Katrina E. Avers

Erica L. Hauck

Lauren V. Blackwell

Thomas E. Nesthus

Civil Aerospace Medical Institute

Federal Aviation Administration

Oklahoma City, OK 73125

October 2009

Final Report

Flight Attendant Fatigue, Part VI: 

Fatigue Countermeasure 

Training and Potential Benefits

DOT/FAA/AM-09/20

Office of Aerospace Medicine

Washington, DC 20591

OK-10-0077-JAH

Federal Aviation

Administration
NOTICE

This document is disseminated under the sponsorship 

of the U.S. Department of Transportation in the interest 

of information exchange. The United States Government 

assumes no liability for the contents thereof.

___________

This publication and all Office of Aerospace Medicine 

technical reports are available in full-text from the Civil 

Aerospace Medical Institute’s publications Web site: 

www.faa.gov/library/reports/medical/oamtechreports
i

Technical Report Documentation Page 

1. Report No. 2. Government Accession No. 3. Recipient's Catalog No. 

DOT/FAA/AM-09/20 

4. Title and Subtitle 5. Report Date 

Flight Attendant Fatigue, Part VI: Fatigue Countermeasure Training and October 2009 

Potential Benefits 6. Performing Organization Code 

 

7. Author(s) 8. Performing Organization Report No. 

Avers KE, Hauck EL, Blackwell LV, Nesthus TE 

9. Performing Organization Name and Address 10. Work Unit No. (TRAIS) 

 

11. Contract or Grant No. 

FAA Civil Aerospace Medical Institute 

P.O. Box 25082 

Oklahoma City, OK 73125 

12. Sponsoring Agency name and Address 13. Type of Report and Period Covered 

 

 

 

Office of Aerospace Medicine 

Federal Aviation Administration 

800 Independence Ave., S.W. 

Washington, DC 20591 14. Sponsoring Agency Code 

15. Supplemental Notes 

Work was accomplished under approved task AM-A-08-HRR-521 

16. Abstract 

Today’s aviation industry is a 24/7 operation that produces a variety of challenges for cabin crew members, 

including extended duty periods, highly variable schedules, and frequent time zone changes. While these 

operational requirements may be necessary, they are far from ideal with respect to the human body’s biological 

rhythms for managing sleep and alertness. In fact, acute sleep loss, sustained periods of wakefulness, and 

circadian factors resulting from this form of misalignment are all contributors to fatigue and fatigue-related 

mishaps (Caldwell, 2005; Rosekind et al., 1996). The strategic management of fatigue is necessary for safety 

improvement throughout the industry. Employee educational programs regarding the dangers of fatigue, the 

causes of sleepiness, and the importance of proper sleep hygiene to improve sleep quality may be critical for 

effective fatigue management (Caldwell, 2005). This report outlines specific recommendations regarding fatigue 

countermeasures training and its potential benefits to flight attendant operations. 

 

17. Key Words 18. Distribution Statement 

 

 

Fatigue, Flight Attendant, Training, Education, 

Countermeasures 

Document is available to the public through the 

Defense Technical Information Center, Ft. Belvoir, VA 

22060; and the National Technical Information 

Service, Springfield, VA 22161 

19. Security Classif. (of this report) 20. Security Classif. (of this page) 21. No. of Pages 22. Price 

Unclassified Unclassified 17 

Form DOT F 1700.7 (8-72) Reproduction of completed page authorized 

iii

Contents

Background . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

Fatigue management. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

Fatigue countermeasure training . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

Review of Fatigue Countermeasure Training Programs. . . . . . . . . . . . . . . . . 3

 Acquisition of training programs. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

 Content analysis of training programs. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

Review of fatigue training effectiveness. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

Individual benefits. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

 Organizational benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

Conclusions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

Appendix A: List of Fatigue Countermeasure Training Materials by Industry. . . . . . . . . . . . . . . . . A1

Appendix B: Recommended Training Course Topics. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . B1

1

Flight Attendant Fatigue, Part VI: 

Fatigue Countermeasure Training and Potential Benefits

Background

While a great deal of research has been conducted on

human circadian processes as applied to the scheduling

and training of flight crews, relatively little research has

been accomplished in cabin crewoperations. Cabin crew

members work in an environment that requires multiple

flight legs,extended duty days, limited time off,early departures,late arrivals, andless-than-optimalsleeping conditions (Caldwell, 2005; Nesthus, Schroeder, Connors,

Rentmeister-Bryant, & DeRoshia, 2007). Performance

of cabin duties is critical to the safety and security of the

flying general public. Sleep researchershavefoundthat all

human performance is vulnerable to sleep loss and daily

variations in physiological processes tied to underlying

body-clock mechanisms (Caldwell, 2005). Theextent of

sleep loss, fatigue, and their impact on performance of

duties among the cabin crew population and within the

current duty regulations is currently unknown. 

In 2005, a Congressional directive to the Civil Aerospace Medical Institute (CAMI) was given to address

issuesregardingflight attendantfatigue. CAMI contracted

with the National Aeronautics and Space Administration

(NASA) Ames Research Center’s Fatigue Countermeasures Group to conduct literature and incident report

reviews and examine a range of typical flight attendant

schedules to assess potential vulnerability to fatigue. Two

reportswere delivered by NASA andwereintegrated into

a published Federal Aviation Administration (FAA) Office of Aerospace Medicine Technical Report (Nesthus

et al., 2007). In this report, NASA concluded that some

degree of fatigue-related performance decrements were

likely under the current regulations and suggested six

areas of research that would facilitate understanding and

government-industry decision making. The six recommendations included: 1) a survey of field operations; 2)

field research on the effects of fatigue; 3) a validation of

models for assessing flight attendant fatigue; 4) a focused

study of incident reports, 5) a review of international

policies and practices, and 6) a review of the potential

benefitsoftrainingwithcorresponding recommendations

for a training program. 

