Safe Tests

To the Oregonian

2008-03-06T13:57:00.000-08:00

This article which I submitted to the Oregonian was not published. However it outlines some of the current issues facing legislators on the issue of worker testing. Clearly my article is promoting BLT technology, it's an Op/Ed piece after all. The proposed new law was shelved.

An Oregonian editorial, “Don’t Make a Bad Marijuana Law Worse” (Feb 4), supports a bill that permits employers to test workers, including those taking legally prescribed marijuana, for drug use. Letters from readers have both criticized and supported this position. Some of the letters make reference to impairment testing which happens to be my special area of expertise. My company, Bowles-Langley Technology, Inc., (BLT), has been developing this technology for the past 10 years and has a practical system for testing workers for impairment before or during work.

The BLT Alertness Test, which takes two (2) minutes to complete, measures reaction time, orientation, decision making and general cognitive performance with a simple computer graphic-based test. Each person is asked to take the test 10 times to establish a baseline. In subsequent testing current performance is measured against this baseline. If an individual measures significantly below his or her baseline, and cannot improve this score in a retest, the individual should be considered to be severely impaired. Employers can develop appropriate policy for management of these individuals based on the nature of the job.

The perfunctory termination of an employee for trace elements of drug metabolites in urine or blood, without regard to his or her actual condition and ability to work, is an arbitrary and unnecessarily crude method to protect the workplace. Practiced as public policy, it actually makes our workplaces less safe because urine testing is used where impairment testing would be superior. Urine testing tests for specific illegal drugs and the results are typically not available for days. The use of legal drugs combined with fatigue or flu, for example, are factors much more likely to cause an employee to be dangerously impaired. But these obvious impairment factors are not considered by urine testing.

If the citizens of Oregon wish to prevent the use of illegal drugs by testing workers’ urine for evidence of past drug use, it is up to them and their representatives. But they should not be misled into thinking that this practice is driven by safety priorities because impairment testing addresses worker safety more efficiently. With the increasing cost of accidents, it is time that worker impairment be addressed directly and not be used as an excuse for promoting popular anti-drug laws that are irrelevant to the issue.

Sleep Trial

2008-01-20T17:34:00.000-08:00

The sleep deprivation trial is complete. Aside from a couple of server problems it went exceedingly well. The trial was conducted at Anneke Heitmann's excellent lab at her Awake! Institute. During this trial subjects were kept awake for two nights (they were allowed a two hour nap on the second day.) Subjects were wired for EEG data and tested every two hours with a battery of tests, a driving simulator and the standard BLT Alertness Test.

We are now looking at the data to see how well the BLT test correlates with the other measures. In general there is some correlation between all the tests.

I would like to see an clear corelation between the BLT test and the subject's circadian patterns and a clear correlation with subject driving simulator performance in particular. But healthy human subjects are complex interactive data generators and we must deal with the real world data, obviously. There is a huge amount of material to look at from this trial and the results will be published as quickly as we can make sense of it.

Research is supported by the NIH.

Union County Accident

2007-07-10T05:21:00.000-07:00

It is not my intent to have this blog focus exclusively on individual accidents. However this one in Union County, Florida was one many people followed to try to understand the cause. Here is an extract of a newspaper article from the Gainsville Sun that explains:

"Under rules that take effect in October [2007], a truck driver cannot drive more than 12 hours in Florida following 10 consecutive hours off duty. The report stated Wilkerson [the truck driver] had the opportunity for about 90 minutes to obtain rest.

"This placed Mr. Wilkerson in an extreme state of fatigue. Like the consumption of alcohol, an extreme state of fatigue places a driver in a temporary impairment state," the report stated. "While in this temporary state of impairment, Mr. Wilkerson's perception and reaction skills are impaired, his judgment is impaired, his attitude is impaired, his attentiveness and coordination are also impaired. Fatigue also affects the brain's thought processing by not allowing the brain to interpret and understand a hazardous traffic situation."

BY:
Lise Fisher (352-374-5092 or fisherl@gvillesun.com)

Fatigue and other Factors

2007-07-03T11:44:00.000-07:00

Driver fatigue is estimated to be the cause of 100,000 highway crashes and 1,500 deaths each year. We would suggest the number attributed to fatigue could be much higher if driver fatigue were to be counted as a contributing condition. Nevertheless the numbers are daunting.

FATALITIES AND INJURIES

Overall: The U.S. Department of Transportation's Fatal Analysis Reporting System at the National Highway Traffic Safety Administration (NHTSA) projects that 43,300 people died in motor vehicle crashes in 2006, down 0.3 percent from 43,443 in 2005. While deaths among passenger vehicle occupants and nonoccupants fell in 2006, motorcycle riders suffered a 5.4 percent increase. This was the ninth consecutive annual increase in motorcycle rider deaths.

By Vehicle Miles Traveled: The fatality rate — measured as deaths per 100 million vehicle miles traveled — as projected by NHTSA was 1.44 in 2006, down from 1.47 in 2005.

By Crash Type: In 2006 there were 5,930,182 police-reported motor vehicle traffic crashes, down 3.7 percent from 6,159,189 in 2005. Of total crashes, 1,710,000 caused injuries and 4,181,000 caused property damage only. NHTSA estimates 10 million or more crashes go unreported every year.

Work-Related: In 2005 crashes involving vehicles on public roadways were the leading cause of work-related fatalities, according to the U.S. Bureau of Labor Statistics, accounting for almost a quarter of all fatal work injuries.

By Age Group: In 2005 older people (65 and older) made up 15 percent of all traffic fatalities, 14 percent of vehicle occupant fatalities and 20 percent of pedestrian fatalities, in large part because they are frailer and more likely to die from their injuries than younger people. (See Older Drivers paper.) In 2004 there were 28 million older licensed drivers, up from 17 percent in 1994. The total number of drivers rose only 13 percent from 1994 to 2004.

In 2005 drivers between the ages of 15 and 20 accounted for 12.6 percent of all drivers in fatal crashes and for 16 percent of all drivers in police-reported crashes. In 2004 (latest available data) drivers in this age group accounted for 6.3 percent of all licensed drivers. To reduce high accident rates among young drivers, states are increasingly adopting graduated driver license programs, which allow young drivers to improve their skills and driving habits.

By Driver Behavior

Speeding: In 2005, 13,113 lives were lost due to speed-related accidents. Speeding was a contributing factor in 30 percent of all fatal crashes. In 2005, 38 percent of 15- to 20-year old male drivers who were involved in fatal crashes were speeding at the time of the crash. NHTSA says that speed-related crashes cost Americans $40.4 billion each year. A crash is considered speed related when the driver is charged with a speed-related offense or a law enforcement officer indicates that exceeding the posted speed limit, driving too fast for conditions or racing was a contributing factor.

Drunk Driving: There is an alcohol-related traffic fatality every 29 minutes. In 2006, 17,941 people died in alcohol-related crashes, up 2.4 percent from 17,525 in 2005 and was projected to be the highest level since 1992. Alcohol was involved in 41 percent of all crash fatalities in 2006. (See Drunk Driving paper.) Alcohol-related crashes are defined as those where someone involved, either a driver or a nonoccupant such as a pedestrian or bicyclist, had a traceable amount of alcohol in his or her blood.

Drunk Driving and Speeding: In 2005, 40 percent of intoxicated drivers (with a blood-alcohol content at or above 0.08, the definition of drunkenness) involved in fatal crashes were speeding, compared with 14 percent of sober drivers involved in fatal crashes.

Red Light Running: The Insurance Institute for Highway Safety (IIHS) says that more than 900 people a year die and nearly 2,000 are injured as a result of vehicles running red lights. About half of those deaths are pedestrians and occupants of other vehicles who are hit by red light runners.

