# NTSB Safety Recommendation P-99-012

- **operation:** document
- **citation:** P-99-012
- **title:** NTSB Safety Recommendation P-99-012
- **source type:** guidance
- **agency:** National Transportation Safety Board
- **status:** guidance
- **official:** true
- **published on:** 1999-06-01
- **effective on:** 1999-06-01
- **summary:** TO THE PIPELINE AND HAZARDOUS MATERIALS SAFETY ADMINISTRATION (ORIGINALLY ISSUED TO RSPA): Establish within 2 years scientifically based hours-of-service regulations that set limits on hours of service, provide predictable work and rest schedules, and consider circadian rhythms and human sleep and rest requirements.
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**body:**

NTSB safety recommendation P-99-012.

TO THE PIPELINE AND HAZARDOUS MATERIALS SAFETY ADMINISTRATION (ORIGINALLY ISSUED TO RSPA): Establish within 2 years scientifically based hours-of-service regulations that set limits on hours of service, provide predictable work and rest schedules, and consider circadian rhythms and human sleep and rest requirements.

Priority: CLASS II

Overall Status: Closed - Acceptable Alternate Action

Issued Date: 1999-06-01

Adopted Date: 1999-05-17

Overall Date Closed: 2010-02-18

Synopsis: During the 1980's, the National Transportation Safety Board investigated several accidents that involved operator fatigue. Following completion of these accident investigations, the safety board in 1989 issued three recommendations to the U.S. Dept. of Transportation (DOT): expedite a coordinated research program on the effects of fatigue, sleepiness, sleep disorders, and circadian factors on transportation system safety (I-89-1), develop and disseminate educational material for transportation industry personnel and management regarding shift work; work and rest schedules; and proper regimens of health, diet, and rest (I-89-2) and review and upgrade regulations governing hours of service for all transportation modes to assure that they are consistent and that they incorporate the results of the latest research on fatigue and sleep issues (I-89-3).

