Transcript Fatigue Risk Assessment Timeline

IDENTIFYING AND MANAGING HUMAN
FACTOR SPAD PRECURORS TO ADVANCE
SAFETY
Presented to
International Rail Safety Conference
by
James McColgan
Fatigue Management Solutions Ltd.
October, 2005
Cape Town, SA
Alertness: Key to Human Performance
Employees require
•aptitude
•training, skills and
knowledge
They must be attentive
•low distraction
•balanced workload
BUT
Without alertness
there is no
performance
Alertness Determinants Include:
Alertness Product of:
•Time of Day
•Time Awake
•Timing of Sleep
•Sleep Regularity
•Duration/Quality of Sleep
•Sleep Bank Balance
Alertness Influenced by:
©Fatigue Management Solutions, Ltd.
•Light
•Activity
•Sound
•Interest, Danger
•Temperature
•Chemicals
The Key to Optimal Alertness
All alertness triggers working in synch
©Fatigue Management Solutions, Ltd
Employee Fatigue
Not a Problem or is It?
Exxon Valdez
Three Mile Island
Chernobyl
©Fatigue Management Solutions, Ltd.
Examples of Working Against the Biological Clock
Surgeons U.K.
After one night’s sleep loss:
• 20% more errors
• 14% longer to complete surgery
• Increased stress
• NHS costs?
Source: Darzi Lancet Medical Journal, 1998
©Fatigue Management Solutions, Ltd.
Train Driver Micro-Sleep - Sweden
Inattention due to micro-sleep events.
Source: Swedish Train Driver, Torsvall & Akerstedt 1987
©Fatigue Management Solutions, Ltd.
FRA - US Railroad SPAD/Accidents
20
# of SPAD
15
Events
10
5
0
1
3
5
7
9
11 13 15 17 19 21 23
Time
©Fatigue Management Solutions, Ltd.
Source: FRA (Federal Railroad Administration)
Impaired Alertness Decreases Driver Performance
Sleep Length
Cumulative Fuel Deviation (GAL)
700
600
4.6 hours
500
400
6.1 hours
300
200
100
7.1 hours
(baseline)
0
-100
Run
10 Hours
Run
Run
10 Hours
10 Hours
Source: Heavy Freight Train (12,400 tons) simulator study. Thomas et al, 1998
©Fatigue Management Solutions, Ltd.
Comparison: Industrial Error & Accident Peaks
and SPAD Patterns
World-Wide Error & Accident Peaks
•
•
•
•
•
•
Within few hours of shift
starts
1st and 2nd days back
1st and 2nd night shifts
Shift starts before 7:30 a.m.
When activity very high or
very low
Between 2 and 6 a.m.
BR & TOC SPAD Patterns
•
•
•
•
•
•
40% shift starts before 7:00
a.m.
Peak 2-4 hrs into shift
10 to 20 times higher 1st and
2nd day back
Monotony = low attentiveness
Drivers report high boredom
Need data
©Fatigue Management Solutions, Ltd.
Lessons Learned Railway Alertness
Programs North America & UK
Regulatory Directive
•Fatigue safety issue
•Adopt Hours of Service
Industry Response
•Apply science
Calgary
•Test/adopt alertness
measures
CANALERT 95
•Joint mgmt/union initiative
•Nap opportunities
•No labour relations precedent,
•Barracks sleep upgrades
operational or driver $ impact
•Pilots: assess baseline fatigue,
EEG, PAMs, logs, surveys
•Implement alertness measures
©Fatigue Management
Solutions, Ltd.
•Reform work/rest cycles
•Cab audio/headsets
•Lifestyle education
drivers/families
•Measure results
Alertness Measures - Provide Multiple Benefits
Alertness
15-30 % improvement in alertness
Crew
Absence
56-60% reduction in absenteeism
Safety
Operating
Costs
Sleep
Health
1 million accident-free & injury-free miles
$100 million per annum - regulatory freedom
17 to 68% reduction in non-productive crew payments
56 % improvement - sleep duration, 65% quality
93% reduction stress, 28% GI symptoms
Result: Improved performance, quality and safety
©Fatigue Management Solutions, Ltd.
1996-7 British Rail Thameslink Driver Alertness Program
95-96 BR Wide Assessment
•Freight, intercity, commuter & regional
drivers
•Work design, conditions, lifestyle &
railway culture
96-97 Thameslink Alertness Program
•110 mph commuter ops to/thru London
•Joint mgmt/union support & task team
•Cost neutral
•No IR precedent
•PAMS, logs, surveys, cab rides
Bedford . London
.
Brighton
©Fatigue Management Solutions, Ltd.
.
•90% survey response
•Developed customised fatigue
countermeasures
Drivers - Self-Reported Sleep Duration
