assessment:

0. GENERAL ISSUES AND FRMS IMPLEMENTATION

FRMS Scope and Implementation

The Organization should define the scope of the use of FRMS within its operation. In establishing an FRMS a GAP analysis

should be carried out and an implementation plan that will address how the organization will transition to a fully functioning

and effective FRMS.

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0.1    In respect of the management

system, has the structure, activities and

the scope of the FRMS operations been

defined?

0.2    Does the FRMS correspond to

the size, nature and complexity of the

operation and the hazards and

associated risks inherent with its

activities?

0.3    Has a gap analysis been carried

out?

0.4    Is there an FRMS

implementation plan that reflects the

gap analysis?

                                                           

1 Yes (Y), No (N) or Partial (P) 2 Where is it documented in your documentation? 3 Provide details that describe or demonstrates your response to the question. 4 This will be completed by the Authority during the assessment process
D‐2 Example of an FRMS Evaluation Form

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1. SAFETY POLICY AND OBJECTIVES

1.1 Management Commitment and Responsibility

The organization should define its FRMS policy which should be in accordance with international and national requirements,

and which shall be signed by the Accountable Manager of the organization. This policy should reflect organizational

commitments regarding fatigue risk, including a clear statement about the provision of the necessary human and financial

resources for its implementation and be communicated, with visible endorsement, throughout the organization. The FRMS

policy should include the fatigue reporting procedures and management commitment to continuous improvement of the

FRMS. It must also reflect the shared responsibility for the management of fatigue risks with all the stakeholders.

The policy should be periodically reviewed to ensure it remains relevant and appropriate to the organization and the

operations to which FRMS applies.

(Where the FRMS is integrated within the Organization’s SMS, these management commitments and responsibilities may be

included in the SMS safety policy. If this is done it must still be possible to demonstrate these responsibilities as clearly

referenced to fatigue.)

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1.1.1 Is there a written FRMS policy

clearly stating the safety objectives of

the FRMS and endorsed by the

accountable manager?  

   

Or are there clear references to fatigue

risk management with the SMS policy as

endorsed by the accountable manager?

1.1.2 Were key staff consulted in the

development of the FRMS policy /

integration of FRMS into the SMS?

1.1.3 Has the FRMS policy been

communicated effectively throughout

the organization?

1.1.4 Does senior management

continuously promote and demonstrate

its commitment to the continuous

improvement of the FRMS?

1.1.5 Does the Policy include a

commitment to; strive to achieve the

highest safety standards, observe all

applicable legal requirements, standards

and best practice, providing appropriate

resources as a primary responsibility of

all Managers?

1.1.6 Does the FRMS policy actively

encourage fatigue reporting?
Example of an FRMS Evaluation Form D‐3

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1.1.7 Is the FRMS management

system based on the FRMS policy?

1.1.8 Does the FRMS policy reflect

the shared responsibility of the

management of fatigue with all

stakeholders?

1.1.9 Does the FRMS policy reflect

the need for periodic review?

1.2 Accountabilities

The organization shall identify the accountable executive who, irrespective of other functions, shall have ultimate

responsibility and accountability, on behalf of the organization, for the implementation and maintenance of the FRMS. The

organization shall also identify the fatigue risk accountabilities of all members of senior management, irrespective of other

functions, as well as of employees, with respect to the performance of the FRMS. Responsibilities, accountabilities and

authorities shall be documented and communicated throughout the organization, and shall include a definition of the levels

of management with authority to make decisions regarding fatigue risk tolerability.  

(Where the FRMS is integrated within the Organization’s SMS, these accountabilities may be included in the SMS

documentation. If this is done it must still be possible to demonstrate these accountabilities as clearly referenced to fatigue.)

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1.2.1 Does the Accountable Manager

have full responsibility and

accountability for the FRMS and

corporate authority for the organization?

1.2.2 Does the Accountable Manager

have an awareness of their FRMS roles

and responsibilities in respect of the

FRMS policy, fatigue risk management

within the safety culture of the

organization?

1.2.3 Are fatigue risk management

accountabilities, authorities and

responsibilities defined throughout the

organization?

1.2.4 Are there clearly defined lines

of fatigue risk management

accountabilities throughout the

organization?
D‐4 Example of an FRMS Evaluation Form

Unedited version

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1.2.5 Are all staff aware of and

understand their accountabilities,

authorities and responsibilities with

regard to fatigue?

