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Driving While Tired: Safety officials are slow to react to operator fatigue

This driver was lucky. He fell asleep and drifted off the road on Sept. 2 on I-90 near Deer Lodge, Mont. The guardrail impaled his Chevy Suburban, passing  through the engine block, the passenger seat and the back window. The NTSB has issued 34 safety recommendations to deal with fatigue on the nation’s roads. Only 17 have been followed.
This driver was lucky. He fell asleep and drifted off the road on Sept. 2 on I-90 near Deer Lodge, Mont. The guardrail impaled his Chevy Suburban, passing  through the engine block, the passenger seat and the back window. The NTSB has issued 34 safety recommendations to deal with fatigue on the nation’s roads. Only 17 have been followed.Montana Highway Patrol via Montana Standard
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A sleep-deprived person behind the wheel or in the cockpit is just as dangerous as a drunken driver.

That’s one of the conclusions scientists have reached after years of study on sleep — and what happens when people don’t get enough of it. Scientific understanding has improved with a surge of research on sleep apnea, internal body clocks, reaction time and the judgment of the sleep-deprived.

But U.S. transportation guidelines lag far behind the science.

Just in airplane crashes over the past four decades, more than 320 accidents and incidents have taken nearly 750 lives in cases where fatigue was cited by investigators as a factor.

The National Transportation Safety Board, created in 1967 to help safeguard travelers, has been trying to persuade federal agencies, industries and states to take steps to reduce these kinds of accidents. The board has issued 138 fatigue-related safety recommendations. Only 68 have been implemented, according to the analysis.

Some of the proposals are still pending decades later. In other cases the board has simply given up, declaring recommendations to be “closed unacceptable.”

That's one conclusion of an analysis by News21, a college journalism coalition, and the Center for Public Integrity, a nonprofit investigative journalism organization. (Many of their stories are being published this week by You can read the full series at News21.)

Accidents happen in a matter of seconds. An airplane pilot takes a moment too long to react in an emergency. A trucker who has been on the road all day wanders across the median. A train engineer, lulled by the isolation and monotony, misses a signal.

Buses still don't have data recorders to track the drivers' hours of service. The "rest time" for airline pilots still includes their time going to and from the airport and through security. Trains still aren't equipped with systems to detect an engineer's lack of movement.

Restrictions on the number of hours that airline pilots can fly haven’t changed significantly since the 1930s, although they are under review. Regulations governing truck and bus drivers were only recently updated, and those changes might be temporary due to legal challenges. And the U.S. Coast Guard has failed to act on at least six NTSB recommendations to limit the hours of crews on cargo ships, oil tankers, ferries and other commercial ships.

The barriers are partly bureaucratic, and partly cultural. NTSB investigator Malcolm Brenner said public attitudes toward fatigue are about the same as attitudes toward drinking and driving 20 years ago.

“At one time, there was a sense that if you’re under alcohol you can power your way through it, but that’s no longer tolerated,” Brenner said.

NTSB board member Robert Sumwalt said, “We need to quit talking about fatigue and we need to start trying to do something about it."

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Jim Hall, former chair of the NTSB, said it’s shocking that U.S. agencies that oversee air, rail, water and highway safety all have failed to reflect the scientific evidence in their regulations.

Transportation Department officials say they are working to clear backlogs and ease delays. Deputy Transportation Secretary John Porcari heads a new DOT Safety Council that has cleared more NTSB recommendations in 2010 than in any of the previous five years, according to the department.

Jill Zuckman, director of public affairs for the U.S. Department of Transportation, said in an e-mail that some NTSB recommendations are impractical or impossible to implement. For example, she said, the NTSB "once recommended that the FAA develop a direct warning system about potential runway collisions for pilots in the cockpit. However, the technology did not exist when the board made that recommendation and still does not exist. … The bottom line is that when it comes to NTSB recommendations, there is often much more to it than meets the eye."

David Castelveter, vice president of communications for the Air Transport Association, a trade group that represents the major airlines, said some safety measures aren’t worth the cost. For example, when the FAA studied a NTSB recommendation to force airlines to require young children to be placed in safety seats in airplanes, the agency came to a surprising conclusion: "If parents were forced to buy seats for their children, some would have to drive instead, and the accident rates for cars is much higher than for airplanes," he said.

The FAA has to "balance the interests of the airlines, the manufacturers, the suppliers, the people who fix the planes and the people who fly the planes," he said. "It’s not just as simple as the NTSB says, ‘Do it,’ so let’s do it."

