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Risk factors for fatigue among airline pilots

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DOI: 10.1007/s00420-016-1170-2

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Int Arch Occup Environ Health
DOI 10.1007/s00420-016-1170-2

ORIGINAL ARTICLE

Risk factors for fatigue among airline pilots

Alwin van Drongelen1,2 · Cécile R. L. Boot1,3 · Hynek Hlobil1,2 · Tjabe Smid1,2 ·
Allard J. van der Beek1,3 

Received: 25 April 2016 / Accepted: 19 September 2016

© Springer-Verlag Berlin Heidelberg 2016

Abstract  recovery (OR 1.02, 95 % CI 1.01–1.04), scored lower on

Purpose The objective of this study is to determine risk
factors for fatigue among airline pilots, taking into account
person-, work-, health-, sleep-, and lifestyle-related
characteristics.
Methods The study population consisted of 502 pilots
who participated in the MORE Energy study. Included risk
factors were either measured through an online question-
naire or provided by the company. The outcome of this
study, fatigue, was assessed using the Checklist Individual
Strength (CIS), and was defined as scoring more than 76
points on this questionnaire. The association of the risk fac-
tors with fatigue was determined using univariate and mul-
tivariate logistic regression analyses.
Results Of the participating pilots, 29.5 % scored more
than 76 points on the CIS and were classified as being
fatigued. The fully adjusted regression model showed that
person-, work-, health-, and lifestyle-related characteristics
were associated with fatigue. Pilots who were aged 31 to
40 (OR 3.36, 95 % CI 1.32–8.53) or 41 to 50 (OR 4.19,
95 % CI 1.40–12.47), an evening type (OR 2.40, 95 % CI
1.38–4.16), scored higher on work-life balance disturbance
(OR 1.22, 95 % CI 1.10–1.36), scored higher on need for
* Cécile R. L. Boot
crl.boot@vumc.nl
1
Department of Public and Occupational Health, EMGO
Institute for Health and Care Research, VU University
Medical Center, PO Box 7057, 1007 MB Amsterdam, The
Netherlands
2 et al. 2000). In addition, prolonged fatigue may affect the
KLM Health Services, Schiphol Airport, Schiphol, The
Netherlands
3 in both the occupational and home setting and has been
Body@Work TNO VUmc, Research Center on Physical
Activity, Work and Health, VU University Medical Center,
Amsterdam, The Netherlands
general health perception (OR 0.31, 95 % CI 0.20–0.47),
were less physically active (OR 0.77, 95 % CI 0.66–0.89),
and had a moderate alcohol consumption (OR 3.88, 95 %
CI 1.21–12.43), were at higher risk for fatigue.
Conclusions Higher age, being an evening type, distur-
bance of the work-life balance, more need for recovery,
a lower perceived health, less physical activity, and mod-
erate alcohol consumption were shown to be risk factors
for fatigue. Further longitudinal research is needed to
elucidate the direction of the associations found and to
evaluate the effects of possible countermeasures in airline
pilots.
Keywords  Fatigue · Risk factors · Cross-sectional study ·
Airline pilots
Introduction
Fatigue is a commonly reported problem in the general
working population. In the Netherlands, for instance,
it was found that about 25 % of the employees report to
be fatigued at work (de Vries et al. 2003). There is an
essential difference between acute fatigue and prolonged
fatigue; they have been shown to be distinct and independ-
ent phenomena (Shen et al. 2006). Whereas acute fatigue
disappears after a period of rest and is characterized by
reversibility, prolonged fatigue is not task specific and
not susceptible for compensation mechanisms (Beurskens
individual’s performance and ability to keep functioning
associated with health problems, impaired performance,
a disturbed work-life balance, sickness absence, and work

