Developing a Safety Management System for Fatigue Related Risks in easyJet(16)

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metrics, safety target thresholds, roster quality indices), which are transmitted, documented, and classified (method classification model).  Identified hazards are initially risk assessed triggering system recovery strategies where appropriate. Tactical and strategic investigations are conducted with resultant change management activity implemented. Risk monitoring and mitigation activity adjusts the system to maintain operational risk within an acceptable safety region in accordance with ICAO SMM 9859 (ICAO, 2008).

S. Stewart, F. Koornneef, R. Akselsson, and C. Turner  - HILAS 2009
The model proposed recognises that fatigue risk to the operation occurs when a fatigued crew interacts with the operational process. Every flight carries a measure of fatigue-related risk, but the role of the FRMS is to determine where crews can adequately perform satisfactorily, all their safety-related duties. Individual and system countermeasures can assist to mitigate the effect of this manifestation. Identified fatigue-related risk areas are investigated and, where evidence supports policy or rule-sets changes, then a larger scope strategic investigation and management process is enacted. The HFMP for example, forms part of a strategic proactive and exploratory risk-assessment activity. The tactical and strategic investigation processes drive decision-
strategic objective of maintaining viability of the organisation provides a productive starting point.
A Learning Agency consists of persons who take on the role to learn on behalf of the organisation and bring in their collective expertise, including tacit knowledge, about daily practice as far as relevant to the operational problem in operational context. The core function is 'inquiry' resulting in a preferred set of measures that are communicated with

S. Stewart, F. Koornneef, R. Akselsson, and C. Turner  - HILAS 2009
line management for implementation, or in identified problems that need to be solved by other stakeholders. Typically, members of a learning agency are very busy and are scarce resources. This stresses the need to store problems and outcomes from the inquiry in organisational memory that can be accessed for reuse of solutions.
Organisational Memory exists in different forms, including external regulation (EASA NPA 2009; CAP 371), fatigue policy, evidenced based rostering rulesets, best practice protocols, FRMS manual, fatigue awareness and education training programs, IT storage & retrieval systems, dedicated meetings, such as Fatigue SAG and Roster Evaluation Group meetings, and group behaviour that can be observed to read out this form of memory. Much knowledge that operators has about daily practice is tacit in nature and can be mobilised for organisational learning in the setting of a more or less formal designed 'learning agency' function.
Fatigue-related risk precursors and consequences can now be effectively represented within a Risk Management framework (Figure 9) that provides a performance trajectory from risk precursor to system risk management activity and feedback processes. This is a step beyond the influence diagrams of the past and facilitates how fatigue factors are risk managed within an FRMS.
　
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