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    Anatomy of a Fatigue-Related Accident
    Anatomy of a Fatigue-Related Accident
    Anatomy of a Fatigue-Related Accident
    Ebook128 pages1 hour

    Anatomy of a Fatigue-Related Accident

    By James C. Miller

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    About this ebook

    How do you know whether human fatigue was a factor in causing an accident? The fatigue scorecard and scoring procedures described here will help you decide. It is relatively easy for fatigue experts to see fatigue-related factors in mishaps. However, most accident investigators do not have this insight. Nor do accident investigators have a tool for determining whether fatigue may have been a factor in a mishap. Fortunately, there is now a reasonably straightforward approach to deciding whether a mishap may be fatigue-related. Seven fatigue indicators are explained here, each with quantitative characteristics. These indicators are meant to raise “red flags” with respect to the likelihood that human performance may have been impaired by fatigue at the time of a mishap. Based upon my experiences over the last four decades, the scorecard should be useful in the field in mishap investigations in commercial and non-commercial highway accidents; mishaps in commercial, general and military aviation; errors in aviation maintenance; mishaps in military and commercial maritime operations; accidents in rail operations; and errors committed in control rooms and command and control centers.

    LanguageEnglish
    PublisherJames C. Miller
    Release dateNov 20, 2013
    ISBN9781310879265
    Anatomy of a Fatigue-Related Accident
    Author

    James C. Miller

    I conducted 45 years of applied research and development concerning human cognitive performance and fatigue. I focused mainly on the measurement and analysis of human physical and cognitive performance in military and civil aviation; highway, rail and maritime transportation; and night and shift work. Operator fatigue was at the center of my interests after my days as an Air Force pilot in the C-130E Hercules tactical transport in Vietnam. I'm also the author of "Fatigue" in McGraw-Hill's Controlling Pilot Error series (2001), and the ASIS CRISP report "Fatigue Effects and Countermeasures in 24/7 Security Operations" (2010). In 2018-2021 I taught Physiology as an Adjunct Professor in the Department of Life Sciences, Texas &M University-Corpus Christi.

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      Book preview

      Anatomy of a Fatigue-Related Accident - James C. Miller

      Anatomy of a Fatigue-Related Accident

      James C. Miller, Ph.D. CPE

      Published by James C. Miller at Smashwords

      Copyright 2013 James C. Miller

      This ebook is licensed for your personal enjoyment only. This ebook may not be re-sold or given away to other people. If you would like to share this ebook with another person, please purchase an additional copy for each recipient. If you are reading this ebook and did not purchase it, or it was not purchased for your use only, then please purchase your own copy. Thank you for respecting the work of the author.

      Discover other titles by Dr. James C. Miller at Smashwords.com:

      Cognitive Performance Research at Brooks Air Force Base, Texas, 1960-2009

      Shiftwork: An Annotated Bibliography

      Fundamentals of Shiftwork Scheduling, 3rd Edition: Fixing Stupid

      Preface

      How do you know whether human fatigue was a factor in causing an accident? The fatigue scorecard and scoring procedures described here will help you decide. It is relatively easy for fatigue experts to see fatigue-related factors in mishaps. However, most accident investigators do not have this insight. Nor do accident investigators have a tool for determining whether fatigue may have been a factor in a mishap. Fortunately, there is now a reasonably straightforward approach to deciding whether a mishap may be fatigue-related. Seven fatigue indicators explained here, each with quantitative characteristics. These indicators are meant to raise red flags with respect to the likelihood that human performance may have been impaired by fatigue at the time of a mishap. This book shows how to score the factors in a mishap investigation. There are printable versions of the scorecard in English and Spanish at http://millergonomics.com.

      Based upon my experiences over the last four decades, the scorecard should be useful in the field in mishap investigations in commercial and non-commercial highway accidents; mishaps in commercial, general and military aviation; errors in aviation maintenance; mishaps in military and commercial maritime operations; accidents in rail operations; and errors committed in control rooms and command and control centers.

