By Jeffrey Marcus
On February 29, 2016, the scientific journal Injury Prevention published “Fatigue in Transportation: NTSB Investigations and Safety Recommendations,” which I co-authored with former NTSB Board Member (and fatigue expert) Dr. Mark Rosekind. We reviewed all recent major NTSB investigations in all modes of transportation for the presence of fatigue in accidents.
Bottom line: fatigue was present in 20 percent of them as a probable cause, a contributing factor, or a finding. The presence of fatigue varied among the modes of transportation, ranging from 40 percent of highway investigations to 4 percent of marine investigations.
And this is after 109 years of federal government action to mitigate the risk of fatigue in transportation. Congress passed the Hours of Service Act on March 4, 1907. Fatigue regulations have been continually reviewed and revised as we learn more about the impact of fatigue; as recently as January 12, 2012, the FAA published a final rule substantially revising and improving the fatigue regulations governing commercial aviation.
However, the NTSB continues to see fatigue in transportation tragedies and incidents in investigations in all modes of transportation. Accordingly, we have issued safety recommendations to help prevent recurrences. Since the NTSB issued its first fatigue recommendation in 1972, we have issued 205 separate fatigue-specific recommendations.
Dr. Rosekind and I divide these recommendations into seven subject categories. We list the number of recommendations in each category, both overall and by transportation mode. We also analyze the types of organizations that received the recommendations, whether the recommended actions have been taken, and the NTSB’s evaluation of whether the actions taken satisfied a given recommendation.
Of the seven subject categories, scheduling policies and practices account for 40% of all fatigue recommendations. Other subject categories included Education/Raising Awareness; Organizational Strategies; Medical issues affecting sleep; Vehicle and Environmental Strategies and Technologies; Research and Evaluation; and Fatigue Management Plans.
Overall, 54 percent of NTSB fatigue safety recommendations were issued to federal agencies, but this percentage varied among modes, with 86 percent of all aviation fatigue recommendations being issued to federal agencies, and only 30 percent of rail recommendations issued to these agencies. Other types of organizations receiving recommendations included transportation operators (both government and private companies), labor unions, and professional associations.
In the more than 40 years since our first fatigue recommendation, the scientific knowledge related to fatigue, sleep, circadian rhythms and sleep disorders has grown enormously, and there has been a parallel increase in investigators’ recognition of fatigue as a causal or contributory factor. In addition, investigative techniques (such as collection of a 72-hour history) are now standard components of major investigations. These advancements in science, recognition, and investigative techniques have resulted in fatigue findings that previously might not have been identified.
The more we know about fatigue, the more clearly we learn that proper sleep is foundational to all human functioning – including in the operation of vehicles in transportation.
Jeffrey Marcus is a Transportation Safety Specialist in the Office of Safety Recommendations & Communications