13

disability (Beurskens et al. 2000; Janssen et al. 2003; Bült-
mann et al. 2002b). In this study, the term “fatigue” reflects
the phenomenon of prolonged fatigue among employees.
It is thought that fatigue has a multifactorial etiology,
related to personal characteristics (e.g., gender, age, coping
mechanisms), health status (e.g., chronic illnesses, bad self-
rated health), lifestyle characteristics (e.g., nutrition, physi-
cal activity), and the working conditions of the individual
(Bültmann et al. 2002a, b; Lewis and Wessely 1992; Huib-
ers et al. 2004; Reynolds and Banks 2010). In a large Dutch
cohort study, it was found that the prevalence of fatigue in
different job types ranged between 0 and 44 % but that the
type of job itself could only explain 3.6 % of the variance,
emphasizing the role of other work-related aspects in the
development and course of fatigue (Bültmann et al. 2001).
One of these aspects concerns the type of schedule employ-
ees are working in. Measurements in the same Dutch
cohort found that, within the same job type, the prevalence
of fatigue differed between 18.1 % for day workers and
28.6 % for shift workers (Jansen et al. 2003b).
The airline industry is a sector in which fatigue is
a potential issue as a result of work schedules. Flight
crew schedules for instance may involve irregular work-
ing hours, long duty periods, crossing of time zones, and
insufficient possibilities to sleep (Sack 2010; Caldwell
2005). Because self-reports from pilots, operational flight
studies, and accident statistics have shown that fatigue is
a concern, the main focus of the airline industry has been
directed toward acute fatigue, trying to improve operational
safety (Caldwell 2005; Akerstedt 2000). As a result, despite
its health and performance effects, knowledge about pro-
longed fatigue in airline pilots is still scarce. This type of
fatigue has been reported as a potential problem in previous
studies, showing that, respectively, 75 % (Jackson and Earl
2006) and 91 % (Reis et al. 2016) of the participating pilots
were classified as being severely fatigued. However, more
knowledge about the risk factors for fatigue in airline pilots
is needed. Therefore, the objective of the present study is to
determine the risk factors for fatigue among airline pilots,
taking into account person-, work-, health-, sleep-, and life-
style-related characteristics.
Methods
Design and population
The study population consisted of the pilots of an airline
company who participated in the MORE Energy study. This
study was performed to evaluate the effects of an interven-
tion using a mobile application. A detailed description of
the design, evaluation, and results of this study has been
13
Int Arch Occup Environ Health
published elsewhere (van Drongelen et al. 2013, 2014). At
baseline, 2222 potential participants were invited to fill in
an online questionnaire measuring person-, work-, health-,
sleep-, and lifestyle-related factors. In total, 502 pilots were
included in the randomized controlled trial. These partici-
pants proved to be significantly younger and to include
more females, but did not differ on other aspects, compared
to the non-participants. According to Dutch law, the MORE
Energy study was exempt from Medical Ethical review.
Outcome
The outcome of the present study was fatigue. The level
of fatigue was measured using the Checklist Individual
Strength (CIS). This questionnaire has 20 items and con-
sists of four dimensions: fatigue (8 items), motivation (4
items), activity (3 items), and concentration (5 items). All
questions have seven answer options (from “yes, that is
correct” to “no, that is not correct”), leading to a sumscore
ranging from 20 to 140 points (Beurskens et al. 2000).
Fatigue was defined as scoring more than 76 points on the
CIS. This cutoff was determined among the general work-
ing population in the study by Bültmann et al. (2000) and
was shown to lead to a specificity of 90 % and a sensitivity
of 73 %.
Potential risk factors
Included person-related risk factors were age, gender,
and chronotype. Data on the age and gender of the pilots
were provided by the airline company. Participants were
divided into four age groups (21–30, 31–40, 41–50, and
51–60 years old). The online questionnaire was used to
determine the participants’ chronotype (morning vs. even-
ing type) with the Dutch version of the Morningness-
Eveningness Questionnaire (MEQ) (Kerkhof 1984).
Work-related risk factors were job title, haul type,
and work-life balance. The airline company provided
information about the job title of the pilots (captain,
first officer or second officer) and the haul type (short-
haul vs. long-haul) they were operating. Work-life bal-
ance was measured using a short version of the Sur-
vey Work-home Interference-Nijmegen questionnaire
(SWING) (Wagena and Geurts 2000; Jansen et al.
2006). Nine items were scored on a four-point scale
ranging from “seldom or never” to “very often” (total
score 9–36). Higher scores indicate more disturbance of
the work-life balance.
The included health-related risk factors, having a
chronic disease, need for recovery, and perceived general
health, were determined with the online questionnaire. Par-
ticipants were asked to report a chronic disease (no, yes),
Int Arch Occup Environ Health
and need for recovery was measured using the 11-item
“Need for Recovery scale” from the Dutch Questionnaire
