frequency and length of breaks during shifts, shift succession, worker commute time, as well as the mental and physical stress of the job. Even though studies support 12-hour shifts are associated with increased occupational injuries and accident (higher rates with subsequent, successive shifts), a synthesis of evidence cites the importance of all factors when considering the safety of a shift. Shift work was once characteristic primarily of the manufacturing industry, where it has a clear effect of increasing the use that can be made of capital equipment and allows for up to three times the production compared to just a day shift. It contrasts with the use of overtime to increase production at the margin. Both approaches incur higher wage costs. Although 2nd-shift worker efficiency levels are typically 3–5% below 1st shift, and 3rd shift 4–6% below 2nd shift, the productivity level, i.e. cost per employee, is often 25% to 40% lower on 2nd and 3rd shifts due to fixed costs which are "paid" by the first shift. Shift system The 42-hour work-week allows for the most even distribution of work time. A 3:1 ratio of work days to days off is most effective for eight-hour shifts, and a 2:2 ratio of work days to days off is most effective for twelve-hour shifts. Eight-hour shifts and twelve-hour shifts are common in manufacturing and health care. Twelve-hour shifts are also used with a very slow rotation in the petroleum industry. Twenty-four-hour shifts are common in health care and emergency services. Shift schedule and shift plan The shift plan or rota is the central component of a shift schedule. The schedule includes considerations of shift overlap, shift change times and alignment with the clock, vacation, training, shift differentials, holidays, etc., whereas the shift plan determines the sequence of work and free days within a shift system. Rotation of shifts can be fast, in which a worker changes shifts more than once a week, or slow, in which a worker changes shifts less than once a week. Rotation can also be forward, when a subsequent shift starts later, or backward, when a subsequent shift starts earlier. Evidence supports forward rotating shifts are more adaptable for shift workers' circadian physiology. One main concern of shift workers is knowing their schedule more than two weeks at a time. Shift work is stressful. When on a rotating or ever changing shift, workers have to worry about