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GCPS 2013 __________________________________________________________________________

Key Strategies for Implementing a Corporate Fatigue Risk Management System

David E. Cummings
E.I. DuPont de Nemours & Co.,Inc.

1007 Market Street, Wilmington DE 19898 david.e.cummings-1@dupont.com

Prepared for Presentation at American Institute of Chemical Engineers 2013 Spring Meeting 9th Global Congress on Process Safety San Antonio, Texas April 28 May 1, 2013 UNPUBLISHED

AIChE shall not be responsible for statements or opinions contained in papers or printed in its publications

GCPS 2013 __________________________________________________________________________ Key Strategies for Implementing a Corporate Fatigue Risk Management System

David E. Cummings
E.I. DuPont de Nemours & Co.,Inc.

1007 Market Street, Wilmington DE 19898 david.e.cummings-1@dupont.com Keywords: fatigue, fatigue management, ANSI/API 755, human factors

The First Edition of ANSI/API Recommended Practice 755 Fatigue Risk Management Systems for Personnel in the Refining and Petrochemical Industries was published in April 2010 as a result of the BP Texas City catastrophe of March 2005. In the last two years, many companies in the petroleum and chemical processing sectors have been working to implement the basic tenants of this new practice. An effective fatigue management program involves a multi-disciplined team approach to engage various functions of an organization, including PSM/EHS, HR, Medical, and Operations. This paper will explore the process, associated elements, and key issues integral to the design, development, and implementation of a formal fatigue management system across DuPont as a global manufacturing organization with a diversity of high hazard processes. This includes internal policies, training and development, standardized procedures and tools, and internal collaboration strategies.

1. Introduction
ANSI/API Recommended Practice 755 was issued in 2011 based on a recommendation issued to the American Petroleum Institute by the U.S. Chemical Safety Board as an outcome of the BP Texas City 2005 incident investigation report. Prior to that time, there was little industry guidance or standards on the subject of fatigue management (FM). There is and has been substantial literature published and technical resources developed on the general issues and concerns with fatigue management in terms of circadian rhythms and the effects on human performance variables, and many industries such as aviation and commercial transportation have adopted specific standards with accompanying regulatory requirements. E.I. du Pont de Nemours & Co. is a global science-based products and services company with over 200 manufacturing units across 70 countries involving nine business segments. It is engaged in technology solutions and innovation across a range of disciplines, including agriculture and industrial biotechnology, chemistry, biology, materials science and manufacturing, offering a wide range of products and services for markets including agriculture and food, building and construction, electronics and communications, general industrial, and transportation. Manufacturing technologies and site operations involves a myriad of process hazards, including flammable liquids and gases, highly toxic materials, reactives, combustible dusts, corrosives, asphyxiants, and thermal/mechanical energies. DuPonts philosophy and current practice is to apply process safety management systems and requirements to all manufacturing operations and locations using one global set of internal elements and technical requirements. Based on the companys current risk profile, process safety systems that help maintain a high degree of operational discipline and reduce the potential for human error, including those that could be related to employee fatigue, are key elements of an integrated risk approach.

GCPS 2013 __________________________________________________________________________ DuPonts process safety management model and system has included a long standing element and requirements for Training and Performance where the performance portion of the element requires a specific focus on physical capabilities (fitness for duty) as well as diminished capacity (mental and psychological capabilities for process safety sensitive jobs, including the effects of fatigue) for operating and maintenance personnel working at all manufacturing locations. DuPont updated the Training and Performance element to specifically include an internal fatigue management policy as an integral part of the global process safety management program in January 2011. Initial implementation of the new technical requirements has been progressing since that time. The program embraces the following key elements of fatigue management as described in ANSI/API 755: Maximum hours of service Training for employees and line management Staff workload balance Work environment evaluations Medical Evaluations (personal risk factors)

Implementing a fatigue management system was integrated into corporate process safety management systems; however, active involvement of other key functions within the organization is important in this area. Within DuPont, the process safety competency serves as the corporate owner on FM, while other key functions such as Human Relations (HR), Integrated Health Services, and Occupational Health (EHS) all have played a meaningful and contributing role in developing and implementing portions of the FM process in the initial design stages, during implementation, and in an ongoing role as part of the run and maintain phase of this work. This collaboration has contributed greatly to the overall results.

