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1Introduction
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11
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12
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Contents
Uncontrolled When Printed
Document comes into force 01/09/2012
Glossary
BAC
CIRAS
Circadian
rhythms
HSE
Fatigue
Confidential Incident Reporting and Analysis System
The name given to the ‘internal body clock’ that regulates
the (roughly) 24 hours cycle of biological processes in
humans
Health and Safety Executive
The reduced mental alertness and performance that results
from prolonged physical or mental effort
FRMS
Fatigue Risk Management System - the systematic and
co-ordinated processes and procedures a company puts
in place to manage and / or mitigate the risks arising from
members of its workforce becoming fatigued
FRI
Fatigue and Risk Index – scientifically developed rostering
tool that calculates worker fatigue and risk indices based
on recorded patterns of working
Night
worker
The EU Working Time Regulations 1998 (as amended)
define a night worker as someone who, as a normal
course, works at least three hours of his or her daily
working time at night, or is likely to work at least such
proportion of annual working time during night time as
specified within a collective agreement or workforce
agreement. ‘As a normal course’ is defined as ‘on a
regular basis’ or at least one third of the working time.
Night time is defined as being between 11pm and 6am
unless a collective agreement sets a different period of not
less than seven hours duration and includes the period
between midnight and 5am.
NTSB
United States National Transportation Safety Board
ORR
Office of Rail Regulation
ROGS
Railways and Other Guided Transport Systems (Safety)
Regulations 2006 (as amended)
RSSB
Rail Safety and Standards Board Limited
SCW
Safety Critical Worker
SMS
Safety Management System
SPI
Safety Performance Indicator
SPAD
Page 4
Blood Alcohol Concentration
Signal Passed at Danger
Managing Fatigue: A good practice guide
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1. Introduction
Uncontrolled When Printed
Document comes into force 01/09/2012
Introduction
1.1 Purpose of document
RSSB have published this good practice guide to assist
industry stakeholders understand and comply with their
duties under the ‘Railways and Other Guided Transport
Systems (Safety) Regulations 2006’ (as amended)
(ROGS) [1] - ‘Regulation 25 – Fatigue’. This document
complements guidance produced by the Office of Rail
Regulation (ORR) on ‘Managing Rail Staff Fatigue’
(2011) [2].
The intention of this guide is to offer infrastructure
managers (IMs) and railway undertakings (RUs)
a practical illustration of how fatigue risks can be
systematically managed to improve the health and
safety of the workforce and therefore operations. It sets
out the key elements of effective fatigue management
and illustrates how these can be incorporated into a
company’s overarching safety management system.
This will assist in reducing the costs associated with
accidents and injuries, sickness, absenteeism and
turnover due to poor fatigue management and to satisfy
a company’s duty of care to its employees and the
public.
This guide will also be of value to transport companies
(eg trams) who should also establish controls, processes
and procedures to manage and mitigate the risk of
workers becoming fatigued.
1.3 Legislative and
regulatory requirements
Following the investigation into the Clapham Junction
rail disaster [6], Anthony Hidden QC made the
following recommendations to address the underlying
management failings:
Recommendation 18 – ‘BR shall ensure that overtime
is monitored so that no individual is working excessive
levels of overtime’ (paragraphs 8.54 – 8.56).
Recommendation 19 – BR, in conjunction with the
Unions, shall introduce the concept of scheduled hours
within the Signals and Telecommunications Department
in order to make better provision for work which has
to be carried out at weekends’ (paragraphs 12.25 and
12.26).
The information in this document is intended as
guidance only. It is based on a variety of sources.
These include railway-specific documents (eg accident
investigations); Health and Safety Executive (HSE)
human factors audit reports; aviation, road transport,
maritime industry publications and RSSB fatigue
research [3,4,5]. The options presented are provided
to give a flavour of the variety of approaches available.
They are not an exhaustive or validated list; they are
simply options for IMs and RUs to consider within the
context of different operating environments and existing
company fatigue management arrangements.
As a direct consequence of the Clapham Inquiry,
industry adopted what became know as the ‘Hidden
Limits’ on working time which were included in an
appendix to Railway Group Standard GH/RT4004
(now withdrawn) (see Appendix 1). The limits were
generic (eg not specific to any particular group of safety
critical workers) and reflected what was achievable in
operational terms at the time, based on expert opinion
and agreed good practice. Although not mandatory, they
were recommendations to assist IMs and RUs comply
with GH/RT4004 and Regulation 4 of The Railways
(Safety Critical Work) Regulations, 19941.
As future research and information becomes available
this good practice guide will be updated accordingly.
The ‘Hidden Limits’, however, did not address all of
the known causes of fatigue (see section 2). There
remained, therefore, no guarantee that workers would
not continue to experience fatigue and therefore the
risks to the operation of the railway were not effectively
managed. For example, simply specifying a minimum
rest period between shifts will not guarantee that a shift
worker is fully recovered. The reason is that the extent
of a person’s recovery will depend upon many factors.
These include, for example, how much sleep a person
has been able to obtain; the quality of that sleep; the
extent to which the rest period coincides with the normal
(circadian) cycle of the biological body clock; and the
conscious effort on the part of the individual to obtain
sufficient sleep.
1.2 Target audience
This guide is primarily aimed at organisations that
have a legislative obligation to comply with ROGS –
Regulation 25 – Fatigue [1]. This will include those
individuals responsible for:
• Defining a company’s Safety Management System.
• Attaining safety certificates.
• Specialists who advise on roster design and other
background sources of information (eg occupational
health; training).
1
The Railways (Safety Critical Work) Regulation, 1994 have now been replaced by The Railways and Other Guided Transport Systems (Safety)
Regulations, 2006 (as amended).
Page 6
Managing Fatigue: A good practice guide
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In April 2006, ‘The Railways and Other Guided Transport
Systems (Safety) Regulations 2006’ (as amended)
(ROGS) came into force [1]. Under ‘Regulation 25
– Fatigue’, new regulatory requirements to manage
fatigue in safety critical workers were introduced.
These requirements address recommendations relating
to driver management and training included in the
Ladbroke Grove Cullen Inquiry [7,8].
Regulation 25 states:
(1) Every controller of safety critical work shall have in
place arrangements to ensure, so far as is reasonably
practicable, that a safety critical worker under his
management, supervision or control does not carry
out safety critical work in circumstances where he is
so fatigued or where he would be liable to become
so fatigued that his health or safety or the health or
safety of other persons on a transport system could be
significantly affected.
The ORR has recently published updated guidance
on fatigue management [2]. The nine stages have
been retained as many companies would have put in
place arrangements based on the original guidance.
It has also been extended to describe legal duties
under ROGS, basic fatigue controls, the fatigue risk
assessment process, features of a more comprehensive
approach to managing fatigue – Fatigue Risk
Management Systems (FRMS) - and also describes
different potential structures for an FRMS, drawing on
the Health and Safety Executive’s (HSE) well known
POPMAR2 framework (HSG65) for successful health
and safety management [14].
(2) The arrangements in paragraph (1) shall be
reviewed by the controller of safety critical work where
he has reason to doubt the effectiveness of those
arrangements.
As is the case in many high risk industries, the
legislation formally shifted the focus away from
prescriptive working time limits which specified, for
example, minimum rest intervals between shifts and
maximum shift lengths, to a more systematic approach
to managing fatigue risks. This is in recognition
of the fact that, in order to reduce the likelihood of
accidents, incidents and errors in which fatigue is a
contributing factor, fatigue risk management requires the
implementation of effective controls at an individual, job
and organisational level.
In July 2006 The Office of Rail Regulation (ORR)
produced guidance to support Regulation 25 entitled
‘Managing fatigue in safety critical work - Railways and
Other Guided Transport Systems (Safety) Regulations
2006’ (as amended) [9]. It specified nine high level
stages that a controller of safety critical work should
address to manage fatigue risks (see Figure 1). If
applied in a co-ordinated and systematic fashion, the
nine stages would constitute a company’s fatigue risk
management arrangements. It is, however, important
to recognise that the stages do not represent a fixed
sequence of static, isolated, steps that must be followed.
Rather, each stage represents just one important
element in an iterative cycle of risk assessment
processes and review procedures that duty holders
should have in place to manage and mitigate the risks
of a workforce becoming fatigued. Further guidance
produced by the ORR to support ROGS is also available
via their website [10].
2
POPMAR is the acronym used to refer to the HSE’s five steps to successful health and safety management – Policy, Organising, Planning and
implementing, Measuring performance, Reviewing
www.rgsonline.co.uk
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Introduction
StageSummary
1
Identifying those safety critical
workers affected
Identify those people carrying out safety
critical work who are liable to be or could
become fatigued when carrying out such work.
2
Setting standards and designing
working patterns
Identify, set and adhere to appropriate
standards and good practice for working hours
and working patterns, observing any relevant
working time limits that apply.
3
Limiting exceedances
Ensure that any standards and limits that have
been identified and set are only exceeded with
your prior approval and only on an infrequent
basis and in exceptional circumstances.
4
Consulting with safety
critical workers
Consult with safety critical workers and their
safety representatives on the arrangements
needed to manage fatigue and when standards
and limits are to be changed.
5
Recording the arrangements
Maintain a record of your arrangements for
managing the risks arising from fatigue in
safety critical workers.
6
Providing information to safety
critical workers
7
Monitoring
8
Taking action when safety
critical workers are fatigued
9
Reviewing the arrangements
Provide all safety critical workers under your
management, supervision or control with clear
and relevant information on risks to health and
safety owing to fatigue and your arrangements
for managing fatigue.
Monitor the arrangements for managing fatigue
to assess how effectively you are controlling
the risks arising from fatigue.
Ensure, so far as is reasonably practicable,
that safety critical workers who report for duty
where they are clearly unfit owing to fatigue,
or who, through the course of their work shift
become clearly unfit owing to fatigue, do not
carry out or continue to carry out safety
critical work.
Review your arrangements for managing
the risks arising from fatigue when you have
reason to doubt the effectiveness of the
arrangements.
Figure 1: SUMMARY OF THE NINE ORR STAGES
(reproduced with kind permission of the Office of Rail Regulation)
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Managing Fatigue: A good practice guide
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Employers also have general responsibilities under
health and safety law to assess and reduce, as far as
reasonably practicable, the risks from staff fatigue (eg
Health and Safety at Work etc Act (1974); Management
of Health and Safety at Work Regulations (1999) [11,12].
Under the Health and Safety at Work etc Act (1974),
employees also have general duties to take reasonable
care for their own health and safety and that of other
people who may be affected by their work activities. The
implication is that employees should take ‘positive steps
to understand the risk factors in their work, such as the
causes of fatigue……’ [26].
In relation to fatigue management, reference is also
often made to The Working Time (Amendment)
Regulations 1998 (WTR) which were introduced under
the UK’s EU “Social Chapter” obligations [13]. The WTR
include limits on the number of hours employees can be
required to work per week by employers, limit night work
hours, and include provision for rest breaks, paid annual
leave and health assessments for night workers.
However, the ORR (and the HSE) do not view the WTR
as a regulatory way of controlling system risk, or the risk
to workers’ health and safety from fatigue. Duty holders
need to consider and comply with the requirements
of WTR, but complying with the WTR is not in itself
sufficient to adequately control risks from staff fatigue.
The WTR are not risk based, nor are they “relevant
statutory provisions” made under the Health and Safety
at Work etc Act (1974) [11] and as a consequence
contain many exemptions2 and opt outs3. For safety
critical workers (as defined under ROGS), the WTR
provisions are therefore in addition to, not instead of,
protection under ROGS.
[Further information on the WTR can be obtained by
contacting the Working Time Officer (WTO), Office of
Rail Regulation].
