Managing Fatigue in Aviation: Enhancing Flight Safety: Mark R. Rosekind, Ph.D. Board Member

Managing Fatigue in Aviation:
Enhancing Flight Safety

Mark R. Rosekind, Ph.D.
Board Member
Aviation Safety Coordinators
July 24, 2013
1) determining the probable cause

of transportation accidents
2) making recommendations to
prevent their recurrence
All Modes
Independent Federal Agency: Created in 1967
~ 132,000 accident investigations

13,500+ safety recommendations
~ 2,500 organizations/recipients
82% acceptance rate
Swiss Cheese Model (Reason)
Hazards
Accident
Successive layers of defenses, barriers, and safeguards
NTSB Characterized as:
moral compass and industry conscience

NTSB Chairman Deborah A.P. Hersman
Go! Flight 1002
early starts, multiple segment days, sleep apnea
Honorable John K. Lauber:
No Accident =
Safe Operation
Uncontrolled In-Flight Collision with Terrain

AIA Flight 808, Douglas DC-8-61, N814CK
U.S. NAS, Guantanamo Bay, Cuba, August 18, 1993
First NTSB aviation accident investigation
to cite fatigue as probable cause
acute sleep loss, sleep debt, circadian disruption
Crew Sleep
History
8/17/93
8/16/93
0000
0800
1600
2400
0800
8/18/93
1600
2400
0800
1600
2400
Accident MGUM
Capt.
8h
9h
2h
17.5 h
F/O
8h
9h
2h
19 h
F/E
9.5 h
15 h
Sleep
6h
9h
Wake
5h
23.5 h
8h
19 h
6h
21 h
Duty
Observed Performance Effects

Degraded decision-making
Visual/cognitive fixation
Poor communication/coordination
Slowed reaction time
Uncontrolled In-Flight Collision with Terrain

AIA Flight 808, Douglas DC-8-61, N814CK
U.S. NAS, Guantanamo Bay, Cuba, August 18, 1993
The National Transportation Safety Board

determines that the probable causes of this
accident were the impaired judgment, decision
making, and flying abilities of the captain and

flight crew due to the effects of fatigue
Owatonna, MN (July 31, 2008)
8 fatalities
Owatonna Crew Fatigue Factors

acute sleep loss (Capt/FO)
cumulative sleep debt (FO)
early start time (Capt/FO)

excessive sleep need (Capt)
insomnia (FO)
self-medicate/prescription sleep med (FO)
Probable Cause/Contributing Factors
Contributing to the accident were . . .

(2) fatigue, which likely impaired both
pilots performance; . . .
Fatal Airline Accidents (Examples)

(fatigue cited)
8/97 Guam: 228 fatalities
6/99 Little Rock AK: 11 fatal
10/04 Kirksville MO: 11 fatalities
8/06 Lexington KY: 49 fatalities
7/08 Owatonna MN: 8 fatalities
2/09 Buffalo NY: 49 fatalities
Challenges of a 24/7 Society
Fatigue Risks
Fatigue can degrade

every aspect of
human capability.
Fatigue Risks
awake/alert
asleep
reduced performance
variability
Fatigue Risks
degraded 20 50%+:
- reaction time
- judgment
- memory
- attention
- communication
- mood
- situational awareness
increased:
- irritability
- apathy
- attentional lapses
- microsleeps
Fatigue and Reaction Times
Doran SM, Van Dongen HP, Dinges DF. Sustained attention performance during sleep deprivation:
evidence of state instability. Archives of Italian Biology: Neuroscience 2001;139:253-267.
Alertness Reports Often Inaccurate

Subjective
alertness
1
4
7
20
Physiological
alertness
15
10
Time
Adapted from Sasaki et al., 1986
Fatigue Factors
sleep
circadian clock
hours awake
sleep disorders
NTSB Safety Recommendations: Fatigue

40 years ago: May 10, 1972
Revise FAR 135 to provide adequate

flight and duty time limitations. (A-72-55)
Classified Closed-Unacceptable
NTSB Recommendations
MOST WANTED 1990 - 2012

~200 fatigue recommendations
Complex Issue:
Requires Multiple Solutions
Scheduling Policies and Practices
Education/Awareness
Organizational Strategies
Healthy Sleep
Vehicle and Environmental Strategies
Research and Evaluation
NTSB Recommendations:
Education/Strategies
Develop a fatigue education and
countermeasures training program
Educate operators and schedulers
Include information on use of

strategies: naps, caffeine, etc.
Review and update materials
NTSB Recommendations:
Education/Strategies
Include information on use of
strategies: naps, caffeine, etc.
No recommendations on
specific personal strategies
Manage Fatigue = Enhance Safety

Acknowledge risks
Educate everyone
Strong policies
Take action/use strategies!
Promote culture change
Good sleep, safe travels

Managing Fatigue in Aviation: Enhancing Flight Safety: Mark R. Rosekind, Ph.D. Board Member

Uploaded by

Copyright:

Available Formats

Managing Fatigue in Aviation: Enhancing Flight Safety: Mark R. Rosekind, Ph.D. Board Member

Uploaded by

Document Information

Original Description:

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Managing Fatigue in Aviation: Enhancing Flight Safety: Mark R. Rosekind, Ph.D. Board Member

Uploaded by

Copyright:

Available Formats

Managing Fatigue in Aviation:

Enhancing Flight Safety

1) determining the probable cause

Independent Federal Agency: Created in 1967

~ 132,000 accident investigations

Swiss Cheese Model (Reason)

NTSB Characterized as:

moral compass and industry conscience

Go! Flight 1002

early starts, multiple segment days, sleep apnea

Honorable John K. Lauber:

Uncontrolled In-Flight Collision with Terrain

acute sleep loss, sleep debt, circadian disruption

Observed Performance Effects

Uncontrolled In-Flight Collision with Terrain

The National Transportation Safety Board

making, and flying abilities of the captain and

Owatonna, MN (July 31, 2008)

Owatonna Crew Fatigue Factors

early start time (Capt/FO)

Probable Cause/Contributing Factors

Contributing to the accident were . . .

Fatal Airline Accidents (Examples)

Challenges of a 24/7 Society

Fatigue can degrade

Fatigue and Reaction Times

Alertness Reports Often Inaccurate

Adapted from Sasaki et al., 1986

NTSB Safety Recommendations: Fatigue

Revise FAR 135 to provide adequate

MOST WANTED 1990 - 2012

Include information on use of

Manage Fatigue = Enhance Safety

Good sleep, safe travels

You might also like