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NTSB/NASA Fatigue Forum, Tysons Corner, Virginia
Jim Hall
NTSB/NASA Fatigue Forum, Tysons Corner, Virginia

(final published version)

Good morning. I would like to welcome everybody to this symposium, probably the first time so many leaders of government and the private sector have been gathered in one place to address one of the major hazards of transportation -- fatigue. With the help of the National Aeronautics and Space Administration, we have put together what we hope will be an educational and thought-provoking conference that will, in the end, save lives.

I want to make sure I acknowledge the tireless work of Julie Beal, the Safety Board's Director of Public Affairs, and her committee for planning, organizing and running this conference. And I want to thank Dr. Mark Rosekind of NASA for his invaluable contribution to the concept and organization of this event.

As you probably know, the National Transportation Safety Board is an independent federal agency with two major tasks: to determine the probable causes of major transportation accidents and to issue safety recommendations aimed at preventing such accidents. We fulfill this mandate in several ways: by investigating accidents, by conducting safety studies, and by convening symposiums like the one we're beginning today.

Although fatigue has assuredly been with us for a long time, it was not until the industrial age and the advent of complex machinery that fatigue became a major hazard to life and limb. With the increasing industrialization of society, people are exposed more and more to the dangers of fatigue. Today, we need only drive from our homes, live near railroad tracks, or board an airplane to face first-hand potential dangers from operator fatigue.

The Safety Board issued nearly 80 fatigue-related safety recommendations since 1972 to the modal administrations in the Department of Transportation, transportation operators, associations and unions. As a result of our experiences in investigating accidents in all modes of transportation over the years, we grew to appreciate the importance of human factors studies and established a human performance office in 1983.

In 1989, we issued three major safety recommendations to DOT, calling for a coordinated and aggressive federal program to address the fatigue problem in all sectors of the transportation industry. (A copy of those recommendations is in your conference binder) In the intervening 6 years, DOT launched initiatives to address these recommendations, and Secretary Pena will undoubtedly describe them to you in depth tomorrow.

The fact is, however, that while we all study the problem, accidents continue to happen. You will hear later this morning about some of the larger accidents the Safety Board investigated in recent years where fatigue was a cause or factor -- the EXXON VALDEZ; the Thompsontown, Pennsylvania freight train collision; and the crash of a DC-8 at Guantanamo Naval Air Station are just three examples.

What is interesting about fatigue is that every one of us here knows exactly how it feels and what it does to us. We've all experienced the dramatic effects of extreme fatigue when we've tried to drive an hour longer than we should, or we tried to stay up to watch a movie, or we tried to act interested listening to one of my speeches.

Oftentimes, though, the effects of fatigue are more subtle and, therefore, more insidious. In the past it was difficult to identify fatigue as a causal factor in an accident investigation. But we are getting better at it, and, more importantly, we're beginning to learn how to counteract it. If you don't already, you will have a good handle on this by the time you leave tomorrow afternoon.

The factors contributing to fatigue are becoming increasingly prominent.

Our society now demands that goods be shipped anywhere in the country -- or even around the world -- overnight. Many factories have adopted just-in-time materials delivery.

Trucking deregulation might have been a boon to businesses and consumers by resulting in lower rates, but it didn't alleviate the problem of fatigue for truck drivers. On the contrary, it might have added to the pressures that lead to fatigue.

Commuter airline pilots often fly a dozen legs in one day, and after a shortened rest period, do it again the next day. The jet age made it possible for both passengers and crew members to experience jet lag, which can cause fatigue by rapid travel across time zones, that even rest cannot immediately alter. As the demand for goods and the availability of transportation continues to grow, and the time we want to wait for such services continues to decrease, we see vehicles getting larger and larger:

  • Jumbo jets now carry more than 500 passengers, and aircraft are on the drawing board that would carry more than 1,000.
  • The average size of ships calling at U.S. ports grew five-fold in the last 50 years, with crew sizes cut in half. In many major ports, the normal clearance from the bottom of the harbor for these deep-draught ships is often as little as two feet.
  • Where once we mostly saw 10-ton vegetable trucks on our highways, we now see double-bottom and triple-trailer trucks on the interstates.
  • More than 200 million hazardous materials shipments cross-cross the country every year by road and rail.