In 2008, Congress provided another directive for

CAMI to conduct follow-up studies in each of the six

recommendation areas noted in the 2007 report. To accomplish this directive, CAMI researchers developed a

project plan for completing each recommendation. To

facilitatesupport for these projects and ensure participation, CAMIresearchers coordinatedwith representatives

of vested organizations (e.g., Air Transport Association,

Regional Airline Association, Coalition of Flight Attendants) and provided themwith the opportunity to review

and comment on aspects of the project plan prior to its

commencement. 

The current report provides specific details regarding

fatigue countermeasure training and the potential benefits it could provide to flight attendant operations and

outlines suggested topics for a flight attendant fatigue

countermeasurestrainingprogram(recommendation#6). 

This report will be incorporated into our consolidated

report to Congress.

Introduction

Technological advances in the last 20 years have produced a 24/7 aviation industry. As a result, cabin crew

members are constantly challengedbymultipleflightlegs,

extendeddutydays,limitedtimeoff,earlydepartures,late

arrivals,less-than-optimalsleeping conditions,jetlag, and

non-standard work hours such as night duty and rotating schedules (Caldwell, 2005). Herein lies the problem. 

Despite operational requirements, the body’s biological

need for sleep to maintain alertness does not change. In

otherwords, individuals are not physiologically prepared

to operate effectively on the 24/7 schedules that define

today’s flight operations. Consequently, a well-planned,

science-based fatigue management strategy is crucial for

combating acute and cumulative sleep loss, sustained

periods of wakefulness, and circadian factors that have

beenshowntocontributetofatigue-relatedflightmishaps

(Caldwell, 2005; Rosekind et al., 1996). 

Fatigue management

Fatigue management generally refers to theidentification of fatigue risk and the implementation of strategic

controls. In the aviation industry, the FAA has traditionally sought to manage fatigue through hours of service

(HOS) regulations (see Table 1). Theincreasing number

offatigue-related Aviation Safety Reporting Systemreports

(Holcomb et al., under review), however, suggests that

HOS regulations areinsufficientforsystematicallymanaging fatiguefor flight attendants. In other words,effective

fatigue management requires more than just scheduled

rest and duty time regulations and might benefit from a
2

multi-level, science-based approach. Systematic fatigue

management requires everyone to take responsibility –

theregulator, the operators, and the cabin crew members

(see Figure 1). For example, the FAA is responsible for

fatigue management regulations, while the operators

have a responsibility for work schedule design, workload

distribution, working conditions, and training (Rosa &

Colligan, 1997). The cabin crew members are responsible for optimizing their rest opportunities to get the

sleep they need to be fit for work and for implementing

personal fatigue countermeasures as needed to mitigate

fatigue and maintain alertness. Thus, an important part

of fatigue management is to raise awareness ofemployees

and managers regarding the causes and consequences of

fatigue and providetraining on scientifically-based countermeasures designed to better manage on and off-duty

fatigue(Caldwell, 2005; Dawson & McCullough, 2005;

Rosekind, Co, Neri, Oyung, & Mallis, 2002; Rosekind,

Gander, Connell, & Co, 2001). 

Table 1. Summarized Flight Attendant (FA) Rest Periods According to CFRs 

Scheduled Duty 

Period 

Normal Minimum 

Rest Period 

Reduced Rest 

Period 

Subsequent Rest 

Period 

Number of FAs 

Required 

14 hours or less 9 hours 8 hours 10 hours Minimum 

14-16 hours 12 hours 10 hours 14 hours Minimum + 1 

16-18 hours 12 hours 10 hours 14 hours Minimum + 2 

*18-20 hours 12 hours 10 hours 14 hours Minimum + 3 

*Applies only to duty periods with one or more flights that land or take off outside the 48 contiguous States and the 

District of Columbia 

Note: Generally, rest periods begin no less than 15 minutes after the aircraft pulls into the gate and continues until 

one hour prior to a flight attendant’s next departure. 

Figure 1. Shared responsibility for fatigue management. 

Regulator Operator

Individual

Fatigue 

Management
3

Fatigue countermeasure training

Education about the dangers of fatigue, the causes of

sleepiness on the flight deck, and theimportance of sleep

and proper sleep hygieneis one key to addressing fatigue

inoperational aviationcontexts(Caldwell,2005; Dawson

& McCullough, 2005; Rosekind et al., 2001a; Rosekind

et al., 2002). Ultimately, cabin crew members and those

responsibleforschedulingtripsmustunderstandthatsleep

and circadian rhythms areimportant issues for consideration and that quality off-duty sleep is the best possible

protection against fatigue prior to beginning their duty

period. Recent studies have made it clear that as little as

two hours of sleep loss can result in almost immediate

performance decrements and an increased likelihood of

error or accidents(Carskadon& Roth,1991; Mitleret al.,

1988). In fact, continuous wakefulness beyond 17 hours

can result in performance decrements comparable to an

individual considered legally drunk (i.e., Blood Alcohol

Content [BAC] = 0.05–0.10; Arnedt, Wilde, Munt, &

MacLean, 2001; Lamond & Dawson, 1999; Maruff,

Falleti, Collie, Darby, & McStephen, 2005). Given the

safety hazards associated with fatigue, it seems clear that

fatigue countermeasuretraining is anecessary component

of systematic fatigue management. Thus, the purpose of

this report is to: 1) identify theessential components of a

fatigue countermeasuretraining programand 2)examine

the benefits a fatigue countermeasure training program

can have for reducing fatigue. 

Review of Fatigue Countermeasure

Training Programs

Fatigue countermeasuretraining isnot anewapproach

to fatigue management. In fact, fatigue countermeasure

training has been utilized across a number of industries

with24/7operations(e.g.,railroad,trucking,watertransport) for more than 20 years (e.g., Nicholson & Stone,

1987). In flight attendant responses to questions regarding fatigue training in a recent CAMI Flight Attendant

Fatigue Survey, 35% of cabin crewmembersrevealed that

their carrier did provide some type of training or information regarding fatigue; however, 79% indicated that

the training airlines were providing did not help reduce

or minimize fatigue (Avers, Nesthus, King, Thomas,

& Banks, under review). This is possibly a result of the

content of the training, the method of training, lack of

personal responsibility, or lack of integration of training

withotherfatigueriskmanagementtools(i.e.,scheduling). 

