The Edge of Safety
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|Tessa Muggeridge and Charlie Litton||October 18th 2010|
Center for Public Intergrity and News21
Accidents happen in a matter of seconds.
An airplane pilot takes a moment too long to react in an emergency. A trucker who has been on the road all day wanders across the median. A train engineer is lulled to sleep by the isolation and monotony of the job and misses a signal.
It’s impossible to say how many accidents are caused by operators who are just too tired to do their jobs, in part because fatigue can’t be measured like the level of alcohol in a person’s system. But fatigue is frequently cited by investigators as a factor in accidents in the air, on the water and on railways and highways.
Over the past four decades, there have been more than 320 airplane accidents and incidents related to fatigue, and nearly 750 people have died, according to an analysis. The National Transportation Safety Board, created in 1967 to help safeguard U.S. travelers, has been trying since its inception to persuade federal agencies, industries and states to take steps to reduce the likelihood of these kinds of accidents. The board has issued 138 fatigue-related safety recommendations. Only 68 have been implemented, according to the analysis. Some of the proposals are still pending decades after they were issued. In other cases, the board has simply given up on its recommendations ever being adopted, declaring those cases “closed unacceptable.”
Many of the recommendations that have been implemented tend to be modest, such as handing out brochures about fatigue or requiring pilots to sit through a 30-minute training video. Meanwhile, major areas of safety regulation have gone unchanged for decades. A regulation that pilots can fly no more than 1,000 hours in a single year hasn’t changed since 1935.
That was the year that a Washington-bound TWA flight carrying 11 passengers plummeted from the sky and crashed into a muddy field outside of Atlanta, Mo. The pilot and four passengers, including U.S. Sen. Bronson Cutting of New Mexico, died. In a memo about the crash investigation, Department of Air Commerce Director Eugene L. Vidal called for a government study of fatigue. The letter is the first known mention of fatigue as a concern in aviation safety.
Fifty-five years and dozens of government studies and reports later, the NTSB listed fatigue on its inaugural “Most Wanted” list—recommendations that the safety board believes are the most critical. Today, fatigue remains on the list, one of just four of the original items that have never been addressed to the board’s satisfaction. “We need to quit talking about fatigue and we need to start trying to do something about it,” said NTSB board member Robert Sumwalt.
Department of Transportation Deputy Secretary John Porcari said the Obama administration considers fatigue “an urgent safety priority.” Its efforts include establishing new rules and expanding education efforts for truckers as well as proposing new rules for pilots. “We are going to continue doing all that we can to make sure roads, skies and rails are as safe as possible for travelers,” he said.
NTSB does not track fatigue-related highway accidents on a regular basis. But in 1993, the board commissioned a study expecting to learn about the effects of drugs and alcohol on trucking accidents. Investigators studied all heavy-trucking accidents that year and made an unexpected discovery: Fatigue turned out to be the bigger problem. The study found that 3,311 heavy truck accidents killed 3,783 people that year, and that between 30 percent and 40 percent of those accidents were fatigue-related.
“Truck drivers drive more hours in a week than pilots fly in a month,” said Jacqueline S. Gillan, vice president of Advocates for Highway and Auto Safety. “Drivers are paid by the mile—that’s an incredible incentive to drive as far and fast as you can.”
The NTSB also found that more than half of all single-driver trucking accidents occurred in the earliest hours of the day when the fewest number of cars are on the road: between 2:00 a.m. and 6:00 a.m. Three-fourths of those early morning accidents were found to be fatigued-related.
NTSB has issued 34 recommendations regarding fatigue on the nation’s roads. Only 17 have been followed. One of the outstanding recommendations is a call to equip buses with data recorders that can track drivers’ hours of service.
On a dark and desolate stretch of highway in the Four Corners region of Utah in 2008, a busload of skiers were returning from a three-day trip to the slopes of Telluride, Colo. Five hours into a long drive to Phoenix, the 71-year-old driver let his bus wander outside the lines of the two-lane highway. At about 8:00 p.m., the bus hit the guardrail, slid down an embankment and rolled into a drainage ditch. The 360-degree roll peeled the top off the Astro Stage Lines Motor Coach and tossed all but three of the 53 occupants into a snow-swept January night. Nine were killed, including five under age 18. The NTSB determined that driver fatigue played a key role in the accident.
