20HUBBL01 IFALPA FATIGUE REPORTING GUIDANCE

BRIEFING LEAFLET 20HUPBL01

22 September 2020

IFALPA Fatigue Reporting Guidance “Fatigue: A physiological state of reduced mental or physical performance capability resulting from sleep loss, extended wakefulness, circadian phase and / or workload (mental and / or physical activity) that can impair a person’s alertness and ability to perform safety related operational duties.”

• ICAO Annex 6

Whatever the cause of fatigue, flight safety must not be affected as a result. Flight Crew Members must not begin to carry out any task for a flight if, due to fatigue, they are or are likely to be, unfit to perform a task required of them during the flight.

The purpose of Fatigue Reports – Safety and Data Trends When a pilot determines they are fatigued, they may already be impaired and in a reduced state of alertness. One of the main purposes of fatigue reports is the identification of fatigue risks in daily operations. They identify areas where fatigue was a risk to safe operations or was anticipated to pose a risk. They also provide an operator with valuable information to establish a record of any accumulated fatigue issues over time. Ideally, fatigue reports inform the safety system so it can adequately resolve unacceptable fatigue risks.

When a sufficient set of fatigue reports exist, a fatigue-trend analysis can be developed from the data. Flight crew should be encouraged to think of fatigue reports as part of a cycle of fatigue data collection, like the collection and trending of aircraft engine data. Fatigue trends inform decision-makers of potential safety risks. Ill-informed decisions could result in ineffectual fatigue mitigations which do not address the identified risk.

It is a responsibility of all flight crew to contribute to the process of fatigue risk identification so that an analysis of fatigue data trends is possible. This is best achieved when the operator embraces a positive safety culture.

When to write a Fatigue Report – Inform the system There are many instances when a fatigue report is clearly required. When a situation is less clear, it may seem subjective whether a fatigue report should be submitted.

Safety Management Systems (SMS) should allow for the reporting of fatigue in these circumstances. Such reports provide fatigue data for use in future trend analysis. Operators with a mature SMS and reporting culture are able to make positive use of reports, even in circumstances when a report isn’t necessarily required. If flight crew are unsure if a report should

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be provided or not, the responsible thing to do is to submit the report and let the SMS decide how to use your information.

Specific circumstances when flight crew should report fatigue include:

• Cancellation of duty due to fatigue issues o Fatigue call by crew member o Duty cancellation by operator
• When utilising an extension to the flight duty limits
• Discontinuation of duty due to fatigue issues
• When the Flight Duty Period (FDP) is completed but only after some mitigating action. For example:  augmenting the crew (through appropriate procedures)  reducing the workload of the duty  delaying the reporting time due to rest requirements  unscheduled inflight rest  increasing supervision/monitoring of crew members or processes.
• when something is noticed in the operating environment that is likely to impact on crew members’ alertness to the extent that safety margins could be reduced to unsatisfactory levels
• where fatigue was observed or where the mitigations were implemented to specifically address a fatigue concern
• Controlled rest (where permitted by your regulator and operator) / uncontrolled sleep during flight duty
• when an incident or event has occurred where fatigue may have been a contributing safety factor
• anytime you are aware of another crew member’s fatigue and they have not provided a report.
• Any other situation listed in your operations manual (or fatigue manual).

Anything that exceeds limits (e.g. FDP, off duty periods, etc.), degrades your performance to an unacceptable level, or is something affecting your current or future fatigue levels, may be worth reporting.

Responsible crew conduct The value of genuine fatigue reports is diminished by misuse of the safety reporting system. Inappropriate use of fatigue reporting in an attempt to get a better roster or other lifestyle benefits is unprofessional and a misuse of the safety reporting system.

Flight crew are personally responsible for using allocated rest periods to arrive at sign-on in a rested state. If you feel like you have truly done all that you can to recover, but still have not

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recovered, you need to follow your operator’s fatigue reporting process. However, if this is not the case, you should adjust your behaviour so that you are sufficiently rested.

How to Write a Fatigue Report – Professional, Accurate, and Factual The language you use in a fatigue report may affect the influence of the report. The use of emotional or extreme language, such as “this roster pairing is completely unsafe” should be avoided. This type of language lacks sufficient nuance to be useful in SMS fatigue risk assessments and may be perceived as less factual or sincere.

Try to use the terminology of the SMS itself in your fatigue report. The use of key SMS and fatigue terms will assist the audience in understanding the concerns and may also increase the likelihood that the report will positively influence a fatigue risk mitigation outcome.

Providing accurate information is important and allows your safety department/FSAG (Fatigue Safety Action Group) to identify trends and investigate further. With accurate information, a proactive approach to producing roster fatigue mitigation can be achieved. Be factual and to the point. It is recommended to write the fatigue report as soon as feasible to provide your most accurate recollection of the event.

An example of a fatigue report and a description of the data fields is provided in Attachment A.

