ORIGINAL RESEARCHPilot Fatigue Survey: Exploring Fatigue Factorsin Air Medical OperationsKevin B. Gregory, BS,1 William Wi...
information to better evaluate factors that led to the acci-          Almost half (48%) of the surveyed pilots reported be...
Figure 1. Flight phase affected by fatigue.the majority of those effects subside within about 20 min-           Strategies...
Figure 2. Rest area environmental conditions.pilots reported being able to get 4 hours or more sleep during       More tha...
Figure 3. Typical and maximum amount of sleep during EMS night shift.tions) produced results showing that pilots on extend...
Figure 4. Ability to sleep during the day.quent awakenings, and less consolidation of nocturnal sleep           occur at a...
Caffeine is another effective strategy that is known to pro-                        4. National Transportation Safety Boar...
Appendix A: NEMSPA Sleep and Fatigue SurveyFor all questions, n = 697 unless otherwise specified. Percentages may not tota...
13. Flight Assignment Category (n = 637)                                Rotor Wing                 92%              Rotor ...
23. How would you best describe the environmental conditions (lighting, temperature, and noise) for the secluded rest area...
31. How would you describe your ability to sleep during the day? (check all that apply) (n5624)                           ...
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Pilot fatigue survey exploring fatigue factors in air medical operations

  1. 1. ORIGINAL RESEARCHPilot Fatigue Survey: Exploring Fatigue Factorsin Air Medical OperationsKevin B. Gregory, BS,1 William Winn, BA, MA,2 Kent Johnson, BS, ATP,2 and Mark R. Rosekind, PhD3Abstract hours of solo flying. Later, he wrote about his experience inIntroduction: Humans confront significant physiological chal- The Spirit of St. Louis, describing his efforts to maintain wake-lenges with sleep and alertness when working in 24/7 operations. fulness in the following way, “My mind clicks on and off . . . I tryMethods: A web-based national survey of air medical pilots exam- letting one eyelid close at a time while I prop the other open withined issues relevant to fatigue and sleep management. my will. My whole body argues dully that nothing, nothing life can attain, is quite so desirable as sleep. My mind is losing resolutionResults: Six hundred ninety-seven responses were received, with a and control.”1majority of rotor wing pilots working 3/3/7 and 7/7 duty sched- Like most technologies in our 21st century world, the avi-ules. Over 84% of the pilots reported that fatigue had affected ation industry has evolved dramatically since Lindbergh’stheir flight performance; less than 28% reported “nodding off” dur- historic flight. Around-the-clock operations, ultra-long-ing flight. More than 90% reported a separate work site “rest” room range flights, overnight cargo, and on-demand air medicalwith a bed available. Over 90% reported no company policies flights are just a few examples of challenging modern avia-restricting on-duty sleep. Approximately half of the pilots reported tion operations. Although technology has changed, and willgetting 4 hours or more sleep during a typical night shift. continue to advance, the human operator working withinApproximately half reported that sleep inertia had never compro- this technological system has not evolved or changed physi-mised flight safety. Over 90% reported that it was better to sleep ologically. Today, the human operator remains responsibleduring the night and overcome sleep inertia if necessary. for safety and confronts the same physiological challengesDiscussion: Survey results reflected practices that can mitigate the so aptly described by Lindbergh. As humans, we have vital physiological requirements fordegrading effects of fatigue, including the availability of designated sleep and a stable internal biological (circadian) clock.work-site sleep rooms. As demands continue to evolve, the need When individuals lose sleep or have their internal clockremains for sustained efforts to address fatigue-related risks in the air disrupted, significant detrimental effects on waking per-medical transport industry. This includes further study of sleep iner- formance, alertness, and safety occur. This is a basic chal-tia issues and the need for alertness management programs. lenge in our modern society: humans were not designed to operate on a 24/7 basis. Abundant scientific data exist thatIntroduction demonstrate the risks associated with human operators in More than 80 years ago, Charles Lindbergh completed his round-the-clock operations.2historic transoceanic flight when he landed in Paris after 33.5 The risks and costs associated with human fatigue in 24/7 operating environments have been observed in many ways. For instance, investigations into major societal disasters such as the Exxon Valdez grounding, the Three Mile Island nuclear1. Alertness Solutions, Cupertino, CA accident, Chernobyl chemical plant, and the Space Shuttle Challenger explosion have all found fatigue to be a causal or2. Intermountain Life Flight, Salt Lake City, UT contributory factor. On a daily basis, individuals confront3. National