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In This Issue Research The link between fatigue and safety The challenges and opportunities of technological approaches In the news Air Traffic Controller Follow-up Alliance Partner News Products and Services Evaluation Software Download Fatigue Audit Software Special Offer Contact Us InterDynamics Pty Ltd +61 2 9975 6925 Alliance Partners Archives |
Welcome to Focus on Fatigue, the official FaidSafe® newsletter Welcome to Focus on FatigueFirst we present the report on the recent grounding of the Shen Neng 1 in the Great Barrier Reef by the Australian Transport Safety Bureau. The report is a reminder of the dangers of fatigue and of the need to have effective fatigue management systems in the transport sector. During the investigation it was found that the ship's chief mate was engaged in a navigational watch at the time of the grounding. In the 38 1/2 hours preceding the incident, he had had only 2 1/2 hours' sleep. A succession of errors in procedure leading to the grounding was traced to the chief mate's fatigue by the ATSB. Errors included his failure to check times for altering the ship's course, relying on an inappropriate course chart, forgetting that the course alteration point had been changed on the paper chart but not entered into the GPS route plan, and relying on the warning systems of the GPS, which were rendered ineffective due to the amended route plan. Not only does this highlight the risk to the safety of the people on board, there is also the environmental impact that occurred due to the location of the incident. In this newsletter we also highlight some recent journal articles on fatigue and its links to injury prevention – you will find all the links to these articles in this newsletter plus recent news articles on fatigue and updates from our alliance partners. If you wish to unsubscribe from our newsletter, please click the unsubscribe link at the bottom of this email. Thank you for your continued support! Work safely. Fiona Johnston Run into the ground; dog tired and dangerous: An update on the Final Report of the Australian Transport Safety Bureau into the Shen Neng 1 incidentBy Michael Tooma and Sophia Christou The report of the Australian Transportation Safety Bureau (ATSB) into the grounding of the Shen Neng 1 provides an important reminder of the need to manage fatigue in the workplace. On 24 March 2010, the Chinese registered bulk carrier Shen Neng 1 ran aground on Douglas Shoal. The shoal is part of the Great Barrier Reef, a declared world heritage marine park (and the largest World Heritage area in the world) off the coast of northern Queensland. At the time of the grounding, the carrier was transporting 68,000 tonnes of coal from Australia to China. During the incident, the ship's hull was damaged, resulting in the loss of approximately 2 1/2 tonnes of fuel into the sea. The salvage operation following the incident lasted 2 months, after which the ship was towed back to China. An investigation into the incident by the ATSB culminated in its Final Report, released in April 2011. The Report made a number of recommendations in line with its findings; these were directed to the ship's management company, Tosco Keymax International (TKI), and to the Australian Maritime Safety Authority. Recommendations to TKI focused upon:
Lack of fatigue management plansThe absence of fatigue management guidelines in the ship's Safety Management System (SMS) was found by the ATSB to be a significant contributing factor to the incident. The ship's chief mate was engaged in a navigational watch at the time of the grounding. In the 38 1/2 hours preceding the incident, he had had only 2 1/2 hours' sleep. A succession of errors in procedure leading to the grounding was traced to the chief mate's fatigue by the ATSB. Errors included his failure to check times for altering the ship's course, relying on an inappropriate course chart, forgetting that the course alteration point had been changed on the paper chart but not entered into the GPS route plan, and relying on the warning systems of the GPS, which were rendered ineffective due to the amended route plan. The incident provides a stark reminder of the dangers of fatigue. What pressures led to the chief mate's fatigue?In comments to the ATSB, Maritime Safety Queensland noted that the loading rates at Australian export terminals have increased dramatically in recent years.17 Coal is a key resource loaded at the Gladstone port where the ship commenced its passage to China. Rates of loading (6000 tonnes per hour at Gladstone's Clinton terminal) have a direct bearing upon the price of this commodity. Consequently, crews engaged in loading coal are conscious of maintaining high loading rates at terminals and ensuring that this is not slowed by errors on their part. The chief mate of the Shen Neng 1 had closely supervised the loading process prior to departing