Fatigue Risk Management integrated within a Management System

Captain Simon Stewart SMS Development Mgr Deputy Director Safety & Security

Some Facts
1995
1 base 3 airports 2 routes 2 leased aircraft Virtual airline!

2008
20 bases 103 airports 26 countries 398 routes 165 aircraft 39 million pax 7000 employees

Safety through intelligent risk management

Safety is our business 4 Everyone committed to maintaining a safe and secure operational environment for our customers, our staff, and our shareholders 4 Our goal is more that just regulatory compliance, our focus is proactive risk management, underpinning the needs of the business

in line with increased crew utilisation, the overall operating environment has become significantly more complex, leading to an increase in levels of operational risk.
UK Civil Aviation Authority 2007

EU Ops compliance is not enough

Maintaining regulatory compliance and operating safely

easyJet has continued to lead the Total System Safety field in SMS

Administrative Regulation The Regulatory environment has Binary regulation. changed EASA has arrived You are either in compliance or you are not. Domain of the quality department easyJet is shaping the future of safety management in aviation

Performance Regulation Integrated management and safety system Domain of the SMS Provides risk transparency to management and the regulator

Just Culture

Management System Model

QA or Safety Management Systems Simplest form - closed loop management system

Plan to do something Plan Take actions to improve Act as required

easyJet

Do the thing Do you planned

Check Check what you did worked as planned

Safety Management System Model

Management Review Safety Performance Measurement Remedial Action Investigation and Follow-up Incident reports Safety Monitoring Verification and Audit Communication Review Communication
Active Safety Management

Business Principles & Safety Policy Corporate Strategy

Safety Objectives Safety Plan Operational Standards Competence and

Plan Feedback Culture Check Do

Accountability Line Management of Operational tasks Risk Assessment Risk Management

We manage risks inherent in the system

Key risks: 4 Cultural differences 4 Operational environment 4 Crew experience gradients 4 Fatigue
System Risk Assessment & Process Analysis

easyJet SAFETY RADAR

System Defence

Analysis
Strategic Decision Making

Tactical Decision Making

Organisational Learning

SIRA

SAFETY ENGINE

Self- Regulation

Safety Culture policy

4 In order to develop organisational learning easyJet promotes a just culture within which it is accepted that people who undertake actions, make decisions or allow omissions, taking into account their training and experience, are not punished when the desired outcome is not achieved; but where gross negligence, gross misconduct and destructive acts are not tolerated.
4 I believe that in formulating this statement of easyJet Safety Policy we build on and reflect our commitment to the Five Pillars of easyJet Policy that our corporate goals are best achieved through embodying the principles of : 4 Safety Integrity Teamwork Passionate Pioneering

Policy Implementation
easyJet will maintain an evidence-based Safety Management System that proactively and continuously delivers safety effectiveness and operational integrity within a risk controlled environment.
4 4 4 4 4 4 4 Effective reactive response to incidents; Proactive risk analysis to maintain system integrity; Risk trending that evaluates control strategies; Explore system risks for future business strategy; Real time knowledge of System Dynamic Risk; Communicate dynamic risk state in standardised format; All management levels have clear understanding of system risk.

This requires the establishment of an open framework of linked databases

Tactical and strategic risk oversight

Sensory Network
Risk Precursor examples Rostering Environment Route risk Individual differences
C O N T R O L

Risk Assessment
Detection Notify & Inquire

Hazardous Event/s

C O N T R O L

Reactive Proactive Exploratory Evaluative Time critical

Risk

Risk Management

Adjust system

Fatig ue: Balancin g Hazardsand against Ope rational criteria Crite ria in Pursuit of Comme rcial Obje ctives Balancing operational criteria performance in pursuit of commercial objectives
Gen eric Hazard s
Co mmercial Objectives

Balan cing Hazards

Safety Criteria Oper ationa l Criteria

Airline H azard s
Fatigue Safe ty Mana gem ent System

Where does FRMS operate in the business

SIRA

What You Can See You Can Avoid

How do you measure detect and investigate fatigue?

