Consultation document: Fatigue management system (FMS) requirements

This document outlines the requirements Transport Canada plans to include in the proposed Fatigue Management System Regulations.

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Since the early 1990s, sleep-related fatigue has been identified as a contributing factor in at least 29 rail occurrences. This has led the Transportation Safety Board (TSB) to include fatigue management as a Watchlist item in 2016 and has since grown to be a key safety issue and Watchlist item for the transportation industry as a whole. The TSB is calling on Transport Canada, together with industry, employees and their bargaining agents, to develop a more comprehensive approach to fatigue management in the rail sector.

Significant improvements to address the issue of fatigue were made with the approval of the Duty/Rest Rules for operating employees in November 2020. These rules address the principles of fatigue science and once fully implemented in 2023, will replace the current Work/Rest Rules. They represent a culmination of several years of collaborative work between the department, industry and employee bargaining agents. The new rules require railway companies to develop fatigue management plans and include provisions which place limits on the length of duty period, increase the length of the minimum rest period between shifts and establish limits on the total number of hours that an operating employee can work in a week or month.

Although beneficial, these prescriptive limits and regulatory instruments only establish requirements relating to operating employees. An examination of the TSB investigation reports between 2014 and 2019 that have identified fatigue as a cause or contributing cause, demonstrate that fatigue in relation to non-operating employees has led to unsafe conditions. The following reports contain examples of non-operating roles that were determined to have been impacted by fatigue:

  • R14W0256 – Managers who completed their shift and then adopted emergency roles
  • R15V0003 – Director of Rail Traffic Control
  • R16D0076 – Flag person
  • R16H0024 – Maintenance of Way employees

It is clear therefore that railway companies must manage fatigue for all employees who carry out duties that are essential to safe railway operations.

Transport Canada recognizes the need for a more systematic approach to fatigue management that identifies and addresses the challenges associated with a purely prescriptive approach. The proposed Fatigue Management System (FMS) provides a comprehensive systematic approach which uses proactive and predictive analysis of operational conditions and continual improvement practices to reduce fatigue related risks for all employees whose duties are essential to safe railway operations.

Additionally, its four components are scalable to the size and scope of a railway company’s operations. In effect, an FMS provides layers of defense to prevent fatigue hazards and error producing conditions from becoming incidents or accidents.


The purpose of the proposed Regulations is to enhance the safety of personnel who carry out duties essential to safe railway operations and to enhance the safety of the public by:

  • requiring railway companies to develop, implement and continually improve an FMS in order to manage employee fatigue in a systematic manner


Subsection 18(1) of the Railway Safety Act (RSA) establishes the following overarching regulatory authority for the proposed Regulations:

18 (1) The Governor in Council may make regulations

  • (a) …
  • (b) Declaring positions in railway companies to be critical to safe railway operations;
  • (c) Respecting the following matters, to the extent that they relate to safe railway operations, in relation to persons employed in positions referred to in paragraph (b):
    • (i) …
    • (ii) hours of work and rest periods to be observed by those persons
    • (iii) …


The following definitions are set out in paragraph 4 of the RSA and would be used for the purposes of the proposed Regulations:

(1) In this Act,

Minister means the Minister of Transport; (ministre)

railway company means a person that constructs, operates or maintains a railway; (compagnie de chemin de fer)

Proposed Fatigue Management System Regulations

1.0 Application

These proposed Regulations apply to employees whose duties are essential to safe railway operations, as defined in these Regulations, and persons other than employees who are authorized by the railway company to access the railway and whose activities may affect the safety of railway operations.

  • 1.1 Railway companies that hold a Railway Operating Certificate must develop, implement and continually improve a Fatigue Management System (FMS) to manage employee fatigue.

2.0 Definitions

The following definitions would apply in the proposed Regulations:

