Evaluation of U.S.

Department of Transportation

Efforts in the 1990s to

Address Operator Fatigue

Safety Report

NTSB/SR-99/01

May 1999

PB99-917002

Notation 7155

National

Transportation

Safety Board

Washington, D.C.
National Transportation Safety Board. 1999. Evaluation of U.S. Department of Transportation Efforts in the 1990s

to Address Operator Fatigue. Safety Report NTSB/SR-99/01. Washington, DC.

During the 1980s, the National Transportation Safety Board investigated several aviation, highway, and marine accidents

that involved operator fatigue. Following completion of these investigations, the Safety Board in 1989 issued three recommendations to the U.S. Department of Transportation (DOT) addressing needed research, education, and revisions to hoursof-service regulations. In the 10 years that have passed, the Safety Board has issued more than 70 additional recommendations to the DOT, States, industry, and industry associations to reduce the incidence of fatigue-related accidents. In response

to the three 1989 recommendations, the DOT and the modal administrations have, in general, acted and responded positively to those addressing research and education; little action, however, has occurred with respect to revising the hours-ofservice regulations. Nevertheless, the Safety Board believes that support has grown in recent years to make substantive

changes to these regulations. This report provides an update on the activities and efforts by the DOT and the modal administrations to address operator fatigue and, consequently, the progress that has been made in the past 10 years to implement

the actions called for in the three intermodal recommendations and other fatigue-related recommendations. The report also

provides some background information on current hours-of-service regulations, fatigue, and the effects of fatigue on transportation safety. As a result of this safety report, the National Transportation Safety Board issued new safety recommendations to the U.S. Department of Transportation, the Federal Aviation Administration, the Federal Highway Administration,

the Federal Railroad Administration, the Research and Special Programs Administration, and the United States Coast Guard.

The Safety Board also reiterated two recommendations to the Federal Aviation Administration.

The National Transportation Safety Board is an independent Federal agency dedicated to promoting aviation, railroad,

highway, marine, pipeline, and hazardous materials safety. Established in 1967, the agency is mandated by Congress through

the Independent Safety Board Act of 1974 to investigate transportation accidents, determine the probable causes of the

accidents, issue safety recommendations, study transportation safety issues, and evaluate the safety effectiveness of government agencies involved in transportation. The Safety Board makes public its actions and decisions through accident reports,

safety studies, special investigation reports, safety recommendations, and statistical reviews.

Recent publications are available in their entirety on the Web at http://www.ntsb.gov/. Other information about available

publications also may be obtained from the Web site or by contacting:

National Transportation Safety Board

Public Inquiries Section, RE-51

490 L’Enfant Plaza, S.W.

Washington, D.C. 20594

(800) 877-6799 or (202) 314-6551

Safety Board publications may be purchased, by individual copy or by subscription, from the National Technical Information Service. To purchase this publication, order report number PB99-917002 from:

National Technical Information Service

5285 Port Royal Road

Springfield, Virginia 22161

(800) 553-6847 or (703) 605-6000
Safety Report

Evaluation of 

U.S. Department of Transportation 

Efforts in the 1990s 

to Address Operator Fatigue

NTSB/SR-99/01

PB99-917002 National Transportation Safety Board

Notation 7155 490 L’Enfant Plaza, S.W.

Adopted May 17, 1999 Washington, D.C. 20594

E P L U R IB U S U N U M

N AT I ON A L T R A S PO R TAT OI N

B O A R D

S A F E T Y

N

iii Safety Report

Contents

Executive Summary............................................................................................................................... v

Part 1: Introduction............................................................................................................................... 1

Current Hours-of-Service Regulations ........................................................................................................... 2

What is Fatigue? ............................................................................................................................................. 5

Scope of the Fatigue Problem ......................................................................................................................... 6

Aviation.................................................................................................................................................... 7

Highway................................................................................................................................................... 7

Marine...................................................................................................................................................... 8

Railroad.................................................................................................................................................... 8

Part 2: Overview of Safety Board Activity Since 1989............................................................ 9

Part 3: DOT Response to the 

Safety Board’s Intermodal Recommendations......................................................................... 13

Safety Recommendation I-89-1 .................................................................................................................... 13

Safety Recommendation I-89-2 .................................................................................................................... 16

Safety Recommendation I-89-3 .................................................................................................................... 19

Findings..................................................................................................................................................... 25

Recommendations................................................................................................................................. 26

Appendixes .............................................................................................................................................. 29

A: Intermodal, Fatigue-Related Safety Recommendations Issued May 12, 1989...................................... 29

B: Fatigue-Related Investigations and Studies Conducted Since May 1989 ............................................. 38

C: Summary of Sleep and Circadian Rhythms........................................................................................... 67

D: Summaries of Fatigue Symposium Working Groups, 1995.................................................................. 82

E: Sampling of Educational Materials Regarding Operator Fatigue.......................................................... 97

F: Flight Time and Rest Requirements Proposed by the FAA .................................................................. 99

G: Summary of Expert Panel on FHWA Hours-of-Service Proposals for 

Commercial Drivers, 1998................................................................................................................ 102
Contents iv Safety Report

Acronyms Used in the Report

AAA American Automobile Association

ANPRM advance notice of proposed rulemaking

ARAC Aviation Rulemaking Advisory Committee

ASRS Aviation Safety Reporting System

CFR Code of Federal Regulations

DOT U.S. Department of Transportation

FAA Federal Aviation Administration

FHWA Federal Highway Administration

FRA Federal Railroad Administration

FTA Federal Transit Administration

GT gross ton

NASA National Aeronautics and Space Administration

NHTSA National Highway Traffic Safety Administration

NPRM notice of proposed rulemaking

RSPA Research and Special Programs Administration

U.S.C. United States Code

USCG United States Coast Guard
v Safety Report

Executive Summary

During the 1980s, the National Transportation Safety Board investigated several

aviation, highway, and marine accidents that involved operator fatigue. Following completion of these accident investigations, the Safety Board in 1989 issued three

recommendations to the U.S. Department of Transportation (DOT) addressing needed

research, education, and revisions to hours-of-service regulations.

Ten years have passed since these safety recommendations were issued. In the

interim, the Safety Board has issued more than 70 additional recommendations to the

DOT, States, industry, and industry associations to reduce the incidence of fatigue-related

accidents. In response to the three 1989 recommendations, the DOT and the modal administrations have, in general, acted and responded positively to the recommendations

addressing research and education; little action, however, has occurred with respect to

revising the hours-of-service regulations. Nevertheless, the Safety Board believes that

support has grown in recent years to make substantive changes to these regulations.

This report provides an update on the activities and efforts by the DOT and the

modal administrations to address operator fatigue and, consequently, the progress that has

been made in the past 10 years to implement the actions called for in the three intermodal

recommendations and other fatigue-related recommendations. The report also provides

some background information on current hours-of-service regulations, fatigue, and the

effects of fatigue on transportation safety.

As a result of this safety report, the National Transportation Safety Board issued

new safety recommendations to the U.S. Department of Transportation, the Federal Aviation Administration, the Federal Highway Administration, the Federal Railroad

Administration, the Research and Special Programs Administration, and the United States

Coast Guard. The Safety Board also reiterated two recommendations to the Federal

Aviation Administration.

1 Safety Report

Part 1

Introduction

During the 1980s, the National Transportation Safety Board investigated several

accidents that involved operator fatigue.1

 Following completion of these accident investigations, the Safety Board in 1989 issued three recommendations to the U.S. Department of

Transportation (DOT):2

Expedite a coordinated research program on the effects of fatigue,

sleepiness, sleep disorders, and circadian factors on transportation system

safety. (I-89-1)

Develop and disseminate educational material for transportation industry

personnel and management regarding shift work; work and rest schedules;

and proper regimens of health, diet, and rest. (I-89-2)

Review and upgrade regulations governing hours of service for all

transportation modes to assure that they are consistent and that they

incorporate the results of the latest research on fatigue and sleep issues.

(I-89-3)

Ten years have passed since these safety recommendations were issued. In the

interim, the Safety Board has issued more than 70 additional recommendations to the

DOT, States, and industry to reduce the incidence of fatigue-related accidents.3 The purpose of this report is to provide an update on the activities and efforts by the DOT and the

1 (a) National Transportation Safety Board. 1985. Collision of Tuba City School District Schoolbus and

Bell Creek, Inc., Tractor-Semitrailer, U.S. 160 Near Tuba City, Arizona, April 29, 1985. Highway Accident

Report NTSB/HAR-85/06. Washington, DC. (b) National Transportation Safety Board. 1986. Grounding of

the Panamanian-Flag Passenger Carferry M/V A. Regina, Mona Island, Puerto Rico, February 15, 1985.

Marine Accident Report NTSB/MAR-86/02. Washington, DC. (c) National Transportation Safety Board.

1986. China Airlines, Boeing 747-SP, N4522V, 300 Nautical Miles Northwest of San Francisco, California,

February 19, 1985. Aircraft Accident Report NTSB/AAR-86/03. Washington, DC. (d) National

Transportation Safety Board. 1987. Trailways Lines, Inc., Intercity Bus Collision With Rising Fast Trucking

Company, Inc., Interstate Highway 40 Near Brinkley, Arkansas, July 14, 1986. Highway Accident Report

NTSB/HAR-87/05. Washington, DC. (e) National Transportation Safety Board. 1988. Collision Between the

USS Richard L. Page (FFG-5) and the U.S. Fishing Vessel Chickadee, the Atlantic Ocean, April 21, 1987.

Marine Accident Report NTSB/MAR-88/04. Washington, DC. (f) National Transportation Safety Board.

1988. Collision Between U.S. Passenger/Car Ferries M/V North Star and M/V Cape Henlopen on Long

Island, Orient Point, New York, July 9, 1987. Marine Accident Report NTSB/MAR-88/06. Washington, DC.

(g) National Transportation Safety Board. 1989. Head-End Collision of Consolidated Rail Corporation

Freight Trains UBT-506 and TV-61 Near Thompsontown, Pennsylvania. Railroad Accident Report

NTSB/RAR-89/02. Washington, DC.

2 The Safety Board’s recommendation letter, issued May 12, 1989, is reproduced in appendix A.

3 See appendix B for the recommendations issued to the DOT and modal administrations.
Part 1 2 Safety Report

modal administrations to address operator fatigue and, consequently, the progress that has

been made in the past 10 years to implement the actions called for in the three intermodal

recommendations and other fatigue-related recommendations. Before addressing the

activities and the progress made regarding these recommendations, the report provides

some background information on current hours-of-service regulations, fatigue, and the

effects of fatigue on transportation safety.

Current Hours-of-Service Regulations

Hours-of-service regulations specify the length of on-duty and off-duty time for

operators in transportation. The current hours-of-service regulations vary from mode to

mode. The motor carrier hours-of-service regulations were developed in 1937 and have

remained essentially unchanged. The Railroad Hours of Service Act was first enacted in

1907; it was substantially revised in 1969, and amended again in 1976 and 1988. Aviation

limits were addressed in the Civil Aeronautics Act of 1938 and the Federal Aviation Act of

1958. In 1985, domestic flight limitations and some commuter limitations were updated;

flag and supplemental operations were not. The work-hour regulations for marine are

specified in Title 46 United States Code (U.S.C.) 8104 and date back to the early part of

the 20th century. The Oil Pollution Act of 1990 contained work-hour limitations for tank

personnel of 15 hours per 24 hours and 36 hours per 72 hours. In 1997, work-hour regulations from the Standards for Training, Certification, and Watchkeeping of the

International Maritime Organization became effective, requiring a minimum 10-hour rest

period during any 24-hour period. The work and rest provisions for operators in the various modes are summarized in table 1–1.

The regulations for aviation, highway, and some marine vessel types impose

weekly work and rest limits. Only the aviation mode has monthly and annual limits as

well. The maximum number of hours an employee of each mode is permitted to work in

the course of a 30-day period is shown in figure 1–1.4

 A commercial pilot may fly up to

100 hours per month; a truckdriver may be on duty up to about 260 hours per month;

licensed individuals on an oceangoing vessel or coastwise vessel of not more than 100

gross tons (GT) may operate up to 360 hours per month when at sea; and locomotive engineers may operate a train up to 432 hours per month.

4 The time for pilots includes only flying time.
Part 1 3 Safety Report

Table 1–1. Summary of the current hours-of-service regulations, 

all transportation modes.

Aviation (14 CFR Part 121; 14 CFR Part 135)

• Pilots flying domestic Part 121 operations may fly up to 30 hours per week, 100 hours per month, and 

1,000 hours per year.

• Pilots flying domestic Part 135 operations may fly up to 34 hours per week, 120 hours per month, and 

1,200 hours per year.

• If the scheduled flight time is less than 8 hours, the minimum rest period in the 24 hours preceding the 

scheduled completion of the flight segment is 9 hours. This time may be reduced to 8 hours if the 

following rest period, to begin no later than 24 hours after the commencement of the reduced rest 

period, is increased to 10 hours.

• If the scheduled flight time is 8–9 hours, the minimum rest period in the 24 hours preceding the 

scheduled completion of the flight segment is 10 hours. This time may be reduced to 8 hours if the 

following rest period, to begin no later than 24 hours after the commencement of the reduced rest 

period, is increased to 11 hours.

• If the scheduled flight time is equal to or greater than 9 hours, the minimum rest period in the 24 hours 

preceding the scheduled completion of the flight segment is 11 hours. This time may be reduced to 

9 hours if the following rest period, to begin no later than 24 hours after the commencement of the 

reduced rest period, is increased to 12 hours.

Motor Carrier (49 CFR Part 395)

• Drivers may drive for 10 hours or be on duty for 15 hours.

• Drivers must have 8 consecutive hours off following a 10/15 hour on-duty period.

• If drivers use a sleeper berth, they may split the 8-hour period into two periods as long as neither period 

is less than 2 hours.

• Drivers may not exceed 70 hours in 8 days, if the carrier operates 7 days a week.

• Drivers may not exceed 60 hours in 7 days if the carrier does not operate every day of the week.

Marine (46 U.S.C. 8104; 46 CFR Parts 15.705, 15.710, and 15.1111)

• Hours-of-service or watch requirements vary depending on type of vessel.

• An officer must be off duty for at least 6 hours within the 12 hours immediately before leaving port 

before taking charge of the deck watch on a vessel when leaving port.

• On an oceangoing or coastwise vessel of not more than 100 gross tons (GT), a licensed individual may 

not work more than 9 of 24 hours when in port or more than 12 of 24 hours at sea, except in an 

emergency.

• On a towing vessel operating on the Great Lakes, harbors of the Great Lakes, and connecting or 

tributary waters between Gary, Indiana; Duluth, Minnesota; Niagara Falls, New York; and Ogdensburg, 

New York, a licensed individual or seaman in the deck or engine department may not work more than 

8 hours in one day, except in an emergency.

• On a merchant vessel of more than 100 GT, the licensed individual shall be divided into three watches 

and shall be kept on duty successively to perform ordinary work incident to the operation and 

management of the vessel.

• On a towing vessel, an offshore supply vessel, or a barge that is engaged on a voyage of less than 600 

miles, the licensed individual and crewmembers may be divided, when at sea, into two watches.

• On a fish processing vessel, the licensed individuals and deck crew shall be divided into three watches. 

However, if the vessel entered into service before January 1, 1988, and is more than 1,600 GT or 

entered into service after December 31, 1987, and has more than 16 individuals on board primarily 

employed in the preparation of fish or fish products, then the licensed individuals and deck crew shall 

be divided into two watches.
Part 1 4 Safety Report

Table 1–1. Summary of the current hours-of-service regulations, 

all transportation modes (continued).

• On a tanker, a licensed individual or seaman may not work more than 15 hours in any 24-hour period or 

more than 36 hours in any 72-hour period, except in an emergency or a drill.

• On a fish tender vessel of not more than 500 GT engaged in the Aleutian trade, the licensed individuals 

and crewmembers shall be divided into at least three watches. However, if the vessel operated in that 

trade before September 8, 1990, or was purchased to be used in that trade before September 8, 1990, 

and entered into that trade before June 1, 1992, the licensed individuals and crewmembers may be 

divided into two watches.

• On a vessel used only to respond to a discharge of oil or a hazardous substance, the licensed 

individuals and crewmembers may be divided into two watches when the vessel is engaged in 

operation less than 112 hours.

• On a towing vessel operating in the Great Lakes, harbors, or connecting or tributary waters or a 

merchant marine vessel of more than 100 GT, a seaman may not work alternately in the deck and 

engine compartments, or be required to work in the engine department if engaged for deck department 

duty or required to work in the deck department if engaged for engine department duty. A seaman 

cannot be required to do unnecessary work on Sundays, New Year’s Day, July 4, Labor Day, 

Thanksgiving day, or Christmas day, when the vessel is in safe harbor. When a vessel is in safe harbor, 

8 hours is a day’s work.

• Offices in charge of a navigational or engineering watch on board any vessel that operates beyond the 

boundary line shall receive a minimum of 10 hours rest in any 24-hour period. The hours of rest may be 

divided into no more than two periods, of which one must be at least 6 hours in length. The hours of 

rest do not need to be maintained in an emergency. The hours of rest may be reduced to 6 hours if no 

reduction extends beyond 2 days and not less than 70 hours of rest are provided in each 7-day period.

Pipeline

There are no Federal regulations for operators or controllers of pipeline systems.

Rail (49 U.S.C. 211; 49 CFR Part 228)

• Maximum duty limit of 12 hours.

• Must be off-duty for 10 consecutive hours, after working 12 consecutive hours or off 8 consecutive 

hours if worked less than 12 consecutive hours. 

• Time spent in transportation (deadheading) to duty assignment counts toward on-duty time.

• Time deadheading from duty assignment does not count toward on-duty or off-duty time.

CFR = Code of Federal Regulations; U.S.C. = United States Code.
Part 1 5 Safety Report

What is Fatigue?

Traditionally, fatigue was viewed as a simple condition related to the amount of

time spent working on a given task.5 Scientific research, however, has shown that fatigue

is related to much more than just the time on a task.6

 Researchers have studied factors that

affect fatigue, such as duration and quality of sleep,7 shiftwork and work schedules,8 circadian rhythms,9

 and time of day.10 Others have examined the influence of drugs and

alcohol on fatigue and compared performance impaired by alcohol to performance

5 McDonald, Nicholas. 1984. Fatigue, Safety and the Truck Driver. London and Philadelphia: Taylor &

Francis. pp. 104-115.

6 Kryger, M.H.; Roth, T.; Dement; W.C., eds. 1994. Principles and Practice of Sleep Medicine. 2nd

edition. Philadelphia: W.B. Saunders Company.

7 (a) Johnson, L.C.; Naitoh, P. 1974. The Operational Consequences of Sleep Deprivation and Sleep

Deficit. AGARD-AG-193, NATO. London: Technical Editing and Reproduction. (b) Rosekind, M.R.;

Gander, P.H.; Connel, L.J.; Co, E.L. 1994. Crew Factors in Flight Operations. X: Alertness Management in

Flight Operations. NASA/FAA Technical Memorandum DOT/FAA/RD-93/18. Washington, DC: National

Aeronautics and Space Administration. (c) National Transportation Safety Board. 1995. Factors That Affect

Fatigue in Heavy Truck Accidents. Safety Study NTSB/SS-95/01 and NTSB/SS-95/02. Washington, DC.

8 (a) Folkard, S.; Monk, T.H.; Lobban, M.C. 1979. “Towards a Predictive Test of Adjustment to

Shiftwork.” Ergonomics 21: 785-799. (b) Thomas, G.R.; Raslear, T.G.; Kuehn, G.I. 1997. The Effects of

Work Schedules on Train Handling Performance and Sleep of Locomotive Engineers: A Simulator Study.

DOT/FRA/ORD-97-09. Washington, DC: Federal Railroad Administration.

9 Kryger, M.H.; Roth, T.; Carskadon, M. 1994. “Circadian Rhythms in Humans: An Overview.” In:

Kryger, M.H.; Roth, T.; Dement, W.C., eds. Principles and Practice of Sleep Medicine. 2nd edition.

Philadelphia: W.B. Saunders Company. pp. 301-308.

10 Wylie, C.D.; Shultz, T.; Miller, J.C.; and others. 1996. Commercial Motor Vehicle Driver Fatigue and

Alertness Study: Project Report. FHWA-MC-97-002. Washington, DC: Federal Highway Administration.