on the Experience and Evaluation of Work (van Veldhoven
and Broersen 2003). Higher scores indicate more need for
recovery. Perceived general health was measured using an
item of the Dutch version of the SF-36 Health Survey con-
taining five answering categories ranging from “bad” to
“excellent” (Ware and Gandek 1994).
The included sleep-related risk factors were sleep qual-
ity, sleep duration, and sleeping medication. Sleep qual-
ity was assessed using the Jenkins Sleep Scale, consisting
of four items (Jenkins et al. 1988). Higher scores indicate
lower sleep quality. Sleep duration (three categories rang-
ing from “>7 h” to “<6 h”) and the use of sleeping medica-
tion (no, yes) were investigated using subscales of the Pitts-
burgh Sleep Quality Index (Buysse et al. 1991).
Included lifestyle-related risk factors were body mass
index (BMI), alcohol consumption, and physical activity.
Participants were asked for their body height (m) and body
weight (kg) in order to compute their BMI (kg/m2). Alcohol
consumption was assessed using one item with five answer
categories ranging from “never” to “daily.” Because of
small numbers in the first two categories, they were com-
bined and used as a single category in the further analyses.
The amount of physical activity per week was determined
using a single question asking about the number of days
per week moderate physical exercise of at least 30 min was
performed (Pollock et al. 1998).
Statistical analyses
Means, standard deviations and frequencies were calculated
for the person-, work-, health-, sleep- and lifestyle-related
risk factors, depending on whether they were continuous
or ordinal/count variables. Subsequently, the association of
the separate risk factors with fatigue was determined using
univariate logistic regression analyses. Afterward, the risk
factors were tested for multicollinearity. If multicollinearity
(r > 0.8) was assumed, the risk factor with the lowest OR
in the univariate analysis was excluded. Next, multivariate
logistic regression analyses were performed. The person-,
work-, health-, sleep-, and lifestyle-related risk factors
were added blockwise in order to compose the final, fully
adjusted model.
Statistical analyses were conducted using SPSS version
22.0.
Results
The characteristics of the participants and the results of the
univariate analyses are shown in Table 1. Of the participat-
ing pilots, 29.5 % scored more than 76 points on the CIS
and were classified as being fatigued. The univariate analy-
ses showed that pilots aged 31–40 years were significantly
more fatigued in comparison with the youngest age group.
Gender was not associated with fatigue but chronotype
was; compared to morning types, more evening types were
fatigued. Of the work-related risk factors, only work-life
balance showed to be associated with fatigue, while more
disturbance of the work-life balance leads to more fatigued
pilots. All health-related risk factors (having a chronic dis-
ease, more need for recovery, and lower general health per-
ception) showed to be significantly associated with fatigue.
Regarding the sleep-related risk factors, better sleep quality
and quantity, and less sleep medication were significantly
associated with prolonged fatigue. In the lifestyle-related
risk factors, it could be seen that a higher BMI and less
physical activity were associated with fatigue. All risk fac-
tors were tested for multicollinearity (r > 0.8), but none of
them had to be removed from further analysis.
The outcomes of the blockwise multivariate logistic
regression analyses are shown in Table 2. The model with
the person-related risk factors showed that all age groups
were at higher risk for developing fatigue compared to the
reference category of 21–30-year-old pilots. Evening types
showed to be at higher risk for fatigue as well. Gender was
not significantly associated with fatigue. After adding the
work-related risk factors, it could be seen that the ORs
for fatigue of the 31–40 and 41–50 age groups remained
significant and increased (OR 3.16 (95 % CI 1.42–7.04)
and 3.30 (95 % CI 1.30–8.38), respectively). The OR of
the evening types increased to 2.52 (95 % CI 1.59–3.99).
Of the work-related factors, only work-life balance was
significantly associated with fatigue, while more distur-
bance led to more fatigue (OR 1.43, 95 % CI 1.31–1.55).
Adding the health-related risk factors in the next block led
to a further increase in the ORs of the 31–40 and 41–50
age groups. In addition, need for recovery and perceived
general health showed to be significantly associated with
fatigue as well. More need for recovery was associated
with more fatigue (OR 1.02, 95 % CI 1.01–1.04), while
a better perceived health was associated with less fatigue
(OR 0.26, 95 % CI 0.17–0.38). Adding the sleep-related
risk factors did not lead to any relevant changes in the
ORs of the person-, work-, or health-related risk factors.
Moreover, none of the sleep-related risk factors showed
to be associated with fatigue. Adding the lifestyle-related
risk factors did not lead to any relevant changes in the ORs
of the previously added risk factors either. The amount of
moderate physical activity showed to be negatively asso-
ciated with fatigue (OR 0.77, 95 % CI 0.66–0.89), and
the group of pilots who indicated to consume alcohol
once a week were more fatigued compared to pilots who
indicated to drink up to once a month (OR 3.88, 95 % CI
1.21–12.43).
13
 Int Arch Occup Environ Health

