Fatigue in transportation: NTSB investigations and safety recommendations.

OBJECTIVE: We aim to place into the scientific literature information on the prevalence of operator fatigue as a factor in causing transportation mishaps, and the categories of improvements identified to address fatigue in transportation. METHODS: We analyzed the number of major National Transportation Safety Board (NTSB) investigations that identified fatigue as a probable cause, contributing factor, or a finding. We divided all NTSB recommendations addressing fatigue issued since the agency was founded into 7 subject categories, and placed each recommendation into the appropriate category. This information was then analyzed to determine the number of recommendations in each category, both overall and by transportation mode. Analysis was also performed regarding the types of organizations that received the recommendations, whether the recommended actions have been taken, and the NTSB's evaluation of whether the action taken satisfied a given recommendation. RESULTS: We reviewed 182 major NTSB investigations completed between 1 January 2001 and 31 December 2012 and found that 20% of these investigations identified fatigue as a probable cause, contributing factor, or a finding. The presence of fatigue varied between among the modes of transportation, ranging from 40% of highway investigations to 4% of marine investigations. The first NTSB recommendation to address the safety risks associated with human fatigue was issued over 40 years ago, in 1972. Since then, the NTSB has issued 205 separate fatigue-specific recommendations. Scheduling policies and practices was the most common subject category accounting for 40% of all recommendations issued. Federal agencies received 54% of all recommendations, with 22% to transportation operators, and 16% to associations. Of all NTSB fatigue recommendations, 24% were open ranging from a low of 9% in highway to 39% in aviation. Overall, only 3% of open recommendations were classified "unacceptable," whereas 16% of all closed recommendations were classified "unacceptable." CONCLUSIONS: Although there has been over 100 years of progress in recognizing and addressing the safety risk posed by human fatigue in transportation, 20% of recent NTSB investigations have identified fatigue as a probable cause, contributing factor or finding. This analysis represents the first-ever examination of fatigue identified in major NTSB investigations across modes and of the focus, recipients, and classification status of fatigue-related safety recommendations. It demonstrates that fatigue remains a significant transportation safety risk.

Awake at the wheel: how auto technology innovations present ongoing sleep challenges and new safety opportunities.

Individuals and society are dependent on transportation. Individuals move about their world for work, school, healthcare, social activities, religious and athletic events, and so much more. Society requires the movement of goods, food, medicine, etc. for basic needs, commerce, cultural and political exchanges, and all of its dynamic, complex elements. To meet these critical daily demands, the transportation system operates globally and around the clock. Regardless of their role, a basic requirement for the individuals operating the transportation system is that they are awake and at optimal alertness. This applies to individuals driving their own cars, riding a bike or motorcycle, as well as pilots of commercial aircraft, train engineers, long-haul truck drivers, and air traffic controllers. Alert operators are a basic requirement for a safe and effective transportation system. Decades of scientific and operational research have demonstrated that the 24/7 scheduling demands on operators and passengers of our transportation system create sleep and circadian disruptions that reduce alertness and performance and cause serious safety problems. These challenges underly the longstanding interest in transportation safety by the sleep and circadian scientific community. An area currently offering perhaps the most significant opportunities and challenges in transportation safety involves vehicle technology innovations. This paper provides an overview of these latest innovations with a focus on sleep-relevant issues and opportunities. Drowsy driving is discussed, along with fatigue management in round-the-clock transportation operations. Examples of cases where technology innovations could improve or complicate sleep issues are discussed, and ongoing sleep challenges and new safety opportunities are considered.

Obstructive sleep apnea screening, diagnosis, and treatment in the transportation industry.