Dr. Richard O’Desky, an Ohio physician in occupational medicine who often examines and certifies truckers, said he speeds past trucks on the highway because he knows how often drivers are impaired.
“My problem now is I know too much—the last place I want to be is next to a truck,” he said. “There are plenty that have no business being behind the wheel.”
The FMCSA has recently stepped up its efforts to target commercial drivers who have demonstrated high-risk behaviors related to fatigue, according to the DOT, its parent agency. Officials also are promoting road designs that slope the edges of pavements so that drivers who stray can more easily get back on the road.
Pilots say fatigue is a constant battle in the cockpit. “I’ve been there where you literally do a little tap dance with your feet and then nod off,” said Roger Nielsen, a retired US Airways captain. “What you try to do is you read each other, you constantly check on how each other is doing, and then if one person says ‘I’m totally bagged’… it’s not uncommon to let somebody take a nap.”
Pilots, controllers and flight crews who report safety problems through an anonymous NASA database frequently mention fatigue as a problem. Since NASA added a fatigue category in June 2009 there have been more than 200 reports from flight crew members concerned about fatigue affecting work performance and safety. NTSB’s Sumwalt said one in five reports submitted to the database are fatigue-related.
Since 1972, the safety board has come up with 37 separate ways to address fatigue, ranging from changing pilot flying hours to commissioning more research on how much—and what kind—of sleep pilots, flight crews, controllers and maintenance workers need. But only 12 have been implemented while the other 25 remain open or the board has given up on them without action ever being taken.
The crash of Colgan Air Flight 3407 outside of Buffalo, N.Y. in February 2009 heightened concerns about pilot fatigue. Four crew members and 45 passengers were killed when the plane went down, crashing into a house. One person on the ground was killed. An NTSB investigation concluded the accident was the result of pilot error and the pilots were likely fatigued. The captain spent the night before sleeping in the company crew room and had been awake at least 15 hours. The first officer had gotten at most 8.5 hours of sleep in the preceding 34 hours—part of that while commuting from Seattle to Newark the night before the accident, according to the report.
The Colgan crash let to more than two dozen NTSB recommendations, including measures to reduce the risk of fatigue. Seventeen months after the crash, the FAA released a proposal to reduce flight and duty time requirements for pilots. The proposal is similar to measures introduced in 1972 and 1995 that failed after encountering industry opposition.
The new rules would require pilots to rest for nine hours rather than eight before reporting for duty. Pilots also would be limited to 13 hours of work between rest periods and get more consecutive time off during the work week. Pilots would be able to decline assignments without penalty if they felt too fatigued to fly. And airlines would be encouraged to put in place individual fatigue risk management systems, according to documents released by the FAA. The proposal could cost airlines $1.3 billion over the next 10 years.
Public comments will be accepted on the plan until Nov. 13, after which the FAA may make revisions. “We pulled together a cross section of the aviation community to help craft changes to pilot fatigue rules that haven’t been updated since the mid-1980s,” said FAA Administrator Randy Babbitt. NTSB spokeswoman Bridget Serchak said it’s too soon to tell if the rules go far enough, but the board “is pleased that the effort has gotten this far along.”
One of the safety board’s key concerns is that U.S. regulations lag far behind modern sleep research—and behind other countries. In the European Union, for example, crew rest time excludes the time spent traveling to or from work. That’s not the case in the U.S. “Incredible as it may seem, the time a pilot spends waiting for a hotel shuttle and going through airport security screening is defined as rest under the current (FAA) regulatory scheme,” Air Line Pilots Association President John Prater told a Senate subcommittee on Aviation Operations, Safety and Security last year.
Australia, a world leader in fatigue regulation, is the only country that considers not only how long a person sleeps but the time of day. Because the body is conditioned to operate on a normal daytime schedule, or circadian rhythm, the most restorative sleep happens at night. Simply put, eight hours of sleep in the middle of the day is not the same as eight hours at night. If the body’s rhythm, which is based on light cues, is disrupted, jet lag can result.