Transportation Safety Board, Washington, DC issues with drowsy driving. The 2009 Sleep in America Poll conducted by the National Sleep Foundation estimates that inDisclosure: When this article was submitted for publication, Mark Rosekind the past year as many as 1.9 million drivers have had a crashwas the President and Chief Scientist for Alertness Solutions. On June 30,2010, he commenced service as a Board Member of the National or near miss because of driving while drowsy.3Transportation Safety Board. The views expressed in this article do not From November 2007 and throughout much of 2008, anecessarily represent the views of the Board or the United States. number of helicopter accidents in air medical transportAddress for correspondence: increased concerns about the safety of these operations.Kevin Gregory, Alertness Solutions, 1601 South De Anza Blvd, Suite 200, Because many of the fatal accidents occurred at night, ques-Cupertino, CA 95014, kgregory@alertsol.com tions have been raised about whether pilot fatigue may1067-991X/$36.00 have been a significant contributing or causal factor. InCopyright 2010 Air Medical Journal Associates February 2009, in response to these accidents, the Nationaldoi:10.1016/j.amj.2010.07.002 Transportation Safety Board held a public hearing to gatherNovember-December 2010 309
  2. 2. information to better evaluate factors that led to the acci- Almost half (48%) of the surveyed pilots reported being ondents and subsequently made recommendations based on a 3/3/7 schedule, which consists of three 12-hour day shiftstheir findings.4,5 followed by 24 hours off, followed by 3 12-hour night shifts, Limited scientific literature has examined fatigue in air followed by 6 or 7 days off. Approximately 41% of themedical transport operations. Studies have investigated issues respondents reported being on a 7/7 schedule, which consistsrelated to preexisting sleep debt before reporting for a night of 7 day shifts, followed by 7 days off, followed by 7 nightshift, the effects of different shift lengths on duty rest pat- shifts and another 7 days off before repeating the cycle.terns, and the effects of outside employment.6-8 This paper presents survey results from air medical pilots Fatigue Effectsrelated to fatigue and sleep management issues; based on the More than 84% of the pilots surveyed reported that fatiguesurvey findings, a discussion is presented of key physiological had affected their flight performance. Almost half (46%) offactors that affect fatigue and how these factors impact air the respondents indicated that both their alertness and overallmedical operations. Potential “next steps” to address fatigue performance were degraded, whereas some specified anissues in air medical operations are discussed also. Although inability to concentrate. Results for the flight phase in whichthe survey results generally support existing research on performance was most affected by fatigue are shown in Figurefatigue in aviation operations, the differences related to air 1, with more than half indicating that it was the en routemedical operations are addressed. through engine shutdown phases. Although most pilots reported being affected by fatigue,Methods more than two thirds (68%) reported never “nodding off” The 34-item (primarily multiple-choice) survey was con- during flight. Of those respondents that did report “noddingducted online in September and October of 2008 using off,” most indicated that this was a rare occurrence.SurveyMonkey (www.surveymonkey.com). The completesurvey (and results) is presented in Appendix A. Work–Rest EnvironmentDistribution occurred on a national basis through both the An aspect of EMS settings that differs from other aviationNEMSPA (National EMS Pilot Association) web site and an operations is that, like firefighters, air medical pilots may haveemail campaign. A press release also promoted the survey, the opportunity to sleep while on duty when there are nowhich was limited to emergency medical services (EMS) flight requirements. About 90% of the pilots reported a dedi-pilots only. Email address information was required to cated “rest” environment at their worksite, with the vastensure nonduplicate submissions. Participants were majority (94%) indicating that a separate room designated forassured through a written statement that their email data the pilot was available. Approximately 3% reported a dedi-would not be shared outside of NEMSPA, and that the cated area shared by the entire flight team. Most (96%)relationship between responses and personal information respondents indicated that a bed was available in the rest area.would be kept confidential. Figure 2 presents results on how the environmental condi- tions of the rest area affected sleep. More than two thirds ofResults the respondents indicated that these conditions do not inter- A total of 697 responses were received, representing fere with their ability to sleep. Only approximately 4%approximately 17% of the estimated nationwide air medical reported that the conditions made it very difficult to sleep.pilot population. Almost 93% of the respondents indicated that company policies or attitudes placed no restrictions or limits for