Many of the NTSB recommendations that have been implemented tend to be modest, such as handing out brochures about fatigue or requiring pilots to sit through a 30-minute training video. Meanwhile, major areas of safety regulation have gone unchanged for decades. A regulation that pilots can fly no more than 1,000 hours in a single year hasn’t changed since 1935.

That was the year that a Washington-bound TWA flight carrying 11 passengers plummeted from the sky and crashed into a muddy field outside of Atlanta, Mo. The pilot and four passengers, including U.S. Sen. Bronson Cutting of New Mexico, died.

In a memo about the crash investigation, Department of Air Commerce Director Eugene L. Vidal called for a government study of fatigue. The letter is the first known mention of fatigue as a concern in aviation safety.

Fifty-five years and dozens of government studies and reports later, the NTSB listed fatigue on its inaugural “Most Wanted” list — recommendations that the safety board believes are the most critical. Today, fatigue remains on the list, one of just four of the original items that have never been addressed to the board’s satisfaction.

Tired — or impaired?
Sleep research shows startling similarities between the workplace performance of people who are fatigued and those who are intoxicated.

Technician Jeffrey Curran preps 57-year-old patient Rodney Chevalier for a night at a Tempe, Ariz., sleep clinic in July. Scientists have made significant advances in sleep research over the past decade. (Photo Tessa Muggeridge/News21)
Technician Jeffrey Curran preps 57-year-old patient Rodney Chevalier for a night at a Tempe, Ariz., sleep clinic in July. Scientists have made significant advances in sleep research over the past decade. (Photo Tessa Muggeridge/News21)Tessa Muggeridge

Someone who has been awake for 24 hours performs at the same level as someone who has a 0.10 percent blood-alcohol content, high enough to qualify as a drunk driver in all 50 states, according to studies conducted in Australia, Switzerland, Austria, England and other countries.

Steven Hursh of the John Hopkins University School of Medicine, who has studied fatigue for more than 30 years, found that tired pilots take longer to react and suffer from attention lapses. They may lose their ability to keep track of multiple tasks at one time, and they do a poor job of assessing risk, making decisions they would consider too dangerous if they weren’t so tired.

“Temporarily, a person who otherwise is very experienced, very well trained, very, very good at what they do — fatigue can make that person stupid,” Hursh said.

When tired, people react more slowly, struggle with attention lapses and take more unnecessary risks. They also suffer from a narrowed field of focus, or tunnel vision, which limits their ability to competently monitor several things at once — such as the many gauges, switches and control settings of a modern commercial airline cockpit.

What’s most dangerous is that people are unable to recognize their own fatigue.

“By the time you feel sleepy or talk about being sleepy, you’re very far gone,” the NTSB’s Brenner said. “You don’t realize how impaired you are. The part of your brain that recognizes what’s happening is impaired.”

The problem is compounded by a culture “that places a lot of value on burning the midnight oil,” said NTSB fatigue transportation research analyst Jana Price.

Many people take pride in working through fatigue, considering it a sign of strength, even if means putting themselves or others in danger, she said. It’s common to hear people brag about how little sleep they got before getting behind the wheel to drive to work in the morning or how late they stayed in the office to finish an important project.

Anyone who gets less than eight hours of sleep is not operating at 100 percent efficiency, said Scott Shappell, a Clemson University professor and director of the school’s Human Factors Institute.

“We’re all walking around with sleep deficits,” he said. “The joke is always: ‘My 90 percent is better than most people’s 100 percent,’” he said. “Well, that’s fine, but it’s not very funny when we have dead people.”

Fatigue is frequently cited by accident investigators as a factor in accidents in the air and on the water, railways and highways.

On the road
NTSB does not track fatigue-related highway accidents on a regular basis. But in 1993, the board commissioned a study expecting to learn about the effects of drugs and alcohol on trucking accidents. Investigators studied all heavy-trucking accidents that year and made an unexpected discovery: Fatigue turned out to be the bigger problem.

Crash investigators said driver fatigue played a key role in a bus accident in Utah in 2008 that killed nine people returning from a ski trip.
Crash investigators said driver fatigue played a key role in a bus accident in Utah in 2008 that killed nine people returning from a ski trip.

The study found 3,311 heavy truck accidents killed 3,783 people that year, and between 30 percent and 40 percent of those accidents were fatigue-related.

“Truck drivers drive more hours in a week than pilots fly in a month,” said Jacqueline S. Gillan, vice president of Advocates for Highway and Auto Safety. “Drivers are paid by the mile — that’s an incredible incentive to drive as far and fast as you can.”