Table 1  Characteristics of the Category Characteristic N % OR (95 % CI)

pilots (n = 502) and results of
the univariate logistic regression Outcome CIS score > 76 No 354 70.5
analyses
Yes 148 29.5
Person Age 21–30 78 15.5 Reference
31–40 145 28.9 2.14 (1.11–4.15)
41–50 208 41.4 1.74 (0.92–3.30)
51–60 71 14.1 2.01 (0.95–4.27)
Gender Female 34 6.8 Reference
Male 468 93.2 1.00 (0.47–2.16)
Chronotype Morning type 297 59.2 Reference
Evening type 205 40.8 1.64 (1.11–2.41)
Work Job title Captain 224 44.6 Reference
First Officer 193 38.4 1.18 (0.77–1.80)
Second Officer 85 16.9 1.15 (0.67–1.99)
Haul type Short-haul 144 28.7 Reference
Long-haul 358 71.3 1.24 (0.80–1.91)
Work-life balance (range 9–36) Mean (SD) 12.9 2.9 1.36 (1.26–1.47)
Health Chronic disease No 482 96.0 Reference
Yes 20 4.0 2.49 (1.02–6.12)
Need for recovery (range 0–100) Mean (SD) 56.4 26.5 1.04 (1.03–1.05)
General health (range 1–5) Mean (SD) 3.4 0.8 0.20 (0.14–0.29)
Sleep Sleep quality (range 0–20) Mean (SD) 7.5 4.0 1.18 (1.12–1.25)
Sleep duration >7 h 175 34.9 Reference
6–7 h 226 45.0 1.21 (0.77–1.91)
<6 h 101 20.1 2.73 (1.62–4.62)
Sleep medication No 455 90.6 Reference
Yes 47 9.4 3.07 (1.67–5.64)
Lifestyle BMI (kg/m2) Mean (SD) 24.1 2.4 1.16 (1.06–1.25)
Moderate physical activity (days/week) Mean (SD) 3.4 1.9 0.72 (0.64–0.80)
Alcohol consumption Up to once a month 33 6.6 Reference
Once a week 124 24.7 1.80 (0.77–4.20)
Sevendays/week 297 57.0 0.90 (0.40–2.02)
Daily 48 9.6 1.10 (0.41–2.95)