Keywords: Fatigue,

Ntsbnumber: 80495

Report Number: SR-99-01

Addressee Name: RSPA

Addressee Status: Closed - Acceptable Alternate Action

Addressee Date Closed: 2010-02-18

Addressee Acronym: RSPA

Addressee Organization Type: G-Federal Government

Communication Date: 2008-12-23

Communication Type: NPRM Response

Communication Contents: Controller Fatigue Mitigation Despite the many positive provisions included in the NPRh4, the Safety Board does not believe the NPRM satisfactorily addresses mitigation of controller fatigue. The Board issued its first recommendation concerning pipeline controller fatigue based on its findings from the June 26, 1996, accident in Fork Shoals, South Carolina.AS a result of the investigation, the Board recommended that the Research and Special Programs Administration (RSPA)~ do the following: The issue of fatigue has been on the Safety Board's Most Wanted List of Transportation Safety Improvements since 1990. Safety Recommendation P-99- 12 was added to the Most Wanted List in 1999 as the result of the Board's evaluation of the U.S. Department of Transportation's efforts to address operator fatigue in all modes of transportation. The 2008 Most Wanted List recommends that PHMSA "set working hour limits for pipeline controllers based on fatigue research, circadian rhythms, and sleep and rest requirements." In this NPRM, PHMSA proposes that each operator implement methods to prevent controller fatigue. The proposed rules are similarly described in the sections discussing the transportation of natural gas (49 CFR 192.63l(d)), LNG facilities (49 CFR 193.2523(d)), and the transportation of hazardous liquids (49 CFR 195.454(d)). Each of these respective sections has a "fatigue mitigation" heading, under which PHMSA discusses specific actions to be taken by operators, including the following: (1) establishing shift lengths and schedule rotations that provide controllers off-duty time sufficient to achieve 8 hours of continuous sleep; (2) educating controllers and their supervisors in fatigue mitigation strategies and how off-duty activities contribute to fatigue; (3) training controllers and their supervisors to recognize and mitigate the effects of fatigue; (4) implementing additional measures to monitor for fatigue when a single controller is on duty; and (5) establishing a maximum limit on controller hours of service, which may include an exception during an emergency with appropriate management approval. The Safety Board commends PHMSA for the efforts it has taken to address controller fatigue both through Advisory Bulletin ADB-05-06 and through this NPRM. The Board is particularly pleased with PHMSA's proposed rule requiring that operators provide controllers an opportunity for 8 hours of continuous sleep. The Board, however, encourages PHMSA to amend the NPRM sections on fatigue mitigation to include additional instruction that is vital to establishing safe and effective work and rest schedules. Specifically, the Board believes that the NPRM should require that operators of these facilities incorporate fatigue research, circadian rhythms, and sleep and rest requirements when establishing a maximum limit on controller shift length, maximum limit on controller hours of service, and schedule rotations. In addition, the Safety Board notes that requiring operators to design their own plans to address controller fatigue is not the same as establishing scientifically based hours-of-service regulations. Rather, the latter is consistent with an approach that has been referred to as fatigue management systems or fatigue risk management systems. Such systems commonly incorporate various strategies to manage fatigue, such as scheduling policies and practices, attendance policies, education, medical screening and treatment, personal responsibility during nonworking periods, task/workload issues, rest environments, and commuting policies. Such systems also typically incorporate a plan for implementing, supervising, and evaluating the success of the system. The Board has stated that fatigue management systems appear to hold promise as a progressive approach to addressing problems associated with fatigue, but has also noted that regulatory refinement and ongoing regulatory oversight are necessary to ensure that such systems will result in the intended outcomes. PHMSA has stated that its proposed rules are performance based because they describe the necessary elements and outcomes that operators must accomplish but do not prescribe exactly how operators must incorporate each element. Considering PHMSA's nonprescriptive approach to fatigue management, the Safety Board would like PHMSA to provide additional information about its criteria for evaluating operators' plans and to explain how it intends to monitor the effectiveness of implementing those plans. Establishing clear evaluation criteria for the plans and their outcomes will improve the likelihood that operators will design effective plans; it also will likely improve the success of their fatigue management systems. The revisions to the NPRM suggested by the Safety Board, combined with PHMSA's proposed requirements, would be positive steps towards satisfying the intent of Safety Recommendation P-99- 12. Oversight To ensure that the appropriate control room managementlhuman factors elements are included in an operator's plan and are satisfactorily implemented, PHMSA must establish an aggressive oversight program that thoroughly examines each operator's process for implementing requirements for control room management. As mentioned earlier, the Safety Board encourages PHMSA to clearly define criteria for evaluation and to outline how PHMSA would monitor compliance with these regulations. Notation 8070: The National Transportation Safety Board has reviewed the Pipeline and Hazardous Materials Safety Administration’s (PHMSA’s) notice of proposed rulemaking (NPRM), “Control Room Management/Human Factors,” that was published at 73 Federal Register 53076 on September 12, 2008. PHMSA is proposing to revise the Federal pipeline safety regulations, 49 Code of Federal Regulations (CFR) Parts 192, 193, and 195, to address human factors and other components of control room management. Overview The Safety Board notes that the NPRM would implement new requirements for control room management at 49 CFR Parts 192, 193, and 195 for natural gas pipelines, liquefied natural gas (LNG) facilities, and hazardous liquid pipelines, respectively. Under the proposed requirements, each operator of a natural gas pipeline, LNG facility, or hazardous liquid pipeline with a controller and control room would have to establish and follow written control room management procedures. The procedures also would have to be integrated into the operator’s operations and maintenance manual, qualification program, and emergency plan, all of which are currently required under 49 CFR Parts 192, 193, and 195. The Safety Board further notes that in order to implement the proposed control room management procedures an operator would be required to do the following: define the roles and responsibilities of the controllers; provide controllers with accurate and timely system data; implement methods to prevent controller fatigue; ensure appropriate controller response to alarms and notifications when Supervisory Control and Data Acquisition (SCADA) systems are used; establish thorough and frequent communications among controllers, management, and field personnel when planning and implementing physical changes to pipeline/facility equipment and configuration; review control room procedures following any event that must be reported under existing regulations; establish and implement a training program that includes an annual review to identify potential improvements; have a qualification program for controllers; and conduct an annual validation by a senior executive for the operator verifying that adequate control room management procedures have been implemented and are being followed. The Safety Board supports the overall direction of the NPRM and believes that the NPRM is comprehensive and focuses on the major ele