3
Subject to workers receiving an equivalent period of compensatory rest, the limits on night working and rest breaks do not apply to the majority
of rail workers (this includes drivers, anyone working in possessions, staff on engineering trains, signallers and platform staff) who, under The
Working Time (Amendment) Regulations 2003 (regulation 21(f)(i),(ii) or (iii)), can all be reasonably classified as “special cases”.
4
For example, the WTR regulations contain provision for workers to opt out of the limit on weekly working hours.
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2. Background
Uncontrolled When Printed
Document comes into force 01/09/2012
Background
2.1 What is fatigue?
2.2.1 Work-related causes
There is no single scientific definition of fatigue but
it is accepted that fatigue is generally a feeling of
extreme tiredness and being unable to perform work
effectively. It is a state of impairment that can result
from prolonged working, heavy workload, insufficient
rest and inadequate sleep and can include mental and/
or physical elements.
The main work-related causes of fatigue include:
2.2 Causal factors
• Long shifts, particularly those that impinge on the
normal hours of sleep (eg nights and early starts).
• Rapid turnarounds (eg insufficient time available
between shifts for rest and recovery).
• High numbers of consecutive shifts.
• Inadequate breaks within a shift.
Fatigue is the result of insufficient sleep and rest
between activities. A combination of work and non-work
factors can interact to cause deteriorations in human
performance and lead to the onset of uncontrollable
sleep. To summarise, these include:
• Variability in the shift pattern (eg a rotating shift
pattern that changes about once a week; short
notices changes to roster; backward rotating shifts;
variable shift start times in a sequence of consecutive
shifts).
• Shift start time.
• Unplanned work (eg on-call duties; overtime;
emergencies).
• Shift duration and time spent in work-related
activities.
• Commuting time.
• Nature of task and working environment.
• Workload and nature of task.
• Opportunity for, and quality of rest before, during and
after work periods.
• Features of the work environment (eg temperature,
noise, vibration).
• Individual factors, such as fitness and health, age,
body clock, lifestyle, activities outside work, including
second jobs and domestic commitments.
The level of work-related fatigue will be similar
across individuals performing the same tasks. It
should therefore be assessed and managed at the
organisational level.
Guidance produced for the road
transport industry on fatigue
management provides the following
interesting comparisons:
• After 17 continuous hours awake, including time
awake before driving, drivers perform as if they had
a Blood Alcohol Concentration (BAC) of 0.05 – this
is above the railway accepted limit of 0.03 (30mg
per 100ml of blood).
• After 24 hours awake, a driver’s performance will
be on par with that of a person with a BAC of 0.10
– greater than three times the railway accepted
limit.
• Drivers awake for a period equal to or in excess of
17 hours per 24 hour period put themselves and
other road users at significant risk.
Page 12
2.2.2 Non work-related causes
The main non-work related causes of fatigue include:
• Domestic and family circumstances that may cause
sleep disruption.
• Health (eg sleep disorders).
• Individual differences (eg body clock and preferences
for certain shifts; age).
• Strenuous activities, such as second jobs.
• Lifestyle (eg diet; alcohol and drugs).
• Stress (eg physical, mental or emotional response to
external events).
Non-work related causes of fatigue are best managed at
the individual level as the impact of different factors will
vary considerably. Employers should ensure however
that employees are aware of the (non work-related) risks
and know how and where to go for further information
and support (eg Occupational Health department) (see
Section 5 on ‘Competence’).
Managing Fatigue: A good practice guide
Uncontrolled When Printed
Document comes into force 01/09/2012
2.2.3 Consequences of fatigue
Shift workers, particularly those
on rotating shifts, have a higher
incidence of:
• Sick leave.
Case study
An investigation into reported accidents on day,
afternoon and night shifts at two paint plants found an
indication of a significant increase in accident rates on
the night shift, particularly during the last three hours
of the shift.
• Visits to clinics at the work site.
• Poorer scores on measures of mental health.
Health problems
One study found that compared to 20% of day
workers, 62% of shift workers complained of sleep
problems [19].
If fatigue is not adequately controlled and sleep
disruption is ongoing, shift workers are at an increased
rate of:
Human performance can become gradually and
insidiously degraded if fatigue is not adequately
controlled. This can lead to impaired decision making,
alertness and reduced vigilance, together with a
general deterioration in motivation and mood. This
situation can be exacerbated in high or low workload
situations. Signs of fatigue include loss of energy,
inability to concentrate and tiredness even after sleep.
The outcome is that fatigue can cause or contribute
to potentially dangerous errors. This can include,
for example, misreading or overlooking a signal,
misunderstanding or forgetting communications,
incorrect route setting, straying into a place of danger or
failing to complete the necessary maintenance checks.
Case study
An analysis of Coast Guard incidents showed that
fatigue contributed to 16% of vessel groundings and
33% of personnel injuries.
- The National Transportation Safety Board (NTSB)
found that a major cause of the Exxon Valdez
grounding was the failure of the operator to provide
a fit and rested crew [33].
On average, individuals require 7-8 hours of nightly
sleep. There are also people who require more or
less than this average amount. If a person’s biological
‘sleep need’ is reduced by one to two hours, they
will experience acute sleep loss and the associated
deteriorations in alertness and performance the next
day. Excessively long shifts and/or consecutive shifts
that curtail the opportunity for sleep, in particular, nights
and early morning starts, will accumulate a ‘sleep debt’
and progressively worsen alertness and performance.
If sleep disruption is ongoing, this can lead to chronic
sleep deprivation, further deteriorations in work
performance and long term physical and mental health
problems.
www.rgsonline.co.uk
• Cardiovascular disorders (hypertension, heart
disease, high cholesterol).
• Gastro-intestinal disorders (heartburn, peptic
ulcers, indigestion).
• Substance abuse (caffeine, nicotine, alcohol,
sleeping pills, drugs).
• Sleep problems (insomnia, sleep apnoea, chronic
fatigue) [4,5].
Research has found that sleep and health problems
among passenger train drivers were common,
sometimes severe, with 15% of drivers surveyed
reporting symptoms indicative of sleep apnoea [3].
Among freight drivers, research found that insomnia,
stress and anxiety correlated with the frequency of
night shifts. A lack of control over shifts worked, and
the stated working hours, correlated with indigestion,
irritability, insomnia, stress and anxiety [4].
People’s physical and psychological functioning
fluctuates throughout the 24-hour day. These
fluctuations are known as circadian rhythms and are
genetically determined by the biological ‘clock’ in the
brain. As this ‘clock’ is sensitive to light and darkness,
people are genetically designed to sleep at night and be
awake during the day. The reason it is difficult to adapt
to shift work is that the body is constantly being drawn
back to the day/night default cycle. Mental and physical
performance capacity therefore inevitably drops when
alertness levels are naturally low in the early morning
hours. This has inevitable consequences for how shift
workers respond to the nature of different job demands
during the course of the day, and particularly on the
night shift.
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Background
Mental alertness
In fully rested people, mental alertness is at its natural
low at about 3-5am (or slightly later on the night
shift) when the biological need for sleep is greatest.
A second drop in alertness occurs mid-afternoon
(eg siesta time). The urge to sleep (and propensity
to make errors) at these times will be even greater
among those who have acquired a ‘sleep debt’, are
working under time pressure, or have a high workload.
A further complicating factor is that people cannot
simply sleep ‘at will’. The natural urge to sleep will be
at its strongest in the early hours of the morning and
to wake up around seven hours later. For this reason,
the daytime sleep of night shift workers has been
consistently found to be one third shorter and of poorer
quality than their night time sleep [34]. This is because
they tend to spontaneously wake up after only a few
hours sleep. Night workers, therefore, have to contend
both with less sleep during the day, plus working during
the natural low point in performance in the early hours of
the morning.
Cross-industry research has also highlighted an
association between different work patterns and, for
example, an increase in accident rates and personal
health problems (see case studies below). These
highlight the broad range of fatigue-based issues, both
for workers and management, which can contribute to
operational safety risk.
Research has shown:
• A clear and significant increase in self-reported
psychological symptoms (such as depression, loss
of self-esteem, difficulty in concentrating, etc) in a
group of nurses, 15 months after commencing shift
work [15].
• A clear decrease in gastrointestinal complaints,
and reduced sickness absence in a group of steel
workers who were transferred from shift work to
day work [16].
• Shift work sleep disorder is now a recognised
condition and pharmaceutical companies are
researching methods of treatment.
2.3 Fatigue in the rail industry
Based on a growing body of operational and scientific
evidence, there is now widespread recognition across a
range of industries of the risks associated with fatigue.
Within the rail industry this has been reinforced by
numerous accident inquiries – for example, Clapham
Junction (1988) [6], Southall (1997) [39], Brentingby
Junction (2006) [36], Badminton (2006) [42], Maltby
Page 14
North (2006) [43], Grayrigg [2007], East Somerset
Junction (2008) [37], Leigh-on-Sea (2008) [41] and
Shap (2010) [38]. Fatigue has also been cited as
a causal or contributory factor in at least 74 railway
accident and incident investigation reports between
2001 and 2009. It is, however, highly likely that fatigue
as a contributor to accidents and incidents has, in the
past, been underestimated, although this situation is
likely to change given improvements in human factors
awareness training in recent years. (See Further
Information in Fatigue and Fatigue Management).
Case study
Investigation into the causes of the Clapham
Junction rail accident in 1988 identified a number of
contributory causes including:
• Degradation of working practices.
• Poor supervision.
• Problems with training.
Uncontrolled levels of overtime working were identified
in the 13 weeks preceding the accident: 28% of the
workforce worked seven days a week; and another
34% worked 13 days out of 14.
The recommendations included monitoring to reduce
excessive overtime working and the introduction of
scheduled hours to make better provision for weekend
engineering working.
Two major fatigue and shift work research studies
have been conducted by RSSB. The first was a direct
response to recommendation 1 of the Southall Inquiry
(2000) that requested that passenger train (TOC)
drivers’ hours of work be reviewed [3]. The second was
triggered following the derailment of a freight train at
Brentingby and specifically targeting the freight driver
and track worker communities [4]. In both accidents
fatigue was identified as an underlying contributory
factor.
Both studies adopted a collaborative approach between
management and staff of the participating companies,
the unions and external experts in the field of fatigue.
Using employee fatigue questionnaires and sleep
diaries, together with analysis of fatigue-related accident
data, company visits and focus groups, the research
identified key factors contributing to an increased risk
of fatigue in the target populations. These factors were
associated with:
• Shift duration - particularly on night shifts and early
starts.
• Time of day (eg when alertness levels are naturally
low).
Managing Fatigue: A good practice guide
Uncontrolled When Printed
Document comes into force 01/09/2012
• Unplanned shift extensions and checks on fitness to
continue beyond 12 hours.
• Actual versus contracted duty hours
(eg overtime levels).
• The first night shift.
• Long consecutive duties.
• Variability in the timing of shifts (eg differences in
shift start time between consecutive shifts of the
same type).
• Days off and recovery from consecutive shifts.
• On-call duties and spare turns.
• Variability in the shift pattern (eg transitions from one
type of shift to another; short notice changes).
• Time off after an overnight or early morning start.
• Lack of control over shifts worked.
• Individual differences (eg shift preferences; ability to
cope with nights).
• Sleep and health problems.
• Employee fatigue management guidance and
training.
• Features of the working environment (eg cab
temperature).
• Remote booking-on.
• Workload factors (eg time spent driving; amount of
physical work activity).
• Long drives to and from work.
Case study
The National Transportation Safety Board (NTSB)
determined that fatigue caused the failure of a railroad
train engineer and conductor to respond appropriately
to wayside signals governing the movement of their
train. This led to a fatal collision with another train
[17].
