Screening Commercial Motor Vehicle Drivers for Obstructive Sleep Apnea Can Save Lives

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.  

This image, taken on the day of the crash, show six of the seven vehicles involved in the March 1, 2018, Elmhurst, Illinois, multivehicle collision. (Source: WFLD-TV)

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.  

NTSB investigators examining the damaged and burnt 2016 Kenworth truck-tractor (the Pioneer truck) involved in the March 1, 2018, Elmhurst, Illinois, multivehicle collision (Source: NTSB)

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.

It’s Past Time to Think About Cognitive Distraction

By Member Jennifer Homendy

When you think of common ways drivers are distracted on the road, you probably think of talking or texting on mobile devices, eating, reading, or perhaps even putting on makeup or shaving. It’s easy to recognize that these risky behaviors are distractions. There are even laws on the books in several states that ban these sorts of distractions—particularly hand-held mobile phone use—so drivers know better than to do these things while driving (even if they do them on occasion anyway). Hands-free mobile phone use, on the other hand . . . that’s okay, right?

Not so fast.

Distracted driving causes an alarming number of deaths and injuries on America’s roads each year, and it has proven to be a hard problem to solve. Data from the National Highway Traffic Safety Administration say that 2,800 people died because of distracted driving in 2018 alone. And distraction is particularly dangerous for vulnerable road users; 400 pedestrians and 77 bicyclists were killed that year.

The United States has made huge improvements in reducing the number of deaths seen on our roadways since the 1960s and 1970s, but, over the past decade, we’ve stagnated in lowering the number of fatalities even further. We’ve greatly improved vehicle and road safety as well as seatbelt law adherence, and we’ve cut drunk driving deaths in half. But distracted driving continues to be an ever-problematic issue on our nation’s roadways. Even my very own friends—knowing what I do for a living—have recently tried to have calls or video chats with me while they were driving! 

Although, like all safety issues, we need to address distracted driving awareness and prevention year round, for 1 month each year, advocates turn up the focus. That’s how critical it is to saving lives. Vice Chairman Landsberg recently wrote a blog in recognition of Distracted Driving Awareness Month. A few months ago, I wrote a blog about my own story of being in a crash caused by a distracted driver. I pointed out that, short of full cell phone bans, drivers can make hands-free calls through Bluetooth, which is still a cognitive distraction.

Why is that important?

A 2011 study detailed three types of distraction:

• Visual (taking your eyes off the road),
• Manual (taking your hands off the wheel to hold something, like food or a mobile device), and
• Cognitive (those distractions that cause a driver to take his or her mind off the primary task of driving safely, like making hands-free calls or even stressing about an important meeting).

Even when your eyes are on the road, simple cognitive distractions can impair your driving performance and diminish your reaction time. Many people don’t realize that cognitive distractions while driving can be like driving while impaired—both reduce your ability to react.

Nearly a decade ago, the NTSB issued a recommendation to all 50 states and the District of Columbia, calling for a ban on all nonemergency use of portable electronic devices for all drivers, which would include prohibiting hands-free cell phone use. Ever since then, we have been advocating for states to ban cell phones while driving, and “Eliminate Distractions” has rightfully been on our Most Wanted List of transportation safety improvements since 2013. Although 48 states have banned texting while driving, no state has banned hands-free cell phone use. 

The National Safety Council and AAA, along with others, remind us that hands-free isn’t risk free. We need to think about and address cognitive distraction and its harmful consequences. When we’re behind the wheel, let’s make sure we keep our families and our roads safe by focusing on the primary task at hand—driving safely.

Joining Forces on Distracted Driving

The blog was co-authored by:

Bruce Landsberg, Vice-Chairman, National Transportation Safety Board

Lorraine Martin, President & CEO, National Safety Council

By now, we all should be aware of the deadly consequences of distracted driving. Yet, driving while distracted by cell phone use has become too common an occurrence on the nation’s roads. This must stop.

It has been nearly a decade since the National Transportation Safety Board (NTSB) called on the states and the District of Columbia to enact laws that prohibit the non-emergency use of cell phones by all drivers. It has been more than a decade since the National Safety Council (NSC) became the first nongovernment organization to call for a total cell phone use ban for all drivers. Yet, tragically, no state has implemented this life-saving measure. 

Between 2011 and 2018, the National Highway Traffic Safety Administration reported that 25,926 people were killed and an estimated 2.4 million more were injured in distraction-affected crashes. While these numbers are staggering, we know that they don’t accurately reflect how big a problem distracted driving is because distracted driving-related crashes are, in fact, greatly underreported.

“Eliminate Distractions” is on the NTSB’s 2019-2020 Most Wanted List of Transportation Safety Improvements. We are calling on states, operators and industry, vehicle manufacturers, and the driving public to take action.

Together, NTSB and NSC have joined forces to urge the following immediate actions:

States: Enact laws that prohibit all cell phone use while driving—yes, even hands free. Laws must send a clear message to drivers that there is no safe way to use a phone while driving.

Employers: Establish strong transportation and driving policies that prohibit cell phone use by employees – no calls, no social media, no texts, no email while driving. The most effective safe driving policies go beyond merely prohibiting all cell phone use to include activities such as using infotainment systems while driving. Policies should also prohibit employees from contacting other employees when you know they will be driving. (Employers don’t have to wait for a state law to tell you to do this; be a leader in safe practices.)

