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Managing fatigue, not fighting it

Inside a critical issue on the Transportation Safety Board Watchlist

July 15, 2019  By Missy Rudin-Brown |

One third of Canadian adults indicate they sleep less than the recommended seven to nine hours per night, according to a 2017 Statistics Canada study. Fatigue is pervasive in our modern societies, which rely on 24/7 industries like transportation. Insufficient quantity or quality of sleep degrades aspects of human performance in ways that may lead to accidents. In the transportation industry, fatigue is even more likely because of challenges to the human body’s circadian (daily) rhythm caused by shiftwork and travel across time zones.

Fighting fatigue when it occurs is better than doing nothing, but managing the risks for fatigue before it occurs is much safer. This is why Fatigue Management in Rail, Marine and Air Transportation is on the Transportation Safety Board (TSB) Watchlist 2018. In the transportation industry, crews often work long and irregular schedules – sometimes in challenging conditions or crossing multiple time zones – that are not always conducive to getting sufficient restorative sleep. As a result, the TSB has identified sleep-related fatigue as a contributing factor or a risk in at least 90 occurrences since the early 1990s – 43 of them in the aviation sector.

Perhaps the most-recent, high-profile occurrence involving fatigue took place in July 2017 at San Francisco International Airport (SFO), when an Air Canada flight cleared to land on runway 28-A lined up instead at the adjacent, parallel taxiway. The aircraft was just 100 feet above the ground when the crew recognized the situation and initiated a go-around. Meanwhile, below them, four other aircraft were lined up on that same taxiway, awaiting departure. The investigation found that minimum separation between the occurrence aircraft and those on the taxiway was between 10 and 20 feet.

The subsequent investigation into that near miss, and the report by the U.S. National Transportation Safety Board (NTSB), found that the aircraft’s captain and first officer were both fatigued “due to the number of hours that they had been continuously awake and [to] circadian disruption.” The captain – a reserve pilot – had been awake for more than 19 hours and the first officer for more than 12. The report also found that Canadian regulations at the time did not always “allow for sufficient rest” and could result in “pilots flying in a fatigued state.” Among the subsequent recommendations was one for Transport Canada to revise its regulations “to address the potential for fatigue for pilots on reserve duty who are called to operate evening flights that would extend into the pilots’ window of circadian low.”


In December 2018, Canada’s Minister of Transport, Marc Garneau, announced that changes to Canada’s flight and duty time regulations had been finalized. Those changes introduce lower limits on annual, monthly, and weekly flight times, as well as reduced duty-time maximums.

Although it remains to be seen what effect these new measures will have, the Watchlist makes it clear that other steps are needed. More specifically, Canadian air operators must implement Fatigue Risk Management Systems (FRMS) to address fatigue-related risks specific to their operations.

What will these systems look like? Well, they will require a profound change in how companies, their managers, employees and even their families, think about fatigue so that the risks can be minimized.

First, all employees in safety-sensitive roles must be made aware of the risks of fatigue and how to minimize its effects. Whether through education or awareness training, employees need to understand what can happen if they work when fatigued. They also need to know what factors can make it worse; and what countermeasures might make it better.

Second, employers and operators need to develop a FRMS plan – and not just a general plan, either. It won’t cut it to just tell employees, “Get more rest.” Rather, the plan must be specific to the elements that create or exacerbate fatigue within their specific operations.

In the meantime, TSB will continue to look for signs of fatigue and its effects on human performance – in all occurrences it investigates. Where we identify that progress has been made to combat the risks of fatigue, we’ll be sure to say so. Where more still needs to be done, we’ll say that too. The safety of passengers everywhere, people on the ground and, indeed, the entire aviation community, depends on it.

Missy Rudin-Brown, Ph.D., CCPE, is a senior human factors investigator and the Manager of the TSB’s Human Factors and Macro Analysis group.


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