Addressee Acronym: RSPA

Addressee Organization Type: G-Federal Government

Communication Date: 2013-04-23

Communication Type: NPRM Response

Communication Contents: Notation 8486: On March 11, 2013, the US Chemical Safety and Hazard Investigation Board (CSB) published a request for public comment on a document released on its website titled “Draft Recommendations Evaluation for Public Comment: Fatigue Risk Management Systems (FRMS)” (CSB Evaluation). Subsequently, CSB staff invited the National Transportation Safety Board (NTSB) to share its experiences in investigating transportation accidents in which human fatigue was identified as a safety issue, and related NTSB safety recommendations. The NTSB is an independent federal agency charged with determining the probable cause of transportation accidents and issuing safety recommendations aimed at preventing future accidents. The NTSB has a long history of making recommendations to reduce fatigue and fatigue-related transportation accidents and, since its inception, has issued over 200 recommendations addressing fatigue in the aviation, highway, marine, railroad, and pipeline modes. We are pleased to share our experiences with the CSB. The CSB Evaluation comments on actions taken by the American Petroleum Institute (API) and the United Steelworkers International Union (USW) in response to Recommendation No. 2005-04-I-TX-7, issued by the CSB in 2005 to those organizations. The CSB recommendation was issued as a result of the March 23, 2005, Texas City, Texas, refinery explosion and fire. The portion of the CSB recommendation pertinent to this letter reads as follows: [D]evelop fatigue prevention guidelines for the refining and petrochemical industries that, at a minimum, limit hours and days of work and address shift work…. In April 2010, the API issued an American National Standards Institute-approved Recommended Practice titled Fatigue Risk Management Systems for Personnel in the Refining and Petrochemical Industries, First Edition (RP-755), and an accompanying technical report titled Fatigue Risk Management Systems for Personnel in the Refining and Petrochemical Industries, Scientific and Technical Guide to RP 755. The CSB Evaluation presents the results of a CSB staff review in which the CSB staff determined that RP-755 does not meet the intent of the CSB recommendation in several areas. The NTSB has reviewed RP-755 as well as the CSB Evaluation. With respect to human fatigue, the NTSB has specific experience with the following issues that are discussed in the CSB Evaluation: • The hours-of-service limits described in RP-755, which are more permissive than what is indicated by current scientific knowledge, and the suggestion that voluntary FRMS programs will compensate for the risk from excessive hours and days at work, and • The emphasis of RP-755 on voluntary efforts by industry and its lack of explicit requirements, especially with respect to elements of an effective fatigue management system. With respect to the hours-of-service limits, RP-755 describes “work sets” during normative conditions, which may include 12-hour day shifts or night shifts for 7 consecutive days, with the possibility of an additional “holdover period” beyond the duty day for training or safety meetings. The RP states that the “holdover period should not exceed 2 hours and, where possible, occur at the end of the day shift.” However, the use of the language “should” is not a requirement but is defined by the document as a “recommendation or that which is advised but not required in order to conform to the RP.” Therefore, a worker could, during a normal work set, work shifts of 14 hours or greater in a 24-hour period for several days. RP-755 also states that during planned or unplanned outages, workers may be called on to work 12-hour shifts for up to 14 consecutive days, with as little as 36 hours between 14-day, 12-hour work sets. Holdover periods of up to 2 hours are also allowed during outages. The RP also has provisions for extending work shifts up to 18 hours. In several of its accident investigations, the NTSB has recognized the relationship between long duty days and fatigue, both directly and through their effects on reduced sleep lengths during off-duty periods. For example, in the investigation of the October 2004 Corporate Airlines accident in Kirksville, Missouri, the NTSB determined that the probable cause of the accident was the pilots’ failure to follow established procedures and properly conduct an instrument approach at night, and that fatigue was one factor that contributed to the pilots’ degraded performance. The length of the pilots’ duty day (at the time of the accident, they had been on duty for 14 1/2 hours) was cited along with less-than-optimal overnight rest time, early reporting time for duty, the number of flight legs, and demanding flight conditions, as factors that resulted in the pilots’ fatigue. In the Kirksville report, the NTSB cited research showing that pilots who worked schedules that involved 13 or more hours of duty time had an accident rate that was several times higher than that of pilots working shorter schedules, and that airplane captains who had been awake for more than about 12 hours made significantly more errors than those who had been awake for less than 12 hours. As a result of the Kirksville investigation, the NTSB issued Safety Recommendation A-06-10 to the Federal Aviation Administration (FAA), which stated the following: A-06-10 Modify and simplify the flight crew hours-of-service regulations to take into consideration factors such as length of duty day, starting time, workload, and other factors shown by recent research, scientific evidence, and current industry experience to affect crew alertness. The NTSB reiterated Safety Recommendation A-06-10 in 2008 following its investigation of the April 2007 Pinnacle Airlines accident in Traverse City, Michigan. In that accident, the NTSB determined that the probable cause of the accident was the pilots’ poor decision-making as they prepared to land the airplane. The NTSB stated that “This poor decision-making likely reflected the effects of fatigue produced by a long, demanding duty day and, for the captain, the duties associated with check airman functions.” The pilots had been on duty for more than 14 hours at the time of the accident. The effectiveness of fatigue management is directly related to the availability of work schedules that allow a sufficient period of time between work shifts for the employee to obtain sufficient restorative sleep. The NTSB has investigated several accidents and serious incidents that provided clear and compelling evidence that air traffic controllers were sometimes operating in a state of fatigue because of their work schedules and poorly managed utilization of rest periods between shifts, and that fatigue had contributed to controller errors. Consequently, the NTSB issued Safety Recommendation A-07-30 to the FAA, which stated the following: A-07-30 Work with the National Air Traffic Controllers Association to reduce the potential for controller fatigue by revising controller work-scheduling policies and practices to provide rest periods that are long enough for controllers to obtain sufficient restorative sleep and by modifying shift rotations to minimize disrupted sleep patterns, accumulation of sleep debt, and decreased cognitive performance. The NTSB’s consideration of how long duty days affect fatigue and safety has not been limited to the aviation mode. Recently, in our investigation of the September 2010 collision of two freight trains near Two Harbors, Minnesota, the NTSB concluded that crew fatigue was a contributing factor in train crew errors that led to the collision. The train crewmembers who made the errors had been awake between 13 and 14 hours at the time of the accident, and the accident occurred during the final hour of a 12-hour shift. In its report, the NTSB cited a study showing that 12 hour work shifts have been associated with decrements in alertness and performanc