  1. Accountable executive means the individual designated by a railway company to be responsible for operations or activities of the railway company to be accountable for the extent to which the requirements of the FMS are met.
  2. Duty period means a period of time beginning when the employee reports for duty at the location and time designated by the railway company for a particular activity, and ending when the employee is released from all activity, including, administrative work, training, and meetings by the railway company.
  3. Duties essential to safe railway operations means the activities of any person who is authorized by the railway company to access the railway and where those activities may affect the safety of railway operations. This includes but is not limited to activities performed by: any person involved in the movement of trains and the maintenance of the equipment and infrastructure, supervisors, and managers.
  4. Employee means, for the purposes of these Regulations, any person carrying out duties essential to safe railway operations.
  5. Fatigue means a physiological state of reduced mental or physical performance capability resulting from sleep loss, extended wakefulness, physical activity or any combination thereof, which may impair an employee’s ability to safely operate equipment or perform safety-related duties.
  6. Fatigue Management System (FMS) means a systematic and structured approach to developing and implementing processes to prevent and manage fatigue risk, and to audit the processes for effectiveness and compliance.
  7. Fatigue hazard means a source of potential fatigue that could cause a fatigue-related error and contribute to an incident or accident.
  8. Fatigue risk means the assessed likelihood and severity of the consequence(s) that could result from a fatigue-related error caused by a fatigue hazard.
  9. Fit for duty, with respect to an employee, means that their ability to operate safely is not impaired by fatigue or any fatigue-related condition and is not likely to become so impaired during the duty period.
  10. Safety performance means an organization’s safety achievement as defined by the extent to which an organization achieves its safety performance targets.
  11. Safety performance indicator means a data-based parameter used for monitoring and assessing safety performance.
  12. Safety performance target means the planned or intended objective or outcome for a safety performance indicator over a given period.

Proposed Fatigue Management System - Components

To improve the management of fatigue in the railway industry, railway companies must implement a robust and comprehensive FMS that includes the components and elements defined in these Regulations. The FMS provides the processes and procedures necessary to demonstrate to Transport Canada that fatigue is being effectively managed. The level of detail required in each of the components is scalable according to the size of the railway company and the scope of its operations.

3.0 The company shall have an FMS that includes:

  1. a fatigue management plan
  2. fatigue management processes and procedures
  3. a fatigue management training and awareness program
  4. a continual improvement process for the FMS

Fatigue management plan

The purpose of the plan is to provide an outline of the railway company’s commitment and approach to the management of fatigue risks specific to their organizational context and operational reality. The fatigue management plan is a road map that explains to employees, company management and Transport Canada how the FMS works, who is responsible for processes, and how it will be monitored and measured to assess whether fatigue is being managed and whether the system is working effectively.

3.1 The company’s fatigue management plan shall include:

  1. a fatigue management policy — signed by the accountable executive — that establishes how responsibility for managing fatigue is shared between the company and employees including a description of the roles, responsibilities and accountabilities of management and employees with regards to that shared responsibility and the method by which the policy will be made accessible to all employees
  2. a description of:
    1. the type of operations conducted by the company, including size, complexity, transportation of dangerous goods, traffic density, traffic patterns
    2. the characteristics of the territory on which the company operates, including geographical considerations
  3. defined responsibilities in relation to fatigue management for:
    1. employees whose duties are essential to safe railway operations
    2. company managers and supervisors
    3. persons managing the FMS; including the accountable executive
  4. safety objectives, including
    1. a prioritized list of safety objectives derived from identified fatigue hazards and related risks and actions taken to address them
    2. a method used to determine risk priorities
    3. a method for managing fatigue risks in day-to-day railway operations
    4. a method and frequency for updating the safety objectives
  5. safety performance indicators to measure the attainment of the safety objectives including:
    1. a description of the indicators used to measure the attainment of the safety objectives mentioned in 4.a.
    2. a method and frequency for monitoring and updating safety indicators
  6. a process that:
    1. defines how the fatigue management plan is reviewed and updated
    2. identifies the person responsible for reviewing and updating the fatigue management plan
    3. requires the accountable executive to approve the plan
  7. a training plan that describes the content, the delivery method and frequency of the initial and recurrent training
  8. a plan for communicating fatigue related information and information about the FMS to employees
  9. an outline of the processes and procedures that comprise the FMS
  10. a procedure for internal reporting and data collection that includes:
    1. defined criteria by which an employee can report that they are not fit for duty due to fatigue and any fatigue hazards, without fear of reprisal and respecting privacy rights
    2. a method that describes the actions that will be taken by the company in reaction to a declaration of being not fit for duty, including how an employee will be replaced when they are unfit for duty or unfit to complete a duty period

Employee collaboration

3.2 The company shall have and implement a process to collaborate with the bargaining agents of those employees involved in the FMS and/or employees, at a minimum, in the development, implementation and continual improvement of:

  1. the policy and procedure for the internal reporting of fatigue
  2. information collection methods
  3. the fatigue risk management process
  4. any risk controls resulting from identified fatigue risks

Fatigue management processes and procedures

The purpose of the fatigue management processes and procedures is to identify, assess and control fatigue risks in railway operations. These use reactive and proactive information to monitor and manage fatigue risks.

