Changing Minds About Sleep & Fatigue Management, for the Sake of Safety

By Clinton Marquardt - Sleep & Fatigue Specialist

About the Author: Clinton Marquardt - Sleep & Fatigue Specialist

As one of Canada’s top Sleep & Fatigue Specialists, Clinton takes the latest science and turns it into practical, implementable solutions that reduce the risk of fatigue and propel the health, safety and productivity of your 24/7 workforce towards excellence. Clinton has authored works for globally recognized books such as The Handbook of Fatigue Management in Transportation and the Transportation Safety Board of Canada’s Guide to Investigating Sleep-Related Fatigue. He is also the only Sleep & Fatigue Specialist qualified by the Superior Court as an expert witness. Clinton shares his expertise through training programs and consulting services to support your quest for excellence in the safety, health and productivity of your 24/7 workforce. To contact Clinton, visit his Web site at www.SleepandDreams.com and be sure to check out his upcoming course on the CARSP Web site:

https://carsp.ca/en/events/fatigue-risk-management-for-managers-safety-stakeholders/

Abstract

Tired of hearing “fatigue wasn’t a factor”? This article demonstrates why that claim often misses the real story. Instead of sensational catastrophes, it spotlights relatable, everyday losses like near-misses, fender-benders and hard landings that could be rooted in fatigue-driven impairments. You will get a clear, three-step blueprint to convince decision-makers, practical tool suggestions and a list of Fatigue Risk Factors to quantify what has been hiding in plain sight. The result: a compelling case for proactive sleep and fatigue management that elevates safety without waiting for a headline-grabbing event.

Sleep-Related Fatigue is a physiological state resulting from insufficient sleep quality and/or quantity, circadian rhythm effects, and long periods of wakefulness.

When I first started trying to change the minds of managers, supervisors, executives and regulators about the need to manage sleep-related fatigue, there were only a handful of safety related attention-grabbing examples I could use to do so. Accidents like the Three Mile Island nuclear meltdown of 1979, the space shuttle Challenger explosion of 1986, and the Exxon Valdez oil spill of 1989 worked well to illustrate how fatigue contributes to disastrous incidents. Although these examples caught safety decision-makers' attention, they did not convince them to take action. This was because they were not relatable. None of my decision-makers were involved with managing huge projects like a space shuttle launch, and the incidents were too disastrous. This made it difficult for them to see how sleep-related fatigue could lead to a world-famous catastrophe for their organization.  

Finding relatable, attention-grabbing examples of incidents resulting from sleep-related fatigue is now easy. Safety investigators have been highlighting the role of fatigue in incidents for many years and the media has a long history of routinely reporting fatal fatigue related outcomes. There is an abundance of examples illustrating the need to manage sleep and fatigue for safety reasons, like reducing incidents and preventing fatalities. A quick internet search using phrases like “safety board says fatigue played a role” or “fatal fatigue incident” would yield many examples.

Fatigue Risk Factor #1: Continuous Wakefulness
Periods of sustained wakefulness that deplete the recovery and regenerative benefits of previous sleep increase the risk of fatigue. In general, one hour of good quality nocturnal sleep subsequently provides two hours of benefits. This means that being awake for 16-17 continuous hours after eight hours of good quality nocturnal sleep reliably increases the risk of fatigue.

Instead of referring to an older world-famous fatigue related incident or a recent fatality that made it to the news, I use disastrous ones from the decision-maker's industry to demonstrate the safety reasons for managing sleep and fatigue. Using examples from their industry makes them relatable and, if they are disastrous, they are attention-grabbing. To change their minds about managing sleep-related fatigue, I begin by highlighting the obvious links between sleep and fatigue issues and the disaster. For example, if I am trying to convince decision-makers from the trucking industry, I might use the fatal highway incident where the Walmart truck driver stayed awake for 28 hours and then slammed into comedian Tracy Morgan’s limo-van at 45 mph, killing Morgan’s friend and seriously injuring Morgan. The link between sleep and fatigue and the safety outcome is obvious because most people can see how easy it would be to fall asleep at the wheel after 28 hours of wakefulness. It is relatable because even though this truck driver broke a regulation, decision-makers know that long work hours are common in their industry. It is disastrous because someone was killed, and the aftermath in the media and legal system stained Walmart’s reputation for many years. 