14 CFR Part 121 49 CFR Part 395 46 U.S.C. 8104 49 U.S.C. 211

(flying time) (on-duty time) (on-duty time) (on-duty time)

0

50

100

150

200

250

300

350

400

450

500

Aviation Highway Marine Rail

Hours

Figure 1–1. Maximum work hours in a 30-day period. For marine, 

the on-duty and off-duty times are for a licensed individual on an 

oceangoing vessel or coastwise vessel of not more than 100 

gross tons at sea. (CFR = Code of Federal Regulations;

U.S.C. = United States Code)
Part 1 6 Safety Report

impaired by fatigue.11 Sleep disorders and the characteristics of sleep patterns at different

ages have also been studied.12 Cumulative sleep loss and circadian disruption can lead to a

physiological state characterized by impaired performance and diminished alertness.13

Fatigue can impair information processing and reaction time, increasing the probability of

errors and ultimately leading to transportation accidents.14 A summary of sleep and circadian rhythms was originally completed for the Safety Board’s investigation of the 1993

American International Airways accident in Guantanamo Bay, Cuba.15 An update of that

summary is provided in appendix C.

Scope of the Fatigue Problem

Fatigue has remained a significant factor in transportation accidents since the

Safety Board’s 1989 recommendations were issued. Although generally accepted as a factor in transportation accidents, the exact number of accidents due to fatigue is difficult to

determine and likely to be underestimated. The difficulty in determining the incidence of

fatigue-related accidents is due, at least in part, to the difficulty in identifying fatigue as a

causal or contributing factor in accidents. There is no comparable chemical test for identifying the presence of fatigue as there is for identifying the presence of drugs or alcohol;

hence, it is often difficult to conclude unequivocally that fatigue was a causal or contributing factor in an accident. In most instances, one or more indirect or circumstantial pieces

of evidence are used to make the case that fatigue was a factor in the accidents. This evidence includes witness statements, hours worked and slept in the previous few days, the

time at which the accident occurred, the regularity or irregularity of the operator’s schedule, or the operator’s admission that he fell asleep or was impaired by fatigue.16

Despite the difficulty in identifying fatigue as a causal factor, estimates of the number of accidents involving fatigue have been made for the different modes of transportation;

the estimates vary from very little involvement to as high as about one-third of all accidents.

11 (a) Roehrs, T.; Beare, D.; Zorick, F.; Roth, T. 1994. “Sleepiness and Ethanol Effects on Simulated

Driving.” Alcoholism: Clinical and Experimental Research 18(1): 154-158. (b) Dawson, D.; Reid, K. [In

preparation]. “Equating the Performance Impairment Associated With Sustained Wakefulness and Alcohol

Intoxication.” Woodville, South Australia: Centre for Sleep Research.

12 (a) Aldrich, M.S. 1994. “Cardinal Manifestations of Sleep Disorders.” In: Kryger, M.H.; Roth, T.;

Dement, W.C., eds. Principles and Practice of Sleep Medicine. 2nd edition. Philadelphia: W.B. Saunders

Company. pp. 413-425. (b) Bliwise, D.L. 1994. “Normal Aging.” In: Kryger, M.H.; Roth, T.; Dement, W.C.,

eds. Principles and Practice of Sleep Medicine. 2nd edition. Philadelphia: W.B. Saunders Company. pp.

26-39.

13 Rosekind, M.R.; Graeber, R.C.; Dinges D.F.; and others. 1993. Crew Factors in Flight Operations.

IX: Effects of Planned Cockpit Rest on Crew Performance and Alertness in Long-Haul Operations. NASA

Technical Memorandum 108839; DOT/FAA/92/94. Washington, DC: National Aeronautics and Space

Administration.

14 (a) Dinges, D.F. 1989. “The Nature of Sleepiness: Causes, Context, and Consequences.” In: Stunkard,

A.; Baum, A., eds. Perspectives in Behavioral Medicine: Eating, Sleeping, and Sex. Hillsdale, NJ: Lawrence

Erlbaum. pp. 147-179. Chapter 9. (b) Dinges, D.F. 1992. “Probing the Limits of Functional Capability: The

Effects of Sleep Loss on Short-Duration Tasks.” In: Broughton, R.J.; Oglivie, R., eds. Sleep, Arousal, and

Performance. Boston: Birkhauser-Boston. pp. 176-188. Chapter 12.
Part 1 7 Safety Report

Aviation

The Federal Aviation Administration (FAA) reported that 21 percent of the reports

in the Aviation Safety Reporting System (ASRS) were related to general issues of fatigue.

This includes reports that mentioned fatigue directly or indirectly. When only reports that

directly mention fatigue are included, the percentage drops to 3.8 percent.17

Highway

The National Highway Traffic Safety Administration (NHTSA) estimates that

each year 100,000 crashes, which result in more than 1,500 fatalities and 71,000 injuries,

are caused by drowsy drivers.18 This amounts to about 1.6 percent of all crashes and about

3.6 percent of fatal crashes. In 1998, the Federal Highway Administration (FHWA)

derived estimates of the percentages of large truck crashes involving fatigue: all policereported crashes (0.53 percent to 1.3 percent); all fatal crashes (2.8 percent to 6.5 percent);

crashes fatal to the truck occupant only (12 percent to 29 percent); and crashes fatal to

nontruck occupants (1.2 percent to 2.8 percent). The FHWA also concluded that more

in-depth investigations yield higher percentages of fatigue-related crashes than indicated

in comparable samples of police accident reports.19 The Safety Board’s 1990 study of 182

heavy truck accidents that were fatal to the driver showed that 31 percent of the accidents

in this sample involved fatigue.20 This number is frequently cited as an estimate of the

incidence of fatigue in truck accidents that were fatal to the truckdriver. The Safety

Board’s numbers regarding fatigue-involved accidents are more revealing because the

Board’s in-depth investigations included such surrogate measures as a 72-hour history of

rest and duty times, the amount of sleep in the last 24 hours, and the regularity of the work

schedule, to name just a few.

15 Rosekind, Mark R. [NASA Ames Research Center]; Gregory, Kevin B. [Sterling Software]; Miller,

Donna L. [Sterling Software]; and others. 1994. “Analysis of Crew Fatigue Factors in ATA Guantanamo

Bay Aviation Accident.” In: Uncontrolled Collision With Terrain, American International Airways Flight

808, Douglas DC-8-61, N814CK, U.S. Naval Air Station in Guantanamo Bay, Cuba, August 18, 1993.

Aircraft Accident Report NTSB/AAR-94/04. Washington, DC: National Transportation Safety Board. pp.

133-144.

16 The Safety Board recognizes that people have a limited ability to predict the onset of sleep and to

determine their level of sleepiness. (Itoi, A.; Cilveti, R.; Voth, M.; and others. 1993. Can Drivers Avoid

Falling Asleep at the Wheel? Relationship Between Awareness of Sleepiness and Ability To Predict Sleep

Onset. Washington, DC: AAA Foundation for Traffic Safety. p. 25.)

17 (a) Federal Register, Vol. 60, No. 244, dated December 20, 1995. (b) Batelle Memorial Institute.

March 1998. A Review of Issues Concerning Duty Period Limitations, Flight Time Limitations, and Rest

Requirements as Stated in the FAA’s Notice of Proposed Rulemaking 95-18. Washington, DC: Federal

Aviation Administration.

18 Knippling, R.R.; Wang, J.S. October 1995. “Revised Estimates of the U.S. Drowsy Driver Crash

Problem Size Based on General Estimates System Case Reviews.” In: 39th Annual Proceedings, AAAM;

October 16–18, 1995; Chicago, IL. Des Plaines, IL: Association for the Advancement of Automotive

Medicine.

19 Federal Highway Administration, Office of Motor Carriers. September 1998. Crash Problem Size

Assessment: Large Truck Crashes Related Primarily to Driver Fatigue. Washington, DC.

20 National Transportation Safety Board. 1990. Fatigue, Alcohol, Other Drugs, and Medical Factors in

Fatal-to-the-Driver Heavy Truck Crashes. Safety Study NTSB/SS-90/01 and NTSB/SS-90/02. Washington,

DC.
Part 1 8 Safety Report

Marine

A 1996 United States Coast Guard (USCG) analysis of 279 incidents showed that

fatigue contributed to 16 percent of critical vessel casualties and 33 percent of personal

injuries.21

Railroad

According to a Safety Board analysis of Federal Railroad Administration (FRA)

data from January 1990 to February 1999, only 18 cases were coded “operator fell asleep”

as a causal or contributing factor. The Board believes that 18 cases in more than 9 years

underestimates the actual number of cases in which fatigue might have been involved. For

example, two Safety Board investigations—Sugar Valley, Georgia (August 9, 1990), and

Corona, California (November 7, 1990)—in which fatigue was cited by the Safety Board

as a causal factor were not coded in the FRA database as fatigue-related but rather as a

failure to comply with signals.

In testimony before the Senate Subcommittee on Surface Transportation and

Merchant Marine22 on September 16, 1998, the Administrator of the FRA stated that

“about one-third of train accidents and employee injuries and deaths are caused by human

factors. We know fatigue underlies many of them.”

In summary, although the data are not available to statistically determine the incidence of fatigue, the transportation industry has recognized that fatigue is a major factor in

accidents, as was clearly demonstrated at the Safety Board’s 1995 symposium on

fatigue.23 Further, the Safety Board’s in-depth investigations have clearly demonstrated

that fatigue is a major factor in transportation accidents.

21 McCallum, Marvin C.; Raby, Mireille; Rothblum, Anita M. 1996. Procedures for Investigating and

Reporting Human Factors and Fatigue Contributions to Marine Casualties. CG-D-09-97. Washington, DC:

U.S. Department of Transportation, U.S. Coast Guard, Marine Safety and Environmental Protection.

22 The subcommittee is an entity of the Senate Committee on Commerce, Science, and Transportation.

23 The symposium is discussed in further detail in part 2 of this report.
9 Safety Report

Part 2

Overview of Safety Board 

Activity Since 1989

Since 1989, the Safety Board has issued more than 70 fatigue-related safety recommendations,24 which were the result of major accident investigations, special

investigations, or safety studies that identified operator fatigue as a factor (see table 2–1).

This includes 11 accident reports or studies in aviation regarding air tours and operations

conducted under Parts 91, 121, and 135; 7 in highway regarding busdrivers and truckdrivers; 3 in marine regarding passenger vessels and tankships; 4 in railroad regarding freight

trains, passenger trains, and rail transit operations; and 1 in pipeline regarding pipeline

controllers.

A 1990 safety study that examined the causes of 182 accidents that were fatal to

the driver of heavy trucks25 found that 31 percent of the fatal-to-the-truckdriver accidents

in the sample involved fatigue. A 1995 study of 107 accidents (62 of which were fatiguerelated) examined the factors that affect fatigue in heavy truck accidents; the Board found

that the three most critical factors that predicted a fatigue-related accident were duration

of sleep in the last sleep period, the total hours of sleep obtained during the 24 hours prior

to the accident, and the presence of split sleep periods.26

The Safety Board has also examined operator fatigue in its safety studies on flight

crew errors, commuter airlines, and aviation safety in Alaska.27 In the flight crew study,

the Board found that crews comprising captains and first officers whose time since awakening was above the median for their crew position made more errors overall. In the study

on commuter airline safety, the Board found that self-reports from commuter airline pilots

indicated that most pilots had flown while fatigued. In the study on aviation in Alaska, the

Board concluded that the consecutive, long duty days permitted by Title 14 Code of

Federal Regulations (14 CFR) Part 135.261 for commuter airline and air taxi flight crews

in Alaska can contribute to fatigue and are a detriment to safety.

24 Thirty-four of these recommendations were issued to the DOT or modal administrations. The

remainder of the recommendations were issued to the States, industry, or industry associations.

25 National Transportation Safety Board. 1990. Fatigue, Alcohol, Other Drugs, and Medical Factors in

Fatal-to-the-Driver Heavy Truck Crashes. Safety Study NTSB/SS-90/01 and NTSB/SS-90/02. Washington,

DC.

26 National Transportation Safety Board. 1995. Factors That Affect Fatigue in Heavy Truck Accidents.

Safety Study NTSB/SS-95/01 and NTSB/SS-95/02. Washington, DC.

27 (a) National Transportation Safety Board. 1994. A Review of Flightcrew-Involved, Major Accidents of

U.S. Air Carriers, 1978 Through 1990. Safety Study NTSB/SS-94/01. Washington, DC. (b) National

Transportation Safety Board. 1994. Commuter Airline Safety. Safety Study NTSB/SS-94/02. Washington,

DC. (c) National Transportation Safety Board. 1995. Aviation Safety in Alaska. Safety Study

NTSB/SS-95/03. Washington, DC.
Part 2 10 Safety Report

Table 2–1. Fatigue-related investigations and studies 

conducted by the National Transportation Safety Board 

since May 1989, by mode.

Location of accident or 

topic of the study that identified 

fatigue-related issuesa

Accident 

date

NTSB report 

number

Aviation

Accident investigation:

Molokai, Hawaii 10/28/89 AAR-90/05

Brunswick, Georgia 04/05/91 AAR-92/03

Pine Bluff, Arkansas 04/29/93 AAR-94/01/SUM

Guantanamo Bay, Cuba 08/18/93 AAR-94/04

Kansas City, Missouri 02/16/95 AAR-95/06

Cheyenne, Wyoming 04/11/96 AAR-97/02

Everglades, Florida 05/11/96 AAR-97/06

Special investigation:

Commercial space launch incident, 

Cape Canaveral, Florida

08/17/93b SIR-93/02

Safety study:

Flight crew-involved accidents 02/03/94b SS-94/01

Commuter airline safety 11/30/94b SS-94/02

Aviation safety in Alaska 12/01/95b SS-95/03

Highway

Accident investigation:

Sutton, West Virginia 07/26/90 HAR-91/01

Donegal, Pennsylvania, and

Caroline, New York

06/26/91, 

08/03/91

HAR-92/01

Evergreen, Alabama 05/19/93 HAR-94/02

White Plains, New York 07/27/94 HAR-95/02

Special investigation:

Selective motorcoach issues 02/26/99b SIR-99/01

Safety study:

Accidents fatal to the truck driver 04/04/90b SS-90/01

Truck driver fatigue 02/07/95b SS-95/01

Marine

Accident investigation:

Valdez, Alaska 03/24/89 MAR-90/04

Santa Catalina Island, California 06/14/89 MAR-90/05

Lynn Canal, Alaska 06/23/95 MAR-97/02

Pipeline

Accident investigation:

Fork Shoals, South Carolina 06/26/96 PAR-98/01
Part 2 11 Safety Report

Operator fatigue has been on the Safety Board’s list of Most Wanted Transportation Safety Improvements since the list’s inception in 1990.28 Had the DOT acted more

aggressively on the three intermodal recommendations issued in 1989, the need for the

70-some additional recommendations to the States and industry may have been minimized. (Pertinent recommendations are discussed in more detail in part 3 of this report in

connection with the specific issues of Safety Recommendations I-89-1, -2, and -3:

research, education, and revisions to hours-of-service regulations, respectively.)

In November 1995, the Safety Board and the National Aeronautics and Space

Administration (NASA) cosponsored a symposium to discuss fatigue countermeasures

and to demonstrate how they can be applied to prevent accidents in all modes of transportation.29 The symposium was designed to practically illustrate the intent of one of the

Safety Board’s 1989 intermodal recommendations (I-89-2): to develop and disseminate

educational material. More than 500 people from 16 countries representing all the modes

of transportation attended the symposium, which attests to the magnitude and interest in

the fatigue problem. As part of the symposium, the participants were divided into modalspecific groups to discuss scheduling, countermeasures, and education. All of the groups

indicated that education was needed for the operators as well as for the management of

transport companies. While the groups believed there was a need for additional technological countermeasures, they also believed there were some steps that could already be taken

or could easily be implemented. For example, both an aviation group and the railroad

Table 2–1. Fatigue-related investigations and studies 

conducted by the National Transportation Safety Board 

since May 1989, by mode (continued).

Location of accident or 

topic of the study that identified 

fatigue-related issuesa

Accident 

date

NTSB report 

number

Railroad

Accident investigation:

Corona, California 11/07/90 RAR-91/03

Sugar Valley, Georgia 08/09/90 RAR-91/02

Brooklyn, New York 06/05/95 RAR-96/03

Special investigation:

Steam locomotives 11/26/96b SIR-96/05

a The titles of the published reports are contained in appendix B.

b The date the safety recommendations were issued.

28 In October 1990, the Safety Board adopted a program to identify the “Most Wanted” transportation

safety improvements. The purpose of the Board’s Most Wanted list, which is drawn up from safety

recommendations previously issued, is to bring special emphasis to the transportation safety issues the Board

deems most critical.

29 National Transportation Safety Board; NASA Ames Research Center. 1996. Fatigue Symposium

Proceedings, November 1–2, 1995. Washington, DC: National Transportation Safety Board.
Part 2 12 Safety Report

group discussed the need for quality sleeping areas while away from home, pointing out

that many hotels do not have rooms that are adequate for daytime sleeping. There was

broad support voiced regarding a need for changes to the hours-of-service regulations. The

participants wanted these regulations to be updated and based on scientific research. The

summaries of the working groups are provided in appendix D.

Another product from the symposium was the development of the Fatigue

Resource Directory, a tool for researchers, industry, and others to use to share information

regarding operator fatigue. Following the symposium, the DOT assumed responsibility for

maintaining the directory. It is now available on the World Wide Web at

<www.hf.faa.gov/dot/fatigue>. The Web site has search capabilities and entries can be

edited or new entries can be added.
13 Safety Report

Part 3

DOT Response to the 

Safety Board’s Intermodal 

Recommendations

The various Secretaries of the DOT and modal Administrators over the years have

expressed their concerns about operator fatigue. In a 1995 summary of the DOT’s fatigue

safety effort, Federico Peña, then Secretary of the DOT, stated that “fatigue among transportation operators remains a critical safety problem.”30 In a 1999 update, Secretary

Rodney Slater stated, “We know that alertness is a key to safe vehicle operation. To reduce

crashes and accidents and their personal and financial consequences, we need to ensure

that vehicle operators are ready and capable of operating their vehicles or other transportation equipment.”31 Despite the many statements made by the DOT about the importance of

addressing fatigue in transportation, only one of the three intermodal recommendations

issued to the DOT more than 10 years ago has been fully implemented (I-89-1).

Safety Recommendation I-89-1

Safety Recommendation I-89-1 asked the DOT to expedite a coordinated research

program on the effects of fatigue, sleepiness, sleep disorders, and circadian factors on

transportation system safety. In its August 1989 response, the DOT stated that coordinated

research efforts on human factors—including the effects of fatigue, sleepiness, sleep disorders, and circadian factors—on transportation safety was a top priority. The Human

Factors Coordinating Committee, formed in 1988 and comprising representatives from

each of the DOT administrations, serves as a means to share research information. A subcommittee has been created to focus on fatigue-related issues. In addition, the DOT

briefed the Safety Board about the various ongoing fatigue-related projects several times

over the years. Safety Recommendation I-89-1 was classified “Closed—Acceptable

Action” on July 19, 1996, because the DOT had made Department-wide research efforts

on operator fatigue. At the time this recommendation was closed, the FAA, FHWA,

NHTSA, FRA, and USCG all had fatigue-related research projects underway.32 In the

Safety Board’s 1996 letter closing the recommendation, the Board encouraged the DOT to

continue its research efforts, which it generally has done.

30 U.S. Department of Transportation. November 1995. Sharing the Knowledge: Department of

Transportation Focus on Fatigue. Washington, DC.

31 U.S. Department of Transportation. March 1999. Managing Fatigue: A Significant Problem Affecting

Safety, Security, and Productivity. Washington, DC.

32 U.S. Department of Transportation. November 1995. Sharing the Knowledge: Department of

Transportation Focus on Fatigue. Washington, DC.
Part 3 14 Safety Report

From fiscal years 1990 through 1998, the DOT spent more than $30 million on

fatigue research. A wide range of research projects has been initiated, such as developing

in-vehicle alerting systems, using high fidelity simulators to determine how different work

schedules affect fatigue and performance, studying the effects of loading and unloading,

and evaluating technologies that monitor operator performance to indicate fatigue. Table

3–1 identifies major research projects completed by the DOT since 1989.33

The Safety Board is disappointed that more research efforts have not been made by

the Research and Special Programs Administration (RSPA) in the pipeline mode. In 1998,

the Board asked RSPA to assess the potential safety risks associated with rotating pipeline

controller shifts and to establish industry guidelines for the development and implementation of pipeline controller work schedules that reduce the likelihood of accidents

attributable to controller fatigue (Safety Recommendation P-98-30).34 The RSPA

responded to the recommendation on May 4, 1999.

