NTSB Chairman Warns Of The Dangers Of Fatigue In Transportation <


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NTSB Chairman Warns Of The Dangers Of Fatigue In Transportation

Daniel Guevarra

March 9, 2010 - Washington, DC - National Transportation Safety Board Chairman Deborah A.P. Hersman on Friday encouraged the sleep research and healthcare community to continue their efforts to educate transportation policy makers of the dangers of fatigue in all modes of transportation.

Speaking before the annual conference of the National Sleep Foundation in Washington, D.C., Chairman Hersman remarked that fatigue has been a concern for the Board since the creation of the agency in 1967 and it has been an issue on the Board's Most Wanted List of Transportation Safety Improvements since the list was established in 1990.

"The work of the National Sleep Foundation and other organizations and individuals is critical to improving transportation safety policy," said Chairman Hersman. "The NTSB is interested and willing to partner with you in developing a greater awareness of fatigue."

Hersman highlighted a number of accident investigations across all transportation modes that included fatigue as the probable cause or a contributing factor to accidents. As a result, the Board has made safety recommendations that range from deploying fatigue detection systems to reduce the occurrence of accidents to installing electronic on-board recorders that collect and maintain hours of service data on vehicle operators. "We can't always prove fatigue as a cause of an accident, but the frequency with which we now routinely document the presence of fatigue-related factors in transportation operations is alarming," Hersman stated.

Hersman remarked that while there are still no definitive tools to conclusively identify the degree to which a person is fatigued, the major challenge is to ensure that all those in transportation report to work rested and fit for duty -- for their own safety and for the safety of those they are transporting.

Below you can find the Remarks of Honorable Deborah A.P. Hersman Chairman National Transportation Safety Board Before The National Sleep Foundation Washington, DC March 5, 2010

Good Afternoon.  Thank you Dr. Balkin for that introduction and for the invitation to be here today.   

You have certainly picked an appropriate venue for your conference.  Just a short stroll from here, down by the waterfront, is a statue called ?The Awakening,? by J. Seward Johnson.  If you haven?t seen it, it depicts a giant coming out of the ground ? but only parts of the giant can be seen ? there is more that lies beneath, waiting to come out.

In many respects, I think those of us in transportation policy are coming to a new awakening ? a better understanding ? about fatigue.  And that is due, in part, to the work of organizations like the National Sleep Foundation, dedicating the time and effort to help better educate all of us about sleep and fatigue research.  Your work is helping transportation policy makers to have their own awakening about the need to address fatigue in all modes of transportation.

The National Transportation Safety Board is an independent Federal agency, with a 5 member Board.  Our members are appointed by the President and confirmed by the United States Senate.  We have a staff of 400, who investigate accidents and conduct studies in all modes of transportation.  Based on the work performed by our investigative and scientific staff, the Board determines the probable cause in transportation accidents and formulates recommendations to address the issues identified in a particular investigation.

Since 1990, the Board has published a Most Wanted List of Transportation Safety Improvements.   This list is essentially the Board?s ?top ten? ? and represents for us the most pressing issues that the Federal regulatory agencies and states need to address to improve transportation safety.  And yes, identifying fatigue and reducing the risks for fatigue in accidents is included on our Most Wanted List.  Just two weeks ago, the Board adopted our Most Wanted List for 2010 and once again, fatigue was included.

In fact, fatigue has been on our Most Wanted List since its inception 20 years ago. In that time, the Board has issued 34 separate recommendations concerning fatigue spanning all modes of transportation: aviation, highway, marine, railroad, and pipeline.  Many of the early recommendations focused on improving the hours of service regulations that govern transportation workers? schedules.  Essentially, the Board wanted to see the scientific research about work hours and fatigue ? the research that many of you have conducted over the years ? integrated into the regulations.  We have continued to push for these improvements in duty time limitations and we have seen some progress.  But, we need to see more, especially in aviation and in marine where the current rules were written before many of today?s workers were born.

In recent years, our understanding of the factors that lead to fatigue has broadened, as have our recommendations. Let me share a few of the factors that the Board has identified in accident investigations that have led us to a more diverse approach to the problem of fatigue.

One risk factor that we have seen linked to many fatigue-related accidents is sleep disorders, particularly obstructive sleep apnea. I hope that you had the opportunity to attend Dr. Mitch Garber?s presentation this morning in which he discussed several accidents across the modes where operators were impaired because of undiagnosed or improperly managed obstructive sleep apnea.