Discussion comparison, previous studies found inconclusive evidence

Main findings
The results of this study showed that fatigue in airline pilots
was univariately associated with several person-, work-,
health-, sleep-, and lifestyle-related risk factors. Once the
potential risk factors for fatigue were analyzed together,
it was shown that higher age (excluding 51–60-year-old
pilots), being an evening type, disturbance of the work-life
balance, more need for recovery, a lower perceived health,
few physical activity, and moderate alcohol consumption
(once a week) remained significantly associated with fatigue.
It could be seen that being 31–40 (OR 3.36) and 41–50
(OR 4.19) years old was associated with fatigue. In
concerning the association between age and fatigue. Step-
toe and Bostock (2012) and Petrie et al. (2004) did not find
significant differences in the proportion of fatigued pilots
across age nor was fatigue correlated with years in rank,
years with current employer, or years as a pilot. In the gen-
eral population, both lacking (Bültmann et al. 2002b; Paw-
liskowska et al. 1994; Loge et al. 1998) and positive asso-
ciations (Lerdal et al. 2005; Friedberg et al. 2015) between
age and fatigue have been found in different countries.
Possible explanations for these contradictory findings
might be the usage of different scales to measure fatigue,
and the adjustment for different covariates. The associa-
tions found in our study might partly be explained by the
relatively healthy reference group of young employees.

13
 Table 2  Results of the blockwise multivariate logistic regression analysis
Category Characteristic OR 95 % CI OR 95 % CI OR 95 % CI OR 95 % CI OR 95 % CI

Person Age 21–30

31–40 2.52 1.28 4.94 3.16 1.42 7.04 3.52 1.48 8.39 3.58 1.50 8.57 3.36 1.32 8.53
41–50 2.14 1.11 4.14 3.30 1.30 8.38 4.43 1.61 12.21 4.27 1.53 11.90 4.19 1.40 12.47
Int Arch Occup Environ Health

51–60 2.43 1.13 5.25 2.97 0.94 9.37 3.23 0.91 11.38 3.12 0.87 11.18 3.57 0.91 13.98
Gender Female
Male 0.96 0.44 2.10 0.82 0.35 1.91 0.93 0.36 2.44 0.99 0.38 2.61 0.70 0.25 1.99
Chronotype Morning type
Evening type 1.84 1.23 2.75 2.52 1.59 3.99 2.35 1.41 3.93 2.36 1.41 3.95 2.40 1.38 4.16
Work Job title Captain
First Officer 1.06 0.58 1.92 1.12 0.58 2.17 1.04 0.53 2.03 1.00 0.50 2.00
Second Officer 2.38 0.94 6.02 2.37 0.86 6.51 2.30 0.83 6.39 2.14 0.74 6.20
Haul type Short-haul
Long-haul 1.14 0.64 2.05 0.77 0.40 1.51 0.76 0.38 1.49 0.74 0.36 1.50
Work-life balance (range 9–36) Mean (SD) 1.43 1.31 1.55 1.24 1.12 1.37 1.23 1.11 1.36 1.22 1.10 1.36
Health Chronic disease No
Yes 1.47 0.49 4.41 1.44 0.48 4.31 1.28 0.40 4.10
Need for recovery (range 0–100) Mean (SD) 1.02 1.01 1.04 1.02 1.01 1.04 1.02 1.01 1.04
General health (range 1–5) Mean (SD) 0.26 0.17 0.38 0.27 0.18 0.41 0.31 0.20 0.47
Sleep Sleep quality (range 0–20) Mean (SD) 1.02 0.95 1.10 1.05 0.97 1.14
Sleep duration >7 h
6–7 h 0.79 0.43 1.44 0.79 0.42 1.47
<6 h 1.17 0.55 2.49 1.10 0.50 2.44
Sleep medication No
Yes 1.72 0.76 3.92 1.97 0.83 4.69
2
Lifestyle BMI (kg/m ) Mean (SD) 1.09 0.97 1.22
Moderate physical activity (days/week) Mean (SD) 0.77 0.66 0.89
Alcohol consumption Up to once a month
Once a week 3.88 1.21 12.43
Several days/week 2.05 0.68 6.16
Daily 2.01 0.51 7.86