from Gladstone. He decided to extend his work hours to do this, and did not adhere to the minimum rest hours for watch keepers set out by the ship's SMS. He was not forced to rest and it appears that inadequate support was on offer by way of a back up mate to take over the chief mate's role. What requirements should the Shen Neng 1 have adhered to?The minimum rest requirements set out in the ships SMS were based on international standards set out by the International Convention on Standards of Training, Certification and Watchkeeping (STCW Convention) and the Seafarers' Training, Certification and Watchkeeping Code (STCW Code). The STCW Convention and STCW Code emphasise the importance of managing watchkeepers' fatigue as a vital element in vessel safety. Despite having a procedure for watchkeepers' rest hours in place, the SMS for the Shen Neng 1 did not provide the crew with any practical guidelines or advice in respect of how the crew were to discharge their obligations under the SMS. In addition, the ATSB found that the requirement for the crew to record their work and rest hours, for the purposes of monitoring and audits, was ineffective. The chief mate had recorded his hours in a way that seemed to comply with the STCW Code and would not reflect badly on himself or his management of the Shen Neng 1. That is, he was responsible for recording his own time with no oversight of this recording process. What recommendations did the ATSB make?The ATSB recommended that TKI address each of these issues by reviewing fatigue management systems, practical guidance and training for crew and record inspection processes. What are the wider implications?Elaborating on regulations under the STCW Convention, the STCW Code sets out a combination of mandatory standards for fatigue management on vessels and recommended guidance on implementing these. However, outside of the shipping industry, the issue of fatigue management is not addressed by proposed OHS legislation in Australia. Neither the Model Work Health and Safety Act, nor the Model Work Health and Safety Regulations, (both of which are due to enacted nationally on 1 January 2012) provide for the management of worker fatigue in situations where alertness, decision making and judgement are vital to safe work practices. Workers who are unfit for their duties due to fatigue present a substantial danger to themselves and others in the workplace, as well as potentially causing incidents with substantial economic and environmental costs. The Shen Neng 1 grounding stands as a strong reminder of the importance of comprehensive workplace fatigue management systems, encompassing appropriate worker guidance and training, and effective record keeping and auditing processes. Reference ResearchAccident Analysis and PreventionListed below are some articles published in edition 43 of Accident Analysis and Prevention The link between fatigue and safetyThe objective of this review was to examine the evidence for the link between fatigue and safety, especially in transport and occupational settings. The review examined the relationship between three major causes of fatigue – sleep homeostasis factors, circadian influences and nature of task effects – and safety outcomes, first looking at accidents and injury and then at adverse effects on performance. Read the full abstract or download the article here. Ref Ann Williamsona, David A. Lombardib, Simon Folkard c,d, Jane Stutts e, Theodore K. Courtneyb, Jennie L. Connorf The challenges and opportunities of technological approaches to fatigue managementThere are a number of different strategies to mitigate the effects of fatigue in transportation and other occupational settings. Over the past decade and a half, there have been considerable advances in relevant technologies, including onboard devices that monitor drivers' state or level of performance as well as devices that predict fatigue in advance of a work cycle or trip. Read the full abstract or download the article here. Thomas J. Balkina,!, William J. Horreyb, R. Curtis Graeberc, Charles A. Czeislerd, David F. Dingese aWalter Reed Army Institute of Research, Dept of Behavioral Biology, 503 Robert Grant Avenue, Room 2A26, Silver Spring, MD 20910, USA