The NTSB also found that more than half of all single-driver trucking accidents occurred in the earliest hours of the day when the fewest number of cars are on the road: between 2 a.m. and 6 a.m. Three-fourths of those early morning accidents were found to be fatigued-related.

NTSB has issued 34 recommendations regarding fatigue on the nation’s roads. Only 17 have been followed. One of the outstanding recommendations is a call to equip buses with data recorders that can track drivers’ hours of service.

On a dark and desolate stretch of highway in the Four Corners region of Utah in 2008, a busload of skiers were returning from a three-day trip to the slopes of Telluride, Colo. Five hours into a long drive to Phoenix, the 71-year-old driver let his bus wander outside the lines of the two-lane highway.

At about 8 p.m., the bus hit the guardrail, slid down an embankment and rolled into a drainage ditch. The 360-degree roll peeled the top off the Astro Stage Lines Motor Coach and tossed all but three of the 53 occupants into a snow-swept January night. Nine were killed, including five under age 18. The that driver fatigue played a key role in the accident.

Dr. Richard O’Desky, an Ohio physician in occupational medicine who often examines and certifies truckers, said he speeds past trucks on the highway because he knows how often drivers are impaired.

“My problem now is I know too much — the last place I want to be is next to a truck,” he said. “There are plenty that have no business being behind the wheel.”

In the air
Pilots say fatigue is a constant battle in the cockpit.

“I’ve been there where you literally do a little tap dance with your feet and then nod off,” said Roger Nielsen, a retired US Airways captain. “What you try to do is you read each other, you constantly check on how each other is doing, and then if one person says ‘I’m totally bagged’… it’s not uncommon to let somebody take a nap.”

Pilots, controllers and flight crews who report safety problems through an anonymous NASA database frequently mention fatigue as a problem. Since NASA added a fatigue category in June 2009 there have been more than 200 reports from flight crew members concerned about fatigue affecting work performance and safety.

NTSB’s Sumwalt said one in five reports submitted to the database is fatigue-related.

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Since 1972, the safety board has come up with 37 separate ways to address fatigue, ranging from changing pilot flying hours to commissioning more research on how much — and what kind of — sleep pilots, flight crews, controllers and maintenance workers need. But only 12 have been implemented while the other 25 remain open or the board has given up on them without action ever being taken.

The crash of a Colgan Air turboprop outside of Buffalo, N.Y., in February 2009 heightened concerns about pilot fatigue. Four crew members and 45 passengers were killed when the plane went down, crashing into a house. One person on the ground was killed. The flight was marketed as Continental Connection Flight 3407.

An NTSB investigation concluded the accident was the result of pilot error and that the pilots were likely fatigued. The captain spent the night before sleeping in the company crew room and had been awake at least 15 hours. The first officer had gotten at most 8.5 hours of sleep in the preceding 34 hours – part of that while commuting from Seattle to Newark the night before the accident, according to the report.

The Colgan crash led to more than two dozen NTSB recommendations, including measures to reduce the risk of fatigue.

Seventeen months after the crash, the FAA released a proposal to reduce flight and duty time requirements for pilots. The proposal is similar to measures introduced in 1972 and 1995 that failed after encountering industry opposition.

The new rules would require pilots to rest for nine hours rather than eight before reporting for duty. Pilots also would be limited to 13 hours of work between rest periods and get more consecutive time off during the work week. Pilots would be able to decline assignments without penalty if they felt too fatigued to fly. And airlines would be encouraged to put in place individual fatigue risk management systems, according to documents released by the FAA. The proposal could cost airlines $1.3 billion over the next 10 years.

Public comments will be accepted on the plan until Nov. 13, after which the FAA may make revisions.

NTSB spokeswoman Bridget Serchak said it’s too soon to tell if the rules go far enough, but the board “is pleased that the effort has gotten this far along.”

One of the safety board’s key concerns is that U.S. regulations lag far behind modern sleep research – and behind other countries. In the European Union, for example, crew rest time excludes the time spent traveling to or from work. That’s not the case in the U.S.

“Incredible as it may seem, the time a pilot spends waiting for a hotel shuttle and going through airport security screening is defined as rest under the current (Federal Aviation Administration) regulatory scheme,” Air Line Pilots Association President John Prater a Senate subcommittee on Aviation Operations, Safety and Security last year.

Australia, a world leader in fatigue regulation, is the only country that considers not only how long a person sleeps but the time of day.