Using relatable incidents with disastrous safety outcomes and obvious links to sleep and fatigue issues will still get decision-makers' attention but using them to change minds is becoming more difficult. The approaches to safety management have improved significantly, making organizations more resilient to fatigue. What I mean by this is that a major incident or a fatality due to fatigue is much less likely now than it was 10 years ago. Anecdotal evidence suggests that automation of equipment, and improvements to systems and processes have fatigue proofed many tasks making it easier for a fatigued person to continue to work safely. Take some of the newer vehicles, for instance. If we are fatigued to the point of falling asleep and our ability to stay focused on driving is compromised, the vehicle can pull us back into our lane when it detects a drift, slow us down when we approach traffic in front of us too quickly and even alert us if we fall fully asleep. With fewer incidents demonstrating obvious links between fatigue and sleep issues and disastrous safety outcomes, it is more difficult to argue that we need to increase our efforts to manage sleep and fatigue for safety reasons. We can no longer say, “look at all the catastrophic outcomes we could prevent by ensuring that people don’t fall asleep while working.”

Although the risk of disastrous safety outcomes due to high levels of fatigue that cause people to fall asleep has decreased, it does not mean that the risk of fatigue has decreased. In fact, with today’s pace of work and life, we have less time available for sleep than we ever did, and this ultimately increases the risk of fatigue. This is why it is still important to remind decision-makers about the link between sleep and fatigue issues and the potential for disastrous safety outcomes.  

Fatigue Risk Factor #2: Chronic Sleep Disruption
Obtaining somewhat less than an adequate quantity and/or quality of sleep repeatedly across periods of time, such as consecutive days, weeks, or possibly even months, increases the risk of fatigue. A chronic disruption to sleep quantity is often referred to as a Sleep Debt.

After highlighting the obvious links between sleep and fatigue issues and disastrous safety outcomes, I turn decision-makers’ attention to less obvious links. To understand these links, the decision-makers must first realize that safety outcomes due to sleep and fatigue issues can occur well before a high level of sleep-related fatigue makes it difficult for people to stay awake. Providing examples of negative safety outcomes where people did not fall asleep shows decision-makers that lower levels of fatigue are also dangerous, and because the outcomes are disastrous, they are attention grabbing. In addition, they show decision-makers how fatigue results in negative safety outcomes before people fall asleep by impairing their workers’ ability to:

• Make appropriate decisions
• Maintain and work with information in short-term/working memory
• Hold information in their minds while they work with it
• Retrieve information from long-term memory
• Perceive visual information
• Pay attention
• Maintain vigilance / stay focused on the task at hand
• Process information
• React quickly
• Plan appropriately for immediate future actions
• Avoid confirmation bias
• Avoid a narrowing of attention
• Avoid distraction
• Move in a coordinated and rapid fashion (often referred to as psychomotor impairment)

Fatigue Risk Factor #3: Acute Sleep Disruption
Obtaining significantly less than adequate quantity and/or quality of sleep in the previous 24 hours increases the risk of fatigue.

When the decision-makers grasp the idea that fatigue per se does not cause disastrous incidents, and impaired abilities like the ones above, they understand how fatigue can also lead to less disastrous outcomes. For example, a fatigued worker’s reaction time could be slowed by fatigue and, while driving a company vehicle, the worker brakes too slowly and is unable to avoid a collision. The collision may not result in a fatality, but it could result in injury and equipment damage. In my experience, numerous examples of safety outcomes with a similar lower severity occur in every organization. Many of them could be due to fatigue-related impairments. Hard aircraft landings, vessel dock strikes, minor train derailments and small motor vehicle incidents happening much more frequently than disastrous incidents have all been linked to abilities impaired by fatigue. There is an even greater number of , but still significant, safety outcomes happening daily within every organization that could be due to fatigue-related impairments. For example, one study estimated that 13% of all workplace injuries could be due to sleep and fatigue issues (1).