2. Foundational Activities for FM Implementation

Building an internal fatigue management system based on the elements in the API standard requires a number of key strategic decisions and initiative planning prior to formal roll-out, as well as ongoing support, training, and tools during the active implementation phase. The following provides examples of many questions that were posed as part of DuPonts initial design strategy for fatigue management: Should the fatigue management program be a global or U.S. based only focus? What is the current state at all sites (does anyone already have an effective FM system)? What will be the major impacts on Operations at each site (resources, costs, tracking tools)? Who are the key stakeholders who should be involved in the design of the system? Which sites will be required to implement a local fatigue management system? How will fatigue management requirements be codified in corporate policies? What elements are consider mandatory versus suggested practices/guidance? What site roles and positions will be included in FM (and not included)? What is the required internal timing for implementation and how will it be tracked? When and how will the PSM auditing process incorporate FM elements during site reviews? How will interpretations and guidance on FM be captured and distributed? Will the program be required for contractors, and if so, which ones? Are there leveraged solutions and tools that can be developed to assist sites for effectiveness and efficiency? Who has primary responsibility to ensure compliance with Table 1 (employees or line managers)?

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2.1 Site Surveys to Define Current State FM Practices

The first step that was taken to develop a fatigue management program across DuPont was to conduct a detailed survey across all manufacturing locations to accurately determine the present state relative to the main elements of ANSI/API 755. This included the following self-assessment parameters: Existence of site level fatigue management written programs and policies Existence of local policy limits on overtime and maximum consecutive work hours Past and present fatigue management training Existence of tools or tracking systems to measure work hours and overtime by work group and employees Local site systems and capabilities to integrate fatigue management into existing medical programs Forecasted requirements and needs with local labor organizations and contracts for fatigue management

Once the site survey was completed, the data was collated and utilized as inputs for the development of corporate policies, timing and implementation plans, management training, and development of internal FM training and guidance documents. The survey was collected and analyzed in a simple excel tool similar to that depicted in Figure 1.

Figure 1: Sample Site Survey Baseline Questions and Spreadsheet

2.2 Corporate PSM Standard Policies and Requirements

DuPont drafted and included a new fatigue management section in the global process safety management standard as part of the Training and Development element as depicted in Figure 2. Specific new content in the corporate standard was intended to incorporate the minimum mandatory requirements involving fatigue management elements described in ANSI/API 755, and not a be a re-statement of the guidelines full technical content. It was also defined with the standard scope that new internal fatigue management requirements would be applied to vital PSM roles within DuPont sites as well as to specific types of contractors, but only at higher hazard site operations (DuPont classifies all global manufacturing locations as higher hazard processes or lower hazard operations). The standard changes went through a broad internal peer review and was published in January 2011.

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Figure 2: DuPonts Process Safety Management Model

2.3 Education and technical guidance to drive consistency

Internal webinars were developed and delivered which were targeted to several different key audiences, including site PSM leaders, operations leadership, site HR leaders, and contract administrators in order to develop foundational knowledge of the new FM program elements across the organization. The initial ANSI/API 755 standard as published is a performance based standard with specific prescriptive FM requirements such as Table 1 maximum hours of service limits, however, it became apparent early in the FM implementation process that numerous technical and interpretive questions existed both on the standard, as well as within DuPonts local site implementation efforts. In order to attain as much consistency as possible, a series of Frequently Asked Questions (FAQs) were collected and formally documented with specific guidance. Once vetted and resolved, these FAQs were distributed to sites and posted on the internal PSM website for retention and routine access. Additional questions and needs for interpretations have continued to surface from sites and functions and been added to the FAQ evergreen document even after almost two years of implementation progress. There is currently no effective platform within industry to collect and address these types of interpretations in a consistent manner. As another step to implement consistency across all locations, DuPont developed and distributed a standard site based written fatigue management program or template which can be applied by each site as a base document and modified to add in local responsibilities, procedures, and line management practices. There are also unique situations that may develop for plant operations that do not fit neatly into the existing definition and guidance in ANSI/API 755 involving outages as it applied to extended consecutive work shifts in Table 1. The existing definition for outages includes the following:
Planned or unplanned interruption in the normal operations of a unit or plant, including mobilizing or demobilizing. Outages include but are not limited to such things as turnarounds, unit shutdowns, operational responses, etc.

This definition does not cover all situations where an extended work set and shift schedules may be applicable and necessary to minimize fatigue, including commissioning new plants or substantive MOC projects where construction, PSSRs, start-ups, and lining out the process may be necessary involving

GCPS 2013 __________________________________________________________________________ operations, technical and R&D resources, response to natural disasters (e.g., hurricanes, earthquakes, etc.), mothballing or dismantlement activities, new product trials in pilot plants, etc. Each company should define when and how these types of situations should be managed in terms of unique conditions and the application of extended work hours and shift schedules with potential fatigue factors. DuPont adopted an internal policy at the site level to develop a formal exception process for situations where the Hours of Service Limits (ANSI/API Table 1) may not be met due to specific circumstances. An exception process is discussed in the standard in Section 4.8.5 with general criteria, however; the specific procedures and details should be developed by each company. For DuPont, the exception approval process has been designed to be executed at the local level for a case-by-case exception by site or unit management. For longer term, permanent, or standing exceptions, off-site leadership approvals are required. In both cases, exceptions will document the situation, the rationale, and any relevant alternative controls or methods to be taken to mitigate the potential effects of fatigue. This includes use of a standardized form and line management approvals for each exception situation.