3.3 The FMS shall include procedures for:

  1. analyzing planned schedules in relation to time worked in order to assess whether additional potential for fatigue may be present beyond what is being considered
  2. adjusting schedules when their maximum scheduled duty period is usually exceeded
  3. limiting duty hours according to fatigue science principles
  4. ensuring there is no extended hours of wakefulness according to fatigue science principles
  5. providing adequate rest time according to fatigue science principles to meet the physiological sleep needs of humans
  6. providing fatigue mitigation measures when work hours include the hours between midnight and 6 am

3.4 The FMS shall include or reference a process to do the following:

  1. track and record all employee duty hours
  2. manage emergency situations that require employees to work beyond their duty time
  3. manage deadheading for employees at the end of a shift to prevent cumulative fatigue and provide adequate rest before the employee’s next shift

3.5 The FMS shall include procedures for information collection and management that include a method for:

  1. employees to submit to the company and the company to collect employee reports of fatigue, fitness for duty and fatigue hazards
  2. the company to acknowledge in writing, to employees, receipt of each fatigue report and advising of any follow-up action
  3. an annual analysis for identifying trends on these reports so mitigating action can be taken
  4. collecting information to identify fatigue-related hazards, including:
    1. near miss information
    2. fatigue data derived from an analysis of current and future work schedules
    3. fatigue data from comparisons of planned schedules in relation to time worked
    4. fatigue studies and scientific data

3.6 The FMS shall include or reference a process for conducting incident and accident investigation where fatigue may be a contributing factor, including procedures for the following:

  1. collecting and storing information about the incident or accident including the time of day, the time the duty period started, number of hours into the duty period the accident happened, whether or not the employee’s shift start time had been delayed and by how much, the hours of duty and rest of the employees in the past 24 hours and the past 7 days
  2. analyzing the results of the investigation, including root cause analysis
  3. developing and implementing remedial action where appropriate, and for measuring its effectiveness
  4. communicating the results of the analysis and measurement of the effectiveness of remedial action to the management, employees, and other stakeholders

3.7 The FMS shall include or reference a process for managing fatigue risk, and shall include procedures for:

  1. identifying the cause of fatigue-related hazards
  2. identifying potential for fatigue by examining employees’ schedules including those hazards associated with lack of advance notice of a change of schedule or schedule start time, working overtime, and working between the hours of midnight and 6am (the Window of Circadian Low)
  3. assessing the likelihood that a fatigue-related event will occur and the severity of its consequences
  4. identifying and prioritizing the risks that require remedial action
  5. creating and updating a register of the risks that are identified
  6. determining the remedial actions to be taken
  7. developing safety performance indicators to measure the effectiveness of the remedial actions taken in accordance with subsection 6.

3.8 Companies must implement the processes and procedures listed in 3.3 to 3.7.

Fatigue management training and awareness program

The purpose of the fatigue management training and awareness program is to ensure that all personnel who carry out duties essential to safe railway operations are knowledgeable about the impact of fatigue on human performance and are trained and competent to perform their FMS duties.

Building awareness of fatigue through employee training is a necessary component of an effective FMS. When employees are aware of their obligations under the FMS and understand why fatigue is a safety hazard, they are motivated to participate in the system and to implement risk controls.

3.9 The company shall develop and implement a fatigue management training and awareness program for all employees with duties essential to safe railway operations which shall include the following subjects:

  1. the components and functioning of the FMS and the accountable executive, employee and management’s accountabilities and responsibilities
  2. the actions to be taken with respect to fatigue-related risks
  3. personal fatigue management strategies relating to:
    1. sleep hygiene
    2. lifestyle, exercise and diet
    3. the consumption of alcohol and drugs
  4. the impact of fatigue on human performance and rail safety, including:
    1. sleep quality and duration
    2. extended hours of wakefulness
    3. inadequate rest and cumulative fatigue
    4. the effect of shift work and overtime
    5. the circadian rhythm
    6. the effects of time zones changes
  5. how to recognize fatigue in themselves and in others and fatigue self-assessment techniques
  6. sleep disorders, their impact on railway safety and treatment options
  7. factors that may exacerbate the impact of fatigue, including but not limited to, weather, traffic, visibility, equipment failures, and time pressure