In Australia, pilots must get extra rest time if their off-duty time doesn’t fall between the normal sleeping hours of 10:00 p.m. and 6:00 a.m.
Limits on hours of duty and flight time also vary between the U.S. and other countries, according to a 2007 report commissioned by the FAA. In the U.S., a single- or two-pilot crew can fly for 10 hours in one day. In Australia, South Africa, and Canada the limit is eight, according to the report.
“Airlines want to fly as much as they can fly, and they want to do it with as few personnel (as possible),” said John Prest, an executive at Fatigue Science, a Honolulu company specializing in fatigue-related technology. “Let’s be realistic—they’re in business to make money.”
NTSB investigators point to an October 2004 crash in Kirksville, Mo., that killed 13 as an example of pilot scheduling that wouldn’t be allowed in other countries.
The pilots, who commuted to work in Missouri from other states, had been awake for more than 16 hours and on duty for more than 14 hours when they got into trouble. In the final moments of the flight, they were peering out the cockpit window looking for the runway, unaware the plane was at a dangerously low altitude until it smacked into a tree.
The one-hour flight was their sixth of the day—and one that wouldn’t have been allowed under British regulations, said NTSB human factors investigator Malcolm Brenner, who worked on the accident. The pilots were scheduled to fly a total of eight legs that day, but two were canceled because of the stormy weather. The NTSB cited fatigue as a probable cause in the crash, but investigators will never know exactly what kind of a role it played or how it affected the pilots’ final decisions as the plane went down.
For the nation’s railways, 25 of 39 fatigue-related recommendations have been implemented. But even when action is taken it often comes too late.
A 1991 recommendation to equip train locomotives with devices to alert conductors to dangers might have helped prevent a fatal accident six years later.
Shortly after 2:00 a.m., outside of Delia, Kan., an engineer apparently nodded off at the controls as the train rolled through several signals and flashing lights. The engineer missed repeated radio calls, and by the time he snapped awake, it was too late. His train lurched through a switch that connects two sets of rail and into the side of an oncoming train that was bounding down the other track at about 70 mph.
In their report, NTSB investigators said they believed the conductor was too sleepy, startled or disoriented after he awoke to realize he needed to apply the brakes. They suggested a mechanical system that could sense an engineer’s lack of movement and rouse him in enough time to avert a crash.
No such system has been implemented.
Former NTSB managing director Peter Goelz said that under railways’ seniority system, veteran engineers get to select their schedules first and often choose to pack more hours into the workday so they can have more days off. “They’re the guys with seniority, who are older, generally overweight, generally with health problems, generally with stuff going on in their lives,” Goelz said. “It’s exactly the wrong people you want on duty at that time.”
In the maritime industry, the NTSB has issued 21 fatigue-related recommendations. Nearly half have not been followed. One of these is a 1988 recommendation that called for the U.S. Coast Guard to establish watch and duty time limitations for crew members on board ferries and other inspected passenger vessels.
Seven years after that recommendation was issued, a cruise ship ran aground off the Alaskan coast after its pilot erred while trying to guide the ship over a well-known and charted rock just before 2:00 a.m. Although he had been on duty for less than two hours, the pilot hadn’t slept longer than five-and-a-half hours the previous day.
When the entire vessel shuddered from the impact of hitting the rock, the pilot didn’t immediately realize the error. “Under normal conditions, such an experienced pilot should have immediately deduced that he had not safely passed Poundstone Rock when he felt the vessel shudder,” the NTSB said. “A fatigued pilot, however, might not be sufficiently alert to realize that he had grounded.” The pilot, who was later diagnosed with severe sleep apnea, suffered from “chronic fatigue,” according to the NTSB report.
Fatigue at sea can be a result of having no escape from the workplace. “A lot of these crews, when they’re on watch, when they’re working, they’re on the vessel,” said David Deaver, a safety analyst at the U.S. Coast Guard’s investigations division. “When they’re done … they’re still on the vessel. They work and reside and live at this same place.”