Fatigue: NHTSA statistics show that at least 100,000 crashes and 1,500 deaths each year are the result of drivers falling asleep at the wheel. A 2002 poll, conducted by the National Sleep Foundation, found that 100 million drivers, close to half of American adult drivers, drive while drowsy and nearly two out of ten admitted to having fallen asleep at the wheel. New Jersey passed a law in 2003 that equates falling asleep at the wheel with reckless driving, and, if a driver falls asleep and kills someone in a crash, he or she can be charged with vehicular homicide and serve up to ten years in jail and pay fines. Although at least four states have considered similar legislation, New Jersey is the only state with such a law on the books.

Near Miss with Tired Pilots

2007-07-03T11:36:00.000-07:00

Airline pilots flying while fatigued poses risk to safety
27 June 2007

A BBC News investigation has revealed growing concerns among airline pilots that fatigue is leading to potentially dangerous incidents in the air. The BBC has heard from 32 pilots who say they have flown while unfit due to fatigue.

The BBC can reveal that an incident – with the first officer sleeping and captain "resting" – required a "quick reaction to avert disaster" as an airliner began turning into the path of another plane.

In another serious incident, investigated by the AAIB (Air Accident Investigation Branch), a fatigued pilot nearly stalled an aircraft in mid–air shortly after take off.

The BBC can also reveal the results of a survey for the pilots union BALPA (British Airline Pilot's Association) which suggests a majority of air crews who responded are affected by fatigue – and that pilots believe passengers should be concerned.

BALPA found that 81% of pilots who responded said that their performance had been affected by fatigue. Pilots the BBC has spoken to blame the growing intensity of the aviation industry – and some say their managers are ignoring their concerns.

One pilot, 'Andy', told the BBC: "I have fallen asleep unintentionally in the air – where you close your eyes for a second and realise that ten minutes have passed."

BALPA commissioned the survey, of over 500 of members, following inquiries by the BBC.

Aviation consultant Dr Ian Perry has treated dozens of fatigued pilots: "You might miss a radio call when you're thinking about 'is my altitude right?' That's chronic fatigue. I think in the last five years it has doubled. So if I see one or two people a fortnight, I'm now seeing four or five people a fortnight, something like that."

Dr Perry added: "... We've been skating on fairly thin ice for some years and have got away with it. For us to have a true fatigue accident I say it could happen at any time now. And then people will turn around and say 'well, why didn't you do something about it?'"

There are limits to how many hours pilots can fly and there's no evidence these are being breached. Most airlines told the BBC that their average hours had barely changed in recent years. But two thirds of pilots surveyed by BALPA said they were flying more than five years ago.

Some short haul crews now do six flights – six landings and take-offs a day – without leaving the cockpit. These require the most concentration and are regarded as the critical periods in the flight.

A pilot working in the low cost sector has told the BBC of an incident when an aircraft, with dozens of passengers onboard, began to turn putting it on a collision course with another passenger plane. Air Traffic Control (ATC) radioed an urgent warning but there was no response.

The aircraft bound for Europe had been on autopilot, while the captain rested. This had been agreed between the two men, and left the first officer in charge. However, on realising there was no response to the ATC warning the captain told the BBC: "So I looked across, and saw he was asleep."

However, in the official report to his airline the captain didn't mention that his co–pilot had been asleep. "I didn't want to get him into trouble. There's no two ways about it. I knew that he would probably be pulled in and be treated fairly harshly ... effectively its gross negligence."

However, many pilots and experts told the BBC that admitting their fatigue to managers is a taboo. Pilot 'Andy' said: "I was genuinely fatigued and whenever I reported that I was completely exhausted the operator says 'are you refusing to do the duty?'. He should not have been asking me, let alone bullying me into doing it."

The pilot added that this "routinely goes on."

This view was reflected in the BALPA poll which found that a third of pilots believed they'd risk disciplinary action if they reported their fatigue. More than one in ten (12%) would carry on flying, without reporting it. Forty percent said they would report fatigue.

The chairman of BALPA, Mervyn Granshaw, claims that fatigue is "the single biggest issue facing aviation today. At the moment we are not seeing it appear as accidents or incidents but we're getting closer to that point."

Another fatigue-related incident published in an AAIB bulletin took place at Birmingham Airport in 2004 (but not reported until April 2006) involving a passenger jet, with 85 passengers on board.

Shortly after leaving the ground the crew raised the plane's wing flaps instead of the landing gear. That created the danger the aircraft could stall – and potentially fall from the sky.

The captain had to lose altitude to increase speed – he recovered at less than 700 feet above the ground. An official investigation by the Air Accident Investigation Board concluded that fatigue was a key factor.

Captain David Chapman, head of flight operations at the UK's air regulator, the CAA (Civil Aviation Authority) maintains the system is working: "We have the finest flight time limitations system in the world. I have no problems at all in saying that I don't believe we have a major fatigue issue."

In a written statement responding to concerns about pilot fatigue, John Hanlon, Secretary General of the ELFAA (European Low Fares Airline Association) said:

"Aircrew flying duties are strictly regulated by the CAA and the IAA in the UK and Ireland which ensures that no pilot can fly more than 900 hours per annum (average 17 hours per week). These safety limits are met by all airlines and are subject to regular audit.

"Europe's low fare airlines have an exemplary safety record and this has been delivered by making safety the number one priority at all times. ELFAA member airlines operate a Just Culture system, whereby all pilots are free to report any issues, which they feel impinge on safety, without having to divulge their identity."

Roger Wiltshire of BATA (The British Air Transport Association) said: "We don’t feel there is a fatigue issue in the industry. Pilots are flying well within the regulated flying hour limits, and in the UK we have some of the most regulated pilot flying hours and duty hours in the world. And although short haul pilots are flying more hours than they were that's because the schedules are more efficient."

FAA on Prescriptive Regulation

2007-06-12T09:46:00.000-07:00

In testimony on 6 June 2007, before the Committee on Transportation and Infrastructure, Subcommittee on Aviation, FAA Deputy Associate Administrator for Aviation Safety Peggy Gilligan responded to concerns voiced the day before by Mark Rosenker, chairman of the National Transportation Safety Board, about the FAA's response to the Board's urgent safety recommendations.

Her excellent comments on the fatigue issue are quoted here:

Flight and Duty time rules have been in existence since the 1950s, and the 121 domestic and 135 scheduled rules were updated in 1985. The rules on pilot flight time and rest have evolved along with advances in commercial air travel. The FAA is confident that, overall, the airline industry complies with the FAA's current rules. In the intervening time, much research has been done on fatigue, which has resulted in a better understanding of complex fatigue-related issues. The research tells us that this issue does not easily lend itself to a set of prescriptive rules. While the existing prescriptive rules have served us well, they do not allow for the flexibility needed to address the various flight regimes that exist.

Understanding the limits of a strictly prescriptive regulatory regime, we worked to alleviate fatigue through other means. Fatigue countermeasures were first developed by NASA, and include providing in-flight rest, as well as training crew members on the use of proper diet, exercising, and even caffeine to manage fatigue. Fatigue countermeasures are covered during Crew Resource Management (CRM) initial training and during CRM recurrent training.

It is also critical to understand the role that personal responsibility plays in fatigue and why prescriptive rules can only provide a framework for safety. Crew members, mechanics, air traffic controllers, everyone involved in the safety of flight must make a personal commitment to report for work well rested and ready to perform their duties. No regulatory scheme can instill that sense of personal commitment and professionalism.

