AC 120-103A - Fatigue Risk Management Systems

AdvisoryU.S. Department

of Transportation

Federal Aviation

Administration Circular

Subject: Fatigue Risk Management Systems Date: 5/6/13 AC No: 120-103A

for Aviation Safety Initiated by: AFS-220 Change:

1. PURPOSE.

a. Contents. This advisory circular (AC):

(1) Describes the basic concepts of Fatigue Risk Management Systems (FRMS), as

prescribed in Title 14 of the Code of Fede ral Regulations (14 CFR) part 117, § 117.7, and how

they relate to aviation industry empl oyees safely performing their duties.

(2) Provides information on the components of an FRMS as applied to aviation, and on

how to implement an FRMS within an aviation operation.

(3) Defines an FRMS as an operator-specific process; therefore, while all FRMSs will

have common elements, the specifics will be tailored to a certificate holder’s particular

conditions.

(4) Provides (in Appendix 2, Fatigue Risk Ma nagement System Development) the

certificate holder with the necessary detailed guidance to prepare for the FRMS approval

process, develop the required documentation, deve lop and apply fatigue ri sk management (FRM)

and Safety Assurance (SA) processes, collect and analyze data, deve lop flightcrew FRMS

operations procedures and a step-by-step proc ess required for Federal Aviation Administration

(FAA) evaluation and validation of the proposed FRMS application.

b. Parts of an FRMS. This AC describes the essential processes and elements for an

effective FRMS.

c. Not Mandatory. This AC is not mandatory and does not constitute a regulation.

However, this AC provides an acceptable method for developing an FRMS application.

2. CANCELLATION. This AC cancels AC 120-103, Fatigue Risk Management Systems for

Aviation Safety, dated August 3, 2010.

3. INTRODUCTION TO FRMS. An FRMS is an optional approach to prescriptive

regulations. A certificate holder se eking to exceed a limitation in part 117 or in 14 CFR part 121

subparts Q, R, or S, would do so under an FAA au thorization. An FRMS is largely developed as

an alternative method of comp liance (AMOC) to prescriptive limitations based upon objective

performance standards. A certificat e holder may be authorized to apply an FRMS to any part or

all of its operation, provided that the certificate holder demonstr ates an effective AMOC that

AC 120-103A 5/6/13

meets or exceeds the safety standards afforded by the prescriptive limitations. Unlike a Fatigue

Risk Management Plan (FRMP) that is requir ed for each certificate holder conducting operations

under part 121, the FRMS is an AMOC to prescr iptive limitations that the certificate holder may

implement for fatigue management and mitigation.

4. WHAT IS AN FRMS? An FRMS is a management system for a certificate holder to use to

mitigate the effects of fatigue in its particular operations. An FRMS is a data-driven system,

based largely upon scientific pr inciples and operational knowledge, that allows for continuous

monitoring and management of safe ty risks associated with fatigue-related error. An FRMS is a

fatigue mitigation tool that minimizes the acute and chronic sources of fatigue and manages the

potential risks associated with fatigue. The FRMS is part of a repetitive performance

improvement process that leads to continuous sa fety enhancements by identifying and addressing

fatigue factors across time and changing physio logical and operational circumstances. The

objective of the FRMS is to manage, monitor, and mitigate the effects of fatigue to improve

flightcrew member alertness and reduce performance errors.

5. CREWMEMBER ALERTNESS AND PERFORMANCE. A certificate holder’s FRMS

will be designed to demonstrate that flightcrew members are sufficiently alert so they can operate to a satisfactory level of perf ormance. Additionally, the FRMS should be designed to achieve a

realistic balance between safety and productivit y. It should proactively identify opportunities to

improve operational processes and reduce risk, as well as to iden tify deficiencies after adverse

events or reports of excessive fatigue.

6. DEFINITIONS.

a. Acute Fatigue. Acute fatigue is closely related to r ecent sleep (i.e., sleep within the last

24 hours), time since last sleep, and current time of day. Less than 8 hours of sleep in the last

24 hours, being awake longer than 17 hours, and working between midnight and 0600 are

associated with acute fatigue in the average person.

b. Biomarkers. Biomarkers are characteristic biologi cal properties that ca n be detected and

measured in the body, such as in the blood or ti ssue. Biomarkers may indicate either normal,

abnormal, or diseased processes in the body. Curr ently, there are no easily obtainable biomarkers

of fatigue. However, several biomarkers of th e circadian rhythm exist, such as core body

temperature and melatonin levels. In the absen ce of biomarkers to identify fatigue, we can

measure fatigue effects directly, in performance variables, or indirectly, by using measures of

sleep and time of day and by modeling the e ffects of these conditions on performance.

c. Chronic Fatigue. The average person needs about 8 hours of sleep per day. If the

average person gets less than the required amount of sleep each day for multiple days, then a state of chronic fatigue can occu r. With chronic fatigue, performa nce is degraded and recovery

tends to be relatively slow. A person can hasten recovery by attempting to sleep longer than the

normal amount for several days.

d. Circadian Fatigue. Circadian fatigue refers to the reduced performance during nighttime

hours, particularly during an individual’s Window of Circadian Low (WOCL) (typically

between 0200 and 0600 hours).

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e. Circadian Rhythm. In humans, the circadian rhythm is a daily alteration in a person’s

behavior and physiology. These be havioral and physiological alte rations are controlled by an

internal biological clock located in the brain (i.e., th e circadian clock). Examples of circadian

rhythms include body temperature, melatonin levels , cognitive performance, alertness levels, and

sleep patterns.

f. Cumulative Fatigue. Cumulative fatigue is fatigue br ought on by repeated mild sleep

restriction or extended hours awake across a series of days.

g. Fatigue. Fatigue is a complex state characterized by a lack of alertness and reduced

mental and physical performance, often accompan ied by drowsiness. Fatigue is objectively

observed as changes in many aspects of performan ce, including increased r eaction time, lapses in

attention (e.g., reaction times greater than 500 m illiseconds), reduced speed of cognitive tasks,

reduced situational awareness, and reduced motivation. A pers on’s perceived fatigue levels are

often lower than observed decrements in performance.

h. Fatigue Risk Manageme nt System (FRMS). A management system that

certificate holders may use to mitigate the effects of fatigue in their operations where the FRMS

is applied. Specifically, an FRMS is the met hod by which a certificate holder may exceed a

flightcrew member flight, duty, or rest limitation, provided the FRMS demonstrates an AMOC

and is approved by the FAA. Essentially, an FRMS is a nonprescriptive fatigue mitigation tool.

i. Transient Fatigue. Transient fatigue is acute fatigue brought on by extreme sleep

restriction or extended hour s awake within 1 or 2 days.

j. Window of Circadian Low (WOCL). Individuals living on a regular 24-hour routine

with sleep at night have tw o periods of maximum sleepine ss, also known as WOCLs. One

WOCL occurs at night, roughly from 0200 to 0600, a time when physiolo gical sleepiness is

greatest and performance capabi lities are lowest. The other WO CL is in the afternoon, roughly

from 1500 to 1700, and is less severe than the nighttime WOCL.

7. RELATED READING MATERIA L (current editions).

 Proceedings of the “Aviation Fatigue Ma nagement Symposium: Partnerships for

Solutions,” June 17-19, 2008.

 AC 120-100, Basics of Aviation Fatigue.

 International Civil Aviation Organization (I CAO) Fatigue Risk Management Systems

Implementation Guide for Operators.

 ICAO Document 9966, FRMS Manual for Regulators.

 Mahon, G. & Cross, T. The Fatigue Manageme nt Program: Alternatives to Prescription.

Queensland Transport: Queen sland, Australia, 1999.

 Mallis M.M., Banks S., & Dinges D.F. Ai rcrew fatigue, sleep need and circadian

rhythmicity (Chapter). In El sevier, E. Salas, T. Allar d, & D. Maurino, (Eds), Human

Factors in Aviation (2nd edition), in press; 2010.

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8. BACKGROUND.

a. Causes of Fatigue. Generally speaking, the main cau ses of fatigue in aviation are:

 Amount, timing, and quality of sleep each day (sleep/wake schedule),

 Amount of time since last sleep period (continuous hours awake),

 Time of day (circadian rhythm),

 Operations through multiple time zones, and

 Workload and time on task.

b. Fatigue Management. The traditional ways to manage fatigue associated with aviation

operations have been prescriptive flight and duty time limitations and rest requirements.

Conventional regulations following this model reduce, but do not eliminate, the conditions that

contribute to fatigue. They are primarily based on “time on task” theories and on the assumption that fatigue accumulates in a linear manner. Co nventional regulations on fatigue management do

not consider the interactions of sleep loss and circadian rhythms. Additionally, conventional regulations cannot address operational complexities on a case-by-case basis.

9. THE FRMS CONCEPT. An FRMS consists of organizational processes and procedures to

control fatigue risk in aviation operations. An FRMS is a data-d riven and scientifically based

process that allows for continuous monitoring and management of safety risks associated with

fatigue-related error. It is part of a repeati ng performance improvement process. This process

leads to continuous safety enhancements, by id entifying and addressing fatigue factors across

time and changing physiological and operational ci rcumstances. Structurally, an FRMS is

composed of processes and procedures for measuring, modeling, managing, mitigating, and

reassessing fatigue risk in a sp ecific operational setting. An FR MS is an effective fatigue

mitigation strategy when the organization bases it on valid scientific principles. An FRMS combines schedule assessment, operational data collection, continuous and systematic analysis,

and both proactive and reactive fatigue mitigations, guided by information provided by scientific studies of fatigue. Overall, an FRMS offers a way to more safely conduct flights by offering

flexibility not available within regulatory limits. An FRMS compleme nts prescriptive flight time,

duty time, and rest period requirements.

a. Operational Demands. An FRMS addresses the complexity of operational demands and

the inherent fatigue-related challenges associated w ith aviation operations. The FRMS approach

is to apply risk management (RM) techniques to identify and reduce the risk of fatigue relevant

to specific operational circumst ances. An FRMS aims to ensure high levels of alertness in

personnel to maintain acceptable le vels of performance and safety.

b. Adaptability. An FRMS provides an interactive and collaborative approach to operation

performance and safety levels on a case-by-case basis. Therefore, an FRMS permits a certificate holder to adapt policies, procedures, and practices to the specific conditions that create

fatigue in a particular aviati on operation. Certificate holders ma y tailor their FRMSs to unique

operational demands and focus on mitigations of fatigue that are practical within the specific operational environment.

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c. Assessment. An FRMS relies on assessments to proj ect and confirm the fatigue effects of

an operation on crewmember sleep and alertness. This permits continuous assessment of fatigue

levels associated with ever-changing operational conditions. The co mmon tool for this

assessment is a biomathematical mode l of fatigue and alertness levels.

d. Risk Management Process (RMP). The FRMS applies the RMP to identify fatigue risks

through the use of data-driven systems. An FR MS includes documented processes for collecting

and analyzing fatigue-related safety data and implementing corrective actions, always allowing

for continuous improvement. A “just” or “safety” culture is integral to a successful FRMS, and it

requires a shared responsibility among all levels of the organization, as well as the involvement

of regulatory agencies.

10. TOOLS FOR AN EFFECTIVE FRMS. There are four basic tools for an FRMS to be

effective. These basic tools are fatigue-related da ta, fatigue analysis methods, identification and

management of fatigue drivers, and application of fatigue mitigation procedures.

a. Fatigue-Related Data. An effective FRMS is data-dri ven, meaning that it relies on the

use of reports, studies, etc., rather than on specula tion. An FRMS is based on scientific principles

and involves continuous monitori ng. Fatigue effects on performance and safety have been

documented and are well recognized (Bonnet, 2000; Carskadon and Dement, 1987; Dinges,

1992; Dinges and Kribbs, 1991; Horne, 1993; Naitoh, 1975) . It is difficult to detect fatigue in

operational settings because there are no biomarke rs for fatigue or simple tests of how an

individual will respond to sleep loss. However, the environmental conditions that promote

fatigue are well known and continue to contribute to performance deficits during operations. The

challenge is that aviation ope rators cannot totally eliminat e fatigue from 24/7 aviation

operations, so certificate holders need to appl y proactive and adaptive mitigation for fatigue.

Managing fatigue risk depends on two type s of operational evidence available to

certificate holders:

(1) The duty schedule directly affects crewme mbers’ opportunities to obtain restorative

recovery sleep. Monitoring work schedules prov ides indirect evidence of potential fatigue

resulting from inadequate or poorly timed opportunities to obtain sleep.

(2) A nonpunitive reporting system permits crew members and other employees to report

subjective fatigue and, from time to time, request relief from duties because of chronic fatigue.

These reports contain valuable data, especia lly when coupled with information about the

conditions that contributed to fatigue, such as the work schedule for the week prior to the report.

Subjective reports of fatigue can underestimate the true extent of performance impairment,

especially when an individual is already suffering from acute or chronic fatigue due to sleep loss

or circadian disruption (Dinges, 1989; Horne, 19 85; Rosekind et al., 1994; Wylie et al., 1996).

Therefore, data on procedural errors and flight exceedances, Aviation Safety Action Program

(ASAP) or Aviation Safety Reporting System (ASRS) reports, and flight operations quality

assurance (FOQA) data may help a certificate holder to objectively document fatigue.

Certificate holders may couple data sources with scheduling information or other event data

reported by crewmembers that implicate the potentia l for fatigue (e.g., flight delays and irregular

operations). A nonpunitive reporting system is esse ntial to encouraging th e reporting of fatigue-

related events as part of the overall safety system.

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b. Fatigue Analysis Methods. An FRMS should be part of the overall risk identification

and management approach that employs both pr oactive and reactive processes to monitor,

manage, and mitigate operational risk. Certif icate holders can use commercially available

computer models to assess average performan ce capability from sleep/wake history, placement

within the circadian cycle, and duty sche dule information (Hursh and Van Dongen, 2010).

Certificate holders can embed models within the FRMS process to help themselves to understand

the likely effects on individual performance of sleep obtained be fore and during trip patterns.

Using these models (although it is not required) incorporates the latest scientific research on

human circadian systems, sleep, and performanc e capability, and can be useful for rapidly

estimating fatigue levels associat ed with proposed new routes or schedule changes. However,

certain assumptions and limitations need to be ta ken into account. Models are not a substitute for

a comprehensive FRMS; they are on e useful component of an FRMS.

(1) Retrospective (Reactive) Processes for Oversight of Schedules. Certificate holders

can use a science-based fatigue model to assess the estimated fatigue levels associated with

current or past schedules and determine whic h schedules are more vulnerable to increased

fatigue levels and reductions in performance. Fi rst, certificate holders identify those schedules

(both trip sequences and monthly pilot schedules) that have been associated with the greatest

levels of fatigue. Next, certificate holders can de rive the fatigue factors present and examine the

potential for schedule changes to reduce fatigue. Such changes mi ght include additional layover

days, additional recovery days , augmented crews to permit in -flight sleep opportunities, or

rescheduled block times to a void critical tasks at time s during or near the WOCL.

(2) Prospective (Proactive) Processes for Oversight of Schedules. Certificate holders

also can assess proposed schedules for potential fatigue impact by using the method described

above. Trip sequences that have been identified as leading to acute and chronic fatigue can be

removed or modified to prevent the accumulation of fatigue across a bid schedule. For scheduled

operations, rules may be embedded into the schedul e creation process to avoid those conditions

that, according to the fatigue model, could lead to exce ssive fatigue risk.

(3) Identification and Management of Aviation Fatigue Drivers. Many operational

drivers of fatigue occur in any aviation envi ronment. Some of the common factors that

certificate holders must manage to minimize fatigue risk in aviation operations are:

 Crew flight and duty periods, a nd rest breaks to reduce fatigue;

 Additional duties assigned to flightcrews that furthe r reduce sleep opportunities;

 Schedule changes that extend dut ies beyond the published schedule;

 The duration and timing of layovers be tween successive flight segments;

 Recovery days, following a trip, that pe rmit sufficient sleep to eliminate any

accumulated sleep debt prior to scheduling or performing additional flight duties;

and

 Optimal utilization of ava ilable rest opportunities.

c. Application of Fatigue Mitigation Procedures. An FRMS is part of a process that

requires shared responsibility among manageme nt and flight/cabin crewmembers and builds on

feedback and nonpunitive reporting within a “just cu lture.” Developing mitigation strategies and

schedule adjustments should be part of a collaborative management process that includes all the

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stakeholders, such as crew schedulers, mark eting, safety, and employee representatives.

An FRMS should employ multiple layers of defe nse to prevent fatigue and fatigue-induced

errors from progressing to a level that enables incidents or accident s. Based on an analysis of the

factors that lead to fatigue and practical mitigatio n alternatives, one or more of these mitigations

may be applied to reduce fatigue associated with specific schedules or situations. The primary

levels of defense and mitigations are:

(1) Viewed together, the flight duty schedule, additional tasks assigned to crewmembers,

and schedule change provide recovery sleep oppo rtunities. It may be necessary to adjust

scheduling rules to reduce the occurr ence of identified fatigue drivers.

(2) Maximizing use of available sleep opport unities reduces cumulative fatigue. This

level of defense is largely the responsibility of the crewmember. Comprehensive fatigue training,

adequate crew rest facilitie s at non-domicile locations, a nd efficient transportation to

rest facilities aid crewmembers in fulfilling thei r responsibility.

(3) Implementing error detection and corrective processes can prevent operational

consequences of fatigue. Crew Resource Manageme nt (CRM) is a recognized and widely used

process to encourage crewmembers to work toge ther to detect and pr event operational errors.

(4) Conducting comprehensive and objective accide nt, incident, and error analyses can

help in determining when fatigue has been a potential contributing f actor, so that those

conditions can be avoided in the future.