I won?t repeat what Dr. Garber said except to note that the Safety Board has recognized that sleep apnea is a major safety issue.  While we still await clear guidance and rules for transportation workers, the science indicates that with proper screening, detection and treatment, obstructive sleep apnea is a disorder that can usually be effectively managed.  The management of the disorder will not only lead to a substantial reduction in the risk of transportation accidents, but will also improve the health and quality of life for those who are diagnosed and treated. There is also a good chance that it will benefit employers in terms of reduced health care costs and sick leave time.

The Board has also addressed policies that allow workers to call in fatigued. This issue arose out of a February 2007 accident involving a Shuttle America/Delta Connection flight that overran the end of the runway while landing at Cleveland-Hopkins International Airport during snow conditions.

The accident captain reported that he had intermittent insomnia, which began approximately one year before the accident.   Although the captain reported that he felt well rested on the day before the accident, the investigation revealed that he was unable to sleep that night -- sleeping only about 45 minutes to an hour.  The captain did not tell anyone about his fatigue, except for the first officer, which we confirmed by the cockpit voice recorder.  Nor did he remove himself from duty, because he feared disciplinary action. In fact, the airline had recently sent him a letter warning that any future absences, including calling in fatigued, could result in his being fired.

The captain?s duty schedule on the day of the accident, although consistent with FAA regulations, was demanding and might have exacerbated the effects of his sleep deprivation.  He reported for duty at about 5:30 in the morning.  This was earlier than his normal waking time on days he did not fly, which was anytime between 6 and 8 AM.  While on duty, he had limited opportunity for rest and did not get planned eating breaks because of quick turnaround times between flights, less than 30 minutes.  The accident occurred almost 10 hours into the captain?s duty day, at which time he had been continuously awake for about 31 hours.

It is interesting to note that the airline?s policies provide that on their first crew pairing, a captain should be the flying pilot.  However, this captain asked the first officer to be the flying pilot because he was tired.  Only later did we learn that the first officer would have preferred not to be the flying pilot because he had just completed a 3-day, 6-leg trip sequence, and had been away from home for the previous 8 days; and, at the time of the accident, he had flown 30 hours in the last 7 days ? the maximum allowed by federal regulation.

Needless to say, the Safety Board determined that the captain?s fatigue influenced his ability to effectively plan for and monitor the approach and landing, and therefore contributed to the accident.  The Board recommended that the FAA develop a ?best practice? attendance policy that considers fatigue, and to require operators to adopt that policy.  Some operators already have such policies, and have adopted other practices that include napping policies, no call policies, and quiet rooms for rest.

The Safety Board has also made several recommendations with respect to technologies that can detect fatigue or decreased performance associated with fatigue.  Some of these recommendations stemmed from an October 2005 highway accident in Osseo, Wisconsin.

At around 2 a.m., a truck-tractor semitrailer combination unit ran off the right side of Interstate 94.  The driver steered to the left and the truck re-entered the roadway and overturned onto its right side, sliding to stop so that it blocked both westbound lanes and shoulders of the highway.   About 1 minute later, a bus, carrying a group of marching band members from a local high school, was traveling westbound on the same unlit highway, traveling between 64 and 78 mph.  It collided with the dark underside of the overturned truck.

The bus driver and four passengers were fatally injured.  The truck driver received minor injuries. The probable cause of the truck rollover was the truck driver?s falling asleep at the wheel.  The truck driver was most likely fatigued because he did not take full advantage of adequate rest opportunities provided to him during his off-duty time.  As a result, he obtained inadequate and disrupted sleep prior to the accident.

The Safety Board recommended that the Federal Motor Carrier Safety Administration develop and implement a plan to deploy technologies in commercial vehicles to reduce the occurrence of fatigue-related accidents. The Board has made similar recommendations for alerting technologies in the railroad industry.

As the result of a fatal truck crash in Michigan, we recommended that all interstate carriers be required to use electronic on-board recorders that collect and maintain data concerning driver hours of service to enable the carriers and enforcement officials to better monitor hours-of-service compliance.

The Board has also made recommendations about adding countermeasures to the environment such as rumble strips or improving roadside rest areas and sleeping facilities.

In recent years, the Safety Board has also called for the development of fatigue management systems, which take a comprehensive approach to reducing fatigue-related risk.  We believe that these systems should be based on empirical and scientific evidence and should include a methodology to continually assess their effectiveness. These recommendations were added to our Most Wanted List just two weeks ago.