The Safety Board is aware that industry groups such as the Association of American Railroads and the American Trucking Associations, Inc., have also participated in and

conducted research on operator fatigue since the 1989 intermodal recommendations were

issued. Additionally, the transportation industry participates in meetings and shares its

research findings with other organizations. The FRA has formed the North American Rail

Alertness Partnership comprising railroad management, union leadership, and FRA representatives that discuss fatigue and exchange information on countermeasures to reduce

fatigue. The FHWA and NHTSA are participants in the National Drowsy Driving Coordinating Committee sponsored by the National Sleep Foundation. This is a forum for

sharing research and educational outreach efforts among government, State, industry, and

nonprofit groups in the highway mode.

The DOT’s efforts to coordinate operator fatigue research have generally been

responsive, with the exception of the RSPA regarding pipeline operations. The Safety

Board encourages the DOT to continue its research, particularly on technology and in the

pipeline mode, and to share information across the modes and with industry.

33 The Safety Board notes that many of the research projects listed in the DOT’s 1999 update were also

listed in the DOT’s 1995 publication on transportation fatigue.

34 National Transportation Safety Board. 1998. Pipeline Rupture and Release of Fuel Oil Into the Reedy

River at Fork Shoals, South Carolina, June 26, 1996. Pipeline Accident Report NTSB/PAR-98/01.

Washington, DC.
Part 3 15 Safety Report

Table 3–1. Fatigue-related research completed 

in the U.S. Department of Transportation since 1989.

Federal Aviation Administration:

Effect of Alcohol and Fatigue on an FAA Readiness-To-Perform Test. (DOT/FAA/AM-95/24)

Handbook of Human Performance Measures and Crew Requirements for Flightdeck Research. 

(DOT/FAA/CT-TN95/49)

Some Effects of 8- vs. 10-Hour Work Schedules on the Test Performance/Alertness of Air Traffic 

Control Specialists. (DOT/FAA/AM-95/32)

Shift Work, Age, and Performance—Investigation of the 2-2-1 Shift Schedule Used in Air Traffic 

Control Facilities: 1. The Sleep/Wake Cycle. (DOT/FAA/AM-95/19)

Human Factors in Aviation Maintenance: Phase 3, Volume 1, Progress Report. (DOT/FAA/AM-95/13)

Handbook of Human Performance Measures and Crew Requirements for Flightdeck Research. 

(DOT/FAA/CT-TN95/49)

Federal Highway Adminstration:

In-Cab Fitness-For-Duty. (FHWA-MC-95-011)

Shipper Involvement in Hours-Of-Service Violations. (FHWA-MC-98-049)

Impact of Local/Short Haul Operations on Driver Fatigue. (DTFH61-C-00105)

Short Haul Trucks and Driver Fatigue. (DTFH61-96-C-00038)

Commercial Motor Vehicle Rest Areas: Making Space for Safety. (PB 97-124705)

Driver Fatigue and Alertness Study. (PB 98-102346)

Local/Short Haul Driver Fatigue Crash Data Analysis. (FHWA-MC-98-016)

Effects of Operating Practices on Driver Alertness. (FHWA-MCRT-99-008)

PERCLOS: A Valid Psychophysiological Measure of Alertness as Assessed by Psychomotor Vigilance. 

(FHWA-MCRT-98-006)

Electronic On-Board Recorders for Hours-of-Service Compliance. (FHWA-MCRT-99-007)

Conference on Managing Fatigue in Transportation. (cosponsored with NHTSA and the FRA)

Conference on Driver Vigilance Monitoring. (cosponsored with NHTSA)

Federal Railroad Administration:

The Effects of Work Scheduling on Train Handling Performance and Sleep of Locomotive Engineers: 

A Simulator Study. (DOT/FRA/ORD-97-09)

Enginemen Stress and Fatigue. (Issued February 1993)

Issues in Locomotive Crew Management and Scheduling. (DOT/FRA/RRR-91-01)

National Highway Traffic Safety Administration:

Crashes and Fatalities Related to Driver Drowsiness/Fatigue. (Research Note, issued November 1994)

Validation of Eye and Other Psychophysiological Monitors. (cosponsored with FHWA) 

(DOT-HS-808 762)

Research on Vehicle-Based Driver Status/Performance Monitoring: Development, Validation, and 

Refinement of Algorithms for Detection of Driver Drowsiness. (DOT-HS-808 247)

Research on Vehicle-Based Driver Status/Performance Monitoring: Seventh Semiannual Research 

Report. (DOT-HS-808 299)

Research on Vehicle-Based Driver Status/Performance Monitoring, Part 1. (DOT-HS-808 838)

Research on Vehicle-Based Driver Status/Performance Monitoring, Part 2. (DOT-HS-808 839)

Research on Vehicle-Based Driver Status/Performance Monitoring, Part 3. (DOT-HS-808 840)

Drowsy Driving and Automoble Crashes. (DOT-HS-808 707)
Part 3 16 Safety Report

Safety Recommendation I-89-2

Safety Recommendation I-89-2 asked the DOT to develop and disseminate educational material for transportation industry personnel and management regarding shift

work; work and rest schedules; and proper regimens of health, diet, and rest. In its 1989

response, the DOT acknowledged the unique demands placed on transportation workers

such as shift-work, long-haul operations, and nighttime duty and that it would review its

current policy on developing educational materials. In a more detailed response in 1996,

the DOT indicated that it had published its 1995 report Sharing the Knowledge:

Department of Transportation Focus on Fatigue and produced two videotapes that

addressed fatigue: one on human factors and one entitled Fatigue Busters—How to

Survive Fatigue in the ’90s. In addition, the FAA also published a fatigue buster brochure.

The Safety Board replied that it was pleased that information had been produced for aviation and highway, but it was concerned that similar information had not been developed

for railroad, marine, and mass transit. On May 4, 1999, the DOT provided the Safety

Board with an update of FRA education activities. Safety Recommendation I-89-2 is

currently classified “Open—Acceptable Response.”

Other organizations, agencies, and industry groups—such as the National Sleep

Foundation, the AAA Foundation for Traffic Safety, and the American Trucking Associations, Inc.—have also developed educational brochures about fatigue. Two brochures,

Awake at the Wheel and Wake Up!, attempt to educate operators about the need for sleep

and to dispel myths such as people can always tell when they are fatigued.35 Appendix E

Table 3–1. Fatigue-related research completed 

in the U.S. Department of Transportation since 1989 (continued).

United States Coast Guard:

Fatigue and alertness in Merchant Marine Personnel: A Field Study of Work and Sleep Patterns. 

(USCG-D-06-97)

Procedures for Investigating and Reporting Human Factors and Fatigue Contributions to Marine 

Casualties. (USCG-D-09-97)

Modeling Techniques for Shipboad Manning: A Review and Plan for Development. (USCG-D-07-93)

Maritime Administration:

Shipboard Crew Fatigue, Safety, and Reduced Manning. (issued November 1994)

Sources: (a) U.S. Department of Transportation, Federal Highway Administration, Office of Motor Carriers. December 16, 

1998. Summary of Driver Fatigue Programs. Washington, DC. (b) Publications on driver fatigue programs listed on the 

National Technical Information Service World Wide Web home page, <http://www.ntis.gov>, April 22, 1999.

35 The brochure Wake Up! was developed jointly by the AAA Foundation for Traffic Safety and the

National Sleep Foundation. It was the basis for the brochure Awake at the Wheel that was developed for

truckdrivers by the FHWA in conjunction with the American Trucking Associations.
Part 3 17 Safety Report

contains a list of some educational materials that have been developed since the intermodal recommendations were issued.

In the early 1990s, NASA developed an education and training module entitled

“Alertness Management in Flight Operations.” It contains information about fatigue with

an emphasis on aviation. The module has three primary objectives: to explain (1) the current state of knowledge about the physiological mechanisms that underlie fatigue; (2)

misconceptions about fatigue; and (3) fatigue countermeasures. The NASA and the FAA

have cosponsored many courses to educate pilots for a large segment of the major U.S. air

carriers as well as for corporate management. The FRA, Federal Transit Administration

(FTA), and FHWA along with industry organizations have used the NASA countermeasures training module as the basis for training modules in the other modes of

transportation.

In addition to Safety Recommendation I-89-2, the Safety Board has issued other

recommendations to the individual modal administrations calling for increased educational efforts regarding the effects of fatigue. In 1995, the Safety Board asked the FHWA

to develop and disseminate, in consultation with DOT’s Human Factors Coordinating

Committee, a training and education module to inform truckdrivers of the hazards of driving while fatigued (Safety Recommendation H-95-5).36 The FHWA and the American

Trucking Associations, Inc., adapted the NASA module for use with the commercial driving industry and developed a train-the-trainer course on fatigue and fatigue

countermeasures. To date more than 2,000 people have been trained; 16 seminars are

being offered in 1999. Safety Recommendation H-95-5 to the FHWA was classified

“Closed—Acceptable Action” on July 7, 1998.

In 1996, the Safety Board also asked the FTA, in cooperation with the American

Public Transit Association, to develop a fatigue educational awareness program and to

distribute it to transit agencies to use in their fitness-for-duty training for supervisors and

employees involved in safety-sensitive positions (Safety Recommendation R-96-20).37

The FTA has developed a seminar, available in four different formats, for a variety of

attendees including employees, managers, and persons involved in scheduling. The Safety

Board is pleased with this effort of the FTA and is aware that more than 600 persons have

attended the seminars. As a result of these efforts, the Safety Board has classified Safety

Recommendation R-96-20 “Closed—Acceptable Action.”

In aviation, the Safety Board asked the FAA to require U.S. air carriers operating

under 14 CFR Part 121 to provide educational programs for pilots (Safety Recommendation A-94-5),38 to require 14 CFR Part 135 air carriers to provide fatigue countermeasure

36 National Transportation Safety Board. 1995. Factors That Affect Fatigue in Heavy Truck Accidents.

Safety Study NTSB/SS-95/01 and NTSB/SS-95/02. Washington, DC.

37 National Transportation Safety Board. Collision Involving Two New York City Subway Trains on the

Williamsburg Bridge in Brooklyn, New York, June 5, 1995. Railroad Accident Report NTSB/RAR-96/03.

Washington, DC.

38 National Transportation Safety Board. 1994. A Review of Flightcrew-Involved, Major Accidents of

U.S. Air Carriers, 1978 Through 1990. Safety Study NTSB/SS-94/01. Washington, DC.
Part 3 18 Safety Report

information to air crews in initial and recurrent training (A-94-73),39 and to provide

fatigue information to the general aviation community (A-97-20).40 The FAA revised

Advisory Circular 120-51B to include fatigue as one of the topics discussed in crew

resource management training. The FAA also developed educational materials to address

the hazards of fatigue for use in safety meetings. These three recommendations have been

classified “Closed—Acceptable Action.”41

In 1997, the Safety Board asked the USCG to advise marine pilots about the

effects of fatigue on performance and about sleeping disorders such as sleep apnea (Safety

Recommendation M-97-41).42 In a letter dated November 11, 1998, the USCG indicated

that it has discussed the effects of fatigue and sleeping disorders with the American Pilots

Association and independent pilot associations, requesting that they inform their members

of the dangers of sleeping disorders such as sleep apnea through their internal media. Further, Navigation and Vessel Inspection Circular No. 2-98, Physical Evaluation Guidelines

for Merchant Marine’s Documents and Licenses, contains guidelines for use by physicians

performing physical examinations of mariners and includes sleeping disorders as conditions to be evaluated for original and renewals of marine pilots’ licenses and for the

required pilots’ physicals. Safety Recommendation M-97-41 was classified “Closed—

Acceptable Action” on April 6, 1999.

The Safety Board is aware that the USCG has developed a research and educational program on crew endurance. The Board is also aware that the USCG held a

workshop on fatigue on April 6, 1999, aimed at masters and safety management personnel

of tugs and barges, passenger vessels, and fishing vessels as well as USCG personnel. The

Board encourages the USCG to add more workshops to its agenda. Such programs could

be promoted through the USCG’s Prevention Through People program. The USCG has

not developed any brochures on operator fatigue for the mariner community.

The Safety Board also issued a recommendation to the FHWA asking that educational materials be developed for commercial truckdrivers (H-90-21, classified “Closed—

Acceptable Action”). As shown in appendix E, the FHWA has developed and disseminated

the brochure Awake at the Wheel and fatigue videos; it has also developed courses to educate truckdrivers about the dangers of driving while drowsy. In February 1999, the Board

asked the FHWA to ensure that the dangers of inverted sleep periods are discussed in the

fatigue video being developed for motorcoaches (Safety Recommendation H-99-4A).

39 National Transportation Safety Board. 1994. In-Flight Loss of Control, Leading to Forced Landing

and Runway Overrun, Continental Express, Inc., N24706, Embraer EMB-120 RT, Pine Bluff, Arkansas,

April 29, 1993. Aircraft Accident Report NTSB/AAR-94/02/SUM. Washington, DC.

40 National Transportation Safety Board. 1997. In-Flight Loss of Control and Subsequent Collision With

Terrain, Cessna 177B, N35207, Cheyenne, Wyoming, April 11, 1996. Aircraft Accident Report.

NTSB/AAR-97/02. Washington, DC.

41 Safety Recommendations A-94-5 and A-94-73 were classified “Closed—Acceptable Action” on

January 16, 1996; Safety Recommendation A-97-20 was classified “Closed—Acceptable Action” on

June 11, 1997.

42 National Transportation Safety Board. 1997. Grounding of Liberian Passenger Ship Star Princess on

Poundstone Rock, Lynn Canal, Alaska, June 13, 1995. Marine Accident Report NTSB/MAR-97/02.

Washington, DC.
Part 3 19 Safety Report

The Safety Board is pleased to see the increase in educational efforts on fatigue

among the DOT modal administrations, particularly the current activities within the FTA.

The Safety Board would like to see more efforts in marine and pipeline to develop and disseminate educational materials on fatigue and will continue to monitor these activities.

The FAA, FHWA, FRA, and FTA have satisfactorily met the intent of this recommendation; however, the Board urges these modal administrations to continue their efforts in this

area. Pending further efforts by the RSPA and the Coast Guard to develop and disseminate

educational information on fatigue in marine and pipeline operations, respectively, Safety

Recommendation I-89-2 remains classified “Open—Acceptable Response.”

Safety Recommendation I-89-3

Safety Recommendation I-89-3 asked the DOT to review and upgrade regulations

governing hours of service to assure that they are consistent and that they incorporate the

results of the latest research on fatigue and sleep issues. In 1989, the DOT stated that it

was reviewing the regulations pertaining to hours of service. It had not found research to

suggest that the regulations should be consistent across all modes of transportation and

that it would continue with research efforts to determine what changes might be made.

The Board has been very disappointed in the DOT’s lack of progress in revising

the hours-of-service regulations. Subsequently, the Safety Board made specific recommendations to the FAA and FHWA to revise the hours-of-service regulations. In

conjunction with its investigation of the crash of American International Airways at Guantanamo Bay, Cuba, in August 1993,43 the Safety Board recommended that the FAA

Revise the applicable subpart of 14 CFR Part 121 to require that flight

time, accumulated in noncommercial “tail end” ferry flights conducted

under 14 CFR Part 91 as a result of 14 CFR Part 121 revenue flights, be

included in the flight crewmember’s total flight and duty time accrued

during those revenue operations. (A-94-105, classified “Closed—

Acceptable Action/Superseded” by Safety Recommendation A-95-113)

Expedite the review and upgrade of Flight/Duty time limitations of the

Federal Aviation Regulations to ensure that they incorporate the results of

the latest research on fatigue and sleep issues. (A-94-106, classified

“Closed—Acceptable Action/Superseded” by Safety Recommendation

A-95-113)

43 National Transportation Safety Board. 1994. Uncontrolled Collision With Terrain, American

International Airways Flight 808, Douglas DC-8-61, N814CK, U.S. Naval Air Station, Guantanamo Bay,

Cuba, August 18, 1993. Aircraft Accident Report NTSB/AAR-94/04. Washington, DC.
Part 3 20 Safety Report

In its report of the accident involving an Air Transport International DC8-63 at

Kansas City International Airport in February 1995,44 the Safety Board recommended that

the FAA

Finalize the review of current flight and duty time regulations and revise

the regulations, as necessary, within 1 year to ensure that flight and duty

time limitations take into consideration research findings on fatigue and

sleep issues. The new regulations should prohibit air carriers from

assigning flight crews to flights conducted under 14 CFR Part 91 unless the

flight crews meet the flight and duty time limitation of 14 CFR Part 121 or

other appropriate regulations. (A-95-113, currently classified “Open—

Acceptable Response”)

In its study of aviation safety in Alaska,45 the Safety Board asked the FAA to

Develop appropriate limitations on consecutive days on duty, and duty

hours per duty period for flight crews engaged in scheduled and

nonscheduled commercial flight operations, and apply consistent

limitations in Alaska and the remainder of the United States. (A-95-125,

currently classified “Open—Acceptable Response”)

On June 15, 1992, the FAA announced the establishment of the flight crewmember

flight/duty rest requirements working group of its Aviation Rulemaking Advisory Committee (ARAC). In its final report submitted to the FAA on June 30, 1994, the working

group indicated that although it had not reached consensus on the specific issues, it did

agree on four major areas that should be addressed in FAA rulemaking: absence of a duty

time limitation, reserve scheduling, back-side-of-the-clock operations, and scheduled

reduced rest.

The FAA issued a notice of proposed rulemaking (NPRM) on December 20,

1995,46 6 years after the Board issued Safety Recommendation I-89-3. The proposed flight

time and rest requirements are provided in appendix F. Comments on the NPRM were

originally due on March 19, 1996; however, the comment period was extended to June 19,

1996. The Board commented on the rulemaking on June 19, 1996, noting several favorable aspects to the NPRM:

• elimination of the ability of carriers to schedule flight crewmember duty

during scheduled rest periods, inclusion of standby reserve time, deadheading

time, and all duties performed for the airline as duty time in the determination

of flight and duty time requirements;

44 National Transportation Safety Board. 1995. Uncontrolled Collision With Terrain, Air Transport

International, Douglas DC-8-63, N782AL, Kansas City International Airport, Kansas City, Missouri,

February 16, 1995. Aircraft Accident Report NTSB/AAR-95/05. Washington, DC.

45 National Transportation Safety Board. 1995. Aviation Safety in Alaska. Safety Study NTSB/SS-95/03.

Washington, DC.

46 Federal Register, Vol. 60, No. 244, dated December 20, 1995.
Part 3 21 Safety Report

• inclusion of ferry, instructional, maintenance, check, and other flights in the

determination of flight and duty time requirements, requirements of minimum

daily rest periods of at least 10 consecutive hours, and 36 consecutive hours of

rest within 7 consecutive calendar days of duty, for flight crewmembers and

flight engineers;

• establishment of explicit standards for approving on-board flight crew rest

areas;

• permit extensions of daily flight and duty intervals to periods of no more than

2 hours and only for operational reasons beyond the control of the airline; and

• limits of duty periods for crewmembers on reserve assignments depending on

the amount of advance notification of reporting time.

In its comments on the rulemaking, however, the Board also expressed concern

that the proposed rule did not include effective mechanisms to address flight operation

during the circadian night and circadian trough, and it lacked recognition of the fatiguing

aspects of multiple takeoffs and landings. There were mixed industry reactions to the

NPRM. In general, air carriers and air carrier organizations opposed the NPRM47 whereas

pilot associations supported the proposal with some reservations, primarily a concern with

loss of income from reduced flying hours and a desire for a more thorough discussion of

back-side-of-the-clock flying time. According to the FAA, it received about 2,000 comments on the NPRM.

With no action since 1996 and the rulemaking effectively abandoned, on July 9,

1998, the ARAC on air carrier operations was assigned to provide a review and analysis of

industry practice with regard to reserve duty for flight crewmembers, which is only a

small part of the flight and duty time issue. A working group was formed and ultimately

delivered recommendations to the FAA on February 9, 1999.48 The pilots and air carriers

on the working group were able to agree on the following:

1. A pilot should be scheduled by the operator to receive a protected time period

as an opportunity to sleep for every day of reserve duty. The operator may not

contact the pilot during this period.

2. An operator should limit the movement of the pilot’s protected time period

during consecutive days of reserve duty to ensure circadian stability.

3. A reserve pilot’s availability for duty should be limited to prevent pilot fatigue

as a result of lengthy periods of time-since-awake.

4. Sufficient advance notice of a flight assignment can provide a reserve pilot

with a sleep opportunity.

47 Batelle Memorial Institute. March 1998. A Review of Issues Concerning Duty Period Limitations,

Flight Time Limitations, and Rest Requirements as Stated in the FAA’s Notice of Proposed Rulemaking

95-18. Washington, DC: Federal Aviation Administration.