One thing we know, aviation operations will always challenge us in the area of flight time and rest. Aircraft design allows for longer and longer flight times. Recently, FAA issued approval to Delta Airlines for flights in excess of 16 hours from New York JFK to Mumbai, India. This approval was our first implementation of a fatigue risk management approach. Delta proposed – and we analyzed and approved – a detailed plan to assure the crew is rested before the flight begins, is provided appropriate rest throughout the flight, and have sufficient rest before conducting the return flight.

The procedure specifically addresses the impact to circadian rhythm, including the recognized affect of circadian law which occurs at specific times in the daily cycle. This is an example of where we need to move in the future -- away from prescriptive rules and into fatigue risk management.

Air traffic

2007-04-17T15:41:00.000-07:00

I am going to Washington DC next week to speak to FAA officials and to NTSB officials.
This article will be part of my package.

WASHINGTON (CNN) -- Fatigued air traffic controllers contributed to four aviation mishaps in recent years, and may have been a factor in last year's Comair crash that killed 49 people, according to federal accident investigators.

The investigators are calling on the Federal Aviation Administration to revise work schedules and take other actions to prevent controllers from becoming tired on the job.

"Controllers are absolutely more tired now than they have ever been, and it's because they are forced to work overtime. This is an understaffed system, and the FAA is lying when they say it's not," said Doug Church, spokesman for the National Air Traffic Controllers Association.

In a letter to the FAA, Mark Rosenker, chairman of the National Transportation Safety Board, said it's still unclear what role fatigue played in the crash of Comair Flight 5191, but four other incidents "provide clear and compelling evidence" that controllers are sometimes operating while fatigued because of their work schedules and poor use of rest periods.

"That fatigue has contributed to controller errors," Rosenker wrote.
Union: 'This is a wonderful gift'

The air traffic controller's union jumped on the report as validation of its long-held claims that the system is severely understaffed and that controllers are being forced to work overtime against their wishes.

"This is a wonderful gift from the NTSB, to finally tell the FAA that their controllers need more rest," Church said.

FAA spokeswoman Laura Brown said the FAA has between 14,500 and 14,600 controllers, about 1,000 fewer than it had in late 2003. But, Brown pointed out, the peak number was based on a contract with controllers that anticipated growing air traffic, not the drop that followed the September 11 terrorist attacks.

Brown said the FAA will look at scheduling practices in light of the NTSB recommendation, but "many of the schedules we have in place are at the request of employees." She noted that the NTSB said it is also incumbent upon controllers to "use personal strategies" to maximize sleep and minimize fatigue.

The FAA determines rest requirements, but it negotiates with unions on how employees are rotated through shifts, Brown said.

"The (NTSB) recommendations don't say anything about understaffing," Brown noted. "There is mandatory overtime at a very small number of facilities."

In many cases, the FAA is able use controllers who request overtime -- or are on a volunteer list -- before seeking others to work overtime, she said.
Controller working on just 2 hours of sleep when plane crashed

In the August 27 Comair crash in Lexington, Kentucky, the lone air-traffic controller was working on just two hours of sleep, according to the NTSB.

The controller cleared the CRJ-100 to take off from the correct runway, which was 7,003 feet long, but the airplane mistakenly turned onto a shorter runway that was just half that length. The plane crashed into a fence and trees at the airport perimeter, killing 49 of the 50 people onboard.

While the NTSB is focusing on the crew's actions, and aviation experts say the controller was not required to observe the plane's departure, the NTSB is evaluating to what extent, if any, the controller's fatigue may have influenced events.

The controller in the tower had worked a 6:30 a.m.-to-2:30 p.m. shift the day before the accident, then returned nine hours later and worked from 11:30 p.m. until the 6:07 a.m. accident, the NTSB says. He told investigators his only sleep between shifts was a two-hour nap.

"Such limited sleep can degrade alertness, vigilance and judgment," Rosenker wrote.
A history of incidents

The four aviation mishaps that allegedly involved tired controllers all involved what are termed runway incursions -- instances in which aircraft or other vehicles improperly intruded onto operating runways.

The four incidents are:

# Chicago, Illinois, March 23, 2006: The NTSB letter says a controller cleared an Airbus A320 passenger plane to cross a runway and then, less than 15 seconds later, cleared a Boeing 737 to take off on the same runway. The pilot of the Boeing saw the Airbus and stopped before reaching the taxiway intersection. The controller told investigators he had slept only four hours during a nine-hour break between shifts.

# Los Angeles, California, August 19, 2004: A controller cleared a Boeing 737 passenger plane to taxi onto and take off from a runway at the same time that another plane, a Boeing 747, had been cleared to land on the same runway. The pilot of the landing plane saw the 737 and pulled up 12 seconds before a collision would have occurred, passing about 200 feet above the runway. The controller had slept five or six hours before returning to work, the NTSB letter says.

# Denver, Colorado, September 25, 2001: A controller approved a request from a Boeing 757 cargo plane crew to depart from a runway, even though the runway had been closed for construction. The aircraft passed within 32 feet of lights that had been erected in the construction zone. Investigators determined that the controller had slept less than two hours during a nine-hour period between work days.

# Seattle, Washington, July 8, 2001: A controller cleared a Boeing MD-80 passenger airplane to cross a runway at the same time a Boeing 767 passenger airplane was about to land on the runway. The pilots in the landing airplane hit their brakes to avoid a collision, stopping only 810 feet short of the MD-80. The controller was working his third shift in two days, with eight-hour rest periods between shifts.

The NTSB recommended the FAA and controllers' union revise work schedule policies and practices and modify shift rotations to minimize sleep disruptions. The FAA should also develop fatigue awareness programs, which should be taught at regular intervals, the NTSB said.

It commended the FAA for a new "resource management program" to help controllers detect controller and pilot mistakes.

Change the Rules

2007-03-19T21:31:00.000-07:00

Quoted from the Columbian, Clark County, Washington:

Columbian editorial staff

Money can compete with safety when it comes to railroads, which is why it is encouraging that the government’s top railroad official is lobbying to change rules concerning workers’ schedules.

The change could lead to reduction in the number of train accidents caused by crew fatigue. The National Transportation Safety Board told Congress in February that fatigue has been a probable cause of 16 major train accidents in the past 23 years.

This policy change could impact a lot of people in Clark County. Vancouver, long a major switching and maintenance yard, has 450 train-yard and engine employees. More than 50 trains a day move through the terminal here.

Statistically, train workers already can expect to be involved in a fatal railroad accident if they spend a working lifetime on the tracks. There are simply too many people sitting, walking along or crossing tracks when they shouldn’t be.

What train engineers should not have to cope with is being so tired on the job that their physical state contributes to a wreck. Antiquated rules concerning the number of hours a person works versus the number of hours of rest between shifts are a problem.

Joseph Boardman, head of the Federal Railroad Administration, is asking Congress to repeal a 100-year-old law that regulates workers’ schedules, saying the laws are not up to date with scientific knowledge of the impact a lack of sleep has on workers. Boardman wants to require more rest between shifts, or shorter work days.

Right now, the Associated Press reports, train crews and signal workers can work 12 hours straight with 10 hours of rest. But if a train employee works even one minute less than 12 hours, law mandates just eight hours of rest. By the time one gets home, settles in and falls asleep, it isn’t hard to imagine workers getting inadequate sleep before they are due back at work. Unpredictable schedules are also a problem. If a worker doesn’t know when he might be called up next, how can he physically prepare and still have a decent family or social life?

While workers might crave more predictability and more rest, they also know any change is likely to hurt their pocketbooks if the industry has to hire more workers. Ensuring that current workers won’t face dramatic drops in income is key. Boardman and the National Transportation Safety Board need to continue working with unions representing train employees to find the best solution.