As a result of the derailment the 16th car in the
train, a tank car loaded with liquefied chlorine, was
punctured. The chlorine vaporized and engulfed the
area surrounding the accident site. Three people, the
conductor and two local residents died from the effects
of chlorine gas inhalation.
The NTSB investigation determined that sleep debt,
disrupted circadian rhythms, limited sleep during the
weekend preceding the accident, and long duty hours
reduced the capacity of the engineer and conductor to
remain awake and alert during the night.
An examination of the engineer’s and the conductor’s
off duty time revealed that neither made effective
use of the time available to them to obtain adequate
rest. The Board therefore determined the two key
contributing factors to the accident were (1) the
crewmembers’ failure to obtain sufficient restorative
rest prior to reporting for duty because of their
ineffective use of off-duty time, and (2) the systems
for scheduling working hours that created inverted
crewmembers’ work/rest patterns.’
”Get enough sleep - it sounds so simple and yet we
continue to see accidents caused by fatigue” said
NTSB Acting Chairman Mark V. Rosenker, “How many
more tragedies have to occur before employers and
employees get the message that being well rested is
critical to job performance?”
• Quality and timing of breaks.
The results from the research clearly indicated that
there are many aspects associated with the scheduling
and design of rail safety critical work that need to be
addressed in order to limit the risks associated with
high levels of fatigue. The remainder of this document
therefore sets out guidance on how to systematically
manage fatigue risks and meet the requirements under
ROGS.
www.rgsonline.co.uk
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3. Fatigue Risk
Management
Uncontrolled When Printed
Document comes into force 01/09/2012
Fatigue Risk Management
3.1 Overview
In a 24/7 railway industry, fatigue is an operational
concern that needs to be effectively managed just
like any other hazard. This is particularly the case in
respect of the work carried out by drivers, signallers and
maintenance workers which is critical to safe operations.
Safety critical work can occur at any time, day or night,
in difficult circumstances and against demanding work
schedules. It is therefore essential that controllers of
safety critical workers understand the multiple causes
of fatigue and adopt a more systematic approach to
managing the risks.
A Fatigue Risk Management System (FRMS) is the
term used to refer to the more formal arrangements
for managing fatigue risks. Rather than simply relying
on specified hours of work and rest periods, FRMSs
take a risk-based approach to ensure workers and the
public are protected as far as reasonably practicable.
An FRMS is an evidence-based, data-driven and
documented process which, through the measurement
of actual risks, enables a company to develop tailored
controls to offset any potential increase in fatigue levels.
There is no generic, ‘one-size-fits-all’ FRMS. Rather, a
company’s FRMS will be dependent upon the nature,
size and complexity of its operations and proportionate
to the likely fatigue risk. Although the precise content of
an FRMS will be specific to an organisation’s needs, key
components include:
- The design of rosters based on good practice.
• Documented arrangements to enable systematic
monitoring, review and audit as part of the continuing
improvement cycle.
The FRMS should not be a standalone system. Rather,
it should be embedded into a company’s overarching
safety management arrangements for the identification,
assessment, control and monitoring of all risks, including
fatigue (see figure 2). This means that, rather than
relying on sporadic and isolated controls, fatigue
management becomes integrated and is considered
regularly as part of day-to-day company business. For
example, rather than being an additional, separate
process, fatigue should form one element of the risk
assessment already being undertaken, within the
workplace risk assessment, for different grades of staff.
This will avoid duplication of effort and may simply
require an extension to existing risk management
practices.
Case study
In the USA, Congress has mandated fatigue risk
management in the rail industry [31] and reports
from some companies, including Union Pacific, have
demonstrated their effectiveness in improving the
health and safety of workers [32].
• A company culture that supports an FRMS,
including policy commitment and the establishment
of a consultation process supported by senior
management. This includes the allocation of key
roles and responsibilities, effective resourcing
and education and training to ensure competency
requirements are met.
• A dedicated fatigue risk identification, assessment,
control and evaluation process. Information sources
that can be drawn upon for this purpose include:
- The identification of safety critical workers at risk.
- Staff feedback.
- A (confidential) reporting system for employees
to raise fatigue-related concerns based on the
principles of a ‘just’ culture (see Appendix 2).
- Investigation of the potential role of fatigue in
incidents.
- The use of predictive models to make an early
assessment of fatigue risks associated with base
rosters (eg the HSE’s Fatigue and Risk Index)
[20,21].
Page 18
Managing Fatigue: A good practice guide
Uncontrolled When Printed
Document comes into force 01/09/2012
Policy (commitment)
Roles and responsibilities
Competence
Consultation
Planning, implementing and
monitoring performance
Fatigue risk management
Audit
Evaluation
Hazard
Identification
Risk
control
Risk
Assessment
Reviewing performance
Figure 2: Fatigue Risk Management within the context of an overarching Safety
Management System
(Adapted from HSG(65) Successful health and safety management)
For ease of reference, each of the key components of an effective FRMS that form part of the overarching safety
management system are discussed separately in the sections that follow.
www.rgsonline.co.uk
Page 19
Uncontrolled When Printed
Document comes into force 01/09/2012
Page 20
Managing Fatigue: A good practice guide
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4. Setting up a FRMS
Uncontrolled When Printed
Document comes into force 01/09/2012
Setting up a FRMS
4.1 Policy Commitment
A fatigue management policy is a statement of an
organisation’s ongoing commitment and intent to the
effective control of fatigue risks. This commitment
should be made visible by the actions of those at senior
management level.
The policy should be developed by management in
consultation with employees and their representatives
and be informed by the fatigue risk assessment process.
It should form an integral part of a company’s written
safety policy and be communicated to all employees.
Suggested items for inclusion in a
fatigue policy
• A statement of commitment to managing fatigue
risks.
• Roles and responsibilities for managing the FRMS
across the organisation.
• Work groups covered by the FRMS.
• An understanding of the human performance risks
associated with fatigue.
• Summary of organisational fatigue management
arrangements (eg policy on overtime, shift
exchange, commuting, on-call duties, provision of
lodgings and rest facilities etc).
• Definition of the shared responsibilities between
employer and employees for managing fatigue.
• Engrain that employees will be consulted and
participate in the development of new processes
and procedures.
• Fatigue relevant company standards and working
time limits.
• Locally negotiated agreements with the trade
unions and staff representatives; terms and
conditions of employment, etc.
• Assurance to implement corrective actions based
on a ‘just culture’ that encourages honest reporting
of errors and safety information.
by early consultation with employees to identify issues,
the establishment of fatigue reporting channels and by
proactive fatigue management education and training
(see section 5.1). This should include the support
available to workers who may be at risk and/or are
experiencing difficulties due to fatigue.
It is, however, the legal responsibility of the employer to
control fatigue risks. Depending on the size and nature
of the organisation, there may be benefit in establishing
a Fatigue Management Steering Committee, or
appointing a Fatigue Champion(s), to provide overall
control of FRMS activities. This requires the allocation
of roles and responsibilities for those responsible for
different actions and adequate resources to enable
effective implementation.
A Fatigue Management Steering Committee, for
example, may be a specially convened group, an
extension of an existing management committee,
roster or safety group at an organisational, divisional,
functional or local/workplace level. It should comprise
a balanced representation of individuals from across
the organisation, including front line staff, union
representatives, planners and roster clerks, trainers, and
operations and safety specialists.
Visible management commitment is essential for
effective fatigue management. Management need to
lead by example and provide clear direction on how
fatigue risks will be identified, managed and controlled.
The committee’s functions could include:
• Allocation of time, resources, roles and
responsibilities for different aspects of the fatigue
management process (eg policy development; risk
assessments, etc).
• Ensuring fatigue controls are coordinated across
organisational functions and locations.
• Consulting with rail safety workers and their
representatives.
4.2 Roles and Responsibilities
• Specifying company business standards, procedures,
training requirements and working practices.
Fundamental to successful fatigue management is
recognition of the shared responsibilities between
employer and employee. Employees must buy-in to,
support and be aware of the rationale behind new work
initiatives designed to manage fatigue. They have
responsibility for ensuring their behaviour does not
create or increase risk. This includes reporting for work
fit for duty, taking the opportunities provided to obtain
sleep and reporting instances where it was not possible
to get sufficient rest. This can be achieved, for example,
• Determining how and when fatigue risk assessments
will be carried out, including use of any ‘tools’, and
what information will be collected.
Page 22
• Agreeing how overtime, shift exchange, travel time,
on-call duties, etc will be controlled.
• Setting company fatigue objectives (eg what is to be
achieved, how and why).
Managing Fatigue: A good practice guide
Uncontrolled When Printed
Document comes into force 01/09/2012
• Establishing a non-punitive fatigue-reporting system.
• Promoting the benefits of early reporting of fatiguerelated issues.
• Identifying activity and outcome safety performance
indicators.
• Agreeing the frequency of monitoring and reviewing
activities.
• Communicating the findings and recommendations
across the organisation.
• Reviewing incidents where fatigue has been an
underlying contributory factor.
• Reviewing any deviations from established FRMS
controls.
Good practice example
Amtrak believes that one of the first steps towards
creating a successful fatigue management plan
is the creation and empowerment of a steering
committee. All the major stakeholders should
be represented, as well as those with direct
knowledge of how fatigue is impacting the
company.
The recorded information can then be used as a
baseline against which the effectiveness of current
arrangements can be monitored and to facilitate a
process of continual improvement.
It is important that those with responsibility for
overseeing the FRMS maintain a record of the
arrangements in place for managing fatigue risks. The
principle here is to establish a management system that
records sufficient information in areas where there may
be a potential fatigue risk. The aim is not to produce
great volumes of additional paperwork, but to focus on
recording information in key areas.
Examples of key information that should be recorded
include, but are not limited to:
• Planned hours versus actual time worked.
• Shift exchanges, overtime.
• Individuals who are working long hours.
• Individual reports of fatigue.
• Exceedances.
• Data on problematic shifts, diagrams, rosters.
• Fatigue-related ill-health and absenteeism.
• Control strategies.
• Mitigations (eg fatigue counter measures).
• Details from risk assessments.
• Actions taken.
www.rgsonline.co.uk
Page 23
Uncontrolled When Printed
Document comes into force 01/09/2012
Page 24
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5. Competence
Uncontrolled When Printed
Document comes into force 01/09/2012
Competence
5.1 Background
The phrase ‘controllers of safety critical work’ is specified
in ROGS. This places a duty on an organisation as an
entity to ensure that persons under its management,
supervision or control are competent, fit for work and not
excessively fatigued. This includes, but is not limited to,
front line staff, those responsible for setting standards
and defining working limits, roster clerks, supervisors
and appointed individuals responsible for coordinating
FRMS activities.
Companies can manage the competence and fitness of
their workers by implementing an effective competence
management system (CMS). Like most management
systems, a CMS involves a cyclical process of
designing, planning, implementing, monitoring and
reviewing activities. The aim is to provide continuous
improvement in staff competence by identifying and
delivering training, development and assessment needs
in a logical and integrated manner. The competency
requirements of different roles covered by the CMS
will depend upon individuals’ responsibilities for FRMS
activities (see below). A variety of resources are
available to assist duty holders develop an effective
CMS, including those published by the ORR and RSSB
[22,23].
5.2 All rail safety workers
Basic knowledge and skills in fatigue management (work
and non-work related) should be provided to all rail
safety workers. This should include information about
the hazards, risks and preventive fatigue measures
and is likely to be delivered through periodic education
and awareness campaigns rather than as part of a
formal CMS. It should also include information on
the company’s approach to fatigue management.
Raising awareness of the risks associated with fatigue
encourages employees to take joint ownership for
managing fatigue risks and promote buy-in to the FRMS.