sleep-Demographics ing on duty. Approximately 3% indicated that sleep was Most of the respondents (92%) were rotor-wing pilots, restricted to certain hours, and less than 3% reported thatwith approximately 7% fixed-wing pilots and less than 1% sleeping on duty was “tolerated, but frowned upon.”both fixed- and rotor-wing pilots. More than 98% flew sin- Approximately half (54%) of the pilots reported being ablegle pilot, with less than 2% operating in a two-pilot envi- to get 3 to 5 hours of sleep during a typical night shift.ronment. Regarding participants’ level of responsibility, Another 22% reported being able to typically get 5 or more73% were line pilots, 24% were base managers or lead hours of sleep during their night shifts. During a night shiftpilots, and approximately 3% were either a chief pilot or a when they did not fly, more than half (51%) of the pilotsdirector of operations. reported they could get 6 hours or more of sleep (Figure 3). With pilots reporting the ability to sleep during night shifts,Schedules some questions were asked regarding the effects of sleep iner- Most of the respondents (98%) reported they worked a tia on the ability of pilots to wake up quickly and respond tofixed schedule with set start and end times. Less than 2% of calls. For this survey, sleep inertia was defined “as the groggi-those who responded were “on call,” meaning that they had ness that you feel immediately after waking up” and “can sig-no “start” or “end” times associated with their shift; it started nificantly affect your performance for anywhere from 10when the pager went off. minutes to 2 hours after waking up, although it appears that310 Air Medical Journal 29:6
  3. 3. Figure 1. Flight phase affected by fatigue.the majority of those effects subside within about 20 min- Strategiesutes.” More than half (53%) of the pilots reported that sleep Approximately 60% of the pilots provided responses to aninertia had never compromised flight safety, and more than a open-ended question regarding suggestions for combatingthird reported that sleep inertia happened rarely. fatigue. Napping (42% of those that responded), exer-Approximately 11% reported that it happened occasionally. cise/activity (12%), food (8%), and caffeine (6%) were theHowever, almost 92% of the pilots responded that they most common responses. Many of the pilots identified thebelieved it was better to sleep during the night and overcome effectiveness of short naps and the importance of a nap beforesleep inertia if necessary, rather than maintaining wakefulness reporting for a night shift.or just taking short naps to prevent sleep inertia. Over 70% of the pilots reported that they needed 6 to 8 Discussionhours of sleep to feel completely rested and alert. Although This national survey of EMS pilots provides valuablethe rest area provided the opportunity for a consolidated insight into their perceptions about fatigue-related issues.sleep period during a night shift, pilots reported obtaining Respondents to the NEMSPA survey reported fatigue issuesonly 3 to 5 hours of sleep on a typical night shift, significantly that resulted in degraded alertness and performance and thatless than needed to feel rested and alert. the en route through engine shutdown phases of flight were most affected. Although generally a rare occurrence, approxi-Daytime Sleep mately one third of the pilots reported having “nodded off” Most pilots reported getting some sleep during the day after during a flight. A quarter of the pilots reported having turneda night shift in which they obtained sleep. Almost half (47%) down a flight request because of fatigue.reported this amount as less than 3 hours of daytime sleep. Survey results also showed that many positive practices areFigure 4 displays feedback on experiences with daytime sleep in place that can mitigate the negative effects of fatigue. Pilotsperiods. Although some (25%) reported being able to sleep predominately worked either a 3/3/7 or a 7/7 shift. More thanduring the day regardless of their sleep the night before, a half of the respondents reported schedules that limited con-similar number reported difficulty sleeping during the day secutive night shifts to three or four, and almost three quar-even if they were awake during the previous night. ters reported sufficient recovery periods after night shifts with Factors that affected the ability to sleep during the day 6 or 7 days off.included noise (52%), light (49%), child care needs (26%), More than 90% indicated that their company had no limi-and temperature (21%). Regarding strategies used for sleep tations or restrictions on sleeping while on duty. Most respon-before a night shift, approximately one third (30%) reported dents also reported a dedicated room with a bed as beingattempting to sleep as much as possible during the day, and available. Such facilities further enhance the potential benefitsanother 45% indicated they generally take a 1- to 2-hour or of on-duty sleep opportunities. Other results reflected the2-plus-hour nap before reporting to work. effectiveness of these rooms, as approximately half of theNovember-December 2010 311
