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Is your Safety at Work at HUGE Risk due to Fatigue or is just Human Error!

Have you ever been told to Hurry!, do it quicker, we need to meet time lines, or the job expectations for quotas to get some many done?    But as we move forward to achieve goals are we impaired by fatigue! In humans, fatigue delays response and reaction times, negatively impacts on logical reasoning and decision making and impairs hand-eye co-ordination – all critical safety issues in the transport industry. A significant body of research has concluded that fatigue is rapidly emerging as one of the greatest single safety issue now facing the transport sector.

Like alcohol intoxication, fatigue-related impairment is a major source of incidents and injuries and represents a significant social cost to the community. Some of the world’s biggest disasters, including Chernobyl and the Exxon Valdez oil spill, have been a result of human error attributable in some way to fatigue.

Fatigue refers to the issues that arise from excessive working time or poorly designed shift patterns. It is generally considered to be a decline in mental and/or physical performance that results from prolonged exertion, sleep loss and/or disruption of the internal clock. It is also related to workload, in that workers are more easily fatigued if their work is machine-paced, complex or monotonous.

Types of Human Error What do we mean by “human error”? Human error is sometimes described as being one of the following: an incorrect decision, an improperly performed action, or an improper lack of action (inaction). It is important to recognize that “human error” encompasses much more than what is commonly called “operator error”. Safety and health at work are extremely important yet they still appear to be one of the most neglected factors in the industry. Almost 90% of incidents that occur in the workplace are due to human errors. In truth, human error can be explained by stress, repetition, fatigue and work environment.

Fatigue influences individuals in different ways and can lead to a combination of the following aspects of decreased mental and physical performance:

·        reduced attention and awareness

·        reduced ability to process information

·        slower reactions and reduced co-ordination

·        underestimating risk

·        poor decision making

·        increased aggressive behaviour and mood swings

·        lapses in memory.

Fatigue results in slower reactions, reduced ability to process information, memory lapses, absent-mindedness, decreased awareness, lack of attention, underestimation of risk, reduced coordination etc. Fatigue can lead to errors and incidents, ill-health and injury, and reduced productivity.

Significant industrial and cultural changes have occurred within the transport industry in recent years. These changes include, but are not limited to:

Pressure to enhance capital utilization

Heightened competition within and between transport modalities

Increasing financial expectations of employees

Management pressure to decrease employee numbers l Increasing perceived value of high hours of work and flexibility from employees One of the main outcomes of these changes is that the transport industry workforce now work longer, more flexible hours, which often includes more shiftwork. There is little doubt that the productivity benefits that can flow from flexible rosters systems are desirable. Nevertheless, it is likely that employers and employees with little knowledge of the financial, biological and psycho-social impacts of shiftwork and fatigue could negotiate work systems that significantly compromise potential benefits.

Employers have a ‘duty-of-care’ to provide safe work schedules that permit an adequate amount of time for an employee to sleep, rest and recover as well as fulfil their social and domestic responsibilities. Conversely, employees have a ‘duty-of-care’ to use their time away from work in a safe and responsible manner.

There are many factors that reduce sleep opportunity including:

Longer hours: not surprisingly, when people work for more than 50 hours per week there is increasing competition between sleep and other activities of daily living.

Night work: as the amount of night work increases, so does the amount of sleep that must be attempted at biologically inappropriate times.

Sleeping ‘out of synch’ with the body’s biological clock results in reduced duration and quality of sleep. This in turn reduces the restorative value of sleep obtained.

Changing psycho-social expectations: For example, the increasing number of two income families means that both partners have less time available for family and social commitments. This can lead to a ‘social debt’ that can compete with the need for sleep.

In general, consequences of fatigue can affect:



Communities. Specific consequences can be catagorised as being either:




INDIVIDUAL The effects of acute sleep loss on individual performance are profound and affect a variety of areas including:

Biological: Cognitive performance impairment leading to decreased ability to process information and make timely, appropriate decisions and actions.

Psychological: Alertness impairment leading to decreased ability to remain awake. Clearly, such impairment can lead to increased likelihood of incidents and injuries.

Social: Mood changes such as increased irritability, decreased motivation and morale.

Key principles in fatigue

1.  Fatigue needs to be managed, like any other hazard.

2.  It is important not to underestimate the risks of fatigue. For example, the incidence of incidents and injuries has been found to be higher on night shifts, after a succession of shifts, when shifts are long and when there are inadequate breaks.

3.  The legal duty is on employers to manage risks from fatigue, irrespective of any individual’s willingness to work extra hours or preference for certain shift patterns for social reasons. Compliance with the Working Time Regulations alone is insufficient to manage the risks of fatigue.

4.  Changes to working hours need to be risk assessed. The key considerations should be the principles contained in HSE’s policies and company programs..

5.  Employees should be consulted on working hours and shift patterns. However, note that employees may prefer certain shift patterns that are unhealthy and likely to cause fatigue.

6.  Develop a policy that specifically addresses and sets limits on working hours, overtime and shift-swapping, and which guards against fatigue.

7.  Implement the policy and make arrangements to monitor and enforce it. This may include developing a robust system of recording working hours, overtime, shift-swapping and on-call working.

8.  Problems with overtime and shift-swapping may indicate inadequate resource allocation and staffing levels.

9.  There are many different shift work-schedules and each schedule has different features. This sheer diversity of work and workplaces means that there is no single optimal shift system that suits everyone. However, a planned and systematic approach to assessing and managing the risks of shift work can improve the health and safety of workers.

10.   There are a number of key risk factors in shift schedule design, which must be considered when assessing and managing the risks of shift work. These are the workload, the work activity, shift timing and duration, direction of rotation and the number and length of breaks during and between shifts. Other features of the workplace environment such as the physical environment, management issues and employee welfare can also contribute to the risks associated with shift work.

11.   Sleep disturbances can lead to a ‘sleep debt’ and fatigue. Night workers are particularly at risk of fatigue because their day sleep is often lighter, shorter and more easily disturbed because of daytime noise and a natural reluctance to sleep during daylight.

Fatigue can affect people differently but could lead to the following health problems:

·        difficulty in falling asleep, and staying asleep

·        difficulty in staying alert and awake at work

·        reduced quality and quantity of sleep

·        gastrointestinal disorders.

All too often, fatigue is seen as a familiar and acceptable part of everyday life. Working long hours may even be accepted in the culture of a workplace as “the thing to do”

The best practice management approach, which will go beyond what is required by health and safety legislation, is through a multi-component approach that includes:

·        careful planning of shift rotas

·        reviewing maximum hours of duty and time for recovery

·        education on sleep routines, nutrition, effects on family and social life, exercise

·        environmental design changes, especially those aspects that can improve alertness, such as temperature, lighting and comfort levels

·        reducing the number of safety-critical tasks planned for the night shift

·        rotating jobs to reduce levels of boredom

·        providing medical advice for employees, especially for those with existing medical conditions.

These simple steps can significantly reduce human error in the workplace and increase employee concentration, improving both safety and well-being.

As you can see, while human errors are all too often blamed on “inattention” or “mistakes” on the part of the operator, more often than not they are symptomatic of deeper and more complicated problems . The discipline of human factors is devoted to understanding human capabilities and limitations, and to applying this information to design equipment, work environments, procedures, and policies that are compatible with human abilities. In this way we can design technology, environments, and organizations which will work with people to enhance their performance, instead of working against people and degrading their performance. This kind of human centered approach (that is, adapting the system to the human) has many benefits, including increased efficiency and effectiveness, decreased errors and accidents, decreased training costs, decreased personnel injuries and lost time, and increased morale.

Terry Penney

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