3. Shift Schedules and Maximum Hours of Service

API 755 includes specific requirements for maximum hours of service provided in Table 1 of the standard. The hours of service element in FM has received the most internal discussion, review and implementation work. A detailed analysis of existing shift rotation schedules at all U.S. site operations was conducted by DuPont HR to ascertain if any inherent conflicts existed in the current schedule structures that were not be fully compatible with Table 1. This included a specific emphasis on the number of consecutive shifts and the total hours of recuperative time for both day and night shift rotations. This review revealed that DuPont had over one hundred (100) different shift rotation schedules in use at all U.S sites for 8, 9, 10, and 12-hour operations and maintenance shifts. In a very limited number of cases, an inherent conflict in the site shift structure existed which did not fully meet the maximum hours of service in Table 1 (mostly involving the transition from day to night 12 hour shift schedules). Figure 3 describes the shift schedule analysis results at all US sites, and figure 4 provides an example of the detailed shift schedules which were generated and reviewed at a typical multi-unit site.

Figure 3: Data Summary for Plant Rotating Work Schedules

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Figure 4: Sample Site Analysis Time and Attendance Schedules A significant part of DuPonts initial evaluation of existing shift schedules and site data survey questions focused on the types of tracking and software (scheduling) tools that were either already in use or could require development to track work hours, including scheduled and unscheduled overtime call-ins. In most cases, site systems tracking overtime rates for work groups but not specific employees other than annual salary statistics. Site level tracking systems which were cataloged that could be modified and used to monitor maximum hours of service and off site recuperation times included the use of an HR work hours and pay status, web based tools, security gate electronic logs, and access data bases. None of these existing systems as structured were deemed an acceptable and reliable means to proactively schedule, manage, and track individual employee work hours. A six sigma black belt resource and project was initiated in order to review each of the work hour and overtime tracking system attributes, and develop a standardized solution that could be used at all sites to help line management ensure that the maximum hours of work in ANSI/API 755 Table 1 maximum hours of work. As part of the six sigma project, the main attributes of an overtime tracking system were captured as illustrated in figure 5.

Figure 5 : Site Survey Data Desirable Attributes for Electronic Scheduling and Tracking

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4. Training
DuPont developed a standardized and leveraged training package which could be applied at each site in order to provide initial and refresher training on fatigue management. Two packages were developed ; one to target employees who were subject of FM (operators and mechanics), and one for line managers who supervise these employees. The guidance and criteria in ANSI/API 755 was used to create the technical content of each package. Initial training was designed to be one hour of information and cover the following topics: Basics of sleep and fatigue including causes, symptoms, and prevention strategies Understanding risk of on the job fatigue and impacts on safety Overview of the site fatigue management system including maximum hours of service criteria

DuPont occupational health resources have also previously partnered with external groups such as the Porcupine Health Unit and the Sudbury & District Health Unit in Canada to develop additional sources of fatigue management training such as the Shiftwork like Clockwork (SWLCW) training modules illustrated in Figures 6 and 7 . These materials provide significant details over nineteen (19) modules that can be used for both initial training of new employees and refresher training for existing employees. DuPont has adopted an internal FM refresher training frequency of three years.

Figure 6: Shiftwork Like Clockwork Training Program

Figure 7: Shiftwork Like Clockwork Training Modules

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5. Staff Workload Balance

Another key tenant of the ANSI/API 755 standard includes a focus to help ensure a staff workload balance is achieved and maintained within each operating area at each site. This should include an analysis of work activities on each shift, and a focus on considerations and impacts related to employee turnover, long term disability, extended time off due to personal reasons (vacation, leave of absence), staffing vacancies, and other sources of long term absenteeism. DuPont has adopted a policy that each site will conduct and document an annual review of staff workload balance within each higher hazard operating unit to periodically evaluate the status and performance in this area. A standardized set of evaluation criteria for the annual review was developed and distributed to all sites as a leveraged tool to help ensure consistency across all locations.

6. Work Environment
DuPont has utilized a series of PHA related tools and checklists to conduct baseline, cyclical and MOC related evaluations for over the past twenty years. A human factors checklist has been one of these historical tools. DuPonts strategy to address FM work environmental factors involved adding content to these existing tools in order to help ensure that fatigue management workplace factors were considered and evaluated during all cyclic and project related PHAs. Integrating this review into existing PHA processes has proven to be a more sustainable and effective practice rather than creating a stand alone fatigue management work environment assessment process.