  4. 4. Figure 2. Rest area environmental conditions.pilots reported being able to get 4 hours or more sleep during More than 8 of 10 of the surveyed pilots indicated that fatiguea typical night shift. These EMS pilots also reported the use of had affected their flight performance. Many pilots fly during anaps before reporting for a night shift, a common practice for major portion of their night shift, resulting in little, if any,individuals working at night. sleep. Obtaining the minimum amount of physiologically Although the effects of sleep inertia merit attention, the sig- required sleep during the day is difficult because of circadiannificant impairment associated with sleep loss and sleep dep- factors, and EMS pilots reported the negative effects of therivation have been well documented in numerous studies. A subsequent cumulative sleep loss.general rule of thumb that “some sleep is better than none”supports the approach that the opportunity to sleep during a Caveatsnight shift provides an effective countermeasure to the effects Although the NEMSPA survey provides valuable informa-of acute and cumulative sleep loss. tion about fatigue issues in air medical operations, the limita- Most survey respondents indicated that they believed it was tions of survey-based research must be recognized. Thebetter to sleep during the night and overcome sleep inertia if subjective nature of the data is dependent on individuals’ per-necessary, a practice supported by existing research. ceptions, personal experience, and interpretation of the ques-Furthermore, they believed that flight safety was compro- tions. In addition, individuals are often poor judges of themised by sleep inertia only on rare occasions. total sleep they obtain and of their waking alertness levels.9 Although the dedicated sleep rooms provided the opportu- Surveys, however, are effective as an initial exploratory stepnity for consolidated sleep periods during night shifts, typi- in gathering data from a diverse and dispersed population.cally these sleep periods were less than the 6 to 8 hours that Substantial information can be collected without the effort ofmost of the pilots indicated was necessary to feel rested and more intensive field studies. The survey findings then can bealert. Most pilots then reported getting some sleep during the used to concentrate subsequent efforts on relevant issues withday after a night shift. However, some of the pilots reported smaller, more focused data collection projects. Such andifficulties sleeping during the day, a physiological phenome- approach was used by the NASA Ames Jetlag/Fatiguenon that can be largely attributed to the effects of the circa- Countermeasures Program, which conducted both surveydian clock, although numerous other reasons are cited. For and field research in a wide range of aviation-related settingsmany of these pilots, the sleep obtained during their night over a period of approximately 20 years.shifts plays a significant role in reducing cumulative sleeploss, especially during the course of three to seven straight NASA Researchnight shifts. Findings from NASA studies provide a useful framework Although most EMS pilots reported the opportunity to for examining fatigue in air medical transport. Three studiessleep during night shifts, the effects of fatigue remain a risk. (in actual short-haul, long-haul, and overnight cargo opera-312 Air Medical Journal 29:6
  5. 5. Figure 3. Typical and maximum amount of sleep during EMS night shift.tions) produced results showing that pilots on extended duty that even a short nap provided significant benefits to subse-days (greater than 8 hours) were subject to less total sleep, quent alertness and performance.15earlier wakeup times, more difficulty getting to sleep, poorersleep quality, increased use of caffeine, and more physical Physiological Factorssymptoms (such as headaches, nasal congestion, and back Physiologic disruption has been shown to create significantpain). Approximately 85% of the pilots accumulated a sleep fatigue-related risks. For example, sleep is a vital physiologicdebt during their work period. Pilots in these settings devel- requirement, just as essential to human existence as food,oped strategies to counter lost sleep by using multiple sleep water, and air. Generally, the old adage of “8 hours of sleep”periods when possible during their layovers or boosting alert- holds true, as the average human adult has a daily sleep needness with the increased use of caffeine.10-12 of approximately 8 hours, although the actual range can vary In other NASA survey studies, high levels of “nodding off” from approximately 7 to 9 hours.16 The amount of sleep thatin the cockpit during flight were reported by regional (80%) an individual requires is genetically determined and cannotand corporate (71%) pilots.13,14 This contrasts with the third be simply learned or unlearned or simply overcome byof NEMSPA survey respondents that reported this issue, per- willpower or “the right stuff.”haps reflecting differences in duty schedules or cockpit envi- Estimates indicate that most adults get approximately 1 to 1.5ronments (eg, rotor vs. fixed wing). hours less sleep than is physiologically required each day.17 NASA also conducted a study