Hours needed to feel alert & well rested (%)
74.7
80
60
40
22
20
3.3
0
5hrs less
6 to 7hrs
7 to 8hrs
Total sleep in 24 hrs when:
60
80
62.8
44
40
60
36
40
19
20
24.2
20
13.3
0
0
5hrs less
6 to 7hrs
7 to 8hrs
Moving from late to early starts (%)
5hrs less
6 to 7hrs
7 to 8hrs
Working on a late start (%)
Thameslink Link 3
Survey: 96% agree roster review
93% to improve quality of life
Week
1
2
3
4
5
6
7
8
1
2
3
4
5
6
7
79% agreed majority choice
Sunday Monday Tuesday Wednesday
Thursday
6.18
6.18
6.18
11.08
13.43
13.43
13.43
2
4.16
4.16 6
4.16
5 23.59
23.02
23.02
23.59
23.59 3
6.40
6.40
6.40
6.40
12.03
13.08
13.08
15.38
1
4.10
4.10
4.10
13.03
13.00
SP
SP
SP
Friday Saturday
6.18
7.26
13.43
13.52
4.16
4.15
24.00 7
8.22
16.05
17.47
4.10
2.45
4
Early morning start after Sunday off
Must work 8-9 consecutive shifts
Weekend starts after late shift
One weekend break in 8 weeks
Day to day transition > 12hours
Single rest days
Two rest days after 9 consecutive shifts
Instead: Clockwise rotation
Coupled rest days
Start time variability four hours
Mid-week PM-AM change, maximise long weekend
Maximum consecutive shifts 7 from 10
3-day long weekends every 3 weeks, 17 per year
©Fatigue Management Solutions, Ltd.
Thameslink Output
Napping
Areas
Only 40% napped
on breaks
Concern discipline
for napping
•Napping/quiet room
•Recliner chair
•Darkened area
•Sound insulation
•Sleep design &
Shiftwork Education
Drivers & Spouses,
Managers
90%+ interested in
learning about
shiftwork adaptation
needs
•Adapting to shiftwork
•Diet, exercise, social
issues
©Fatigue Management Solutions, Ltd.
Thameslink Output (Cont’d)
Cab
(Work Environment)
Improvements`
87% rated cab comfort/heating
poor
73% rated induced weariness
92% poor ventilation
82% restricted leg movement
72% routine monotony
Diagram
Breaks
66% high boredom
75% isolation
•Seating, arm rests
•Air fans, cut
consoles
•Bottled water, face
wipes
•Short breaks, 5-10
minutes
•Walk, snack,
tea/coffee
•Luton based
Remote Booking
Off Duty
30% Luton based
©Fatigue Management Solutions, Ltd.
drivers book
off option @
Luton
FATIGUE OUTPUT
TRAIN CANCELLATIONS, CUSTOMER SERVICE
HIGH
Poor
Mood
Reduced
Customer
Satisfaction
Attitude
Reduced
Revenues
CHRONIC
FATIGUE
Increased
Absenteeism
Increased
Hiring &
Training
Costs
©Fatigue Management Solutions, Ltd.
Increased
Train Delays
&
Cancellations
Impact the
Bottom
Line
Increased
Operating
Costs
SPAD Management Through Driver Performance
RAILWAYS APPLY
DRIVERS ADVISE
• Candidate Screening
• Training/License Renewals
• Defensive Driving
• Alcohol/ Drug Policy
• Fitness Duty Testing
• Conduct SPAD
• Tiredness
• Monotony, Boredom
• Loss Concentration
• Distraction
• Cab Environment ,i.e. heat,
limited movement
Investigations
• Signal Changes
Impact Reduces:
Alertness, Attentiveness,
& Concentration
Driver
Performance
©Fatigue Management Solutions, Ltd.
SPAD
Potential
Increases
2 Steps - Target Human Factors & Create a
Systematic SPAD Management Program
I. Reactive (Post SPAD)
II. Pro-Active (SPAD Prevention)

Design SPAD investigation
- systematic questions on
alertness/attentiveness

Educate drivers and management on
alertness issues - include signallers
& regulators

Train investigators in
human alertness issues

Alertness enhancing rosters, ARC
modelling

Focus investigation into a
problem solving exercise
(root causes analysis)

Napping policies

Cab design/mods for alertness

Objective duty fitness testing

Conduct SPAD data analysis
accident patterns/alertness
Create A Human-Based Vigilance System
©Fatigue Management Solutions, Ltd.
Alertness Program Elements
Work & Rest
Scheduling
Practices
Workplace
Countermeasures
Management
Education
Promote
Alertness
Lifestyle
Education
Strategies
Operating
Practices
©Fatigue Management Solutions, Ltd.
Human
Centred
Policies
Thank you for your time
James McColgan
Managing Director
Fatigue Management Solutions Ltd
Tel +1 403 617 0604
Fax +1 403 264 9218
E-mail [email protected]
www.fatiguesolutions.ca