Drivers (you and me!): Use your phone’s “do not disturb” feature. Place your phone out of reach or simply turn your phone off until you reach your destination. No call, no text, no update is worth your life or the life of someone else.

Manufacturers of portable electronic devices: Develop a distracted driving lock-out mechanism or application for portable electronic devices that will automatically disable any driver-distracting functions when a vehicle is in motion, but allows the device to be used in an emergency.

The NTSB and NSC are committed to eliminating preventable crashes caused by cell phone use. The research is clear: we cannot safely multitask behind the wheel. So, when you choose to drive distracted, you don’t just pose a risk to yourself, you are a risk to the safety of the others you share the road with.

October was National Distracted Driving Awareness Month, but we need to focus on this issue all year. We will continue in our fight and efforts to end the preventable crashes, injuries and fatalities caused by distracted driving. Join us in this commitment by acting responsibly and making attentive, distraction-free driving your goal when behind the wheel. We are aware of the problem; now let’s take action to prevent any more needless tragedies.

World Day of Remembrance for Road Traffic Victims

By Nicholas Worrell, Chief, NTSB Safety Advocacy Division

Sunday, November 15, is the World Day of Remembrance for Road Traffic Victims. I’ve known many of you who have lost loved ones this way, and I’ve worked alongside many survivor advocates for years. Along with the courage and strength I’ve seen among these survivors, it’s plain to me that nobody who loses a loved one in a traffic crash needs a day of remembrance. For them, that remembrance is always there, no matter what day. The World Day of Remembrance is for the rest of us. It’s a time to reflect on these often preventable losses and work to prevent future ones from occurring. In 2020, it feels like we need this commemoration day more than ever. With the uncertainty of a global pandemic, far too many people are forgetting—or becoming numb to—the year-in, year-out toll that traffic crashes take on our country.

I was recently invited to speak on an International Road Federation panel on the topic, “Crashes: The Forgotten Pandemic.” I reminded participants of Dr. Anthony Fauci’s statement earlier this year when asked about the annual 40,000 US road deaths in America. He said that the COVID pandemic is emergent, but road crash deaths are a chronic condition.

However, although the condition is chronic, it’s not untreatable.

My talk touched on some of the ways that the road safety community is working to protect the most vulnerable road users: bicyclists, motorcyclists, and pedestrians. I also pointed out that, unlike COVID-19, the road crash pandemic strikes the young disproportionately. In fact, in the United States, from early in childhood to well into middle age, a young person is more likely to die in a motor vehicle crash than any other way.

The impact on young peoples’ lives from our acute COVID pandemic is incalculable. Students whipsaw between learning in person and on-line, with little certainty of what style comes next, and face restrictions on seeing friends. Yet, the far more pressing danger to a young person comes from the risks of speeding and of distracted, drowsy, or impaired driving. In fact, speeding crashes have increased markedly this year as the volume of traffic has decreased.

Remembrance is about honoring those we’ve lost. It’s also respecting those who, thankfully, are still with us. This World Day of Remembrance, we can respect the living and honor those lost by recommitting ourselves to practicing safe driving habits—some of which we may not have had the opportunity to use for a while. Before you get behind the wheel, make sure you’re rested and sober. Put the phone away. Don’t speed. With all the younger generations are doing to protect high‑risk loved ones from COVID, let’s do the same to lower their risk of dying in a motor vehicle crash. Let’s finally put both pandemics behind us.

Drowsy Driving Prevention Week

By Robert Molloy, PhD, Director, NTSB Office of Highway Safety

As we wrap up Drowsy Driving Prevention week, I want to remind drivers about the importance of getting adequate rest before operating their car, truck, or bus. Drowsy Driving Prevention Week (November 1–8) was established by the National Sleep Foundation to draw attention to the hazards associated with operating a motor vehicle while fatigued. The NTSB, regulators, industry, and individual drivers all play a role in reducing fatigue-related crashes.

Drowsy and fatigued driving are not new problems. According to research conducted by the AAA Foundation for Traffic Safety, every year, about one in ten crashes on our roadways involves a drowsy driver, and one in five of those crashes is fatal. “Reducing fatigue-related accidents” is on our NTSB’s Most Wanted List of transportation safety improvements because our many investigations have shown that fatigue is a significant factor in highway crashes. For example, we recently completed two investigations of commercial truck crashes, one in Boise, ID, and the second in Elmhurst, IL, in which we found that the drivers failed to stop for slowed traffic as a result of fatigue. In the Boise crash, the driver’s fatigue was related to inadequate sleep duration; in Elmhurst, it resulted from a sleeping disorder related to sleep apnea.

In preparation for Drowsy Driving Prevention Week, we hosted a webinar on Managing Commercial Motor Vehicle Driver Fatigue Risks. This joint effort between NTSB staff and industry experts from trucking and busing looked at programs companies can implement to reduce the risk of fatigued driving, and we discussed how the North American Fatigue Management Program, guidelines and materials that enable motor carriers to implement a comprehensive fatigue management program, can be an effective tool to prevent driver fatigue. You can watch the webinar online.  

From an individual perspective, we all need to take responsibility for our fitness to get behind the wheel, not only to protect ourselves and our passengers, but to keep other road users safe. Commercial drivers have provided heroic services to our nation during the COVID-19 pandemic; the least we can do is ensure that we aren’t putting them at risk by getting behind the wheel drowsy or fatigued.

Drowsy and fatigued driving have real-life—and death—consequences. As this week of special attention comes to an end, don’t let alert driving take a back seat.