It was not difficult for the Board to find that fatigue was a probable cause or contributing factor in the accidents that I?ve mentioned.  But yet, the Board has struggled in other accident investigations when fatigue is present, yet the facts or circumstances do not lead you to a clear and unequivocal conclusion that an operator?s fatigue caused or even contributed to an accident.  This is not to suggest that the Board didn?t recognize fatigue in these other accidents.  But establishing the role that fatigue played in an accident has proven to be difficult, if not sometimes completely elusive.

There have been a number of accidents:  the Staten Island ferry crash in 2004, the Cosco Busan allision into the Bay Bridge in San Francisco in 2007, to Lexington, Kentucky -- where an airplane took off on the wrong runway in August of 2006 ? in which fatigue has been considered in the accident investigation, but other factors weighed heavier in the ultimate decisions on the probable cause.  Perhaps it is because with fatigue, we are more comfortable identifying it as a cause only when everything else is ruled out.

For example, if an accident investigation finds a fatigued operator who is also taking sedating medication, or is a poorly trained or inexperienced, or just has a history of poor performance, we may identify these other factors, and not fatigue, in our probable cause determination.  My point is that we are not failing to identify fatigue in investigations, but perhaps we are experiencing our own awakening regarding the role that fatigue plays in an accident, especially when there are multiple factors present.  We can?t always prove fatigue as a cause of an accident, but the frequency with which we now routinely document the presence of fatigue-related factors in transportation operations is alarming.

Last month, the Safety Board completed our investigation of the airplane accident in Buffalo, New York, that occurred just over a year ago.

While the report of that investigation identified fatigue on the part of both the pilot and first officer, the final report did not conclude that fatigue was a contributing factor in that accident.  Although I supported the report, I questioned whether we were missing an opportunity to highlight the issue of fatigue when both pilots commuted from over 1,000 miles away and neither had a crash pad in the vicinity.  Our investigation determined that the Captain had spent the night before the accident in the crew room and the First Officer had flown through the night prior to the accident in the jumpseat of a cargo flight from Seattle to Memphis and then another jumpseat flight from Memphis to Newark.  It was disappointing that after decades of research, documentation and investigation, it was still a challenge for us to determine whether fatigue played a role in the accident.

Accident investigations are complex and multiple issues will arise in the course of these investigations.  And at least in the Colgan situation, the prevailing opinion was that the crew did not respond appropriately to the situation consistent with prior practical test failures, inadequate training and failure to adhere to the sterile cockpit rule.  Fatigue is a human performance issue.  And our understanding of it must involve an awakening to the full extent of how fatigue affects performance.   I hope that our thinking will evolve ? much like our understanding of alcohol impairment has evolved in the last few decades.

Today, the impairing effects of alcohol are well understood and accepted by NTSB investigators and society at-large. However, this has not always been the case. Early in the Safety Board?s history, the prevailing view was that an individual could be under the influence with a blood alcohol content above today?s legal limit, and still not be considered drunk.

For example, we investigated the 1967 collision in Baker, California, between a car travelling the wrong way on the highway and a bus, which resulted in 20 fatalities and 11 injuries.  The NTSB calculated that at the time of the collision, the driver of the car had a blood-alcohol level of between .15 and .19 (or higher). Nonetheless the accident report states, I quote: ?there is a difference between being "under the influence" of alcohol and varying degrees of drunkenness.  In the common acceptance of the term, "drunkenness" is taken to mean that a person is in a helpless state of immobility.?  The report goes on to determine that the driver was not ?drunk? because prior to the accident he successfully traveled around town by car, talked with friends and, again I quote, ?therefore, it is logical to believe that he was able to read, comprehend and respond to traffic control devices, although probably not as well or as quickly as if he were sober.?

Thus, the Safety Board concluded that because the driver could still function on some level and was not immobilized by the alcohol, alcohol was not the primary cause of the accident, although it was cited as one of four contributing factors.  The use of alcohol, to a certain extent, was tolerated in the transportation industry and by society in general if an impaired individual could still function at some level.

Fortunately, we have advanced beyond this limited viewpoint.  Alcohol testing is now a routine component of our accident investigations, and society has placed stricter limits on alcohol use.  Today, safety-sensitive transportation employees are subject to random and post-accident drug and alcohol testing, and every state now has impaired driving laws with an .08 or higher breath or blood concentration legal limit, with federal regulations establishing an even lower .04 limit for transportation professionals.