11. COMPONENTS OF AN FRMS. An FRMS is more than a collection of tools, it is a

management process built on organizational polic ies and procedures that implement a systems

approach to fatigue management. A “systems a pproach” means that FRMS is an integrated

network of people and other resources performing activities designed to minimize fatigue in the

operational environment. This network of people a ddressing potential fatigue uses the four basic

tools described in paragraph 9. Below is a list of the six organizational components of the FRMS,

as required under § 117.7. They will vary in comple xity based on the size and diversity of the

operational environment.

a. FRMS Policy. The first required component, as pres cribed in § 117.7(b)(1), is an FRMS

policy. The FRMS policy will be part of the overall fatigue management policy of the

corporation. This policy defines the following:

(1) The organizational structure and composition of the FRMS in term s of people and job

functions. This group may include individuals responsible for crew scheduling, operational

safety, human resources, marketing, training, la bor relations, and human factors research and

analysis.

(2) At a minimum, scheduling policies assure that the organization adheres to all

applicable FAA flight and duty time regulati ons. Beyond that minimum, the organization may

develop additional scheduling constraints and rules that have proven to be useful in preventing

fatigue under certain situations. Some of these limits and constraints may be formulated during

collective bargaining agreements with labor organizations.

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(3) Individuals are expected to report fit for duty. In the cas e of fatigue, employees are

expected to report for duty sufficiently well rested to be able to safely perform the duties of the

job. Likewise, it is the responsibilit y of the individual to alert the organization when her or she is

not sufficiently rested to perfor m safely, and the organization mu st have a policy for replacing

that person with someone who is well rested. The “absent for fati gue” policy must be designed to

ensure that the individual reporting fatigued is not coerced into performing duties.

(4) Fatigue is a complex topic. All crewme mbers should have adequate training to

understand the causes of fatigue, how an indivi dual can maximize the benefits of rest

opportunities, the use of various countermeasures to minimize the effects of fatigue, and the

overall responsibilities of the individual to report for duty fit to safely perform duties.

(5) Policies should define mechanisms for repor ting errors and events related to fatigue,

including policies that define a nonpunitive fatigue reporting system (refer to “Just Culture;”

Reason, 1997).

(6) Depending on the size and complexity of th e organization, this policy will define

various methods utilized to collect objective data on fatigue and the effects of fatigue on

performance.

(7) The overall FRMS is a Continual Improvement Process (CIP). This requires a set of

policies that define how the data on fatigue are subsequently u tilized to further improve the

management of fatigue. In other words, th ese are procedures by which the system is

self-corrective and adaptive to chan ging conditions that may cause fatigue.

(8) Policies should define manager and empl oyee responsibilities relative to managing

fatigue, both on the job and between assignments, including policies providing adequate rest

opportunities between assignments and requiring individuals to report fit for duty (i.e., well

rested).

b. Education and Awareness Training Program (§ 117.7(b)(2)). Comprehensive

education and awareness training programs app licable to the certificate holder’s FRMS are

essential in providing a foundation and unders tanding for managing and mitigating fatigue

associated with operations where the FRMS aut horization is applied. The certificate holder

should develop their education and training program to focus on the specifics of the FRMS

authorization and applicable f lightcrew FRMS operation procedures. Each FRMS authorization

will be different; therefore, the education and aw areness training program for that FRMS will be

specific to that FRMS authorization. If th e certificate holder is issued multiple FRMS

authorizations, the cert ificate holder should iden tify the training items associated with that

authorization. For specific guidance in developing an education and awareness training program

refer to Appendix 2, Section 3.

c. Fatigue Analysis and Report ing System (§ 117.7(b)(3)).

(1) This component defines the processes needed to detect, report, and investigate cases

of fatigue risk from internal and external so urces. It includes objectiv e operational data and

methods that enable the certificate holder to develop and evaluate reactiv e and proactive methods

to reduce and manage fa tigue risk, including:

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 Trip scheduling,

 Crew scheduling (rostering), and

 Rest periods.

(2) There are analysis methods, such as biomathematical models of fatigue, which can be

used to evaluate the fatigue implications of specific city pairs or trips and monthly pilot

schedules. This system includes two components: an analysis of the risk of fatigue associated

with the trip/schedule and an analysis of the pot ential consequences of th at fatigue risk. Based on

this risk and consequence analysis, proactive corrective action can be taken to mitigate the risk. In addition, the fatigue reporting system may sugg est that certain schedu les are causing fatigue,

and corrective steps can be taken to analyze the s ource of the fatigue and pr event a similar set of

circumstances in the future.

d. Monitoring Fatigue in Flight and Cabin Crew (§ 117.7(b)(4)). Conceptually, this is

similar to the fatigue analysis and reporting system component, but this component focuses on

individual crewmember reports of fatigue. Thes e reports provide feedb ack to the certificate

holder about conditions perceive d to contribute to fatigue.

(1) To maximize the utility of such reports, procedures must be arranged to capture all

relevant information, such as the schedule leadin g up to the fatigue report, the actions of the

employee to obtain rest, subjective and objective evidence of fatigue, environmental conditions

that may have exaggerated or contributed to fatigue, relevant health or medical conditions,

specific actions (commissions and/or omissions) related to the incident, and communications

prior to and during the event. Corporate policy must provide pr otection of privacy and methods

to protect the employee from adverse actions that would discourage reports of fatigue.

(2) Technologies developed to monitor sleep and performance in crewmembers can be

used to supplement self-reports of fatigue. While it may not be practical to apply these

technologies continuously, periodic studies of actual sleep (using actigraphs or logbooks) and fatigue (using performance measures and subj ective ratings) can be highly valuable for

objectively measuring the extent of fatigue across different kinds of operations and isolating key

fatigue drivers (Hursh and Van Dongen, 2010). The certificate holder can use the results of these

assessments to inform the analysis and forecas ting functions of the FRMS to better assess

potential fatigue in future operations (e.g., in a proposed new schedule).

e. Incident Reporting Process (§ 117.7(b)(5)). Reports of adverse events that may be

attributable wholly or in part to fatigue are similar to crew reports, and can serve as a mechanism

for obtaining all relevant information regarding fatigue contributions to the incident. Ideally,

corporate policy would define how an advers e event is evaluated for potential fatigue

involvement and also define a methodology for conducting a detailed Root Cause Analysis

(RCA). Details of RCAs are available elsewhere (r efer to the current ed ition of AC 120-59, Air

Carrier Internal Evaluation Programs) but at a mi nimum, the incident investigation and reporting

process must obtain all the necessary information to trace the root cause of the incident, especially the potential level of fatigue and the conditions that contributed to the fatigue-related

event. The FRMS policy must provide for prot ection of privacy and methods to protect the

employee from adverse actions that would discourage reporting events and conditions

surrounding the events.

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f. Performance Evaluation (§ 117.7(b)(6)). An FRMS is a self-c orrecting process that

includes evaluating the results of prior monito ring, analysis, training, and mitigation. Policies

and procedures, based on the evaluation of results and the effectiveness of the FRMS in reducing

fatigue, provide feedback to the system for continuous performance improvement.

(1) The CIP includes the following:

 A system for evaluating and reporting th e effectiveness of the FRMS, including

reporting that is available to the regulator.

 A process whereby the results of eval uations provide guidance to the FRMS

program for self-correction and improvement.

 A system for periodic inde pendent review of the FRMS for its effectiveness in

managing fatigue-related risk.

(2) While not required, it may be desirable to have a process for capturing economic

benefits and costs of the program.

12. THE CONTINUOUS FRMS PROCESS. This paragraph reviews f our steps that comprise a

typical continuous FRMS process (refer to Figure 1, Fatigue Risk Manageme nt System Process).

Calling an FRMS a “process” means that it consists of a series of actions that build on corporate

policies, organizations, and procedures. An FRMS is not just a written set of rules, but a living

system that envisions certific ate holders detecting and adapti ng to fatigue impact on their

operation and employees carrying out specific actions that implement the policies and procedures

within an established organization. The specific actions that comprise the FRMS process break

down into four general steps that repeat, lead ing to continuous performance improvement and

reductions in fatigue-related risk. Each step in the process relies on one or more of the fatigue

management tools.

FIGURE 1. THE FATIGUE RISK MANAGEMENT SYSTEM PROCESS

The FRMS

Process

a. Measure and Assess

Current Conditions

b. Modeling and Analysis of

Fatigue Risk

c. Manage and Mitigate

Fatigue Risk

d. Assessment and

Feedback

a. Measurement and Assessment of Current Conditions. The first step is to measure and

assess the level of fatigue risk associated with current sche dules and operations by collecting

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information on crewmember reports of fatigue or fatigue-related errors and incidents, and

information on the schedules that led up to these reported fatigue-related errors and incidents.

Understanding the current conditions within the orga nization is critical for the development of a

valid mitigation plan.

b. Modeling and Analysis. This second step helps to dete rmine the root cause of fatigue by

modeling the work schedules and analyzi ng fatigue risk associated with them. This step is crucial

to the process because it uses scientific principles about fa tigue, perhaps aided by computer

modeling, to find the specific operational and cr ewmember factors that could contribute to

significant performance changes due to fati gue (Hursh and Van Dongen, 2010). Managing and

mitigating fatigue depends on this step because fatigue risk needs to be measured and connected

to the conditions (fatigue drivers) that contribute to the risk. Analysis of the fatigue risk can be

broken down into two components: likelihood of occu rrence of a particular level of fatigue and

the severity of the consequen ce of fatigue, should it occur (Van Dongen and Hursh, 2010). For

example, flight time that occurs between mi dnight and 0600 will inevitably include the period

identified as the WOCL. This low point in perf ormance should be evaluated in relation to the

duties to be performed at that time; an expected raised level of fati gue is of greater concern if it

coincides with critical flight maneuvers.

c. Management and Mitigation of the Fatigue Risk. This third step is based on the

measurement and analysis of the fatigue-causing conditions. It require s explicit and regular

management activity to consider the informati on from the first two steps and engage all the

stakeholders in a collaborative process to de velop solutions to address the fatigue-causing

factors.

d. Assessment and Feedback. The fourth step in the proce ss is collection of evidence of

success in the form of improved schedules, additional sl eep opportunities, enhanced training, and

revised policies combined with objective data that demonstrate that these changes have

effectively reduced fatigue. Evidence of reduced fatigue includes fewer reports of fatigue and/or

errors due to fatigue, evidence of increased sleep, or modeling of schedules that predicts improved performance and reductions in fatigue rela ted risk. This step is important and essential

for continuous process improvement. Some meas ures may not prove to be as effective in

reducing fatigue as anticipated, leading to a need for further adjustments. Additionally, changes

in schedules, turnover in the workforce, adde d demands for service, and the addition of new

routes can lead to emerging pressu res that contribute to increased fatigue risk. This step allows

for further adjustments to improve current op erations and correct for changes in future

operations.

13. ROLES AND RESPONSIBILITIES. This paragraph describes the general roles and

responsibilities of the th ree primary stakeholders in the FRMS process: the certificate holder, the

employees, and the FAA. The stakeholders should regard the roles and responsibilities described

here as a starting point. These general roles and responsibilities are not an exhaustive description

of the various actions to be taken by each gr oup during the development and execution of the

FRMS. Many of the details left to be defi ned depend on the specifics of each operation.

a. Certificate Holder. For the certificate holder, there are five general responsibilities:

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(1) Initial Commitment. The certificate holder is responsib le for taking the initiative to

develop, document, and implement the scientifical ly based FRMS. First, the organization must

understand what developing an FRMS entails and mu st garner the commitme nt of its leadership

to support the process. Second, the organization mu st be willing to comm it the resources of time

and money to assign individuals in the orga nization to develop and sustain the FRMS.

(2) Assign FRMS Team. Once the certificate holder identifies a team to develop the

FRMS, the certificate holder is re sponsible for tasking the team to develop policies, training, data

acquisition processes, analysis methods, and management procedures to implement, audit, and

guide the FRMS process.

(3) Commitment of Resources. An FRMS is not a one-time activity; an FRMS is a

living system that requires a continuing commitme nt of resources to su pport the effectiveness

and progressive improvement of the process. The size of the resource commitment will depend on the size and complexity of the operation, but it does not end once the certificate holder

establishes the FRMS.

(4) Collaboration. An effective FRMS is a collabor ative process that involves all the

stakeholders in discussion and joint action to be successful. It is the certificate holder’s

responsibility to provide the mechanisms fo r collaboration/consu ltation among managers,

employees, and the regulator. The certificate hold er is responsible for creating a “just culture”

where managers and employees can share informati on about fatigue without threat of reprisal or

disciplinary action. In keeping with the respons ibility of each crewmemb er to only accept duty

when he or she is adequately rested to safely perf orm his or her duties, it is the responsibility of

the organization to develop a nonpunitive policy for responding to legitimate reports of fatigue and providing reserves to repla ce fatigue-impaired crewmembers.

(5) Customization. The certificate holder can tailor an FRMS to the size of the

organization. For a large organization with an entire department dedicated to each primary

function, it will be necessary to have a Fatigue Safety Action Group (FSAG) to coordinate the

fatigue-related initiatives across departmental boundaries. Within a sma ller organization, it may

only require that a single pers on be assigned the responsibil ities to overs ee the program.

Likewise, within a large organization, there may be multiple sources available to support the data

requirements of the FRMS, while, in a small or ganization, data may be limited to reports of

fatigue from pilots and occasional reports of procedural errors.

b. Employees/Crew. For the employees/crew there are three main re sponsibilities:

(1) Get Enough Sleep. The only remedy for sleep depriv ation is sleep and it is the

employee’s responsibility to use the facilities an d sleep opportunities to ob tain rest, sleep, and

meals. Each person has a unique requirement for sleep and only the individual can decide how

much sleep is adequate to maintain alertness and performance. As a general guide, the average

person is thought to require a bout 8 hours of sleep per day, al though individual differences exist

in sleep need, ranging from 7-9 hours. In general, it is the employee’s re sponsibility to get as

much sleep as they need and to take additional sleep when they feel fatigued or unfit for duty.

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5/6/13 AC 120-103A

(2) Plan Sleep Ahead of Time. Getting adequate sleep re quires planning with future

duty times in mind. For example, if duty will re quire an early morning awakening, then the

employee should plan to go to bed ea rly the night before so as to be fully rested for the next duty.

If the next duty will commence in the evening, the employee is responsible for taking an

afternoon or evening nap so that her or she does not start work with eight or more hours of

continuous wakefulness before the start of duty.

(3) Report Fatigue. If circumstances preclude sufficient sleep for the employee to be

adequately alert and rested a nd to perform duty, whether they are the result of the schedule,

delays, illness, life events, or personal actions, it is the employee’s responsibility to report his or her state of fatigue to the certificate holder. The employee should not accept the responsibilities

of duty when fatigued or feeling unf it to perform assigned duties to the extent that the safety of

the flight may be jeopardized.

c. Regulator. A regulator needs to be able to see th at a certificate holder has a well defined

FRMS plan that provides for at least an AMOC to that provided by the applicable prescriptive

flight, duty, and rest regula tions. Beyond evaluation of the plan, the regulator has the

responsibility to monitor the appl ication of the FRMS plan and ev aluate measures of outcomes to

ensure that an AMOC is, in fact, provided by th e FRMS. Both of these steps are critical to the

success and public acceptance of an FRMS. Th e assessment requires evaluation of both the

FRMS plan and the FRMS process and outcomes. The following are the regulator’s responsibilities for guiding and assess ing a certificate holder’s FRMS:

(1) The regulator has the responsibility to provide descriptions of the essential

components and guidance for the steps required to implement an acceptable FRMS. Given the complexity of the aviation industry, such guidance will necessarily be genera l in nature to allow

for adaptation to the size of the organization. Th is AC provides useful gui dance for the regulator

and certificate holder.

(2) For each certificate holder, the regulator reviews the components of the system

(structures, policies, and process) and assesse s whether those components are implemented on an

ongoing basis.

(3) Prior to implementation, the regulator ev aluates whether the FRMS, as planned,

would be expected to establish an AMOC (forecasting function) to that provided by compliance with established flight time/duty time regulations.

(4) Once implemented, the regulator periodically evaluates if the FRMS, in practice, is

meeting safety goals (auditing function).

(5) The regulator must evaluate if the FRMS pr ocess itself is responsive to feedback for

continuous improvement (tracking progress).

14. IMPLEMENTATION. Details of implementation will depend greatly on the complexity of

the organization and the demands of the operatio nal conditions confronted by flightcrew. This

AC does not provide a step-by-step implement ation guide, but rather details the general

progression of the implementation process and several potential implementation pitfalls.

Par 13 Page 13

AC 120-103A 5/6/13

a. Resources. In order to implement an effectiv e FRMS, the organization must commit

resources to acquire and devel op the four basic building bloc ks (refer to Figure 2, Building

Blocks of a Fatigue Risk Management System):

FIGURE 2. BUILDING BLOCKS OF A FATIGUE RISK MANAGEMENT SYSTEM

Building Blocks of an FRMS

Organization and Personnel

Training and Publicity

Policies and Procedures

Tools and Methods

(1) Policies and Procedures. The foundation of the FRMS is documentation that defines

the policies and procedures that guide FRM, repr esenting the commitment of the organization to

the process and clear statements defining how th e system will function. The basic elements of

that documentation have been outlined in this AC , but the detail and complexity of the system

will depend on the size and diversity of the organization and its operation.

(2) Organization and Personnel. An FRMS is more than doc umentation; it is an active

process that is implemented by members of the or ganization who regularly meet to review data

on fatigue indicators, analyze cont ributing factors to fatigue, take reactive and proactive actions

to mitigate fatigue, audit the effectiveness of the system, and take corrective action to

continuously improve the system. Most organiza tions can form a defined FSAG to implement

the system. The committee should include repres entatives of all departments and groups that

have a role in reporting, managing, and mitigating fatigue.

(3) Tools and Methods. A variety of tools and methods are instrumental in aiding the

activities of the FRMS organization, such as fa tigue modeling, statistical analysis software,

performance and sleep measurement systems, and reporting forms and databases. The tools do not constitute the FRMS, but they are essentia l for the system to function effectively. The

organization must be willing to commit resources to procure the necessary supporting tools if the

FRMS is to be effective.