Addressee Acronym: RSPA

Addressee Organization Type: G-Federal Government

Communication Type: Official Correspondence

Communication Contents: At the 1990 Board meeting addressing the NTSB’s Most Wanted List of Transportation Safety Improvements (MWL), the Board voted to place Safety Recommendations I-89-1 through I-89-3 and R-89-19 on the MWL under the issue category “Cross Modal Human Fatigue/ Hours-of-Work Policy.” Safety Recommendations H-95-1, A-94-194, A-95-113, A-97-71, A-99-45, I-99-1, H-99-19, R-91-45, R-91-47, R-91-48, R-96-20 through R-96-22, R-96-56, R-99-2, P-98-30, P-99-12, M-99-1, A-06-10, A-07-30, A-07-32, and A-08-44 were added to this category at later dates.

Addressee Acronym: RSPA

Addressee Organization Type: G-Federal Government

Communication Date: 2001-04-18

Communication Type: Official Correspondence

Communication Contents: The Safety Board understands that RSPA is reviewing previous pipeline accidents and research on fatigue and rotating work schedules and has met with representatives of pipeline trade associations to discuss the issue of fatigue in the pipeline industry. RSPA is working cooperatively with the industry to determine the role of fatigue as a factor in pipeline incidents and to gather information on existing fatigue guidelines in pipeline operations. The RSPA is also monitoring the progress of a multi-year human factors research initiative by the American Petroleum Institute to develop industry guidelines covering, among other human factors, fatigue and successful mitigation and intervention techniques, which RSPA will closely monitor. The Safety Board further understands that RSPA is participating both on the DOT's effort to address fatigue issues across all modes of transportation and on the DOT Human Factors Coordinating Committee, which provides a mechanism to enhance planning, implementation, and education related to human factors research within the transportation community. RSPA advises that the goals of the committee are to assist in the development and implementation of a national strategic agenda for intermodal human factors research and applications in transportation; the committee also seeks to be a human factors information resource to the transportation community. Accordingly, because RSPA is making progress on the fatigue issue in pipeline safety, both Safety Recommendations P-98-30 and P-99-12 remain classified "Open--Acceptable Response," pending our receipt of further information on this issue. Specifically, the Board would appreciate being informed of the timeframe for issuing the advisory bulletin to the owners and operators as discussed in the April 24, 2000, letter.