We conducted an extensivereviewof thefatiguetraining literatureto identify the critical components of an effectivefatigue countermeasurestrainingprogram. Existing

fatigue countermeasuretraining programswere collected

from diverseworkforces and content analyzed to develop

a basic outline of critical fatiguetraining topics. Wethen

computeda frequency index todeterminehowofteneach

topic occurred across training programs. This index was

then used to identify the topics that were deemed most

criticalforinclusionina fatigue countermeasurestraining

program. When available, general information regarding

the benefits and effectiveness of fatigue countermeasure

training programs was also collected and reviewed. 

Acquisition of training programs

Acquiring information on fatigue countermeasure

training programs beganwith a three-pronged approach:

1) a search of scientific literature databases, 2) a general

search of public and private educational materials, and

3) a series of inquiries to prominent fatigue researchers. 

Initially, an extensiveliteraturesearch was conducted using sevenacademic computerdatabases(Academic Search

Premier, Business Source Premier, ERIC, E-Journals,

Military & Government Collection, PsycARTICLES,

and PsycINFO) and the CAMI Online Library. Separate

searches were also run on the FAA and NASA Websites

to identify aviation-specific technical reports. General

search terms included phrases like alertness management,

fatigue countermeasures, fatigue management, fatigue 

education, and shiftwork training. To expand the search

beyond scientifically published training programs, a

general Internet search was conducted to locate public

and privatetraining programs. In particular,thisInternet

search attempted to locate programs available online and

to identify companies that may have developed orimplemented fatigue management training programs. Using

the GoogleTM search engine, key phrases such as fatigue 

training and fatigue risk management were entered to locatefatiguetraining programs. Theidentified companies

were then contacted to request a copy of their complete

trainingprogrammaterialsor anoutlineofthetopic-areas

covered in their training program. The third approach

was to contact a number of prominent fatigue researchers requesting information regarding training program

materials they had used or helped to develop. Responses

from the companies and researchers that were contacted

were very positive (73% response rate) and ultimately

resulted in the collection of 50 training programs. 

Inclusion criteria. After collecting thetraining program

materials, each was reviewed and evaluated using three

inclusioncriteria:1)thematerialsprovidededucationand

training on fatigue, shiftwork, or alertness management,

2) the materials were created or published after 1985,

and 3) the materials included, at a minimum, at least an

outline and summary of the topic areas included in the

training program. If a program did not meet all three of

these requirements, we dismissed it from further content analysis. Using these criteria, two doctoral students
4

reviewed each of the programs, and 49 programs were

retained for further analysis (100% agreement). See Appendix A forthe completelistoffatiguetrainingprograms.

Characteristics of training programs. The training programs included in this study covered a broad spectrum

of educational materials that were developed for various

workforces,instructedordisseminatedtoemployeesusing

multiple methods, and designed for different purposes

according to organizational or work task requirement. 

Specifically, six programs were developed for the general

driving population; 17 programs were developed for

unspecified populations or general shiftworkers; 22 were

developed for thetransportation industry, and four were

developed for an “others” category. Of the 22 programs

developed for the transportation industry, 13 were developed for aviation-specific operations: pilots (n=4),

maintenance workers (n=2), air traffic controllers (n=2),

and general or unspecified (n=5). Dissemination of the

educationalmaterialsto employees alsoutilizedanumber

ofdifferent approaches andmediavenues,including:video

(n=2), Web-basedcourses(n=2),printedmaterials(n=30),

classroom instruction (n=6), combination of the above

methods(n=7), andtwowithundocumentedapproaches. 

Some of the educational materials were developed by

businesses, consideredproprietaryinformation,marketed,

and sold for profit. As such, some training programs

were only available for review in summary outline form

(n=10). However, full training materials were obtained

for the remaining programs (n=39). 

Content analysis of training programs

Eachprogramwasreviewedtodevelopa comprehensive

outline of the topic-areas that appeared to be critical to

a fatigue education and countermeasures training program. Once the outline was established, the programs

were content-analyzed by the two raters to identify the

presence of each topic area; inter-rater agreement was

sufficient (κ=.85). Each topic area was only to be considered present in the training program if at least three

sentences were devoted to it or one specific, prescriptive

recommendation was described. The purpose of this

content analysis was to quantify the topics included in

the training programs by creating a frequency index of

how often each topic area had occurred across the various training sources. The frequency index thus provided

the basis for identifying a hierarchical listing of critical

topics for the fatigue countermeasures training program

(see Table 2). 

Identified topics areas. The content analysis revealed

thateach of thetopic areas included in theinitial outline

should be included in the recommended fatigue countermeasures training program. In general, the fatigue

experts consistently agreed on the most important topic

areas that are necessary for an effective fatigue countermeasurestraining program. Topicswere consistent across

the overall training programs reviewed and even more

consistent among the aviation-specific trainingprograms. 

Any variations notedweremostly a function ofthe degree

of detailed information provided and the specific focus

of the training program (e.g., on-duty countermeasures

vs. off-duty countermeasures). As expected, fatigue was

a focal topic in all of the training programs (100%). 

However,not allfatigue-relatedfactorswereincludedwith

the same degree of frequency across programs. To break

this down, topic areas such as sleep, circadian rhythms,

nutrition, work hours, and substance use (e.g., caffeine,

alcohol) were cited more frequently, while commuting,

workload, and hydrationtopicswere cited lessfrequently. 

All topic areas were cited in at least eight of the 49 training programs reviewed and could arguably be included

in a comprehensive fatigue training program. 

Organization of training topics. To organize the

training topic areas for this report, the raters reviewed

the educational materials and used a q-sort procedure

that identified three broad content areas: introductory

fatigue information, off-duty rest and activities, and

on-duty or operationally specific issues. Within each of

thethree content areas, topics were broken into multiple

sub-levels to ensure that all relevant information would

be included. For instance, under the off-duty rest and

activities section, there are two secondary headings:

sleep fundamentals and lifestyle. Each secondary topic

was further delineated to provide in-depth guidelines

regarding content development. See Appendix B for the

final proposed training outline. 

