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Clockwork Research Publishes “A Framework for Investigating Fatigue”

  • Paper provides a structured approach to investigating fatigue-related incidents or accidents
  • Explains how bio-mathematical models can be used in an investigatory environment

Clockwork Research, a leading fatigue risk management consultancy and part of the Consulting & Training division of Air Partner plc, today publishes its latest white paper, “A Framework for Investigating Fatigue”.

The paper provides a structured approach to investigating fatigue-related incidents or accidents and explains how bio-mathematical models can be used in an investigatory environment. The framework was presented by Dr Camille Burban at the recent European Society of Air Safety Investigators (ESASI) conference and is due to be presented in a workshop at a Royal Aeronautical Society (RAeS) conference on 9 May, entitled “Staying Alert: Managing Fatigue in Maintenance”.

In the past decade, fatigue has increasingly been considered as one of the most significant hazards to aviation safety and other safety-critical industries. However, despite the extensive knowledge developed through scientific research and operational experience, investigating fatigue remains a challenge. This white paper aims to provide safety practitioners with a better understanding of the process of investigating fatigue.

Investigating fatigue can mean two very different things, namely analysis of fatigue reports submitted by crew and investigating occurrences where fatigue is likely to have been a contributory factor. The former does not generally require a full investigation, whereas the latter necessitates a more thorough process to first identify whether fatigue was present, then whether it was the reason for any observed impaired performance, and finally to identify whether these potential errors had any causal role in the event. The white paper demonstrates the importance of distinguishing the two types of ‘fatigue investigation’ and provides guidance on how to conduct each of these investigations.

The framework proposed in the paper enables the safety practitioner to investigate step by step whether or not fatigue was involved in an incident or accident, by considering the different levels where fatigue should be examined and by asking the right questions. This approach highlights the importance of considering both individual and organisational responsibilities in the management of fatigue and in turn, in the making of safety recommendations in the aftermath of a fatigue-related accident or incident.

We believe that this specific investigation framework is not restricted to commercial flight crew fatigue but could also be applied to any safety-critical operations such as helicopter operations and ATC, and also in the wider transport industry, health, and oil and gas industries.

Commenting on the research, author Dr Camille Burban, Senior Behavioural Researcher at Clockwork Research, said: “Differentiating between the analysis of fatigue reports and the investigation of fatigue events is essential for an organisation. If an organisation were to run a complete investigation of every fatigue report, it would use valuable resources such as time and money and place intolerable demands on the workload of the safety team, as well as delaying individual feedback.

It’s fundamental that the data from all reports is collated and analysed, and that the resulting metrics are reviewed by a dedicated fatigue safety group on a regular basis to identify trends and potential hazards, as well as taking actions when necessary.”