Addressee Acronym: RSPA

Addressee Organization Type: G-Federal Government

Communication Date: 2002-06-28

Communication Type: Official Correspondence

Communication Contents: Although RSPA has not committed to establishing scientifically based hours-of-service regulations, because RSPA continues to make progress on assessing the fatigue issue in pipeline safety, both Safety Recommendations P-98-30 and P-99-12 remain classified "Open--Acceptable Response." We would appreciate another update on these initiatives as they near completion.

Addressee Acronym: RSPA

Addressee Organization Type: G-Federal Government

Communication Date: 2005-04-29

Communication Type: Official Correspondence

Communication Contents: The pipeline industry remains the only transportation mode that has no hours-of-service regulations. In 2002, the Safety Board was advised that PHMSA was tasking the Volpe National Transportation Systems Center to develop information about work-rest cycles, fatigue measurement, and fatigue management for pipeline controllers. According to PHMSA, this project determined that there was very little information available to assess the extent of fatigue issues in pipeline transportation or to provide industry and labor with tools and techniques to manage any problems. The Safety Board reviewed materials from the Volpe project submitted by PHMSA. Its statement of work lists three objectives including (1) a poll of industry and labor on their current scheduling practices, (2) a meeting with PHMSA, Safety Board, and Volpe staff regarding proposed responses to Board recommendations, and (3) preparation of a full field data collection activity to understand and manage fatigue in the pipeline industry. The documents submitted on the Volpe project suggest only the first objective was accomplished. The Board notes that had the third objective been completed as outlined in its statement of work, PHMSA would have better information with which to assess the extent of fatigue issues in pipeline transportation, and to establish industry guidelines to reduce the likelihood of accidents attributable to controller fatigue. The Safety Board notes that PHMSA's review of its accident records did not indicate that controller fatigue was a contributor to pipeline accidents. We do not find this outcome surprising because there are certain limits to PHMSA's pipeline accident database regarding fatigue data. The issue of fatigue is not directly solicited in the questions for the database. In addition, the reports are generally self-reported and require companies to collect fatigue data in their investigation and then report it to PHMSA. The Safety Board notes that PHMSA has contracted with Battelle Memorial Institute (Battelle) for a project titled, Human Factors Analysis of Pipeline Monitoring and Control Operations. As part of this project, Battelle plans to discuss with Safety Board staff the overall reasoning and issues underlying the Board's fatigue recommendations; to date this contact has not been initiated. Although supportive of efforts to better understand how human factors can adversely affect the safety of pipeline monitoring and control operators, the Board is concerned that the project will only result in laying the groundwork "for assessing the need for further regulatory action." This project is not expected to be completed until October 2006, more that 8 years after the first fatigue safety recommendation was issued to PHMSA. Because PHMSA continues to assess the fatigue issue in pipeline safety, Safety Recommendations P-98-30 and P-99-12 remain classified "Open--Acceptable Response." However, because the pipeline industry is the only mode of transportation without hours-of-service regulations, and because more than 7 years have elapsed since these recommendations were issued, the Safety Board strongly encourages PHMSA to commit to taking action soon, beyond investigations and studies, to address fatigue in the pipeline industry. Without such action, the Board may have no alternative than to reclassify these recommendations to an unacceptable status. We would appreciate receiving periodic updates on these initiatives as they near completion.