Review of fatigue training 

effectiveness

Although a number of focused and detailed fatigue

training programsexist,relatively feworganizations have

evaluated and reported the effectiveness or recurrence

recommendationsoftheirfatiguetrainingprograms. The

preliminary evidence, however, doessuggestthattraining

provides a number of physiological and psychological

benefits to theindividual, as well as the organization and

should be considered one aspect of a company’s overall

fatigue mitigation strategy. 

Individual benefits

In2005, Gander andcolleagues adapteda NASA Ames

Fatigue Countermeasures Program and administered it

to both heavy- and light-vehicle drivers. Heavy-vehicle

drivers were tested on key concepts using a test administered before and after each training session and also

by a follow-up survey sent out within 26 months of the
5

Table 2. Frequency of Fatigue Topics Across Training Programs 

Overall Aviation Specific 

Topics # Ta Total 

Tb % Tc Programsd # Ta Total 

Tb % Tc

Fatigue 49 49 100% 1,2,3,4,5,6,7,8,9,10,11,12,13,14,15,16,17,18,19,20,21,22,23,24, 

25,26,27,28,29,30,31,32,33,34,35,36,37,38,39,40,41,42,43,44,45, 

46,47,48,49 

13 13 100%

Definition 21 49 43% 2,9,10,11,16,18,20,22,23,24,25,26,27,29,30,42,44,45,46,47,48 10 13 77%

Symptoms 33 49 67% 1,2,3,4,5,8,9,11,15,16,18,19,20,22,23,24,25,26,27,28,29,30,31,35,

36,42,43,44,45,46, 47,48,49 

12 13 92%

Causes 36 49 73% 2,5,6,7,8,9,10,11,15,16,18,19,20,21,22,23,24,25,26,27,28,29,30, 

32,33,35,36,38,40,41,42,45,46,47,48,49 

13 13 100%

Consequences 45 49 92% 1,2,3,5,6,7,8,9,10,11,13,14,15,16,17,18,19,20,21,22,23,24,25,26, 

27,28,29,30,31,32,33,34,35,36,37,39,40,41,42,44,45,46,47,48,49 

13 13 100%

Mental 40 45 90% 2,3,5,6,9,10,11,13,14,15,16,17,18,19,20,21,22,23,24,25,26,27,28,

29,30,33,34,35,36,37,39,40,41,42,44,45,46,47,48,49 

13 13 100%

Physical 41 45 91% 1,2,3,5,6,9,10,11,13,14,15,16,17,18,19,20,21,22,23,24,25,26,27, 

28,29,30,31,33,34,35,36,37,39,40,41,42,44,45,47,48,49 

13 13 100%

Health/Well-being 34 45 76% 1,2,3,5,6,9,10,11,13,14,15,16,17,18,20,21,22,23,24,25,26,27,28, 

29,30,36,37,40,42,44, 45,47,48,49 

12 13 92%

Digestive 16 34 47% 1,3,6,9,10,11,14,15,17,18,22,27,30,42,45,48 4 12 33%

Cardiovascular 16 34 47% 1,3,6,9,10,11,14,15,17,18,22,27,30,42,45,48 4 12 33%

Mood 24 34 71% 2,3,6,9,10,11,13,16,20,21,22,23,24,25,26,27,28,29,30,36,42,45, 

48,49 

11 12 92%

Circadian Rhythm 40 49 82% 1,3,4,5,6,7,9,11,13,14,15,16,17,18,19,20,21,22,23,24,25,26,27,28,

29,30,31,32,33,35,36,38,39,43,44,45,46,47,48,49 

13 13 100%

Sleep 44 49 90% 1,3,4,5,6,7,9,10,11,12,13,14,15,17,18,19,20,21,22,23,24,25,26,27,

28,29,30,31,32,33,35,36,37,38,39,40,41,43,44,45,46,47,48,49 

13 13 100%

Cycle 22 44 50% 1,3,5,6,9,18,19,22,23,24,25,26,27,29,30,35,37,39,44,46,48,49 10 13 77%

Debt 26 44 59% 1,4,9,11,18,19,20,21,22,23,24,25,26,28,29,30,32,33,35,36,38,40, 

44,47,48,49 

12 13 92%

Quantity 39 44 89% 1,3,4,5,6,9,10,11,13,14,15,17,18,19,20,21,22,23,24,25,26,27,28, 

29,30,32,33,35,36,37,39,40,41,44,45,46,47,48,49 

13 13 100%

Quality 35 44 80% 1,3,4,9,12,13,14,15,17,18,19,20,21,22,23,24,25,26,27,28,29,30, 

35,36,37,39,40,41,43,44,45,46,47,48,49 

13 13 100%

Notes 

a Number of training programs that included information on the topic area. b

Total number of training programs included in the percentage calculations based on category breakdowns. c Percentage of training programs that included information on the topic area. d Training programs that included information on the topic area (see Appendix A for the list of training programs) 
6

Table 2 (cont.). Frequency of Fatigue Topics Across Training Programs

Overall Aviation Specific

Topics # Ta Total 

Tb

% 

Tc Programsd # Ta Total

 Tb

% 

Tc

Napping 30 49 61% 1,3,6,11,12,13,15,18,19,21,22,23,24,25,26,27,28,29,30,31,32,33, 

35,36,43,44,45,47,48,49 

12 13 92%

Work Hours 35 49 71% 1,3,4,5,6,9,11,13,14,15,17,18,20,21,22,23,24,25,26,27,30,33,35, 

36,37,39,40,41,42,44, 45,46,47,48,49 

10 13 77%

Shiftwork 28 34 82% 1,3,4,5,6,9,11,13,14,15,17,18,20,21,22,23,24,25,26,27,33,35,37, 

44,45,46,48,49 

9 10 90%

Overtime/Extended Hours 19 34 56% 9,11,13,14,15,18,23,24,25,26,35,36,40,41,42,45,46,48,49 5 10 50%

Shift Scheduling 25 34 74% 3,6,9,11,13,14,15,17,18,21,22,23,24,25,26,27,35,36,37,44,45,46, 

47,48,49 

8 10 80%

Nutrition 34 49 69% 1,3,5,6,7,9,10,12,13,14,15,17,18,19,21,22,23,24,25,26,27,29,30, 