Obstructive sleep apnea (OSA) is a common, identifiable, and treatable disorder with serious health, safety, and financial implications-including sleepiness- related crashes and incidents-in workers who perform safety-sensitive functions in the transportation industry. Up to one-third of crashes of large trucks are attributable to sleepiness, and large truck crashes result in more than 4,000 deaths annually. For each occupant of a truck who is killed, 6 to 7 occupants of other vehicles are killed. Treatment of OSA is cost-effective, lowers crash rates, and improves health and well-being. A large body of scientific evidence and expert consensus supports the identification and treatment of OSA in transportation operators. An Advanced Notice of Proposed Rulemaking regarding the diagnosis and treatment of OSA in commercial truck and rail operators was issued by the Federal Motor Carrier Safety Administration and Federal Railroad Administration, but it was later withdrawn. This reversal of the agencies' position has caused confusion among some, who have questioned whether efforts to identify and treat the disorder are warranted. In response, we urge key stakeholders, including employers, operators, legislators, payers, clinicians, and patients, to engage in a collaborative, patient-centered approach to address the disorder. At a minimum, stakeholders should follow the guidelines issued by a medical review board commissioned by the Federal Motor Carrier Safety Administration in 2016 alone, or in combination with the 2006 criteria, "Sleep Apnea and Commercial Motor Vehicle Operators," a Statement from the Joint Task Force of the American College of Chest Physicians, the American College of Occupational and Environmental Medicine, and the National Sleep Foundation developed by a joint task force. As research in this area continues to evolve, waiting is no longer an option, and the current standard of care demands action to mitigate the burden of serious health and safety risks due to this common, treatable disorder. CITATION: Das AM, Chang JL, Berneking M, Hartenbaum NP, Rosekind M, Gurubhagavatula I. Obstructive sleep apnea screening, diagnosis, and treatment in the transportation industry. J Clin Sleep Med. 2022;18(10):2471-2479.

Enhancing public health and safety by diagnosing and treating obstructive sleep apnea in the transportation industry: an American Academy of Sleep Medicine position statement.

Obstructive sleep apnea (OSA) may lead to serious health, safety, and financial implications-including sleepiness-related crashes and incidents-in workers who perform safety-sensitive functions in the transportation industry. Evidence and expert consensus support its identification and treatment in high-risk commercial operators. An Advanced Notice of Proposed Rulemaking regarding the diagnosis and treatment of OSA in commercial truck and rail operators was issued by the Federal Motor Carrier Safety Administration and Federal Railroad Administration, but it was later withdrawn. This reversal has led to questions about whether efforts to identify and treat OSA are warranted. In the absence of clear directives, we urge key stakeholders, including clinicians and patients, to engage in a collaborative approach to address OSA by following, at a minimum, the 2016 guidelines issued by a Medical Review Board of the Federal Motor Carrier Safety Administration, alone or in combination with 2006 guidance by a joint task force. The current standard of care demands action to mitigate the serious health and safety risks of OSA. CITATION: Das AM, Chang JL, Berneking M, et al. Enhancing public health and safety by diagnosing and treating obstructive sleep apnea in the transportation industry: an American Academy of Sleep Medicine position statement. J Clin Sleep Med. 2022;18(10):2467-2470.

Sleep disorders and work performance: findings from the 2008 National Sleep Foundation Sleep in America poll.

Chronic sleep deprivation is common among workers, and has been associated with negative work outcomes, including absenteeism and occupational accidents. The objective of the present study is to characterize reciprocal relationships between sleep and work. Specifically, we examined how sleep impacts work performance and how work affects sleep in individuals not at-risk for a sleep disorder; assessed work performance outcomes for individuals at-risk for sleep disorders, including insomnia, obstructive sleep apnea (OSA) and restless legs syndrome (RLS); and characterized work performance impairments in shift workers (SW) at-risk for shift work sleep disorders relative to SW and day workers. One-thousand Americans who work 30 h per week or more were asked questions about employment, work performance and sleep in the National Sleep Foundation's 2008 Sleep in America telephone poll. Long work hours were associated with shorter sleep times, and shorter sleep times were associated with more work impairments. Thirty-seven percent of respondents were classified as at-risk for any sleep disorder. These individuals had more negative work outcomes as compared with those not at-risk for a sleep disorder. Presenteeism was a significant problem for individuals with insomnia symptoms, OSA and RLS as compared with respondents not at-risk. These results suggest that long work hours may contribute to chronic sleep loss, which may in turn result in work impairment. Risk for sleep disorders substantially increases the likelihood of negative work outcomes, including occupational accidents, absenteeism and presenteeism.

Pilot fatigue survey: exploring fatigue factors in air medical operations.

INTRODUCTION: Humans confront significant physiological challenges with sleep and alertness when working in 24/7 operations. METHODS: A web-based national survey of air medical pilots examined issues relevant to fatigue and sleep management. RESULTS: Six hundred ninety-seven responses were received, with a majority of rotor wing pilots working 3/3/7 and 7/7 duty schedules. Over 84% of the pilots reported that fatigue had affected their flight performance; less than 28% reported "nodding off" during flight. More than 90% reported a separate work site "rest" room with a bed available. Over 90% reported no company policies restricting on-duty sleep. Approximately half of the pilots reported getting 4 hours or more sleep during a typical night shift. Approximately half reported that sleep inertia had never compromised flight safety. Over 90% reported that it was better to sleep during the night and overcome sleep inertia if necessary. DISCUSSION: Survey results reflected practices that can mitigate the degrading effects of fatigue, including the availability of designated work-site sleep rooms. As demands continue to evolve, the need remains for sustained efforts to address fatigue-related risks in the air medical transport industry. This includes further study of sleep inertia issues and the need for alertness management programs.