Addressee Acronym: RSPA

Addressee Organization Type: G-Federal Government

Communication Date: 2010-04-28

Communication Type: Official Correspondence

Communication Contents: The NTSB has reviewed PHMSA’s final rule, published on December 3, 2009, Pipeline Safety: Control Room Management/Human Factors, effective February 3, 2010, which requires that each operator implement methods to prevent controller fatigue that could inhibit a controller’s ability to carry out the roles and responsibilities defined by the operator. The final rule represents a significant step forward for an industry that did not previously have any rules governing HOS. Although the NTSB recognizes that the rule requires operators to establish shift lengths that provide off-duty time sufficient to achieve up to 8 hours of continuous sleep, we remain concerned that the rule does not explicitly address fatigue that may arise from circadian desynchrony caused by unpredictable or rotating schedules. Nevertheless, we appreciate that PHMSA has accepted the responsibility of evaluating and monitoring the HOS limits that will be contained in the operators’ fatigue management plans, and given PHMSA’s intent to provide oversight of operators’ limits and procedures, the final rule represents an acceptable alternative approach to this issue. Accordingly, at the NTSB’s February 18, 2010, Most Wanted List Board meeting, Safety Recommendation P 99-12 was classified Closed Acceptable Alternate Action, and the issue area was removed from the Most Wanted List.

Addressee Acronym: RSPA

Addressee Organization Type: G-Federal Government

Communication Date: 2008-02-11

Communication Type: Official Correspondence

Communication Contents: Although the pipeline industry remains the only transportation mode without any hours of service regulations, the Safety Board is optimistic that with the enactment of the Pipeline Inspection, Protection, Enforcement, and Safety Act (the Act) of 2006, (specifically Section 12, stated below), PHMSA will establish hours-of-service regulations as requested by Safety Recommendation P-99-12. § 60137. Pipeline control room management (a) IN GENERAL.Not later than June 1, 2008, the Secretary shall issue regulations requiring each operator of a gas or hazardous liquid pipeline to develop, implement, and submit to the Secretary or, in the case of an operator of an intrastate pipeline located within the boundaries of a State that has in effect an annual certification under section 60105, to the head of the appropriate State authority, a human factors management plan designed to reduce risks associated with human factors, including fatigue, in each control center for the pipeline. Each plan must include, among the measures to reduce such risks, a maximum limit on the hours of service established by the operator for individuals employed as controllers in a control center for the pipeline. In addition, PHMSA’s work with the Department of Transportation’s Human Factors Coordinating Committee on a holistic approach to address fatigue issues throughout the workforce and the decision to include this approach within PHMSA’s development of Prevention Through People regulatory initiative, should address fatigue and satisfy the recommendation to establish hours-of-service regulations. Accordingly, pending receipt of further information from PHMSA, Safety Recommendation P-99-12 is classified Open Acceptable Response.