Consideration should also be given to the regularity,
timing and location of information strategies (eg
sensitivity to those working nights and weekends) as this
will also play a role in determining the ongoing success
of any approach and demonstrate management’s visible
commitment to fatigue risk management.
Information provided is likely to include some or all of
the following:
• Company fatigue policy.
• Recognising the common signs and symptoms of
fatigue.
• Understanding the causes of fatigue and associated
risks.
Page 26
• Strategies for fatigue management (eg sleep quality
and environment, healthy lifestyle, diet, time and
stress management).
• Company standards and working limits, including
circumstances in which limits can be exceeded with
prior approval.
• The risks of driving when fatigued.
• Employer and employee responsibilities.
• Fatigue reporting channels.
• Sleeping disorders and employee assistance
programmes.
• Education material for family members.
• Sleep hygiene/management training.
• Fatigue and shift work guidance booklets and leaflets
produced by the HSE and RSSB (see ‘Further
information for fatigue and fatigue management’
section).
Good practice
Network Rail has produced an e-learning CD-ROM to
introduce learners to:
• What fatigue is and how it develops.
• How fatigue affects behaviour and performance.
• What steps you can take to manage fatigue.
For those responsible for working with rosters the
programme aims to improve understanding of:
•
•
•
•
•
The legal and industry requirements to manage
working time.
Network Rail standards and procedures.
How to limit exceedances.
The principles of fatigue-friendly rostering.
How to risk assess roster patterns.
For more information, contact the Network Rail Human
Factors team.
IMs and RUs may like to consider expanding the above
to include, for example, guidance on how to challenge
co-workers who are identified as fatigued. It is vital
that employees know what they must do should they
experience problems with fatigue (eg due to sleeping
disorders). Company policy and employee support
channels should therefore be made clear. This may
include referral to Occupational Health and/or a General
Practitioner. In this respect, issues of confidentiality
must also be addressed, together with on-going
monitoring of the individual. It is also important to
Managing Fatigue: A good practice guide
Uncontrolled When Printed
Document comes into force 01/09/2012
determine how information will be recorded and fed
back into the FRMS for ongoing review and continuous
improvement.
Good practice
Information on fatigue management could be included
in worker recruitment, selection and induction practices.
For example, potential applicants should be provided
with a realistic job preview of the hours of work involved,
the effects of shift work and fatigue on them and their
family, and the responsibilities of being a safety critical
worker (eg preparing for shifts prior to being at work by
getting adequate sleep and excluding drug and alcohol
intake).
Capital Metro (a US bus company) runs a one hour
safety training session every other month for all
employees. Employees are paid overtime to attend
these sessions.
RSSB has produced a free booklet and briefing
materials on ‘Coping with shift work and fatigue’ (see
‘Further information in fatigue and fatigue management’
section) which was specifically designed for workers. It
contains the key applicable research findings following
work that RSSB has completed in this area, including
topics such as:
• Fatigue countermeasures, such as napping and
caffeine.
• Nutrition.
• Sleep management.
Fatigue management
training and awareness
RSSB research reported a general feeling amongst
front line staff that more information and training
on good fatigue management is needed - 80% of
passenger train drivers reported they wanted more
effective training [3].
Good practice
The aviation industry has some good practices in
this area, including providing staff with shift-based
meal planning cards, for example, what and when
to eat prior to commencing a night shift. Additionally,
they also use an acronym for their pilots to assess
their fitness for duty - I’M SAFE - Illness; Medication;
Stress; Alcohol & Drugs; Fatigue; Eating. A similar
acronym could be used by companies to help remind
staff of their responsibilities when signing on for duty.
American Airlines have a corporate ‘Fatigue Hotline’
which employees can call for advice on fatigue issues.
Define the formal and informal channels for
communication of fatigue issues.
Greyhound Bus Line has a training programme which
specifically educates drivers about off-duty behaviour
and how it can affect on-duty performance [44].
5.3 Staff with responsibilities
for implementing the FRMS
Staff with responsibilities for implementation of the
FRMS, for example, Fatigue Champion(s), those
responsible for setting standards and designing work
patterns, roster clerks, supervisors of safety critical
workers, members of a Fatigue Steering Committee,
etc should receive more structured training in fatigue
management to ensure that they have the required
level of competence commensurate with their role.
Recommended training topics include, but are not
limited to:
• Familiarisation with relevant legislation.
• Effective consultation.
• Guidelines for the recruitment of safety critical staff.
• Assessment and training of staff fatigue management
competencies.
• Fatigue risk assessment process.
• Identifying and implementing fatigue risk reduction
strategies.
• Roster development and design principles based on
good practice (eg identifying safety critical workers
affected; recovery time and rest periods between
shifts; work/life balance, etc).
• Assessment and review of rosters for their potential
to lead to work-related fatigue.
• Fatigue management reporting mechanisms.
• Fatigue countermeasures eg napping policy; driving
policy.
• The use of bio mathematical models to assess
fatigue risks.
• Workforce planning and the specification of minimum
staffing levels.
• Overtime and call-out arrangements.
www.rgsonline.co.uk
Page 27
Uncontrolled When Printed
Document comes into force 01/09/2012
Competence
• Resource allocation and contingency planning (eg to
cover sickness, vacancies, unplanned maintenance,
emergencies and operational disruptions).
• Strategies for managing shift workers returning from
extended leave.
• Opportunities and processes for organisational
learning.
• Capturing and recording fatigue-related hazards and
actions.
• Recognising the early signs of fatigue and taking
appropriate action.
Good practice
Ask the trainees to evaluate the effectiveness of
company training in fatigue management as part of the
continuous improvement process.
For further information on good practice in training and
evaluation, contact the RSSB Human Factors team.
Page 28
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6. Consultation
Uncontrolled When Printed
Document comes into force 01/09/2012
Consultation
6.1 Overview
Consultation with safety critical workers is crucial to the
success of an FRMS. Workers should be consulted
as part of the ongoing development of new policies
and procedures to manage fatigue risks and before
the implementation of any changes to current working
practices, standards and working time limits.
The involvement of a broad spectrum of workers
will provide a rich source of information and inform
decision makers. Front line workers have a practical
understanding of the potential issues with work
processes and the associated hazards. They are also
those most at risk of developing health issues as a result
of work-related exposure.
Good practice
Encourage employees to share their experiences of
different work patterns (eg at the end of safety briefs
where practicable); discuss which work patterns are
the hardest and why; provide examples of alternative
work patterns; encourage open discussion and
feedback.
Consultation should also include relevant third parties
(eg safety representatives, trade unions, interfacing
organisations and ORR inspectors) to ensure (local)
agreements on working hours and practices are
consistent with the company’s fatigue policy. This
process should ideally be supplemented by feedback
received from other channels. For example, accident/
incident reporting systems, informal discussions held
between staff and their supervisors, confidential and/
or anonymous reporting forms or phone lines. This
information can be used to enhance a company’s
existing FRMS by pinpointing, for example, particular
roles or tasks that are more fatigue-inducing.
The amount and quality of information received from
staff will largely depend on the company culture. A
company culture refers to the set of values and norms
that govern how people understand – and what they
expect from – each other within an organisation (see
Appendix 2). Some companies will have cultures where
asking for feedback from workers will result in a large
amount of valuable information. Other companies,
however, may find that requests for such information
could be met with employee suspicion and large
numbers of refusals to participate.
Employees will be more likely to share information if
they have seen, or hold the belief that:
• Previously reported information has been responded
to appropriately and in a timely manner.
• Matters of a serious nature have been dealt with
swiftly.
• Workers are kept informed of matters that are
currently being addressed.
• Workers are informed of the reasons why, a particular
issue has or has not been addressed.
• Colleagues have not been disciplined, either formally
or informally, for making a reasonable suggestion.
• Sufficient time will be given before implementing
changes.
• Sufficient people who are affected have been
consulted.
Good practice
One company, in addition to using the Fatigue Risk
Index, asked their workers which were the more
tiring rosters and then targeted those rosters for
improvement first.
Good practice
Consult employees as part of the design and
development of the fatigue management system and
involve staff in writing procedures and planning and
reviewing performance.
Page 30
Managing Fatigue: A good practice guide
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7. Fatigue Risk
Management Process
Uncontrolled When Printed
Document comes into force 01/09/2012
Fatigue Risk Management Process
7.1
Overview
At the core of an FRMS is a dedicated fatigue risk
management process. It involves a continuous
improvement cycle of four key steps:
(i) Hazard identification – to assess fatigue risks
associated with current conditions (see section 7.2).
(ii) Risk assessment – a dynamic process of evaluating
the likelihood and potential consequences of fatigue
arising from the identified hazards (see section 7.3).
• Feedback from staff on rosters and working
practices.
• Evaluation of indoor and outdoor work environments.
• Trends in safety performance data.
• Lessons learned and best practice.
• Review of employee surveys/feedback and company
analysis of shift work success, etc.
• Audit results.
(iii) Risk control – the process of eliminating or reducing
the risk by putting in place control measures such
as shorter shifts, fewer consecutive shifts, fatigue
management training and education (see section
7.4).
• Feedback from staff fatigue reports.
(iv) Evaluation – performance monitoring to evaluate
the success of control measures put in place and to
make further adjustments as necessary (see section
7.5).
• Occupational health reports (eg screening for sleep
apnoea [5], staff sickness and turnover rates.)
As with any system, the effectiveness of the fatigue risk
management process is dependent upon the quality
of data and information that informs its design. It is
therefore necessary to establish good quality systems
that can monitor and measure fatigue risks. This
includes ensuring fatigue is considered as part of
investigations, encouraging the early reporting of fatigue
issues, monitoring trends in overtime, shift exchanges,
planned versus actual hours, introducing safety
performance indicators, use of fatigue risk assessment
tools, and a comparison of staff fatigue survey ratings
and assessment tool scores before and after any
changes.
7.2
Hazard identification
The principle here is to provide an informed and
coordinated approach to identifying and understanding
fatigue risks associated with current conditions. The
process would begin by consulting the workforce
(including contractors). In addition, a variety of
information sources can be used, including:
• Review of workforce demographics (eg age
profile; health; medication; social and domestic
arrangements).
• Information on fatigue-related errors from accident
and incident reports.
• Staff fatigue training and competency assessments.
Good practice
Studies have shown some success in predicting
individuals’ ability to working at unusual times and
long-term adjustment to shift work has been achieved
using measures of flexibility of sleeping habits [24,25].
Non-prescriptive software tools are available to
industry to plan and manage work schedules that are
based on an understanding of operator fatigue [12]
Individual differences
RSSB research has found considerable individual
differences in preference for working, and ability to
cope with, different shifts. Some of these differences
correlated with circadian type . For example, those
who experience peak alertness and activity early in
the day are known as ‘morning types’ or ‘larks’. Those
who perform better later in the day, are called ‘evening
types’ or ‘owls’.
The severity of sleep problems was found to increase
with age. Older individuals found it harder to sleep
after the night shift and more difficult to concentrate
during the night shift. The night shift was also
perceived to impact more on quality of life [3,4].
• Identification of factors that may affect the onset of
fatigue (eg job design, nature of the work, workload,
and environmental conditions).
• Discussions with workers and their representatives.
• Inspections and task analyses.
• Review of working time exceedances.
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7.3
Risk assessment
The Health and Safety Executive (HSE) has produced
specific good practice guidelines on assessing and
managing the risks associated with shift work [26]. For
example, it is recommended that IMs and RUs carry out
a suitable and sufficient assessment of the fatigue risks
(and root causes) associated with current conditions.
This should take into account the likelihood of a safety
critical worker becoming fatigued (eg how long a
worker is required to be awake, work intensity, sleep
opportunity and quality) and the possible consequences.