Pointing Fingers at Fatigue

2007-02-19T15:09:00.000-08:00

The tragic finger pointing going on here cannot obscure the fact that fatigue more than any other factor caused this accident. Management has an obligation to speak up when crew error is involved and unions need to take responsibility for the action and mistakes of their members. At the same time, the unions are correct about
the hidden issue of fatigue cause by excessive hours.

Here is the summary report:

Safety of Workers and the Public at Risk

WASHINGTON, Feb. 13 /PRNewswire-USNewswire/ -- A Teamsters Rail
Conference official told the House Subcommittee on Railroads, Pipelines and
Hazardous Materials today that worker fatigue is a significant safety
threat to rail workers and the public.
"There is no question in our minds that safety degradation because of
fatigue is a ticking time bomb in the rail industry," said Tom Pontolillo,
Director of Regulatory Affairs of the Brotherhood of Locomotive Engineers
and Trainmen (BLET), which is part of the Teamsters Rail Conference. "The
National Transportation Safety Board (NTSB) has on numerous occasions
pointed to crew fatigue as a potential contributing factor in an accident."
Last year the NTSB adopted a report determining that the 2004 Macdona,
Texas, collision and toxic chlorine release, which killed three people, was
caused by a fatigued locomotive crew's failure to respond to wayside
signals. The crew was criticized by the NTSB for failing to effectively use
off-duty time, thereby not obtaining sufficient restorative rest prior to
reporting for duty and Union Pacific was criticized for train crew
scheduling practices that created inverted crew members' work and rest
patterns.

The Drive Home (2)

2007-01-29T15:27:00.000-08:00

The drive home is often the most dangerous part of work.

This article reminds us of how serious this problam is:

A Dakota County grand jury returned an indictment charging a Farmington woman with misdemeanor careless driving that resulted in the death of teenager Jacquelynn Devney on July 27, 2006.

The jury heard the case on Jan. 18 that involved the defendant Laura Ann Brockhaus, 40, of Farmington, who allegedly fell asleep at the wheel when her car jumped a curb off Pilot Knob Road and hit Devney who was working a summer job weeding the roadside area. The coroner determined that Devney, 18, died instantly after being hit.

The jury declined to indict Brockhaus on a more serious charge of felony criminal vehicular homicide that is punishable up to 10 years in prison and charged her with the careless driving misdemeanor that is punishable with up to 90 days in jail.

Investigations found that Brockhaus worked as a registered nurse at the Veterans Administration Medical Center in Minneapolis. In the three days prior to the car accident she had worked overnight shifts from 7:30 p.m. to 8 a.m. and Brockhaus told police she had only slept three to three and a half hours during the morning of July 26, and about five to six hours during the morning and early afternoon on July 25.

Skipper is Asleep

2007-01-22T20:37:00.000-08:00

A fishing boat grounded on a beach in Tory Channel last April because the skipper fell asleep, an investigation has found.

The Venture, a 13m Nelson-based fishing vessel, grounded at the base of a cliff just north of Tipi Bay in the Marlborough Sounds while on the way from Picton to Oamaru on April 19.

As the boat was in no immediate danger and the crew were uninjured the skipper decided to wait until daylight before seeking help. But the crew of a passing ferry noticed the boat aground and reported it.

The Venture was undamaged and was successfully refloated on the next high tide with help from a tug.

A Transport Accident Investigation Commission (TAIC) report said the skipper of the Venture was probably suffering from fatigue at the time of the grounding.

The report said his fatigue was probably due to a change in his normal routine, combined with stress from navigating unfamiliar waters.

"Had the skipper been more aware of the signs and symptoms of fatigue he would have been better prepared to deal with it," the report said.

It would have been "more prudent" for the skipper to have remained in Picton until the next day to make sure he and the crew were well rested.

If the vessel had had a watchkeeping alarm system it would not have stopped the skipper falling asleep, but may have woken him in time to avoid the grounding, the report said

TAIC recommendations included making sure all vessels owned by the company had a copy of the Fish SAFE organisation's "Safety Guidelines for Small Commercial Fishing Vessels" on board.

Thank you New Zealand Herald

Killer Trucks

2006-10-18T21:22:00.000-07:00

Here is an article by V. Srinivas Ram in the Times of India, 10.18.06 as a reminder that it's not just a problem in the US.

HYDERABAD: Killer trucks are on the loose in the city. There have already been 34 deaths due to trucks in the first five months this year.

The accident on Monday, where eight persons were injured when a truck ran amok at Toli Chowki, is just the latest in the list. This accident happened on a route ‚ NH-9 leading to Mumbai‚ where trucks are permitted. But there are hundreds who are getting away with rash driving on restricted routes in the city. Heavy vehicles are banned from arterial roads, Sardar Patel Road, Mahatma Gandhi Road, Raj Bhavan road, Charminar road, Bank Street ‚ in the city. The situation is even worse in Cyberabad. In areas such as Habsiguda, L B Nagar, it is a free for all.

Moreover, there has been a spurt in accidents involving heavy vehicles on main routes like Mettuguda-Tarnaka, Dilsukhnagar-Malakpet and Retibowli.

In 2004, 85 people were killed by trucks in the city, while the figure was 67 in 2005. According to a UN report, truck driver fatigue due to long hours and sleeplessness was a major cause of accidents. The report suggests states develop trip sheets to overcome this problem, pointing out that 1 pm to 4 pm was the time most of the accidents involving trucks were taking place. Incidentally, the accident at Toli Chowki happened at about 2.30 pm.
...

Places such as Medak and Nalgonda surrounding the city are also highly-accident prone.

Individual Awareness

2006-10-13T08:07:00.000-07:00

This article from Newswire is an excellent reminder.

***

Accident Prevention Begins With Individual Awareness

The safe operation of any vehicle is determined by the attentiveness, alertness and ability of an individual to focus on the task at hand. Increasing your own driver awareness can go a long way to help prevent costly accidents

Whether you drive an SUV, a delivery van, an RV or a long haul truck, it’s vital to always bring along one item… your safety awareness! The safe operation of any vehicle is determined by the attentiveness, alertness and ability of an individual to focus on the task at hand. Increasing your own driver awareness can go a long way to help prevent the costly accidents, fatalities and material losses that affect us all.

Drowsy or Distracted, Both Are Deadly

Impaired mental faculty due to limited sleep, mixed with high demands on alertness and attentiveness, makes for a dangerous combination, one that has been attributed to some $12 billion in yearly costs and thousands of deaths (U.S. Department of Transportation). Driver distraction, or more precisely, driver lapses in attention caused by cell phones, MP3 players, GPS devices and other in-vehicle entertainment, has been named one of the leading safety hazards in the transportation industry. There is no shortage of overwhelming data supporting the need for more safety solutions to mitigate the horrific accidents and fatalities occurring as the result of drowsy or distracted driving. While new technologies are bringing better safety products to market, life saving changes can be made by increasing your individual knowledge about the causes of preventable accidents. Education is a powerful tool, understanding the dangers of unfocused driving may help you think twice. Before you end up on the wrong side of a senseless driving disaster, consider there were 43,443 deaths from motor vehicle accidents in 2005! My guess is numerous were preventable…

The Problem is Everyone’s

Over the last 50 years much has been discussed about the perils of sleep-deprived truck drivers, tired individual drivers and drivers not paying attention. Further complicated by the ever increasing number of trucks on the road, additional concerns arise as a result of the dramatic shortage of qualified drivers, moving an ever growing supply of consumer and consumable products. Moreover, the problem is not limited to truck drivers as is clearly detailed in a report from the NHTSA (National Survey of Distracted and Drowsy Driving Attitudes and Behavior, April, 2003). The survey findings show that most drivers at least occasionally engage in behaviors that draw some percentage of their attention away from their driving task. These behaviors include talking with other passengers (81%), changing radio stations or CDs (66%), and eating or drinking while driving (49%). making outgoing & taking incoming cell phone calls (25%) and dealing with children riding in the rear seat (24%). While it is estimated that more than a billion driving trips are made weekly by drivers engaging in each of these behaviors, fewer than one in four drivers perceive these particular activities as distracting or as making driving much more dangerous! Don’t take the risk of ignorance; always give your full attention to driving whenever you navigate a motor vehicle.