1.3 Appointment of key safety personnel

The organization shall identify a FRMS manager to be the responsible individual and focal point for the implementation and

maintenance of an effective FRMS. There needs to be a clear mechanism for ongoing involvement of all involved personnel

through a functional group responsible for coordinating FRMS activities throughout the organization, which should be

defined and documented. (The reference used in this document is to the Fatigue Safety Action Group (FSAG).)

(Where the FRMS is integrated into the SMS, the FRMS manager would normally report to the Safety Manager, who would

have a direct reporting line to the Accountable Manager. Where the organization is small but with a functioning SMS, it may

not be practical to have a FSAG but to have fatigue as an agenda item on the Safety Action Group meetings.)

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1.3.1 Has a FRMS Manager (or

equivalent) been appointed with the

appropriate knowledge, skills and

experience as defined in the guidance

material?

1.3.2 Is there a direct reporting line

between the FRMS Manager and the

Accountable Manager? (Or where

integrated with SMS, between the FRMS

manager and the Safety Manager.)

1.3.3 Does the FRMS Manager carry

out the functions as detailed in the ICAO

guidance material?

1.3.4 Has a Fatigue Safety Action

Group or equivalent been established?

1.3.5 Does the Board monitor the

performance and effectiveness of the

FRMS as detailed in the guidance

material?

1.3.6 Is the Fatigue Safety Action

Group’s membership and frequency of

meetings defined and minuted?
Example of an FRMS Evaluation Form D‐5

Unedited version

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1.3.7 Has a Fatigue Safety Action

Group or equivalent been established

that fulfils the functions defined in the

guidance material?

1.4  FRMS Documentation

The organization shall develop and maintain FRMS documentation describing the FRMS policy and objectives, the FRMS

requirements, the FRMS processes and procedures, the accountabilities, responsibilities and authorities for processes and

procedures, and the FRMS outputs. The organization shall develop and maintain a FRMS manual to communicate its

approach to the management of safety throughout the organization, or shall incorporate the FRMS documentation into its

existing SMS documentation.

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1.4.1 Does the FRMS management

manual contain all the elements as

detailed in the guidance material?

1.4.2 Is it regularly reviewed?

1.4.3 Is there a system for recording

scheduled and actual flight times, duty

and rest periods with deviations and

reasons for any deviations?

1.4.4 Is there a system for the

recording and storage of FRMS outputs

i.e. hazard logs, risk assessments, fatigue

reports, safety cases, roster metrics,

FSAG minutes, etc?

2. FATIGUE RISK MANAGEMENT

2.1 Hazard Identification  

The organization shall develop and maintain a formal process that ensures that fatigue hazards are identified. This should

include the investigation of incidents and accidents to identify potential fatigue hazards. Fatigue hazard identification shall be

based on a combination of reactive, proactive and predictive methods of data collection.

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2.1.1 Is there a process for

establishing how fatigue hazards are

identified and from what sources?

2.1.2 Is there a confidential fatigue

reporting scheme that encourages

fatigue related issues to be reported by
D‐6 Example of an FRMS Evaluation Form

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staff? (This needs to be open to

proactive and predictive as well as

reactive information.)

2.1.3 Is there feedback to the

reporter and the rest of the

organization?

2.1.4 Does fatigue hazard

identification include reactive, proactive

and predictive schemes?

2.1.5 Have the major fatigue hazards

been identified and assessed for the

organization and its current activities?

2.1.6 Do safety investigations

throughout the organization include

fatigue hazards as possible causal

factors?

2.1.7 Are the fatigue hazards

identified from fatigue investigations

addressed and communicated to the rest

of the organization?

2.1.8 Are fatigue related errors,

hazards and near misses being reported

by staff?

2.2 Fatigue Safety Risk assessment and mitigation process

The organization shall develop and implement formal risk assessment procedures that determine the probability and

potential severity of fatigue related events and identify those that require mitigation. They shall also develop and implement

risk mitigation procedures. The Fatigue Safety Action Group is often used to assess the risks and develop the mitigations.

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2.2.1 Is there a process to assess the

risks associated with identified fatigue

hazards?

