Claude Preitner Senior Medical Officer Civil Aviation Authority

     Why talk about fatigue management What is fatigue Effect of fatigue Physiology of sleep Management of fatigue

“The nose is down, the wing low, the plane is diving and turning. I've been asleep with open eyes... I kick left rudder and pull the stick back... My eyes jump to the altimeter...I'm at 1600 feet. The turn-indicator leans over the left - the airspeed drops - the ball rolls quickly to the side...My plane is getting out of control!”

          1993 DC8 @ Guantanamo Bay 1994 Air Algerie 737 @ Coventry 1997 Korean Air 747 @ Guam 1999 American Airlines MD82 @ Little Rock 2001 Crossair BAe 146 @ Zurich 2002 Challenger 604 @ Birmingham 2004 MK Airlines 747 @ Halifax 2004 Corporate Bae Jetstream 31 @ Kirkville 2004 Med Air Lear 35a @ San Bernardino 2005 Loganaira BN Islander @ Machrihanish

“ The effects of fatigue are particularly prevalent when all these three factors overlap...” The crew had:    limited sleep in the previous 48 hours been awake more than 19 hours during both day and night periods to be at a high level of alertness during a period of time (3-5 PM) associated with sleepiness.

 “Inability to function at one’s optimum level, because physical and mental exertion exceeds existing capacity” (P. Gander)  Multifactorial: ◦ Work duration and intensity (time on task fatigue) ◦ ◦ Inadequate recovery sleep, which has cumulative and dose dependant effects Working at inappropriate times in the circadian cycle

 No biochemical markers for fatigue, no breathanalyzer, no blood component  Electrical registration of ◦ ◦ ◦ ◦ ◦ heart activity (ECG) brain activity (EEG) eye movement (EOG) body core temperature measurement of blood- and urine content of enzymes and hormones

 ECG showed increased parasympathetic regulatory trend, most pronounced during return flight (indication for drowsiness)  EEG showed signs of increased sleepiness, most pronounced during return flight  Microsleeps (sleep-periods of more than 8 sec duration) were found in pilots 5 times /hour in average during the last part of the return flight

 ◦ ◦ Overtime  higher injury rate >12 h per day  37 % increase >60 h /week  23 % increase (Dembe A & al, Occup Environ Med 2005:62:588-595)  Safety and productivity reduced at night  Bhopal, Three Mile Island, Chernobyl, Exxon Valdez: all at night !

 Junior doctors: 70% more than 50 h/week, 13 % more than 70 h per week. 42% clinical error in past 6 months.

 Sleep loss, i.e < ~ 8 h per day  ◦ ◦ ◦ Continuous hours awake 17 h awake ~ 0.05 alcohol 22 h awake ~ 0.08 alcohol – legal limit 24 h awake ~ 0.10 alcohol  Sleep quality: sleep apnoea, micturition, pain, infant crying etc.  Circadian cycle upset [jet lag – night duty]

 Lack of patience / snappy  More forgetful  Instrument cross check breaks down  Reduced Situational Awareness  Slows reaction time  Reduced G tolerance  Micro-sleeps

Sleep Cycle

Awake Drowsy state REM Stage 1 Stage 2 Stage 3 Stage 4 1 2 3 4 5 6 7 8 HOURS

       Prior sleep Prior wakefulness / stress Alcohol / coffee / tea /coca Environmental/work conditions Medications Age Circadian phase

 Body functions follow a pattern through the day and night, fluctuating over app. 25 h (free run) ◦ ◦ ◦ ◦ ◦ Hormones Alertness Heart rate Body temperature Bowel function  Body responds to “zeitgebers”’ (e.g. light)  Moving to a new light/dark schedule (e.g. shift work or time zone change) can create desynchronization

Circadian Rhythm - Efficiency

The distribution, by time of day, of 6,052 vehicular accidents that were judged by investigators to be fatigue related.