Dangerous Vehicles, Large & Small

It is a well known and documented fact (Commercial Motor Vehicle Facts, Federal Motor Carrier Safety Administration, April 2005) that commercial motor vehicle (CMV) driver alertness/drowsiness is a major safety hazard in modern day society. There are approximately 7.9 million large trucks on our roads today, some driven by drivers working excessive hours, complicated by a shortage of qualified truck drivers. Large trucks alone make up over 400,000 accidents a year with an average cost of over $62,000.00 per incident. In 2002 alone the Total Cost of Fatigue-Related Crashes (in 1999 Dollars) exceeded $2.3 billion! What is a lesser known and reported danger is the ever increasing number of overworked, overtired and highly distracted individuals driving noncommercial trucks, SUV’s and cars numbering over 220 million vehicles. While these automobiles are smaller in size and weight, they are no less dangerous in the hands of a sleep deprived or inattentive driver.

Extending Success

2006-10-10T15:01:00.000-07:00

We just got an amazing email from the NIH. Our research plan for 2007-8 has been approved. We can now make a good test a great test and we will be able to prove it. Thank you NIH.

We like to think this funding has come to us because of our continued success in the field but, realistically, it comes from a recognition of the importance of much work in alertness testing everywhere. Human impairment continues to plague industrial society worldwide through accidents and critical errors. We will never eliminate these errors, our goal is simply to help reduce them, particularly in critical professions. If our research can make a small difference that is enough.

Properly testing and validating any psychological test with human subjects is a significant undertaking. Done properly it would strain the resources of any small company. But this funding allows us to continue building on the years of good scientific progress we have made through incremental steps in university labs and through clinical trials at private corporate labs. We will be conducting advanced clinical trials with hundreds of subjects at some of the best labs in the world at Stanford University, at Harvard Uiversity and on to implementation trials involving many more subjects in real world conditions.

As many of our users know the BLT basic alertness test is a very simple test. It was designed to be just challenging enough to be sensitive to significant human impairment - but not to be so difficult that the average person would find it unpleasant or tricky. We have a number of other tests but the basic alertness test is what we are testing now.

In the next two years we will further refine our "test bed" measurement techniques and our test testing validation methodology including human stress testing and sleep deprivation experiments. We will be able to use the same test bed and other proven techniques to measure the sensitivity and reliability of other test designs.

This means we can test new tests against a known benchmark. Test and game designers who would like to work with us on the next generation of human alertness tests should contact us. Keep in mind the following constraints: 1. Keep it less than 1.5 minutes, 2. Non-linguistic, 3. Easy to learn, 4. Not annoying (the test should not trick the subject). We like the Macromedia Flash application, but, provided the test is web capable, we are interested in ideas for the next generation.

Lack of Sleep Causes Accident

2006-07-13T14:00:00.000-07:00

The National Transportation Safety Board (NTSB) has just released its findings on an accident that occurred 3 years ago near San Antonio, Texas. It is rare for the NTSB to list fatigue as the primary cause of an accident. Usually something like equipment failure or operator error is indicated as the primary cause with fatigue often being a contributing cause. So this is new.

But at 5:30 a.m., Monday, June 28, 2004, a westbound Union Pacific Railroad (UP) freight train was under the control of a conductor and engineer both of whom were probably asleep. They did not respond to wayside signals to stop. Just outside of the rail siding in Macona, Texas the UP freight train smashed into an eastbound BNSF Railway Company train. The collision derailed 4 locomotives and 36 rail cars including one carrying liquid Chlorine. Steel cargo in one car ruptured the Chlorine tank. The escaping gas killed two local resident and the UP train conductor.

Given the schedule the conductor and engineer were working under, it is no wonder they were tired. But it did not help that they apparently made ineffective use of what off time they did have - drinking and card playing. The evidence suggests that both men were asleep or incapacitated by fatigue.

This fatigue would almost certainly have been detected with a simple screening test. More importantly, if they had known that a screening test for fatigue was likely, they would have acted differently and better used their off duty time. I think.

I call upon the railroads look at a program of impairment testing when crews are assigned difficult schedules and duty times.

Against Drug Testing?

2006-07-02T14:39:00.000-07:00

As most readers know, I am not against urine testing per se. If it is seen as a campaign to stop the use of drugs, and it seems to work, well that’s fine with me. But urine testing has little to do with making sure workers are ready for work and it should not be a substitute for alertness testing.

Urine testing raises other issues as well. Here is an excellent article about a case in Canada.

“A construction company discriminated against an employee when it fired him after his pre-employment drug test showed traces of marijuana, an Alberta judge has ruled.

“Justice Sheilah Martin said the man should have been treated like someone with a drug addiction, and that is considered a disability in a growing body of human rights case law across Canada. It is believed to be the first time that Alberta's Court of Queen's Bench has addressed the issue of pre-employment drug testing under human rights legislation, the Canadian Press said.

The ruling is "important for all workers," said Leanne Chahley, an Edmonton labour lawyer who regularly represents unions. It means that a worker does not have to be disabled to challenge a policy as discriminatory, she said. It also means that companies cannot use drug tests to weed out potential employees who test positive. "It's not your employer's [business] if it doesn't affect your work. "No one wants to encourage impairment at work, but a drug test is an invasion of your privacy," Chahley said. "It shouldn't matter to your employer what you might do on off-duty time. That's your business. It's not your employer's [business] if it doesn't affect your work."

The case began in 2002 when John Chiasson was hired by Kellogg Brown & Root for a job as a receiving inspector at Syncrude's oil sands plant north of Fort McMurray, Alta. As a non-unionized employee, he was required to pass a pre-employment drug test. After taking the test, Chiasson was immediately put to work. Nine days later, the company learned his urine was positive for the active ingredient in marijuana. He admitted he had smoked pot five days before the test and was immediately fired, as called for by the company's zero-tolerance policy. Chiasson complained to the Alberta Human Rights Commission, which ruled he was not discriminated against. But Martin overturned that decision in a ruling handed down last month.

Though Chiasson never used drugs at work, the policy treated him as if he had, the judge wrote. The requirement that he be tested for drugs, with an automatic penalty for a positive result, is discriminatory, she added. Alberta human rights legislation prohibits discrimination under 13 grounds, including race, religious beliefs and physical and mental disabilities.
Andrew Robertson, the Calgary lawyer representing Kellogg Brown & Root, said he could not comment on the decision. Company officials could not be reached.

Roadside Screening

2006-06-07T09:46:00.000-07:00

Driving under the influence of drugs is, of course, just as dangerous as driving under the influence of alcohol. And a new survey out of Scotland suggests that "drug driving" is surprisingly common. A survey of 1,072 young people (25-35) found that 20% had taken illegal drugs before driving. This study, conducted by More Than, a major insurance company, has encouraged a movement to introduce additional roadside testing by the police. The push to do this is very strong in Britain where 18% of drivers killed in road accidents have traces of illicit drugs in their blood.