48 Aviation Rulemaking Advisory Committee, Reserve Rest Working Group. January 8, 1999. Pilot

Members Submission: Proposal of 77,955 Airline Pilots.
Part 3 22 Safety Report

The pilots and the air carriers, however, could not reach agreement about how to

meet these goals. The Safety Board understands the difficulty in reaching an agreement on

the issue of reserve duty and rest; nevertheless, it remains deeply concerned and disappointed that no further rulemaking action has been taken on the overall issue of hours of

service and that duty and rest requirements continue to be different for Part 121 and Part

135 operations. According to the FAA, rather than proceed to a final rule with the NPRM,

it will likely issue a supplemental NPRM, which, in the Safety Board’s opinion, will only

further delay any resolution to this important safety issue.

In its 1995 study on factors that affect fatigue in heavy truck accidents,49 the Safety

Board asked the FHWA to

Complete rulemaking within 2 years to revise 49 CFR 395.1 to require

sufficient rest provisions to enable drivers to obtain at least 8 continuous

hours of sleep after driving for 10 hours or being on duty for 15 hours.

(H-95-1, currently classified “Open—Unacceptable Response”)

Complete rulemaking within 2 years to eliminate 49 CFR 395.1 paragraph

(h), which allows drivers with sleeper berth equipment to cumulate the 8

hours of off-duty time in two separate periods. (H-95-2, currently classified

“Open—Unacceptable Response”)

In November of 1996, the FHWA issued an advance notice of proposed rulemaking (ANPRM) that requested additional fatigue research.50 Rather than proposing any

changes to the current hours-of-service regulations, the ANPRM was a general solicitation

for comments on hours-of-service regulations. The comment period closed on March 31,

1997. The FHWA received about 1,600 comments to the ANPRM. An expert panel was

convened in the summer of 1998 to review and evaluate, based on selected scientific criteria established by the panel, a series of hours-of-service proposals. None of the proposals

met the scientific criteria established. The expert panel also developed an additional proposal intended to meet the scientific criteria established. A summary of these proposed

hours-of-service regulations is provided in appendix G.

Currently, the FHWA has reported that it is pursuing two different avenues of rulemaking—traditional rulemaking and negotiated rulemaking.51 In a letter dated November

3, 1998, the FHWA indicated that it intended to publish an NPRM in early 1999, was contracting with the University of Michigan Transportation Research Institute to perform a

cost/benefit analysis, and was considering negotiated rulemaking to expedite the process.

In a response dated February 25, 1999, to the FHWA, the Safety Board expressed disappointment that it had taken more than 18 months since the ANPRM comment period

49 National Transportation Safety Board. 1995. Factors That Affect Fatigue in Heavy Truck Accidents.

Safety Study NTSB/SS-95/01 and NTSB/SS-95/02. Washington, DC.

50 Federal Register, Vol. 61, No. 215, dated November 5, 1996.

51 Basically, a procedure by which representatives of all interests affected by a rulemaking are brought

together to discuss fully the issues under conditions conducive to narrowing or eliminating differences and

to negotiating a proposed rule acceptable to each interest.
Part 3 23 Safety Report

closed to reach the NPRM stage and that the FHWA expected that a 120-day comment

period on the NPRM would not be sufficiently long to receive comments, thus prolonging

activity to issue a final rule. The Safety Board also indicated that it would support a negotiated rule if it would expedite the process. In testimony at the Safety Board’s April 14,

1999, public hearing on truck and bus safety,52 an FHWA representative indicated that a

decision on negotiated rulemaking was expected to be made within 2 weeks. The FHWA

representative also indicated that development of an NPRM through the traditional process was taking place simultaneously with the discussions on a negotiated rule to avoid

any further loss of time.

In a May 4, 1999, letter to the Safety Board, the DOT indicated that “FRA submitted legislation to Congress last year, and may again this year, to require railroads to submit

fatigue management plans designed to reduce fatigue experienced by railroad employees.”

The letter further stated that “should we be successful in gathering support and passage of

such a legislative initiative, we believe fatigue will be greatly reduced in railroad

operations.”

Although the DOT and the modal administrations have taken positive steps in the

area of education and research, they have not acted decisively to revise the antiquated

hours-of-service regulations. In fact, as outlined above, little regulatory action has been

initiated. The DOT believes that countermeasures to fatigue are preferred over regulation

because sleep during a rest period cannot be enforced.53 The Safety Board points out that

hours-of-service rules exist to set limits on allowable scheduling practices, not to prescribe

those schedules, and while the Board agrees that sleep cannot be regulated, it also believes

that time for adequate sleep must be guaranteed by any Federal regulation related to hours

of service.

The Safety Board is aware that the FHWA, and others, are looking at onboard

devices to test fitness-for-duty and monitor impairment of operator performance.

Although the Safety Board supports pre-duty testing for performance as a result of fatigue,

alcohol, drugs, or other condition, it does not believe that operators should be driving up to

the point that they fail a valid fitness-for-duty test as a result of fatigue, which could occur

in the middle of a trip.

In 1998, DOT Secretary Slater launched the ONEDOT program. This program is

to build on collaborative efforts among the various transportation agencies to reduce

duplication and save resources. One of the goals of ONEDOT is to develop a common,

positive framework relating to work hours, overtime, and incentives. Within the concept

of ONEDOT, the DOT Safety Council works toward development of a safety policy for

the Department. Fatigue is one of the areas on which the Council intends to act.

52 The hearing was held April 14–16, 1999, in Washington, D.C. Discussion panels included

representatives from the DOT, highway transportation industry, and public safety groups.

53 U.S. Department of Transportation. 1999. Managing Fatigue: A Significant Problem Affecting Safety,

Security, and Productivity. Washington, DC.
Part 3 24 Safety Report

The Safety Board acknowledges this as yet another initiative to address fatigue and

revisions to hours-of-service regulations; nevertheless, the Board remains extremely

disappointed in the lack of rulemaking by the DOT.

Scientific research has shown that certain sleep factors can affect fatigue and performance: insufficient sleep, irregular and unpredictable schedules, working during low

points in the circadian rhythm. The current hours-of-service regulations do not accommodate these concerns. The Safety Board believes these factors should be considered when

revising the hours-of-service regulations. Therefore, the Safety Board recommends that

the DOT require the modal administrations to modify the appropriate Codes of Federal

Regulations to establish scientifically based hours-of-service regulations that set limits on

hours of service, provide predictable work and rest schedules, and consider circadian

rhythms and human sleep and rest requirements. The Safety Board also recommends that

the DOT seek Congressional authority, if necessary, for the modal administrations to

establish these regulations. Based on the issuance of this new recommendation, Safety

Recommendation I-89-3 is being classified “Closed—Unacceptable Action/Superseded.”

The Safety Board is also recommending separately that each modal administration—the

FAA, FHWA, FRA, USCG, and RSPA—establish, within 2 years, scientifically based

hours-of-service regulations that set limits on hours of service, provide predictable work

and rest schedules, and consider circadian rhythms and human sleep and rest requirements. Further, because the FAA’s efforts have not resulted in any changes to the flight and

duty time regulations, the Safety Board has reclassified Safety Recommendations

A-95-113 and A-95-125 “Open—Unacceptable Response.” These recommendations are

being reiterated in conjunction with this report. For the FHWA, the revised regulations, at

a minimum and as recommended by the Safety Board in 1995, should also (a) require sufficient rest provisions to enable drivers to obtain at least 8 continuous hours of sleep after

driving for 10 hours or being on duty for 15 hours, and (b) eliminate 49 CFR 395.1 paragraph (h), which allows drivers with sleeper berth equipment to cumulate the 8 hours of

off-duty time in two separate periods. As a result of this new recommendation to the

FHWA, Safety Recommendations H-95-1 and -2 are being classified “Closed—

Unacceptable Action/Superseded.”
25 Safety Report

Findings

1. Since 1989, the U.S. Department of Transportation has initiated a wide range of

research projects to address the issue of operator fatigue in the transportation

environment, with the exception of pipeline operations.

2. Since 1989, the Federal Aviation Administration, the Federal Highway

Administration, the Federal Railroad Administration, and the Federal Transit

Administration have developed and disseminated various educational materials,

including brochures and videotapes, to the industry on the detrimental effects of

fatigue in the transportation environment. The Research and Special Programs

Administration and the U.S. Coast Guard need to make a more concerted effort to

develop and disseminate educational information on fatigue in pipeline and marine

operations, respectively.

3. Despite the acknowledgment by the U.S. Department of Transportation that fatigue is

a significant factor in transportation accidents, little progress has been made to revise

the hours-of-service regulations to incorporate the results of the latest research on

fatigue and sleep issues.
26 Safety Report

Recommendations

As a result of this safety report, the National Transportation Safety Board made the

following safety recommendations:

To the U.S. Department of Transportation:

Require the modal administrations to modify the appropriate Codes of

Federal Regulations to establish scientifically based hours-of-service

regulations that set limits on hours of service, provide predictable work and

rest schedules, and consider circadian rhythms and human sleep and rest

requirements. Seek Congressional authority, if necessary, for the modal

administrations to establish these regulations. (I-99-1) (Supersedes I-89-3)

To the Federal Aviation Administration:

Establish within 2 years scientifically based hours-of-service regulations

that set limits on hours of service, provide predictable work and rest

schedules, and consider circadian rhythms and human sleep and rest

requirements. (A-99-45)

To the Federal Highway Administration:

Establish within 2 years scientifically based hours-of-service regulations

that set limits on hours of service, provide predictable work and rest

schedules, and consider circadian rhythms and human sleep and rest

requirements. At a minimum, and as recommended by the National

Transportation Safety Board in 1995, the revised regulations should also

(a) require sufficient rest provisions to enable drivers to obtain at least 8

continuous hours of sleep after driving for 10 hours or being on duty for 15

hours, and (b) eliminate 49 CFR 395.1 paragraph (h), which allows drivers

with sleeper berth equipment to cumulate the 8 hours of off-duty time in

two separate periods. (H-99-19) (Supersedes H-95-1 and H-95-2)

To the Federal Railroad Administration:

Establish within 2 years scientifically based hours-of-service regulations

that set limits on hours of service, provide predictable work and rest

schedules, and consider circadian rhythms and human sleep and rest

requirements. (R-99-2)
Recommendations 27 Safety Report

To the Research and Special Programs Administration:

Establish within 2 years scientifically based hours-of-service regulations

that set limits on hours of service, provide predictable work and rest

schedules, and consider circadian rhythms and human sleep and rest

requirements. (P-99-12)

To the United States Coast Guard:

Establish within 2 years scientifically based hours-of-service regulations

that set limits on hours of service, provide predictable work and rest

schedules, and consider circadian rhythms and human sleep and rest

requirements. (M-99-1)

Also as a result of this safety report, the National Transportation Safety Board

reiterated the following safety recommendations to the Federal Aviation Administration:

Finalize the review of current flight and duty time regulations and revise

the regulations, as necessary, within 1 year to ensure that flight and duty

time limitations take into consideration research findings on fatigue and

sleep issues. The new regulations should prohibit air carriers from

assigning flight crews to flights conducted under 14 CFR Part 91 unless the

flight crews meet the flight and duty time limitation of 14 CFR Part 121 or

other appropriate regulations. (A-95-113)

Develop appropriate limitations on consecutive days on duty, and duty

hours per duty period for flight crews engaged in scheduled and

nonscheduled commercial flight operations, and apply consistent

limitations in Alaska and the remainder of the United States. (A-95-125)

By the National Transportation Safety Board

James E. Hall John A. Hammerschmidt

Chairman Member

Robert T. Francis II John Goglia

Vice Chairman Member

George W. Black, Jr.

Member

Adopted: May 17, 1999

29 Safety Report

Appendix A

Intermodal, Fatigue-Related 

Safety Recommendations

Issued May 12, 1989
Appendix A 30 Safety Report
Appendix A 31 Safety Report
Appendix A 32 Safety Report
Appendix A 33 Safety Report
Appendix A 34 Safety Report
Appendix A 35 Safety Report
Appendix A 36 Safety Report
Appendix A 37 Safety Report
38 Safety Report

Appendix B

Fatigue-Related Investigations and Studies 

Conducted Since May 1989

This appendix lists the fatigue-related investigations and studies conducted by the 

National Transportation Safety Board since May 1989. Only the safety recommendations 

that were issued to the U.S. Department of Transportation (DOT) and the modal administrations are included.

Safety Board Document: Aircraft Accident Report

Title: Aloha IslanderAir, Inc., Flight 1712, 

De Havilland Twin Otter, DHC-6-300, 

N707PV, Halawa Point, Molokai, Hawaii, 

October 28, 1989

Report Number: NTSB/AAR-90/05

Date Recommendation(s) Issued: November 21, 1990

Fatigue Cited as a Cause of or 

Contributing Factor to the Accident:

No

Abstract:

This report explains the crash of Aloha IslandAir flight 1712, a de Havilland Twin

Otter DHC-6-300 near Halawa Bay, Molokai, Hawaii, on October 28, 1989.

Fatigue-Related Conclusions:

The captain was probably fatigued because of a full-time training schedule with

Aloha Airlines, late night habits, and a part-time flight schedule with Aloha

IslandAir.

Fatigue-Related Recommendations 

Issued to the DOT:

None
Appendix B 39 Safety Report

Safety Board Document: Aircraft Accident Report

Title: Atlantic Southeast Airlines, Inc., Flight 

2311, Uncontrolled Collision With Terrain 

and Embraer EMB-120, N270AS, 

Brunswick, Georgia, April 5, 1991

Report Number: NTSB/AAR-92/03

Date Recommendation(s) Issued: May 14, 1992

Fatigue Cited as a Cause of or 

Contributing Factor to the Accident:

No

Abstract:

This report explains the loss of control in flight and crash of Atlantic Southeast

Airlines, Inc., flight 2311 while the airplane was conducting a landing approach to

runway 07 at the Glynco Jetport, Brunswick, Georgia.

Fatigue-Related Conclusions:

Commuter air carriers, including Atlantic Southeast Airlines, use the reduced rest

provisions of 14 CFR Part 135 to routinely schedule reduced rest periods in daily

operations, contrary to the purpose of the regulation, which is primarily to allow

for scheduling flexibility.

Fatigue-Related Recommendations 

Issued to the DOT:

Issue an Air Carrier Operations Bulletin (ACOB) directing Principal Operations

Inspectors to clarify with their operators that the intent of 14 CFR Section 135.265

is not to routinely schedule reduced rest, but to allow for unexpected operational

delays, and to require compliance with the intent of the regulation. (A-92-28)

Recipient(s) Status

Federal Aviation Administration Open—Acceptable Response

Safety Board Document: Special Investigation Report (Aviation)

Title: Commercial Space Launch Incident: Launch 

Procedure Anomaly, Orbital Sciences 

Corporation, Pegasus/SCD-1, 80 Nautical 

Miles East of Cape Canaveral, Florida, 

February 9, 1993

Report Number: NTSB/SIR-93/02
Appendix B 40 Safety Report

Date Recommendation(s) Issued: August 8, 1993

Fatigue Cited as a Cause of or 

Contributing Factor to the Accident:

No

Abstract:

This report explains the procedural anomaly that occurred during the launch

sequence of an Orbital Sciences Corporation Pegasus expendable launch vehicle,

which was subsequently deployed successfully from an NB-52B airplane on

February 9, 1993.

Fatigue-Related Conclusions:

There is a high probability that fatigue caused by the disruption of the circadian

rhythms and sleep loss adversely affected the performance of some critical

personnel during the launch.

Fatigue-Related Recommendations 

Issued to the DOT:

Require that, as a condition for license for commercial space launches, as a

minimum, the company applying for the license include in its license application a

provision for mandatory rest periods before the launch for key participants that

provide for an adequate and specified time period for uninterrupted sleep. The

quantitative criteria for such rest periods should be developed by appropriate

human performance experts to ensure applicability to the assigned tasks.

(A-93-90)

Recipient(s) Status

U.S. Department of Transportation Open—Acceptable Response

Safety Board Document: Safety Study (Aviation)

Title: A Review of Flightcrew-Involved, Major 

Accidents of U.S. Air Carriers, 1978 

Through 1990

Report Number: NTSB/SS-94/01

Date Recommendation(s) Issued: February 3, 1994

Fatigue Cited as a Cause of or 

Contributing Factor to the Accident:

Not applicable
Appendix B 41 Safety Report

Abstract:

U.S. air carrier operations are extremely safe, and the accident rate has declined in

recent years. However, among the wide array of factors cited by the National

Transportation Safety Board as causal or contributing to airplane accidents,

actions or inactions by the flightcrew have been cited in the majority of fatal air

carrier accidents. Recognizing that deficiencies in various aspects of the aviation

system may adversely influence flightcrew performance, the Safety Board

conducted this study to learn more about flightcrew performance by evaluating the

characteristics of the operating environment, crewmembers, and errors made in

major accidents of U.S. air carriers between 1978 and 1990 in which the

flightcrew was cited by the Board. Characteristics of the operating environments

and flightcrews were identified from information derived from major

investigations of 36 accidents and 1 incident. The errors identified were evaluated

in light of the contexts in which they occurred.

Fatigue-Related Conclusions:

Half the captains for whom data were available had been awake for more than 12

hours prior to their accidents. Half the first officers had been awake more than 11

hours. Crews comprising captains and first officers whose time since awaking was

above the median for their crew position made more errors overall, and

significantly more procedural and tactical decision errors.

Fatigue-Related Recommendations 

Issued to the DOT:

Require U.S. air carriers operating under 14 CFR Part 121 to include, as part of

pilot training, a program to educate pilots about the detrimental effects of fatigue,

and strategies for avoiding fatigue and countering its effects. (A-94-5)

Recipient(s) Status

Federal Aviation Administration Closed—Acceptable Action

Safety Board Document: Aircraft Accident Report

Title: In-Flight Loss of Control, Leading to Forced 

Landing and Runway Overrun, Continental 

Express, Inc., N24706, Embraer EMB-120 

RT, Pine Bluff, Arkansas, April 29, 1993

Report Number: NTSB/AAR-94/02/SUM

Date Recommendation(s) Issued: March 17, 1994
Appendix B 42 Safety Report

Fatigue Cited as a Cause of or 

Contributing Factor to the Accident:

Yes

Abstract:

This report explains the in-flight loss of control of N24706, leading to a forced

landing and runway overrun at Pine Bluff, Arkansas, on April 29, 1993.

Fatigue-Related Conclusions:

The crew rest periods scheduled for the trip sequence were within company

guidelines and FARs. However, the crew did not take advantage of the rest

periods, and the combined effects of cumulatively limited sleep, a demanding day

of flying, and a time of day associated with fatigue were factors in the crew’s

inadequate judgment and performance.

Fatigue-Related Recommendations 

Issued to the DOT:

Require that 14 CFR Part 135 air carriers provide air crews, as part of their initial

and recurrent training, information on fatigue countermeasures relevant to the

duty/rest schedules being flown by the company. (A-94-73)

Recipient(s) Status

Federal Aviation Administration Closed—Acceptable Action

Safety Board Document: Aircraft Accident Report

Title: Uncontrolled Collision With Terrain, 

American International Airways Flight 808, 

Douglas DC-8-61, N814CK, U.S. Naval Air 

Station, Guantanamo Bay, Cuba, August 18, 

1993

Report Number: NTSB/AAR-94/04

Date Recommendation(s) Issued: May 18, 1994

Fatigue Cited as a Cause of or 

Contributing Factor to the Accident:

Yes

Abstract:

This report explains the crash of American International Airways flight 808, a

DC-8-61, about 1/4 mile from the approach end of runway 10 at Leeward Point

Airfield, U.S. Naval Air Station, Guantanamo Bay, Cuba, on August 18, 1993.
Appendix B 43 Safety Report

Fatigue-Related Conclusions:

The flightcrew members had experienced a disruption of circadian rhythms and

sleep loss, which resulted in fatigue that had adversely affected their performance

during a critical phase of flight.

The flightcrew had been on duty about 18 hours and had flown approximately

9 hours at the time of the accident. The company had intended for the crew to ferry

the airplane back to Atlanta after the airplane was offloaded in Guantanamo Bay.

This would have resulted in a total duty time of 24 hours and 12 hours of flight

time, the maximum permitted under 14 CFR Section 121.521, supplemental rules

for overseas and international flights.

If the flightcrew had been scheduled to conduct a flight within the United States

similar to that of flight 808, the flightcrew would have exceeded the flight and

duty time requirements of 14 CFR 121.505.