Risk factors likely to lead to significant fatigue (eg shift
patterns that deviate substantially from recommended
good practice) and those that can be easily controlled
should then be prioritised.
In addition to the information sources highlighted
above, the use of fatigue risk modelling tools (eg such
as the HSE’s Fatigue and Risk Index (FRI)) can assist
in identifying specific factors that could lead to fatigue
[20,21]. They can be used to assist in the planning
of work rosters, be applied to key safety critical roles,
both during normal operations and following incidents,
to highlight those at risk from fatigue and to evaluate/
review existing practices (eg work type within different
shifts) before and after implementing changes to work
patterns. Such tools must, however, be used with
caution and only in conjunction with other sources of
fatigue-related information as part of a holistic FRMS
approach to fatigue management. See Appendix 3 for a
summary of uses and limitations of fatigue risk modelling
tools.
The gathering and evaluation of this information should
be recorded (see section 4.2). This intelligence can then
be used to determine the actions an organisation needs
to take to address any potential weaknesses through
the implementation of additional control measures. This
may include, for example, shorter shifts, the provision of
rest facilities, compensatory time off following extended
working hours, reduced variability in shift start times,
extended reporting system, fatigue management
training and employee education (see section 7.4).
This also provides a baseline against which future risk
assessments can be made as part of the continuous
improvement cycle.
Good practice
Ask safety critical staff for feedback on the extent to
which the working patterns implemented are effective
in controlling fatigue.
Factors that should be considered when assessing
fatigue risks associated with different groups of safety
critical workers include, but are not limited to:
www.rgsonline.co.uk
Roster design and work planning:
• Is there enough time between shifts to allow for
adequate sleep, taking into consideration circadian
rhythm effects (eg time of day), and where sleep is
taken?
• Shift duration (eg is any one shift longer than 12
hours (including overtime/call-outs), how long are
night and early shifts, and shifts starting before 05:00
hours?).
• Number of consecutive shifts (eg are too many
consecutive night and early shifts being worked?).
• Quality, timing and duration of rest breaks within a
shift (eg do breaks enable workers to recuperate,
refresh and nourish themselves?).
• Shift pattern (eg are shifts forward or backward
rotating? Is shift rotation fast or slow?).
• Are split shifts required?
• Standby and on-call duties, overtime working,
emergencies and unplanned work (eg how much
notice are staff given of changes to the roster? Are
good rostering principles taken into account when
making roster changes? Are staff asked if they are
fit-to-continue if duties are extended?).
• Actual versus contracted weekly hours (eg how
many hours per week are being worked, including
overtime?).
• Commuting (eg are long drives to and from work
reducing the time available for restorative sleep?
Is transport/lodgings provided for workers with long
commutes?).
• Supervision (eg does a worker have good support
from their supervisor/manager? Do workers have
face-to-face contact with a supervisor/manager? Do
they receive recognition of good work?).
• Training (eg is training/refresher training/continuing
professional development factored in to the number
of working hours?).
• Shift swapping (eg do staff have control over shifts
worked? How is shift swapping controlled?).
• Resources (eg are there sufficient numbers of staff to
cover normal/emergency/degraded operational safety
critical requirements?).
Individual and non-work factors:
• Individual differences (eg have the demographics/
shift preferences of the workforce been taken into
account when designing rosters – such as younger/
older workers, contractors, owls/larks?).
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• Welfare (eg is there any evidence of health problems,
such as sleeping disorders, psychological issues,
drug/alcohol use?).
• Education and awareness campaigns (see section
6 and further information in Fatigue and Fatigue
Management Section).
• Other personal factors (eg is there any evidence of
domestic/social problems, such as relating to family
illness, poor sleep environment, second job, etc?).
• Changes to CMS arrangements (see section 5).
• Employee fatigue management guidance and
training (eg have staff been trained in good fatigue
management and are they kept up-to-date with
company FRMS policies and procedures?).
Working environment:
• Fatigue reporting channels (eg do staff use/are they
aware of how to report fatigue related issues?).
• Type of work activity (eg Is the work physically
demanding? Is the work repetitive or monotonous?
Does the work require high levels of sustained
concentration and vigiliance? Is the work conducted
under time pressure? Does the worker have
any control over the work pace? Are complex or
strenuous tasks scheduled at the end of a shift,
particularly on the night shift?).
• Work-related road driving (eg does the work require
long periods of driving between sites? How is this
managed?).
• Physical environment (eg is the worker exposed
to sustained extreme conditions, such as high/low
temperature, noise, vibration?).
• Team working/lone working (eg does the work involve
working alone or in a work group?).
• Familiarity with work environment (eg how familiar is
the worker with the working environment?).
7.4
Risk control
Based on a comprehensive understanding of current
conditions, the need for new, and adequacy of existing,
controls to reduce or eliminate fatigue risks can be
determined. Consideration must be given to timeframes,
roles and responsibilities, employee consultation,
communication and training. New controls may include,
but are not limited to:
• Setting new standards and re-designing working
patterns, based on good practice (see section 7.4.1).
7.4.1 Setting standards
and designing
working patterns
The approach to setting standards and designing work
patterns may differ between IMs and RUs according
to the size and complexity of the organisation. As
stated previously, duty holders will need to assess the
probability of fatigue risk specific to its operations. In
situations of medium to high risk, it is essential that
the adequacy of existing control measures in place, or
planned, to mitigate the effects of fatigue are assessed.
Cross-industry examples of different approaches to
fatigue management are included at the end of this
guide [27,28,29].
In keeping with the FRMS approach and move
away from prescriptive hours, this section presents
aspirational recommendations for the design of work
schedules based on good rostering practice and
informed knowledge of current working practices across
the rail industry [3,4]. It is not proposed to specify fixed
limits relating to duty hours and roster design, but, in
recognition of the multiple causes of fatigue, to focus
on a systematic approach to fatigue management
rather than hours of work. Where specific numbers are
mentioned, these should be regarded as indicative of
good practice. Duty holders should therefore consider
their practical application in the context of their specific
operational environments.
Good rostering principles
The extent to which fatigue accumulates is a function of
shift length, rest intervals between shifts, and recovery
following a block of consecutive shifts. Other factors
include the nature of the work, working environment
and quantity and quality of rest breaks. Fatigue experts
therefore agree that the following rostering principles,
marked by ‘►‘, should be considered when designing
work schedules for safety critical workers:
►
Minimise the build up of fatigue during a shift
and by restricting the number of consecutive
night and/or early morning shifts
• Limiting working time exceedances (see section
7.4.2).
Shift duration
• Introducing new fatigue countermeasures and
procedures for dealing with staff who are fatigued
(see section 7.4.3).
Duration of shift is a key factor influencing fatigue,
with tiredness steadily increasing with increasing shift
duration. The relative risk of an accident or incident has
also shown to increase with increasing shift length over
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eight hours [4]. The interaction with shift start time and
time of day that the shift is being undertaken also has
a strong influence on levels of fatigue, particularly on
nights and early morning shifts.
Good practice
There is a strong case for limiting the duration of a
shift to 12 hours (and if 12 hours, then no overtime),
with further restrictions on duties that impinge
significantly on normal hours of sleep, for example,
10 hours for nights or early morning starts. RSSB
research [3] recommends limiting very early starts
(eg those starting before 0500hrs) to eight hours. If a
member of staff works longer than their rostered hours
(ie due to overrunning engineering work), checks on
their fitness to continue working should always be
undertaken.
As well as shift duration and timing, it is also important
to consider the content of a shift, including the frequency
and adequacy of rest breaks (see below), as the effects
of fatigue can be more evident on, for example, tasks
that are repetitive, monotonous or those that demand
continuous concentration.
Consecutive shifts
It is essential to minimise the build up of fatigue by
restricting the number of long shift sequences, in
particular consecutive nights and very early starts.
For example, it has been estimated that an individual
may lose two hours sleep for each night shift worked
[14]. Research has also shown an increase in SPAD
risk after six consecutive shifts [4]. This risk is further
compounded over consecutive early or night shifts.
Whilst people may prefer to work more consecutive
shifts in order to take a block of days off at the end, this
needs to be balanced against the risks associated with
the effects of cumulative fatigue.
Good practice
It is advisable to set limit of say six consecutive duties,
with a lower shift duration limit (eg 10 hours) on duties
that impinge significantly on normal hours of sleep (eg
consecutive nights, and early shifts). RSSB research
[3] recommends setting a limit of five consecutive
duties for early shifts. Where night shifts exceed eight
hours, it is recommended consecutive shifts be limited
to a maximum of three before a rest day.
www.rgsonline.co.uk
Duty hours
In the rail industry working hours are currently
determined on a weekly basis. This allows a high
number of hours to be worked each week, long shifts
and short recovery times. It is therefore crucial to allow
sufficient recovery time between shifts.
Good practice
Consider adopting a duty hour limit based on a sevenday rolling period which is limited to 55 hours before
a rest day is scheduled [4]. This is comparable with
restrictions in other industries (eg aircrew and heavy
goods vehicle drivers).
►
Afford workers sufficient opportunity to rest
and recover before, during and between a block
of consecutive shifts
The first night shift in a sequence of nights has also
been reported to be the most fatiguing and nights
and early morning shifts identified as the times when
mistakes were more likely [4]. This is due to the
difficulties workers can have adapting their sleep
patterns due to the effects of the internal body clock
which corresponds to the normal cycle of night and day
(see section 2.2.3).
It is important therefore to allow sufficient time for
recovery, both before the start of a sequence of
shifts, within a shift, and between consecutive shifts,
particularly on nights and earlies, so that individuals can
‘recharge their batteries’ and maintain work performance
on return to work.
Good practice
Research has suggested that even individuals who
work constant night shifts never fully adapt [46].
Although staff may adjust to working nights during
the week, there will be (circadian) disruption at the
weekend when presumably they adopt a more social
day pattern when not at work.
Where night work has to be done, shifts should rotate
clockwise (eg day to evening to night), and include
plenty of rest days between shifts and the avoidance
of early morning starts.
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Rest between shifts
Good practice
Include a minimum rest period of 12 hours between
consecutive shifts and extend this to 14 hours [3]
between consecutive nights. This would, however, in
most cases be addressed by limiting the night shift to
10 hours as outlined above.
The current industry standard is for a minimum rest
period of 12 hours between booking off from a turn of
duty to booking on for the next turn. However, RSSB
research [4] found evidence of rest periods between
shifts of less than 12 hours. Shortened rest periods was
also an important factor contributing to fatigue, sleep
and health issues. Evidence has also been found of the
smallest recovery between two nights or early shifts,
with overall fatigue levels at the end of a shift found to
be a five on a seven-point scale of sleepiness [4]. In
safety critical industries that is indicative of the need to
introduce fatigue mitigation measures.
Good practice
Build regular free weekends into the shift schedule.
Shift workers should be given a minimum number of
work-free hours in a 14-day period to aid recovery.
This should include provision for two full nights’ sleep.
Rest day working should be kept to a minimum to
ensure planned recovery time is used effectively.
It is also important to consider the travelling time of
the workforce as this can reduce the opportunity for
rest between shifts. Long travel times to and from work
should be monitored and shift workers should be given
guidance on the risks of long periods spent driving.
Good practice
Where travel time is anticipated to exceed one and
a half hours, alternative arrangements should be
considered where practical, in the form of provision of
transport or lodgings [4]. This is particularly important
when long shifts are anticipated and after the night
shift.