Asleep at the Wheel-The Road to Addressing Drowsy Driving.

Drowsy driving is a dangerous behavior that leads to thousands of deaths and injuries each year. It is also a controllable factor for drivers. Drivers are capable of modifying this behavior if given sufficient information and motivation. Our goal is to establish a comprehensive and strategic effort to end drowsy driving crashes and deaths. This article highlights some of the conclusions of a unique recent meeting of sleep experts and highway safety professionals and describes the first steps the community has taken and plans to take in the future to address this issue.

Improving alertness and performance in emergency department physicians and nurses: the use of planned naps.

STUDY OBJECTIVE: We examine whether a 40-minute nap opportunity at 3 AM can improve cognitive and psychomotor performance in physicians and nurses working 12-hour night shifts. METHODS: This is a randomized controlled trial of 49 physicians and nurses working 3 consecutive night shifts in an academic emergency department. Subjects were randomized to a control group (no-nap condition=NONE) or nap intervention group (40-minute nap opportunity at 3 AM=NAP). The main outcome measures were Psychomotor Vigilance Task, Probe Recall Memory Task, CathSim intravenous insertion virtual reality simulation, and Profile of Mood States, which were administered before (6:30 PM), during (4 AM), and after (7:30 AM) night shifts. A 40-minute driving simulation was administered at 8 AM and videotaped for behavioral signs of sleepiness and driving accuracy. During the nap period, standard polysomnographic data were recorded. RESULTS: Polysomnographic data revealed that 90% of nap subjects were able to sleep for an average of 24.8 minutes (SD 11.1). At 7:30 AM, the nap group had fewer performance lapses (NAP 3.13, NONE 4.12; p<0.03; mean difference 0.99; 95% CI: -0.1-2.08), reported more vigor (NAP 4.44, NONE 2.39; p<0.03; mean difference 2.05; 95% CI: 0.63-3.47), less fatigue (NAP 7.4, NONE 10.43; p<0.05; mean difference 3.03; 95% CI: 1.11-4.95), and less sleepiness (NAP 5.36, NONE 6.48; p<0.03; mean difference 1.12; 95% CI: 0.41-1.83). They tended to more quickly complete the intravenous insertion (NAP 66.40 sec, NONE 86.48 sec; p=0.10; mean difference 20.08; 95% CI: 4.64-35.52), exhibit less dangerous driving and display fewer behavioral signs of sleepiness during the driving simulation. Immediately after the nap (4 AM), the subjects scored more poorly on Probed Recall Memory (NAP 2.76, NONE 3.7; p<0.05; mean difference 0.94; 95% CI: 0.20-1.68). CONCLUSION: A nap at 3 AM improved performance and subjective report in physicians and nurses at 7:30 AM compared to a no-nap condition. Immediately after the nap, memory temporarily worsened. The nap group did not perform any better than the no-nap group during a simulated drive home after the night shift.

Alertness management in aviation operations: enhancing performance and sleep.

INTRODUCTION: Fatigue is an acknowledged safety risk in diverse operational settings. As a result, there has been growing interest in developing and implementing activities to improve alertness, performance, and safety in real-world operations where fatigue is a factor. METHODS: A comprehensive Alertness Management Program (AMP) that included education, alertness strategies, scheduling, and healthy sleep was implemented in a commercial airline. An operational evaluation was conducted with 29 flight crewmembers, first when flying a standard schedule without AMP components (i.e., standard condition) compared with full AMP implementation, which included flying an innovative schedule that incorporated physiological sleep and alertness principles (i.e., intervention condition). The evaluation included objective measures of sleep quantity (actigraphy), psychomotor vigilance task (PVT) performance, and subjective reports of daily activities and sleep. RESULTS: The results showed that the 3.5-h educational CD improved pre-education test scores from an average 74% correct to a post-education average of 98%. Alertness strategies showed minimal changes, though the daily diary did not allow for refined evaluation of duration, frequency, and timing of use. The intervention condition was associated with significantly more sleep (1 h, 9 min; p < 0.01) during the trip period compared with the standard schedule. All performance metrics showed significantly better performance during the intervention condition trip schedule (p < 0.01) compared with the standard condition. DISCUSSION: This first-ever evaluation of a comprehensive AMP showed significantly improved knowledge, support for the use of alertness strategies, and increased sleep and performance during actual operations. The robust and consistent findings support the use of an AMP approach to effectively manage fatigue in operational settings.