32,35,36,37,39,43,44, 45,47,48,49 

11 13 85%

Hydration 15 49 31% 1,17,18,23,24,25,26,27,29,36,40,41,43,47,49 7 13 54%

Exercise 30 49 61% 1,3,4,5,7,9,13,14,15,17,18,19,21,22,23,24,25,26,27,29,30,35,36, 

37,39,43,44,45,48,49 

11 13 85%

Substances 35 49 71% 1,3,4,5,6,7,9,10,11,13,14,15,18,19,21,22,23,24,25,26,27,28,29,30,

31,32,35,36,43,44, 45,46,47,48,49 

12 13 92%

Alcohol 30 34 88% 1,3,4,5,6,9,10,11,13,14,15,18,19,21,22,23,24,25,26,27,28,29,30, 

31,35,36,45,47,48,49 

12 12 100%

Caffeine 33 34 97% 1,3,4,5,6,9,10,11,13,14,15,18,19,21,22,23,24,25,26,27,28,29,30, 

31,32,35,36,43,44,45, 47,48,49 

12 12 100%

Nicotine 14 34 41% 1,3,5,13,14,18,19,21,26,27,30,36,47,48 6 12 50%

Other Drugs 26 34 76% 1,3,4,5,6,7,9,13,14,15,18,21,23,24,25,27,29,30,32,35,36,43,45,46,

48,49 

8 12 67%

Sleeping Disorders 26 49 53% 1,4,9,13,14,18,19,21,23,24,25,27,28,29,30,32,33,35,36,40,41,44, 

45,46,48,49 

10 13 77%

Workload 8 49 16% 11,15,16,24,25,29,40,46 3 13 23%

Family & Social Life 26 49 53% 1,3,4,5,6,7,11,12,13,14,15,16,17,18,20,21,22,27,31,35,36,39,43, 

45,47,48 

5 13 38%

Work Environment 22 49 45% 1,3,5,9,13,14,15,16,17,20,22,23,24,25,29,33,35,40,41,45,47, 48 6 13 46%

Commuting 17 49 35% 1,3,4,6,9,10,11,13,18,21,22,27,30,39,40,41,48 5 13 38%

Jet Lag (if applicable) 10 10 100% 18,19,20,23,24,25,28,29,46,49 8 8 100%

Other Countermeasures 40 49 82% 1,3,4,5,6,7,8,9,10,11,12,13,15,16,17,19,22,23,24,25,26,27,29,30, 

31,32,33,34,35,36,37,38,39,40,43,44,45,47,48,49 

10 13 77%

Notes:

a Number of training programs that included information on the topic area. 

b

Total number of training programs included in the percentage calculations based on category breakdowns. c Percentage of training programs that included information on the topic area. d Training programs that included information on the topic area (see Appendix A for the list of training programs) 
7

initial training. Thesurvey inquired about the usefulness

ofthetraining course and about knowledgeretentionand

use of fatigue countermeasures. The results indicated a

significant change between the pre- and post-measures

of knowledge. The median ratio of correct responses for

the pre-measure was 9/16 items and 14/16 items for the

post-measure. The follow-up survey revealed a median

ratio of 13/14 items correct, with 82% answering at least

12/14 correctly. Seventy-five percent of drivers thought

that thefatiguetraining was at least “moderately useful,”

with 47% changing the fatigue management strategies

that they used at home and 49% changing the strategies

they used at work. Sixty-one percent of drivers indicated

that they would benefit from recurrent fatigue management training to refresh and update their knowledge on

countermeasure strategies.

For light-vehicle drivers, a more informal follow-up

questionnaire assessing the usefulness of training was

administeredwithin 2 years oftheinitialtraining. Results

of these assessmentsindicated that 70% answered at least

11/13 questions correctly, and 91% found the training

at least “moderately useful.” A total of 50% reported

having changed their fatigue management strategies at

home, while 43% had changed their strategies at work. 

A handful of drivers in this study also reported that they

thought that management had made positive changes,

including improved roster designs and increasingly open

communication with drivers regarding fatigue.

Using a similar pre- and post-test design, Kerin and

Aguirre(2005) administered a training program to mining company employees and their spouses or domestic

partners in a single, 4-hour group session that included

10-50 people. It’s been suggested that training may have

the greatest impact when partners are included because

shiftwork schedules affect theentirefamily. Thetraining

course itself was meant to “provide factual information

on solutions to the special challenges of shiftwork” (p. 

202). Before completingthetrainingcourse,workersfilled

out sleep/wake logs for a 28-day shift cycle, including a

questionnaireregardingtheirsleephabits,lifestyle,family/

homelife, fatigue, alertness, health, and safety to provide

a baseline measure of behavior. Six weeks after attending

thetraining session,workers completedthesleep/wakelog

and the questionnaire again. The differences between the

pre- and post-measures were used to assess the effectiveness of training. Results from the study indicated that

six weeks following thetraining, there was a reduction in

the number of workers reporting that it was difficult to

fulfill their domestic responsibilities(41% vs. 23%), find

timeforentertainment andrecreational activities(46%vs. 

23%), or believing that their health would improve with

a different schedule (77% vs. 50%). The miner’s average

scores onthe gastrointestinal index declined considerably

(17.9 to 13.6), as did theirexcessive use of caffeine(32%

vs. 8%). The amount of sleep obtained during daytime

hours increased by nearly an entire hour (from 4.8 to

5.8 hr), and more workers reported getting at least 5

hours of sleep each night (45% vs. 67%). Additionally,

over half of the workers that completed thetraining with

their partners reported making changes in their physical

environmenttomakeitmore conduciveto sleep. Overall,

the feedback from both managers and workers was very

positive andindicatedthatfatiguetrainingwasbeneficial. 