Because the body is conditioned to operate on a normal daytime schedule, or circadian rhythm, the most restorative sleep happens at night. Simply put, eight hours of sleep in the middle of the day is not the same as eight hours at night. If the body’s rhythm, which is based on light cues, is disrupted, jet lag can result.

In Australia, pilots must get extra rest time if their off-duty time doesn’t fall between the normal sleeping hours of 10 p.m. and 6 a.m.

'Let's be realistic'
Limits on hours of duty and flight time also vary between the U.S. and other countries, according to a 2007 report commissioned by the FAA. In the U.S., a single- or two-pilot crew can fly for 10 hours in one day. In Australia, South Africa and Canada the limit is eight, according to the report.

“Airlines want to fly as much as they can fly, and they want to do it with as few personnel" as possible,  said John Prest, an executive at Fatigue Science, a Honolulu company specializing in fatigue-related technology. “Let’s be realistic — they’re in business to make money.”

NTSB investigators point to an October 2004 crash in Kirksville, Mo., that killed 13, as an example of pilot scheduling that wouldn’t be allowed in other countries.

The pilots, who commuted to work in Missouri from other states, had been awake for more than 16 hours and on duty for more than 14 hours when they got into trouble. In the final moments of the flight, they were peering out the cockpit window, looking for the runway, unaware the plane was at a dangerously low altitude until it smacked into a tree.

The one-hour flight was their sixth of the day — and one that wouldn’t have been allowed under British regulations, said NTSB human factors investigator Malcolm Brenner.

The NTSB cited fatigue as a probable cause in the crash, but investigators will never know exactly what kind of a role it played or how it affected the pilots’ final decisions.

On rails
For the nation’s railways, 25 of 39 fatigue-related recommendations have been implemented. But even when action is taken it often comes too late.

In 1997, an engineer nodded off at the controls of a train outside of Delia, Kan., according to a National Transportation Safety Board investigation. The train hit the side of an oncoming train at about 70 mph. (NTSB Photo)
In 1997, an engineer nodded off at the controls of a train outside of Delia, Kan., according to a National Transportation Safety Board investigation. The train hit the side of an oncoming train at about 70 mph. (NTSB Photo)

A 1991 recommendation to equip train locomotives with devices to alert conductors to dangers might have helped prevent a fatal accident six years later.

Shortly after 2 a.m. outside of Delia, Kansas, an engineer apparently nodded off at the controls as the train rolled through several signals and flashing lights. The engineer missed repeated radio calls, and by the time he snapped awake, it was too late. His train lurched through a switch that connects two sets of rail and into the side of an oncoming train that was bounding down the other track at about 70 mph.

In their report, NTSB investigators said they believed the conductor was too sleepy, startled or disoriented after he awoke to realize he needed to apply the brakes. They suggested a mechanical system that could sense an engineer’s lack of movement and rouse him in enough time to avert a crash.

No such system has been implemented.

Former NTSB managing director Peter Goelz said that under rails’ seniority system, veteran engineers get to select their schedules first and often choose to pack more hours into the workday so they can have more days off.

“They’re the guys with seniority, who are older, generally overweight, generally with health problems, generally with stuff going on in their lives,” Goelz said. “It’s exactly the wrong people you want on duty at that time.”

On the water
In the maritime industry, the NTSB has issued 21 fatigue-related recommendations. Nearly half have not been followed.

One of these is a 1988 recommendation that called for the U.S. Coast Guard to establish watch and duty time limitations for crew members on board ferries and other inspected passenger vessels. (The Coast Guard, which is under the U.S. Department of Homeland Security, declined repeated requests for interviews.)

Seven years after that recommendation was issued, a cruise ship ran aground off the Alaskan coast after its pilot erred while trying to guide the ship over a well-known and charted rock just before 2 a.m. Although he had been on duty for less than two hours, the pilot hadn’t slept longer than five-and-a-half hours the previous day.

The pilot, who was later diagnosed with severe sleep apnea, suffered from “chronic fatigue,” according to the NTSB report.

When the entire vessel shuddered from the impact of hitting the rock, the pilot didn’t immediately realize the error.

“Under normal conditions, such an experienced pilot should have immediately deduced that he had not safely passed Poundstone Rock when he felt the vessel shudder,” the NTSB said.

“A fatigued pilot, however, might not be sufficiently alert to realize that he had grounded.”

Part two: Video in the cockpit, a question of safety vs. privacy

Part three: Truckers are fit to drive — if a chiropractor says so

Part four: Outsourcing safety: Airplane repairs move abroad

Related: Napping in the cockpit

News21 reporters Ryan Phillips and Ariel Zirulnick contributed to this story.