Underestimating the societal costs of impaired alertness: safety, health and productivity risks.

Modern society now operates on a 24/7 global basis, with around-the-clock requirements that often ignore sleep, circadian rhythms, irregular work schedules and geographical time zones. Despite overwhelming evidence, there is gross underestimation and very little acknowledgement of the risks and costs related to sleep loss, circadian disruption, sleep disorders, reduced alertness and performance. Understanding the specific factors that impede our progress in addressing impaired alertness as an important societal issue could lead to raised awareness of the risks and costs and subsequent implementation of change. Effecting change requires an understanding of the complexity of the issue and a multidimensional approach. Real world data and outcomes are required to determine the exact extent of the health and safety risks related to impaired alertness. More public awareness of the potential hazards of impaired alertness is needed among the general population to increase societal knowledge and appreciation. Physicians need to be educated about the importance of detecting impaired alertness in their patients and should be aware of the range of actions needed to help these individuals so that they do not cause harm to themselves or others. A comprehensive approach using scientifically based alertness management principles and practices offers society an opportunity to operate 24/7 while reducing the risks and costs associated with impaired alertness.

Sleep, fatigue, and medical training: setting an agenda for optimal learning and patient care.

The difficult issues surrounding discussions of sleep, fatigue, and medical education stem from an ironic biologic truth: physicians share a common physiology with their patients, a physiology that includes an absolute need for sleep and endogenous circadian rhythms governing alertness and performance. We cannot ignore the fact that patients become ill and require medical care at all times of the day and night, but we also cannot escape the fact that providing such care requires that medical professionals, including medical trainees, be awake and functioning at times that are in conflict with their endogenous sleep and circadian physiology. Finally, we cannot avoid the reality that medical education requires long hours in a constrained number of years. Solutions to the problem of sleep and fatigue in medical education will require the active involvement of numerous parties, ranging from trainees themselves to training program directors, hospital administrators, sleep and circadian scientists, and government funding and regulatory agencies. Each of these parties can be informed by previous laboratory and field studies in a variety of operational settings. including medical environments. Education regarding the known effects of sleep. circadian rhythms, and sleep deprivation can help to elevate the general level of discourse and point to potential solutions. Empiric research addressing the effects of sleep loss on patient safety, education outcomes, and resident health is urgently needed: equally important are the development and assessment of innovative countermeasures to maximize performance and learning. Addressing the economic realities of any changes in resident work hours is an essential component of any discussion of these issues. Finally, work-hour regulations may serve as one component of improved sleep and circadian health for medical trainees. but they should not be seen as substitutes for more original solutions that rely less on enforcement and more on collaboration. By working together to address the problems of sleep and fatigue in its own trainees, the medical field can provide a valuable legacy to patients and to future generations of healthcare providers--a legacy or optimal medical education, healthy doctors, and healthy patients.

The risks and implications of excessive daytime sleepiness in resident physicians.

PURPOSE: To assess the levels of physiologic and subjective sleepiness in residents in three conditions: (1) during a normal (baseline) work schedule, (2) after an in-hospital 24-hour on-call period, and (3) following a period of extended sleep. METHOD: In 1996, a within-subjects, repeated-measures study was performed with a volunteer sample of 11 anesthesia residents from the Stanford University School of Medicine using three separate experimental conditions. Sixteen residents were recruited and 11 of the 16 completed the three separate experimental conditions. Daytime sleepiness was assessed using the Multiple Sleep Latency Test (MSLT). RESULTS: MSLT scores were shorter in the baseline (6.7 min) and post-call (4.9 min) conditions, compared with the extended-sleep condition (12 min, p =.0001) and there was no significant difference between the baseline and post-call conditions (p =.07). There was a significant main effect for both condition (p =.0001) and time of day (p =.0003). Subjects were inaccurate in subjectively identifying sleep onset compared with EEG measures (incorrect on 49% of EEG-determined sleep episodes). CONCLUSION: Residents' daytime sleepiness in both baseline and post-call conditions was near or below levels associated with clinical sleep disorders. Extending sleep time resulted in normal levels of daytime sleepiness. The residents were subjectively inaccurate determining EEG-defined sleep onset. Based on the findings from this and other studies, reforms of residents' work and duty hours are justified.