By Member Tom Chapman
Is it possible to have a sleep disorder and not know it? From personal experience, I can tell you the answer is yes. A few years ago, my doctor told me that I was at risk for obstructive sleep apnea (OSA), which is a sleep disorder involving episodes of airway obstruction and periods of not breathing while sleeping. OSA is not “just snoring”—it can result in fragmented sleep and subsequent daytime sleepiness. My doctor suggested I undergo a sleep study, which showed that I did indeed have OSA. The treatment I receive has made a major difference in the quality of my sleep and my overall wellness.
OSA is more common than many people think. Recent research has shown that between 6 percent and 17 percent of adults have moderate to severe OSA, and it’s particularly common among males, older individuals, and those who are overweight. Untreated OSA can lead to health problems like diabetes and heart disease, and it increases a driver’s risk of being in a crash. However, with screening and, if needed, proper treatment, that risk can be significantly reduced. A 2020 Federal Motor Carrier Safety Administration (FMCSA) study on commercial driver safety risk factors found that drivers aged 34 to 51 with treated OSA were significantly less likely to be involved in carrier-defined preventable crashes than drivers with untreated OSA.
Treating OSA improves safety, which is why “Require Medical Fitness—Screen and Treat for OSA” is on our Most Wanted List of transportation safety improvements. For more than a decade, the NTSB has recommended that the FMCSA implement a program to help identify and document treatment for commercial drivers with OSA. We also recommended that the FMCSA disseminate guidance for drivers, employers, and physicians about OSA, emphasizing that when OSA is effectively treated, drivers are routinely approved for continued medical certification.
Unfortunately, the FMCSA has not yet implemented these recommendations, and we continue to investigate crashes that could have been prevented with a more robust medical certification system. For example, we recently determined that a March 1, 2018, crash in Elmhurst, Illinois, was due to fatigue from a driver’s OSA-related sleep disorder. In that case, a large truck struck a car that had slowed due to traffic congestion. The rear-end collision initiated a chain of crashes involving two other large trucks and three more cars, killing one person and injuring five others.
The driver of the striking truck in Elmhurst had a history of OSA and other health issues; however, he didn’t report his health history accurately to the certified medical examiner (CME) and was thus able to obtain a medical certificate. He later told investigators he believed he had recovered from OSA, but a postcrash sleep study showed that he still had a sleep disorder. Did this driver know his sleep disorder was not resolved? Regardless of what he believed, he should have accurately reported his health history, but, as we have seen in multiple investigations, drivers sometimes omit key health information during their medical review. In the Elmhurst report, the lack of a robust medical certification evaluation process to identify and screen commercial drivers at high risk for OSA contributed to the crash.
The FMCSA has not taken the steps we believe are necessary to effectively address the safety risks of OSA for all drivers. In 2016, the agency tasked its Medical Review Board (MRB) with identifying factors the agency should consider with respect to potential future rulemaking concerning OSA. In November of that year, the MRB and the FMCSA’s Motor Carrier Safety Advisory Committee (MCSAC) issued several joint recommendations that provide authoritative and useful guidance for screening commercial drivers for OSA. These recommendations also demonstrate that the large majority of drivers being screened or tested for OSA can continue to work during their evaluation (and treatment, if needed).
Some of the conditions that the group felt merited a referral for OSA diagnostic testing included the following:
- reporting excessive sleepiness while driving or having a crash associated with falling asleep
- having a body mass index (BMI) greater than or equal to 40
- having a BMI between 33 and 40 as well as 3 or more additional risk factors, such as hypertension, type 2 diabetes, loud snoring, large neck circumference, age 42 and above, or being a male or a postmenopausal female.
CMEs need to know how to access MRB/MCSAC recommendations on OSA screening. Why? Because screening drivers for OSA—and following up with diagnostic testing and treatment, as needed—is a win-win for drivers, carriers, and the public. In 2017, we recommended that the FMCSA make the MRB/MCSAC recommendations easily accessible to CMEs to be used as guidance when evaluating commercial drivers for OSA risk. We will continue to encourage the FMCSA to implement all our open recommendations involving OSA. Until then, the MRB/MCSAC recommendations can serve as useful guidance for carriers and for the medical community.