These proposed roadside test would check the driver’s saliva for drug traces and require a FIT test administered by a police officer. ( FIT tests typically ask the subject to perform a series of movements.)

While roadside screening is becoming more practical with the advent of better testing equipment this version seems unnecessarily invasive. If it must be done, computer based performance test (like ours) may be far more acceptable to the population and, therefore, much more likely to be used.

Research was conducted via myvillage.co.uk with 1,072 people between 13 April and 8 May 2006. (69 per cent of myvillage.co.uk users are aged between 25 – 35 years).

Provigil Is the Answer?

2006-04-19T11:47:00.000-07:00

As many of my readers already know, there is a new and wildly popular drug called Provigil by Cephalon (generic name modfinal and is also marketed as “Alertec” by a rival company) to combat fatigue. Revenues from Provigil were $1.2 billion in 2005 and are growing. It is currently promoted to treat specific medical conditions such as narcolepsy but it is also being used as a “lifestyle drug” of choice for fighting drowsiness and fatigue.

So far the drug appears to be non-addictive and it does not cause hand shaking and heart racing like caffeine. Still the FDA is being cautious until more is know. Off-label prescriptions seem to be fueling the run up in demand. It has been used for over ten years so there should be a lot of reports on its down side. But a search of the internet shows only a few reported problems. For example: Anxiety, depression, diarrhea, difficulty sleeping, dizziness, dry mouth, headache, infection, loss of appetite, loss of muscle strength, lung problems, nausea, nervousness, prickling or tingling feeling, runny nose, sore throat. That’s not too bad for a drug that gives you a lift and keeps you working. It obviously does not bother a lot of people.

Is this the magic elixir, the solution to the alertness problem? Pilots report staying awake for three days with this product. It worries me because of the potential for psychological addiction and the long term effects of not getting enough sleep. Will it lead to more stressed out workers when the effects wear off? What happens to human performance after extended use? Does it affect judgement?

We will be conducting sleep deprivation trials this summer to calibrate the BLT alertness test. Maybe our next trial should include Provigil.

Just after I wrote the above, I found this interesting reference to a 2005 study.
Note the very substantial number of subjects and the severity of the sleep deprivation (85 hrs!).

Journal of Sleep Research
Volume 14 Page 255 - September 2005
doi:10.1111/j.1365-2869.2005.00468.x
Volume 14 Issue 3

Performance and alertness effects of caffeine, dextroamphetamine, and modafinil during sleep deprivation
NANCY J. WESENSTEN, WILLIAM D. S. KILLGORE and THOMAS J. BALKIN
Summary
Stimulants may provide short-term performance and alertness enhancement during sleep loss. Caffeine 600 mg, d-amphetamine 20 mg, and modafinil 400 mg were compared during 85 h of total sleep deprivation to determine the extent to which the three agents restored performance on simple psychomotor tasks, objective alertness and tasks of executive functions. Forty-eight healthy young adults remained awake for 85 h. Performance and alertness tests were administered bi-hourly from 8:00 hours day 2 to 19:00 hours day 5. At 23:50 hours on day 4 (after 64 h awake), subjects ingested placebo, caffeine 600 mg, dextroamphetamine 20 mg, or modafinil 400 mg (n = 12 per group). Performance and alertness testing continued, and probe tasks of executive function were administered intermittently until the recovery sleep period (20:00 hours day 5 to 8:00 hours day 5). Bi-hourly postrecovery sleep testing occurred from 10:00 hours to 16:00 hours day 6. All three agents improved psychomotor vigilance speed and objectively measured alertness relative to placebo. Drugs did not affect recovery sleep, and postrecovery sleep performance for all drug groups was at presleep deprivation levels. Effects on executive function tasks were mixed, with improvement on some tasks with caffeine and modafinil, and apparent decrements with dextroamphetamine on others. At the doses tested, caffeine, dextroamphetamine, and modafinil are equally effective for approximately 2–4 h in restoring simple psychomotor performance and objective alertness. The duration of these benefits vary in accordance with the different elimination rates of the drugs. Whether caffeine, dextroamphetamine, and modafinil differentially restore executive functions during sleep deprivation remains unclear.

Red Bull is Not the Answer

2006-03-27T09:39:00.000-08:00

Combining alcohol and Red Bull® reduces the 'perception' of impairment

Alcohol's harmful effects on motor coordination, however, remain intact

Study results show that drinking alcohol and Red Bull® together significantly reduces the perception of headache, weakness, dry mouth and impairment of motor coordination.
Red Bull® does not, however, significantly reduce alcohol-related deficits on objective measures of motor coordination and visual reaction time.
People who combine alcohol with energy drinks may be at even greater risk for problems such as automobile accidents because they believe they are unimpaired.
The combined use of alcohol and "energy drinks" such as Red Bull® have become increasingly popular among youth and young adults in recent years. Users often report reduced sleepiness and increased sensations of pleasure. In the April issue of Alcoholism: Clinical & Experimental Research, Brazilian researchers conduct the first controlled scientific study on the effects of combining alcohol with Red Bull®. Results show a considerable disconnect between subjects' perceptions and objective measures of their abilities: although combined use reduces the sensation of tiredness and sleepiness, actual capabilities are significantly impaired.

"In Brazil, as in other countries, young people believe that Red Bull and other energy drinks avoid the sleepiness caused by alcoholic beverages and increase their capacity to dance all night," explained Maria Lucia O. Souza-Formigoni, associate professor in the department of psychobiology at the Federal University of São Paulo in Brazil and corresponding author for the study. "In fact, many night clubs offer this mix among their cocktails."

In a previous study on the use of energy drinks among Brazilians, Souza-Formigoni said that users reported greater happiness (38%), euphoria (30%), uninhibited behavior (27%), and increased physical vigor (24%). It is unclear, however, if this indicates the ability of energy drinks to reduce the depressant effects, increase the excitatory effects of alcohol, or both.

"This study appears to show us that the use of energy drinks might predispose people to abuse alcohol when its depressant effects – or at least the perception of such effects – are masked by them," said Roseli Boerngen de Lacerda, associate professor in the department of pharmacology at the Universidade Federal do Parana, Brazil.

For the current study, participants (n=26 males) were randomly assigned to one of two groups that received either 0.6 g/kg of alcohol (n=12), or 1.0 g/kg of alcohol (n=14). All participants completed three experimental sessions in random order, seven days apart: ingesting alcohol alone, energy drink alone, or alcohol and energy drink combined. At each session, researchers recorded the participants' subjective sensations of intoxication, as well as objective measures of their motor coordination, breath alcohol concentration, and visual reaction time.

Compared to the ingestion of alcohol alone, the combined ingestion of alcohol and Red Bull® significantly reduced the subjects' perception of headache, weakness, dry mouth and impairment of motor coordination. Red Bull® did not, however, significantly reduce deficits caused by alcohol on objective measures of motor coordination and visual reaction time.

"There are two key points," said Souza-Formigoni. "Although combined ingestion decreases the sensation of tiredness and sleepiness, objective measures of motor coordination showed that it cannot reduce the harmful effects of alcohol on motor coordination. In other words, the person is drunk but does not feel as drunk as he really is. The second important point is that many users reported using energy drinks to reduce a not-so-pleasant taste of alcoholic beverages, which could dangerously increase the amount (as well as the speed of ingestion) of alcoholic beverages."

"The implications of these findings," added Boerngen, "are that this association of alcohol and energy drinks is harmful rather than beneficial, as believed by consumers. Especially because those individuals who combine alcohol and energy drinks, believing they are less impaired than reality would indicate, are actually at an increased risk for problems such as automobile accidents."