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Recovery following a sequence of shifts
It is important to ensure staff are given sufficient
time to recover following a sequence of consecutive
duties. The length of shifts and daily rest intervals
will need to be taken into account. Where a sequence
of consecutive night shifts are worked, a single rest
day may not provide adequate recovery and it may be
necessary to schedule more time off. For example,
following a night shift that ends at 0600 hours, there
will be a requirement for more than a single day off to
ensure complete recovery.
Good practice
Given the difficulties in adapting to circadian rhythm
effects (eg adjusting the timing of sleep to meet the
demands of different shift types), it is recommended
that the first shift following a period of extended leave
should not be rostered as a night or early morning
shift.
Following a late shift, provision should be made for
a full night’s sleep (eg 30 hours minimum) before
moving to another shift, especially an early shift. It is
also recommended that provision is made for two rest
days (eg 54 hours minimum) when changing from a
night to an early shift.
Breaks
Good practice
Following a review of SPAD incidents, research
findings recommend a maximum period of work of
four hours before a break of 15 minutes which is
completely free of all work-related activities [3]. The
HSE recommended good practice limit is three hours.
The duration of continuous duty without a break
contributes to fatigue. Breaks are an effective way
of controlling the build up of fatigue and restricting
the period of continuous duty. RSSB research found
evidence of an increase in SPAD risk after five hours or
more, together with an interaction with early starts and
night shifts [4]. This highlights the importance of rest
breaks in reducing the risk of incidents. Inadequate
breaks (eg in terms of their timing and quality) were also
found by the research to be linked to issues such as
health, dissatisfaction with the shift pattern and levels of
fatigue.
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Good practice
Provide similar facilities at night as those available
during daytime (eg refreshments and rest rooms)
and ensure shift workers are given adequate time off
for access to training and development (eg build into
roster patterns).
Provide sufficient resources to cover breaks,
emergencies, unplanned events.
Provide adequate facilities for workers to refresh, rest
and nourish themselves during breaks.
To maximise the beneficial effects of breaks it is
important to consider their timing within a shift.
Scheduling breaks at the start or end of a shift reduces
any beneficial effects. Ideally breaks should be
scheduled towards the middle of a shift or at a suitable
time with regard to task activities. It is important
they allow the opportunity to relax, away from work
interruptions, and provide access to adequate rest
facilities, including food and drink.
The facility to take a short nap during a break can
also be effective in controlling the build up of fatigue,
particularly for safety critical workers on the night shift
(see section 7.4.3 for more detail).
►
Rostering practices – plan shift rotations and
minimise variability in shift start times
Good practice
Reduce the day-to-day variation in the timing and
duration of shifts and include greater contingency
in the roster to deal with unplanned events, such as
overrunning engineering work. Provide staff involved
in planning and managing with rosters training in
factors that impair sleep and alertness.
Although some variability in the start times of shifts is
inevitable when running an efficient railway, it makes it
difficult for staff to predict when they are working and be
able to plan adequate rest and domestic arrangements.
For example, the shift start time of a driver on a ‘spare
turn’ can vary by up to four hours. Irregular, non
rostered hours of work and on-call duties also make it
difficult for workers to plan sufficient sleep.
Organisational arrangements should be put in place
to ensure that staff are given sufficient opportunity
for sleep to manage all foreseeable scenarios. This
includes overrunning maintenance work, long standing
vacancies, sickness absence, organisational changes
and training delays.
www.rgsonline.co.uk
A lack of roster stability, frequent short notice changes
to shift start time, and the lack of control over working
hours and shifts worked has been found to contribute
to fatigue, stress, problems with sleep and job
dissatisfaction [6]. This is often overcome by workers
by swapping shifts. However, this may contribute to
the potential risk by increasing the variability in the shift
pattern, and therefore needs to be managed.
Good practice
Allow some individual choice and consider individual
preferences for certain shifts when designing work
patterns.
If occasional shift swapping is permitted, it may be
possible for workers to undertake shifts they find
less fatiguing and that fit better with their domestic
situation. Careful monitoring of actual shift patterns
and number of hours worked would be needed to
avoid exceeding set limits and to prevent the revised
shift patterns being more fatiguing that the original
rosters. Checks would also need to be made to
ensure workers do not lose job-specific knowledge by
selecting only certain shifts.
Amongst freight staff, research has found that variability
in the timing of shifts was the most important factor
contributing to fatigue and sleep problems, with 40% of
drivers surveyed reporting sleep problems [4]. Switching
from regular weekday to weekend working and back to
weekday rosters, or switching from a late or night shift
to an early start, has also been found to be particularly
fatiguing.
Case study
RSSB research into fatigue among the train driver
population [3] found that drivers were more satisfied
with the shift system when they had a higher level of
control over the specific shifts they worked.
It is therefore essential to plan shift start times and oncall duties and to put in place contingency arrangements
in the event of unforeseen circumstances which may
extend a shift beyond the recommended limits. Where
this is not possible, additional control measures should
be put in place, for example, planning additional breaks
during a shift, reducing the length of a shift, asking the
worker if they are fit to continue beyond 12 hours, a
longer rest period before resuming work. Consecutive
shifts with large variation in shift start time should be
avoided due to the increased levels of fatigue-related
risk.
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Evidence suggests that rapid changes from one type
of shift to another and back again often did not include
sufficient time for recovery [4]. A rapid switch from a
late finish or night shift to an early shift is particularly
fatiguing. This is known as a backward rotating shift
pattern in which a shift starts earlier than the previous
one. It is therefore recommended that the principle of
forward rotation is used when designing schedules, eg
shifts to start later than the previous one.
Good practice
Consider the nature of different jobs, eg workload
and potential for mental and physical fatigue, when
designing work schedules.
Allow workers time for social/domestic commitments
between shifts/cycles.
Remain vigilant of non-work/individual factors.
Provide access to (confidential) occupational health/
employee assistance/sleep disorder clinic.
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Table 1 below provides a summary of the key good practice recommendations arising from RSSB research [3,4] which
investigated fatigue and shift work issues amongst passenger and freight train drivers and track workers.
Fatigue management - A summary of RSSB research and good practice recommendations
Duration of shift
Hours to be worked (eg length of shift) per turn of duty to vary with type of shift
• Day shift – 12 hours.
• Night & early shifts – 10 hours.
• Shifts starting before 05:00hrs – eight hours (from TOC study).
Duty hours
A target of 55 hours per seven day period as a maximum for any rolling week.
Rest between shifts
12 hour minimum rest period between booking off from a turn of duty to booking on for the next turn. This should be
extended to 14 hours between consecutive night shifts.
Consecutive shifts
Number of consecutive shifts before a rest day:
• Day (including mixed patterns) – six.
• Night – three (where nights exceed eight hours).
• Early – five.
Rest days:
• Two days before an early start after a night shift. (minimum 54 hours rest when changing from nights to early
shifts).
• A single rest day following a sequence of night shifts may not provide adequate recovery – may be necessary
to schedule more time off.
• One day before an early shift after a late shift.
• Option of representing rest days in hours to ensure an adequate recovery period.
Additional recommendations
• A maximum period of work of four hours before a break of 15 minutes which is completely free of all workrelated activities. The HSE recommended good practice limit is three hours.
• Avoid scheduling breaks at the start or end of a shift and improve the quality of breaks (eg facilities).
• Minimise variability of shift start times and last minute changes to the roster.
• Limit overtime so that the total time working does not exceed 12 hours.
• Minimise rest day working.
• Company informed shift swapping should accommodate, were practicable, individual differences in shift
preferences.
• Use of the HSE Fatigue and Risk Index [20,21] to aid roster design and modifications.
• Consider implementing a napping policy for freight drivers.
• If commuting before the start of a shift exceeds one and a half hours make arrangements to provide transport
or lodgings for staff.
• Consider nature of work content (eg mental/physical demands) and design tasks to maximise alertness
(particularly at the end of long shifts).
• Ensure checks on fitness to continue are undertaken.
• Put in place contingency arrangements to cover unplanned events, emergencies, absentees.
• Build regular free weekends into the shift schedule where possible.
• Facilitate communication between workers and supervisors (eg reporting of problems, particularly at shift
handover).
• Use the principle of forward rotation (eg next shift starts later than the last). For example, for three-shift
systems, better patterns rotate rapidly in a forward direction – MMMAANNRR – where M=morning shift,
A=afternoon shift, N=night shift, R=rest day.
• Research suggests a more rapidly or slowly rotating shift pattern is easier to adjust to than one that changes
about once a week.
• Remain aware of non-work/individual factors and provide access to (confidential) occupational health/
employee assistance schemes.
Table 1 Summary of key RSSB research and good practice recommendations
www.rgsonline.co.uk
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7.4.2 Limiting exceedances
It is important to ensure that any standards and limits
that have been identified and set are only exceeded
with prior approval and only on an infrequent basis
in exceptional circumstances. This is to avoid
employees working excessive hours (eg overtime;
on-call duties) that could lead to someone being tired
or slower to recover from long working hours. Safety
briefings, planned or delayed training, long standing
job vacancies, a block of maintenance work extending
over a few days and organisational changes should not
be a reason for exceeding working limits. They are all
foreseeable circumstances that should be taken into
consideration when planning or altering rosters.
Therefore, once company standards and working limits
have been set, it is necessary to provide clear criteria for
those infrequent and exceptional circumstances when
these limits may be exceeded with prior approval. The
controls required to ensure all risks are mitigated will
also need to be defined.
Factors for consideration include, but are not limited to:
• The outer limits which workers cannot exceed (eg
what is an acceptable level of overtime, number of
call-outs, number of times an additional shift may be
permitted in a roster period?).
• Clear criteria for when limits may be exceeded on
an infrequent one-off basis (eg failed trains, extreme
weather) and the controls in place.
• A documented process for whom has responsibility
for authorising exceedances, and under what
circumstances.
• Capacity of rail safety worker to continue working
safely.
• Circumstances when safety critical workers can
decline to continue working beyond agreed limits.
• Clear means of reporting exceedances, summarising
the risks considered and corresponding fatigue
controls and mitigation measures put in place.
• Limiting the availability of workers following additional
hours of work.
• How the company will examine the differences
between master and actual rosters to allow for
continual refinement of the master roster.
• Utilising a fatigue risk modelling tool.
• Consultation – employee buy-in; how have
employers consulted with their employees?
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Those with responsibility for overseeing the FRMS
should be notified of exceedances as part of the
continuous review process.
Good practice
1) One company monitors their exceedances as a
key safety performance indicator, with trends being
addressed accordingly. Other companies may
prefer to track, for example, exceedances to their
organisational-specific operating limits or notable
deviations from master rosters.
2) Provide additional justification and control
measures for when operating at a higher level of
risk under certain circumstances.
3) Do not roster staff to the limits as it leaves no time
available for contingencies.
4) Where staff are required to exceed working
limits, where practicable, provide relief as soon
as possible in order to minimize the amount of
exceedance.
5) Once company policy and standards on work
patterns have been set, and any related withincompany agreements are in place, these should
be reflected in individuals’ terms and conditions of
employment.
7.4.3 Additional control
measures
Further control measures that IMs and RUs may like to
consider include:
Sleep contracts
This is a new area and further investigation is required
into the efficacy of sleep contracts for the railway
industry. A brief summary is provided below, however, to
introduce the concept.
A sleep contract refers to a joint framework for setting
working limits and managing fatigue that is negotiated
between an employer and employee and that both
parties sign up to. For example, it would include
clarification on:
- What is too tired to work?
- What actions a company would take if a worker was
found to be, or reported themselves to be, fatigued
on a number of occasions over a pre-defined time
period (eg one, three or 12 months).
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- What actions would a company take to address
different underlying causes of fatigue, eg inadequate
sleep or company rostering practices?
- What constitutes a valid reason for being fatigued?
A publication by the Energy Institute [30] discusses
the topic of sleep contracts and presents some useful
methods and ideas for consideration to address fatigue.