Organizational benefits

Additional research suggests that organizations benefit from fatigue-related countermeasure training. Large

scale surveys of shiftwork facilities have linked fatigue

and shiftwork training to reduced turnover, reduced

absenteeism, fewer fatigue problems, and fewer morale

issues for organizations (Kerin & Aguirre, 2005). Fatigue countermeasure training has also been predictive

of worker perceptions of safety (Arboleda, Morrow,

Crum, & Shelley, 2003) and fewer accidents and injuries

(Moore-Ede, Heitman, Dawson, & Guttkuhn, 2005). A 

follow-up survey for onetraining program indicated that

over half of the respondents surveyed reported that the

educational materials were the basis for positive change

as related to fatigue in their organizations (Rosekind et

al., 2001b). Even seasoned long-haul truck drivers had

very positiveresponses to fatiguetraining,with as high as

96% reporting that they have applied the course lessons

presented during training and intend to continue using

them (Dinges, Maislin, Brewster, Krueger, & Carroll,

2005). Clearly, the evidence suggests that fatigue countermeasure training programs can be beneficial to both

the individual and the organization. 

Conclusions

Mitigating fatiguein complex aviation operations is a

challenging proposition. Results of this report, nonetheless, suggest that fatigue can be managed to some extent

with a well-developed fatigue countermeasure training

program. The content analysis conductedwiththefatigue

training programs reviewed for this report revealed the

topic areas that should beincluded in an effectivefatigue

countermeasure training program. Despite the scarcity

of research regarding fatigue training effectiveness, the

availableevidencesuggeststhattrainingprovides anumber

of benefits to both the individual and the organization. 

These benefits can only be realized, however, when individuals take personal responsibility and are committed

to change. Additionally, someevidencesuggests the need

to integrate training with a broader focus on fatigue risk

management, including scheduling relative to circadian
8

variations in alertness (e.g., Gander et al., 2005). Taken

together, the training content analysis and review of

countermeasure training benefits indicate that a flight

attendant fatigue countermeasure training program is a

viable and potentially beneficial method for managing

and mitigating the effects of fatigue. 

Consequently, we make two recommendations: 1)

Airlines should implement training as outlined in Appendix B (tailored to the flight attendant population);

and 2) Training should beintegrated into broaderfatigue

risk management strategies.

References

Arboleda, A., Morrow, P.C., Crum, M.R., & Shelley,

M.C. (2003). Management practices as antecedents

ofsafety culturewithin thetrucking industry:similarities and differences by hierarchical level. Journal 

of Safety Research, 34, 189-97.

Arnedt, J.T., Wilde, G.J.S., Munt, P.W., & MacLean,

A.W. (2001). How do prolonged wakefulness and

alcohol compare in the decrements they produce

on a simulated driving task? Accident Analysis & 

Prevention, 33, 337-44.

Avers, K., King, J., Nesthus, T., Thomas, S., & Banks,

J. (under review). Flight Attendant Fatigue Part I:

National Duty, Rest, and Fatigue Survey (Technical Report DOT/FAA/AM-XX/X). Washington,

DC: Federal Aviation Administration Office of

Aerospace Medicine.

Caldwell,J.A. (2005). Fatiguein aviation. Travel Medicine 

and Infectious Disease, 3, 85-96. 

Carskadon, M.A., & Roth, T. (1991). Sleep restriction. In

T.H. Monk (Ed.), Sleep, Sleepiness and Performance

(pp. 155-67). Chichester: Wiley.

Dawson, D.,& McCulloch, K. (2005). Managing fatigue:

It’s about sleep. Sleep Medicine Reviews, 9, 365-80.

Dinges, D.F., Maislin, G., Brewster, R.M., Krueger,

G.P., & Carroll, R.J. (2005). Pilot testing of fatigue

management technologies. Transportation Research 

Record: Journal of the Transportation Research Board, 

1922, 175-82.

Gander, P.H., Marshall, N.S., Bolger, W., & Girling,

I. (2005). An evaluation of driver training as a

fatigue countermeasure. Transportation Research 

Part F, 8, 47-58.

Holcomb, K., Avers, K., Dobbins, L.,Banks,J.,Blackwell,

L., & Nesthus, T., (under review). Flight Attendant 

Fatigue Part II: Analysis of Incident Reports. (Technical Report DOT/FAA/AM-XX/X). Washington,

DC: Federal Aviation Administration Office of

Aerospace Medicine.

Kerin, A., & Aguirre, A. (2005). Improving health,

safety, and profits in extended hours operations

(shiftwork). Industrial Health, 43, 201-08.

Lamond, N., & Dawson, D. (1999). Quantifying the

performance impairment associated with fatigue. 

Journal of Sleep Research, 8, 255-62. 

Maruff, P., Falleti, M.G., Collie, A., Darby, D., & McStephen, M. (2005). Fatigue-related impairmentin

the speed, accuracy and variability of psychomotor performance: Comparison with blood alcohol

levels. Journal of Sleep Research, 14, 21-7.

Mitler M.M., Carskadon, M.A., Czeisler, C.A., Dement,

W.C., Dinges, D.F., & Graeber, R.C. (1988). 

Catastrophes, sleep, and public policy: Consensus

report. Sleep, 11, 100-9. 

Moore-Ede, M., Heitmann, A., Dawson, T, & Guttkuhn,

R. (2005). Truckload driver accident, injury, and

turnover rates reduced by fatigue risk-informed

performance-based safety program. In Proceedings 

of the 2005 International Conference on Fatigue 

Management in Transport Operations (pp. 1-15),

Seattle, WA. 

Nesthus, T.E., Schroeder, D.J., Connors, M.M., Rentmeister-Bryant, H.K., & DeRoshia, C.A. (July,

2007). Flight attendant fatigue. (Report No. DOT/

FAA/AAM-07/21). Washington, DC:Federal Aviation Administration Office of Aerospace Medicine. 

Nicholson, A.N. & Stone, B.M. (1987). Sleep and wakefulness: Handbook for flight medical officers. North

Atlantic Treaty Organization, Advisory Group for

Aerospace Research & Development. Loughton,

Essex: Specialized Printing Services Limited.

Rosa, R.R., & Colligan, M.J. (July 1997). Plain language

about shiftwork. (National Institute for Occupational Safety and Health No. 97-145). Cincinnati,

Ohio. 

Rosekind, M.R., Gander, P.H., Connell, L.J., & Co, E.L. 