Fatigue Risk Factor #4: Acute Sleep Disruption
Obtaining significantly less than adequate quantity and/or quality of sleep in the previous 24 hours increases the risk of fatigue.

Providing your decision-makers with examples from their industry of less disastrous and minor incidents due to fatigue-related impairments makes them relatable and often convinces them of the need to manage sleep and fatigue. I suggest taking it one step further to show your decision-makers that the examples you provided from external incident reports reflect what is probably going on in their organization. To do this, I comb through the organization’s safety reports to find incidents that could have been linked to an ability that could be influenced by fatigue. For example, I may find an incident report that made a conclusion such as, “The driver was not paying attention and struck a rapidly slowing vehicle.” We know that attention can be impaired by fatigue, but because the organization is not yet convinced of the need to manage sleep-related fatigue, they are probably not considering it as a contributor to their incidents. This means fatigue would not have been included in the incident report. It is up to us to show decision-makers that fatigue-related impairments could be occurring in their organization, and that if their workforce is fatigued, it is likely that fatigue is contributing to the organization’s negative safety outcomes. In other words, I follow a three-step process with decision-makers: First, I show them that the impaired abilities contributing to the negative safety outcomes documented in their safety reports can be impacted by fatigue (sometimes I facilitate this by providing research papers linking the impairment to fatigue); second, I show them that their workforce is likely experiencing fatigue;  third, I make the link by pointing out that if the impaired abilities documented in their safety reports can be affected by fatigue, and fatigue is occurring, then fatigue is likely contributing to their organization’s negative safety outcomes.

Fatigue Risk Factor #5: The Post Lunch Dip Circadian Rhythm Effect
Due to innate biological rhythms, fatigue risk naturally increases in the middle to late afternoon for about 1-2 hours. This is known as the Post-Lunch Dip and it occurs when biological rhythms are synchronized to each other and to clock time such that the brain and body are naturally aligned with daytime wakefulness.

The second step requires elaboration; I use two different methods to show decision-makers that their workforce is likely experiencing fatigue. If the decision-makers understand the link between insufficient sleep quality and/or quantity, circadian rhythm effects, and long periods of wakefulness and fatigue, I gather data about the workforce’s sleep. Surveys, quizzes through the organization’s intranet or e-mail system, or a sampling of sleep data from the workforce’s wearable tech can all be used as data. I use the data to document the presence of insufficient sleep quality and/or quantity, circadian rhythm effects, and long periods of wakefulness; that is, I show the decision-makers that fatigue risk factors are being experienced by their workforce. If fatigue risk factors are present, then there is at least a risk of fatigue. 

Fatigue Risk Factor #6: The Circadian Trough Circadian Rhythm Effect
The circadian trough, also known as the Window Of Circadian Low (WOCL), is a naturally occurring 4-6 hour night period when fatigue risk is at its greatest. Like the Post-Lunch Dip, the circadian trough occurs when biological rhythms are synchronized to each other and to clock time such that the brain and body are naturally aligned with daytime wakefulness.

If the decision-makers are not yet aware of the fatigue risk factors, I show them that fatigue is occurring by gathering data about the workforce’s fatigue levels directly. There are two options for doing this; one is to measure the workforce’s fatigue levels at specific times during the day, the other is to measure average levels across longer periods of time. Although you could create your own fatigue scales for these measurements, I do not recommend this approach because there would be no comparators for your measured levels of fatigue that would help you understand what each level means. For example, if your scale is 1 to 5, where 5 is extreme fatigue, and everyone scores 5 on this scale, it may look like there is a real problem with fatigue. However, there may be something different about your workforce that leads them to feel that their fatigue is level 5, whereas a different workforce may feel the same but interpret this as a level 3 fatigue. Plus, you would not know how impaired people were at the different levels on your scale because you have not correlated it with any fatigue related impairments. To avoid these problems, I recommend only using widely accepted and validated fatigue scales. These scales have lots of research behind them that allow you to compare your workforce’s fatigue levels to those of other workforces and understand how impaired your workforce may be. 