Sleepiness at work and signing-on for duty
This area presents a genuine challenge for IMs and RUs
in their approach to fatigue management. IMs and RUs
may like to consider the following options for monitoring
fatigue.
in this guide, it is unlikely that an accurate assessment
of fatigue levels among workers will be achieved.
Alternatively, these strategies could be used as
reminders at worker signing-on points, as prompt
questions for roster staff when allocating overtime, or at
other times that an organisation deems appropriate.
Ultimately the success of the above options will depend
upon a company’s culture and the extent of employee
involvement in and awareness of the purpose of
systems to manage fatigue. The aim should be to
encourage employee participation in the FRMS and to
promote a culture of mutual responsibility, openness
and trust. This will encourage workers to openly report
genuine issues with fatigue.
The first option is to conduct a fatigue risk assessment,
whereby safety critical workers are asked to indicate
the amount and quality of sleep they have had prior to
signing on for duty (see Table 2 on page 42).
An alternative approach is to consider the use of some
of the following questions:
• Do you feel fatigued, exhausted, tired or not up to
par?
• Do you feel that in some way your sleep was not
refreshing or restful?
• Have you had periods during the day when you have
trouble paying attention, remembering things or
staying awake?
• Have you experienced any of the following today:
- Trouble keeping your head up?
- Wandering, disconnected thoughts?
- Eyes closed for a moment or went out of focus?
- Eyelids drooped?
- Couldn’t stop yawning?
- Couldn’t remember driving the last few miles?
- Missed a brake or acceleration notch?
- Braked too late/too much?
The options presented above for asking safety critical
workers to indicate the amount and quality of sleep they
have had prior to signing-on can be used in a variety
of ways by IMs and RUs. However, they all have the
limitation in that they are transparent and consequently
workers will quickly learn their intent. How workers then
react will most likely depend on the way the company
responds to a fatigued individual. If IMs and RUs choose
to punish workers who admit to being fatigued or are
deemed to be fatigued via any of the options presented
www.rgsonline.co.uk
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Amount of Sleep
Little to No sleep
Some sleep
Normal amount
of sleep
Poor
Quality of
sleep
Average
Good
Table 2 Example sign-on sleep risk assessment to be used by roster staff with safety critical workers
(Note: this is a subjective scale where ‘poor’ (quality of sleep) is typically taken to mean broken/disturbed
sleep, to ‘good’ referring to unbroken/undisturbed sleep with no waking up).
Key:
The worker is fit for work.
The worker is fit for safety critical work with additional risk mitigation strategies (eg, extra breaks)
(see stage 8).
The worker is not fit for safety critical work.
*Further questions required, eg is it a one-off? – if the answer is “yes” then consider fit to work; if the answer is “no”
then consider additional risk mitigation strategies.
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Taking action when safety critical workers are
fatigued
The advice presented below focuses on ensuring, so far
as is reasonably practicable, that safety critical workers
who report for duty where they are clearly unfit owing
to fatigue, or who, through the course of their work shift
become clearly unfit owing to fatigue, do not carry out or
continue to carry out safety critical work.
The practicality of the options will obviously vary
depending on the circumstances involved, such as what
has caused the fatigue and where the worker is located.
It is important to highlight that it is not acceptable to
simply ask if a worker feels fit to continue as there is
now clear scientific evidence to support the link between
fatigue and an increase in accident rates.
The options include:
• Putting on a replacement worker.
• Putting a worker on alternative non safety critical
duties.
• Modifying the scheduling of breaks to allow a worker
to have a nap.
• Providing food and liquid refreshments.
The options presented above are reactive in nature,
and consequently quite limiting for IMs and RUs.
Alternatively, considering the following points during
work planning and scheduling and/or during the
supervision of work can help mitigate the effects and/or
the build up of fatigue:
• Varying the work being undertaken, to minimise the
effects of completing repetitive tasks.
• Where the working conditions are uncomfortable,
ensure opportunities are provided for the individual to
take breaks away from that environment.
• Ensure arrangements for additional monitoring or
additional support from a colleague or supervisor is in
place.
• Ensure regular breaks of at least 15 minutes
duration, which are completely free from all workrelated activities.
• Consider those shifts/workers which are already
high risk or bordering on high risk, before a shift
commences. This will allow contingency plans to
be put in place in the event of an unplanned event
affecting the duration of shift in question.
www.rgsonline.co.uk
Napping
The concept of napping is not a new one in the area of
fatigue management. The principles are fairly straight
forward, in that a person supplements their primary
sleep period with additional shorter sleep periods, which
are referred to as naps. It is important to emphasise,
however, that the concept of napping is not appropriate
to all groups of safety critical workers, eg those required
to provide a continuous monitoring function whilst on
shift.
It may be useful to put this in context for shift workers at
this point (eg proactive anticipatory naps taken before a
night shift, or reactive compensatory naps taken after a
period of sleep loss such as following the night shift).
Napping can be roughly divided into two categories.
Those that can combat the accrual of a ‘sleep debt’ (the
difference between the amount of sleep a person needs
and what they actually get) and last for around one and
a half to two hours in length. Alternatively, naps can
help to mitigate or delay the onset of fatigue and are
considerably shorter in length, around 10 – 40 minutes
in length.
The logic behind these figures relates to the changes in
the body during the sleep state. Sleep can be divided
into a series of stages which differ in their level of ‘depth’
and restorative effects. A complete sleep cycle lasts
for approximately 90-120 minutes, and consequently,
the longer napping option allows a person to receive
the restorative benefits of all sleep stages and then
awaken at a lighter sleep stage. Consequently, they
will experience less sleep inertia or ‘grogginess’ when
they rise. Additionally, napping for shorter periods of
time is also designed to ensure that a person avoids
sleep inertia. However, if you are sleep deprived you
can quickly enter what is referred to as slow wave sleep
(SWS) and experience sleep inertia. By limiting the nap
period you are trying to limit the chances of entering
deep sleep and hence reduce the impact of sleep
inertia.
It may be useful to point out that there is a balance to
be struck between the benefits in terms of alertness and
the duration and nature of sleep inertia. A nap of say one
hour will be beneficial over a longer period than a short
nap of 20 minutes. However, the impact of sleep inertia
is likely to be greater and longer in a nap of one hour
than for the 20 minute nap. So it depends on whether
you need to mitigate fatigue over the short or long term.
The information presented so far is based on the
premise that a person does not start the shift with any
accrued fatigue. However, this is often not the case on
the railways, even during day work. A person may have
an accrued sleep debt, been awake a considerable
period of time before commencing work or, about to
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Fatigue Risk Management Process
work during a period when the body is used to being
asleep. All of these scenarios could result in a person
immediately falling into one of the deeper sleep stages
and waking with the associated grogginess. The
resulting effect for employers and workers is to allow
sufficient recovery time so that employees can recover
their alertness sufficiently to either undertake their safety
critical duties at work or get themselves safely to work
after napping in preparation for their upcoming shift.
To optimise any napping period it is also important to
plan for a person to fall asleep (some airlines allow 10
minutes for this), awaken from sleep and be fit for safety
critical work (eg 20-30 minutes). See Table 3 below for
an example napping schedule. Other good practice
points of napping are:
• Naps taken before a shift commences (proactive
napping) are generally better at enhancing worker
performance when compared to naps taken once
a person is already fatigued (reactive napping).
Consequently workers could be encouraged to plan
in a nap to help them prepare for the night shift or to
aid recovery following an early shift, for example.
• Naps are best taken in the afternoon (eg the siesta
period, 14:00 to 16:00hrs) when the body naturally
slows down. Alternatively, naps can be at their least
effective if taken during the peak in the circadian
rhythm (in terms of performance and alertness)
which is generally considered to occur at around
18:00hrs. It will therefore be more difficult to initiate
and maintain sleep during this period.
• Workers will vary in their response to napping
opportunities and ease of napping. One option is
for a company to provide relaxation training for its
workers so that they can optimise the benefits of
napping by reducing the time it takes to fall asleep.
• As people age, sleep quality taken during the night
time can decrease, resulting in increased sleepiness
during the day. Consequently, napping for older
workers could have particular importance.
Time Period
Napping Components
Sub-Activities
10 minutes
Sleep preparatory behaviour
• Worker has a cup of coffee.*
• Worker starts relaxing away from bright
lights, social interaction etc.
• Worker prepares napping environment to
their liking eg lighting, temperature, angle
of chair recline, setting alarm.
20 minutes
Napping
15 minutes
As indicated above it may
be better to suggest at least
20 minutes
Sleep Recovery Period
Worker leaves the napping environment
and uses alerting strategies such as social
interaction, eating a light meal, moving into
bright lights, etc.
* Caffeine takes approximately 30 minutes to affect a person’s alertness; therefore by taking it prior to napping, it can help mitigate the effects of
sleep inertia during the sleep recovery period. It is important that employees are educated to use stimulants, such as caffeine from coffee, only
when needed at work, as the body gets used to their use and consequently their effects are reduced.
Table 3 Example napping schedule
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Consideration also needs to be given to the napping
environment, eg those facets that impact on sleep
quality. This may include the immediate environment
where the person naps (eg quiet, darkened room that is
at a suitable temperature, possibly with eyeshades and
earplugs) and what the location is (eg bed or reclining
chair). Finally, providing an alarm is a good strategy for
limiting the nap duration as this will reduce the likely
impact of sleep inertia which results when a person
enters the deeper stages of sleep.
A final point to consider on the area of napping is that
of individual differences within the workforce. Each
worker will vary in the benefit received, time taken to
recover and level of comfort with napping. IMs and
RUs will need to consult with staff to agree on the most
appropriate implementation of napping, that will jointly
meet the needs of the business and its staff.
Further information on napping and other sleep topics
can be found on the National Sleep Foundation website
(www.sleepfoundation.org).
7.5Evaluation
It is important to evaluate any arrangements made for
managing fatigue to assess how effectively the risks
have been reduced. IMs and RUs should therefore
consider developing policies and procedures to ensure
that regular monitoring of their chosen operating limits
and management arrangements are formally integrated
into their FRMS or overarching SMS. This will also
reinforce management’s commitment to the objectives
set out in the fatigue policy and encourage continuous
improvement in the development of a positive health and
safety culture (see Appendix 2).
As part of the monitoring process, it is important that
risk assessments are repeated at regular intervals
to evaluate the effect of existing and any new
arrangements/changes made to working patterns. This
will enable attention and resources to focus on key
areas where additional improvements may be required
(eg to address an increase in fatigue-related reports
from safety critical staff). It is also important to evaluate
the success of arrangements in place to manage fatigue
risks.
Information to monitor the performance of the FRMS
can be generated through the use of safety performance
indicators (SPIs) [35]. There are two key types of SPI:
• Activity indicators – these are measures of whether
a risk control system is in place. They enable
weaknesses in the implementation of the FRMS (to
address fatigue risks at the organisational, job, and
individual levels) to be identified and direct actions to
strengthen and improve processes and procedures
before an accident or incident occurs.
www.rgsonline.co.uk
• Outcome indicators – these are measures of events
after they have occurred, such as fatigue-related
sickness absence, ill-health, accidents and incidents.
They provide an indication of the effectiveness of the
risk controls in place.
A variety of company sources will be available that can
be used for such purposes and a sample of these is
highlighted below:
Accidents, near misses and safety critical events
One measure of success is to examine records to see
if there has been a reduction in accidents, near misses
and safety critical events.
Post-incident and accident investigations provide a
rich source of data on the performance of an FRMS.
In order for this to be effective, however, accident
reporting guidelines need to include relevant questions
or processes to determine the contribution, if any,
of fatigue. Listed below are questions IMs and RUs
could consider asking to determine if fatigue was a
contributory factor:
• At what time of day did the incident take place?
