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EP32: Navigating fatigue risk with the defences in depth approach · Safe As Podcast

• 0:06
  Fatigue is bad. I'm OK.
• 0:08
  Well, not really, but let's jump into a paper from Dorset and
• 0:12
  Mcculloch's Fatigue, Defences and Death Framework, published
• 0:15
  in their 2005 paper called Managing Fatigue.
• 0:18
  It's about Sleep in Sleep Medicine reviews.
• 0:23
  As the title may have given away, fatigue really is about
• 0:26
  sleep. Today we're talking about
• 0:28
  cognitive or mental fatigue, which isn't just about being
• 0:32
  tired, but it generally is intimately connected with sleep
• 0:35
  and circadian factors. These are the structured means
• 0:38
  to address occupational fatigue risk quickly.
• 0:42
  They conceptualise A fatigue related incident as the final
• 0:45
  outcome of a causal error trajectory.
• 0:48
  It would make more sense if you actually saw a picture they have
• 0:51
  in their paper. An effective fatigue risk
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  management system establishes multiple layers of defences
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  across 5 levels to manage risk proactively.
• 1:00
  Level 1 is the level of sleep opportunity or the average sleep
• 1:04
  obtained of employees. This ensures rosters and
• 1:07
  schedules provide adequate opportunity for employees to
• 1:10
  obtain sufficient sleep. Not necessarily to get
• 1:13
  sufficient sleep, but they're afforded the opportunity.
• 1:17
  So interventions would be implementing prescriptive hours
• 1:20
  of service rules like maximum shift and minimum break
• 1:23
  durations, using fatigue modelling to assess if the work
• 1:27
  patterns adequately limit waking time and provide enough sleep
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  opportunity Level 2. This is the actual sleep
• 1:36
  obtained. So this determines if an
• 1:38
  individual actually obtains sufficient sleep despite the
• 1:41
  opportunity. This addresses factors like
• 1:44
  personal choices or sleep disorders.
• 1:47
  For interventions, you can use things like the prior sleep and
• 1:50
  wake models or other sorts of sleep and fatigue estimation
• 1:53
  tools. This could be where employees
• 1:56
  track their own sleep levels and organisational interventions to
• 2:01
  assess fitness for work. For instance, if workers have
• 2:06
  had less than five hours sleep in the prior 24 hours and less
• 2:11
  than 12 hours sleep in the prior 48 hours, or have been awake for
• 2:15
  longer than the amount of sleep obtained in the prior 48 hours,
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  they're almost certainly at a higher risk of fatigue.
• 2:22
  Level 3 behavioural symptoms. So the focus here is identifying
• 2:27
  individuals exhibiting fatigue related symptoms or behaviours
• 2:31
  when the other proceeding controls fail.
• 2:34
  So interventions could be using symptom checklists or subjective
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  fatigue scales, having people put up their hand and report
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  that they feel tired. These are typically over
• 2:44
  utilising organisations, these types of behavioural symptom
• 2:47
  interventions, even though they're really nowhere near the
• 2:50
  most effective level 4 fatigue related errors.
• 2:54
  Now this leverages this idea of fatigue proofing, which I'll go
• 2:57
  into more detail shortly. The focus here is identifying
• 3:01
  near misses, so performance variability and errors and
• 3:05
  whatnot which haven't actually led to an incident yet.
• 3:08
  Things that could be done at this level include error or task
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  analysis, learning from normal daily work, things like that to
• 3:14
  actually help ensure that these errors in this performance
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  variability don't actually progress through to full
• 3:20
  incidents without actually fully lose control of the process.
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  Level 5. The actual incidents, fatigue
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  related incidents. This is the final outcome.
• 3:28
  A fatigue related incidents actually occurred or at least an
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  incident that's been substantially influenced by
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  effects of fatigue interventions.
• 3:35
  Probably not too surprising. A robust incident analysis and
• 3:39
  investigation procedure really to understand why all the prior
• 3:42
  defences failed. How did it actually get to this
• 3:45
  stage? In a later paper they discussed
• 3:48
  this idea of fatigue briefing. Fatigue proofing refers to
• 3:52
  informal adaptive behaviours workers spontaneously employ to
• 3:56
  reduce fatigue related risk while working.
• 3:58
  Fatigue. This is just fatigue.
• 4:00
  It's been found in other areas like firefighters and whatnot
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  will employ these types of self protective behaviours.
• 4:07
  In any case, it aligns really nicely with some of the adaptive
• 4:10
  philosophies like safety tool and resilience engineering where
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  we try to build resilience skills into our workforce and
• 4:17
  the environments we work in and the capacities to fail safely.
• 4:21
  These are typically not part of formal safety management systems
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  and approaches. They tend to hide in the shadows
• 4:28
  for Some of the suggestions around fatigue proofing could be
• 4:31
  task related strategies like slowing the task down, reducing
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  the pace of the workflow, task buffering, building an extra
• 4:40
  time or space for error correction, double checking or
• 4:43
  cross checking, checking one's own work or seeking cheques from
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  colleagues. Supervisors providing extra
• 4:48
  supervision when it's needed. Behaviour based strategies like
• 4:53
  task verbalization, talking out loud to to yourself or to others
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  to detect issues and errors and increases in social interaction,
• 5:02
  engaging in non task dialogue or teasing and joking behaviour to
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  improve alertness. They actually found this in some
• 5:07
  studies where people when they're under fatigue states
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  will close off to banter, dialogue or jokes or just give
• 5:14
  weird responses to questions. So they use jokes and they tease
• 5:18
  each other to actually check in to see how people are tracking.
• 5:22
  Anyway, that's it. In this quick aside, check out
• 5:24
  the paper and let me know how you go about managing fatigue.
• 5:28
  Thanks everyone.