3.10 The fatigue management training and awareness program shall ensure that employees with specific FMS duties are provided with a competency-based training program that includes processes to:

  1. establish the competencies necessary for employees to be able to effectively perform duties related to the FMS
  2. provide competency-based training for persons who have been assigned duties in respect of the FMS
  3. measure the level of competency attained by each person who receives the training

3.11 The company shall provide refresher fatigue training to employees, whenever the following occurs:

  1. changes to FMS processes and the fatigue management plan
  2. a need is indicated by the fatigue information collected as per section 3.5
  3. changes to the status of safety objectives and indicators required by subsections 3.1.4. and 5.

3.12 The company shall maintain a training record that includes:

  1. a list of all the training that each employee has received in accordance with these Regulations, including the date
  2. evaluation results for each employee who has received training in accordance with sections 3.9 and 3.10
  3. a record of remedial measures taken where an employee fails to achieve an acceptable evaluation result
  4. a copy of all training material

3.13 For the purposes of raising awareness of fatigue management, a company shall have and implement a procedure for communicating the following information to its employees:

  1. industry reports on fatigue
  2. industry best practices in respect of fatigue management
  3. the results of a review or audit of the FMS

Continual improvement process for the Fatigue Management System

A continual improvement process provides management with feedback regarding compliance to regulatory requirements, FMS policies, processes and procedures, and helps identify where corrective or preventative actions are required. The update, review and audit requirements allow companies to better understand the effectiveness of FMS processes, fatigue risk controls, and safety performance. Both compliance and effectiveness are essential to achieving safety objectives.

Requirement to update the FMS

3.14 The company shall have and implement a process for the review and update of the FMS in circumstances where:

  1. there is a change in the size and scope of railway operations
  2. information collected indicates an adverse trend in the level of fatigue

Requirement to review the FMS

3.15 The company shall establish and implement a process for the annual review of the effectiveness of its FMS that includes procedures for the assessment of:

  1. the fatigue management process
  2. the adequacy of the safety performance indicators
  3. the attainment of the safety objectives

3.16 As part of its FMS review, the company shall:

  1. determine what remedial actions are necessary to remedy any deficiency identified by the review
  2. implement the remedial actions
  3. keep a record of any determination made under subsection 1. and the reason for it

Fatigue Management System audit

3.17 The company shall conduct an audit of its FMS once every three years and when the following occurs:

  1. after an incident or accident for which fatigue is determined to be a cause, root cause, or contributing cause and that the company is required to report under the Canadian Transportation Accident Investigation and Safety Board Act to the Canadian Transportation Accident Investigation and Safety Board
  2. after a major change in the company’s activities, operations or practices that could affect the levels of fatigue or alertness of the employees, such as an increase in the scope of operations, or a reduction in the number of employees, or increase in employees’ responsibilities

3.18 The audit shall include procedures for:

  1. assessing the extent to which the company has developed and implemented its FMS
  2. assessing the effectiveness of its FMS
  3. analyzing the findings of the audit and determining their cause and contributing factors
  4. developing, implementing and monitoring preventive measures and remedial actions to address the findings of the audit
  5. maintaining records, including the findings of the audit, the preventive measures and remedial actions to address those findings and any follow up taken in respect of those measures and actions

3.19 The company shall not assign auditing duties to any person who is responsible for carrying out a task or an activity that will be evaluated by the process except where the size, nature and complexity of the company operations and activities, make it impractical to assign the duty to a person who is not responsible for carrying out the task or activity.

3.20 The company shall notify the Minister and identify any changes made to the FMS as the result of an audit within 60 days after the change is made.

Documentation and information storage

3.21 The company shall ensure that the FMS is documented, including the policy, plan, and all other procedures and processes that have been established and implemented in accordance with these Regulations.

3.22 The company shall ensure that the results of implementing the processes and procedures developed in accordance with these Regulations are documented.

3.23 The company must use a secure data storage system to protect fatigue information provided by or collected from employees requiring:

  1. a method for retaining records of any information collected as per section 3.5
  2. a method to limit access to employee fatigue information

3.24 The company must keep the documentation and records in accordance with these Regulations for 6 years after the day on which they are created.

3.25 All documentation pertaining to the FMS shall be made available to the Minister upon request.

Coming into force

4.0 The proposed Regulations would come into force on the first anniversary of their publication in the Canada Gazette, Part II.

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