Transportation safety: Efforts to curb fatigue-related accidents often languish

By Tessa Muggeridge and Charlie Litton
Monday, September 27, 2010; 2:51 AM

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 monotony of the job and misses a signal.

Fatigue can't be measured like the level of alcohol in a person's system, but it 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, more than 320 fatigue-related incidents have taken nearly 750 lives in airplane crashes alone, according to an analysis by News21, a national university student reporting project, and the Washington-based Center for Public Integrity, a nonprofit investigative journalism organization.

Scientists, lawmakers, industry executives, safety advocates and operators themselves all say fatigue is an issue that needs more attention, but the regulatory process sometimes allows proposals to languish for decades.

The National Transportation Safety Board, created in 1967 to help safeguard U.S. travelers, has issued 138 fatigue-related safety recommendations since its inception. 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 NTSB has simply given up.

"We need to quit talking about fatigue and we need to start trying to do something about it," said NTSB board member Robert L. Sumwalt, a former commercial pilot.

Transportation Department Deputy Secretary John Porcari, who heads the department's new Safety Council, said the Obama administration considers fatigue "an urgent safety priority." Its efforts include establishing new rules and expanding education efforts for truckers and 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.

A problem in the air

Pilots, flight crews and air traffic controllers who report safety problems through an anonymous NASA database frequently mention fatigue as a problem.

Sumwalt said one in five reports submitted to the database is fatigue-related.

"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."

Since 1972, the safety board has issued 37 recommendations that address fatigue. Only 12 have been implemented.

The crash of Continental Connection Flight 3407 outside Buffalo in February 2009 heightened concerns about pilot fatigue. Four crew members, 45 passengers and one person on the ground were killed when the plane crashed into a house.

The NTSB found that the accident was the result of pilot error and that the pilots were probably fatigued. The captain had been awake at least 15 hours, and the first officer had gotten at most 81/2 hours of sleep in the preceding 34, according to the report.

Seventeen months after the crash, the FAA released a proposal to reduce flight and duty time requirements for pilots, similar to measures introduced in 1972 and 1995 that failed after encountering industry opposition.

"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," FAA Administrator Randy Babbitt said.

According to FAA documents, the 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 workweek. They would be able to decline assignments without penalty if they felt too fatigued to fly. And airlines would be encouraged to establish individual fatigue risk management systems.

NTSB spokeswoman Bridget Serchak said the agency will be reviewing the proposed flight-duty rules and that the board "is pleased that the effort has gotten this far along."

On the roads and rails

In 1993, the NTSB commissioned a study expecting to learn about the role of drug and alcohol use in trucking accidents. Investigators made an unexpected discovery: Fatigue turned out to be the bigger problem.

The study found 3,311 heavy-truck accidents killed 3,783 people that year, and between 30 and 40 percent of those accidents were fatigue-related.

"Drivers are paid by the mile - that's an incredible incentive to drive as far and fast as you can," said Jacqueline S. Gillan, vice president of Advocates for Highway and Auto Safety, a coalition of insurance companies and consumer, health and safety groups.

The NTSB has issued 34 recommendations regarding fatigue on the nation's roads. Seventeen have been followed.

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 a.m. outside Delia, Kan., an engineer apparently nodded off at the controls as his train rolled through several signals and flashing lights. His train lurched through a switch that connects two sets of rails and into the side of an oncoming train.

In their report, NTSB investigators said they thought 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 the engineer in enough time to avert a crash, but no such system has been implemented.

Former NTSB managing director Peter Goelz said that under rails' seniority system, veteran engineers get to select their schedules first and often 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."

Trouble at sea

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 aboard ferries and other inspected passenger vessels.

Seven years after that recommendation, 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 a.m. The pilot hadn't slept more than 51/2 hours the previous day.

When the vessel shuddered from hitting the rock, the pilot did not 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.

The pilot, who was later diagnosed with severe sleep apnea, suffered from "chronic fatigue," according to the NTSB report.

When tired, people react more slowly, struggle with attention lapses and take more unnecessary risks. The problem is compounded by a culture "that places a lot of value on burning the midnight oil," said Jana Price, an NTSB fatigue transportation research analyst.

And public attitudes toward fatigue are about the same as attitudes toward drinking and driving 20 years ago, NTSB investigator Malcolm Brenner said.

"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," he said.

Safety advocates hope that, in the near future, operating under the influence of fatigue will be just as unacceptable.

News21 reporters Ryan Phillips and Ariel Zirulnick contributed to this report.

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