13

After adding the health-related variables to the analysis,
a relevant increase in the association between age and
fatigue could be seen, indicating worse health of the older
pilots. In addition, younger pilots might return home to a
household that is less demanding compared to their older
colleagues. We did not include household composition or
having children in our analyses, but it is known that both
factors are associated with a diminished tolerance to cope
with irregular working hours, and lead to an increased
risk for fatigue and chronic sleep loss (Jansen et al. 2006;
Costa 2003).
Next to age, our results showed that chronotype was
an important risk factor to consider. The odds for pilots to
suffer from fatigue was 2.4 as high for evening types com-
pared to morning types. Until now, there has not been much
literature regarding the influence of chronotype in airline
pilots. However, from shift work literature it has become
clear that short-term tolerance to irregular working hours
can depend on the chronotype of the individual and the
type of work schedules the employee with a certain chrono-
type is exposed to (Costa 2003). Van de Ven et al. (2015)
for instance found that evening types reported shorter
sleep length and more disturbed sleep during a period of
early shifts, and more sleep during a period of night shifts.
It is still unclear whether long-term tolerance for irregu-
lar working hours is higher for evening or morning types
(Costa 2003; Saksvik et al. 2011; Blok and de Looze
2011). The results of our study indicate that given the work
schedules of this group of airline pilots, evening types tend
to have a lower tolerance to their work schedules, resulting
in a higher risk for fatigue. This finding coincides with a
study among students who had to work during the evenings
and nights, in which evening types were shown to be more
sleep deprived and to have a poorer sleep quality, leading
to higher levels of fatigue in comparison with morning
types. The authors explained their findings by arguing that
the biorhythm of evening types was more disturbed due
to lower levels of light exposure and less social cues as a
result of the combination of their work schedules and pre-
ferred activity pattern (Martin et al. 2012).
Interestingly, the work-related factors job title and haul
type were not associated with fatigue in the univariate nor
the multivariate analyses of this study. More disturbance of
the work-life balance was associated with fatigue in both
types of analyses. Both findings are in accordance with the
outcomes of the previous fatigue-related studies among
airline pilots. Steptoe and Bostock (2012) and (Petrie et al.
(2004) found that job title and haul type were not associ-
ated with fatigue, although haul type was found to be of
influence in two studies among Portuguese pilots (Reis
et al. 2013, 2016). Steptoe and Bostock (2012) also found
that the prevalence of fatigue was significantly higher
among pilots who reported high job demands and low
13
Int Arch Occup Environ Health
social support. Although the association between work-life
balance and fatigue could work in both ways, Jansen et al.
(2003a) found that in male employees, factors such as psy-
chological and emotional job demands, conflicts with cow-
orkers or supervisors, irregular working hours, having full
responsibility for housekeeping, and caring for ill family
members at home increased the risk for work–family con-
flict, subsequent need for recovery, and fatigue. A similar
pathway might partly explain the results of our predomi-
nantly male sample of airline pilots as well.
Regarding the health-related risk factors, it could be
seen that more need for recovery and a lower perceived
general health was associated with more fatigue. The asso-
ciation between need for recovery (Beurskens et al. 2000),
general health (Bültmann et al. 2002a; Loge et al. 1998),
and fatigue has been clearly established in the general pop-
ulation before. In addition, the two previously mentioned
studies among airline pilots also found low self-assessed
general health to be associated with a higher risk for fatigue
(Steptoe and Bostock 2012; Petrie et al. 2004). Our results
also showed that the included sleep-related risk factors
were univariately associated with fatigue, but that none
of them were significantly associated with fatigue in the
multivariate analyses. This is a rather surprising finding.
Reis et al. (2016) for instance found a considerable higher
fatigue risk for pilots with sleeping complaints. Regarding
sleep medication, however, Petrie et al. (2004) also found
that sleep medication was not associated with fatigue of
both short- and long-haul pilots. The lacking association
between sleep and fatigue might be explained by sleep
outcome differences in the age and chronotype subgroups.
Bonnefond et al. (2006) for instance found that older air-
line maintenance employees slept significantly shorter
compared to their younger colleagues, but that this did not
lead to differences in sleepiness and performance at work.
Furthermore, van de Ven et al. (2015) found older blue-col-
lar workers to sleep shorter as well, but they also found that
age was no longer associated with sleep quality and quan-
tity outcome measures after adjustment for chronotype.
Risk factors determining sleep behavior, instead of sleep
quality or quantity outcomes, have been found to be associ-
ated with fatigue instead. A good sleep hygiene is argued to
be one of the most important factors to improve the toler-
ance to irregular working hours (Costa 2003). In addition,
strategic napping behavior might be able to improve alert-
ness and to alleviate fatigue in shift workers (Ruggiero and
Redeker 2014), and to lead to significantly lower levels of
fatigue in airline pilots (Petrie et al. 2004; Hartzler 2014).
The fully adjusted multivariate model was composed
by adding the lifestyle-related risk factors. Less physical