• Was the operator’s normal circadian rhythm
disrupted (eg did the incident occur during a period of
low or high alertness)?
• Time on duty.
• Time on tasks.
• How many hours had it been since the operator
awoke?
• Does the 72 hour sleep history suggest a sleep
deficit?
• Does the person(s) involved display any common
fatigue characteristics, eg impaired memory, slower
reaction times, poor decision-making, reduced
vigilance, slurred speech, moodiness, etc?
• Was the person involved working for more than four
and a half hours without a break?
Organisations may also want to consider the following
points in an investigation context:
• Focus on actual hours worked (including any
overtime) and examine the previous shifts since the
individual had a reasonable time period off work (eg
three or more days off).
• Sleep history over the past week.
• Examine precursor events, eg the levels and
distribution of overtime, shift swapping and number
and duration of vacancies within safety critical roles
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Fatigue Risk Management Process
relevant to the people involved.
• Examine what role the organisation’s, and respective
depot/work team’s approach to fatigue management
played in the incident (eg rostering practices, local
culture relating to admitting feeling fatigue).
• Job factors, such as workload, variety, etc.
• Environmental factors such as weather, temperature,
noise, etc.
• Work history over the previous 14 days. This should
include variable start times, breaks, number of
consecutive shifts, night work, etc.
• Review of records to determine if there has been an
increase/change in performance and/or productivity.
• Review of records to determine if there has been a
reduction in absenteeism and staff turnover.
A final option that could be considered is to identify
operational markers of fatigue. For example, On Train
Data Recorder (OTDR) downloads, where specific
attention is paid to delayed acceleration or braking
curves, instances of over-braking, etc. Obviously, this
would not provide conclusive evidence that a person is
fatigued; however it would be another form of data for
IMs and RUs to integrate into their FRMS.
• Individual factors, such as length of time in post,
training, competency levels, family commitments
(eg caring for an elderly parent or a new baby),
commuting and personal health.
Good practice example
One company has extended their current incident
investigation process to capture more information on
possible precursor events, prior to a major incident
(eg station overruns, fail to call) occurring. By doing
so, they can monitor and respond to trends between
these precursor events and consequently reduce the
likelihood and possible severity of a major incident in
the future.
Good practice
Define who is responsible for frequent monitoring and
what procedures are followed.
Further options available to IMs and RUs to monitor
fatigue include, but are not limited to, the following:
• Introduction of a non-punitive fatigue reporting
system.
• The use of fatigue risk modelling tools to identify if
the arrangements made for managing fatigue have
reduced the risks.
• Comparing actual work patterns against good
practice.
• Monitoring shift exchanges, overtime, on-call duties,
commuting times and working time exceedances.
• Interviews and focus groups with staff to collect
feedback on particular shifts.
• Comparison of fatigue questionnaire rating scores
before and after the introduction of fatigue risk
controls.
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8. Reviewing
Performance
Uncontrolled When Printed
Document comes into force 01/09/2012
Reviewing Performance
8.1 Overview
The FRMS should be a self correcting system which
incorporates review ‘triggers’. Various occurrences
could trigger IMs and RUs reviewing their FRMS.
Obvious events include: fatigued-related incidents/
accidents; reports from safety critical staff; internal/
external audit findings; changes to the work patterns
and tasks, when the maximum limits are consistently
exceeded, changes in recommended good practice for
managing fatigue. This may also be supplemented,
for example, with information relating to regular shift
swapping for particular turns.
Good practice
Define the purpose and frequency of reviews, who
is involved and the process for making system
corrections and changes. Integrate FRMS reviews
into the overarching SMS.
Other sources of information available for review
purposes include, but are not limited to:
• Effectiveness of consultation process and key roles
and responsibilities assigned.
Reviews of a company’s FRMS should, where
practicable, be conducted by competent persons outside
the scope of the review (eg internal audit/external
specialists).
• Key safety performance indicators (eg percentage of
staff deemed competent in fatigue management).
Gathering feedback directly from workers (and
occupational health and safety representatives) can be a
valuable source of information for a company to identify
fatigue-inducing conditions or work practices. IMs and
RUs will need to consider their own needs in relation to
gathering information in this area, such as establishing
a new system, modifying an existing reporting
arrangement to cover the area of fatigue, or utilising
information gained from existing reporting mechanisms
within the industry (eg CIRAS).
• Number of recorded fatigue-related errors.
Another option for IMs and RUs is to measure the
effects of fatigue and shift work within different groups
of safety critical workers in the workforce. RSSB’s
research in this area was built around a questionnaire
and diary shift work survey. Similar measuring tools
can be used by IMs and RUs to assess fatigue levels
over a period of time, eg 12 months. They could also
be used to measure the effectiveness of specific fatigue
countermeasures or an enhanced FRMS if administered
both before, and after, a change has been implemented.
RSSB can provide further guidance in this area as
needed.
• Changes in fatigue assessment tool scores.
• Deviations of actual hours worked from planned
hours and review against company policy and
benchmark levels.
• Evidence of increased sleep.
• Self reports.
• Management/safety representatives’ inspections and
safety tours.
• Evaluation of fatigue management training and
education.
It is essential that rail operators act upon
recommendations from reviews to ensure the
arrangements in place are effective in managing fatigue.
Any changes or remedial actions taken should be
communicated to staff to ensure their continued buy-in
and support for the FRMS.
Good practice
Review the arrangements when:
- An incident or accident has occurred where fatigue
has been a causal or contributory factor.
- Work patterns change, or
- When the maximum limits are increased.
Page 48
Managing Fatigue: A good practice guide
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a g53
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Appendices
Uncontrolled When Printed
Document comes into force 01/09/2012
Appendices
Appendix 1 Hidden limits on working time
‘Hidden Limits’ on working time
1. No more than 12 hours to be worked per turn of duty.
2. No more than 72 hours to be worked per calendar week (Sunday to Saturday).
3. A minimum rest period of 12 hours between booking off from a turn of duty to booking on for the next turn. This
may be reduced to eight hours at the weekly shift changeover, in the case of staff working a shift pattern which
rotates or alternates on a weekly basis.
4. No more than 13 turns of duty to be worked in any 14 day period.
5. For Signalling and Telecommunications Testing Staff, a maximum of 23 turns duty in any two consecutive 14
days periods.
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Managing Fatigue: A good practice guide
Uncontrolled When Printed
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Appendix 2 Key elements of a positive safety culture
• Effective and appropriate management systems:
Organisational systems, procedures, training and workplace environment that support safe working behaviours
and foster positive attitudes (eg do excessively complex procedures and controls unwittingly induce unsafe
behaviours)?
• Demonstrable (senior and line) management commitment to health and safety:
Visible (senior and line) management commitment, leadership and involvement in improving health and safety
performance is vital. The interest in, and priority placed on, safety by management needs to be ‘felt’ by the
organisation (eg management modelling of safe behaviours, good quality and effective communications, safety
tours).
• Participation, involvement and workforce attitudes to health and safety:
Taking personal responsibility for safety means that staff at all levels accept they have a role in making sure their
behaviour and decisions do not endanger others. Individuals (peers and managers) should feel comfortable to
intervene and challenge unsafe behaviour, but this should be done from a coaching, not blame perspective.
• Organisational learning and continuous improvement:
Incidents and failures are seen by organisations with good safety cultures as valuable opportunities to improve
operations and learn lessons to avoid more serious events. This includes: (i) in-depth root cause analysis and
learning from accidents, incidents & near misses; (ii) soliciting and responding to ideas from employees, and (iii)
providing timely feedback and sharing of information across the organisation.
• A Just Culture:
In a just culture, the company line is more clearly drawn between acceptable (non-culpable) and unacceptable
(culpable) behaviour (eg clear statement in company safety policy) so that appropriate action can be taken to
prevent a recurrence. Based on an understanding of human factors, unintentional unsafe acts (eg honest errors,
routine and situational violations) are seen as opportunities for organisational learning. Conversely, deliberate,
intentional unsafe acts (eg reckless non-compliance, criminal behaviour, substance abuse and sabotage) are dealt
with accordingly, with the required level of sanction.
• A reporting culture:
An effective reporting culture recognises that the ‘system’ needs to be proactively monitored to accommodate
human error to ensure continual improvement. This should include the use of good quality lead indicators
to provide feedback on key organisational behaviours (eg number of suggestions for safety improvements;
perceptions of management commitment to safety; safety policy published; number of safety tours carried out;
percentage of improvement solutions closed out). Employees need to be encouraged and willing, even rewarded,
for coming forward and reporting essential safety-related information (eg errors they have made; behaviours
they have observed) without fear of sanction. This crucially depends on how an organisation handles blame and
punishment and the building of an atmosphere of trust.
www.rgsonline.co.uk
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Uncontrolled When Printed
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Appendices
Appendix 3 Fatigue assessment tools – Important considerations
The table below provides a summary of the potential benefits and limitations of fatigue risk assessment tools. It is
important therefore that duty holders are aware of the specific assumptions and limitations made by different tools
when using them as part of the fatigue risk assessment process.
Benefits
Limitations
They can assist in the identification of likely fatigue risk
associated with current work schedules.
They are based on a set of mathematical predictions to
estimate the probability of fatigue and relative risk of an
incident.
They can assess the likely impact of fatigue associated
with proposed changes to the working pattern.
They do not take account of the multiple causal factors
of fatigue, eg individual differences, circadian type,
commuting, job role, workload, work and non-work
environment.
They can identify particular shifts or shift sequences
within a work pattern associated with a higher risk
of fatigue to enable risk reduction strategies to be
implemented accordingly.
They make assumptions that individuals will get sleep
of sufficient quality and quantity between shifts.
They can identify particular features associated with
different shifts, shift sequences or work patterns and to
estimate the benefits of compensatory measures such
as providing additional breaks or shortening shifts.
The outputs should be treated with caution and used
alongside other sources of fatigue information, such
as staff reports and feedback, as part of the broader
FRMS.
They can be used to explore whether fatigue was a
contributory factor as part of incident investigations.
Recommended thresholds are not a definitive measure
of a good fatigue control. They are indicative values
based on the theoretical knowledge and assumptions
made by the model’s developers.
Some tools can be incorporated into an organisation’s
resource planning and monitoring systems.
They are not a substitution for a well thought out and
comprehensive FRMS, but just one element of a
company’s overarching approach to effective fatigue
management.
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Further Information on Fatigue and Fatigue Management
British Nutrition Foundation
www.nutrition.org.uk
Federal Railroad Administrationwww.fra.dot.gov
Food Standards Agency
www.food.gov.uk
Health and Safety Executivewww.hse.gov.uk
Medical fitness standardswww.rgsonline.co.uk
(GO/RT3451, GO/RC3561, GO/GN3655)
National Sleep Foundationwww.sleepfoundation.org
Office of Rail Regulationwww.rail-reg.gov.uk
Opsweb
www.Opsweb.co.uk
RSSBwww.rssb.co.uk
RSSB
Professional Driving DVD enquirydesk@rssb.co.uk
RSSB
Human Factors CD ROM enquirydesk@rssb.co.uk
RSSB
Human Factors Awareness Training Materials enquirydesk@rssb.co.uk
The Sleep Apnoea Trustwww.sleep-apnoea-trust.org
Additional RSSB leaflet titles available on the RSSB website
RSSB
‘Feeling Tired?’ Leaflet
RSSB
‘Coping with Shift work & Fatigue – a good practice guide for drivers’ Handbook
RSSB
Understanding Human Factors – a guide for the railway industry
www.rgsonline.co.uk
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www.rgsonline.co.uk
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