Summary In order to gain a sufficient dataset for analysis, it is essential that the culture of the operator normalize and encourage fatigue reporting. The operator and flight crew both have roles to play in building and maintaining an effective fatigue reporting culture and these groups should work together to achieve this outcome.

Fatigue reports are also an important tool for aviation authorities in overseeing operators' fatigue risk management or safety in general. Without fatigue reports it is difficult for authorities to evaluate if flight operations pose unacceptable risks due to fatigue.

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Appendix A: Completing an Example Fatigue Report (Source: Doc 9966 - Manual for the Oversight of Fatigue Management Approaches)

Personal Details

Time of Occurrence & Flight Details

Occurrence Details and Alertness-scale

Casual Factors & Sleep Evaluation

Mitigation strategies utilised

Suggested future improvement

Fatigue reports are typically structured with these sections and require: o Personal Details – This is information including your position and name. There should be an option for a confidential report, this does not mean that it is an anonymous report. o Time of Occurrence & Flight Details – Information from this section helps to gather data that is related to the effect on (or from) circadian disruption, WOCL-encroachment and the effects of time on duty and sectors flown, etc. It is also a way to gather data for specific flights to see if any patterns or trends are emerging.

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o Occurrence Details and Alertness-Scale - Details about the event itself. To provide an understanding of the effects of fatigue, try to communicate how your duties were affected. (I.e. “experienced micro-sleeps”, “missed radio calls”, “forgot procedures”, “had a hard time doing basic maths” etc.). Simply writing “felt tired” is not indicative of performance decrease and possible threats arising from it

Note: If the occurrence details require reference to people and decisions, use official position names such as Operational Staff, Dispatch Crew, Captain etc. Avoid the use of names or gendered pronouns such as he or she. This will help focus the necessary attention on the report rather than any particular individual.

o Use of Alertness Scales – the alertness scales used in this part are normally either the “Samn-Perelli Scale” or the “Karolinska Sleepiness Scale (KSS)”. Both are shown below and are simple subjective measures that are deemed fairly accurate in conjunction with a fair and honest approach to reporting fatigue hazards.

Samn-Perelli Scale (SP) Karolinska Sleepiness Scale (KSS) 1 Fully alert, wide awake 1 Extremely alert 2 Very lively, somewhat responsive but 2 Very alert not at peak 3 OK, somewhat fresh 3 Alert 4 A little tired, less than fresh 4 Rather alert 5 Moderately let down, tired 5 Neither alert nor sleepy 6 Extremely tired, very difficult to 6 Some signs of sleepiness concentrate 7 Completely exhausted, unable to 7 Sleepy, but no effort to keep awake function effectively 8 Sleepy, some effort to keep awake 9 Very sleepy, great effort to keep awake, fighting sleep

o Causal Factors and Sleep Evaluation - This part is designed to determine the causal factors behind the fatigue. It might be more or less extensive depending on your company, but there’s often a “free text” option here. This is where it is important to use accurate, factual, SMS terminology. Examples of appropriate SMS terminology and causal factors may include: o Inappropriate rest facilities (i.e. poor sleep environment; noise, temperature, comfort) o Insufficient rest time/Sleep deprivation (i.e. reduced rest, poor scheduling) o Disruptive schedules (i.e. alternating day/night duties, duties encroaching the window of circadian low (WOCL), roster disruption/changes)

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o Personal Reasons/Factors (i.e. health issues, family problems, commuting) o Time awake and stress o Multiple sectors o Stressful/demanding duties (I.e. systems failures/lack of automation, MELs, weather/environmental degradation, poor company/operational support, night flying, time critical operations, cockpit temperature and pressurization, route variations, aerodrome unfamiliarity, high noise or vibration level) o Commuting and positioning flights o Poor sustenance (I.e. dehydration/dryness and or crew meal issues) Remember, there may be multiple causal factors, and all should be noted in the report.

o Mitigation Strategies Used - This is where you report what you did to counteract or reduce the threats of the fatigue. Options may include co-ordination/reduction of workload, food & drink, caffeine intake, in-flight rest/napping (where permitted), or simply informing the other crew members of the issue. For chronic, and/or re-occurring fatigue issues, you might include any changes in sleeping patterns, daily stress management, doctor’s visits, etc. The effect of the strategy(ies) used in mitigating the fatigue can also provide useful information. o Suggested Future Improvement – This section is the reporter’s opportunity to provide proactive suggestions for the fatigue mitigation remedy. The mitigation suggestions should be proportionate to that of the actual fatigue risk raised in the report. Include suggestions related to individual and organisational responsibility when appropriate. A good starting point for suggestions is to pair them with the causal factors previously noted in the report.

©2020 The International Federation of Air Line Pilots’ Associations. This publication is provided for information purposes only, in all cases pilots should follow their company’s guidance and procedures. In the interest of flight safety, reproduction of this publication in whole or in part is encouraged. It may not be offered for sale or used commercially. All reprints must credit IFALPA.

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