(4) Training and Publicity. Training operational personnel and managers about the

physiological and behavioral foundations of fatigue , the operational and envi ronmental drivers of

fatigue, and effective fatigue mitigations is esse ntial to managing fatigue risk. Furthermore, all

personnel must know the corporate policies that are the foundation of the corporate FRMS

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5/6/13 AC 120-103A

process, including policies and pro cedures that govern fatigue re porting, fitness for duty, absence

for fatigue, incident reporting, employee privacy, and prevention of coercion to perform duties

while fatigued. Finally, an effective FRMS include s feedback and publicity about the system to

all affected employees to encourage cooperative participation in the co rporate FRM strategy.

b. Extending Processes. The building blocks of the FRMS will be an extension of existing

processes to manage overall operational safety. Fo r example, incident report forms may already

exist and need only be expanded to collect info rmation relevant to a fatigue analysis. An

organizational structure may already exist to im plement safety management, and the addition of

an FSAG might be the only change in the organization.

c. Developing an FRMS. The initial development of an FRMS will start with a

certificate holder assembling the building blocks described above, starting with developing the

policies and procedures and es tablishing the FRMS organizati on. The organization will then

acquire the necessary tools and methods, and develop supporting training and publicity

programs. There are several pitfalls to avoid in this complex process.

(1) The FRMS organization, such as the FSAG, should include representatives of all the

key departments and groups that have a role in identifying, managing and mitigating fatigue in operations. FRM is a collaborative process and w ill require the commitment of key leaders of the

organization and the cooperative participation of relevant groups. An example would be the

marketing department, which plays a key role in defining trips and schedules. While their

primary responsibility is to advance the business interests of the corporation and provide service

to customers, marketing also has a key role in de fining the requirements of schedules that may be

causing excessive fatigue. Its participation in finding acceptable alternatives that reduce fatigue

is essential to a successful FRMS. At the same time, employee groups (e.g., union representatives) should also participate in the process because managing and mitigating fatigue is

a shared responsibility between the organization and the employees. Ensuring that employees understand and embrace their responsibilities to repor t for duty well rested is just as important as

arranging schedules that provide sufficient rest opportunities.

(2) There is a danger that the FSAG may a dopt a reactive approach to fatigue

management, taking constructive action only in res ponse to reports of fatigue or fatigue-related

adverse events. The more effec tive approach is to minimize fatigue by using available tools to

forecast potential fatigue well in advance of act ual operations, and taking corrective action to

proactively eliminate potentially fatiguing schedules or conditions prior to their occurrence. An

indicator of a highly effective FRMS is the frequency of such proactive corrective actions.

(3) The FRMS should include a methodology for evaluating the success of the program

and make changes in the program for process improvement. Two e qually important parts of the

evaluation and validation process are necessary. The first is self-evaluation using established

metrics that reflect the degree of fatigue in the organization. The FSAG should monitor those

metrics regularly, looking for trends over time that suggest the need for change or validate the

effectiveness of actions alrea dy taken. The second is an occa sional independent audit of the

program by an outside agency or consultant.

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AC 120-103A 5/6/13

(4) An outside observer familiar with FRMS principles and cognizance of best practices

developed by other organizations can be an i nvaluable aid to improving the effectiveness and

efficiency of the FRMS process.

15. FRMS APPLICATION PROCESS. For a full description of the FRMS approval process,

see Appendix 2, Section 7. The FRMS approval pro cess consists of five steps that must be

satisfactorily completed in succession. Each step is referred to as a phase. Within each phase are

specific tasks that must be completed before the certificate holder may move to the next phase.

These tasks are compiled into number gates. Each gate must be completed in succession before

that phase is considered completed. Appendix 2, Figure 2-6, Fatigue Risk Management System

Approval Process, provides a graphic depiction of the FRMS approval process. The five phases

of the approval process are:

 Phase 1: Preapplication, Planning, and Assessment (4 Gates).

 Phase 2: Formal Application (2 Gates).

 Phase 3: Documentation and Data Collection Plan (1 Gate).

 Phase 4: Demonstration a nd Validation (1 Gate).

 Phase 5: Authorization, Implemen tation, and Monitoring (1 Gate).

NOTE: Appendix 2 of this AC provides a complete, step-by-step process for

applying for an FRMS authorization.

/s/

for

John M. Allen,

Director, Flight Standards Service

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Appendix 1

APPENDIX 1. REFERENCES

1. Bonnet, MH. Sleep Deprivation . In M. H. Kryger, T. Roth, & W. C. Dement (Eds.),

Principles and Practice of Sleep Medicine (3rd ed). Philadelphia: Saunders; 2000:53–71.

2. Carskadon, MA, Dement, WC. Daytime Sleepiness: Quantific ation of a Behavioral State .

Neuroscience Biobehavioral Review 1987; 11:307–17.

3. Dinges, DF. The Nature of Sleepiness: C auses, Contexts and Consequences . In A. Stunkard

& A. Baum (Eds.), Perspectives in Behavior al Medicine: Eating, Sleeping and Sex. Hillsdale,

NJ; 1989: Lawrence Erlbaum. 4. Dinges, DF. Probing the Limits o Functional Capabili ty: the Effects of Sleep Loss on Short-

duration Tasks . In R. J. Broughton & R. D. Ogilvie (E ds.), Sleep, Arousal, and Performance.

Boston: Birkhauser; 1992:177–88. 5. Dinges, DF, & Kribbs, NB. Performing While Sleepy: Effect s of Experimentally-induced

Sleepiness . In T. Monk (Ed.), Sleep, Sleepiness, and Performance. Chichester, UK: John Wiley

and Sons, Ltd; 1991:98–128. 6. Horne, JA. Human Sleep, Sleep Loss and Behaviour: Implications for Prefrontal Cortex and

Psychiatric Disorder. British J ournal of Psychiatry 1993; 162:413–9.

7. Horne, JA, Reyner, LA. Sleep Related Vehi cle Accidents. Br Me d Journal 1985; 310:565–7.

8. Hursh, SR & Van Dongen, HPA. Fatigue and Performance Modeling . In Meir H. Kryger,

Thomas Roth, William C. Dement (Ed.), Principles and Practice of Sleep Medicine, 5th edition.

Saunders; 2010 (in press). 9. Naitoh, P. Sleep Deprivation in Humans. In P. H. Venables & M. J. Christie (Eds.), Research

in Psychophysiology. London: John Wiley; 1975. 10. Reason, JT. Managing the Risks of Organi zational Accidents. New York: Ashgate

Publishing; 1997. 11. Rosekind MR, Graeber RC, Dinges DF, Connell LJ, Rountree MS, Spinweber CL, et al.

Crew Factors in Flight Operations IX: Effect s of Planned Cockpit Rest on Crew Performance

and Alertness in Long-haul Operations. Moffe tt Field, CA: NASA Ames Research Center; 1994

Report No: DOT/FAA/92/24. 12. Van Dongen, HPA & Hursh, SR. Fatigue, Performance, Errors and Accidents . In Meir H.

Kryger, Thomas Roth, William C. Dement (Ed.), Principles and Pr actice of Sleep Medicine, 5th

edition. Saunders; 2010 (in press). 13. Wylie CD, Shultz T, Miller JC, Mitler MM, Mackie RR. Commercial Motor Vehicle Driver

Fatigue and Alertness Study: Project Report (Report No.: FHWA-MC-97-002). Washington,

DC: U.S. Department of Transportation; 1996.

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Appendix 2

APPENDIX 2: FATIGUE RISK MANAGEMENT SYSTEM DEVELOPMENT

SECTION 1. INTRODUCTION

1. PRACTICAL APPLICATION OF A FA TIGUE RISK MANAGEMENT SYSTEM

(FRMS). An FRMS is as an alternative regulator y approach to providing a means of managing,

monitoring, and mitigating fatigue to improve flightcrew member alertness and reduce

performance errors. Under an FRMS, a certificat e holder develops processes that manage and

mitigate fatigue that serve as an alternate me thod of compliance (AMOC) to the prescriptive

rule. Essentially, a certificate holder may appl y an FRMS, which is an approved AMOC, to a

specific limitations imposed by Title 14 of the C ode of Federal Regulations (14 CFR) part 117.

However, before the certificate holder ma y conduct operations under a Federal Aviation

Administration (FAA)-approved FRMS, the certificate holder must satisfactorily demonstrate to

the FAA that their proposed FRMS satisfactoril y demonstrates that the AMOC provides an

equivalent level of safety to the safety stan dards set forth in part 117. At a minimum, the

certificate holder’s proposed FRMS must incl ude the following elements listed in part 117,

§ 117.7:

 A Fatigue Risk Management (FRM) policy,

 An education and awareness training program,

 A fatigue reporting system,

 A system for monitoring flightcrew fatigue,

 An incident reporting process, and

 A performance evaluation.

2. FRMS STRUCTURE. An FRMS structure employs multilayered defensive strategies to

manage fatigue-related risks, regardless of thei r source. It includes da ta-driven, ongoing adaptive

processes that can identify fatigue hazards and th en develop, implement, and evaluate controls

and mitigation strategies. These include both organizational and personal mitigation strategies.

However, the cost and complexity of an FRMS may not be justified for operations that remain

inside the flight and duty time limits and where fatigue-related risk is low. Some

certificate holders, therefore, may choose to place only certain parts of their operations under an FRMS, or not to implement an FRMS at all. N onetheless, where an FRMS is not implemented, it

remains the certificate holder’s responsibility to manage fatigue-relate d risks through their

existing safety management processes, the Fa tigue Risk Management Plan (FRMP), and the

prescriptive flight, dut y, and rest limitations.

3. FRM AND SAFETY ASSURANCE (SA). FRM and SA are the core components of the

FRMS. These core activitie s are governed by an FRMS policy and supported by FRMS

promotion processes, and the syst em must be documented. The FRMS relies on the concept of an

effective safety reporting culture, in which pe rsonnel have been trained and are constantly

encouraged to report hazards whenever they obs erved them in the operating environment. To

encourage the reporting of fatigue hazards by a ll personnel involved in an FRMS, a certificate

holder must clearly distinguish between uninten tional human errors, which are accepted as a

normal part of human behavi or and are recognized and ma naged within the FRMS, and

deliberate violations of rules, policies, and established procedures. Th e certificate holder should

have processes independent of the FRMS to d eal with intentional noncompliance. Table 2-1,

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AC 120-103A 5/6/13

Appendix 2

Components of Fatigue Risk Ma nagement Systems, describes the basic components of an

FRMS.

TABLE 2-1. COMPONENTS OF FATI GUE RISK MANAGEMENT SYSTEMS.

Components Elements

Fatigue Risk Management System (FRMS)

policy and documentation

Fatigue Risk Management (FRM)  Identification of hazards

processes  Risk assessment

 Risk mitigation

Safety Assurance (SA) processes  FRMS performance monitoring

 Management of operational and

organizational change

 Continuous FRMS improvement

FRMS promotion processes  Training programs

 FRMS communication plan

4. THE ADVANTAGE OF FRMS. Since an FAA-approved FRMS is applied to exceed a

specific limitation, the potential exposure to a fa tigue-related event must be mitigated, managed,

and monitored. Typically, accidents and incidents result from interactions between organizational processes (i.e. workplace conditio ns that lead crewmembers to commit active

failures) and latent conditions that can penetrat e current defenses and have adverse effects on

safety. The FRMS approach is designed to apply fatigue science and safety management. It is

intended to provide an equivale nt, or enhanced, level of safety, while also offering greater

operational flexibility to that provided by the prescriptive limitation(s).

5. PERFORMANCE-BASED APPROACH. Essentially, an FRMS represents a performance-

based regulatory approach. This means that the FRMS defines the requirements and processes

required for certificate holders to measure, manage , mitigate, and monitor potential fatigue risk

associated with the operation for which the FRMS is applied. Data collection and analysis are

vital in determining the flightcrew members’ level of performance during that operation

proposed by the certificate holde r. The FRMS requirements and processes are derived from the

data collection and analysis output. Appl ying the FRM and SA components, the FRMS

requirements and processes are measured, managed, and monitored for continuous improvement of the FRMS.

6. FRMS LIMITATIONS AND CONDITIONS. The certificate holder’s FAA-approved

FRMS authorization will be based on analyzed and validated data applicable to the specific

limitation to be exceeded under the FRMS. Theref ore, the FAA will impose specific limitations

and conditions applicable to the FRMS aut horization. While conducting operations under an

FRMS authorization, the certific ate holder must comply with these limitations and conditions

along with their FAA-approved FRMS processes and procedures.

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Appendix 2

7. FRMS COMPLEXITY. The complexity of the FRMS structure will vary according to:

 The size of the organization,

 The scope of the FRMS,

 The type of operations where the FRMS will be applied,

 The type and complexity of the operations being managed,

 The relative maturity of the FRMS; and

 The relative importance of the fatig ue hazards governed by the FRMS.

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AC 120-103A 5/6/13

Appendix 2

SECTION 2. FRMS POLICY AND DOCUMENTATION

1. OVERVIEW OF FRMS POLICY AND DOCUMENTATION. The FRMS policy and

documentation are instrumental in defining the organizational measures to support the core

operational activities of the FRMS. While FR MS policy specifies the certificate holder’s

commitment and approach to the management of fatigue risk, it shoul d be noted that the

certificate holder must clearly define all elemen ts of their FRMS policy. The certificate holder’s

FRMS policy must be distinguishable from the general safety policy to allow for a separate

review. FRMS documentation describes the com ponents and elements of the entire FRMS.

Additionally, the use of FRMS documentation makes it possible to audit the effectiveness of the

FRMS (internally and externally) to verify that it is meeting the safety objectives defined in the

FRMS policy. 2. FRMS DOCUMENTATION. The FRMS documentation describes all the elements of the

FRMS and provides a record of FRMS activ ities and any changes to the FRMS. The

documentation can be centralized in an FRMS manual. However, it needs to be accessible to all

personnel who may need to refer to it and to the FAA for auditing purposes. The current edition

of ICAO Annex 6, Part I, Appendi x 8 requires that the certificate holder shall develop and keep

current FRMS documentation th at describes and records:

 FRMS policy and objectives;

 FRMS processes and procedures;

 Accountabilities, responsibilities and author ities for these processes and procedures;

 Mechanisms for ongoing involvement of mana gement, flight and cabin crewmembers,

and all other involved personnel;

 FRMS training programs, training requi rements, and attendance records;

 Scheduled and actual flight times, duty periods, and rest periods with significant

deviations and reasons for deviations noted; and

 FRMS outputs including findings from coll ected data, recommendations, and actions

taken.

3. FATIGUE SAFETY ACTION GROUP (FSAG). As a way of meeting the ICAO

requirements described in paragraph 2, it is expe cted that a certificate holder establish a

functional group that is responsible for coordinating the fatigue ma nagement activities within the

organization.

a. FSAG Role. This task should be the responsibilit y of the FSAG. The FSAG is a group

comprised of representatives of all stakeholder groups (e.g., management, scheduling, and

crewmembers) together with specialist scientif ic, data analysis, and medical expertise, as

required), that is responsible for coordinating all fatigue management activities in the

organization. The principle functions of the FSAG are to:

(1) Develop and maintain the FRMS documentation;

(2) Manage the FRM processes;

(3) Contribute to the FRMS SA processes;

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Appendix 2

(4) Be responsible for the FRMS promotion processes; and

(5) Maintain the required documentation.

b. FSAG Composition. The composition of the FSAG should reflect the shared

responsibility of individuals and management by including representatives of all stakeholder

groups (management, scheduling staff, and crewme mbers and/or their representatives) and other

individuals as needed to ensure that it has appropriate access to sc ientific and medical expertise.

c. FSAG Scalability. The size and composition of the FSAG will vary for different

certificate holders, but should be related to the size and complexi ty of the operations covered by

the FRMS, and to the level of fatigue risk in those operations. Figure 2-1, Midsize and Large

Air Carriers, illustrates midsize and large air carrier operations and Figure 2-2, Small

Air Carriers, depicts operations for a small air carrier. In small certif icate holders, a single

individual may represent more than one stakeholder group; for example, the chief pilot may also be the primary scheduler. In very small operati ons, there may not even be a designated FSAG,

but simply extra items on the safety meetings age nda, as long as long as all FRM activities are

documented. Larger airlines will have specialized departments that interact with the FSAG. While the FAA may wish to observe FSAG meetings as part of its oversi ght activities, the FAA

is not a required part of this group. However, th e FAA may also wish to review the minutes and

outputs of such meetings as part of their continuous ove rsight activities.

4. FRMS SCOPE. Within the FRMS manual, the certificat e holder must identify the scope of

the FRMS operations for which the FRMS is applied to their operations. Otherwise, all operations not covered by the FRMS must operate under the applicable prescriptive flight time,

duty time, and rest limits. A certificate holder may choose to apply the FRMS to all its

operations, or only to specific types of its operations (e.g., a particular fleet, a particular route, or

only ultra long-range (ULR) operations). Because th e policy statement is typically short, it does

not have to detail the scope of the operations to which the FRMS app lies; however, the policy

statement must identify where the scope of FRMS operations is deta iled. As a certificate holder’s

familiarity and experience with the FRMS builds, they may wish to expand the scope of the

FRMS.

5. FRMS POLICY. The FRMS policy provides the umbrella under which the FRMS operates.

Within the FRMS policy, the certificate holder sh all clearly define all elements of the FRMS.