This conference will highlight for you the importance of fatigue countermeasures, and how they can be applied to prevent accidents in all modes of transportation. The American taxpayer invested millions of dollars in research into programs that examine fatigue. This forum presents an opportunity for us to learn specifically about the NASA countermeasures program, as well as sharing information on specific research projects currently underway.

In recent years, Congress has set up the National Commission on Sleep Disorder Research, and issued a report on the role biological rhythms play in fatigue. As I've already mentioned, DOT took initiatives on several fronts to study fatigue. Along with the trucking industry, DOT is conducting a truck driver fatigue study and an older driver study. We at the Safety Board early this year completed a major study on truck driver fatigue.

We applaud all that has been accomplished in the field of research from the government, academia and the private sector. But at some point we must decide that, while research should never end, the time for study must yield to a time for action. It is time to put what we have learned, and what has been provided to us by the taxpayer, into the hands of the transportation operators for the protection of the American people.

This conference is structured around another government funded study, the Fatigue Countermeasures Program developed by Dr. Mark Rosekind at NASA Ames Research Center. Although developed for aviation, it can be adapted for the other modes of transportation as well.

This kind of "cross pollination" between transportation modes is not unique. In fact, the Safety Board is always looking for innovative ways to address a transportation problem, even if it originates in a different mode.

Fifteen years ago, a concept called Cockpit Resource Management was developed for the aviation industry. Again originating from pioneering work at NASA Ames, this training method is now called Crew Resource Management. The Board recommended that the FAA and the airline industry adopt this training method that encourages teamwork, with the captain as the leader who relies on the other crew members for vital safety-of-flight tasks. The Safety Board recommended it for other modes, and it is gaining acceptance in the marine industry, which calls it Bridge Resource Management.

We believe that borrowing successes from one mode or one State for the betterment of another is nothing more than spreading the word on practical, cost-effective methods that work. We did just that more than 20 years ago when we saw how effective the few pipeline one-call systems were in preventing underground damage accidents. We asked all States to implement similar programs. Today, the entire country is served by these lifesaving programs.To promote the use of these programs and others aimed at preventing these accidents, we convened a national excavation damage workshop last year.Twenty years ago we learned of the "Operation Lifesaver" rail/highway grade crossing program that was in use in 6 or 7 States. We asked all States to initiate these programs and urged that a national coordinating effort be launched. Today, 49 States have Operation Lifesaver programs and the number of deaths at crossings have been reduced by half.

Another major success story we can point to deals with how the States are combating the drinking-and-driving problem. Based on what we found to work in a few States -- raising the drinking age and instituting administrative license revocation, for example -- we asked all States to follow suit. As a result of our efforts and those of many others, including grass roots organizations, drunk driving fatalities dropped 35 percent in the last 12 years. The age-21 laws alone saved almost 15,000 lives.

And that, after all, is why we're here -- to save lives. It is a fact that more than 43,000 Americans lost their lives in transportation accidents last year. That should provide us with all the motivation we need.

Tomorrow, after hearing from Secretary Pena, you'll be breaking into working groups in which you and your fellow professionals will determine how to adapt the NASA Ames Fatigue Countermeasures Program to your mode's specific needs.

The fruits of this conference won't be known for years. The trucking industry, for example, could very well develop useful fatigue countermeasures for its long-haul drivers. But it is estimated by industry that trucks account for just 4 percent of highway fatigue-related crashes. If these numbers are true, imagine the impact of these countermeasures when they eventually spread to the general automobile-driving population, the source of the other 96 percent of fatigue-related highway crashes.

I believe this conference will prove to be a pebble thrown into a pond. The ripple effect will be felt for many years to come as all of you begin to apply what you've learned here to the betterment of your company or industry. I'm proud that NASA and the National Transportation Safety Board were able to put this conference together, but its success depends on you.

With all this said, it is time to move on with the program. We will begin today with a presentation by Jim Danaher. Jim is currently the Chief of the Operations Division in our Office of Aviation Safety, and he has been with the Board virtually since its inception as an independent agency. More importantly, Jim was one of the founding fathers of the human performance division at the Board and has seen first-hand the evolution of our ability to document fatigue as a significant safety factor in transportation.

Jim will be describing the history of the Safety Board's investigations into fatigue-related accidents.

Thank you for coming, and now let's get to work.



Jim Hall's Speeches