September 7, 2010 | Mark Paradies

ANSI/API Fatigue Risk Management System Recommended Practice

The American Petroleum Institute and the American National Standards Institute have published a recommended practice titled: Fatigue Risk Management Systems for Personnel in the Refining and Petrochemical Industries (ANSI/API Recommended Practice 775, First Edition, April 2010).

You can download the standard at this site:

Now, what do incident investigators need to know about this standard when performing a root cause analysis? If you are at a refinery or petrochemical plant, you are required to consider fatigue when doing your investigation. The standard says:

4.7 Incident/Near Miss Investigation

The investigation of incidents should be conducted in a manner that facilitates the determination of the role, if any, of fatigue as a root cause or contributing cause to the incident. Information collected should include the time of the incident, the shift pattern, including the number of consecutive shifts worked, the number of hours awake, the number of hours of sleep in the past 24 hours by the individuals involved; the shift duration (and any overtime worked); whether the incident occured under normal operations or an extended shift; whether an outage was occurring; and, other fatigue factors. It should be noted that for individual incidents, often no definitive conclusion regarding the role of fatigue may be possible. However, aggregate analysis of incidents may reveal patterns suggestive of the role of fatigue that is not apparent by evaluating incidents individually.

When using TapRooT®, fatigue has always been considered as part of the “15 Questions” asked for every Human Performance Difficulty. The first question asks:

Was the person excessively fatigues, impaired, upset, distracted, or overwhelmed?

This question is expanded on in the Root Cause Tree® Dictionary. These questions were developed with the help of Circadian Technologies. We also worked with them to develop a free internet based fatigue evaluation tool called FACTS (Fatigue Accident/Incident Causation Testing System). You can try it for free at:

Want to find out more about fatigue and FACTS? The attend the TapRooT® Summit. Rainer Gutkuhn (one of the designers of FACTS) will show attendees in the Behavior Change & Stopping Human Error Track how to use FACTS in an investigation.

That’s just one of the many great sessions at the Summit. See:

for the complete Summit Schedule.

Root Cause Analysis
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