Encode, Risk Classification & notify Incidents & Safety Performance information
D D E E E C D D E E B C C D E A B C C E A B B C D

Organisational learning
Risk Threshold Events Feedback to individual and organisation

Investigation
Hazard investigation

All Events

Data Analysis
(Including sample data extrapolation and frequency consideration) Undesirable indications

All Data

Risk Mgt Risk Assessment

identified hazards from investigations and adverse trends

Stakeholder decisions against risk treatment options

Implementation Actions
Monitor, track & evaluate actions

reactive

Significant Hazards

Proactive assessment of Significant changes to system or operations

HAZID/OP Analysis

Risk Performance Reporting

(Historical trends and predictions) Day to day and strategic risk trends

easyJet SIRA-ECAST safety cycle 2008

Fatigue Risk Detection

EVENTS are risk triaged by the Safety Data Team

Reasonable worst case potential consequences Major accident with significant loss of life Limited accident sceanario with limited loss of life Minor accident with some injuries and damage Degradation of safety margins but with little consequence Defences that avoided consequences

Event Category and Risk Value

D 15 D 12 E8 E1
Normal Intervention

C 50 C 40 E 10 E5
Non-normal safety nets

B 85 C 60 D 30 E

A 100 B 90 C 60 D 15

Increasing 10 Trust/Accountability
Abnormal human intervention

Providence

Fatigue Events: Example fatigue report form data representation

Fatigue Indicators Commute LT Trend 12 month chart April Prev month 3 month 12 month

APRIL CONTRIBUTORS TO FATIGUE (AS % OF TOTAL FRFs RECEIVED FOR MONTH)

3 3 3 3

8%

7%

5%

6%

Delay(s)

31%

21%

24%

27%

Early Start Time

8%

38%

22%

28%

Early to Late Transition

8%

21%

14%

10%

Health

8%

10%

8%

7%

Home Issues

8%

10%

12%

17%

Home Rest

Crew cited contributors to fatigue

31%

14%

23%

24%

Hotel Rest

38%

17%

20%

12%

Insufficient Rostered Rest Time 31% Late Finish 38% Late to Early Transition 28% 32% 29% 24% 28% 26%

8%

0%

3%

4%

Long Duty Day 54% Long-Term Fatigue 55% 59% 54%

23%

31%

20%

16%

Positioning

8%

21%

16%

9%

Roster Disrutpion 38% 24% 26% 23%

Survey data is reviewed as part of data collection

SurveyDatacollectedandanalysed
For each day of the roster Severity of fatigue Frequency of fatigue-related performance impairment Fatigue risk (severity x frequency) Duration of sleep Frequency of naps Duration of naps Contributors to fatigue 5 most influential contributors identified Severity of fatigue caused by each contributor Frequency with which each contributor causes fatigue Risk (severity x frequency) Other Demographic data including age, base and experience Roster preference

Morningness/eveningness Commute Crews comments and suggestions

EVENTS will be investigated, systemic causal factors analysed

SIRA Investigation process
Event detection Sensory network Case based reasoning: reuse (in context) similar event investigation findings in AQD?
N Y

Classification risk grading & notification

SME triage

Define scope, context & investigation team; Document risk keywords/event

Select investigation tools for investigation context & apply

N

Toolbox directory Tool Context People Task output

Secure information: Data gathering, tabulation against scope Event & conditional factor analysis

Is safety report accurate?

Document & rank systematic causal factors & recomendations from investigation

Review AQD investigations & actions for risk keywords per event category

SIRA Strategic & tactical decision process against risk treatment options (cost and impact)

Allocate, communicate, implement, evaluate

TU Delft, Lund, City Universities 2008

Example tool: Control Change Analysis

NRI-TUDELFT

Bowtie Model: Barriers and controls of fatigue risks are examined

Identify
Hazard

assess

Hazardou s or Top Event

control

recover

Example Fatigue Investigation Findings

Fatigue Investigation Results - Example
Block Structure Operational Hassle Factors Contributed to Symptoms of Fatigue Inadequate rest (FAID) Transition Commute Elongated Duties Sub-Optimal rest periods Roster Disruption Home Issues Hotel Rest High Cumulative Hours Positioning of SIM duties Health Night Stops 0 5 10 15 20 25

How do you manage fatigue risk?