Fatigue-Related Recommendations 

Issued to the DOT:

Revise the applicable subpart of 14 CFR Part 121 to require that flight time,

accumulated in noncommercial “tail end” ferry flights conducted under 14 CFR

Part 91, as a result of 14 CFR Part 121 revenue flights, be included in the flight

crewmember’s total flight and duty time accrued during those revenue operations.

(A-94-105)

Recipient(s) Status

Federal Aviation Administration Closed—Acceptable Action/Superseded

♦♦♦

Expedite the review and upgrade of fight/duty time limitations of the Federal

Aviation Regulations to ensure that they incorporate the results of the latest

research on fatigue and sleep issues. (A-94-106)

Recipient(s) Status

Federal Aviation Administration Closed—Acceptable Action/Superseded

Safety Board Document: Safety Study (Aviation)

Title: Commuter Airline Safety

Report Number: NTSB/SS-94/02

Date Recommendation(s) Issued: November 30, 1994
Appendix B 44 Safety Report

Fatigue Cited as a Cause of or 

Contributing Factor to the Accident:

Not applicable

Abstract:

The commuter airline industry has grown dramatically and has experienced

significant changes in operating characteristics in the past 15 years. In response to

safety recommendations issued by the National Transportation Safety Board and

through other initiatives taken by government and industry, regulatory revisions

and other actions have resulted in an improved safety record for commuter airlines

conducting operations under Title 14 Code of Federal Regulations Part 135.

However, despite efforts to bring about safety improvements, accident rates for

commuter airlines continue to be higher than the rates for domestic Part 121

airlines. The higher accident rate, the differences in regulatory standards between

Parts 135 and 121, and findings of the Safety Board’s investigations of recent

accidents prompted the Board to initiate this study of commuter airline safety.

Fatigue-Related Conclusions:

Part 135 regulations on flight time and crew rest allow air carriers to establish

schedules that result in reduced rest, and many commuter airlines routinely take

advantage of these reduced rest provisions for scheduling flightcrews rather than

using the provisions for the intended purpose of accommodating unforeseen

circumstances.

Self-reports from the commuter airline pilots surveyed indicate that most have

flown while fatigued. The most common reasons given for flying while fatigued

were the length of duty days, early shift duty followed by late shift duty, and

inadequate rest periods.

The practice of scheduling Part 135 pilots for training, check flights, or other

nonrevenue flights at the end of a full day of scheduled revenue flying reduces the

value of the training and increases the potential for fatigue-related accidents.

Fatigue-Related Recommendations 

Issued to the DOT:

Require principal operations inspectors to periodically review air carrier flight

operations polices and practices concerning pilot task performed between flights

to ensure that carriers provide pilots with adequate resources (such as time and

personnel) to accomplish those tasks. (A-94-193)

Recipient(s) Status

Federal Aviation Administration Closed—Acceptable Alternate Action

♦♦♦
Appendix B 45 Safety Report

Revise the Federal Aviation Regulations contained in 14 CFR Part 135 to require

that pilot flight time accumulated in all company flying conducted after revenue

operations—such as training and check flights, ferry flights, and repositioning

flights—be included in the crewmember’s total flight time accrued during revenue

operations. (A-94-194)

Recipient(s) Status

Federal Aviation Administration Open—Acceptable Response

Safety Board Document: Aircraft Accident Report

Title: Uncontrolled Collision With Terrain, Air 

Transport International, Douglas DC-8-63, 

N782AL, Kansas City International Airport, 

Kansas City, Missouri, February 16, 1995

Report Number: NTSB/AAR-95/06

Date Recommendation(s) Issued: November 14, 1995

Fatigue Cited as a Cause of or 

Contributing Factor to the Accident:

Yes

Abstract:

This report explains the accident involving an Air Transport International

DC-8-63, which was destroyed by ground impact and fire during an attempted

takeoff at Kansas City International Airport, Kansas City, Missouri, on February

16, 1995.

Fatigue-Related Conclusions:

The flightcrew assigned to the ferry had a shortened rest break after performing an

international trip. Federal regulations permit companies to eliminate these rest

periods after flying a 14 CFR Part 121 operation when the flight will be conducted

as a ferry operating under 14 CFR Part 91.

At the time of the accident, the flightcrew was suffering from fatigue as a result of

limited opportunities for rest, disruption to their circadian rhythms, and lack of

sleep in the days before the accident. However, the Safety Board was unable to

determine the extent, if any, to which their fatigue contributed to the accident.

Existing FAR Part 121 flight time limits and rest requirements that pertained to the

flights that the flightcrew flew prior to the ferry flights did not apply to the ferry

flights flown under FAR Part 91. This permitted a substantially reduced flightcrew

rest period when conducting the nonrevenue ferry flights.
Appendix B 46 Safety Report

Fatigue-Related Recommendations 

Issued to the DOT:

Finalize the review of current flight and duty time regulations and revise the

regulations, as necessary, within 1 year to ensure that flight and duty time

limitations take into consideration research findings in fatigue and sleep issues.

The new regulations should prohibit air carriers from assigning flightcrews to

flights conducted under Title14 Code of Federal Regulations Part 91 unless the

flightcrew meet the flight and duty time limitations of 14 CFR Part 121 or other

appropriate regulations. (A-95-113)

Recipient(s) Status

Federal Aviation Administration Open—Unacceptable Response

Safety Board Document: Safety Study (Aviation)

Title: Aviation Safety in Alaska

Report Number: NTSB/SS-95/03

Date Recommendation(s) Issued: December 1, 1995

Fatigue Cited as a Cause of or 

Contributing Factor to the Accident:

Not applicable

Abstract:

Flight operations in Alaska are diverse, and they are responsive to the State’s

challenging aviation environment and its unique air transportation requirements.

The National Transportation Safety Board conducted this study to examine

Alaska’s current aviation environment and air transportation activities, to identify

the associated risk factors and safety deficiencies, and to recommend practical

measures for managing the risks to safe flight operations given the reality of

Alaska’s aviation environment and the potential of new technologies.

Fatigue-Related Conclusions:

The consecutive, long duty days currently permitted by Part 135.261 for

commuter airline and air taxi flightcrews in Alaska can contribute to fatigue and

are a detriment to safety.

Fatigue-Related Recommendations 

Issued to the DOT:

Develop appropriate limitations on consecutive days on duty, and duty hours per

duty period for flightcrews engaged in scheduled and nonscheduled commercial

flight operations, and apply consistent limitations in Alaska and the remainder of

the United States. (A-95-125)
Appendix B 47 Safety Report

Recipient(s) Status

Federal Aviation Administration Open—Unacceptable Response

Safety Board Document: Aircraft Accident Report

Title: In-Flight Loss of Control and Subsequent 

Collision With Terrain, Cessna 177B, 

N35207, Cheyenne, Wyoming, April 11, 

1996

Report Number: NTSB/AAR-97/02

Date Recommendation(s) Issued: March 21, 1997

Fatigue Cited as a Cause of or 

Contributing Factor to the Accident:

No

Abstract:

On April 11, 1996, about 0824 mountain daylight time, privately owned Cessna

177B, registration N35207, collided with terrain after a loss of control following

takeoff from runway 30 at the Cheyenne Airport, Cheyenne, Wyoming. The pilotin-command, pilot trainee, and rear seat passenger (the pilot trainee’s father) were

fatally injured. Instrument meteorological conditions existed at the time, and a

visual flight rules flight plan had been filed. The flight, which was a continuation

of a transcontinental flight “record” attempt by the youngest “pilot” to date (the

pilot trainee), was operated under the provisions of 14 CFR Part 91.

Fatigue-Related Conclusions:

The pilot-in-command suffered from fatigue on the day before the accident.

Information on fatigue and its effect, and methods to counteract it, might have

assisted the pilot-in-command to recognize his own fatigue on the first day of the

flight, and possibly enhanced the safety of the trip.

Fatigue-Related Recommendations 

Issued to the DOT:

Expand the development and increase the dissemination of educational materials

on the hazards of fatigue to the general aviation piloting community. (A-97-20)

Recipient(s) Status

Federal Aviation Administration Closed—Acceptable Action
Appendix B 48 Safety Report

Safety Board Document: Aircraft Accident Report

Title: In-Flight Fire and Impact With Terrain, 

ValuJet Airlines, Flight 592, DC-9-32, 

N904VJ, Everglades, Near Miami, Florida, 

May 11, 1996

Report Number: NTSB/AAR-97/06

Date Recommendation(s) Issued: September 9, 1997

Fatigue Cited as a Cause of or 

Contributing Factor to the Accident:

No

Abstract:

This report explains the in-flight fire and impact with terrain of ValuJet Airlines

flight 592, a DC-9-32, N904VJ, in the Everglades near Miami, Florida, on May

11, 1996.

Fatigue-Related Conclusions:

The maintenance duty time limitations of 14 CFR Part 121.377 may not be

consistent with the current state of scientific knowledge about factors contributing

to fatigue among personnel working in safety-sensitive transportation jobs.

Fatigue-Related Recommendations 

Issued to the DOT:

Review the issue of personnel fatigue in aviation maintenance, then establish duty

time limitations consistent with the current state of scientific knowledge for

personnel who perform maintenance on air carrier aircraft. (A-97-71)

Recipient(s) Status

Federal Aviation Administration Open—Response Received

Safety Board Document: Safety Study (Highway)

Title: Fatigue, Alcohol, Other Drugs, and Medical 

Factors in Fatal-to-the-Driver Heavy Truck 

Crashes

Report Number: NTSB/SS-90/01 and NTSB/SS-90/02

Date Recommendation(s) Issued: April 4, 1990

Fatigue Cited as a Cause of or 

Contributing Factor to the Accident:

Not applicable
Appendix B 49 Safety Report

Abstract:

This report is an analysis of human factors in fatal-to-the-driver, heavy truck

accidents in eight States over a 1-year period, October 1, 1987, through September

30, 1988. Data presented are derived from in-depth investigation of 182 accidents

that involved 186 heavy trucks and resulted in 207 fatalities. The accident

investigations were conducted in California, Colorado, Georgia, Maryland, New

Jersey, North Carolina, Tennessee, and Wisconsin. These accidents represent

approximately 25 percent of this type of accident nationwide. Volume 1

(NTSB/SS-90/01) of the study includes an analysis of fatigue, alcohol, and other

drug prevalence and medical factors in these accidents, presents findings, and

makes recommendations to improve heavy truck safety. Volume 2

(NTSB/SS-90/02) contains the 182 case summaries that provided the data

discussed in Volume 1.

Fatigue-Related Conclusions:

The most frequently cited accident probable cause or factor in fatal-to-the-driver

heavy truck accidents was fatigue (57 cases or 31 percent), followed by alcohol

and other drug impairment (53 cases or 29 percent). Of the 57 drivers who were

fatigued, 19 were also impaired by alcohol and/or drugs.

Fatigue and fatigue-drug interactions were involved in more fatalities in this study

than alcohol and other drugs of abuse.

Fatigue, drugs that are taken to counteract the symptoms of fatigue, drugs that

aggravate fatigue, and the interaction of fatigue and drugs appear to be major

factors in accident causation.

There is a strong association between violation of the Federal hours-of-service

regulations and drug usage. More than half the drivers who had violated Federal

hours-of-service regulations tested positive for some drug of abuse. The largest

difference among these two groups of drivers appeared to occur with marijuana,

which was the most prevalent drug of abuse among the drivers who were in excess

of the Federal regulations. Greater use of amphetamines, cocaine, and alcohol by

drivers who violated Federal hours-of-service regulations were also indicated.

Drug-free drivers appear more likely to have accidents during certain time periods

(when there is increased exposure and at times when people tend to be less alert

and in accordance with low periods in circadian rhythm) whereas drug-involved

drivers appear to have accidents throughout the day.

Investigators found that logbooks were routinely falsified where they were

required by regulation. It was common to find two sets of logbooks (three sets in

one case) kept by the accident-involved drivers. In only one case was a vehicle

equipped with a tachograph. Five case vehicles were equipped with on-board

recorders.
Appendix B 50 Safety Report

Fatigue-Related Recommendations 

Issued to the DOT:

Conduct a detailed review of, and report on, trucking industry structure,

operations, and conditions, especially shipping, dispatching, and receiving

requirements, shipment broker operations, just-in-time shipments, and

truckload/less-than-truckload operations which may create incentives for drivers

to violate hours-of-service regulations and to use drugs of abuse. (H-90-10)

Recipient(s) Status

Department of Transportation Open—Acceptable Response

♦♦♦

Disseminate safety information to national, State, and local police agencies, public

service and safety agencies, professional truckdriver groups and individual

truckdrivers, regarding the effects of fatigue, alcohol, and other drug use; the

interaction of alcohol, drugs, and fatigue; the prevalence of drug and alcohol abuse

among professional commercial vehicle operators; and methods of minimizing

conditions which lead to commercial vehicle operators driving while fatigued.

(H-90-21)

Recipient(s) Status

Federal Highway Administration Closed—Acceptable Action

♦♦♦

Require automated/tamper-proof on-board recording devices such as tachographs

or computerized logs to identify commercial truckdrivers who exceed hours-ofservice regulations. (H-90-28)

Recipient(s) Status

Federal Highway Administration Closed—Unacceptable Action

♦♦♦

As part of the FHWA ongoing study on fatigue and loss of alertness among

commercial vehicle operators, investigate the interactions of fatigue and drug

usage. (H-90-29)

Recipient(s) Status

Federal Highway Administration Closed—Unacceptable Action

♦♦♦

Revise 49 CFR Parts 391 and 395 to establish driver hours-of-service violations,

logbooks irregularities, or the presence of multiple logbooks as a reasonable cause

requiring a drug test of the driver. Amend the regulations and provide notice to

drivers of these revised regulations. (H-90-30)
Appendix B 51 Safety Report

Recipient(s) Status

Federal Highway Administration Closed—Unacceptable Action

♦♦♦

Amend 49 CFR Parts 392 and 395 to prohibit employers, shippers, receivers,

brokers, or drivers form accepting and scheduling a shipment which would require

that the driver exceed the hours-of-service regulations in order to meet the

delivery deadline (similar to current regulations regarding schedules which would

require the driver to exceed the speed limit [49 CFR 392.6]). In conjunction with

the Interstate Commerce Commission, provide for operating certificate and

financial penalties appropriate to the offense. (H-90-32)

Recipient(s) Status

Federal Highway Administration Closed—Unacceptable 

Action/Superseded

Safety Board Document: Highway Accident Report

Title: Multiple Vehicle Collision and Fire in a 

Work Zone on Interstate Highway 79 Near 

Sutton , West Virginia, July 26, 1990.

Report Number: NTSB/HAR-91/01

Date Recommendation(s) Issued: June 20, 1991

Fatigue Cited as a Cause of or 

Contributing Factor to the Accident:

Yes

Abstract:

This report explains the multiple vehicle collision and fire in a work zone on

interstate Highway 79 near Sutton, West Virginia, on July 26, 1990.

Fatigue-Related Conclusions:

The Double B truckdriver drove more than the 10 1/4 hours reported; therefore, it

is unlikely that he spent 7 1/2 hours sleeping or resting in the truck’s cab the

morning before the accident.

Fatigue-induced inattention, exacerbated by an inadequate and unbalanced diet the

day of the accident, caused the Double B truckdriver to fail to heed warning signs

and to slow the truck in time to avoid the collision.
Appendix B 52 Safety Report

Fatigue-Related Recommendations 

Issued to the DOT:

Encourage the use of work zone safety devices and procedures, such as “rumble

strips,” that alert the various senses. (H-91-28)

Recipient(s) Status

Federal Highway Administration Closed—Acceptable Action

Safety Board Document: Highway Accident Report

Title: Greyhound Bus Run-Off-the-Road 

Accidents: Donegal, Pennsylvania, 

June 26, 1991; and Caroline, New York, 

August 3, 1991

Report Number: NTSB/HAR-92/01

Date Recommendation(s) Issued: April 1, 1992

Fatigue Cited as a Cause of or 

Contributing Factor to the Accident:

No

Abstract:

On June 26, 1991, about 1:50 p.m., a greyhound bus traveling from Cleveland,

Ohio, to Washington, D.C., ran off the right side of the roadway and overturned on

the Pennsylvania turnpike near Donegal, Pennsylvania. One passenger was fatally

injured, the driver and 14 passengers were injured, and 1 passenger was uninjured.

On August 3, 1991, about 6:45 a.m., a greyhound bus traveling from New York

City to Buffalo, New York, ran off the right side of the roadway, and overturned on

State Route 79 near Caroline, New York. The driver and 33 passengers were

injured, and 5 passengers were uninjured.

Fatigue-Related Conclusions:

The limited rest both busdrivers had received prior to the accident trips was one of

several physiological factors that may have caused these busdrivers to be

inattentive to their driving tasks.

Fatigue-Related Recommendations 

Issued to the DOT:

None
Appendix B 53 Safety Report

Safety Board Document: Highway Accident Report

Title: Tractor-Semitrailer Collision With Bridge 

Columns on Interstate 65, Evergreen, 

Alabama, May 19, 1993

Report Number: NTSB/HAR-94/02

Date Recommendation(s) Issued: May 4, 1994

Fatigue Cited as a Cause of or 

Contributing Factor to the Accident:

Yes

Abstract:

On May 19, 1993, a tractor with bulk-cement-tank semitrailer was traveling

southbound on Interstate 65 near Evergreen, Alabama, and collided with a

supporting bridge column of the County Road 22 overpass. Two spans of the

overpass collapsed onto the semitrailer and the southbound lanes of the Interstate.

An automobile and a tractor-semitrailer then collided with the collapsed bridge

spans. The cement-tank truckdriver was seriously injured; the drivers of the other

vehicles were killed.

Fatigue-Related Conclusions:

The truckdriver exhibited a reduced alertness that is consistent with falling asleep.

Fatigue-Related Recommendations 

Issued to the DOT:

None

Safety Board Document: Safety Study (Highway)

Title: Factors That Affect Fatigue in Heavy 

Truck Accidents

Report Number: NTSB/SS-95/01 and NTSB/SS-95/02

Date Recommendation(s) Issued: February 7, 1995

Fatigue Cited as a Cause of or 

Contributing Factor to the Accident:

Not applicable
Appendix B 54 Safety Report

Abstract:

Because of the significant number of heavy truck-related fatalities and the

significant role of fatigue in such accidents, the Board initiated this study of

single-vehicle heavy truck accidents to examine the role of specific factors, such

as drivers’ patterns of duty and sleep, in fatigue-related heavy truck accidents and

to determine potential remedial actions. The purpose of the Board’s study was to

examine the factors that affect driver fatigue and not the statistical incidence of

fatigue. The study analyzes data from 107 single-vehicle heavy truck accidents in

which the driver survived. Volume 1 of the study contains the Board’s analysis of

the data and its conclusions and recommendations. Volume 2 of the study contains

the summaries of the 107 accidents.

Fatigue-Related Conclusions:

The most critical factors in predicting fatigue-related accidents in the Board’s

sample are the duration of the most recent sleep period, the amount of sleep in the

past 24 hours, and split sleep patterns.

Whereas sleep measures were the critical factors in discriminating between a

fatigue-related and nonfatigue-related accident, schedule irregularity was the

major factor in discriminating between a long-haul and a short-haul operation.

The truckdrivers in fatigue-related accidents in this sample obtained an average of

5.5 hours sleep in the last sleep period prior to the accident. This was 2.5 hours

less than the drivers involved in nonfatigue-related accidents (8.0 hours).

The truckdrivers involved in fatigue-related accidents obtained 6.9 hours sleep in

the 24 hours prior to the accident (the amount they reported usually needing to feel

rested). This was 2.4 hours less sleep than the drivers involved in nonfatiguerelated accidents (9.3 hours).

The hours-of-service regulations currently do not provide the opportunity to

obtain an adequate amount of sleep (at least 8 continuous hours) because they do

not consider time needed for travel, eating, personal hygiene, recreation, or

inability to fall asleep immediately at the beginning of the 8-hour off-duty period.

Many of the truckdrivers in the accident sample who were involved in fatiguerelated accidents did not recognize that they were in need of sleep and believed

that they were rested when they were not. About 80 percent of the drivers involved

in fatigue-related accidents rated the quality of their last sleep before the accident

as good or excellent.

The data from this study indicate that driving at night with a sleep deficit is far

more critical in terms of predicting fatigue-related accidents than simply nighttime

driving.
Appendix B 55 Safety Report

Truckdrivers with split sleep patterns obtained 8 hours sleep in a 24-hour time

period; however, they obtained it in small segments, on average of 4 hours at a

time. The data and research indicate that sleep accumulated in short time blocks

impedes the recovery of performance abilities.