activity and moderate alcohol consumption were shown
to be significantly associated with fatigue. Among short-
haul pilots, Steptoe and Bostock (2012) found that fatigued
Int Arch Occup Environ Health
pilots were less likely to exercise during leisure time, indi-
cating the reciprocity of the association between these fac-
tors. In a general working population study, it was found
that not being engaged in sports activities was a powerful
predictor of fatigue and that fatigue was not related to alco-
hol consumption as well (Kristal-Boneh et al. 1996). Step-
toe and Bostock (2012) did not find an association between
alcohol consumption and fatigue either. The results of our
study showed that the group of pilots who indicated to
drink alcohol once a week was at higher risk for fatigue.
Although they did not reach statistical significance, the
ORs of the other categories also tended toward a higher risk
for fatigue. In general, limited alcohol intake is thought to
be associated with better health when compared to a refer-
ence group of nondrinkers (Roerecke and Rehm 2014). The
nondrinkers in these studies, however, often contain former
drinkers with a relative poor health status. It is possible
that we found contradictory results because the small ref-
erence group (n = 33) in our study did consist of healthy,
nondrinking pilots who had decided to abstain from alcohol
intake in order to be as fit for the job as possible.
Strengths and weaknesses
We performed an extensive study with a representative
sample of internationally operating short- and long-haul
pilots, and measured a wide range of risk factors, including
person-, work-, health-, sleep-, and lifestyle-related char-
acteristics. The results of our study, however, might have
been hampered due to selection effects, in case the pilots
decided to participate in the MORE Energy study because
they were more fatigued than their non-participating col-
leagues. It should also be acknowledged that our study is
limited by its cross-sectional nature so that causal relations
cannot be established. Another limitation of our study is
that we mainly relied on self-reports through online ques-
tionnaires, which may have caused misclassification. How-
ever, we expect this misclassification to have been non-
differential, producing a bias toward the null. Because our
outcome measure was dichotomized, a possible misclassifi-
cation of fatigue cannot be excluded either. The CIS cutoff
that was used, however, was derived in the general working
population and has been shown to have a high sensitivity
and specificity (Bültmann et al. 2000). Finally, considering
the homogeneous study population and the specific work-
ing situation of airline pilots, it is difficult to generalize the
results of our study to other working populations.
Implications
Because of the cross-sectional nature of our study,
researchers should try to confirm causality and to further
elucidate the direction of the associations found, thereby
clarifying the roles of the different person-, work-, health-,
and lifestyle-related risk factors in the development of
fatigue. For this purpose, there is a need for longitudi-
nal studies examining the relation between risk factors
for, and consequences of fatigue. In these studies, fatigue
could be treated as a continuous instead of a dichotomous
variable in order to obtain as much information as possible
about the etiology of fatigue. In addition, instead of using
self-reports, it would be valuable to explore opportunities
to include objective assessments of prolonged fatigue in
future studies, for instance by using salivary biomarkers
such as cortisol (Michael et al. 2012; Merkus et al. 2015).
In order to externally validate the results, these studies
should not only be performed among cohorts of airline
pilots, but in other employees dealing with irregular work-
ing hours as well.
Prevention of fatigue is difficult given the specific nature
of the flight schedules of airline pilots. For the companies
involved, however, it is important to pay attention to both
acute and prolonged fatigue. Whereas acute fatigue has
been shown to be associated with an increased accident
risk (Caldwell 2005; Akerstedt 2000), prolonged fatigue,
as measured by the CIS in the present study, should be
regarded as a fatigue level that puts the employees involved
at risk for future sick leave or work disability (Bültmann
et al. 2000). Our finding that 29.5 % of the participat-
ing pilots suffered from fatigue is in accordance with the
28.6 % found among shift workers in a large cohort rep-
resenting the general Dutch working population (Bültmann
et al. 2002a; Jansen et al. 2003b) and indicates that there is
a need for interventions aiming to prevent fatigue, either at
an individual or a group level.
The found higher risk for fatigue among evening types
for instance might be a reason to introduce chronotype-
dependent scheduling. Although the long-term effects are
not yet known, several studies have shown that this type of
scheduling can lead to improvements in work-life balance
(Vetter et al. 2013) and to higher tolerance toward irregular
working hours (Ingre et al. 2012). In addition, a project in
which New Zealand pilots were provided opportunities to
determine their own, chronotype-dependent, flight sched-
ules showed to lead to reduced fatigue and lower reliance
on sleep medication (Powell et al. 1998).
Because it was shown that pilots with a disturbed work-
life balance were at higher risk for fatigue, it also seems
useful to support employees with a lot of responsibilities
at home, due to for instance the care for young children or
elder family members. Since more need for recovery was
also found to be a risk factor for fatigue, has been identi-
fied as an early symptom in the pathway toward long-term
health effects of irregular working hours (Puttonen et al.
2010), and has been associated with increased disturbance
of the work-life balance (Jansen et al. 2003a), this might
13