"Alcohol affects not only the motor coordination but also the capacity of decision, because it affects one important area of the brain - the prefrontal cortex," explained Souza-Formigoni. "Drunk drivers are dangerous not only because their reactions are delayed and motor coordination affected, but mainly because their capacity to evaluate the risks to which they will be exposed is also affected. People need to understand that the 'sensation' of well-being does not necessarily mean that they are unaffected by alcohol. Despite how good they may feel, they shouldn't drink and drive. Never."

Both Boerngen and Souza-Formigoni spoke of the need for further studies to test higher doses of both alcohol and energy drinks, which Souza-Formigoni is doing with the use of animal models. "We are also testing separately the different substances of energy drinks – caffeine, taurine, etc. – in combination with alcohol to determine which of them are responsible for [for what effects during] interaction."

###
Alcoholism: Clinical & Experimental Research (ACER) is the official journal of the Research Society on Alcoholism and the International Society for Biomedical Research on Alcoholism. Co-authors of the ACER paper, "Effects of Energy Drink Ingestion on Alcohol Intoxication," were: Sionaldo Eduardo Ferreira, Marco Túlio de Mello, and Maria Lucia Oliveira de Souza-Formigoni of the Department of Psychobiology at the Federal University of São Paulo, Brazil. The study was funded by the Associação Fundo de Incentivo à Psicofarmacologia, the Conselho Nacional de Desenvolvimento Científico e Tecnológico, and the Fundação de Amparo à Pesquisa do Estado de São Paulo.

Contact: Maria Lucia O. Souza-Formigoni, Ph.D.
mlformig@psicobio.epm.br
55-115-539-0155
Federal University of Sao Paulo
Roseli Boerngen de Lacerda, Ph.D.
boerngen@bol.com.br
55-419-139-4761
Universidade Federal do Parana

Staten Island Incident

2006-01-10T12:01:00.000-08:00

We all recall the Staten Island ferry accident three years ago. In this incident a comuter ferry, after crossing New York Harbor, inexplicably ran into the dock, killing 11 people. The cause of this accident was difficult to figure, although it did seem to be a sudden lapse on the part of the pilot rather than any kind of equipment failure. Rumors circulated about the pilot’s health.

Well, now the details are out. Captain Richard Smith was sentenced yesterday to 18 months in prison and has apologized to the families of the victims. Capt. Smith, suffering from extreme fatigue and from the effects of pain killers, simply blacked out while docking the ferry. The ship hit the concrete maintenance pier at full speed. There were 1,500 passengers on board at the time of the collision.

Two points: 1. It could have been much worse. 2. It could have been prevented.

My drive and another drive

2005-11-29T17:24:00.000-08:00

My daughter's flight came in to Oakland, California at 6:30 PM on Monday. I picked her up and we drove the 350 miles south on Highway 101 to Carpinteria. We stopped for a 30 minute dinner and got in at 11:30 PM, 6 hours of driving, no big deal. After dropping her off at school, I thought about driving home to Alameda (350 miles) but, as I began to think about how tired I was, I decided to motel it for the night.

The following morning, as I was leaving the Best Western in Carpinteria, the headline on the Santa Barbara News-Press caught my attention, "Fatigue cited in deadly crash." The subhead read: "Accident kills man. pregnant woman."

A Greyhound bus on highway 101 - the same highway I was driving that day - had gone off the road, turned over and killed three of the 44 passengers. Many others were badly injured. Why had this happened?

The bus driver, a 63 year old man named Samuel Henry Bishop, had started his shift at 8 PM on Saturday (11/26/05) in Fresno. He drove a bus loaded with people to Los Angeles. The article says that it should have taken him 5 1/2 hours - according to the Greyhound schedule. So, in theory, he was done with that drive at 1:30 AM on Sunday. I say "in theory" because it was in holiday traffic. He then got behind the wheel of a second bus at 3:15 AM in Los Angeles for the drive to San Luis Obispo. The bus was seen to drift off the road at 7:10 AM near Santa Maria, hit a tree and flip over. The driver had been working for 11 hours at that point. (He may have been driving for 12 or 13 hours if he had to commute to work.)

I know Greyhound has a good safety record. And I know many drivers can work for 11 hours. But, I suspect that this driver was exhausted and simply fell asleep at the wheel. No drugs or alcohol were involved. Holiday traffic is a whole level of difficulty harder to deal with and that may have added to his stress.

Imagine how much harder it is to drive a bus load of people than it is for me to drive my car. And I was tired from half the driving he did. But the schedule speaks for itself and we need to see his shift schedule.

I thought about it as I was driving home. Could BLT technology have prevented this accident? Yes. Had the driver taken an alertness test at the end of his first drive, it is likely he would have been unable to perform near his baseline. Furthermore, if he knew he would have to take such a test, it is probable he would not have even tried it. The deterrent effect of this technology may be its most valuble contribution to workplace safety.

Nuclear Fatigue and the NRC

2005-11-04T07:01:00.000-08:00

Think of the nuclear power industry and you think of controlled risk, of operators in huge control rooms monitoring dials and computer screens, all day every day, until something happens. And nothing much happens - a perfect formula for the conditions that promote fatigue and inattention.

The Nuclear Regulatory Commission “NRC” is deeply concerned with these issues though. They have done some of the best studies available on fitness for work testing. They are acutely aware that maintaining operator vigilance is very important.

In the following article, extracted from their web archives, particularly note the attention paid to the under representation of fatigue as a causal factor in reported incidents. This is a common problem in industry.

Extract from the NRC report: ASSESSMENT OF THE NRC’S “POLICY ON FACTORS CAUSING FATIGUE OF OPERATING PERSONNEL AT NUCLEAR REACTORS” (See NRC - Reading Room)

"Incidence of Fatigue-Related Events

Only a limited number of events at nuclear power plants have been directly attributed to fatigue. This may be in part be the result of the levels of defense-in-depth at nuclear power plants which redesigned to reduce the potential for personnel errors to have consequential effects on plant safety. However, the staff is not able to state with certainty the actual number of events that result from fatigue, and any estimates should be interpreted with caution. In fact, plant incident reports typically do not contain much of the critical information needed to determine the contribution of human error. As noted in an EPRI report concerning control room operator alertness, “it is often necessary to rely on anecdotal evidence when presenting the case for the critical importance of operator alertness in the safe and efficient operation of a nuclear power plant” (EPRI, 1990).

One reason that the staff believes that the number of events attributed to fatigue may be underrepresented is that the research literature and operational data suggest that the conditions of shift work in nuclear power operations are such that one would reasonably expect personnel to be at risk of fatigue-induced impairment.

This research includes the following examples:

• Studies show that personnel who work more than 12 hours a day are at increased risk of personnel error (Folkard, 1997; Dawson and Reid, 1997; Rosa, 1991). The NEI data concerning the use of deviations from the policy statement indicate that thousands of 24 person-hours are worked by personnel when they are at increased risk of impairment (see Section 6).

• Several studies show that nuclear power plant personnel exhibit circadian variations in alertness, and there are variations in the incidence of nuclear power plant personnel errors and events that coincide with these circadian variations in alertness (Bobko, 1998; Cox and Cox, 1996; Maloney, 1992).

• Studies show that personnel who are fatigued have impaired ability to maintain their attention (Harrison and Horne, 2000; Williamson, 2000; Bobko et al., 1998; Dawson and Reid, 1997; Dinges, 1995; Dinges, 1992; Rosa, 1991). The staff reviewed the Human Factors Information System (HFIS) data for 1997 through 1999 and found more than 5,000 instances of less-than-adequate independent verification, self-checking, and awareness or attention.