(November, 2001a). Crew factors in flight operations 

X: Alertness management in flight operations education 

module.(NASA/TM-2001-211385). MoffettField,

CA: National Aeronautics and Space Administration, Ames Research Center.
9

Rosekind, M.R., Co, E.L., Neri, D.F., Oyung, R.L.,

& Mallis, M.M. (February, 2002). Crew factors 

in flight operations XV: Alertness management in 

general aviation education module. (Report No. 

NASA/TM-2002-211394). Moffett Field, CA:

National Aeronautics and Space Administration,

Ames Research Center. 

Rosekind, M.R., Neri, D.F., Gregory, K.B., Mallis,

M.M., Bowman, S.L., & Oyung, R.L. (2001b). A 

NASA education and training module on alertness

management: A survey of Implementation and

Application. Sleep, 24, A415-16.

Rosekind, M.R., Gander, P.H., Gregory, K.B., Smith,

R.M., Miller, D.L., Oyung, R., Webbon, L.L., &

Johnson, J.M. (1996). Managing fatigue in operational setting 1: Physiological consideration and

countermeasures. Behavioral Medicine, 21, 157-65.

A1

APPENDIX A

List of Fatigue Countermeasure Training Materials by Industry

General

1. Moore-Ede, M. (2006). Working nights: Health and safety guide. Circadian Information.

2. Moore-Ede, M. (2009). The definition of human fatigue. Unpublished document. Circadian. 

3. Shapiro, C., Heslegrave, R., Beyers,J., & Picard, L. (1997). Working the shift: A self-health guide. Black Moss Press.

4. National Highway Traffic Safety Administration (2000). Sick and tired of waking up sick and tired? U.S. Department of Transportation.

5. Reed, A.T. (1993). Shift wise: A shiftworker’s guide to good health. Transport Canada. 

6. Monk, T.H. & Folkard, S. (1992). Making shiftwork tolerable. London: Taylor & Francis.

7. Clockwork Research. Clockwork fatigue awareness & countermeasures training. Unpublished document.

8. Enform (2007). Guide to safe work: Fatigue management. Unpublished document.

9. Department of Industrial Relations (2005). Fatigue management guide. Unpublished document. Queensland

Government

10. Department of Industrial Relations (2005). Managing fatigue: Handy tips for shiftworkers. Unpublished document. Queensland Government.

11. Scuffham, A., Pringle, D., & Gander, P. (2004). Guidelines for managing fatigue. Unpublished document.

12. Kerin, A., & Aguirre, A. (2005). Improving health, safety, and profits in extended hours operations (shiftwork).

Industrial Health, 43, 201-208.

13. Klein, M. & Dubas, K. (1986). The shiftworkers guide to better sleep, health and family/social relations. Lincoln,

NE: SynchroTech.

14. Saskatchewan Labour: Occupational Health and Safety Division (1998). Managing shiftwork. Unpublished

document.

15. Rosa, R.R. & Colligan, M.J. (1997). Plain language about shiftwork. (Publication No. 97-145) U.S. Department

of Health and Human Services, National Institute for Occupational Safety and Health.

16. WorkSafe Western Australia Commission (2001). Reducing the risk of fatigue at the workplace. Government of

Western Australia. 

17. Canadian Centre for Occupational Health & Safety. Rotational shiftwork. Retrieved June 11, 2009, from www.

ccohs.ca/oshanswers/ergonomics/shiftwrk.html.

Aviation 

18. McCulloch, K., Baker, A., Ferguson, S., Fletcher, A., & Dawson, D. (2007). Fatigue management strategies for 

employees. (Report No. TP 14573E). Transport Canada.

19. Delta Air Lines (2007). Alertness management guide. Unpublished document.

20. Civil Aerospace Medical Institute (2003). Pilot fatigue in aviation. Federal Aviation Administration, Oklahoma

City, OK.

21. European Organisation for the Safety of Air Navigation EuroControl (2005). Fatigue and sleep management. 

Brussels, Belgium: DAS/HUM EuroControl.

22. Civil Aerospace Medical Institute(2001). Shiftwork coping strategies. Federal Aviation Administration, Oklahoma

City, OK.

23. Rosekind, M.R., Gander, P.H., Connell, L.J., & Co, E.L. (2001a). Crew factors in flight operations X: Alertness 

management in flight operations education module. (NASA/TM – 2001-211385) NASA Ames Research Center. 

24. Rosekind, M.R., Co, E.L., Neri, D.F., Oyung, R.L., & Mallis, M.M. (2002). Crew factors in flight operations XV: 

Alertness management in general aviation education module.(NASA/TM –2002-211394) NASA Ames Research Center.

25. Rosekind, M.R., Co, E.L., Neri, D.F., Oyung, R.L., & Mallis, M.M. (2002). Crew factors in flight operations 

XIV: Alertness management in regional flight operations education module. (NASA/TM – 2002-211393) NASA 

Ames Research Center.

26. Rankin, B. (2009). Fatigue and sleep. [PowerPoint slides]. Boeing.

27. Hughes, R. (2009). Dealing with shiftwork and fatigue. [PowerPoint slides]. JetBlue Airways.

28. Delta Air Lines (2006). Sleep/fatigue management guide. Unpublished document.

29. Virgin Blue (2007). Fit for duty: Fatigue risk management guidance booklet. Unpublished document.
A2

30. Rhodes, W. & Gil, V. (2002). Fatigue management program for Canadian marine pilots. (Report No. TP 13958E)

Transport Canada.

Driving

31. Royal Automobile Association (2001). Driver fatigue is a killer. Unpublished document.

32. Rural Ambulance Victoria & Metropolitan Ambulance Service(2001). Too tired to drive? Unpublished document.

33. Gander, P.H., Marshall, N.S., Bolger, W., & Girling, I. (2005). An evaluation of driver training as a fatigue

countermeasure. Transportation Research Part F, 8, 47-58.

34. Department of Transportation (2007). Fatigued driving is impaired driving. Government of the Northwest Territories. Retrieved June 11, 2009, from www.dot.gov.nt.ca/_live/pages/wpPages/FatigueImpairment.aspx.