FRMS Team will allow management to assess options and rank risks for continuous improvement People, environment, assets, reputation
Frequency Consequence A Severity People Environment Assets Reputation
Never heard of in industry

B
Has occurred in industry

C
Has occurred in company

Occurs several Occurs frequently times per year in in company company

No injury

No effect

No damage

No impact

Slight Injury

Slight effect

Slight damage

Slight impact

Manage for continuous improvement

Minor injury

Minor effect

Minor damage

Limited impact

Major injury

Localised effect

Localised damage

Considerable impact

Incorporate risk reduction measures

1-3 fatalities

Major effect

Major damage

National Impact

Intolerable

multiple fatalities

Massive effect

Extensive damage

International impact

We manage the risks inherent in the system

Director Safety and Security Board

Safety Review Board Airline Safety Action Group Departmental Safety Action Group

Risk Transparency

Chair: CEO

Chair: AOC Accountable Manager Chair: Post Holder

Just Culture

Risk Management
The Risk Zone The broader the triangle to bigger the risk
Intolerable region The risk is unacceptable and requires improvement action If the risk can be mitigated, it is acceptable. Risk reduction should be supported by a cost benefit analysis.

Towards As Low As Reasonably Practicable

ALARP
Acceptable region Tolerable region

The risk is acceptable as it currently stands

-Technical feasible
-Reasonable to do -Affordable

Decision making process

Structured decision making process (after Failing et al., 2007)

ALARP Model
Reducing Risk Increasing Costs $$

Optimal Point ALARP Contracted Requirement A step to Far

Gold-plating Level Screening Level Tolerability Level Mandatory Level

Company Standards

Compliance with

Regulations

Best Practice

easyJets fatigue management cycle

Achieving commercial objectives

Safety Performance Criteria

Operational Performance Criteria

easyJet Key Performance Indicators

4 easyJet operates 25,000 Flights per month and has a safety occurrence reporting rate of 45 per 1000 operated sectors against an industry standard of between 2025/1000 sectors. Of this Fatigue reporting rate is between 50-60/month. This reflects a strong safety cultural environment amongst our crew. 4 The safety department has 100% Flight Data Monitoring capture rate for systematic proactive operation oversight. FDM event traces support Fatigue event investigations. 4 easyJet FRMS KPIs are linked to rostering and operational performance. They include roster fatigue modeling risk rating, duty discretion, rostering violation reporting, roster stability, air safety reports (fatigue contributors), fatigue reporting rate, commute risk events (domestic & international), roster workload risk events, transition duty changes and crew error events (fatigue antecedent contributors) 4 The airline reviews strategic safety performance against an overall computed risk value combined from Flight, Ground and Engineering operations. This is compared to a reference value so we can detect strategic practical drift and adverse tactical trends.

Informing the decision making process

This system will enhance the CEO and executive teams ability to keep their finger on the risk pulse of the easyJet operation

SRB/AMB can make timely and better informed decisions

We can target risk with laser accuracy and cost effectiveness, minimising our risk signature

Safety Protection & Cost Benefit

Indirect Cost Benefits of Safety

Insurance Premium linked to risk signature

Regulator fees Linked to oversight Requirement of business model

Process optimisation with evidenced safety protection Lean Initiative Kaizen/6 sigma

Self-governance with effective SMS capability

easyJet continuing to invest in safety

easyJet strives to remain at the cutting edge of risk management capability to meet easyJet operational risk oversight and future regulatory requirement

4 Our strategic partners: 4 Regulators 4 Rule Makers 4 EU HILAS programme 4 NASA 4 Academic Institutions