Addressee Acronym: RSPA

Addressee Organization Type: G-Federal Government

Communication Date: 2009-04-06

Communication Type: Official Correspondence

Communication Contents: The Safety Board has reviewed PHMSA’s October and December updates, as well as the notice of proposed rulemaking (NPRM) published at 73 Federal Register 53076 on September 12, 2008, to address human factors and other components of control room management. On December 23, 2008, the Board submitted comments on the NPRM. Although the proposed rule requires that operators provide controllers an opportunity for 8 hours of continuous sleep, the Board believes that the sections of the proposed regulation that address fatigue should be strengthened to include additional instruction vital for establishing safe and effective work and rest schedules. In 2005, PHMSA issued an advisory bulletin titled Pipeline Safety: Countermeasures to Prevent Human Fatigue in the Control Room (ADB-05-06), which was designed to provide guidance to pipeline operators on factors that can affect controller fatigue and ensure that controllers are not assigned to duties while fatigued. The advisory bulletin advised operators to (1) limit work schedules to no more than 12 hours in any 24-hour period, (2) develop procedures to manage unusual circumstances in which a controller must work more than 12 hours in a 24-hour period, (3) schedule at least a 10-hour break between work periods, and (4) develop shift rotation practices to minimize fatigue caused by the disruption of normal sleep patterns. In the September 12, 2008, NPRM, PHMSA proposes that each operator implement methods to prevent controller fatigue that could inhibit a controller’s ability to carry out the roles and responsibilities defined by the operator. The proposed rules are similarly described in the sections discussing the transportation of natural gas (49 Code of Federal Regulations [CFR] 192.7(d)) and hazardous liquids (49 CFR 195.3(d)), and liquefied natural gas facilities (49 CFR 193.2523(d)). Under the heading fatigue mitigation, PHMSA discusses specific actions to be taken by operators, including (1) establishing shift lengths and schedule rotations that provide controllers off-duty time sufficient to acquire 8 hours of continuous sleep; (2) educating a controller and his supervisor in fatigue mitigation strategies and ways in which off-duty activities contribute to fatigue; (3) training a controller and his supervisor to recognize and mitigate the effects of fatigue; (4) implementing additional measures to monitor for fatigue when a single controller is on duty; and (5) establishing a maximum limit on controller HOS, which may include an exception during an emergency, with appropriate management approval. The Safety Board commends PHMSA for the efforts it has taken to address controller fatigue both through Advisory Bulletin ADB-05-06 and through this NPRM. The Board is particularly pleased by PHMSA’s proposed rule requiring that operators provide controllers an opportunity for 8 hours of continuous sleep. However, the Board strongly encourages PHMSA to include in the final rule additional instruction vital in establishing safe and effective work and rest schedules. Specifically, the Board believes that the rule should include language that emphasizes the importance to operators of these facilities of incorporating fatigue research, circadian rhythms, and sleep and rest requirements when establishing a maximum limit on controller shift length, maximum limit on controller HOS, and schedule rotations. In addition, the Safety Board notes that requiring operators to design their own plans to address controller fatigue is not the same as establishing scientifically based HOS regulations. Rather, it is consistent with an approach that has been referred to as fatigue management systems or fatigue risk management systems. Such systems commonly incorporate various strategies to manage fatigue such as scheduling policies and practices, attendance policies, education, medical screening and treatment, personal responsibility during nonworking periods, task/workload issues, rest environments, and commuting policies. Such systems also typically incorporate a plan for implementing, supervising, and evaluating the success of the system. The Board has stated that fatigue management systems appear to hold promise as a progressive approach to addressing problems associated with fatigue but has also noted that regulatory refinement and ongoing oversight are necessary to ensure that such systems will result in the intended outcomes. Finally, PHMSA has stated that its rule is performance based, in that it describes the necessary elements and outcomes that operators must accomplish but does not prescribe exactly how operators must incorporate each element. In light of PHMSA’s non-prescriptive approach with respect to fatigue management, the Safety Board would like PHMSA to provide additional information about its criteria for evaluating operators’ plans and ways in which PHMSA intends to monitor the effectiveness of operators’ implementations of those plans. Establishing clear evaluation criteria for the plans and their outcomes will not only improve the likelihood that operators will design effective plans but is also likely to improve the success of those programs. Accordingly, pending publication of the final rules with the above-described changes, Safety Recommendation P-99-12 is classified Open Acceptable Response.

Addressee Acronym: RSPA

Addressee Organization Type: G-Federal Government

Communication Date: 1999-10-15

Communication Type: Official Correspondence

Communication Contents: THE SAFETY BOARD IS PLEASED TO NOTE THAT RSPA IS REVIEWING PREVIOUS PIPELINE ACCIDENTS AND RESEARCH ON FATIGUE AND ROTATING WORK SCHEDULES AND THAT RSPA IS ALSO COORDINATING WITH OTHER DEPT. OF TRANSPORTATION AGENCIES AND THE PIPELINE INDUSTRY TO ADDRESS FATIGUE ISSUES ASSOCIATED WITH ROTATING PIPELINE CONTROLLER SHIFTS. THE BOARD UNDERSTANDS THAT RSPA HAS BOLSTERED ITS EXAMINATION OF FATIGUE AS A CAUSATIVE FACTOR IN PREVIOUS PIPELINE ACCIDENTS AND HAS BEGUN AN ANALYSIS OF RECENT INCIDENTS TO ANSWER THIS QUESTION AND HAS MODIFIED ITS INSPECTION PROCESS TO FOCUS ON FATIGUE'S INFLUENCE AND OR THE LEVEL OF INDUSTRY AWARENESS OF FATIGUE AS A CONTRIBUTOR TO PIPELINE ACCIDENTS. ACCORDINGLY, PENDING A REPLY FROM RSPA ON THE STATUS OF THESE INITIATIVES, P-99-12 IS CLASSIFIED "OPEN--ACCEPTABLE RESPONSE."