The FRMS policy shall also requir e that the scope of the certifi cate holder’s FRMS operations be

clearly defined in their FRMS manual.

a. Minimum Requirements. The FRMS policy must identify and address the minimum

requirements of the FRMS, which are essentiall y the prerequisites of an FRMS. As with

prescriptive flight and duty lim itations, the management of fati gue-related risks associated with

the FRMS is a joint responsibility between the certificate holder and individual crewmembers

due to the particular nature of fatigue. Th e FRMS policy specifies the certificate holder’s

commitment and approach to the management of fatigue risk. It is the responsibility of the

certificate holder to clearly de fine all elements of the FRMS in its policy. Additionally, the

certificate holder’s FRMS policy must be able to be distinguished from the general safety and

operational policy to allow separate review. Minimum requireme nts for the FRMS policy shall:

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AC 120-103A 5/6/13

Appendix 2

(1) Reflect the joint responsibility among the ce rtificate holder’s management, flight and

cabin crews, and othe r involved personnel;

(2) Clearly state the safety objectives of the FRMS;

(3) Be signed by the accountable ex ecutive of the organization;

(4) Be communicated, with visible endorsement, to all the relevant areas and levels of the

organization;

(5) Declare management’s commitment to effective safety reporting;

(6) Declare management’s commitment to provi ding adequate resources for the FRMS;

(7) Declare management’s commitment to continuous improvement of the FRMS;

(8) Require that clear lines of accountability for management, flight and cabin crews, and

all other involved personnel are identified; and

(9) Require periodic reviews of the FRMS policy to ensure that it remains applicable and

appropriate.

b. Responsibility of Crewmembers. Fatigue is affected by a ll waking activities, not only

work demands, sometimes described as “day-t o-day life issues.” For example, crewmembers

have personal responsibility because they can choose the amount of time they spend trying to

sleep during available rest breaks, and choose when to use personal fatigue mitigation strategies. They have a responsibility to use rest periods effectively to be properly rested and fit for duty. Ultimately, as required in § 117.5( d), it is the responsibility of the flightcrew member to

affirmatively state on the dispatch or flight release, pr ior to commencing a flight segment, that he

or she is fit for duty. To that point, it is impera tive that the flightcrew member obtain the proper

amount of rest to safely perform their assigne d duties during that f light. In addition, their

cooperation is vital for voluntary reporting of fati gue hazards, and when fatigue levels need to be

measured for FRM processes and FRMS SA pro cesses. Crewmembers’ willingness to cooperate

will depend on their confidence that the certificat e holder is committed to promoting a “just”

culture an effective safety reporting culture.

c. Responsibility of Management. Management is primarily responsible for the

management and mitigation of fatigue risk because it schedules the work activities of personnel and the distribution of resources in the organization. The FRMS is an organizational system that enables management to meet that responsibilit y. The accountable executive, when signing the

FRMS policy, accepts accountability for the FRMS, either directly or through supervision and

management of others, including those to whom the accountable executiv e has delegated this

responsibility. The safety objectives in the FRMS policy must specify wh at the certificate holder

wants the FRMS to achieve. To track whethe r the FRMS is meeting these objectives, its

performance needs to be monito red. The FRMS policy needs to be reviewed periodically by the

certificate holder to ensure that it is adequate to meet changi ng operational demands. In addition,

it will be subject to pe riodic review by the FAA.

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Appendix 2

FIGURE 2-1. MIDSIZE AN D LARGE AI R CARRIERS

NOTE: The FSAG should consist of members from management,

flight operations, and dispatch or flight following, as applicable. Advisors are

assigned to provide the FSAG with input on their area of responsibility to

shape the overall FRMS. Additionally, the FSAG will communicate specifics

regarding the FRMS to the advisors, as it relates to the advisor’s area of

responsibility.

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AC 120-103A 5/6/13

Appendix 2

FIGURE 2-2. SMALL AIR CARRIERS.

FSAG

Management

Flight Operations

Dispatch/Flight

Following

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Appendix 2

SECTION 3. FATIGUE RISK MANAGEMENT SYSTEM PROMOTION PROCESSES

1. INTRODUCTION TO FRMS PROMOTION PROCESSES. This section outlines the

FRMS promotion processes, wh ich includes training programs, a communication plan, and the

links between the FRMS promotion processes and other FRMS components. Along with the

FRMS policy and documentation, the FRMS promotion processes support the core operational

activities of the FRMS.

a. Training. An Education and Awareness Training program, as prescribed in part 117,

§ 117.7(b)(2), is a required element of the certi ficate holder’s FRMS. The objective of the

certificate holder’s FRMS Education and Awarene ss Training program is to ensure that all

involved personnel are trained and competent to undertake their responsibi lities relevant to the

certificate holder’s FRMS. In addition to the FRMS training program, the training completion

standards for both initial and r ecurrent training should be specified in the FRMS documentation.

The certificate holder must maintain FRMS tr aining records in accordance with 14 CFR part

121, § 121.683. The FRMS training program should em phasize the key principles of fatigue

science, management of sleep, and understand ing the effects of the circadian body clock to

illustrate the relevancy not only to individual’s role s in the FRMS but also to their lives outside

of work. Thus, FRMS training co vers issues that everyone can identify with personally and

promotes the concept of shared responsibility in an FRMS.

b. Communication. An FRMS relies on effectiv e communication throughout the

certificate holder’s organization. On the one hand, there needs to be regular communication about the activities and safety performance of the FRMS to a ll stakeholders. Depending on the

structure of the organization, this may come from the FSAG or an accountable executive

responsible for the FRMS communication pla n. On the other hand, crewmembers and other

stakeholders need to communicate promptly and clearly about fatigue hazards to the FSAG or

other relevant management.

2. FRMS PROMOTION PROCESSES. FRMS promotion proce sses support the ongoing

development of the FRMS and the continuous improvement of its overall performance for

maintaining optimum safety levels. The following shall be established and implemented by the

certificate holder as part of its FRMS:

a. Training Programs. Training programs to ensure competency commensurate with the

roles and responsibilities of ma nagement, flight and cabin crew , and all other involved personnel

under the planned FRMS; and

b. Communication Plan. An effective FRMS co mmunication plan that:

(1) Explains FRMS policies, procedures, and res ponsibilities to all re levant stakeholders;

and

(2) Describes communication channels used to gather and disseminate FRMS-related

information.

3. FRMS EDUCATION AND AWAREN ESS TRAINING PROGRAMS. In addition to the

above requirements, the current edition of ICAO Annex 6, Part I, Append ix 8 requires that a

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certificate holder maintain documentation that describes and records FRMS training programs,

training requirements, and attendance records. It further recommends th at regulators have

competency requirements for FRMS training inst ructors, who may be part of a certificate

holder’s internal traini ng department or exte rnal contractors.

4. WHO NEEDS TO BE TRAINED? For an FRMS to be effective, all personnel who

contribute to FRMS safety performance need to have appropriate trai ning. The FRMS training

audience should include the executive accountable for the FRMS, crewmembers, crew

schedulers, dispatchers, pers ons holding operational control, individuals responsible for

management oversight of these areas, all memb ers of the FSAG, and personnel involved in

overall operational risk assessm ent and resource allocation.

5. FRMS TRAINING PROGRAM. The content of training programs should be adapted

according to the knowledge and skills required for each group to play their part effectively in the

FRMS. All groups require basic education about the dynamics of sleep loss and recovery, the

effects of the daily cycle of the circadian body cl ock, the influence of workload, and the ways in

which these factors inter act with operational demands to prod uce fatigue. In addition, it is useful

for all groups to have information on how to ma nage their personal fatigue and sleep issues.

Schedulers and dispatchers should have a co mprehensive understanding in the use and

limitations of any scheduling tools and biomathema tical models or other algorithms that may be

used to predict the levels of crewmemb er fatigue across schedules and rosters.

a. Curriculum. The FRMS training curriculum shou ld provide a full understanding of all

FRMS components and elements: po licy and documentation; proce sses for hazard identification,

risk assessment, mitigation, and monitoring; SA processes for monitoring FRMS performance,

managing change, and continuously improving th e FRMS; and FRMS promotion processes,

including training and communica tion. The training should provide a robust understanding of

how scheduling affects sleep oppor tunities and interacts with the circadian biological clock

cycle, the fatigue risk that this creates, and how it can be mitigated through scheduling. The

training should provide an in-d epth understanding of the certificate holder’s flightcrew member

FRMS operating procedures. Lastly, the traini ng program should highlight the processes and

procedures for implementing scheduli ng changes recommended by the FSAG.

b. Outline. The following is an outline of subjects that may be in corporated into the FRMS

training curriculum:

(1) Overview of the FRMS Concept.

(a) Definition.

(b) Purpose.

(c) An overview of the FRMS structure and how it works in the certificate holder’s

organization, including the concepts of shared responsibility and an e ffective reporting culture.

(d) FRMS SA metrics used by the organization.

(e) FRMS regulatory requirements.

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(f) FRMS structural components.

(g) The role of the FSAG.

(h) The current edition of Advisory Circ ular (AC) 120-100, Basics of Aviation

Fatigue.

(2) Fatigue Mitigation and Managing Rest.

(a) An overall understanding of crewmember fatigue and the safety risk that it

represents to the organization.

(b) Basic environmental factors that lead to fatigue.

(c) General strategies to maintain alertness and recover from sleep loss.

(d) Causes and consequences of fatigue in the operation(s).

(e) Signs of fatigue.

(f) The importance of accurate fatigue data (both subjective and objective).

(g) Personal strategies that they can use to improve their sleep at home and to

minimize their own fatigue risk while on duty.

(h) Basic information on sleep disorders and their treatment.

(3) Tools for an Effective FRMS. (a) Fatigue assessment and analysis methods.

(b) Identification and management of aviation fatigue drivers.

(c) Fatigue mitigation approaches.

(d) Positive safety culture.

(4) Components of an FRMS. (a) FRM policies.

(b) Education and awareness training.

(c) Fatigue analysis and reporting system.

(d) Fatigue monitoring methods.

(e) Fatigue-related incident reporting process.

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(f) FRMS performance evaluation.

(g) Continuous improvement process.

(5) FRMS Roles and Responsibilities.

(a) Certificate holder.

(b) Crewmember/employee.

(c) Schedulers/dispatchers.

(d) Operational control personnel.

(e) Management personnel.

(f) FSAG.

(g) Other stakeholders.

(h) FAA responsibilities.

(6) FRMS Implementation. (a) Policies and procedures.

(b) Organization and personnel.

1. FSAG.

2. Relationships to other safety personnel.

(c) Tools and methods.

(d) Training and awareness.

(7) Safe Scheduling Policies and Procedures.

(a) Proactive and adaptive fatigue mitigation.

(b) Work schedule oversight and monitoring.

(c) Crew augmentation.

(d) Circumstances beyond the control of the certif icate holder.

(8) Records and Reports. (a) Schedule accuracy.

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(b) Reports of fatigue by flightcrew members.

(c) Fatigue-related events.

(d) How reports of fatigue and othe r related data are processed.

(e) Records of the activities of the FSAG and resulting interventions.

(9) FRMS Implementation Policies and Procedures.

(a) Organizational policies and procedures that establish the FRMS.

(b) Flightcrew member operating pr ocedures related to FRMS.

(10) Continuous Performance Improvement Process. (a) FRMS performance evaluation.

(b) Work schedule modeling and fatigue risk analysis.

(c) Management and mitigation of fatigue risk.

(d) Assessment, feedback and corrective action.

(e) Reporting intervals.

6. DELIVERY OF FRMS TRAINING. There is a variety of ways in which FRMS training

can be delivered, each of which has strength s and limitations. Live tr aining sessions with a

trained instructor have the adva ntage that crewmembers can ask questions about their specific

issues or concerns and can learn from each other’s experiences. Face -to-face contact with

different stakeholders in the FRMS can facilita te building the safety culture. However, live

training requires coordinating a time and place that groups of participants can attend, and

involves time getting to and from the venue, in addition to the time required for the actual

training session.

a. Alternative Methods. Web-based learning and distributed training (for example, using

DVDs) allow greater flexibility in the time and pl ace that training occurs. Individualized training

allows participants to proceed at their own pace through the training materials. In Web-based

learning, sessions can be networked so that multiple participants can join in with a tutor online.

Material can also be made interactive (a task has to be completed, e.g., a short quiz must be

answered, before the particip ant can move on to the next part of the training).

b. Alternative Materials. Providing different materials and formats for recurrent training

can help to maintain interest. For example, r ecent fatigue reports or FSAG interventions can be

used as case studies to illustrat e and revise concepts covered in the initial training material.

Recurrent training can also cover changes to th e operations or the FR MS and scientific and

regulatory updates. The frequency and nature of recurrent training need s to be decided by the

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FSAG, in consultation with professional trainers (internal or external to the certificate holder) as

needed.

7. TRAINING FREQUENCY. The FRMS training program must contain an initial and

recurrent curriculum. The frequency of the recurrent FRMS training is every

12 calendar-months. 8. FRMS TRAINING EVALUATION. The effectiveness of FRMS training and education

programs should be periodically evaluated. Exam ples of evaluation tools can include the

following.

a. Quizzes. To evaluate immediate knowledge transfer from a training session, participants

can be given a short quiz assessing fatigue knowledge, to be completed before and after the

training session.

b. Surveys. To evaluate the amount of knowledge re tained, crewmembers’ use of suggested

countermeasure strategies, and perceived usefulness of training, a survey can be conducted at a

fixed time (e.g., 6 months) after training.

c. Feedback and Improvement. Findings from the quizzes and surveys can be used to:

(1) Revise the content of the training package, to improve the training on topics that a

significant proportion of crewmembers have not fully understood;

(2) Provide feedback to trainers on areas where they may need to change or improve their

teaching approaches; and

(3) Identify areas that need to be revi ewed or added in recurrent training.

9. FRMS TRAINING DOCUMENTATION. The current edition of ICAO Annex 6, Part I,

Appendix 8 requires that a certificate holder ke ep documentation that describes and records

FRMS training programs, training requirements, and attendance records.

10. FRMS COMMUNICATIONS PLAN. The current edition of ICAO Annex 6, Part I,

Appendix 8 requires a certificate holder to have an FRMS communication plan that explains

FRMS policies, procedures and responsibilities to all stakeholders; and describes communication

channels used to gather and disseminate FRMS-related information.

a. Communication. The FRMS training programs are clearly an important part of the

communication plan. Since training intervals are annual, ongoing co mmunication to stakeholders

is required. Various media channels may be used to report the activities and safety performance

of the FRMS, to sustain interest in fatigue-re lated matters, and to encourage the continuing

commitment of all stakeholders to the FRMS processes. A variety of types of communication

can be used, including electronic media (Web site s, online forums, email), newsletters, bulletins,

seminars, periodic poster campaigns in strategic locations, and the like.

b. Content. Communications about the activities and safety pe rformance of the FRMS

(from the FSAG or other designated management ) need to be clear, timely and credible

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(i.e., consistent with the facts and with previous statements). The information provided also

needs to be tailored to the need s and roles of different stakehol der groups, so that people are

provided information that is re levant, practical, and concise.

c. Crewmember Feedback. Communications from crewmembers are vital for fatigue

hazard identification, for feedback on the effec tiveness of controls and mitigations, and in

providing information for FRMS safety performa nce indicators (e.g., by participating in surveys

and fatigue-monitoring studies). For these comm unications to be open and honest, all FRMS

stakeholders need to have a clear understandi ng of the policies governi ng data confidentiality

and the ethical use of information provided by cr ewmembers. There also must be clarity about

the thresholds that separate nonculpable fatigue-rel ated safety events from deliberate violations

that could result in penalties. Timely feedback to crewmembers who submit fatigue reports is

vital. Feedback does not require completion of a full investigation. Every crewmember should

receive a timely response to thei r report with some i ndication of the plan ned follow-up activity,

such as: “This report has been forwarded to the Fatigue Safety Action Group, which is currently investigating an adverse trend in fatigue reports associated with this trip and is evaluating a

number of potential m itigation strategies.”

d. Documentation and Assessment. The communication plan need s to be described in the

FRMS documentation and assessed periodically as part of FRMS SA processes. The

communications plan explains FRMS policies, procedures and responsibilities to all

stakeholders, and providing timely information on FRMS-related activities, trends, corrective

actions, pairing and scheduling policy changes, and fatigue management tips for crewmembers.

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SECTION 4. DATA COLLECTION

1. DATA COLLECTION SOURCES. Data collection is a fundamental element for

determining the effectiveness of an FRMS. Data collection and analysis is not a task undertaken

once in the life cycle of an FRMS; rather, it is one of the certificate holder’s day-to-day

functions. Data collection provides the certificate holder with an understanding of the suspected

areas that contribute to fatigue. It is essential for th e certificate holder to gather enough data and

information to be confident that they can identify the likely fatigue hazards in their operations. It

is instrumental in achieving the objective that the certificate hol der must have a good

understanding of the operational factors that are likely to cause crewmember fatigue.

a. Prioritization. Because fatigue-related impairment affects many skills and has multiple

causes, there is no single measurement that gi ves a total picture of a crewmember’s current

fatigue level or the factors that might cause fatigue. To decide which types of data to collect, the

most important thing to consider is the expected level of fatig ue risk. It is not a good use of

limited resources to undertake intensive data collection with multiple measures on a route where the fatigue-related risk is exp ected to be minimal. Therefore, resources should be targeted

towards operations where the risk is expected to be highest.

b. Efficiency. A balance needs to be maintained between gathering enough data for the

certificate holder to be confident about its deci sions and actions and the additional demands and

cost of the data collection and an alysis. Data analysis should provi de the certificate holder with

an idea of the appropriate mitigations and controls necessary for managing the risk. All measures require resources (finan cial and personnel) for data collection and analysis. Limited resources

need to be used effectively to identify fatigue hazards where controls and mitigations are most needed.

c. Sample Sources. A sampling of the following data co llection sources might be useful

and should be considered by the certificate holder:

(1) Crew Reporting.

 Reports of sickness.

 Crews calling in fatigued.

 Crews filing fatigue reports.

(2) The Company.  Flat or peaking flying program on monthly and seasonal basis.

 Category of airfields or seas onality of airfield use.

 Single- or multi-flightcr ew member operations.

 Market sector.

 Aircraft operated.

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(3) Scheduling.