that investigated the effects of When “lost” sleep adds up over time, it builds into what isplanned cockpit rest periods during trans-Pacific flight pat- termed a “sleep debt.” As an example, if an individual gets 1.5terns. Pilots in the study were split into two groups: a “nap” hours less sleep than needed over the course of a 5-day work-group that received a 40-minute planned in-flight cockpit nap week, the individual will have a 7.5-hour sleep debt at the end ofopportunity (one pilot at a time); and a “control” group with an the week, almost the equivalent of a full night of lost sleep. As aidentified 40-minute control period, but without the opportu- comparison, research has compared the performance-impairingnity to nap. Pilots were able to sleep during 93% of the nap effects of sleep loss with those of alcohol consumption. Theseopportunities, and on average fell asleep in less than 6 minutes data show that an individual with just 2 hours of sleep loss canand then slept for about 26 minutes. Subsequent in-flight per- perform at a level equal to .049% breath ethanol concentration,formance measures indicated 34% better performance by pilots or equal to the consumption of two to three 12-oz beers.18in the nap group compared with those in the control group. Three factors that can dramatically affect sleep are age,There was also a 54% improvement in measures of physiologi- alcohol, and sleep disorders. Perhaps the most dramaticcal alertness during the last 90 minutes of flight, as the control changes in sleep occur as a normal function of the aginggroup had far more “microsleeps” (5 seconds or longer in dura- process.19 At approximately age 50, significant changes intion) than the nap group. These findings clearly demonstrated sleep begin to occur that include less deep sleep, more fre-November-December 2010 313
  6. 6. Figure 4. Ability to sleep during the day.quent awakenings, and less consolidation of nocturnal sleep occur at approximately 9 to 11 am. and 9 to 11 pm. A variety ofperiods. In addition, most sleep disorders increase in preva- factors affect the specific timing of these windows of alertnesslence and severity with age. and sleepiness and the degree of change observed during these Alcohol is widely used as a sleep aid in America, yet its use times. The most powerful cue that sets the circadian clock iscan degrade both the quantity and quality of sleep.20 light, with daily exposure to sunlight as a primary source thatAlthough the amount of alcohol that leads to sleep disruption controls an individual’s circadian timing.is dependent on various factors, including tolerance and body Research has demonstrated that the internal, physiologicalmass, in general, alcohol disrupts the normal architecture of period of the circadian clock is slightly longer than the 24-sleep and can reduce sleep quantity and quality. hour clock we live on, extending to approximately 24.2 Almost 90 different sleep disorders exist and can affect sleep hours.24 Abruptly transitioning to a new schedule or timeand waking function.21 A variety of physiologic and psycholog- zone can result in desynchronization of the clock. Anywhereical factors can cause these disorders. In many cases, the indi- from a few days to a number of weeks may be needed for fullvidual sufferer is unaware of the disorder, but most sleep circadian resynchronization after disruption.disorders can be effectively diagnosed and treated at specializedcenters by board-certified sleep experts. Examples of sleep dis- Future Considerationsorders include insomnia, restless legs syndrome, circadian A variety of strategies are available that can help individualsrhythm sleep disorder, and sleep apnea.20 and organizations manage fatigue-related issues. Based on the The other principal physiologic factor that determines alert- survey results reported here, many are recognized and in use inness and performance is the circadian clock.22 Located in the the EMS industry. For individuals, naps, caffeine, and goodsuprachiasmatic nucleus of the hypothalamus, the circadian sleep habits are three straightforward strategies that can be sim-clock controls the 24-hour rhythm and fluctuations for a wide ply integrated into everyday routines. Effective scheduling poli-range of functions, including physiologic, performance, alert- cies and practices are best addressed at the organizational level.ness, behavioral, and mood. For example, each 24 hours, Naps are an especially effective strategy for managing fatigue,humans are programmed for two windows of physiological because they directly address the physiological need for sleepsleepiness and two windows of alertness. Generally, maximal and can reduce the hours of continuous wakefulness. Naps cansleepiness occurs at the lowest point of the circadian cycle, typi- be used before duty, during a shift, after a duty period, and oncally from approximately 3 to 5 am. This is the period when the off-duty days. Many of the survey respondents recognize thelowest levels in many functions will be observed, such as tem- utility of naps and reported their use, especially before nightperature, mood, and performance; and it is when most fatigue- shifts, a practice also found in NASA research with overnightrelated errors, incidents, and accidents occur.23 A second cargo pilots. The NASA study of planned cockpit nap periodswindow of sleepiness occurs during the afternoon at approxi- demonstrated that even a short sleep period could lead to sig-mately 3 to 5 pm. The two windows of programmed alertness nificantly improved alertness and performance.314 Air Medical Journal 29:6