The use of the sleeper berth exemption [now found in 49 CFR 395.1(h)] promotes

split sleeping that can result in performance decrements earlier than for drivers

who obtain sleep in longer continuous periods.

About 67 percent of the drivers with schedule irregularities were involved in

fatigue-related accidents (48 of 73), and about 38 percent of drivers with regular

schedules had fatigue-related accidents (13 of 34). Seventeen of the 107 drivers

had inverted their duty/sleep periods on the accident trip; that is, the accident

occurred at a time when on the previous day the driver had been sleeping. All but

one of these drivers (94 percent) had a fatigue-related accident. Irregular and

inverted schedules can result in longer hours awake than normal and can prevent

drivers from obtaining adequate sleep without careful planning.

Twenty-seven of the 107 drivers exceeded the hours-of-service limits at least once

in the 96 hours preceding the accident. Of those drivers who exceeded the limits,

about 82 percent (22 of 27) had a fatigue-related accident. The obvious

implication for drivers who exceed the hour-of-service limits is the fewer number

of hours available to obtain adequate sleep.

Providing education to transportation employees about the factors affecting

fatigue is a vitally important component of overall efforts to combat fatigue in

transportation.

The results of this study suggest a possible link between the method of driver

compensation and fatigue-related accidents—an issue that has not been previously

addressed in detail.

Fatigue-Related Recommendations 

Issued to the DOT:

Complete rulemaking within 2 years to revise 49 CFR 395.1 to require sufficient

rest provisions to enable drivers to obtain at least 8 continuous hours of sleep after

driving for 10 hours or being on duty for 15 hours. (H-95-1)

Recipient(s) Status

Federal Highway Administration Closed—Unacceptable 

Action/Superseded by H-99-19

♦♦♦

Complete rulemaking within 2 years to eliminate 49 CFR 395.1 paragraph (h),

which allows drivers with sleeper berth equipment to cumulate the 8 hours of

off-duty time in two separate periods. (H-95-2)
Appendix B 56 Safety Report

Recipient(s) Status

Federal Highway Administration Closed—Unacceptable 

Action/Superseded by H-99-19

♦♦♦

Examine truckdriver pay compensation to determine if there is any effect on

hours-of-service violations, accidents, or fatigue. (H-95-3)

Recipient(s) Status

Federal Highway Administration Open—Acceptable Response

♦♦♦

Complete rulemaking within 2 years to amend 49 CFR Parts 392 and 395 to

prohibit employers, shippers, receivers, brokers, or drivers from accepting and

scheduling a shipment which would require that the driver exceed the hours-ofservice regulations in order to meet the delivery deadline (similar to current

regulations regarding schedules which would require the driver to exceed the

speed limit [49 CFR 392.61]. (H-95-4) (Supersedes H-90-32)

Recipient(s) Status

Federal Highway Administration Open—Unacceptable Response

♦♦♦

Develop and disseminate, in consultation with the U.S. Department of

Transportation Human Factors Coordinating Committee, a training and education

module to inform truckdrivers of the hazards of driving while fatigued. It should

include information about the need for adequate amount of quality sleep, strategies

for avoiding sleep loss such as strategic napping, consideration of the behavioral

and physiological consequences of sleepiness, and an awareness that sleep can

occur suddenly and without warning to all drivers regardless of their age or

experience. (H-95-5)

Recipient(s) Status

Federal Highway Administration Closed—Acceptable Action

Safety Board Document: Highway Accident Report

Title: Propane Truck Collision with Bridge 

Column and Fire, White Plains, New York, 

July 27, 1994

Report Number: NTSB/HAR-95/02
Appendix B 57 Safety Report

Date Recommendation(s) Issued: November 27, 1995

Fatigue Cited as a Cause of or 

Contributing Factor to the Accident:

Yes

Abstract:

On July 27, 1994, a tractor cargo-tank semitrailer loaded with 9,200 gallons of

propane (a liquefied petroleum gas) and traveling east on Interstate 287 in White

Plains, New York, drifted across the left lane onto the left shoulder and struck the

guardrail. The tank hit a column of the Grant Avenue overpass. The tractor and the

semitrailer separated, and the front head of the tank fractured, releasing the

propane, which vaporized into gas and ignited. The tank was propelled northward

about 300 feet, landing on a frame house and engulfing it in flames. The driver

was killed, 23 people were injured, and an area within a radius of approximately

400 feet was engulfed by fire.

Fatigue-Related Conclusions:

The driver chose to sacrifice his rest in order to complete his deliveries within his

normal schedule. At the time of the accident, he had probably fallen asleep

because he was suffering from acute fatigue.

The carrier’s policy of paying by the load instead of by the hour appeared to

encourage drivers to violate hours-of-service regulations.

The driver might have rested before trying to complete his last load had he been

trained in understanding the effects of deficit sleep and irregular or inverted rest

schedules.

The carrier’s oversight of the driver’s hours of service was inadequate.

Fatigue-Related Recommendations 

Issued to the DOT:

Cooperate with the American Association of Motor Vehicle Administrators and

the American Trucking Associations to review and augment the commercial

drivers license manual and test materials to include information on the role of

fatigue in commercial vehicle accidents and methods to identify and address

fatigue. (H-95-36)

Recipient(s) Status

Federal Highway Administration Open—Acceptable Response

Safety Board Document: Special Investigation Report (Highway)

Title: Selective Motorcoach Issues
Appendix B 58 Safety Report

Report Number: NTSB/SIR-99/01

Date Recommendation(s) Issued: February 26, 1999

Fatigue Cited as a Cause of or 

Contributing Factor to the Accident:

Not applicable

Abstract:

This report contains the findings of a special investigation conducted as a result of

two fatal motorcoach accidents. In the first accident, on October 14, 1995, two

passengers sustained fatal injuries, 13 sustained serious injuries, and 26 received

minor injuries when a 1989 Eagle motorcoach operated by Hammond Yellow

Coach Lines, Inc., overturned upon entering an Interstate 70 exit ramp in

Indianapolis, Indiana. In the second accident, on July 29, 1997, 1 passenger

sustained minor injuries, the driver and 3 passengers sustained serious injuries,

and 28 passengers sustained minor injuries when a 1985 Transportation

Manufacturing Corporation (TMC) motorcoach operated by Rite-Way

Transportation, Inc., drifted off the side of Interstate 95 near Stoney Creek,

Virginia, and down an embankment into the Nottoway River, where it came to rest

on its left side, partially submerged in water. 

Fatigue-Related Conclusions:

The Rite-Way busdriver fell asleep and ran off the road.

The Rite-Way driver became fatigued because the Pathways to Freedom tour

schedule imposed inverted duty-sleep periods and because additional well-rested

drivers were not provided for relief.

Although the exact cause of the Hammond driver’s failing to respond

appropriately cannot be determined, several factors, including fatiguing conditions

and the driver’s unfamiliarity with the route, may have contributed to his failing to

slow down for the exit ramp.

Fatigue-Related Recommendations 

Issued to the DOT:

Require that the Federal Highway Administration’s fatigue video that is being

developed for motorcoaches discuss the dangers of inverted duty-sleep periods

(H-99-4A)

Recipient(s) Status

Department of Transportation Open—Await Response

♦♦♦
Appendix B 59 Safety Report

In the assessment that is mandated by the Transportation Efficiency Act for the

21st Century, include the inverted work schedules of motorcoach carriers in the

study of how the operations of shippers, brokers, freight forwarders, consignees,

or others, such as tour or charter operators, encourage the violations of the hoursof-service rules (H-99-5)

Recipient(s) Status

Department of Transportation Open—Await Response

Safety Board Document: Marine Accident Report

Title: Grounding of the U.S. Tankship Exxon 

Valdez on Bligh Reef, Prince William Sound 

Near Valdez, Alaska, March 24, 1989

Report Number: NTSB/MAR-90/04

Date Recommendation(s) Issued: September 18, 1990

Fatigue Cited as a Cause of or 

Contributing Factor to the Accident:

Yes

Abstract:

This report explains the grounding of the U.S. tankship Exxon Valdez near Valdez,

Alaska, on March 24, 1989.

Fatigue-Related Conclusions:

The performance of the third mate was deficient, probably because of fatigue,

when he assumed supervision of the navigation watch from the master about 2350.

The third mate’s failure to turn the vessel at the proper time and with sufficient

rudder probably was the result of his excessive workload and fatigued condition,

which caused him to lose awareness of the location of Bligh Reef.

There were no rested deck officers on the Exxon Valdez available to stand the

navigation watch when the vessel departed from the Alyeska Terminal.

Many conditions conducive to producing crew fatigue on the Exxon Valdez exist

on other Exxon Shipping Company vessels because many are three-mate vessels

and because the company has pursued reduced manning procedures.

Exxon Shipping Company manning policies do not adequately consider the

increase in workload caused by reduced manning.

The Exxon Shipping Company had incentives and work requirements that could

be conducive to fatigue.
Appendix B 60 Safety Report

The Exxon Shipping Company had manipulated shipboard reporting of crew

overtime information that was to be submitted to the U.S. Coast Guard for its

assessments of workloads on some tankships.

The Coast Guard was unduly narrow in its perspective when it evaluated reduced

manning requests for the Exxon Valdez; it based manning reductions primarily on

the assumption that shipboard hardware and equipment might reduce the workload

at sea but did not consider the heavier workload associated with cargo operations

in port and the frequency of such operations.

Fatigue-Related Recommendations 

Issued to the DOT:

Develop a means for rigorous enforcement of 46 U.S.C. 8104(a) to ensure that

officers on watch during departures from ports have had at least 6 hours of

off-duty time in the previous 12 hours. (M-90-32)

Recipient(s) Status

U.S. Coast Guard Closed—Unacceptable Action

♦♦♦

Increase the manning level at the Marine Safety Office, Valdez, Alaska, to provide

the following: enough watchstanders to plot all participating vessels between the

pilot station south of Bligh Reef and their berths in Port Valdez; an officer-incharge of the Vessel Traffic System who will have time to manage and supervise

the system effectively; and sufficient additional officers to staff a duty officer

watch with officers capable of monitoring and supervising vessel traffic

watchstanders outside normal working hours. (M-90-37)

Recipient(s) Status

U.S. Coast Guard Closed—Acceptable Action

Safety Board Document: Marine Accident Report

Title: Sinking of the U.S. Tug Barcona by the U.S. 

Navy Nuclear Attack Submarine USS 

HOUSTON (SNN713), San Pedro Channel 

Near Santa Catalina Island, California, June 

14, 1989

Report Number: NTSB/MAR-90/05

Date Recommendation(s) Issued: October 20, 1990

Fatigue Cited as a Cause of or 

Contributing Factor to the Accident:

No
Appendix B 61 Safety Report

Abstract:

This report explains the sinking of the U.S. tug Barcona by the U.S. Navy nuclear

attack submarine USS Houston (SSN 713) in San Pedro Channel near Santa

Catalina Island, California, on June 14, 1989.

Fatigue-Related Conclusions:

The Houston’s officer of the deck was fatigued when he assumed the navigation

watch prior to this accident.

The fatigued condition of the Houston’s officer of the deck did not contribute to

the failure of the navigation watch to detect the presence of the Barcona and its

tow before the submarine reached periscope depth.

Current U.S. Navy operational instructions are not adequate to ensure that officers

of the deck are sufficiently rested when they assume underway watches.

Fatigue-Related Recommendations 

Issued to the DOT:

None

Safety Board Document: Marine Accident Report

Title: Grounding of Liberian Passenger Ship Star 

Princess on Poundstone Rock, Lynn Canal, 

Alaska, June 23, 1995

Report Number: NTSB/MAR-97/02

Date Recommendation(s) Issued: June 26, 1997

Fatigue Cited as a Cause of or 

Contributing Factor to the Accident:

Yes

Abstract:

On June 23, 1995 the passenger vessel Star Princess, traveling from Skagway to

Juneau, Alaska, grounded on Poundstone Rock, Lynn Canal, about 21 miles

northwest of Juneau. The vessel’s bottom sustained significant damage. No

injuries or death resulted from this accident. The total cost resulting from required

repairs and delay before the vessel could return to service was estimated at $27.16

million.

Fatigue-Related Conclusions:

The pilot was chronically fatigued as a result of obstructive sleep apnea.

Fatigue may have reduced the pilot’s ability to appropriately assess and respond to

the developing situation.
Appendix B 62 Safety Report

Fatigue-Related Recommendations 

Issued to the DOT:

Advise pilots about the effect of fatigue on performance and about sleeping

disorders such as sleep apnea. (M-97-41)

Recipient(s) Status

U.S. Coast Guard Closed—Acceptable Action

♦♦♦

Review, in consultation with experts in occupational health, your medical

standards, guidelines, and examination forms to ensure that they require the

disclosure and appropriate evaluation of the history of presence of any medical

conditions, symptoms, or medication use that would affect an individual’s fitness

to pilot a vessel. (M-97-42)

Recipient(s) Status

U.S. Coast Guard Open—Acceptable Response

Safety Board Document: Pipeline Accident Report

Title: Pipeline Rupture and Release of Fuel Oil 

Into the Reedy River at Fork Shoals, South 

Carolina, June 26, 1996

Report Number: NTSB/PAR-98/01

Date Recommendation(s) Issued: November 18, 1998

Fatigue Cited as a Cause of or 

Contributing Factor to the Accident:

No

Abstract:

About 11:54 p.m. eastern daylight time on June 16, 1996, a 36-inch-diameter

Colonial Pipeline Company pipeline ruptured where a corroded section of the

pipeline crossed the Reedy River at Fork Shoals, South Carolina. The rupture

pipeline released about 957,600 gallons of fuel oil into the Reedy River and

surrounding areas. The estimated cost to Colonial for cleanup and settlement with

the State of South Carolina was $20.5 million. No one was injured in the accident.

Fatigue-Related Conclusions:

Fatigue resulting from the relief controller’s inverted work schedule may have

affected his alertness, vigilance, and responsiveness during the accident sequence.
Appendix B 63 Safety Report

Fatigue-Related Recommendations 

Issued to the DOT:

Assess the potential safety risks associated with rotating pipeline controller shifts

and establish industry guidelines for the development and implementation of

pipeline controller work schedules that reduce the likelihood of accidents

attributable to controller fatigue. (P-98-30)

Recipient(s) Status

Research and Special Programs 

Administration

Open—Await Response

Safety Board Document: Railroad Accident Report

Title: Atchison, Topeka and Santa Fe Railway 

Company (ATSF) Freight Trains ATSF 818 

and ATSF 891 on the ATSF Railway 

Corona, California, November 7, 1990

Report Number: NTSB/RAR-91/03

Date Recommendation(s) Issued: August 23, 1991

Fatigue Cited as a Cause of or 

Contributing Factor to the Accident:

Yes

Abstract:

This report explains the collision between two Atchison, Topeka and Santa Fe

Railway freight trains in Corona, California, on November 7, 1990.

Fatigue-Related Conclusions:

The engineer of train 818 failed to stop his train on the Corona siding at the stop

signal because he was asleep or in a microsleep brought about by chronic and

acute fatigue.

The chronic and acute fatigue of the engineer of train 818 was a result of the

irregularity and unpredictability of his work schedule.

Because of fatigue the conductor of train 818 either was asleep or experienced a

microsleep as his train approached the stop signal on the west end of the Corona

siding.
Appendix B 64 Safety Report

The brakeman of train 818 failed to take action to stop the train probably because

she fell asleep as a result of fatigue.

The Atchison, Topeka and Santa Fe Railway Company did not have a policy or

procedure in place to address the issue of an employee notifying the carrier of his

or her lack of sufficient sleep.

Fatigue-Related Recommendations 

Issued to the DOT:

None

Safety Board Document: Railroad Accident Report

Title: Collision and Derailment of Norfolk 

Southern Train 188 With Norfolk Southern 

Train G-38 at Sugar Valley, Georgia, 

August 9, 1990

Report Number: NTSB/RAR-91/02

Date Recommendation(s) Issued: September 16, 1992

Fatigue Cited as a Cause of or 

Contributing Factor to the Accident:

Yes

Abstract:

This report explains the 1990 collision of two Norfolk Southern freight trains near

Sugar Valley, Georgia.

Fatigue-Related Conclusions:

The engineer of train 188 had changed his work and rest routine just before the

accident.

The engineer’s failure to bring the train to a stop at the signal probably was caused

by a microsleep or inattention due to distraction.

The conductor of train 188 was either distracted or fell asleep sometime after

verifying the signal status at CP Davis.

The engineer of train 188 could have canceled the alerter system while he was

asleep by a simple reflex action that he performed without conscious thought.

Fatigue-Related Recommendations 

Issued to the DOT:

In conjunction with the study of fatigue of train crewmembers, explore the

parameters of an optimum alerter system for locomotives. (R-91-26)
Appendix B 65 Safety Report

Recipient(s) Status

Federal Railroad Administration Closed—Unacceptable Action

Safety Board Document: Railroad Accident Report

Title: Collision Involving Two New York City 

Subway Trains on the Williamsburg Bridge 

in Brooklyn, New York, June 5, 1995

Report Number: NTSB/RAR-96/03

Date Recommendation(s) Issued: September 11, 1996

Fatigue Cited as a Cause of or 

Contributing Factor to the Accident:

Yes

Abstract:

This report explains the collision of two New York City Transit subway trains on

the Williamsburg Bridge in Brooklyn, New York, on June 5, 1995. One person

was killed and 69 people were treated at area hospitals for minor injuries sustained

in this accident. The total estimated damages exceeded $2.3 million.

Fatigue-Related Conclusions:

The J train operator failed to take action to stop his train on the Williamsburg

Bridge because he was asleep.

Fatigue-Related Recommendations 

Issued to the DOT:

In cooperation with the American Public Transit Association, develop a fatigue

educational awareness program and distribute it to transit agencies to use in their

fitness-for-duty training for supervisors and employees involved in safetysensitive positions. (R-96-20)

Recipient(s) Status

Federal Transit Administration Closed—Acceptable Action

Safety Board Document: Special Investigation Report (Railroad)

Title: Steam Locomotive Firebox Explosion on the 

Gettysburg Railroad near Gardners, 

Pennsylvania, June 16, 1995

Report Number: NTSB/SIR-96/05
Appendix B 66 Safety Report

Date Recommendation(s) Issued: November 26, 1996

Fatigue Cited as a Cause of or 

Contributing Factor to the Accident:

No

Abstract:

On June 16, 1995 the firebox crownsheet of Gettysburg Passenger Services, Inc.,

steam locomotive 12378 failed while the locomotive was pulling a six-car

excursion train about 15 mph near Gardners, Pennsylvania. The failure resulted in

an instantaneous release (explosion) of steam through the firebox door and into the

locomotive cab, seriously burning the engineer and the two firemen. This accident

illustrates the hazards that are always present in the operation of steam

locomotives.

Fatigue-Related Conclusions:

Gettysburg Passenger Services, Inc., management was not aware of the Hours of

Service Act.

Fatigue-Related Recommendations 

Issued to the DOT:

In cooperation with the Tourist Railway Association, Inc., promote awareness of

and compliance with the Hours of Service Act. (R-96-56)

Recipient(s) Status

Federal Railroad Administration Open—Acceptable Response
67 Safety Report

Appendix C

Summary of Sleep and Circadian Rhythms

The summary in this appendix is an excerpt from information prepared by Dr.

Mark Rosekind in April 1999 for the National Transportation Safety Board. The summary

was adapted from material included in the Safety Board’s report on its investigation of a

1993 aircraft accident. (Rosekind, Mark R. [NASA Ames Research Center]; Gregory,

Kevin B. [Sterling Software]; Miller, Donna L. [Sterling Software]; and others. 1994.

“Analysis of Crew Fatigue Factors in ATA Guantanamo Bay Aviation Accident.” In:

Uncontrolled Collision With Terrain, American International Airways Flight 808, Douglas DC-8-61, N814CK, U.S. Naval Air Station in Guantanamo Bay, Cuba, August 18,

1993. Aircraft Accident Report NTSB/AAR-94/04. Washington, DC: National Transportation Safety Board. pp. 133–144.)
Appendix C 68 Safety Report

Fatigue in Transportation: Physiological, 

Performance, and Safety Issues1

Mark R. Rosekind

Alertness Solutions

April 1999

Introduction

Maintaining safe transportation operations is a complex task. The undertaking

must address a range of issues from the functioning of large systems to the individual

human operator. For the foreseeable future, the human operator (pilot, driver, maintenance

person, etc.), remains central to safe, efficient, and reliable transportation activities. Therefore, the importance of addressing human-related error, which accounts for at least 70% of

transportation accidents, remains critical to maintaining and improving safety (Ref 1).