also be an important factor that could be used to identify
individual pilots at risk for fatigue.
A possibility for prevention at a group level includes
the promotion of a healthy lifestyle and, as a possible
consequence, general health. This includes stressing the
importance of physical activity during leisure time and
healthy nutrition during duty, and might be facilitated by
the introduction of a digital health platform. Examples of
digitally applied interventions have been shown to be able
to improve behavior by tailoring information to the spe-
cific needs of the individual and can have positive effects
on health knowledge and behavior among adults (Kroeze
et al. 2006; van den Berg et al. 2007). Moreover, the RCT
of which the present study was part of showed that an inter-
vention applied through a smartphone app and consisting
of specific, to flight schedule tailored advice on exposure to
daylight, sleep, physical activity, and nutrition, was able to
reduce fatigue, and improve sleep quality, physical activity,
and snacking behavior (van Drongelen et al. 2014).
Conclusions
Although prolonged fatigue has been reported as a problem
for both health and performance, more knowledge about
this type of fatigue in airline pilots is needed. The present
study showed that the risk factors for prolonged fatigue
among airline pilots included person-, work-, health-, and
lifestyle-related characteristics; it was shown that a higher
age, being an evening type, disturbance of the work-life
balance, more need for recovery, a lower perceived health,
less physical activity, and moderate alcohol consumption
was associated with fatigue. These results provide a basis
for interventions aiming to prevent fatigue in airline pilots,
either at an individual or a group level. However, further
longitudinal research is needed to elucidate causality, the
direction of the associations found, and the effects of coun-
termeasures aiming to reduce fatigue in this specific work-
ing population.
Acknowledgments  We would like to thank all participating pilots for
their cooperation.
Funding  This study was funded through internal funding only.
Authors’ contributions In addition to the first author, all authors
have contributed to conception and design of the study and helped
to analyse and interpret the results; revised the manuscript critically
for important intellectual content; and approved the version to be
published.
Compliance with ethical standards  study. J Occup Environ Med 45(5):479–491
Conflict of interest  The authors declare that they have no conflict of
interest.
13
Int Arch Occup Environ Health
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