Developing a Safety Management System for Fatigue Related Risks in easyJet(6)

S. Stewart, F. Koornneef, R. Akselsson, and C. Turner  - HILAS 2009
dynamic information on the extent of the fatigue-related risk and a system for managing that risk proactively. They have recognized that emphasis must move away from reacting to recorded events and focus on proactive identification of potential threats, that can compromise safety. This has been given impetus by the advent of Corporate Manslaughter legislation in the UK (Ministry of Justice, 2007) and associated legislation in the EU (e.g. Corporate Manslaughter and Corporate Homicide Act) that states that not knowing or being unaware of the risk does not relieve a corporation of accountability. The first step in the development of a management system for fatigue-related risk is to establish the basis of a performance model that represents fatigue risk precursors and
environment that they work it in and any operational influences. The level of fatigue that different crew members encounter when working a roster varies greatly. Some of this variability is due to individual differences such as age, sleep need, the ability to sleep at irregular times and health. How hours of work interact with an individual’s lifestyle will also influence fatigue. Lifestyle factors which can influence fatigue include having young children at home, second jobs, social engagements and domestic disharmony. In addition to work hours, the level of fatigue crew experience depends on operational influences,

S. Stewart, F. Koornneef, R. Akselsson, and C. Turner  - HILAS 2009
such as hassle factors (delays, technical failures, airspace complexities, ramp congestion), adequacy of training, and environmental variables including noise and temperature.

Rosekind et al, 1996). The DC-8 Guantanamo freighter accident (NTSB, 1994; Rosekind et al, 1996) is a particularly interesting case as the investigation report cited the presence and interaction of three principle fatigue antecedent factors:  transient sleep loss, elongated duty period (continuous wakefulness) and operations in the afternoon window of sleepiness. The official investigation was conducted by the NTSB (as an independent agency) to determine the root cause and contributory factors and the data collection was supported by cockpit voice recorder and the Captain’s testimony. The crew performance effects cited in the report due to fatigue related risk included: 1) degraded decision-
S. Stewart, F. Koornneef, R. Akselsson, and C. Turner  - HILAS 2009
making, 2) visual/cognitive fixation, 3) poor communication/coordination, and 4) slowed reaction time. This was the first time in a major U.S. aviation accident that the NTSB cited fatigue as the probable root cause.
Fatigue increases the risk of an incident or accident occurring by degrading human performance (Folkard, 2003 & 2004). easyJet research has identified fatiguing performance decrements such as increased rates of error commission, decreased error detection and increased threat mismanagement (Stewart & Abboud, 2005). Aviation is not unique in its exposure to fatigue risk. Research in the medical fraternity suggests that
　
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