  7. 7. Caffeine is another effective strategy that is known to pro- 4. National Transportation Safety Board. Public Hearing: Helicopter Emergency Medical Services, February 3-6, 2009. Available at: www.ntsb.gov/events/Hearing-vide a boost to physiological alertness. Although less than HEMS. Accessed December 22, 2009.10% of survey respondents cited caffeine use for combating 5. National Transportation Safety Board. Four Safety Recommendation Lettersfatigue, specifics of how it is used and its effectiveness for Concerning Helicopter Emergency Medical Services. Available at:these respondents is unknown. However, research shows that www.ntsb.gov/Publictn/2009/AB09-HEMS.htm. Accessed Mar 29, 2010.using caffeine in a strategic manner (ie, best timing and effec- 6. Thomas F, Hopkins RO, Handrahan DL, Walker J, Carpenter J. Sleep and cognitive per- formance of flight nurses after 12-hour evening versus 18-hour shifts. Air Med Jtive dosage) can provide the greatest benefit for individuals, 2006;25:216-25.with up to a 30% boost in performance. Awareness of caf- 7. Frakes MA, Kelly JG. Off-duty preparation for overnight work in rotor wing air med-feine’s potential negative effects on subsequent nap or sleep ical programs. Air Med J 2005;24:215-7.periods is also important in its effective application. 8. Frakes MA, Kelly JG. Shift length and on-duty rest patterns in rotor-wing air medical Good sleep habits are another basic strategy that individuals programs. Air Med J 2004;23:34-9.can use to enhance sleep quality and quantity. These include 9. Roehrs T, Carskadon MA, Dement WC, Roth T. Daytime sleepiness and alertness. In: Kryger MH, Roth T, Dement WC, editors. Principles and practice of sleep medicine.establishing a pre-sleep routine that can be used at any time or 4th ed. Philadelphia: Elsevier; 2005:39-50.any place (eg, at home or at a work site rest area), relaxation 10. Gander PH, Graeber RC, Foushee HC, Lauber JK, Connell LJ. Crew factors in flightskills, or using sleep aids such as eye masks or earplugs. operations II: psychophysiological responses to short-haul air transport operations For organizations, scheduling policies and practices are the (Technical Memorandum 108856). Moffett Field, California: National Aeronauticsmost direct mechanisms for addressing fatigue issues. Most and Space Administration; 1994. 11. Gander PH, Graeber RC, Connell LJ, Gregory KB. Crew factors in flight operations VIII:respondents reported the availability of dedicated rooms for factors influencing sleep timing and subjective sleep quality in commercial long-on-duty sleep opportunities and company policies that placed haul flight crews (Technical Memorandum 103852). Moffett Field, California:no limits or restrictions on sleeping while on duty. Pilots National Aeronautics and Space Administration; 1991.reported predominantly working either a 3/3/7 or a 7/7 shift, 12. Gander PH, Gregory KB, Connell LJ, Miller DL, Graeber RC, Rosekind MR. Crew factorsand over half reported schedules that limited consecutive in flight operations VII: psychophysiological responses to overnight cargo opera- tions (Technical Memorandum 110380). Moffett Field, California: Nationalnight shifts to three or four. Aeronautics and Space Administration; 1996. Like Charles Lindbergh and modern pilots working in various 13. Co EL, Gregory KB, Johnson MJ, Rosekind MR. Crew factors in flight operations XI: Aother aviation settings, air medical transport pilots deal with survey of fatigue factors in regional airline operations (Technical Memorandumissues related to fatigue, sleep loss, and circadian disruption. As 208799). Moffett Field, California: National Aeronautics and Space Administration;technologies and operational demands continue to evolve, we 1999. 14. Rosekind MR, Co EL, Gregory KB, Miller DL. Crew factors in flight operations XIII: Aneed sustained efforts to address fatigue-related risks in the air survey of fatigue factors in corporate/executive aviation operations (Technicalmedical transport industry. For example, the sleep inertia issue Memorandum 2000-209610). Moffett Field, California: National Aeronautics andshould be further studied. Scheduling policies and practices Space Administration; 2000.should be evaluated to determine which are most effective or 15. Rosekind MR, Graeber RC, Dinges DF, Connell LJ, Rountree MS, Spinweber CL, etwhat may need revision. Although experienced pilots develop al. Crew factors in flight operations IX: effects of planned cockpit rest on crewpersonal strategies for dealing with fatigue, a NASA survey of performance and alertness in long haul operations (Technical Memorandum 108839). Moffett Field, California: National Aeronautics and Spacecorporate aviation pilots found that almost 80% had received no Administration; 1994.formal training on