7. Medical Evaluations (Personal Risk Factors)

DuPont Integrated Health Services, in coordination with the process safety competency, developed a fatigue management medical screening approach and screening form which could be used as a voluntary tool during periodic health exams for shift employees who may be subject to fatigue risks. The health services group also provided targeted FM training to site medical professionals (nurses, doctors, and NPs) in order to consistently apply FM medical aspects, including both the proactive (voluntary) approaches as well as for cause evaluations where potential fatigue has been observed by line management in the work place. DuPont Medical also worked with the corporate HR, labor relations, and legal functions to develop and communicate consistent medical guidance and case management methods where employee fatigue concerns have been identified. This is an area where emerging issues, specific interpretations, and case law should be considered by each entity such as the following (examples only): 1) Where additional FM medical testing is prescribed based on an employees physical status and personal risk factors (obesity, concerns about sleep apnea) which could relate to fatigue in the workplace, should the costs for further medical evaluations be borne by the employee as part of personal health care or as part of the occupational medical program for a given company? 2) How should an employee be managed if they refuse to participate in additional medical screening or specific diagnostic tests that focus on fatigue management? 3) Are certain medical conditions that can cause fatigue in the work place subject to the 1990 Americans with Disabilities Act (ADA) in the United States and if so, which ones, and what may be the expectations for reasonable accommodations?

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8. Contractors
DuPont has also adopted internal process safety requirements for a fatigue management program applied to selective contractors who work in higher hazard process areas which typically is limited to resident maintenance service providers, test and inspection consultants, and specialized services resources who may be on-site only during major turnarounds. Contractors are required to develop their own internal programs with the basic elements of fatigue management as described in ANSI/API 755. DuPont will typically audit their systems and performance at the site level on a periodic basis to verify the program is adequately implemented. Many major contractors have embraced an enhanced focus to manage fatigue risks. In one example, a resident maintenance contractor developed a modified approach for their employee work scheduling during an annual shutdown with a DuPont site in Protection Technologies in order to improve fatigue management practices. The shutdown typically lasts 15 days involving 12 hour shifts and the contractor reduced the shift duration to 11 hours and inserted a day off for each employee during the process. Feedback from the employees was very positive, and this modifications were managed so that there were no additional costs or delays in the shutdown schedule. This unique approach serves as a good example where the owner/operator (DuPont) worked in collaboration with contactor partners to achieve a common objective which also supported the business and operations.

9. Incident Investigation Processes

DuPont maintains a global internal incident investigation reporting, classification and investigation policy for both EHS and process safety incidents which addresses communications, investigation teams, root cause failure analysis (RCFA), recommendations tracking, and overall documentation. The existing policy does not specifically include or consider fatigue management components as they may relate to contributing factors and human error as part of the overall RCFA process. At some point in the future, the policy will be updated to include a focused consideration of fatigue during all formal investigations, particularly when human error has been identified. This may include a standardized review of employee work shift schedules and overtime for at least the previous two weeks prior to the incident date.

10. Conclusion
Based on the lessons learned from the BP Texas City incident in 2005 and the new ANSI/API 755 Recommended Practice, internal company initiatives to integrate fatigue management into existing risk management systems is a prudent and necessary step to help minimize the potential for human error and the associated episodic incidents in high hazard process operations. The process safety function should be the logical process owner, however, the initial systems design and implementation activities involving fatigue management necessitate a collaborative effort between other key company and site level resources and functions, including operations, human relations, health services and occupational health, in order to develop an integrated system and achieve maximum risk management benefits. Since the ANSI/API RP 755 standard includes primarily performance based content, implementation also may involve a substantial number of internal corporate or local policy decisions, and potential issues which require focused discussions and interpretations to promote consistency with internal applications at each site. The initial FM implementation process may span two to three years in order to plan, educate, develop, implement and monitor site level organizations and accompanying results. Organizations that include

GCPS 2013 __________________________________________________________________________ fatigue management requirements in existing PSM policies should recognize that implementation progress may vary at each site depending on size, complexity, shift schedules, the existence of labor unions with collective bargaining agreements, and other factors. These potential variations on the rate of progress require a simplified process to track implementation across all applicable operating sites (see figure for an example of tracking based on the six main program elements). Integration of fatigue management evaluation criteria into existing PSM audit protocols and systems is typically the last step in a long term FM implementation and performance measurement process.

Figure 8: Example of Visual Management Board Site Progress

11. References
(1) American National Standards Institute (ANSI)/American Petroleum Institute (API) Fatigue Risk Management Systems for Personnel in the Refining and Petrochemical Industries - RP 755 (First Edition, April 2010)