Addressee Acronym: RSPA

Addressee Organization Type: G-Federal Government

Communication Date: 2002-04-24

Communication Type: Official Correspondence

Communication Contents: Letter Mail Controlled 05/07/2002 10:51:59 AM MC# 2020457 RSPA has been participating in the Department of Transportation Human Factors Coordinating Committee (HFCC) to assess approaches to the control of human fatigue in transportation, including pipeline operations HFCC has sponsored several research studies and conferences on transportation fatigue issues at which RSPA engineers and pipeline industry representatives made presentations on the pipeline worker fatigue issues. As a result of the NTSB recommendations and the work of the HFCC, we recognized the need to evaluate how rotating controller schedules in the pipeline industry may be related to human fatigue and safety outcomes in the pipeline industry. Fatigue and work-rest patterns are a continuing concern for all modes of transportation. Fatigue is a particular issue in transportation given the preponderance of night work, concentrated/compressed schedules, overtime and rotating work, etc Concerns include job critical safety-related performance, worker safety during their commute, and general health effects. RSPA recently tasked the Volpe National Transportation Systems Center (VNTSC) to develop information about work-rest cycles, fatigue measurement, and fatigue management for pipeline controllers. We will use this information, and, if upon review we conclude measures need to be taken, we will provide industry and labor with tools and techniques to manage the problem. In this project RSPA is approaching these concerns by examining the actual scope of the fatigue problem and applying the new Organizational Fatigue Management (OFM) technologies and procedures developed by the HFCC. The initial step in the study is to collect pipeline operator work and other fatigue-related scheduling data from selected companies and unions. This data will be used to identify existing and potential fatigue problems and develop a comprehensive work plan to address them. RSPA will analyze the data and the resulting plan will be provided as an initial report. The report will guide further work in this area and address issues raised by NTSB. The plan will chart a course of work focused on implementing the planned research and providing the pipeline enterprise with fatigue management tools tailored to its needs. In addition, RSPA will soon issue a second Broad Agency Announcement (BAA), to invite proposals for pipeline safety research, including research on fatigue-related problems, fatigue measurement, and fatigue management. The RSPA BAA is a two-step process: Step one is the submission of a "White Paper/Pre-Proposal" by interested offerors. Each submission is evaluated by a technical panel. Step two is the submission of full proposals by those offerors deemed to have the most technically promising projects. Full proposals are evaluated by the same technical team and projects are selected for funding. Following the assessment of human fatigue in pipeline operations and the results of the research and standards efforts now underway, RSPA will evaluate the need for further development and application of guidelines to reduce the threat of pipeline incidents attributable to operator fatigue. RSPA believes these efforts will provide the necessary information for an assessment of the need for further regulatory action. Action Requested: RSPA requests that NTSB Safety Recommendations P-98-30 and P-99-12 continue to be classified as "Open - Acceptable Action" while we continue to pursue the actions described above.

Addressee Acronym: RSPA

Addressee Organization Type: G-Federal Government

Communication Date: 2010-06-21

Communication Type: Official Correspondence

Communication Contents: Letter Mail Controlled 7/6/2010 1:08:34 PM MC# 2100235

Addressee Acronym: RSPA

Addressee Organization Type: G-Federal Government

Communication Date: 2010-02-03

Communication Type: Official Correspondence

Communication Contents: Letter Mail Controlled 7/29/2010 3:59:18 PM MC# 2100063 - PHMSA has acted through the following initiatives designed to address the recommendation through a comprehensive and data-driven approach involving multiple stakeholders: - PHMSA published four advisory bulletins in 1999 (2), 2002, and 2007, notifying operators and States of the risks associated with plastic pipe and the need to monitor performance and to take action(s) to remedy problems. The fourth bulletin expanded on the information provided in the three prior bulletins by listing two additional pipe materials with poor performance histories relative to brittle-like cracking. The owners and operators of natural gas pipeline distribution systems were also encouraged to review the three previous bulletins in their entirety. - PHMSA and the American Gas Association (AGA) jointly established the Plastic Pipe Database Committee (PPDC), which remains active today, in response to the NTSB Special Investigation Report, Brittle-Like Cracking in Plastic Pipe for Gas service' and Recommendation P-98-2. NTSB was invited to sit on the PPDC and has provided valuable input along with members representing State regulators, trade associations, operators and manufacturers of plastic piping systems. PPDC's original scope was to collect and analyze data voluntarily submitted by operators on plastic pipe through-wall failure
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