 Schedule stability (especially changes of plus or minus 2 hours, unplanned night

stops, time between schedule ch ange, and new/revised duty).

 Scheduling buffers.

 Use of reserves flightcrew members.

 Block hours.

 Duty hours.

 Extensions of flight duty periods (FDP).

 Extension of flight times.

(4) Days Off.  Number of days off.

 Days off spread through the schedule.

 Frequency of singl e day off usage.

 Leave (how many days taken and ho w long since last leave period).

(5) The Duties.  Duty transitions.

 Working the Window of Circadian Low (WOCL) (early, la te, night duties,

scheduled and actual).

 Rest between duties.

 Number of segments per day (scheduled and actual).

 Long/extended duty days (including exte nded duties due to positioning or 14 CFR

part 91 operations).

 Length of FDPs.

 Number of consecutive duty days.

 Augmented and unaugmented flightcrew operations.

 Time zone crossings: fr equency and direction.

 Augmented crew routes.

 Length of layovers.

 Rest facilities on the aircraft: class of rest facility.

 Travel time between airport a nd hotel and the return trip.

 Waiting time for transport (hotel pickups).

(6) Contingency Plans.  Delayed report usage.

 Reserve assignments.

 Time between reserve call and show time.

 Working on days off.

 Delays during the FDP.

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(7) Scheduled vs. Actual.

 Task analysis of the duty days.

 Operational issues.

(8) Reportable/Measurable Data.  Fatigue incident reports.

 Aviation Safety Reporting Systems (ASRS).

 Aviation Safety Action Program (ASAP) reports.

 Biomathematical computer modeling: fatigue modeling.

 Modeling of pairings, assignments, and actual FDPs and flight times.

(9) Internal Actions.  FSAG meeting minutes.

 Fatigue survey.

 Fatigue report data.

 Internal incident/accident reports.

 External reports, studies, reviews, and accident/incident reports.

(10) Planned Data Collections.  Sleep data.

 Cognitive performance data.

 Flight performance data.

 Scheduling data.

(11) Other Data Sources.  Hazard reporting and investigations.

 Operational data related to fatigue.

 Audits and surveys.

 Reviews and fatigue studies.

2. FATIGUE REPORT. A fatigue reporting system is an in tegral component of the FRMS, as

it supports the evaluation of the air carrier’s FRMS and provides data points from fatigue-related

occurrences. However, to be effective, the fatigue reporting policy must be based upon open

communications encouraging employees to report fatigue-related occurren ces without fear of

reprisal. Voluntary disclosure has proven to be an excellent vehicle for conveying safety

information to those individuals having the au thority to effect and change policy. The air

carrier’s fatigue reporting system should support this concept. In return, the air carrier is afforded

the opportunity to collect valuable safety info rmation and effect changes in policies, as

appropriate, and continue to build upon their safe ty culture. Figure 2-3, Sample Fatigue Report,

is a sample fatigue report providing multiple data points. This sample report may be incorporated

as one of the certificate hold er’s data collection sources.

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FIGURE 2-3. SAMPLE FATIGUE REPORT

SAMPLE FATIGUE REPORT Answer

A Fatigue Occurrence

9 In the previous 12 calendar-months, how many times have you experienced

fatigue and reported the occurrence?

When the fatigue event occurred, how many consecutive days had you been

on duty?

In the days leading up to this fatigue occurrence, how many segments had you

flown during each duty day within the previous 72-hour period?

Were you rescheduled for duty during the previous 72-hour period? (Yes or

No)

Prior to this notification, how long has it been since you were on duty or

operating as a flightcrew member?

In the days leading up to this fatigue occurrence, how many hours had you

flown during each duty day within the previous 72-hour period?

In the days leading up to this fatigue occurrence, how many duty hours had

you worked during each duty day within the previous 72-hour period?

Were you performing any other duties for the air carrier on any day within the

previous 72-hour period? (Yes or No.) If Yes, answer the following question.

If you were performing other duties, wh at was the total time worked each day

performing those duties?

B Commuter

6 Are you a commuter? (Yes or No.) If No, indicate so and move to the next

section.

What form of transportation was used for your commute?

How long is your commute?

What was that total time from the time you left your home to start your

commute until the time you reported for duty?

How much time elapsed between the ti me you arrived at your domicile and

your report time?

Did you receive any additional rest at your domicile prior to reporting for

duty? If so, how much?

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C Reserve Pilot Assignment

7 8 9 During the previous 72-hour period, were you assigned as a reserve pilot?

(Yes or No.) If No, indicate so and move to the next section.

Do you regularly hold a reserve line? (Yes or No)

How many hours had your flown during the previous 24-hour period? How many hours had you been on duty during the previous 24-hour period? How many hours had your flown during the previous 72-hour period?

How many hours had you been on duty during the previous 72-hour period?

How many days had you been on duty during the previous 30 days?

How many hours had your flown in the previous 30 days?

When was the last period that you had been assigned at least 24 hours free

from all duty?

D Operational Issues

6 Did you experience any operational or maintenance delays within the previous

72-hour period? If so, please provide details.

How many rest periods did you have in the previous 72-hour period leading

up to the fatigue occurrence?

Did you have the opportunity to get additional rest between flights? If so, what

was the quality of that rest?

During the previous 72-hour period, di d your duty period involve consecutive

night duty or continuous duty overnights? (Yes or No)

If you answered “Yes” to question D4, how many consecutive nights of duty

did you perform consecutively?

If you answered “Yes” to question D4, how many continuous duty overnights

did you perform consecutively lead ing up to the fatigue occurrence?

E Augmented Crew

2 During the 72-hour period leading up to the fatigue occurrence, did you serve

as an operating crewmember in an augmented crew? (Yes or No.) If you

answered No, move to the next section.

Within the previous 24 hours, how many hours did you operate as an

augmented crew?

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10 Within the previous 72 hours, how many hours did you operate as an

augmented crew?

What classification of onboard rest facility did you use for in-flight rest?

(Class 1, 2, or 3)

What would you estimate was the quality of rest you received during the

previous 24-hour period? (Good, Fair, or Poor)

What would you estimate was the quality of rest you received during the

previous 72-hour period? (Good, Fair, or Poor)

What was the length of your duty period within the previous 24-hour period?

How many hours had you spent on flight duty periods (FDP) during the

previous 72-hour period?

Did you perform as an operating crewmember during the landing phase? If so,

were you the flying pilot or the monitoring pilot?

During the previous 72-hour period, ha d you served in a two-pilot crew? (Yes

or No.) If Yes, please provide details regarding the length of FDP, number of

segments flown in a two-pilot configuration, and the timeframe in which this

occurred during the previous 72-hour period.

F Hotel/Suitable Accommodation

6 Within the previous 72-hour period, wh at type of suitable accommodation did

you use? (Hotel or at Home)

If you rested at home, were there conditions that interrupted your sleep? (Yes

or No.) If Yes, how many interruptions?

Were the hotels you stayed in regular hotels used by your carrier? (Yes or No)

Were your hotel rooms located close to the elevator, ice machine, or high

traffic area?

Did you experience environmental issues interrupting your ability to sleep

such as social events occurri ng in the hotel, vehicular traffic, or air traffic?

(Yes or No.) If Yes, please explain.

Did you experience noise from hotel construction or remodeling that

interrupted your ability to sleep during your rest period? (Yes or No)

G Rest (During the 72-hour period leading up to the fatigue occurrence)

1 What was the difference (in time) between your scheduled rest periods and

your actual rest periods?

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2 How long (in time) was your sleep opportunity during your scheduled rest

periods?

H Sleep Opportunities

3 Within the 24-hour period leading up to the fatigue occurrence, how many

hours did you sleep?

Within the 48-hour period leading up to the fatigue occurrence, how many

hours did you sleep?

Within the 72-hour period leading up to the fatigue occurrence, how many

hours did you sleep?

I Circadian Issues

4 Within the previous 72-hour period, di d any part of your duty period fall

within the window of circadian low (WOCL)? (Yes or No.) If Yes, please

elaborate.

How many time zones had you flown through within the previous 24-hour

period?

How many time zones had you crossed within the previous 72-hour period?

Within the previous 72-hour period, had you operated through the nighttime

hours (Between 0200 and 0559)? (Yes or No.) If Yes, please explain.

J Nutrition and Hydration

3 4 During the 24-hour period leading up to the fatigue occurrence, what was the

quality of your meals? (Good, Fair, or Poor)

During the 72-hour period leading up to the fatigue occurrence, did you have

the opportunity to eat properly? (Yes or No)

During the 24-hour period leading up to the fatigue occurrence, have you

experience dehydration? (Yes or No)

During the 72-hour period leading up to the fatigue occurrence, did you have

the opportunity to properly hydrate yourself? (Yes or No)

K Personal Factors

1 Are you currently experiencing any personal issues that may have contributed

to your fatigue occurrence? (Yes or No)

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L Pre-Duty Activities

2 Within the 24-hour period leading up to the fatigue occurrence, were you

engaged in any pre-duty activities? (Y es or No.) If Yes, please explain.

Within the 72-hour period leading up to the fatigue occurrence, were you

engaged in any pre-duty activities? (Y es or No.) If Yes, please explain.

Remarks Section

Question # Comments

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SECTION 5. FATIGUE RISK MANAGEMENT PROCESSES

1. SETTING UP FRM PROCESSES. This section describes the basic steps for setting up and

applying FRM processes. FRM processes within an FRMS are specifically designed to manage

the risks related to crewmember fatigue. Figur e 2-4, Fatigue Risk Ma nagement Processes,

illustrates these processes.

FIGURE 2-4. FATIGUE RISK MANAGEMENT PROCESSES

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a. Processes. FRM processes are one part of the day- to-day operations of the FRMS. They

are designed to enable the certificate holder to ac hieve the safety objectives defined in its FRMS

policy, and are managed by the FSAG. The basic FRM processes are:

(1) Identify where fatigue is a hazard;

(2) Assess the level of risk that a gi ven fatigue hazard represents; and

(3) If necessary, put in place controls and m itigation strategies, and monitor them to

make sure that they manage the risk to an acceptable level.

b. Data Analysis. To be effective at managing risks, FRM processes require data input from

a number of sources, including measurements of the crewmembers’ fatigue levels and

measurement of operational performance. Th e key is choosing the right combination of

measurements applicable to each operation covere d by the FRMS. However, just collecting data

is not enough. The data must be analyzed for data output that will be used by the FSAG and

others accountable for FRM processes so that in formed decisions can be made relative to the

FRMS safety performance.

2. FRM PROCESSES OUTLINE. The following outlines the FRM processes: a. Process 1.0: Identify Operation(s) to which FRMS Processes will be Applied. It is

important that the certificate holder clearly id entify the operations where the FRMS will be

applied. Different types of flight operations can involve different causes of crewmember fatigue

and may require different controls and strategies to mitigate the associated risks. Within its

FRMS, a certificate holder may need to develop multiple sets of different FRM processes for

different operations. These shoul d be clearly identifiable.

b. Process 2.0: Collect and Analyze Data. The FRMS must provide an AMOC and

demonstrate that it meets or exceeds the limitations (safety standards) prescribed in part 117. To

demonstrate an AMOC of the FR MS, the certificate holder must, prior to FAA approval, define

measurements of fatigue that will serve as perfor mance safety standards for the evaluation of the

effectiveness of the FRMS.

(1) Measurements Summary. An AMOC demonstration of effectiveness of the FRMS

will require a combination of measurements.

 Subjective fatigue and sleepiness ratings,

 Objective performance measurements,

 Sleep monitoring and measurement, and

 Circadian rhythm measurements.

(2) Required Measurements. The suite of measurements should include the following:

(a) Performance Measurement. A range of objective performance tests are used in

scientific research. Things to consider wh en choosing a performance test for measuring

crewmember fatigue include the following:

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1. How long does the test last? Can it be completed at multiple time points

(e.g., in the operations room during preflight preparations, near top of climb, near top of descent,

and post-flight before disembarking from the ai rcraft) without compromising a crewmember’s

ability to meet duty requirements?

2. Has it been validated? For example, has it been shown to be sensitive to the

effects of sleep loss and the circadian body clock cycle under controlled experimental

conditions?

3. Is the test predictive of more comp lex tasks (e.g., crew performance in a

flight simulator)?

4. Has it been used in other aviation operations, and are the data available to

compare fatigue levels between operations?

(b) Measurement Methodology. The certificate holder must provide a measurement

methodology that will be sufficient to demonstrat e that operations under the FRMS do not induce

additional fatigue relative to operations under the prevailing prescriptive rules. The data

collection and analysis methodology must specify the following components:

1. A description of the study population and the operations under which

measurements will be collected. The methodology must provide for an unbiased and voluntary

selection of participants.

2. A definition of what metrics will be derived from each measurement. For

example, a reaction time test can provide multiple metrics, such as mean reaction time, long

reaction times (lapses), and mean speed.

3. A definition of what level of each metr ic will serve as the safety standard,

based on data collected during operations under th e prevailing prescriptive rules. The safety

standard serves as the baseline against whic h operations under the FRMS will be evaluated.

4. The duration of the study and a schedule of measurements. The data collection

schedule must include measurements under the al ternative operating procedures, as well as

measurements during any subsequent trip by the same individuals.

5. A statistical analysis plan that will define how measurements under the FRMS

will be evaluated against the safety standard to demonstrate an adequate level of compliance.

6. A description of methods used to assure the accuracy and integrity of all data

collected to support the proposed FRMS.

(c) Fatigue Modeling. The analysis of empirical da ta may be supplemented by the

use of a biomathematical model to estimate the le vel of fatigue or perf ormance. For example,

measurement of sleep could be used as input to a biomathematical model to derive estimates of

fatigue or performance. If modeling is used, a justification of the choice of model must be provided, all modeling assumptions, parameters, a nd initial conditions must be defined, and a

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modeling safety standard must be defined, based on the prevailing pr escriptive rules, that serves

as the baseline for evaluation of fatigue or performance estimates under the FRMS operation.

(3) The collection and analysis of data are a prerequisite for the approval of the FRMS

and issuance of Operations Specification (OpSpe c) A318, Authorization to Conduct Operations

under an FRMS. Once the FRMS is approved, similar measurements will be obtained

periodically as part of the SA process to confirm the conti nued effectiveness of the FRMS

relative to the established safety standards.

c. Process 3.0: Identify Hazards. Identify the specific nature of the fatigue hazard(s)

associated with the proposed operations where FRMS will be applied that may need to be

managed. The current edition of ICAO Annex 6, Part I, Appendix 8 requires that a

certificate holder develop, maintain, and documen t three types of processes for fatigue hazard

identification. These are referred to as predic tive, proactive, and reactive processes. A

certificate holder shall develop and maintain the following three fundamental and documented

processes for fatigue hazard identifica tion as part of the approved FRMS:

(1) Predictive. The predictive process shall identi fy fatigue hazards by examining crew

scheduling and taking into account factors known to affect sleep and fatigue and their effects on

performance. Methods of examinati on may include but are not limited to:

 Certificate holder or industry operational experience and data collected on similar

types of operations;

 Evidence-based scheduling practices; and

 Biomathematical models.

(2) Proactive. The proactive process shall identify fatigue hazards within current flight

operations.

(a) Methods. Methods of examination may include but are not limited to:

 Self-reporting of fatigue risks;

 Crew fatigue surveys;

 Relevant flight and cabin crew performance data;

 Relevant flight and cab in crew sleep data;

 Available safety databases a nd scientific studies; and

 Analysis of planned versus actual time worked.

(b) Crewmember Fatigue Reports. Reports citing high fatigue levels or

fatigue-related performance issues are vital to keep the FSAG informed about fatigue hazards in

day-to-day FRMS operations. A series of fatigue re ports on a particular route can be a trigger for

further investigation by the FSAG. An effective fatigue reporting system requires an effective

reporting culture. It needs to:

1. Use forms that are easy to access, complete, and submit;

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2. Have clearly understandable rules about confidentiality of reported

information;

3. Have clearly understandable volun tary reporting protection limits;

4. Include regular analysis of the reports; and

5. Provide regular feedback to crewmembers about decisions or actions taken

based on the reports and lessons learned.

(c) Crew Fatigue Surveys. Crew fatigue surveys fall into two basic types:

1. Retrospective surveys that ask crewmemb ers about their sleep and fatigue in

the past. These can be relatively long and ar e usually completed only once, or at long time

intervals (e.g., on ce a year); and

2. Prospective surveys that ask crewmember s about their sleep and fatigue right

now. These are typically short and are often comp leted multiple times to monitor fatigue across a

duty period, trip, or schedule. They usually include measures such as sleepiness, fatigue, and

mood ratings.

(d) Performance Measurements. Performance measurements provide objective data

that can be used to supplement the subjective data collected in fati gue reports and survey

responses. Currently, there are th ree main approaches to monitoring crewmember performance:

1. Simple tests, developed in the laboratory, which measure aspects of an

individual’s performance (e.g., reaction time, vigilance, and short-term memory). These

performance measurements used to monitor the e ffectiveness of the FRMS may be the same as

those utilized to obtain FAA approval of the FRMS;

2. Flight data analysis (FDA), which examines the relationship between

identified elements of aircraft perf ormance and pilot performance; and

3. Having trained flight deck observers rating the performance of crewmembers

on the flight deck (e.g., Line-Oriented Safety Audit).

(e) Sleep Measurements. Sleep measurements provide obj ective data that verify that

the sleep assumptions that were the foundation of the FRMS approval remain valid during the

implementation of the FRMS. Sleep measur ement technology used for ongoing hazard

identification may be similar to t hose used for the FRMS approval.