fatigue-related issues.14 Education and train- 16. Wehr TA, Moul DE, Barbato G, Giesen HA, Seidel JA, Barker C, et al. Conservation ofing on sleep, sleep disorders, the circadian clock, and the effec- photoperiod-responsive mechanisms in humans. Am J Physiol 1993;265:R846-R857.tive use of strategies such as naps, caffeine, good sleep habits, 17. National Commission on Sleep Disorders Research. Wake up America: A nationaland light are critical for all individuals working in 24/7 opera- sleep alert. Washington, DC: National Commission on Sleep Disorders Research; 1992.tions and provide a necessary foundation for the effective imple- 18. Roehrs T, Burduvali E, Bonahoom A, Drake C, Roth T. Ethanol and sleep loss: A “dose”mentation of all other fatigue management efforts.2 Although comparison of impairing effects. Sleep 2003;26:981-5.EMS pilots have the advantage and opportunity to obtain some 19. Bliwise DL. Normal aging. In: Kryger MH, Roth T, Dement WC, editors. Principles andsleep during night shifts, fatigue remains a significant issue. In practice of sleep medicine. 4th ed. Philadelphia: Elsevier; 2005:24-38.addition to the effective scheduling policies and practices 20. Kryger MH, Roth T, Dement WC, editors. Principles and practice of sleep medicine. 4th ed. Philadelphia: Elsevier; 2005.reported by most in this survey, implementing comprehensive 21. American Academy of Sleep Medicine. International classification of sleep disorders,alertness/fatigue management programs in the challenging, sin- revised: Diagnostic and coding manual. Chicago: American Academy of Sleepgle-pilot environment of air medical transport should be given Medicine, 2001.serious consideration.25 22. Van Dongen HPA, Dinges DF. Circadian rhythms in sleepiness, alertness, and per- formance. 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Alertness management in aviation operations: Accessed December 4, 2009. enhancing performance and sleep. Aviat Space Environ Med 2006;77:1256-65.November-December 2010 315
  8. 8. Appendix A: NEMSPA Sleep and Fatigue SurveyFor all questions, n = 697 unless otherwise specified. Percentages may not total 100% per question because of rounding or multipleresponses allowed.1. Name2. Email Address3. Do you currently hold another job in addition to your EMS flying job? (If “No” skip the next question) Yes 14% No 86%4. How many hours do you spend at your additional job(s) during a typical month? (n = 153) Response Average 27 Response Total 42025. In what ways has fatigue affected your flight performance? (check all that apply) (n = 590) Can’t concentrate 21% Alertness degraded 81% Performance degraded 55% Other 15%6. When your flight performance is affected by fatigue, which phase of flight performance is most affected? (n = 566) Preflight planning 21% Enroute 42% Preflight/walk-around 5% Descent 1% Engine start/taxi 11% Approach/landing 16% Takeoff 3% Engine shutdown 3%7. How often do you catch yourself “nodding off” during a flight? (n = 637) Never 68% Somewhat frequently 1% Rarely 27% Frequently 1% Occasionally 5%8. Have you ever turned down an EMS flight request because of fatigue? (n = 634) Yes 25% No 75%9. In retrospect, are there EMS flights that you should have turned down because of fatigue? (n = 638) Yes 65% No 35%10. Sleep inertia is defined as the grogginess that you feel immediately after waking up. Sleep inertia can significantly affect your per- formance for anywhere from 10 minutes to 2 hours after waking up, although most of these effects appear to subside within about 20 minutes. In your role as an EMS pilot, how often does sleep inertia affect your performance to the point where flight safety is com- promised? (n = 641) Never 53% Somewhat frequently 1% Rarely 35% Frequently 1% Occasionally 11%11. Based on your own experience, is it better for you to remain awake during the night so that you will not feel the effects of sleep iner- tia, or is it better for you to sleep during the night and overcome the short-term effects of sleep inertia? (n = 639)It is better for me to sleep during the night and overcome sleep inertia if necessary 92%It is better for me to stay awake during the night and not have to experience sleep inertia 9%12. Please list any suggestions or ideas you may have for combating fatigue. This could include ideas that have been successful for you personally, as well as known remedies. What works for you? (n = 434)316 Air Medical Journal 29:6