2.2.2 Is there a criterion (e.g. risk

tolerability matrix) that evaluates risk

and the tolerable levels of risk an

organization is willing to accept? Is the

criterion and process appropriate for the

operation?
Example of an FRMS Evaluation Form D‐7

Unedited version

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2.2.3 Are the mitigation actions,

including timelines and responsibilities

documented?

2.2.4 Is there a clear process to select

the appropriate mitigation actions?

3. FATIGUE SAFETY ASSURANCE

3.1 Fatigue safety performance monitoring and measurement

The organization shall develop and maintain the means to verify the fatigue safety performance of the organization, and to

validate the effectiveness of fatigue risk controls and mitigations. The fatigue safety performance of the organization shall be

verified in reference to the fatigue safety performance indicators and fatigue safety performance targets of the FRMS.

  

(Where the FRMS is incorporated into the SMS, the fatigue safety performance indicators and fatigue safety performance

targets must be clearly identified.)

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3.1.1 Are fatigue risk mitigations and

controls being verified / audited to

confirm the effectiveness?

3.1.2 Are lessons learnt incorporated

into the policy and procedures?

3.1.3 Have fatigue safety

performance indicators been defined,

promulgated and being monitored and

analyzed for trends?

3.1.4 Is the FRMS audited to assess its

effectiveness and that the regulations

and standards are being followed? Are

these audits documented?

3.1.5 Are fatigue surveys carried out?

3.1.6 Are fatigue studies carried out?

(where appropriate)

3.2  The Management of Change

The organization shall develop and maintain a formal process to identify changes within the organization and / or operation

which may affect established processes in relation to fatigue risk. These process need to ensure fatigue safety performance

before implementing changes and to eliminate or modify fatigue risk mitigations that are no longer needed or effective due

to changes in the operational environment.
D‐8 Example of an FRMS Evaluation Form

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3.2.1 Is there a documented change

management process to proactively

identify fatigue hazards and to mitigate

fatigue risks during organizational and

operational changes?

3.2.2 Are there periodical reviews of

the fatigue safety performance after

organizational or operational changes to

assure assumptions remain valid and the

change was effective?

3.3 Continuous improvement of the FRMS   

The organization shall develop and maintain a formal process to review the performance of the FRMS, with the aim of

continuous improvement of the system. Also to determine the implications of substandard performance of the FRMS, and

eliminate or mitigate such causes.

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3.3.1 Is there a means to monitor the

overall performance of the FRMS to

allow for continuous improvement to be

achieved?

3.3.2 Is there a means to eliminate

and / or modify risk controls that have

unintended consequences or are no

longer needed?

3.3.3 Is there evidence of continuous

improvement being achieved?   

4. FRMS PROMOTION

4.1 Training and Education  

The organization shall develop and maintain a fatigue awareness and countermeasures training program that ensures that

personnel are trained and competent to both perform their FRMS duties and manage fatigue risks in actual operations. The

scope of the training shall be appropriate to each individual’s involvement in the FRMS.

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Documented2

Reference:

How is it achieved?3 Inspectors assessment

remarks4

4.1.1 Have all staff received training

on the organization’s FRMS and their

roles and responsibilities in respect of

the FRMS including the Accountable

Manager, Senior Management,

Managers, supervisors and operational
Example of an FRMS Evaluation Form D‐9

Unedited version

In

place1

Documented2

Reference:

How is it achieved?3 Inspectors assessment

remarks4

staff?

4.1.2 Is the initial and recurrent

training syllabus suitable for the

organizations FRMS operations?

4.1.3 Is the effectiveness of the

training measured and documented?

4.2 FRMS communication  

The organization shall develop and maintain formal means for FRMS communication that ensures that all personnel are fully

aware of the FRMS, conveys fatigue related safety critical information, and explains why particular actions are taken and why

procedures are introduced or changed.

In

place1

Documented2

Reference:

How is it achieved?3 Inspectors assessment

remarks4

4.2.1 Does FRMS communication

reach all levels of staff in the

organization?

4.2.2 Does the FRMS communication

clearly explain the policies, procedures

and responsibilities? Does it complement

and enhance the organization’s safety

culture?

4.2.3 Is the FRMS information

disseminated in a suitable

communication channels and is it and

monitored for its effectiveness?