In the NewsLast issue we reported about how Aviation authorities in the United States are investigating whether an air traffic controller fell asleep at Reagan National Airport near Washington as two planes attempted to land. Its now reported that The Federal Aviation Administration had suspended a controller in Miami for nodding off on the job, the fifth incident of that type identified in recent weeks and the second at a major centre. The good news is that the FAA are now investigating all of these disclosures and may now ban scheduling practices most likely to result in drowsiness at work. NZTA welcomes changes to improve the safety of young driversResearch shows that the over-representation of young drivers in crashes is due to three interwoven factors: youthfulness; lack of driving experience; and exposure to some higher risk situations (eg driving with passengers, driving late at night). It's a known fact that teenagers have altered circadian rhythms through their teenage years and suffer from sleep deprivation. Ministry of Transport statistics show that between 2005 and 2009, 'Driver tired or fell asleep' was the major factor in almost 10% of fatal crashes for 15 to 19 year olds. Lets hope this initiative will have a positive impact on fatigue related crashes of the younger population. Blood pressure management: Sleep on itA daytime sleep could have cardiovascular benefits according to new research by Ryan Brindle and Sarah Conklin, PhD, from Allegheny College in Pennsylvania in the US. Long work schedules, shift work, increased anxiety and a greater use of the internet and television late at night - all characteristics of our modern society - have had an impact on nocturnal sleep. We no longer sleep as long as we used to: The average sleep duration is now almost 2 hours shorter per night than it was 50 years ago. And this could be impacting our long-term health. For example, sleeping less has been linked to an increased risk of hypertension and cardiovascular problems generally. Fatigue and the Delivery of Medical CareThe problem is that all 168 hours throughout every week of every year have to be covered and there are a finite number of doctors to shoulder the burden. There are many strongly held views about how best to provide night-time and week-end care. Constructive innovations are thin on the ground. The biggest gap is between administration and doctors with financial considerations being the limiting factor. It is, however, generally accepted on all sides that sleep loss and fatigue can have adverse effects on both patients and doctors. Working long hours raises heart attack riskResearchers at University College, London report that working more than 11 hours a day increases the risk of heart disease by 67%, compared to working 7-8 hours a day. The authors suggest that information on working hours could be useful to GPs when calculating a patient's risk of heart disease alongside other measures such as blood pressure, diabetes and smoking habits. Alliance Partner NewsNZAIA / NZAAA, July 2011Avinet will attend AIA / NZAAA tradeshows in New Zealand this July. Teaming up with local alliance partner, Shiftwork Services, the Avinet team are excited about attending the tradeshows on the back of the success there last year. More information will be detailed closer to the event. Avinet Air MaestroAir Maestro® is a web-based aviation software application allowing your personnel to update and manage operational information anywhere, anytime via a secure connection over the internet. Air Maestro® is targeted at aviation operators and enables you to achieve greater Safety, Efficiency and Compliance with integrated features supporting:
Upcoming EnhancementsRelease 2.7 Custom Safety Reports - Air Maestro's Safety Module has been overhauled to provide custom report types with custom fields in each report type. The changes flow into the investigation process which will be more flexible and also promote greater links between the Audit and Hazard Modules. It is currently at Beta test stage. System eases pilots' heavy safety loadAir Maestro has also been featured recently in 'Adelaide Now'. Read the article below to find out a little history of the development of Air Maestro and how its helped fatigue management with Australian Helicopters. Shiftwork Services Based in New Zealand, Shiftwork Services provides a specialised advisory/training service to organisations whose employees work shifts or extended hours. Services include specialist workshops, fatigue risk management, wellness programmes, training materials, roster design. Call us to discuss your safety and performance issues. Working GloballyFaidSafe alliance partners are based in Australia, Europe, New Zealand and North America. Between us we are taking FaidSafe to the global market. We want to make this service available to every organisation that is exposed to fatigue risks. No matter where you are, we would like to hear from you. We want to add value to your business. About the Custodian of the BrandInterDynamics have been in the scheduling and risk business since 1992. InterDynamics has been privileged to work with leading operational practitioners, scientists and risk engineers to develop and deliver world class fatigue risk programs and products. FaidSafe® is offered as a global benchmark for risk-based integrated fatigue management solutions. FAID® and FaidSafe® are registered brand names of InterDynamics® Pty Ltd. For more information on InterDynamics, visit the InterDynamics website. FAID® received a WorkCover SA SAfeWork 2001 Award
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