1200 1100 1000 900 800 700 600 500 400 300 200 100 Midnight 6 a.m

.

Noon

Time of day International Data (N=6,052)

6 p.m.

Midnight

From Pack et al. (1995)

Shift work Jet Lag

   Crossing multiple time zones changes the zeitgebers The body’s normal circadian rhythms are disrupted Different physiological functions are out of step with each other

    The internal clock cannot adapt immediately to a new time or to a duty/rest schedule change The more time zone you cross, the longer it takes Faster adaptation with westward flights because biological clock is longer than 24 hours Faster adaptation when duty days progressively begin later each day

   Different people adapt at different rates “Evening-people” adapt faster than “morning-people” Ability to adapt decreases with age

Sleep loss Fatigue Effects of fatigue in aviation operations Circadian Rhythms

The New York Times

http://www.nytimes.com/ GLOBAL EDITION - Since 1879

LACK OF FATIGUE LEGISLATION KILLS 300 IN RUNWAY EXCURSION

Even after aviation authorities were gathered in safety seminar, early this year in Brazil, nothing was done. There is no fatigue legislation and no one is even preoccupied for the increased work hours for pilots and crewmembers. Market is dictating new labor rules everyday and authorities around the world are too startled to react, or play the game of the capitals.

In efforts to cut costs, pilots are asked to be more productive, or they will be left jobless. Manufacturers are suggesting bizarre solutions too, they are offering new harnesses for passengers to travel standing up, and went as far as proposing only one pilot in the cockpit during long-range flights.

  Fatigue management SARPS, in Annexe 6 operation of aircraft - Part 1 - International Air Transport – Aeroplanes Current proposal for amendment by the Fatigue Risk Management Task Force (FRMSTF)   FAA Fatigue management on most wanted list Regulating flight duty time limit is not enough

 SARPS Implementation via local (NZ) legislation  Part 141 requirement for operators to have a fatigue management system as part or SMS ?

 Address: ◦ ◦ Duration of work (time on task fatigue) Duration of rest  Do not generally address: ◦ ◦ ◦ ◦ ◦ ◦ Workload Circadian rhythms disruption Sleep opportunities Schedules Life away from work Safety risks associated with fatigued crewmembers 32

 An integral part of SMS designed to limit the degradation of alertness of the crew due to fatigue.

 Science-based process and flexible.

 Increase safety by reducing errors, incidents and accidents caused by low levels of alert.

Training / Education Students !! Regulations Company Policies & Procedures Individual Coping Strategies

     Encourage reporting of fatigue Allow withdraw from duty Nap permitted <45 ‘ (middle to long haul) Shift work: rotate forward i.e Morning evening, night Code of conduct for off duty rest ◦ ◦ Students Instructors

 ◦ Preventive strategies Used before duty and on layovers to reduce adverse effects of fatigue, sleep loss, and circadian disruption (scheduling)  ◦ Operational strategies Used in-flight to maintain alertness and performance

 Begin a trip /a shift as rested as possible  ◦ At home & Layovers Maximize sleep 1-2 days before departing on trip  ◦ Strategic napping can be very effective 45 minutes or less, if just before duty

 Alcohol consumption can have “major disruptive effects” on sleep quality  Exercise regularly, but avoid just before bedtime  Avoid TV or thrillers before bedtime  If you can’t fall asleep in 30 minutes, get up and engage in some relaxing activity ◦ Don’t just lay in bed and be frustrated

 ◦ ◦ ◦ ◦ Strategic caffeine consumption Best not to constantly drink caffeine before, during and after duty Use it to best increase alertness Don’t use it when already alert (start of duty or after a nap) Avoid caffeine near bedtime  Sensible nutrition and stay hydrated

 A fatigued pilot has nothing to do in cockpit  A pilot will – at best – declare himself unfit for duty due to fatigue one day too late  A pilot should be nearly as alert for duty on the last day as on the first