Fatigue, sleep loss, and circadian disruption created by transportation operations

can degrade performance, alertness and safety. An extensive scientific literature exists that

provides important physiological information about the human operator, which can be

used to guide operations and policy. For example, there are human physiological requirements for sleep, predictable effects of sleep loss on performance and alertness, and patterns for recovery from sleep loss. Additionally, the circadian clock is a powerful

modulator of human performance and alertness, and in transportation operations, it can be

disrupted by night work, time zone changes, and day/night duty shifts. Scientific examination of these physiological considerations has documented a direct relationship to errors,

accidents, and safety. This scientific information can provide important input to policy and

regulatory considerations.

Managing fatigue in the complex and diverse transportation environment requires

an integrated and multi-component approach. The complexity and diversity of operational

requirements preclude a simple solution, and managing fatigue will benefit from addressing education, hours of service, strategies, technology, design, and research. The transportation industry has established a strong safety record by identifying and proactively

addressing both substantiated and potential risks. Effectively managing fatigue in transportation operations offers the opportunity to further reduce risks and improve safety.

1

Adapted from the following references: (a) Rosekind MR, Gregory KB, Miller DL, Co EL, and Lebacqz

JV. “Analysis of crew fatigue factors in AIA Guantanamo Bay Aviation Accident.” Uncontrolled Collision

With Terrain, American International Airways Flight 808, Douglas DC-8-61, N814CK, U.S. Naval Air Station in Guantanamo Bay, Cuba, August 18, 1993. Aircraft Accident Report NTSB/AAR-94/04. Washington,

DC: National Transportation Safety Board, 1994. (b) Rosekind, MR, Neri, DF, and Dinges, DF. (1997).

“From laboratory to flightdeck: Promoting operational alertness.” Fatigue and Duty Time Limitations—An

International Review: Proceedings of the Royal Aeronautical Society, London, UK, 16 September 1997.
Appendix C 69 Safety Report

This overview provides an introduction to the scientific foundation that exists

regarding the physiology of and performance related to fatigue in transportation. It also

examines the human physiological requirement for sleep and the functioning of the

circadian clock.

The Biological Imperative: 

Human Sleep Need and the Circadian Clock

Human Sleep Requirements

Sleep is a vital physiological function. Historically, sleep has been viewed as a

state when the human organism is turned off. However, scientific findings have clearly

established that sleep is a complex, active physiological state that comprises different

stages. On average, most people physiologically require about 8 hrs of sleep per night.

When provided adequate time to sleep, humans can average about 8.25 to 8.5 hrs of physiological sleep (Refs 2,3). Laboratory studies use physiological measures (i.e., brain, eye,

and muscle activity) of sleep quantity and quality and daytime sleepiness to determine the

number of hours of sleep that provide an optimal level of waking alertness (Refs 4–6). It is

important to distinguish this physiologically determined sleep requirement from both

habitual and reported sleep amounts. Some studies have examined the reported amount of

habitual sleep over time and other studies have collected one-time surveys inquiring about

average sleep amounts. Overall, most adults report an average of about 7–7.5 hrs sleep per

night (Ref 7). However, data obtained in controlled laboratory settings challenge whether

this “reported” amount of sleep is sufficient for optimal levels of waking alertness. Studies

have demonstrated that extending sleep beyond the reported 7–7.5 hrs of “usual” sleep

significantly increases daytime alertness (Refs 3,8). The National Sleep Foundation commissioned a Gallop survey examining the report of daytime sleepiness in a random sample

of 1,001 individuals. The findings demonstrated that 75% reported daytime sleepiness,

with 32% of these reporting severe levels. Thirty-two percent reported that their sleepiness

interfered with activities and 82% of the respondents believe that daytime sleepiness has a

negative effect on their productivity (Ref 9). 

These amounts are averages and there are individuals at both extremes of short and

long sleep requirements. These sleep requirements change significantly with age (Ref 10).

Younger individuals require more total sleep and this amount decreases to that needed by

adults (although it is not the case that older people need less sleep than other adults). Sleep

structure also changes with age (e.g., less deep sleep, more awakenings in older adults). In

summary, humans physiologically require about 8 hrs of sleep, though they report usual

sleep amounts of about 7–7.5 hrs. A majority of the adult population report daytime sleepiness, and when sleep is extended, there is a significant increase in alertness.

Effects of Sleep Loss

Sleep loss is common and can be acute or cumulative. In an acute situation, sleep

loss can occur either totally or as a partial loss. Total sleep loss involves a completely

missed sleep opportunity and continuous wakefulness for about 24 hrs or longer. Partial

sleep loss occurs when sleep is obtained within a 24-hr period but in an amount that is

reduced from the physiologically required amount or habitual total. Sleep loss also can
Appendix C 70 Safety Report

accumulate over time into a “sleep debt.” For example, an individual who requires 8 hours

of sleep and obtains only 6 hours is essentially sleep deprived by 2 hours. If the individual

sleeps only 6 hours over 4 consecutive nights, then the 2-hour-per-night sleep loss would

accumulate into an 8 hour sleep debt. Sleep loss, whether total or partial acute or cumulative, results in significantly degraded performance, alertness, and mood (Refs 7, 11–21).

The reduced human performance capability that results from total sleep loss is well

documented (Refs 11–18). However, perhaps the most common occurrences in transportation operations are acute partial sleep loss and accumulation of a sleep debt. A review of

the relevant scientific literature indicates that as little as two hours of sleep loss on just one

occurrence can result in “impairment of performance and levels of alertness” (Ref 7).

Therefore, an average individual with a physiological requirement of 8 hours sleep who

obtains only 6 hrs of sleep may demonstrate significantly degraded waking performance

and alertness. Cumulative sleep debt also significantly reduces alertness and performance

(Refs 19–21). Studies have demonstrated that not only does the sleep loss accumulate but

that the negative effects on waking performance and alertness also are cumulative and

increase over time (Ref 20).

Performance decrements due to sleep loss can occur across diverse functions. For

example, studies have demonstrated slowed reaction time, reduced vigilance, cognitive

slowing, memory problems, time-on-task decrements, and optimum response decrements

(e.g., Refs 13,14,16,18). Performance variability also increases with sleep loss. Therefore,

overall performance can be significantly reduced with an increased variability or unevenness in responding (Ref 16). Consider that these findings occur in some of the simplest

performance challenges, such as reaction time to a single stimulus or minimal choice

memory task. These basic psychomotor and cognitive functions are the foundation for any

task requiring complex, higher-order performance. 

An important phenomenon, highly relevant to operational environments, is that

there is a discrepancy between the subjective report of sleepiness/alertness and physiological measures. In general, individuals will report higher levels of alertness than indicated

by physiological measures (Refs 22–24). Data from an international study of flight crews

had an example where the highest subjective rating of alertness occurred at a time when

physiologically the individual was falling asleep within 6 minutes (an indicator of severe

sleepiness) (Ref 22). Likewise, subjective and physiological self-assessment of performance can differ significantly. The operational relevance of this phenomenon is clear. For

example, an individual might report a low level of sleepiness or fatigue but could be carrying an accumulated sleep debt with a high level of associated physiological sleepiness.

This individual, in an environment stripped of factors that conceal the underlying physiological sleepiness, would be susceptible to the occurrence of spontaneous, uncontrolled

sleep episodes and to the performance decrements associated with sleep loss.

Recovery from Sleep Loss

When determining requirements for providing a recovery opportunity from sleep

loss, two factors should be considered. First, when does the internal sleep architecture

return to usual levels? Second, when do waking performance and alertness levels return to
Appendix C 71 Safety Report

their baseline? After sleep loss, recovery is not accomplished through an hour-for-hour

restitution. Even after extremely prolonged wakefulness, initial recovery sleep may last

only 12–15 hrs (Ref 25). Rather, recovery is accomplished through an increase in deep

sleep (Non-Rapid-Eye-Movement or NREM slow wave sleep) observed starting on the

first night of regular sleep (Refs 26–28). Generally, two nights of recovery sleep (slightly

longer than an average night’s sleep) are needed to resume a normal baseline sleep pattern

(Refs 26,29), though this can be dependent on the duration of the continuous wakefulness.

Also, typically, two nights of recovery sleep are needed to return to a normal baseline of

waking performance and alertness (Refs 20,30), though this too can be dependent on the

length of prior wakefulness (e.g., Ref 3).

The Circadian Clock

Besides sleep, the other major physiologic determinant of waking performance and

alertness is the internal circadian clock (Refs 31–33). Circadian (circa = around, dies =

day) rhythms fluctuate on a 24-hr cycle with peaks and troughs occurring in a regular pattern. These patterns are controlled by a circadian pacemaker located in the suprachiasmatic nucleus (SCN) in the brain. The SCN is the circadian timekeeper for a wide range of

human functions. One of the most prominent is the 24-hr sleep/wake cycle programmed

for a daytime period of consolidated wakefulness and a nighttime period of consolidated

sleep. There are circadian patterns for cognitive and psychomotor performance, physiological activity (e.g., digestion, immune function, thermoregulation, DNA synthesis),

alertness, and mood (Refs 34–38). Even birth and death have circadian patterns that peak

during the night (see Ref 31).

Body temperature is often used as a marker of the internal circadian clock (sometimes referred to as the “hands of the clock”). The trough or low point of the clock is

around 3 am to 5 am, with many functions demonstrating reduced levels from 12 am to 6

am. The lowest level of function (e.g., alertness, performance, subjective mood, temperature) occur within the 3 am to 5 am trough. Sleepiness has bimodal distribution (i.e., two

peaks and two troughs each day), being most severe at 3 am to 5 am with a less marked but

significant expression between roughly 3 pm to 5 pm. This afternoon increase in sleepiness occurs whether or not a meal has been consumed, though the meal may exacerbate

the underlying sleepiness (Ref 39).

Zeitgebers (“time givers”) are cues that synchronize circadian rhythms to their

24-hr pattern. To date, light has been demonstrated to be among the most powerful zeitgebers to synchronize the circadian pacemaker. Bright light can dramatically shift the phase

of the human circadian clock when applied at responsive times in the 24-hr cycle (Refs

40–42). Without cues, the intrinsic rhythm of the clock is longer than 24 hrs. Generally,

data have demonstrated a free-running pattern approximating 24.9 hrs, though recent findings suggest this may be closer to 24.2 hrs (Refs 31–33,43). An intrinsic period longer

than 24 hrs provides an inherent tendency to support circadian delays (e.g., staying awake

longer) and to oppose advances (e.g., trying to go to sleep earlier).

Moving to a new light/dark schedule, such as a shift to nightwork or a time zone

change, can create internal and external desynchronization. These involve an internal
Appendix C 72 Safety Report

desynchrony among circadian rhythms and a discrepancy between internal circadian timing and external/environmental cues, respectively. The internal clock can take from several days to weeks for adjustment or, in some circumstances, not fully resynchronize at all.

Scientific studies have demonstrated these findings in the laboratory and in field studies

conducted during actual transportation operations (e.g., Refs 31–33, 44–54).

[Additional discussion is not included in this appendix.]
Appendix C 73 Safety Report

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82 Safety Report

Appendix D

Summaries of Fatigue Symposium 

Working Groups, 1995

The working group summaries in this appendix are reprinted from the proceedings

of the 1995 multimodal symposium on fatigue in transportation. (National Transportation

Safety Board and NASA Ames Research Center. 1996. Fatigue Symposium Proceedings,

November 1–2, 1995. Washington, DC: National Transportation Safety Board. pp. 91–105.
Appendix D 83 Safety Report

THE AVIATION WORKING GROUP 

Moderator Dr. Barry Strauch, National Transportation Safety Board

Analyst Dr. Ben Berman, National Transportation Safety Board

Technical Representatives

Mr. Bob MacIntosh, National Transportation Safety Board

Mr. David Schroeder, Federal Aviation Administration

Hours of Service and Scheduling

The group expressed the view that, because of the criticality of scheduling

on human fatigue and alertness, that

duty time limits should be upgraded for

flightcrew members and established for flight

attendants, as well as address issues of circadian rhythms and human performance. All proposed rule changes should be based on the results of scientifically sound sleep research. In

addition, it was suggested that rules be promulgated to establish controlled rest during

long-haul flight operations.

Nevertheless, concerns were raised that revised

flight and duty time rules not be so rigid as to

create their own safety hazards. For example,

an issue in the Tenerife ground collision between KLM and Pan American Boeing 747s

was the inflexible flight and duty time restriction the KLM flightcrew faced at the end of

the scheduled flight to Amsterdam. One suggestion was to pattern rules after the advanced

qualification program (AQP), which provide

airlines considerable flexibility to tailor pilot

training to their own needs and circumstances,

while maintaining a high degree of FAA oversight. Finally, some attendees expressed concern that proposed rules not place United States

aviation interests in the global economy in

jeopardy against those of nations that have less

restrictive rules and regulations in place.

Personal and Technological

Countermeasures

Many innovative proposals were offered during the session. For example, one attendee suggested that airlines and flightcrews work together to obtain “circadian friendly” hotel

rooms in which quiet corridors would be maintained, blackout curtains hung in the rooms,

and other measures implemented to enhance

rest during those periods when most people are

active. An additional proposal called for using FOQA (flight operations quality assurance)

data to match pilot performance against flight

schedule and other data that have been associated with fatigue. Also, expert systems could

be used that, with existing data on sleep, help

pilots bid schedules, and airlines employ pilot

bids, that could minimize the emergence of

fatigue during subsequent flight operations.

Similarly, a proposal was offered to employ

automatic devices in cockpits that would alert

crewmembers or require crewmember responses during a flight, to assure that pilots

would remain alert during a long flight.
Appendix D 84 Safety Report

Education and Training

Attendees suggested that education for all personnel was critical to the effectiveness of countermeasures. Further, the group believed that

successful countermeasures against fatigue require the active participation of all corporate

levels, execute/managerial as well as those directly involved in flight operations. Attendees expressed the view that, following the conclusion of the conferences, the NTSB and

NASA inform airline executives directly of the

results of the Symposium to help obtain their

cooperation in reducing the effects of fatigue

at their airline. In addition, basic guidelines

should be provided to airlines to assist their

management in implementing fatigue countermeasures program at their airline.

Some attendees, representing general aviation

interests, also raised the issue of educating general aviation pilots and corporate aviation departments in the need for effective fatigue countermeasures.

SUMMARY VIEWGRAPH

Scheduling

 Upgrade Flight/Duty/Rest (F/D/R)

rules

Regulate, not negotiate, F/D/R rules

Apply science to F/D/R rules

Finalize rule on F/D/R

Avoid rigidity in F/D/R rules

Level the F/D/R playing field world

wide

Countermeasures

Sleeping quarters at duty site and

“circadian-friendly” hotel rooms

Correlate flight data recorder readouts

with crew fatigue factors

Expert systems to help managers

design crew schedules and help pilots

bid schedules

Educate top managers

Cockpit crew alertness monitoring

devices

Education

Educate personal countermeasures,

and educate the family

Big and small airlines need basic

guidelines

Top-level buy-in is essential

Integrate personal and company

countermeasures

Don’t forget general aviation

92
Appendix D 85 Safety Report

THE AVIATION WORKING GROUP 

Moderator Mr. Jim Danaher, National Transportation Safety Board

Analyst Dr. Malcolm Brenner, National Transportation Safety Board

Technical Representatives

Mr. Bob Benzon, National Transportation Safety Board

Mr. Ronald Simmons, Federal Aviation Administration

Hours of Service and Scheduling

The Aviation Group 2 felt that government regulation of flight and duty timestandards was the starting point and

foundation for all activities at controlling fatigue in operations. These regulations set the

minimum standards for operations beyond

which personal and company countermeasures

can be applied. The group felt that it was important that the regulations provided core

guidelines but also captured important differences in the industry, especially, for example,

by providing special provisions applicable to

overnight operations. The group felt that “rest”

should be defined more operationally than the

present definition as the number of hours offduty. That is, “off duty” time rarely equals

“rest” time. It is necessary to allow time for

commuting, personal hygiene, and sustenance.

Fatigue issues should be addressed more actively in accident and incident reports by the

NTSB and the FAA. Fatigue should be assumed to be present until the investigation can

rule it out.

Personal and Technological

The group felt that technology was a support,

but not a substitute for personal management.

Industry and individuals both have responsibilities for minimizing fatigue in operations.

Industry can help by developing procedures so

pilots can report themselves “too fatigued” to

work without punishment, and by providing

rest accommodations for quality sleep without

noise interruptions. Employees can help by

arriving at work rested, arranging their commutes from home and activities during the offduty time so they are properly rested. When

technology is developed, it should not be used

to erode other existing or future fatigue countermeasures based on scheduling or personal

management.

Education and Training

The group felt that there should be a clearing

house to collect and make available successful

training materials on fatigue developed by different transportation modes, different disciplines, and different nations. Education is the

Countermeasures

93
Appendix D 86 Safety Report

most basic countermeasure for fatigue. It

should be provided to managers, schedulers,

and the general public to change attitudes and

recognize the importance of fatigue. Pocket

checklists, and checklists integrated into normal operations should address fatigue issues

in heightening awareness of the fatigue-producing aspects of duty periods and in judging

personal fitness for flight. ASRS reporting

forms should enhance their reporting of fatigue,

and NTSB/FAA investigations should enhance

their monitoring of fatigue issues. Fatigue

should be examined on the part of pilots, air

traffic controllers, mechanics, and all other personnel in the operational system.

SUMMARY VIEWGRAPH

Scheduling

Overnight flying - special regulations

Address fatigue in mishaps

 Government regulation essential

Define “rest” more operationally

Countermeasures

Technology supportive of personal

management

Industry support of individual

management and decisionmaking -

industry support systems and “too

fatigued”

De-link technology and punitive

actions

Balance between industry/individual

responsibility - commutes, rest

accommodations, and rest periods

Education

Intermodal, international, interdisciplinary training clearinghouse

Mangers, schedulers, and the public

need education

Fatigue-related work schedule guidelines

Enhance ASRS, NTSB, and FAA

monitoring of fatigue
Appendix D 87 Safety Report

THE RAIL WORKING GROUP

Moderator Mr. Bruce A. Magladry, National Transportation Safety Board

Analyst Mr. David Mayer, National Transportation Safety Board

Technical Representatives

Mr. Robert Lauby, National Transportation Safety Board

Mr. Garold Thomas, Federal Railroad Administration

Hours of Service and Scheduling

The lack of schedule predictability and

regularity were identified by the group

as the number one fatigue producing

problems for both train crews and management.

For, without timely, accurate schedule information, railroad employees cannot effectively

manage their off-duty time to minimize fatigue.

The scheduling difficulties that give rise to

unpredictability and irregularity are derived

from several interrelated, but often conflicting

demands that the railroads themselves cannot

fully control. Factors that impact scheduling

include: equipment breakdowns, emergencies,

and power failures, imbalances in the direction of traffic flow, and the demands of customers who have increasing moved to just-intime pick-up and delivery. Pool dispatch, extra board scheduling, and deadheading of crews

also contribute to the problem.

Exacerbating scheduling difficulties is the

Hours of Service (HOS) Act developed in

1907. It was not based on science and does

not necessarily permit sufficient’ continuous

sleep periods. nor does it incorporate modem

knowledge of circadian rhythms. Historically,

it has also promoted an adversarial relationship between labor and management. The

group felt it no longer works well. In a spirit

of cooperation, government, management and

labor should seek innovative and flexible

schedule solutions and HOS reforms through

pilot projects. However, as a basic tenet of

railroad operations, the HOS should not be

changed without a firm scientific basis and

careful review by all the affected parties.

Personal and Technological

Countermeasures

Currently employed fatigue countermeasures

are not adequate. Alerters, for example, can

be complied with while an employee is severely

fatigued. Some existing crew quarters, intended to facilitate rest away from home, are

not adequate for daytime sleeping because of

noise or lighting or even maid service. Another countermeasure, albeit an unauthorized

one, napping, can actually bring on disciplinary action. Nevertheless, there are times when

it could be safely and effectively used to reduce fatigue and improve alertness. The group

felt appropriate napping should be legitimized.

Group members felt some conditions and procedures seemed to induce fatigue, like poor

locomotive cab environments and boring tasks.

It was suggested crew input could improve both

cab and task design. It was also suggested that

various communications equipment and methods should be explored to give employees the
Appendix D 88 Safety Report

most up to date and valid line-up information

so that they plan their sleep accordingly in order to report to work well rested. However,

when significant line-up changes occur and an

employee is called to duty early without having slept, there should be a mechanism to allow him to mark off without penalty. To do

otherwise, may force a fatigued employee to

work and create a danger to himself, his railroad and the public.