(3) Reactive. The reactive process shall identify th e contribution of fatigue hazards to

reports and events associated with potential nega tive safety consequences in order to determine

how the impact of fatigue could have been minimized. At a minimum, the process may be

triggered by any of the following:

 Fatigue reports,

 Confidential reports,

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 Audit reports,

 Incidents, and

 Flight data analysis events.

d. Process 4.0: Assess Safety Risk. Conduct a safety risk assessment for each identified

hazard. Decide which risks require mitigation. A certificate holder shall develop and implement

risk assessment procedures that determine the proba bility and potential seve rity of fatigue-related

events and identify when the associated risks re quire mitigation. The risk assessment procedures

shall review identified hazards and link them to:

 Operational processes,

 Their probability,

 Possible consequences, and

 The effectiveness and controls of ex isting safety barriers and controls.

e. Process 5.1: Select and Implement Contro ls and Mitigations (Risk Management

(RM)). Implement appropriate mitigation strategies and communicate them to all relevant

personnel. When it is decided that a particular fatigue hazard requires ac tion, then controls and

mitigations must be identified and implemente d. The specific expertise of the FSAG should be

used in the selection of these controls and mitigations.

(1) All involved personnel should clearly understand the hazard and the controls and

mitigations designed to reduce the associated risk. The certificate holder shall develop and

implement risk mitigation procedures that:

(a) Select the appropriate mitigation strategies,

(b) Implement the mitigation strategies, and

(c) Monitor the strategies’ implementation and effectiveness.

(2) If the controls and mitigations perform to an established safety standard, they become

part of normal operations and are monitored by the FRMS SA processes. If, however, the controls and mitigations do not perform to an acceptable standard, then it will be necessary to

reenter the FRM processes at the Process 2.0, Collect and Analyze Data. This will require

gathering additional information and data; and/or re-evaluation of the fatigue hazard and the

associated risks; and/or identification, implemen tation, and evaluation of new or revised controls

and mitigations.

f. Process 5.2: Set Safety Performance Indicators. Set safety performance indicator(s) to

be able to assess whether the mitigation strategi es are delivering the required level of risk

reduction. Data collected during the first 4 months of the FRMS operation will be compared to the respective model predictions and the performance safety sta ndards from the FRMS validation

(Process 2.0) to establish whether crewmember performance and fatigue are in the acceptable range. By the fourth month of the FRMS ope ration, the fatigue repor ting rate (reports per

flight segment) and average fatigue report risk level should be comparable to operations under the prevailing prescriptive rules. No “intol erable” fatigue reports should be received.

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g. Process 5.3: Develop Flightcrew FRMS Operations Procedures. Flightcrew FRMS

operations procedures, are developed by the certificate holder and approved by the FAA to

provide operational guidance for flightcrew memb ers, dispatchers, schedulers, persons holding

operational control, and individu als with oversight management of these areas for operations

where an FAA-approved FRMS is applied. Therefore, flightcrew FRMS operations procedures serve as the foundation for dissemi nating safety-related guidance a nd procedural information for

operations where an FRMS is proposed. FRMS ope rations procedures should be designed with

supporting validated data collected and analyzed from various sources associated with the FRMS operation. Such data sources includes, but not limited to, actigraphy, performance tests,

biomathematical modeling, and fatigue monitoring and reporting. Whenever FRMS is applied to any operation flightcrew members, dispatchers, schedulers, persons holding operational control,

and individuals with oversight management of th ese areas for operations, all must comply with

the FRMS operations procedures for that operation.

(1) As mitigations and controls are identifi ed and validated to reduce fatigue risks

associated with a specific FRMS operation, the certificate holder will be responsible for

developing operating procedures that support thos e mitigations and controls. Specific limitations

and conditions outlined in the certificate holder’s OpSpec A318, Authorization to Conduct

Operations under an FRMS, must also be refl ected in the FRMS operating procedures. The

certificate holder should use FRM and SA to validate and update their FRMS operation

procedures. This process adds an additional laye r of safety with regard to demonstrating the

certificate holder’s FRMS operation procedures support their AMOC.

(2) As part of the FRMS continuous mon itoring and improvement process, the

certificate holder will be respons ible for evaluating the effectiveness of the FRMS and updating

these procedures to support the data results. Th is data shall be submitted with the certificate

holder’s reporting interval data. The certificate holder must make available to each flightcrew

member, dispatcher, scheduler, pe rson holding operational control, and individual with oversight

management of these areas for operations a cu rrent copy of the flightcrew FRMS operations

procedures. When an FRMS is being applied to any part of the certif icate holder’s operation,

each person involved with the FRMS shall comp ly with the flightcrew FRMS operations

procedures.

h. Process 6.0: Set Up Processes for Monitoring the Effectiveness of Controls and

Mitigations. If mitigation strategies pe rform to an acceptable standard, they become part of

normal operations and are monitored by the FRMS SA processes. If mitigation strategies do not perform to an acceptable standard, then reenter the FRM processes at the appropriate step.

(1) There is a defined validation period for th e first 4 months of the operation that

involves more intensive monitoring. The FSAG w ill have regular oversi ght of all data and

fatigue reports coming in and will act in a timely manner when issues arise. Copies of all data

collected and associated monito ring data, along with actions take n by the certificate holder to

mitigate fatigue events and occurrences, shall be submitted to the FAA during regular scheduled

reporting intervals. A report will be compiled and routine processes will be defined for fatigue

risk monitoring and management. This report will be available to all interested parties, including

the FAA. If the performance in dicators are acceptable, the oper ation will revert to routine

monitoring.

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(2) If the controls and mitigations perform to an acceptable standard, they become part of

normal operations and are monitored by the FRMS SA processes. If the controls and mitigations

do not perform to an acceptable standard, then it will be necessary to reenter the FRM processes

at the appropriate ste p. This could require:

 Gathering additional information and data;

 Reevaluation of the fatigue hazard and the associated risks; and/or

 Identification, implementation, and evalua tion of new or revised controls and

mitigations.

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SECTION 6. FATIGUE RI SK MANAGEMENT SYSTEM SAFETY ASSURANCE

PROCESSES

1. INTRODUCTION TO FRMS SA PROCESSES. The FRMS processes is the part of the

day-to-day FRMS operations focusing on identify ing fatigue hazards, assessing safety risks,

putting in place controls and mitig ation strategies, and monitori ng their effectiveness. This

section works through the basic steps in FRMS SA processes, which form another layer in a

certificate holder’s defenses against fatigue-related risk.

a. SA Processes. Figure 2-5, Fatigue Risk Management and Safety Assurance Processes,

illustrates the combined elements of the FRM a nd FRMS SA processes. FRMS SA processes are

also part of the routine operation of the FRMS, and they monitor how well the entire FRMS is

functioning. The FRMS SA processes:

(1) Check that the FRMS is functioning as intended;

(2) Check that it is meeting the safety objectives defined in the FRMS policy;

(3) Check that it is meeti ng regulatory requirements;

(4) Identify where changes in the operating e nvironment have the potential to increase

fatigue risk; and

(5) Identify areas for improvement in the ma nagement of fatigue risk (continuous

improvement of the FRMS).

b. Continuous Monitoring. The certificate holder shall de velop and maintain FRMS SA

processes to provide for continuous FRMS perf ormance monitoring, analysis of trends, and

measurement to validate the effectiv eness of the fatigue safety risk controls. The sources of data

may include, but are not limited to:

(1) Hazard reporting and investigations,

(2) Operational data related to fatigue,

(3) Audits and surveys, and

(4) Reviews and fatigue studies.

c. Management Process. The certificate holder shall prov ide a formal process for the

management of changes which shall include, but is not limited to:

(1) Identification of changes in the operationa l environment that ma y affect the FRMS;

(2) Identification of changes within the orga nization that may affect the FRMS; and

(3) Consideration of available t ools that could be used to maintain or improve FRMS

performance prior to implementing changes.

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d. Continuous Improvement. The FRMS SA process must provide for the continuous

improvement of the FRMS. This sha ll include, but is not limited to:

(1) The elimination and/or modification of ri sk controls that have had unintended

consequences or that are no longer needed due to changes in the operational or organizational

environment;

(2) Routine evaluations of facilities, e quipment, documentation, and procedures;

(3) Trending of safety performance indicators to determine if there is a need to introduce

new processes and procedures to mitiga te emerging fatigue-related risks; and

(4) As an option, retrospective and prospec tive biomathematical modeling of schedules

to assess potential schedule-related fatigue risk.

e. Safety Performance Indicators. The FRMS SA processes us e a variety of data and

information as safety performance indicators th at can be measured and monitored over time.

Having a variety of safety perfor mance indicators, plus a safety target for each, is expected to

give better insight into the overall performan ce of the FRMS than having a single measure.

Safety performance targets must fall in the to lerable region defined in the risk assessment

process and they may need to be revised as operational circumstances change. The information,

data, and safety performance indicators from the FRMS processes provide a source of

information for the FRMS SA processes. In addition, the FRMS SA processes:

(1) Use information and expertise from other sources, both from within the

certificate holder’s organization and external to it, to evaluate the functioning of the FRMS;

(2) Evaluate trends in safety performance i ndicators to identify emerging or changed

hazards and refer these back to the FRM processes;

(3) Identify changes in the operating environmen t that could affect fa tigue risk and refer

these back to the FRM processes; and

(4) Provide input for improving the operation of the FRMS.

2. FRMS SA FIVE-STEP PROCESS. The FRMS SA processes consist of a five-step process

that focuses on identifying fatigue hazards, assess ing safety risks, putting in place controls and

mitigation strategies, and monitoring their effectiv eness. The objectives of each individual step

are outlined below.

a. Step 1: Collect and Review Information.

(1) Safety Performance Indicators. This process involves collecting and reviewing

information gained through the FRMS processe s to examine the overa ll performance of the

FRMS. Performance of the FRMS should be examined through indentifying a variety of safety

performance indicators. This should include inform ation specific to the FRMS as well as safety

performance indicators.

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(2) Examples. Examples of safety performance indicators specific to an FRMS will

include measures obtained through the FRMS processes, such as:

 The number of exceeded maximum duty days in operations covered by the

FRMS,

 The number of voluntary fa tigue reports per month,

 The average “fatigue call” rate by fl ightcrews on a specific pairing (trip),

 The ratio of fatigue reports from operations covered by the FRMS to fatigue reports from operations covered by th e prescriptive flight and duty time

regulations,

 Attendance at FRMS training sessions,

 Results on FRMS training assessments,

 The level of crewmember participation in fatigue-related data collection; and

 The number of times fatigue is identified as an organizational factor contributing

to an event.

(3) Sources of Data. The sources of data for monitoring the safety performance of the

FRMS may include (but are not limited to):

 Hazard reporting and investigations,

 Audits and surveys, and

 Reviews and fatigue studies.

(4) Hazard Reporting and Investigations. Trends in voluntary fatigue reports by

crewmembers and others can provide valuable insights into the effectiveness of the FRMS.

Safety events in which crewmember fatigue has b een identified as a contributing factor should be

less common than fatigue reports. However, regular review of these events may also highlight

areas where functioning of the FRMS could be improved. The va lue of both these sources of

information depends on appropriate met hods to identify the role of fatigue.

(5) Audits and Surveys. Audits and surveys can provide measures of the effectiveness

of the FRMS without having to rely on fatigue le vels being high enough to trigger fatigue reports

or fatigue-related safety events (both of which are relatively rare events).

(a) Audits focus on the integrity of, and a dherence to, the FRMS processes. These

audits should answer questions such as:

 Are all departments implementing the recommendations of the FSAG?

 Are crewmembers using mitigation stra tegies as recommended by the FSAG?

 Is the FSAG maintaining the required documentation of its activities?

(b) Audits can also periodically assess th e effectiveness of the FRMS (e.g., by

looking at the status of FRMS safety performance indicators and targets). Audits are external to

the FSAG, but may still be internal to the ce rtificate holder (i.e., conducted by other groups

within the organization) . In addition, feedback from regulatory audits can provide useful

information for FRMS safety performance monitori ng. Another type of audit that can be used in

this context is a review by an independent scie ntific review panel that periodically reviews the

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activities of the FSAG and the scientific integrity of their decisions. A scientific review panel can

also provide the FSAG with periodic updates on ne w scientific developments relevant to the

FRMS.

(c) Surveys can provide information on the e ffectiveness of the FRMS. For example,

they can document how schedules and assignments are affecting crewmembers, either by asking

about their recent experiences (retrospective) or tracking them across time (prospective). Surveys

for this purpose should include validated measures, such as standard rating scales for fatigue and

sleepiness and standard measures of sleep timing and quality. Remember that a high response

rate (ideally, more than 70%) is needed for survey results to be considered representative of the

entire group, and response rates tend to declin e when people are surveyed too frequently

(participant fatigue).

(6) Reviews and Fatigue Studies. In general, safety review s are used to ensure that

safety performance is adequate during times of change (e.g., during th e introduction of a new

type of operation or a significant change to an existing operation covered by the FRMS).

(a) A review would start by identifying the ch ange (e.g., moving a trip to a crew base

in a different time zone, changes in on-board crew rest facilities, significant changes in the total

trip, or a change of equipment being used for the trip). It would then evaluate the appropriateness

and effectiveness of the FRMS ac tivities relative to the change (for exam ple, proposed methods

for fatigue hazard identification, the risk assessm ent process, proposed controls and mitigations

to address the fatigue hazard(s), and measures of their effectiveness to be used during the

implementation of the change).

(b) Fatigue studies, as part of FRMS SA processes, are undertaken when a

certificate holder is concerned a bout a broad fatigue-rela ted issue for which it is appropriate to

look at external sources of information. Th ese could include the experience of other

certificate holders, industry-wide or nation-wide studies, and scien tific studies. External sources

of information are particularly helpful when an internal consensus for a course of action cannot

be reached or to supplement the limited experience and knowledge within that

certificate holder’s organization. Fa tigue studies in this context are mainly used for gathering

information about large-scale issu es related to the FRMS, rather than for identifying specific

fatigue hazards.

(7) FRMS Safety Performance Indicators. Trends in FRMS safety performance

indicators are also an important source of information about the effectiveness of the FRMS. This

may include indicators identified by the FSAG as part of the FRMS processes. They may also

include indicators that capture more global aspects of the safety performance of the FRMS.

b. Step 2: Evaluate FRMS Performance.

(1) This process is intended to validate the effectiveness of the fatigue controls and

mitigations by analyzing the data collected and revi ewed in Step 1 of the FRMS SA processes to

determine whether:

(a) All specified FRMS safety perf ormance targets are being met;

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(b) All specified FRMS safety performance indicators remain in the tolerable region

defined in the risk assessment process;

(c) The FRMS is meeting the safety objectiv es defined in the FRMS policy; and

(d) The FRMS is meeting all regulatory requirements.

(2) The following are examples of safety performa nce targets and indicators that could be

used in FRMS SA processes and that corres pond with the safety performance indicators

identified above:

(a) The length of the maximum duty days in operations covered by the FRMS does

not exceed the limits defined in the FRMS polic y. This is reviewed monthly by a computer

algorithm and trends across time are evaluated every 3 months.

(b) By the fourth month after the introduction of a new ope ration, there must be a

stable, low number of voluntar y fatigue reports per month or a clear downward trend in the

number per month (allowing time for crewmembers a nd other affected personnel to adjust to the

new operation).

(3) The FSAG is responsible for providing a writ ten report on the validation phase of the

new operation, including analysis of all fatigue-re lated events and voluntary fatigue reports, and

documentation of the corresponding adjustments ma de in fatigue controls and mitigations.

Additionally, the following information that should be included in the report:

(a) The rate of fatigue calls under the FRMS operation in comparison to the rate

under non-FRMS operations.

(b) Actions taken when the rate of fatigue reports for operations conducted under the

FRMS exceed the rate of fatigue reports for non-FRMS operations. The actions by the certificate

holder taken must be re ported to the FAA.

(c) Evidence that, in the last quarter, desi gnated management has provided adequate

resourcing for the FRMS, as specified in the FRMS policy.

(d) Evidence that, in the last quarter, the FSAG has met as often as is required in the

FRMS policy and has maintained all the documenta tion of its activities re quired for internal and

regulatory auditing.

(e) Evidence that all personnel responsible for schedule design and assignments have

met annual FRMS training requirements as speci fied in the FRMS promotion processes.

(f) Measures of the effectiveness of FRM training and education programs.

(g) Evidence that quarterly levels of absenteeism are below the target specified for

each operation covered by the FRMS.

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(4) When FRMS safety performance targets ar e not met or when safety performance

indicators are not at an acceptable level, the controls and mitigations in use may need to be

modified by reentering the FRMS pr ocesses at Step 2 or beyond. It may also be appropriate to

seek additional information from outside the orga nization (e.g., by looking at fatigue studies). It

may be necessary to undertake a review of co mpliance of crewmembers and other departments

with the recommendations of the FSAG. It may also sometimes be necessary to review the

functioning of the FSAG itself to find out why the FRMS is not working as intended.

c. Step 3: Identify Emerging Hazards.

(1) Analysis of trends in safety performance indicators may indicate the emergence of

fatigue hazards that have not previously b een recognized through the FRMS processes. For

example, changes in one part of the organiza tion may increase workload and fatigue risk in

another part of the organizati on. Identifying emerging fatigue-re lated risks is an important

function of FRMS safety performance processes, which take a broader system perspective than

FRMS processes.

(2) Any newly identified fatigue risk, or combin ation of existing risks for which current

controls are ineffective, shoul d be referred back to the FSAG for evaluation and management

using FRMS processes (risk assessment and design and implementation of effective controls and

mitigations).

d. Step 4: Identify Changes Affecting the FRMS.

(1) In our dynamic aviation environment, change s are a normal part of flight operations.

They may be driven by external factors (e.g., new regulatory requirement s, changing security

requirements, or changes to air traffic control) or by internal factors (e .g., management changes

or new routes, aircraft, equipment, or procedures). Changes can introduce new fatigue hazards

into an operation, which need to be managed. Changes may also reduce the effectiveness of

controls and mitigations that have been impl emented to manage existing fatigue hazards.