35. Hartley, L.R. (1996). Drive alert: A driver’s guide to fatigue and alertness. Unpublished document, Institute for

Research in Safety and Transport, Murdoch University.

36. Department for Planning and Infrastructure(2004). Staying alert at the wheel. Government of Western Australia.

Railroad 

37. Leutzinger, J.A., Holland, D.W., & Richling, D.E. (1999). Good moon rising: Union Pacific Railroad’s alertness

management program. AWHP’s Worksite Health, Spring, 16-20.

38. Sherry, P. (2000). Fatigue countermeasures in the railroad industry: Past and current developments. Association of

American Railroads, Burlington Northern Santa Fe.

39. Sherry, P. (2000). Fatigue countermeasures in the railroad industry: Past and current developments. Association of

American Railroads, Norfolk Southern Railroad.

Water Transport

40. Maritime New Zealand (2007). Fatigue management for fishing boats. New Zealand Government.

41. Maritime New Zealand (2007). Fatigue management for work boats. New Zealand Government.

42. International Transport Workers’ Federation (2006). Fight fatigue: Safer ships demand realistic manning.

Trucking

43. National Transportation Commission of Australia (2008). Apply basic fatigue management strategies. Retrieved

June 11, 2009, from www.ntc.gov.au/ViewPage.aspx?DocumentId=01618.

44. Dinges, D.F., Maislin, G., Krueger, G.P., Redmond, D.P., et al. (2004). Mastering alertness and managing driver 

fatigue. Unpublished document. Federal Motor Carrier Safety Administration, U.S. Department of Transportation, and Transport Canada.

Mining

45. Aliaga, A., van de Linde, A., Eksteen, A., Aspeling, C., Lusse, C., & Cather, D. (2005). Operator fatigue management guide (Document No. AAC_OH_000003) Anglo American, Kumba Resources.

Other

46. Nicholson, A.N. & Stone, B.M. (1987). Sleep and wakefulness: Handbook for flight medical officers. North Atlantic

Treaty Organization, Advisory Group for Aerospace Research & Development. Loughton, Essex: Specialized

Printing Services Limited.

47. Caldwell, J.A. & Caldwell, J.L. At ease: A fatigue management guide for marines. U.S. Marine Corps, Office of

Naval Research. 

48. McCallum, M., Sanquist, T., Mitler, M.,& Krueger, G. (2003). Commercial transportation operator fatigue management 

reference. Unpublisheddocument. U.S. Departmentof Transportation, Researchand SpecialPrograms Administration. 

49. VonThaden, T. (2009). Sleep, jet-lag, and fatigue. [PowerPointslides]. University ofIllinois at Urbana-Champaign.
B1

APPENDIX B 

Recommended Training Course Topics 

I. INTRODUCTORY FATIGUE INFORMATION 

1. Goals of Training 

a. Education about the causes and consequences of 

fatigue 

b. Provide strategies for fatigue management on and 

off the job 

2. Topic Areas 

a. Fatigue basics 

i. Definition 

ii. Signs & symptoms 

iii. Misconceptions 

b. Causes of fatigue 

i. Circadian rhythm 

ii. Homeostatic sleep process 

1. Sleep quality 

2. Sleep quantity 

3. Total amount of continuous 

wakefulness 

iii. Shiftwork 

iv. Workload 

v. Previous hours and days worked 

vi. Time zone changes 

vii. Illness / Stress 

viii. Off-duty activities & responsibilities 

ix. Nutrition, hydration, substance use 

c. Introduction to the FAA regulations & NTSB 

recommendations on fatigue management 

i. Code of Federal Regulations 

ii. NTSB recommendations 

d. Consequences of fatigue 

i. Fatigue research 

1. Prevalence of fatigue 

2. Implications 

a. Mental 

b. Physical 

c. Health / Well-being 

i. Digestive 

ii. Cardiovascular 

iii. Mood 

iv. Cancer risk 

d. Accidents & job performance 

e. Post-duty 

i. Dead-heading 

ii. Driving concerns 

ii. Evidence of fatigue management training 

effectiveness 

II. OFF-DUTY FATIGUE ISSUES: 

PREVENTATIVE STRATEGIES 

1. Topic Areas 

a. Sleep fundamentals 

i. Stages of sleep 

ii. Sleep quality & quantity 

iii. Sleep debt 

b. Alertness and the circadian rhythm 

c. Common sleep disorders 

d. Physiological v. subjective assessments 

i. Countermeasures 

1. Napping 

2. Sleep environment 

3. Good sleep habits 

4. Scheduling sleep 

e. Lifestyle 

f. Nutrition 

i. Hydration 

g. Exercise 

h. Substance use 

i. Caffeine 

ii. Alcohol 

iii. Nicotine 

iv. Sleep aids 

i. Domestic situation / Family / Social life 

i. Women-specific issues 

ii. Partners, children, elder family care 

j. Commuting 

i. Recovery and preparatory rest 

strategies 

k. Countermeasures 

i. General health strategies 

ii. Appropriate substance use 

iii. Scheduling and management of nonwork life 

APPENDIX B

Recommended Training Course Topics
B2

III. ON-DUTY FATIGUE ISSUES: OPERATIONAL 

STRATEGIES 

1. Topic Areas 

a. Work environment 

i. High ambient temperature 

ii. Noise 

iii. Cabin pressure 

b. Dehydrating effects of aircraft 

c. Workload 

i. Physical 

ii. Mental / Emotional 

d. Scheduling 

i. Extended duty time 

ii. Rest periods 

1. Continuous wakefulness 

iii. Multiple flights 

iv. Night flying 

v. Reserve duty 

e. Transmeridian / Time zone changes 

i. Eastbound v westbound 

ii. Recovery time 

iii. Seasonal effects 

f. Ultra long range, long-haul, and short-haul flights 

g. International v domestic 

h. Countermeasures 

i. Strategic naps 

1. Sleep inertia 

ii. Breaks 

iii. Strategic nutrition (sensitive to circadian 

digestive issues) 

1. Nutritious food and snacks 

2. Strategic caffeine use 

iv. Social interaction 

v. Physical activity