Fitness for duty testing was also addressed. It

was felt that current tests are not yet valid and

reliable, and that they miss the point anyway.

Efforts should be directed toward developing

schedules and working conditions that prevent

fatigued employees rather than keeping the

current conditions in place and trying to detect

fatigued employees. Finally, responsibility for

developing and promoting effective countermeasures was believed to belong to all affected

parties.

Education and Training

Addressing fatigue through education and

training was deemed essential and was considered a win-win proposition for labor and management, improving safety and productivity for

each. The group felt that employees should

receive training about sleep, sleep disorders,

sleep strategies, and fatigue countermeasures.

Both labor and management employees should

receive the training in order to provide a common understanding of the issue. The training

should be based on science with practical solutions, but should not ignore the important

components of personal responsibility and behavioral change. Follow-up and feedback were

also considered essential to determine efficacy

and to reinvigorate individual efforts.

Several railroads already have fatigue education programs in place. The group acknowledged the value of such programs if they do

not stand alone. They should be part of a multifaceted approach designed to manage fatigue

and promote alertness. Training must accompany other efforts from labor and management

to alter operations to facilitate individual employee actions to alleviate fatigue. Thought

should also be given for protection of the jobs

of employees who come forward after recognizing they have a sleep disorder.

n

n

n

n

n

SUMMARY VIEWGRAPH

Scheduling

Schedule predictability and regularity

Hours of service flexibility; Minimize

deadheading and overnights

Hours of service provisions based on

science and modem demands

Railroads should conduct hours of

service pilot projects

Enhanced trust to promote innovative

thinking

Countermeasures

What is needed:

n Crew quarters suited for sleep

n Crewmembers should be able to mark

off when fatigued without penalty

n Tasks that minimize boredom

96
Appendix D 89 Safety Report

n Legitimize sensible crew napping

n Fitness for duty testing -- not yet valid

or reliable and misses the point

Improved cab design using input from

locomotive crews

Education

Addressing fatigue is a win-win

situation

n Education and training is essential -

not a stand alone component

n All labor and management should

receive training

n Training must be based on science

with practical solutions

n Follow-up and feedback are essential

n Job protection for those who seek

treatment
Appendix D 90 Safety Report

THE HIGHWAY WORKING GROUP

Moderator Dr. Vern Ellingstad, National Transportation Safety Board

Analyst Ms. Elaine Weinstein, National Transportation Safety Board

Technical Representatives

Mr. Joe Osterman, National Transportation Safety Board

Mr. Ron Knipling, National Highway Traffic Safety Administration

Ms. Deborah Freund, Federal Highway Administration

Hours of Service and Scheduling

There is more than enough research

today to begin to effect changes in the

scheduling practices of the trucking industry. The hours-of-service regulations are

50 years old and need to be changed. They

do not fit with the circadian clock. The trucking industry is behind other modes in making

changes to the hours-of-service regulations and

scheduling practices based upon current research knowledge. The industry can initiate

changes separately from federal regulation.

The changes cannot be done in a vaccuum and

need to consider employee, shipper and customer needs. There is also a need to address

the problem across the industry and consider

the differences between large and small companies. Some of the implications for public

policy include the shortage of parking and

driver safety at rest stops.

The solutions include regulatory and performanced-based measures.

n Revise the hours-of-service regulations

n Increase the number of driver rest

areas

n Consider large versus small companies

n Develop performance-based measures

Personal and Technological

Countermeasures

Personal and technological countermeasures

should be explored and implemented on parallel tracks. Technology includes fitness-forduty and alerting methods. Fitness-for-duty

technologies are about three years away; alerting method technologies are five-ten years

away. Personal countermeasures include napping, education, and medical fitness. They can

be implemented immediately.

New technologies must be cost effective, show

a safety benefit, and maintain the current level

of productiveness. There was some concern

expressed that fitness-for-duty detection would

give drivers a false sense of security and they

would thus be more likely to drive drowsy.

Consideration to inter-individual differences

needs to be considered along with how the fitness-for-duty testing device would be used. Is

it for the driver, the employer, or the regulator? There was agreement that there should be

penalties for failing a fitness-for-duty test.
Appendix D 91 Safety Report

Education and Training

Society needs to undergo major attitudinal

changes towards driving when fatigued, similar to that experienced with drunk driving.

Some promising efforts have been made in the

area of education, such as the Wake UP brochure developed by the AAA Foundation and

the American Trucking Associations. There

is a need to evaluate the effectiveness of these

educational materials to determine if they actually change behavior.

Training for management and drivers is not

widespread. ATA Safety Management Council is developing a best practices manual to help

educate drivers on how to prepare for work.

n

n

n

n

Enforcement training is needed

inspectors and police officers.

SUMMARY VIEWGRAPH

Scheduling

for

Revise hours of service regulations

Increase driver rest areas

Consider small vs. large companies

Also performance based measures

Countermeasures

Technology -- there is none -- it is

five-ten years away

n

n

n

n

Major cultural change toward fatigue

needed -- like drunk driving

Promising efforts toward general

education have been made

Specific training for drivers and management have been less widespread

Enforcement training is needed

Personal - napping, medical screening, adequate sleep
Appendix D 92 Safety Report

THE MARINE WORKING GROUP

Moderator Dr. Gerald D. Weeks, National Transportation Safety Board

Analyst Dr. Meg Sweeney, National Transportation Safety Board

Technical Representatives

Ms. Marjorie Murtagh, National Transportation Safety Board

Mr. Alexander C. Landsburg, Maritime Administration

Dr. Marc B. Mandler, United States Coast Guard

The working group consisted of more

than 80 representatives from various

sectors of the maritime industry. Their

affiliations reflected the breadth and diversity

of the industry. Shoreside managers and shipboard personnel represented many shipping

companies in the inland towing, coastwise, and

oceangoing trades. Other attendees came from

six maritime schools, seven pilots’ associations, and a variety of government agencies.

The group’s task was to discuss three topics

on managing fatigue in the marine industry:

Hours of Service & Scheduling, Personal &

Technological Countermeasures, and Education & Training. Discussions of each topic

addressed three questions concerning implementation: What is currently used, what is

needed, and who is responsible? Highlights

of the discussions follow.

Hours of Service and Scheduling

Most mariners stand two- or three-section

watches when at sea and so they have multiple work periods in a day. The group felt that

although the watch system satisfies current

hours-of-service regulations, problems of sleep

fragmentation and sleep deprivation can arise.

The group noted that the potential for long-term

fatigue must also be considered--crew members may sign contracts of 10-12 months duration when sailing on foreign flag vessels. Some

members of the group observed that an important issue underlying fatigue is workload. In

turn, workload is correlated with manning levels. The group felt that there is a need to conduct shipboard workload assessments before

regulators consider changes to hours-of-service

or to manning regulations. The group concluded that industry should take the lead, in

coordination with the regulators, to initiate such

workload assessments.

Personal and Technological

Countermeasures

Several of the attendees reported that their companies had implemented a variety of fatigue

countermeasures. The countermeasures do not

have to be “hi tech” to be effective. Even little

things like having decaffeinated coffee available near the end of the watch can facilitate

sleep during the off-duty period. As another

example, some companies had installed acoustic insulation in berthing spaces or relocated

those spaces to provide a more restful sleeping

environment. Other companies had delegated

certain tasks to ratings so as to relieve the

workload of the licensed officers. The group
Appendix D 93 Safety Report

determined that a continued effort was needed

to promote both corporate and personal alertness management strategies. They felt that additional interdisciplinary meetings, similar to

this Symposium, would be useful for exchanging ideas and experiences with successful fatigue countermeasures. The participants concluded that it is the industry’s responsibility to

take the initiative in this area.

Education and Training

Currently, there is only a modest amount of

education being conducted on fatigue and fatigue countermeasures. The attendees agreed

that more education was needed and several of

the maritime educators in attendance reported

that their institutions were developing courses

or course modules on the physiological basis,

consequences, and ways of managing fatigue.

The group felt that the first and foremost need

was to shift the mariners’ cultural attitudes concerning fatigue--to dispel the “iron-man” myth

that fatigue can be overcome by increased motivation and experience. The group concluded

that the greatest likelihood of success for developing and disseminating education was to

forge a partnership triangle among management, labor, and government.

SUMMARY VIEWGRAPH

Scheduling

n Duration of the tour

n Review manning

n Industry led initiatives

Countermeasures

n Some countermeasures are being used

in the industry

Continued effort

n Industry initiatives

Education

n Training and education is available

n Shift culture

n Partnership triangle
Appendix D 94 Safety Report

THE PIPELINE WORKING GROUP

Moderator Mr. Barry Sweedler, National Transportation Safety Board

Analyst Mr. Bill Gossard, National Transportation Safety Board

Technical Representatives

Mr. Bob Chipkevich, National Transportation Safety Board

Ms. Linda Daugherty, Research & Special Projects Administration

Three distinct topical areas were discussed at the Fatigue Symposium addressing fatigue in the pipeline industry: hours of service and scheduling; personal

and technological countermeasures; and education. A summary of the pipeline group discussion follows.

Hours of Service and Scheduling

In the area of hours of service and scheduling,

it was determined that there currently are neither Federal or State standards nor are there

any industry guidelines or recommended practices. Therefore, there are great differences in

scheduling from company to company. Some

general observations were that many employees in the industry rely on unscheduled overtime; in many companies employees have significant input into the schedules that they work;

and that most schedules are rotating with 12

hour shifts. Most employees have little idea

of the effects of fatigue and there is very little

technical information available specific to the

pipeline industry.

It was the group’s conclusion that there is a

definite need for information and guidance on

fatigue/alertness issues. It also was concluded

that there is a need for all levels (senior management, supervisors and employees) to learn

about fatigue concerns. It was noted that there

are industry associations such as the American Gas Association, American Petroleum Institute, the Institute of Gas Technology, and

others that could address fatigue concerns and

proper interventions in the area of hours of service and scheduling for the industries.

Personal and Technological

Countermeasures

Presently, fatigue has not been considered as a

problem by much of this industry, therefore,

there has been little focus on personal or technological countermeasures. However, the industry does use a number of interventions that

have been successful in mitigating some fatigue

concerns such as; 2-hour call-ins to remote locations, deadman alarms, video cameras,

bright lights and temperature control in control rooms. These interventions were not developed specific to fatigue concerns. The participants agreed that a “napping strategy” could

possibly be a useful countermeasure, however,

considerable education and understanding by

senior management and supervisors of this fatigue countermeasure would be necessary.
Appendix D 95 Safety Report

There are no fitness for duty countermeasures

in this industry with the exception of the

liquified natural gas industry where Federal

standards require a self-reporting system that

the person leaving a shift must state that the

person coming on duty is fit to work. The participants concluded that personal countermeasures could be addressed by company employee assistance programs.

Eduation and Training

Education on fatigue issues is scant. There is

some abstract concern about fatigue by senior

management and supervisors, however, that

concern is not necessarily directed to operational concerns. In other words, most concern

over fatigue involves emergency response conditions not day-to-day operations and shift

work. The participants agreed that educational

programs for senior management, supervisors

and employees on fatigue/alertness issues could

be conducted for employees first through company employee assistance programs and then

to families, if employees saw the merit. It also

was agreed that if fatigue countermeasures

were marketed as a performance enhancement

tool, perhaps senior management would support fatigue safety improvements such as

scheduling strategies. The participants indicated there is a need for data on the relationship of fatigue and productivity in order to sell

this initiative as an opportunity to top management. There was interest in tailoring the

NASA/ Ames program on fatigue to make it

more specific to the pipeline. industry.

SUMMARY VIEWGRAPH

Scheduling

Employee reliance on unscheduled

overtime

Employees have significant input into

schedules

All schedules are rotating

Currently there are no guidelines

Need information and guidance on

fatigue

Need for more awareness by all

Countermeasures

Use techniques for monitoring

Bright lights and temperature controlthese techniques are not specific to

fatigue

Napping strategy may work with

education

No fitness for duty countermeasures

EAP address seminar on fatigue

Education

Abstract concern about fatigue

Some knowledge not very detailed
Appendix D 96 Safety Report

n Need for programs on expectations

and fatigue

Performance enhancement tool -

scheduling strategy

n Data relationship fatigue-productivity

n Work smart - Play smart
97 Safety Report

Appendix E

Sampling of Educational Materials 

Regarding Operator Fatigue
Appendix E 98 Safety Report

Table E–1. Sampling of fatigue-related educational material by 

agency or organization.

Organization Type of material Title or topic

U.S. Department of Transportation

Aviation:

Federal Aviation 

Administration

Brochure Fatigue Busters

Highway:

Federal Highway 

Administration

Brochure (developed for 

truckdrivers)

Awake at the Wheela

Radio public service 

announcements

Awake at the Wheel

Placemats (in future) Awake at the Wheel

Videotape Training

Instructional program Train-the-trainer

Dissemination of brochures 

(in future)

Driver Wellness Program

National Highway 

Traffic Safety 

Administration

Report Drowsy Driving and Automobile Crashes

Report Educating Youth About Sleep and Drowsy Driving

Brochure Safe Driving Tips

Private Sector Organizations

AAA Foundation for 

Traffic Safety

Audio cassette Wake Up!

Brochure Wake Up!

National Center for 

Sleep Disorders 

Research

Report Drowsy Driving and Automobile Crashes

Report Educating Youth About Sleep and Drowsy Driving

National Heart, Lung, 

and Blood Institute

Brochure (emphasis on 

teenage drivers)

Awake at the Wheel

National Sleep 

Foundation

Fact sheets Drowsy Driving

Videotape Heads Up at the Wheel: Home Safe

Videotape Driver Fatigue: Deadly Slumber

Videotape Day/Night Strategies for Shift Workers

Brochure Day/Night Strategies for Shift Workers

Newsletter President’s Circle Update

Consensus Use of Continuous Shoulder Rumble Strips

Report Report of the National Sleep Foundation

Audio cassette Wake Up!

Brochure Wake Up!

Bumper Stickers I’m Alert. Are You?

a This brochure uses the same information as Wake Up!, which was developed jointly by the AAA Foundation for 

Traffic Safety and the National Sleep Foundation.
99 Safety Report

Appendix F

Flight Time and Rest Requirements 

Proposed by the FAA

The tables in this appendix were contained in the FAA’s notice of proposed rulemaking “Flight Crewmember Duty Period Limitations, Flight Time Limitations and Rest

Requirements,” Docket No. 28081; Notice No. 95-18, Federal Register Vol. 60, No. 244,

December 20, 1995.
Table F–1. Proposed pilot duty period, flight time, and rest requirements. Number of pilots Duty period hours Flight time hours Minimum rest hours Reduced rest hoursa Rest hours following reduced rest (compensatory) 1 (Part 135) No more than 14. No more than 8. 10 9, May only be reduced if duty period has not exceeded 14. 11 

2 No more than 14. No more than 10. 10 9, May only be reduced if duty period has not exceeded 14. 11 3 No more than 16. No more than 12. 14 12, May only be reduced if duty period has not exceeded 16. 16 3 Each pilot must have sleep opportunity, and approved sleeping quarters must be available. More than 16, but no more than 18. No more than 16. 18 16, May only be reduced if duty period has not exceeded 18. 20 4 Each pilot must have sleep opportunity, and approved sleeping quarters must be available.c More than 18 but no more than 24. No more than 18. 22 20, May only be reduced if duty period has not exceeded 24. 24 

a Rest periods may be reduced only when the actual duty period does not exceed the maximum scheduled duty period for that crew composition and if th

compensatory rest period. This compensatory rest period must be scheduled to begin no later than 24 hours after the beginning of the reduced rest perio

b The flights to which the pilot is assigned must at block out time be expected to reach their destination within the extended duty period.cApplies only to duty periods with one or more flights that land or take off outside the 48 contiguous States and the District of Columbia.
Table F–2. Proposed flight engineer duty period, flight time, and rest requirements. Number of flight engineers Duty period hours Flight time hours Minimum rest hours Reduced rest hoursa Rest hours following reduced rest (compensatory) 1 No more than 14. No more than 10. 10 9, May only be reduced if duty period has not exceeded 14. 11 

2 No more than 16. No more than 12. 14 12, May only be reduced if duty period has not exceeded 16. 16 

3 Each flight engineer must have sleep opportunity, and approved sleeping quarters must be available. More than 16, but no more than 20. No more than 16. 18 16, May only be reduced if duty period has not exceeded 18. 20 

4 Each flight engineer must have sleep opportunity, and approved sleeping quarters must be available. More than 18 but no more than 24.c No more than 18. 22 20, May only be reduced if duty period has not exceeded 24. 24 

a Rest periods may be reduced only when the actual duty period does not exceed the maximum scheduled duty period for that crew composition and if t

provided a compensatory rest period. This compensatory rest period must be scheduled to begin no later than 24 hours after the beginning of the reduc

b The flights to which the flight engineer is assigned must at block out time be expected to reach their destination within the extended duty period.c 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.
102 Safety Report

Appendix G

Summary of Expert Panel on FHWA 

Hours-of-Service Proposals for 

Commercial Drivers, 1998

The information in the table was summarized from the following report:

Transportation Research Institute, University of Michigan. 1998. Potential

Hours-of-Service Regulations for Commercial Drivers. Contract

DTFH61-96-C-00038. Washington, DC: Office of Motor Carriers, Federal

Highway Administration, U.S. Department of Transportation.
Table G–1. Summary of the expert panel who reviewed the candidate options for hours-of-service regul

Evaluation criteriaa Federal Highway Administration candidate option 123456

Option A, Current Policy: Current hours-of-service regulations. Drivers may work a 15-hour shift, with a maximum of 10 hours of driving. Must have an 8-hour off-duty period after the first 10 hours of duty. FFFFFF

Option B: Based on a 24-hour cycle. Requires minimum of 9 consecutive hours off duty for sleep (12 hours for home-base drivers) with the recom- mendation that this 9-hour period begin at the same time each day. Minimum of 1 hour off allowed for any combination of rest, personal and family activity, etc. For regional drivers sleeping at home and split- shift drivers, the 1-hour minimum is extended to 3 hours. A maximum of 14 hours on-duty time is allowed, with a maximum of 12 hours for driving. The maximum on-duty time is 12 hours for regional drivers sleeping at home, split-shift, and home-base drivers. For labor primarily other than driving, the maximum on-duty time is extended to 15 hours, only 6 for driving. PFFFFFOption C: Similar to option B. It increases the minimum additional hours off duty allowed for long distance drivers and regional drivers away from home, for personal and family activities to 2 hours, and maximum time on one shift is reduced from 14 hours to 13 hours. Drivers away from home may accumulate 78 hours in 7 days but not more than 130 hours in 14 days. Drivers not away from home may accumulate no more than 65 hours in 7 days. PFPFFF
Table G–1. Summary of the expert panel who reviewed the candidate options for hours-of-service regul

Evaluation criteriaa Federal Highway Administration candidate option 123456

Option D: Based on 24-hour cycle. Minimum of 9 consecutive hours off for sleep (12 hours off for home-base drivers and 8 hours for labor primarily other than driving), plus a minimum of 3 hours for long distance, regional, and split shift for rest or personal activities. For labor primarily other than driving, 1 hour is required for these activities. On-duty time is maximum of 12 hours, except for labor primarily other than driving where it is 15 hours. Maximum driving time is 12 hours except for labor primarily other than driving where it is 6 hours. A maximum of 72 hours can be accumulated in a 6-day period, and all hours can be for driving. For home-based drivers, the maximum is 60 hours within a 7-day period. P FPb F Pb F 

Option E: Retains 10-hour driving limit in current system but based on a 24-hour cycle. Allows for up to 2 additional hours for on-duty time. P F P F P F

Option F: All drivers have a maximum of 12 hours on duty, all available for driving, with a 24-hour day. A minimum of 12 hours off, including 9 hours for sleeping. Drivers may not be on duty for more than a total of 18 hours during the interval of midnight and 6:00 a.m. in a 7-day period. Drivers may not be on duty for more than 120 hours in a 14-day period. For drivers who return home each day, on-duty time may not exceed 60 hours in a 7-day period. This policy attempts to meet all evaluation 

P = pass (meets criterion); F = fail (does not meet criterion).a The evaluation criteria are defined as follows: (1) 24-hour cycle; (2) nighttime differential; (3) continuous time off duty daily; (4) split-shift drivers; (5) on-

time; (6) sleeper berth use; (7) limits on cumulative on-duty time; (8) adequate recovery time; (9) foreknowledge of work schedule.

b Except for labor primarily other than driving.c For daytime driving.d For nighttime drivinge Depends on amount of nighttime driving.
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