(2) During Step 4, the objective of FRMS SA pr ocesses is to identify new hazards that

may be a result of change. The current edition of ICAO Annex 6, Part I, Appendix 8 requires that

a certificate holder has FRMS SA processes that provide a formal methodology for the

management of change. These must include (but are not limited to):

(a) Identification of changes in the operational environment that may affect the

FRMS;

(b) Identification of changes within the orga nization that may affect the FRMS; and

(c) Consideration of available t ools that could be used to maintain or improve FRMS

performance prior to implementing changes.

(3) A change management process is a documented strategy to pro actively identify and

manage the safety risks that can accompany si gnificant change. When a change is planned, the

following steps can be followed.

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(a) Use the FRM processes to identify fatigue hazards, assess the associated risk, and

propose controls and mitigations; and

(b) Obtain appropriate management and/or regulatory signoff that the level of

residual risk is acceptable.

(4) During the period of implementation of the change, use the FRMS SA processes to

provide periodic feedback to line managers that the FRMS is f unctioning as intended in the new

conditions. Documentation of the ch ange management strategy in relation to fatigue management

is also the responsibility of the FSAG. Cha nges in the operational environment may also

necessitate changes in the FRMS itself. Exam ples include bringing new operations under the

scope of the FRMS, collecting different types of data, and adjusting training programs. The

FSAG should propose such changes and obtai n approval for them from the FAA for

implementation.

e. Step 5: Improve Effectiveness of the FRMS.

(1) Ongoing Evaluations. Ongoing evaluation by the FR MS SA processes not only

enables the FRMS to be adapted to meet changing operational needs: it also allows the FRMS to

continuously improve the management of fatigue risk. In doing so, risk controls that have

unintended consequences or that are no longer needed due to changes in the operational or

organizational environment can be identified and then modified or eliminated through the FRMS

processes. Examples include:

(a) Routine evaluations of facilities, equi pment, documentation, and procedures; and

(b) The determination of the need to intr oduce new processes and procedures to

mitigate emerging fatigue-related risks.

(2) Documentation. It is important that changes ma de to the FRMS are documented by

the FSAG so that they are available for internal and regulatory audits.

(3) Assigning Responsibility for FRMS SA Processes.

(a) To deliver effective oversight of the functioning of the FRMS, the FRMS SA

processes need to operate in close communica tion with the FSAG, but with a degree of

independence. The objective is to avoid the FSAG from reviewing its own performance.

(b) Primary responsibility for the FRMS SA processes is assigned to a quality

assurance (QA) person or team (as appropriate) th at is accountable to the executive management

team. In smaller operations, responsibility for th e FRMS SA processes might reside with an

individual rather than a team. This indi vidual may also have a variety of other QA

responsibilities.

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FIGURE 2-5. FATIGUE RISK M ANAGEMENT AND SAFETY ASSURANCE

PROCESSES

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SECTION 7. FRMS AUTHORIZATION PROCESS

1. HOW AN FRMS IS APPLIED. An FRMS is a data-driven system based upon scientific

principles that must be eval uated and validated by the FAA for safety and effectiveness.

Typically, a certificate holder wi ll utilize an FRMS authorization as a means to apply an AMOC

to a prescriptive rule. Therefore, the certificate holder’s AMOC mu st be evaluated and validated

for safety and effectiveness. The certificate hold er must also develop flightcrew member FRMS

operations procedures that are supported by the validated data and evaluated and approved by the

FAA as demonstrating compliance with the FRMS authorization.

2. DEFINITION OF TERMS. The following terms are applied to FRMS and the approval

process:

a. Actigraph. A wristwatch-like device containing an accelerometer to detect movement.

Activity counts are recorded every minute. The patterns of movement can be analyzed using

purpose-built software to estimate when the wear er of the actigraph is asleep, and to provide

some indication of how restless a sleep period is (i.e., to measure sleep quality). Actigraphs are

designed to record continuously for several weeks, so they are valuable tools for monitoring

sleep patterns before, dur ing, and after a trip.

b. Biomathematical Model. A computer program (a fatigue model) designed to predict

crewmember fatigue levels, based on scientific understanding of the f actors contributing to

fatigue. All biomathematical models have limita tions that need to be understood for their

appropriate use in an FRMS and the dete rmination of predicted fatigue levels.

c. Controls. System-level defensive strategies de signed to minimize fatigue risk on an

ongoing basis.

d. Data. Routine or planned collection of sleep, performance, and alertness measurements.

Other sources of data include flightcrew member reports of fatigue, repor ts of fatigue-related

events, actions taken by the certificate holder to mitigate future fatigue events, and continuous

monitoring of performance indi cators to determine the overall effectiveness of the FRMS.

e. Data Collection. Application of a scientific me thodology during flight operations

designed to acquire the information (data) necessary for comparisons between groups or

conditions or across time to assess the re lative levels of fatigue experienced by

flightcrew members both before FRMS operation s and after FRMS operations combined with

mitigating strategies.

f. Data Package. A description of data collection me thods, a compilation of collected data,

the results of the analysis of the data with comparisons betwee n groups or conditions or across

time, and the FRMS operations procedures that are constructed to support the results of data

analysis for FRMS approvals and continuous monitoring.

g. Fatigue Risk Management (FRM). The management of fatigue in a manner appropriate

to the level of risk exposure and the nature of the operation in order to minimize the adverse

effects of fatigue on the safety of operations.

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h. Fatigue Risk Management (FRM) Processes. FRM processes are one part of the

day-to-day operations of the FRMS. They are de signed to enable the certif icate holder to achieve

the safety objectives defined in its FR MS policy, and are managed by the FSAG.

i. Fatigue Safety Action Group (FSAG). A group comprised of representatives from all

stakeholder groups that are respons ible for coordinating all fatigue management activities in the

organization.

j. Flightcrew Member FRMS Operations Procedures. Flightcrew member operations

policy and procedures demonstrating complian ce during operations where FRMS is applied.

k. Mitigations. System-level interventions designed to reduce a specific identified fatigue

risk.

l. Reporting Intervals. Specific timeframes for when the certificate holder is required to

provide reports to the FAA rega rding data collection, analysis, and the demonstration of the

effectiveness of their overall FRMS.

m. Safety Assurance (SA) Processes. SA processes monitor the en tire FRMS to check that

it is functioning as intended and meeting the safe ty objectives in the FRMS policy and regulatory

requirements. SA processes al so identify operational and organizational changes that could

potentially affect the FRMS, and identify areas where the safety performance of the FRMS could

be improved (continuous improvement).

n. Safety Performance. The level of safety achieved in a risk-controlled environment,

measured against a safety level deemed as low as reasonably practicable.

o. Study Design. The definition of the goals or aims of the study, the descri ption of the data

collection methods, the groups or conditions that will be studied and compared, the

measurements to be taken, the frequency and tim ing of those measurements, the crewmembers to

be studied, the timeframe of the da ta collection, the methods of analys is, the criteria to be applied

to evaluate the findings relative to the goals or aims of the study, and the proposed approach to

establish that an FRMS pr ovides an effective AMOC.

3. FRMS APPROVAL PROCESS OVERVIEW. The FRMS authorization process is a

systematic and progressive approach to obtain ap proval of a certificate holder’s proposed FRMS.

This process provides a means for the certificate holder to demonstrat e their proposed FRMS

provides an AMOC for managing and mitigating fatigue along with a continuous monitoring

output.

a. Meet with the FAA. Prior to development of the FRMS application package, the

certificate holder should contac t the Air Transportation Division (AFS-200) to schedule time to

discuss their plans for operati ng under an FRMS. This meeting may be conducted as either an

in-person meeting or a teleconference. During this meeting, the FAA will review the approval

process with the certificate holder and outline all of the items required for the process.

Additionally, this meeting will se rve as an opportunity for the cer tificate holder to ask the FAA

any questions relative to any pa rt of the approval process.

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b. Approval Process. The FRMS approval process consists of five phases and nine gates,

all of which must be satisfactorily comple ted in succession. See Figure 2-6, Fatigue Risk

Management System Approval Process, for a graphic representation of the FRMS approval

process.

(1) The five phases of the approval process are:

 Phase 1: Preapplication, Planning, and Assessment.

 Phase 2: Formal Application.

 Phase 3: Documentation and Data Collection Plan.

 Phase 4: Demonstration and Validation.

 Phase 5: Authorization, Implementation, and Monitoring.

(2) Phase 1 has four gates, Phase 2 has two ga tes, and Phases 3 through 5 have one gate

per phase. Each gate must be satisfactorily comp leted in succession before the certificate holder

may move to the next phase.

(3) The certificate holder is responsible for developing the requirements outlined in each

gate and satisfactorily demonstrat ing the effectiveness of those items. The FAA is responsible for

reviewing, evaluating and validating the eff ectiveness of each phase completed by the

certificate holder.

c. Submit Application. Each part 121 certificate holder must develop their draft FRMS

application package in a manne r acceptable to the FAA for review. When the draft FRMS

application package is ready for FAA submissi on, the certificate hold er will electronically

submit it to AFS-200 via email at 9-AWA-AVS -AFS-200-Air-Transportation-Division@faa.gov

and provide its principal operati ons inspector (POI) with a copy. Upon receipt of the package,

AFS-200 will acknowledge to the se nder receipt of the package via email reply, copying the

respective POI and Regional Office (RO).

d. Primary Objectives. Upon satisfactory conclusion, this process will yield four primary

objectives relative to the certificate holder’s proposed FRMS, including:

 Validation,

 Authorization,

 Phased implementation, and

 Continuous improvement monitoring.

e. Basic Steps for the Approval of an FRMS Application Package.

(1) The certificate holder devel ops their plan for an AMOC to a prescriptive rule.

(2) The certificate holder presents their fatigue modeling results or another form of data

acceptable to the FAA that s upports their proposed AMOC.

(3) The certificate holder presents thei r study design to verify the AMOC.

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(4) The FAA reviews and validates the certi ficate holder’s proposed AMOC, study

design, flightcrew FRMS operations procedures, a nd data package. If the FAA determines that

the certificate holder has satisfa ctorily demonstrated that they can safely conduct the data

collection operations outlined in the proposed ap plication, the FAA may au thorize the operation.

(5) The certificate holder conducts data collection and analysis (in real time) and submits

results to the FAA.

(6) The FAA validates the certificate holder’s da ta collected and the associated analysis.

(7) The certificate holder submits flightcrew member FRMS operations procedures

supported by the validated data that demonstrates compliance.

(8) The FAA approves the certificate holder’s FRMS operations procedures and methods

for continuous performance improvement.

(9) The certificate holder inserts statements in their operations manual that each

flightcrew member, scheduler, dispatcher, pers on holding operational co ntrol, and any person

having management oversight of these areas must comply with the FAA-approved FRMS

operations procedures where the FRMS is be ing applied to that flight operation or

flight segment.

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FIGURE 2-6. FATIGUE RISK MANAGEM ENT SYSTEM APPROVAL PROCESS

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4. PHASE ONE: PREAPPLICATION , PLANNING, AND ASSESSMENT. The

certificate holder develops plans for a proposed AMOC to the prescriptive rule(s). The plan

should be based upon fatigue modeling data or so me other form of data acceptable to the FAA

that supports the proposed AMOC. The certificate holder will de velop appropriate FRM and SA

processes to identify and document risks and to apply appropriate mitigations to reduce the

likelihood and severity of thos e risks. The certificate holder will utilize the FRM and SA

processes in the development of flightcrew member FRMS opera tions procedures throughout the

FRMS approval process, which will be driven by data and appropriate fatigue analysis methods.

a. Certificate Holder Responsibilities. The certificate holder will develop a data package

to serve as a repository for all collected and analyzed data. Additionally, the certificate holder

will maintain a collection of all amendments to their draft flightcrew member FRMS operations

procedures to illustrate policy and procedural changes, driven by the results of the data analysis and the FRM and SA processes.

b. Objectives. This phase is designed as the platform from which the certificate holder will

present their ideas, assessment, and plans fo r applying for a proposed FRMS authorization.

Phase 1 also serves as the initial meeting betw een the certificate holder and FAA to discuss the

milestones and provide their proposed FRMS pla nning and assessment. The FAA will review the

certificate holder’s proposed FRMS plans, identify the necessary guidance resource documents, and outline the phased authorization process for their proposed FRMS. The four gates in this

phase are designed to give the ce rtificate holder the necessary tools to develop the framework for

their proposed FRMS. The objective of this phase is to prepare the certificate holder for data

collection and ultimately to deve lop their proposed FRMS. The certificate holder should expect

to accomplish modifications to some of th eir submissions required in Gates 1-4.

(1) Gate 1. The certificate holder will:

(a) Perform a needs analysis that defines th e specific operational conditions for which

a proposed FRMS will be applied to justify a devi ation from prescriptive rules and why such an

operation must or should be conducted unde r alternative duty and rest conditions.

(b) Define how proposed operational proce dures will require an AMOC to the

prescribed flight time, duty time, and rest requi rements, citing the specific regulatory section and

the applicable justification.

(c) Describe how proposed operational proce dures will provide sufficient fatigue

mitigations to provide an AMOC to that provided by current prescriptive rules.

(d) Perform a gap analysis to: 1. Identify elements of the proposed FRMS that are already av ailable in existing

systems and process.

2. Identify existing systems and process that could be modified to meet the needs

of proposed FRMS (to minimi ze “reinventing the wheel”).

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3. Identify where new systems and proce sses need to be developed for the

proposed FRMS.

(e) Prepare an FRMS policy statement signed by the accountable executive. Expect to

revise the policy statement between phases and as the proposed FRMS becomes operational. The

policy statement shall:

1. Reflect the shared responsibility of ma nagement, flight and cabin crews, and

other involved personnel.

2. Clearly state the safety obj ectives of the proposed FRMS.

3. Be signed by the accountable ex ecutive of the organization.

4. Be communicated, with visible endorsem ent, to all the relevant areas and

levels of the organization.

5. Declare management’s commitment to effective safety reporting.

6. Declare management’s commitment to the provision of adequate resources for

the proposed FRMS.

7. Declare management’s commitment to continuous improvement of the

proposed FRMS.

8. Require that clear lines of accountability for management, flight and cabin

crews, and all other involved personnel are identified.

9. Require periodic reviews to ensure that it remains relevant and appropriate.

(f) Develop the FRMS documentation plan. Th e certificate holder shall develop and

keep current FRMS documentation that describes and records:

1. FRMS policy and objectives.

2. FRMS processes and procedures.

3. Accountabilities, responsibilities and authorities for these processes and

procedures.

4. Mechanisms for ongoing involvement of management, flight and cabin

crewmembers, and all ot her involved personnel.

5. FRMS training programs, training re quirements and attendance records.

6. Scheduled and actual flight times, dut y periods and rest periods with

significant deviations and r easons for deviations noted.

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7. FRMS outputs including findings from collected data, recommendations, and

actions taken.

NOTE: Expect to revise this document between phases and as the FRMS

becomes operational.

(g) Identify and allocate financial and human resources. The FRMS accountable

executive needs to have the authority and control to ensure th at this happens.

(h) Establish an FSAG, or its equivalent. Define the mission of the FSAG and outline

the roles and responsibilities of each member, along with company resources. The stage at which

the FSAG is established will vary according to the size and complexity of the organization and

the FRMS and whether there are suitably qualified people in other parts of the organization who

are available to begin these activities.

(i) Develop the FRMS communication plan. The current edition of ICAO Annex 6,

Part I, Appendix 8 requires th e certificate holder to have an FRMS communication plan that:

1. Explains FRMS policies, procedures, a nd responsibilities to all stakeholders.

2. Describes communication channels us ed to gather and disseminate

FRMS-related information.

(j) There needs to be ongoing communication to stakeholders about the activities and

safety performance of the FRMS and initiatives to ensure the commitment of all stakeholders.

Communications about the activitie s and safety performance of the FRMS (normally from the

FSAG) need to be clear, timely, a nd credible. The information provide d also needs to be tailored

to the needs and roles of different stakehol der groups, with a minimum of unnecessary or

irrelevant information. The certificate holder should choose from a variety of types of

communication such as electronic media (Web s ites, online forums, and email), newsletters,

bulletins, seminars, periodic poster campaigns in strategic locations, and the like.

(k) Communications from crewmembers are vita l for fatigue hazard identification in

obtaining feedback on the effectiveness of controls and mitigations and in providing information

for FRMS safety performance indicators. For th ese communications to be open and honest, all

FRMS stakeholders need to have a clear understanding of the po licies governing data

confidentiality and the ethical use of information provided by cr ewmembers. Expect to revise

this document between phases and as the FRMS becomes operational.

(2) Gate 2. The certificate holder will:

(a) Develop the FRMS implementation plan. The results of the gap analysis are used

as the basis for the development of the cer tificate holder’s FRMS implementation plan.

Essentially, this provides a roadmap describi ng how the development of each of the FRMS

processes will proceed. Expect to revise this document be tween phases and as the FRMS

becomes operational.

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(b) Develop a fatigue reporting system. A fatigue report is a method for a

flightcrew member to communicate to mana gement personnel (and the FSAG) when they

encounter a nonadverse fatigue event. There should be a clear process outlining how the fatigue

report will be handled to include a Root Cause Analysis (RCA) and fatigue data collection and

retention. The FRMS policy must provide for prot ection of privacy and methods to protect the

employee from adverse actions that would discourage reporting events and conditions

surrounding the events. The process should outline the length of time the data will be retained

and a path to mitigation or manage ment of the fatigue occurrence. Expect to revise this document

between phases and as the FRMS becomes operational.

(c) Develop a fatigue incident reporting system. A fatigue in cident is defined as an

adverse event, in which fatigue is suspected to have been a causal or contributing factor, that

results in an accident, incident, pilot deviat ion or noncompliance with FRMS policies or

procedures. The fatigue incident reporting system is a method by which a flightcrew member

communicates an adverse fatigue event to ma nagement personnel (and the FSAG). Reports of

adverse events that may be attributable wholly or in part to fatigue are similar to crew reports,

and can serve as a mechanism for obtaining a ll relevant information regarding fatigue

contributions to the incident. FRMS policy would define how an adverse event is evaluated for

potential fatigue involvement, as well as de fine a methodology for conducting a detailed RCA.