Fatigue-impaired performance is not unlike alcohol-impaired performance.  There have been numerous studies that have shown such things as:

? sleep loss is at least as potent as ethanol in its performance-impairing effects and two hours of sleep loss equates to a breath ethanol concentration of approximately .05%;

?  prolonged wakefulness significantly impairs speed and accuracy, hand?eye coordination, decision making, and memory;

?  prolonged wakefulness correlates with impairment:   being awake for 16 hours is equivalent to a .05 BAC.

We have successfully identified the problem of impairment due to alcohol and drugs in the workplace, and regulators and industry have devised rules, testing and treatment countermeasures to address the problem. Developing a standard means of identifying a problem is an important step in addressing that problem.

It is well understood that an individual?s performance is dependent on the individual.  We know that people tolerate alcohol differently.  The same goes for fatigue.  Personally, I do not drink much, so one margarita is my limit.  I wouldn?t even think about driving after one drink because I know I would be impaired.

I have 3 boys, all under the age of 10 ? let me tell you, that is a demanding job, so between my day job and my family, I do not always get my preferred 8 hours of sleep.  Like many people, I feel I can handle fatigue better than alcohol, but we know that fatigue-impaired individuals are terrible at recognizing their own impairment, and if I am impaired ? whether from alcohol or fatigue ? and I get into a car accident, does it really change the outcome?

We simply do not yet have the tools to conclusively determine the degree to which a person is fatigued.  No blood test exists to establish fatigue impairment levels (yet) so we cannot pinpoint whether fatigue results in 20% memory reduction, 50% degraded decision-making ability, 25% slower reaction time, or some other value. This difficulty, however, does not mean we cannot ? or should not ? find that fatigue contributed to an accident.

One of the major challenges we face now is in refining the ways that we identify fatigue and its impairing effects. Whether it is using predictive scheduling tools, technology such as eye or voice assessment, administering self tests to quickly assess fatigue or even coming up with a blood test to identify the extent to which fatigue is affecting an individual?s ability to be vigilant, react quickly and avoid both lapses of attention and response errors ? we need to address this critical problem.

The issue of fatigue challenges us to periodically adjust our lens and take a fresh look to ensure that all those in transportation  -- the pilots of the planes, the captains of ships, the truck drivers, the train engineers -- report to work rested and fit for duty. Because fatigue is complex and multifaceted, we all have a role to play.  At the Safety Board, we have committed to developing a methodology that will help investigators determine when fatigue played a role in a transportation accident.  Right now, we are conducting a study to validate that methodology, and once we do, I believe that it will have implications for identifying fatigue-related crashes beyond our investigations.

Regulators have a role to play in establishing hours of service regulations that provide a safety-net for workers and in setting standards that will help to identify and mitigate sources of fatigue.

Educating the industry about fatigue and its implications regarding the safety of transportation is not limited to rulemakings and government action.  There is a responsibility on the part of the transportation industry to have policies that allow their employees to call in fatigued.  This should be a written policy that will address the implications of fatigue calls.

There is an element of professional responsibility on the part of the employee ? to report for duty well rested and prepared to assume their duties. 

As I said, I am the mother of three young boys.  One of their favorite films these days is the movie ?Cars.?  In that movie, a tractor trailer truck named Mack needs to carry the famous racecar, Lightning McQueen, across the country for a big race. Mack tries to explain to Lightning that there are federal regulations that govern driving hours, but Lightning pushes him to drive anyway.  Mack ends up falling asleep on the highway and has a near crash after which he states, ?One should never drive while drowsy.?

If a message as simple as that can be conveyed to our children, surely we can find a way to craft policies and regulations that do the same for professionals.

We?ve come a long way.  Yet despite our current understanding of fatigue and sleep disorders, we still have more to learn about the human condition and sleep.  It is forums like this that allow us to come together to develop a better understanding.  The work of the National Sleep Foundation and other organizations and individuals is critical to improving transportation safety policy.  The NTSB is interested and willing to partner with you in developing a greater awareness of fatigue.

In the sculpture of ?The Awakening,? most of the giant is underneath the ground ? only his face is seeing the light of day.  It is my hope that all of us ? researchers, clinicians, industry and policy makers ? will work together to bring the issues surrounding fatigue into the sunshine.

I appreciate the opportunity to be here with you today to share these thoughts and wish you a successful conference.  Thank you.
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