These data were compared with HFIS data on findings related to the use of overtime. This analysis revealed that nuclear plants with repeated findings concerning use of overtime have a 50-percent higher incidence of HFIS causal factors related to fatigue. Another reason that the staff believes that the number of events attributed to fatigue is underrepresented is that event investigation methodologies may not adequately address fatigue as a root cause, as indicated by the following factors:

• Depth of assessment – Most incidents at nuclear power plants are not subjected to an in-depth analysis that would identify fatigue as the underlying cause. Licensee event reporting requirements (10 CFR Parts 50.72 and 50.73) have not included causes of human performance problems at a level that would necessarily identify fatigue.

• Root cause assessment tools – There are no accepted criteria or structured approaches for evaluating the role of fatigue in accidents (Rosekind et al., 1997). As a result, when events are subjected to root cause assessment, fatigue may still not be identified. McCallum and Raby (1995) assessed investigation procedures employed by the NRC, the Federal Aviation Administration (FAA), and several international transport authorities. They found that the existing procedures do not adequately address the factors underlying fatigue as a causal element in cases in which the initial screening suggests fatigue as a factor.

• Lack of objective proof – When conducting a root cause analysis of events that involve personnel error, it is difficult to conclude that fatigue is a cause because there is little objective proof, absent the person sleeping, that the individual was impaired by fatigue. Even when nuclear plant personnel have been found with their eyes closed, they have asserted that they were not asleep, and investigators have concluded that the individual was “inattentive” (e.g., Peach Bottom, 1989).

• Ease of substantiating event causal factors – Fatigue degrades an individual’s abilities but does not necessarily cause the event. For example, the alert individual recognizes an error in a procedure, whereas the fatigued individual does not and implements an incorrect procedure. As a result, an investigator would focus on objective contributing factors (e.g., the procedure error) or describe the behavior (e.g., cognitive error) without citing a contributor, such as fatigue, that is difficult to substantiate.

• Accuracy of post-event observations – When individuals are debriefed following an incident, they may appear alert because of the stimulation of responding to, or potential consequences of, the event. Impairment from fatigue would not be readily apparent in such circumstances.

• Accuracy of self-assessment – Although self-assessment of fatigue can often indicate the level of fatigue, research suggests that other factors may influence such self-assessments (Wylie et al., 1996; Dinges, 1995 ). In addition, studies have shown that individuals may believe that they are relatively more alert than indicated by physiological indices (Wylie et al.,1996; Dinges, 1995; Rosekind and Schwartz, 1988).

• Veracity of self-assessment – For various reasons, individuals may be reluctant to
acknowledge that they were fatigued at the time of an event involving personnel error, including the implication that they were not fit for duty (Horne and Reyner, 1995).

One outcome of these challenges to identifying fatigue as a causal factor is that the investigation identifies the observable effects or consequences of fatigue, rather than fatigue itself. Other agencies and investigative bodies have come to similar conclusions concerning the attribution of fatigue to events. A letter from Jim Hall, Chairman of the NTSB, to DOT Secretary Rodney E. Slater, dated June 1, 1999, included the following statement.

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. . . .

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 transportation accidents. Similarly, the DOT has concluded that fatigue statistics that are founded solely on accident reports underestimate the true extent of the problem (DOT, 65 FR 25545). In addition, the staff has learned that the Air Force Safety Center is revising the documentation to be used by accident investigation teams since they now believe that fatigue is underreported as a factor (Palmer et al., 1996). Also, a U.S. Coast Guard study suggests that direct measurement of fatigue may underestimate its true extent (Maritime Safety Committee, 1997). After the Coast
Guard revised its procedures for investigating events, they found that the contribution of fatigue was 20 times greater than previous estimates.

Summary
• Few events at U.S. nuclear power plants have been attributed to fatigue.
• The number of events attributed to fatigue should be interpreted with caution and cannot be reported with certainty.
• Many factors challenge the ability of event investigators to identify fatigue as a causal factor."

The full text can be downloaded from the NRC site.
The "Reading Room" link below is well worth a visit. Try searching on a relevant topic and you will be amazed at the amount of material that is available.

NRC - Reading Room

Inattention

2005-11-02T20:28:00.000-08:00

I am just going to quote this in full. Thank you DDC.

Inattention and Fatigue Primary Causes of Workplace Accidents
Jessica Walter, DDC Command Affairs

During a recent Defense Distribution Center (DDC) Safety and Occupational Health Council meeting, DDC Safety Manager Dave Mack revealed the root cause of most workplace accidents: inattention and fatigue.

According to an internal Accident Review and Analysis, one in every five accidents is due primarily to inattention on the part of the worker. “Inattention is a normal occurrence, and although we cannot eliminate it totally, we can substantially reduce inattention in the workplace by simply reminding people to work safely,” explained Mack. “People get so absorbed in what they’re doing that they don’t realize that they’re no longer paying attention to what is going on around them,” he added. Most DDC workplace injuries occur over the summer months, so Mack and his team are working to promote safety awareness by supplying DDC depots with posters and other marketing materials to remind them to stay alert. Individual behaviors, namely inattentiveness and fatigue, accounted for nearly half of the root causes of workplace accidents according to the Accident Review and Analysis. Accidents with ambiguous root causes and equipment problems accounted for the rest.

We Don't Want to Know (!)

2005-10-10T21:12:00.000-07:00

We have had many meetings with top safety managers at some of the world's leading operating companies. These men, and women, are immensely interested in impairment testing. They are well aware of how fatigue and impairment can undermine safety and, incidentally, the bottom line.

But, occasionally, we get an astonishing reaction. "We do not want to know if an employee is impaired". These are managers in companies with an elaborate system of drug testing and well financed safety programs. And keep in mind that our tests are set to detect severe impairment - the equivalent of three or four drinks. Letting someone drive a truck or operate a crane in that condition is unthinkable. But they do not want to know.

Worker and management teamwork and trust has been undermined in such places. That issue has to be addressed first. But part of this reaction comes from the need to see a way to integrate impairment testing with other testing systems and with safety in general. A company that has never tried impairment testing does not have a policy on managing the process. Handling an employee who does not pass an impairment test seems to be a major issue. So better "not to know." But, of course, these companies do have a policy on this. It is the same policy that dictates how to handle workers who come in intoxicated.

We, at BLT, do not want to write policy for a Fortune 500 company. But we can now offer a draft for their consideration. It simply outlines a series of logical steps for dealing with an employee who cannot pass an impairment test. Ask for it if you are interested.

AlertnessCentral.com is Alive!

2005-09-30T15:51:00.000-07:00

We have just introduced AlertnessCentral - our new alertness testing site. (You need a password to access the system.)

Before we introduced our alertness system on the web, we wanted to be sure quality would not be compromised. We were concerned about data privacy and with security. We also wanted to be sure that test accuracy remained consistent. But the web has grown and improved. Developments of the past three years have provided solutions to many of the problems we anticipated. Still we have been very cautious about this offering.

But after completing the sleep-deprivation trials last year in Boston, Ted and I decided it was time to take the web step. Our web team was brought in and the project was launched. The results are tremendous. This will allow us to offer web-based testing worldwide. Our customers will not have to rent or purchase hardware from us. They can simply sign on with us and be given access to the site AlertnessCentral.com.

Here is how it works. We discuss your company's needs with you and suggest a configuration for your business. We then provide authorization for any number of workers you wish to sign up. We provide a password and you are ready. Suddenly any PC in your organization is an alertness testing station, available all day, every day. Your administrator can configure the system and its reports as he wishes. And we stand by - available to do custom applications as you wish.