At a minimum, the incident investigation and reporting process must obtain all the necessary

information to trace the root cause of the incident, especially the potential level of fatigue and the

conditions that contributed to the fatigue-related event. The fatigue reporting policy must protect

the privacy of employees and minimize adverse ac tions that would discou rage reporting events

and circumstances surrounding the events. Expect to revise this document between phases and as

the FRMS becomes operational.

(d) Develop a system for monitoring flight crew member fatigue as part of an overall

FRMS. The data collected provides feedback to the certificate holder regarding conditions

perceived to contribute to fatigue . To maximize the utility of such reports, procedures must be

developed to capture all relevant information, such as the schedule leading up to the fatigue

report, the actions of the employee to obtain re st, subjective and objectiv e evidence of fatigue,

environmental conditions that may have exaggerated or contributed to fatigue , relevant health or

medical conditions, specific actions related to the incident, and communications prior to and

during the event. Expect to revise this doc ument between phases and as the FRMS becomes

operational.

(e) Develop a FRM process and a SA proce ss to identify fatigue risks and apply

effective safety mitigations throughout the data collection process.

(f) Develop a training plan specific to the FRMS. The list below identifies general

FRMS training subjects for the training pla n. In addition to the general subjects, the

certificate holder’s training plan should also include specific subj ects relative to their proposed

FRMS. Expect to revise this document between phases and as the FRMS becomes operational.

Figure 2-7, Fatigue Risk Management System Training Outline, outlines a sample FRMS

training curriculum.

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FIGURE 2-7. FATIGUE RISK MANAGEM ENT SYSTEM TRAINING OUTLINE

1) Overview of the Fatigue Risk Management System (FRMS) concept

i. Definition

ii. Purpose

iii.Structural components

iv.Overview of the certificate holder’s FRMS

v. Relationship between FRMS and Fatigue Risk Management Plan (FRMP)

vi.AC 120-100 Basics of Aviation Fatigue

vii. AC 120-103 Fatigue Risk Management Systems for Aviation Safety

2) Tools for an effective FRMS

i. Fatigue analysis methods

ii. Identification and management of aviation fatigue drivers

iii.Fatigue mitigation approaches

iv.Positive safety culture

3) Components of an FRMS

i. Fatigue Risk Management (FRM) policy

ii. Education and awareness training

iii.Fatigue analysis and reporting system

iv.Fatigue monitoring methods

v. Fatigue related incident reporting process

vi.FRMS performance evaluation

vii. Continuous improvement process

4) Roles and responsibilities

i. Certificate holder responsibilities

ii. Fatigue Safety Action Group (FSAG)

iii.Crewmember/employee responsibilities

iv.Federal Aviation Administration (FAA) responsibilities

5) FRMS Implementation

i. Policies and procedures

ii. Organization and personnel

a) FSAG

b) Other supporting departments and personnel

c) Roles and responsibilities

iii.Tools and methods

iv.Training and awareness

6) Safe scheduling policies and procedures

i. Proactive and adaptive fatigue mitigation

ii. Work schedule oversight and monitoring

iii.Crew augmentation

iv.Unforeseen operational circumstances

7) Records and reports

i. Schedule accuracy

ii. Reports of fatigue by flightcrew members

iii.Fatigue-related events

iv.Records of actions of the FSAG

8) Continuous performance improvement process

i. FRMS performance evaluation

ii. Work schedule modeling and fatigue risk analysis

iii.Management and mitigation of fatigue risk

iv.Assessment, feedback, and corrective action

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(3) Gate 3. The certificate holder will:

(a) Develop a data collection plan following the guidelines described in the FRM

process. Expect to revise this document between phases.

1. Develop an initial data collection plan.

2. Define how the data collection plan w ill establish the effectiveness of the

FRMS.

3. Identify the necessary resources and tools (Actigraph, Psychomotor Vigilance

Testing (PVT), modeling, etc.) (FAA review).

4. Specify study design, timeline for data collection, and context of the study

(FAA review).

5. FAA evaluates the data collection plan for feasibility, completeness, and

credibility.

6. Adjust the plan accordingly (FAA review).

(b) Develop a data analysis plan followi ng the guidelines described in the FRM

process. Expect to revise this document between phases.

1. Describe the initial data analysis plan (FAA review).

2. Based on the proposed sleep and performance measures, define safety

standards that will be used to evaluate th e effectiveness of the proposed operation under

alternative duty and rest conditions.

3. Describe how the data analysis plan will support the eff ectiveness of the

FRMS based on those safety standards.

4. Describe how these data will be used to establish an AMOC.

5. Identify the necessary resources and data analysis tools (FAA review).

6. Specify study design, timeline for data an alysis plan, and context of the data

output.

7. Justify the proposed safety standards for establishing effectiveness of the

FRMS and the validity of the data collection and analysis plan to establish that the proposed

FRMS meets those standards (FAA review).

8. Adjust the plan accordingly (FAA review).

(c) Design and develop plans for proposed data collection flights in accordance with

the proposed FRMS policy statement that will be used for data collection.

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1. The data collection plan information shall outline the following operational

parameters and indicate to what extent th ey will exceed prescriptive flight time and duty

limitations:

 Pre- and post-rest duty requirements,

 Start time (acclimated) of the FDP,

 Start time (unacclimated) of the FDP,

 Flightcrew complement (number of p ilots) and unbiased method to select

voluntary study participants,

 Predominant direction of flight (north, south, east, or west),

 Duration of the proposed FDP,

 Length of total flight time,

 Maximum proposed flight deck duty pe riod for each flightcrew member

during that FDP,

 Number of planned theater crossings,

 The number of flight segments and the timing of the takeoffs and landings

for acclimated and unacclimated flightcrew members,

 Provisions for layover rest, and

 Number and class of installed onboard rest facilities.

2. Consider and compensate for the length of typical delays.

3. If required, propose a petition for exemp tion for the data collection operation

based upon the data collection plan. If an exemption is required, the FAA will impose applicable

safety limitations and conditions asso ciated with the proposed exemption.

4. If required, the certificate holder will file a petition for exemption. If granted,

the exemption will be limited in duration to collect the data.

(4) Gate 4. The certificate holder will:

(a) Define the scope of the data collection requirement utili zing the guidelines

described in Section 4. In additi on, the certificate holder shall satisfactorily demonstrate that all

data collection flights can be safely conducted u tilizing the processes outlined in the FRM and

the FRMS SA sections of this appendix The plan shall, as a minimum, accomplish the following:

1. Develop flightcrew member operational procedures based upon FRM

processes and SA processes for operations where FRMS will be applied.

2. Develop an in-flight rest scheme for flightcrew members operations on the

data collection flights. Define target sleep patterns for in-flight rest.

3. Develop pre- and post-FDP re st schemes for the data co llection flights. Define

target sleep patterns for pre- and post-duty rest periods.

4. Develop any special procedures specifi cally applicable to the planned data

collection flights.

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5. Provide a list of aircraft that will be authorized for data collection by make,

model, and series (M/M/S), to include a descrip tion (class) of the installed onboard rest facility.

6. Develop procedures for situations wh en an operating flightcrew member

becomes fatigued in-flight and mitigations to reduce the flightcrew member’s level of fatigue.

(b) Develop FRMS processes based on reactive hazard identificati on, including risk

assessment and the development, implementation, and monitoring of appropriate controls and

mitigations based upon the planned data collection flights.

1. Identify hazards, risk assessment, risk mitigation, SA process, and promotion

process based upon the planned data collection flights.

2. Verify that FRMS documentation pro cesses are established to support the

current version of the FRMS.

3. Verify FRMS training program activities are established to support the current

version of the FRMS. (Stakeholders need training to ensure that they are competent to undertake

their responsibilities in the FRMS as the implementation plan rolls out.)

4. Develop a method for exclusively retain ing all FRMS training records and

implement that process.

5. Verify FRMS communication processes ar e established to su pport the current

version of the proposed FRMS.

5. PHASE TWO: FORMAL APPLICATION. Upon satisfactory completion of Gates 1–4,

the certificate holder may pro ceed to Phase Two. This phase involves the certificate holder

submitting all their formal documentation (as requir ed in Gates 1–4) to the FAA as outlined in

Gates 5 and 6. The FAA will evaluate and validate the certificate hol der’s documentation. Upon

satisfactory completion of Gates 5 and 6, the ce rtificate holder may proceed to Phase Three.

Based upon the certificate holder’s proposed AM OC, the certificate holder will develop and

submit a proposed data collection plan and a data analysis plan for review, evaluation, and

validation. The data collection plan will outlin e the resources and methods for collecting all

measurements. The data analysis plan will descri be the method(s) for analyzing the data and how

the results will be applied to evaluate the effec tiveness of the FRMS. At this stage, the primary

focus for the FAA will be to determine that the data collection operation can be safely

conducted. Secondly, the FAA will eval uate the effectiveness of the data collection plan and the

data analysis plan. The certificate holder will revise, as necessary, thei r operational procedures

for data collection, which will be reviewed and evaluated by the FAA prior to authorizing the certificate holder to collect da ta. The certificate holder will also revise the operating manual to

direct flightcrew members, schedulers, dispat chers, personnel holding operational control and

persons having direct management oversight of these areas to comply with the FRMS operation

procedures whenever the FRMS is applie d to a flight or series of flights.

a. Gate 5. The certificate holder will provide docum ented evidence of the following items,

which will be reviewed, evaluated and validated by the FAA:

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 Formal FRMS policy statement.

 Formal documentation plan.

 Formal communications plan.

 Formal training plan.

 Formal implementation plan.

 Formal description of flightcrew member fatigue monitoring process.

 Formal reporting process to include fatigue reporting and fatigue incident reporting,

which will include RCA.

 A performance evaluation process to suppor t continuous improvement of the FRMS.

 Formal documentation of the data collecti on and analysis plan to support the policy

statement.

 That roles and responsibilitie s for ensuring the safety pe rformance of the FRMS are

developed, to include the roles a nd responsibilities of the FSAG.

 That the necessary communication channels are active.

 That FRMS processes based on reactive, proactive, and predictive hazard

identification are operational, including ri sk assessment and the development,

implementation, and monitoring of appr opriate controls and mitigations.

 That FRMS documentation processes have been established to support the current

version of the proposed FRMS.

 That FRMS training activities have been es tablished to support the current version of

the proposed FRMS.

 That FRMS communication processes have been established to support the current

version of the proposed FRMS.

b. Gate 6. The FAA will review, evaluate, and validate the following:

 FRMS safety performance indicators ha ve been developed and agreed on.

 Formal statement of how the FRMS will demonstrate an effective AMOC.

 The procedures and processes for periodi c evaluation of the safety performance

indicators have been established.

 Appropriate feedback has been establis hed between the FRMS processes and the

FRMS SA processes.

 FRMS documentation processes are fully implemented.

 FRMS training processes are fully implemented.

 FRMS communication processe s are fully implemented.

 Processes for monitoring the effectiveness of controls and mitigations are fully

implemented.

6. PHASE THREE: DOCUMENTATIO N AND DATA COLLECTION PLAN. Upon

satisfactory completion of Gates 5–6, the certific ate holder may proceed to Phase Three. The

certificate holder will provide the FAA with their planned data collectio n flight information.

a. Overview. During this phase, the FAA will evaluate the certificate holder’s data

collection plan and all their documentation outlining their policies and pro cedures to support all

flight operations during data co llection. Upon satisfactory completi on of Gate 7, if required, the

certificate holder will be authorized by exemp tion to collect data for their proposed FRMS.

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b. Gate 7. The FAA will:

(1) Assess and model the proposed data collection flight plan information to determine

the anticipated levels of fatigue.

(2) Evaluate the certificate holder’s documentation outlining their policies and

procedures to support all flight operations during data collection.

(3) Determine whether the certificate holder’s proposed FRMS can demonstrate an

effective AMOC.

(4) Assess any fatigue modeling analysis of the proposed AMOC if any part of the

justification is based on modeli ng. The FAA will review justification of the modeling choice and

all modeling assumptions, parameters, and ini tial conditions, including the modeling safety

standard that serves as the ba seline for evaluation of fatigue or performance estimates under the

FRMS operation.

(5) Validate and authorize data collection and that the data collection and analysis

method will be sufficient to demonstrate an effective AMOC. The FAA will evaluate the data

collection and analysis plan base d on the guidelines described in the FRM process. Collect and

analyze data.

(6) Evaluate policy, documentation, procedures, and processes.

(7) Evaluate safety performance indicators and provide input.

(8) Evaluate proposed FRMS policy and documentation, along with processes and

procedures.

(9) Evaluate the FRM process and SA, base d on the guidelines provided in the SA

process.

(10) Upon satisfactory evaluation and validation, approve the proposed data collection

flight operation information.

(11) Issue applicable exemption with specific limitations and conditions for the data

collection flight operation.

(12) With the certificate holder, establish, agree upon, and document reporting intervals.

(13) The certificate holder is then ready for data collection.

(14) If required, the FAA authorizes the certifi cate holder through an exemption to collect

data for a specific duration.

7. PHASE FOUR: DEMONSTRATION AND VALIDATION. The certificate holder will

collect and analyze the data. The data collected and analyzed will be compiled into a data

package. Throughout this process, the certificate holder will also collect and analyze other data,

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such as fatigue reports, and will compile these data with the data package. Once all the data have

been collected, analyzed and compiled in the data package, the certificat e holder will submit the

data package to the FAA for review and validation.

a. FRMS Procedure Revisions. Additionally, the certificate ho lder will revise their FRMS

operational procedures, as necessary, in support of the data analysis outcomes. Upon successful

validation of the data, the FAA will review and evaluate the certificate holder’s FRMS operation

procedures to ensure that these procedures suppo rt the validated data an alysis. If required, the

certificate holder may be required to revise their FRMS operation proced ures to support the

validated results.

b. Data Package Submission. Upon completion of Gate 8, the certificate holder will submit

the data package to the FAA for evaluation a nd validation. The FAA will validate the data and

evaluate the certificate holder’s policies, procedures, and processes to ensure that the

certificate holder’s proposed FRMS meets an AMOC. Upon satisfactory completion of Gate 8,

the FAA will prepare the appropriate OpSpec A318 for use of that FRMS flight operation with

specific limitations and conditions based upon the cer tificate holder’s policies, procedures, and

processes.

c. Gate 8.

(1) The certificate holder will prepare a complete review and analysis of the results of the

data collection with specific emphasis on how the data confirm that the alternative operation

outside the prescriptive rules provides an effec tive AMOC with safety standards. The collection

and analysis of data should follow the guideline s described in the FRM process. Collect and

analyze data.

(a) Describe the aggregate findings from each of the measures specified in the

proposed data collection plan.

(b) Provide specific information on how the results relate to the defined safety

standards established in the data collection plan.

(c) Show how the results establis h the effectiveness of the proposed FRMS relative to

operations conducted under the prescriptive rules.

(d) Identify any evidence of excessive fatigue discovered in association with the

proposed operation and how this fatigue is mitigated so that the proposed FRMS will

demonstrate effectiveness and compliance.

(e) Adjust the data collection plan accordingl y and provide the FAA with evidence of

the effectiveness of any proposed mitigations (FAA approval of amended mitigations to the

proposed FRMS).

(f) Amend the proposed FRMS polices, procedures and processes, as required, to

support their revised FRMS.

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(2) The FAA will evaluate the validity of the data analysis results and determine if the

results demonstrate the effec tiveness of the proposed FRMS operation as an AMOC. The FAA

will determine if the data provided are adequate for demonstrating the effectiveness of the

proposed FRMS and will request ad ditional details, as necessary.

(3) The FAA will evaluate changes to the certificate holder’s amended policies,

procedures and processes to determine if the am ended policies, procedures, and processes will

support an AMOC.

(4) The FAA will do one of the following:

(a) Approve the proposed FRMS operation and issue an OpSpec A318; or

(b) Disapprove the proposed FRMS and reco mmend changes for a revised FRMS

application package.

8. PHASE FIVE: AUTHORIZATION, IMPLEMENTATION AND MONITORING.

a. FAA Authorization. Upon satisfactory completion of th is process, the FAA may grant

authorization to operate in accordance with the FRMS flight operation by issuance of

OpSpec A318.

b. FRMS Operations Manual. Lastly, the certificate holder will amend their FRMS

operations manual to direct flightcrew member s, schedulers, dispatchers, personnel holding

operational control, and persons having direct management oversight of these areas to comply

with the FRMS operation procedures whenever the FRMS is applied to a flight or series of

flights.

c. Gate 9.

(1) The FAA issues OpSpec A318.

(2) The FAA approves a phased implementati on of the proposed FRMS operation.

(3) The FAA approves an ongoing SA process to monitor the conti nued success of the

FRMS operation (refer to the guidelines outlined S ection 6). This process will specify courses of

action that will be taken if reports of fatigue occur under the FRMS operation, including a

process for informing the FAA and a process to ensure safe operations while effective fatigue

mitigations and associated policies ar e implemented for the FRMS operation.

(4) The FAA determines the duration of OpSpec A318.

(5) The FAA establishes a regular audit schedul e (at a minimum, quarterly for the first

24 months of operations) to ensure that fatigue reports and othe r safety indicators support the

effectiveness of the FRMS operation.

(6) The certificate holder provides the FAA with all monitoring data at the specified

intervals for evaluation.

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(7) The FAA approves the certificate ho lder’s FRMS implementation plan.

(8) The certificate holder develops a method to declare those flig hts operating under an

FAA-authorized FRMS.

(9) Unless otherwise specified, for the purpos e of continuous monitoring, the certificate

holder will comply with the fo llowing reporting intervals:

 First year: quarterly.

 Second year: quarterly.

 Third year: semi-annually.

 Fourth year and beyond: annually.

NOTE: Under extraordinary conditions, based on the frequency of the

proposed FRMS operations, alternative reporting intervals may be required.

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