Lack of Action
Virtually everyone—scientists, lawmakers, industry executives, safety advocates and even operators themselves—says that fatigue is an issue ripe for more attention. “We’ve got enough evidence on fatigue now so we know how the human body responds broadly,” said Goelz, the former NTSB managing director. “We should be able to regulate and operate based on scientific evidence.”
But the regulatory process sometimes allows proposals to languish in bureaucratic purgatory, with no real action for decades, if at all.
Gerald Dillingham, director of civil aviation issues at the Government Accountability Office, published a report in 2001 that detailed the inefficiency of the FAA’s rulemaking. The report stated that between 1995 and 2000 the FAA completed 29 major rules, each averaging about 2.5 years, but six rules took 10 years or more to complete. “The rulemaking process is a very, very circuitous, complicated and time-consuming process,” Dillingham said.
The FAA, for example, twice proposed hours-of-service rule changes for pilots—once in 1972 and again in 1995. Neither was adopted. The 1995 proposal was withdrawn in 2009. In the intervening 14 years there were no fewer than 97 aviation accidents and incidents in which fatigue was a factor, resulting in nearly 500 deaths.
FAA Administrator Randy Babbitt made fatigue one of the agency’s highest priorities when he assembled a committee shortly after his confirmation in the summer of 2009. This September, the agency issued its new rule proposals that are now in the public comment period.
“We badly need a new flight and duty-time regulation,” Prater of the Air Line Pilots Association told senators last year. “While we have been told it will be done in mid-2010, we have seen too many times in the past that the FAA has not delivered on its promises with regard to pilot fatigue regulations.”
A Culture of Fatigue
No amount of training or experience can overcome the insidious effects of fatigue, as any pilot, truck driver, boat captain or anyone who’s stayed up too late watching TV knows.
“Temporarily, a person who otherwise is very experienced, very well trained, very, very good at what they do—fatigue can make that person stupid,” said Steven Hursh, a fatigue expert at Johns Hopkins University who has developed tools that are intended to track fatigue.
When tired, people react more slowly, struggle with attention lapses and take more unnecessary risks. They also suffer from a narrowed field of focus, or tunnel vision, which limits their ability to competently monitor several things at once—such as the many gauges, switches and control settings of a modern commercial airline cockpit.
The effects of fatigue mirror those of alcohol, as proven in scientific studies around the world. After being awake for as little as 24 hours, a person’s workplace performance can be equivalent to that of someone with a blood-alcohol content of 0.10 percent, equal to or greater than the legal intoxication limit in all 50 states.
What’s most dangerous is that people are unable to recognize their own fatigue. Even worse, they usually can’t register how it’s affecting their performance until it’s too late and something has gone wrong.
At present, one of the few tools investigators have to determine whether fatigue was a factor in an accident is listening to what pilots say on a flight recorder, such as talking about sleep or being tired. “By the time you feel sleepy or talk about being sleepy, you’re very far gone,” the NTSB’s Brenner said. “You don’t realize how impaired you are. The part of your brain that recognizes what’s happening is impaired.”
The problem is compounded by a culture “that places a lot of value on burning the midnight oil,” said NTSB fatigue transportation research analyst Jana Price. Most people take pride in working through fatigue, considering it a sign of strength, even if means putting themselves or others in danger, she said. It’s common to hear people brag about how little sleep they got before getting behind the wheel to drive to work in the morning or how late they stayed in the office to finish an important project.
NTSB investigator Malcolm Brenner said public attitudes toward fatigue are about the same as attitudes toward drinking and driving 20 years ago. “At one time, there was a sense that if you’re under (the influence of) alcohol you can power your way through it, but that’s no longer tolerated,” Brenner said.
Someday in the near future, safety advocates hope that operating under the influence of fatigue will be just as unacceptable.
Tessa Muggeridge and Charlie Litton write for News21, from which this article is adapted. News21 reporters Ryan Phillips and Ariel Zirulnick and Center for Public Integrity staff members Michael Pell and Nick Schwellenbach contributed to this story.