      Table of Contents

      Preface

      Chapter 1. Introduction

      Chapter 2. Fatigue

      Chapter 3. Sleep

      Chapter 4. The Body Clock

      Chapter 5. Other Fatigue Checklists

      Chapter 6. Origins of the Fatigue Factors

      Chapter 7. Length of Prior Wakefulness (LPW)

      Chapter 8. Amount of Prior Sleep for the Preceding 72 Hours (APS)

      Chapter 9. Time of Day (TOD)

      Chapter 10. Number of Night Shifts in Preceding 30 Days (NNS)

      Chapter 11. Time Zone Change and Days in Zone (TZ)

      Chapter 12. Types of Human Errors (HE)

      Chapter 13. Physical Exertion (EX)

      Chapter 14. The Fatigue Scorecard

      Chapter 15. How to Use an Activity Log

      Chapter 16. Examples

      Chapter 17. HFACS and Fatigue

      References

      Chapter 1. Introduction

      With 40 years of fatigue research and study, noticing the telltale signs of a fatigue effect in a mishap is much easier for me than it is for an accident investigator without that experience. How would you know whether human fatigue was a factor in causing an accident? Most accident investigators do not have this insight. Nor do accident investigators have a tool for determining whether fatigue may have been a factor in a mishap. The fatigue scorecard and scoring procedures described here will help you make that determination.

      The effects of fatigue on workplace safety have been studied by scientists for many decades (8,78). In 2001 I published a book that focused on how fatigue has played a role in accidents in general aviation (79). Many of my friends and I have written extensively on that subject in the ensuing years with respect to military aviation (18–20).

      Dr. Robert R. Mackie and I introduced our 1978 report concerning truck and bus driver fatigue with a description of a bus accident that occurred at 4:15 in the morning on a clear, dry road. There has been longstanding concern about the effects of fatigue on:

      - Highway safety (43,67,68,86,126);

      - Rail safety (35,47,61,72,77,92,102) ; and

      - Maritime safety (21–26,37,40,42,56–58,73,84,90,93,97,104,106,108,115,116,120).

      Fatigue effects on safety in the non-transportation workplace have also been a concern (3,6,38,41,59,63,66,94–96,98,110,113,118,119). I have cited here only a few of the many studies of fatigue effects in the workplace.

      The absence of insight about fatigue-causation in the workplace is obvious in statements from such U.S. government groups as the National Transportation Safety Board (NTSB), the Federal Aviation Administration (FAA) and the National Highway Traffic Safety Administration (NHTSA). For example, The NTSB stated in 2011:

      Fatigue-countering mechanisms must include science-based, data-driven hours-of-service limits, particularly for professional drivers, pilots, mechanics, and air traffic controllers. The medical oversight system must recognize the dangers of sleep-related medical impairments, such as obstructive sleep apnea, and incorporate mechanisms for identifying and treating affected individuals. Employers should also (1) establish science-based fatigue management systems that involve all parties (employees, management, interest groups) in developing environments to help identify the factors that cause fatigue, and (2) monitor operations to detect the presence of fatigue before it becomes a problem. Because powering through fatigue is simply not an acceptable option, fatigue management systems need to allow individuals to acknowledge fatigue without jeopardizing their employment. (http://www.ntsb.gov/safety/mwl-1.html, 30 Sep 2013)

      Similarly, the U.S. Pipeline and Hazardous Materials Safety Administration (PHMSA) stated in 2012:

      Control Room Management: Fatigue Mitigation ... Fatigue can be an important factor affecting controller performance. NTSB has recommended that PHMSA establish requirements in this area, and the PIPES Act requires that operator human factors plans include a maximum hours of service limit. Fatigue is something that affects all people at some time. The CRM rule requires that operators implement methods to reduce the risks associated with fatigue. (http://primis.phmsa.dot.gov/crm/fm.htm, 30 Sep 2013)

      Over the decades, I have provided forensic expert opinions for a number of fatigue-related highway mishaps. Most of these were run-off-the-road or lane crossing accidents that occurred when the driver fell asleep at the wheel. During the period 2001 through 2006, I assisted USAF investigation boards in a number of investigations of major aviation mishaps I provided each board with an opinion about whether fatigue was likely to have been a factor in the mishap. The mishaps included:

      - C-130E Hercules tactical transport that landed nearly 3000 feet short of the runway in Kuwait in January 2001, with three passenger fatalities

      - B-1B Lancer crash into the Indian Ocean in December 2001; all crewmembers ejected safely and were rescued

      - A fatal helicopter crash in early 2002

      - C-21 Learjet crash at Ellsworth AFB in February 2002 with two fatalities

      - F-16 Falcon friendly fire mishap at Tarnak Farm near Kandahar AB, Afghanistan in April 2002, with four Canadian Forces fatalities on the ground

      - King Air crash near Tonopah AFB in Nevada in March 2004, with five fatalities

      - B-1B gear up landing at Diego Garcia in May 2006, with no injuries

      When I have been asked to provide opinions on aviation and highway mishaps, the request has been dependent upon someone who is not a fatigue expert recognizing that such an opinion was needed. Who knows how many times a request should have been made and was not? Fortunately, there is now a reasonably straightforward, quantitative approach to deciding whether fatigue may

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