Fatigue Risk Factor #7: Circadian Rhythm Desynchronization
Irregular sleep-wake patterns and exposure to the biological time cues of light, eating, socializing, and physical activity at inappropriate clock times can desynchronize natural biological rhythms from each other and from clock times.  This circadian rhythm desynchronization increases the risk of fatigue.

To measure fatigue at specific times during the day, I use the original 9-point Karolinska Sleepiness Scale (KSS) (2). For the measurement times, I have the workforce complete the scale before they do a safety critical activity, like driving a company vehicle a long distance at night, landing a plane or docking a vessel. Using these times can help convince your decision-makers of the need to manage sleep and fatigue, because if the measurements show that some people are fatigued when they really need to be at their most alert the risk of a negative safety outcome is increased. To measure fatigue across longer periods of time, I use the Epworth Sleepiness scale (ESS) (3). Using this scale, the workforce rates their fatigue levels for recent times in their usual way of life. Presenting ESS data to decision-makers can be very persuasive because if it shows that fatigue is present in the workforce, it means they are fatigued all the time, and this increases the risk of a negative safety outcome at all times for all work-shifts instead of at specific times.

Fatigue Risk Factor #8: Medical & Psychological Conditions, Illnesses and Drugs/Consumables
These influences can disrupt sleep quantity and/or quality which increases the risk of fatigue. These influences can also cause fatigue on their own independent of previous sleep quantity and/or quality.

Armed with data about the workforce’s fatigue risk factors or fatigue levels, and facts about the impaired abilities that are causing the organization’s negative safety outcomes, we are now ready to counter statements like, “We have never had a fatigue-related incident, so why do we need initiatives to manage it.”  Here is how I would present the general argument:

"Although we may not have had an incident due to someone falling asleep, we have probably had many that were due to fatigue. Recall that fatigue impairs abilities X, Y, Z. Here are a number of safety reports from our organization that have documented the contribution of X, Y, Z. According to data collected from our workforce, people are experiencing fatigue risk factors A, B, C that are increasing the risk of fatigue, or the ESS or KSS scores indicate that our workforce is fatigued.  With a fatigued workforce and fatigue-related impairments contributing to the incidents documented in our safety reports, isn’t it difficult to argue that fatigue is not contributing to our safety incidents?  If you agree, then shouldn’t we start initiatives to manage fatigue, and because fatigue is intrinsically linked to sleep? Shouldn’t we also start some to help our workforce manage their sleep to reduce the risk of fatigue?” 

Demonstrating how the whole gamut of negative safety outcomes, including disastrous to minor ones, that are occurring within an organization could be resulting from fatigue and using relatable examples to do so, can help to change minds and show decision-makers, such as managers, supervisors, executives and regulators, that one of the most important organizational reasons for managing sleep and fatigue is for safety's sake.

References

1. Uehli, K., Mehta, A., Miedinger, D., Hug, K., Schindler, C., Holsboer-Trachsler, E., Leuppi, J., & Kunzli, N. Sleep problems and work injuries: A systematic review and meta-analysis. Sleep Medicine Reviews. 2014; 18(1): 61-73.
2. For more information about the Karolinska Sleepiness Scale, see Åkerstedt, T. .  Karolinska Sleepiness Scale (KSS), In A. Shahid, K. Wilkinson, S. Marcu, C. Shapiro (Eds.), STOP, THAT and One Hundred Other Sleep Scales. 2021, Springer.
3. For more information about the Epworth Sleepiness Scale (ESS) see: [A] Johns, M.  A new method for measuring daytime sleepiness: The Epworth sleepiness scale.  Sleep. 1991; 14(6): 540-545, and [B] https://epworthsleepinessscale.com/about-the-ess/