  9. 9. 13. Flight Assignment Category (n = 637) Rotor Wing 92% Rotor and Fixed Wing 1% Fixed Wing 7%14. Which of the following best describes your level of responsibility? (n = 632)Line pilot with basic added responsibilities 59% Lead pilot or base manager 24%Line pilot with significant added responsibilities 14% Chief Pilot or Director of Operations 3%15. Do you fly single or dual pilot? (n = 637) Single pilot 98% Dual pilots 2%16. Are you typically “on call” or “on duty”? Being “on call” implies that you generally work from home and start your “duty” time when paged or called for a flight request. An “on duty” shift implies that you have scheduled start of shift and end of shift times. You can be “on duty” either from home or assigned to a base. NOTE: Your personal information will NOT be associated with any specific survey answers. Your identity WILL be kept anonymous. (n = 635) On Call 1% On Duty 99%17. Which statement best describes your physical work assignment? (n = 637) I work from home 2% I am assigned to more than one base 7% I am assigned to a base 91%18. How many consecutive DAY shifts do you typically work? (n = 637) 1 or 2 1% 7 41% 3 or 4 48% Greater than 7 5% 5 or 6 4% I am on call or typically don’t work night shifts 1%19. How many consecutive NIGHT shifts do you typically work? (n = 637) 1 or 2 3% 7 37% 3 or 4 53% Greater than 7 4% 5 or 6 2% I am on call or typically don’t work night shifts 1%20. How long are you typically OFF when transitioning from DAY shifts to NIGHT shifts? (n = 637) 24 hours 56% 6 to 7 days 33% 2 to 3 days 3% Greater than 7 days 2% 4 to 5 days 3% N/A 2%21. How long are you typically OFF when transitioning from NIGHT shifts to DAY shifts? (n = 636) 24 hours 5% 6 to 7 days 73% 2 to 3 days 6% Greater than 7 days 4% 4 to 5 days 7% N/A 5%22. Which of the following best describes your most secluded “rest” environment at the base where you typically work? (n = 629) Hospital waiting room 1% Hospital lounge area for employees only 1% Dedicated area shared by entire flight team 3% Separate room designated for pilot 94% I work from home 2%November-December 2010 317
  10. 10. 23. How would you best describe the environmental conditions (lighting, temperature, and noise) for the secluded rest area you identi- fied in the previous question? (n = 626) Conditions make it very difficult to sleep 4% Conditions make it somewhat difficult to sleep 28% Conditions don’t affect my ability to sleep 37% Conditions make it easier to sleep 31%24. Which best describes the sleep or rest surface provided to you in the secluded area described above? (n = 630) Bed 96% Non reclining chair (padded) 0% Fully reclining chair 1% Non reclining chair (non padded) 0% Partially reclining chair 1% Sofa/couch 3%25. Which best describes your company’s policy or attitude regarding sleeping while on duty? (n = 630) No limitations or 93% Tolerated, but frowned upon 3% restrictions Restricted to certain hours 3% Against policy, but happens anyway 1% Other restrictions 1% Not tolerated 0%26. How much do you typically sleep during an EMS night shift?Night Sleep (Night Shift) 1 hr 1-2 hr 2-3 hr 3-4 hr 4-5 hr 5-6 hr 6-7 hr 7 hrAverage/typical night 4% 7% 14% 24% 31% 17% 4% 1%(n = 607)Maximum (Most you 1% 1% 3% 7% 14% 23% 25% 25%are able to sleep if youdon’t fly) (n = 582)27. How much sleep do you typically require to feel completely rested and alert during the day? (n = 625) Less than 5 hours 5% 7 to 8 hours 30% 5 to 6 hours 21% Greater than 8 hours 3% 6 to 7 hours 41%28. How much are you typically able to sleep during the day if you HAVE BEEN AWAKE for most, if not all of the night before? (n = 624) Less than 3 hours 8% 6 to 7 hours 18% 3 to 4 hours 16% 7 to 8 hours 9% 4 to 5 hours 20% Greater than 8 hours 3% 5 to 6 hours 27%29. How much are you typically able to sleep during the day if you have been ABLE TO SLEEP for most, if not all of the night before? (n = 624) Less than 3 hours 47% 6 to 7 hours 4% 3 to 4 hours 28% 7 to 8 hours 2% 4 to 5 hours 12% Greater than 8 hours 1% 5 to 6 hours 8%30. Describe your sleeping habits during the daytime, before reporting for a night shift (check all that apply). (n = 624) I attempt to sleep as much as possible during the day. 30% It depends on how much sleep I had the night before. 38% I generally take a 1–2-hour nap before coming to work. 27% I generally take a 2 hour nap before coming to work. 25%318 Air Medical Journal 29:6
  11. 11. 31. How would you describe your ability to sleep during the day? (check all that apply) (n5624) I can sleep well during the day if I was awake the night before. 39% I have difficulty sleeping during the day even if I was awake the night before. 25% I can sleep well during the day regardless of how much I slept the night before. 25% I am able to take short naps (less than 2 hours) during the day. 32% I am generally unable to even take short naps (less than 2 hours) during the day. 2%32. Which of the following significantly (at least 25% of the time) affects your ability to sleep during the day? (check all that apply) (n = 549) Children (playing, needing 26% Work interruptions 8% attention, school) Spouse/roommate(s) 18% Social interruptions 16% Sleep area 7% Personal concerns (worrying) 14% Light 49% Work-related concerns 13% Noise 52% Additional job 2% Temperature 21% Other 20%33. How does knowing that the possibility exists for you to sleep during a night shift influence your daytime (before the night shift) sleeping habits? (n = 625)That possibility does not influence my daytime habits. 60%That possibility might influence my daytime habits if I have something important to do during the day. 27%That possibility definitely influences my daytime habits if I have something important to do during the day. 7%That possibility always influences my daytime habits. 6%34. Please add any additional comments or suggestions you may have. Note that these comments may be eventually shared throughoutthe EMS industry. (n = 335)November-December 2010 319