When Compliance Doesn't Equal Safety
October 15, 2010
Finally, a fatigue-related crash has come to the forefront that exposes the chasm that often exists between safety and compliance.
The National Transportation Safety Board last month released its report on the tragic truck crash near Miami, Okla., that claimed 10 lives in June 2009. It cited driver fatigue stemming from acute sleep loss and circadian disruption as the principal cause of the crash. There was no mention of hours-of-service violations, falsified logs, speeding, substance abuse, or any other illegal activity. The driver, Donald Creed, age 76, was totally compliant at the time, and had been since he hired on with the company in 1992, company and DMV records show.
NTSB found no fault with the truck, the carrier's safety record, or Creed's driving history, yet 10 people died because of a simple failing of human nature: Creed apparently became unaware of his surroundings for a brief instant because he was sleepy. The crash showed the classic signs of an asleep-at-the-wheel scenario: no skid marks prior to impact, and many witnesses say he took no evasive action and made no attempt to avoid the crash. NTSB stopped short of saying he was asleep at the wheel, because that cannot be proven, but Creed was obviously oblivious to the developing situation.
Accident reconstruction evidence shows that Creed, traveling eastbound on I-44 between milepost 320 and 322, would have had line-of-sight view for about 1.5 miles of a previous crash that occurred minutes earlier at MP 321.76, and a clear view of that accident scene from about one-quarter of a mile away. It's hard to imagine any task inside the cab that would have occupied the driver's attention for 15 seconds or longer, distracting him to the point that the previous crash scene escaped his attention. ON AUTOPILOT?
If Creed wasn't technically asleep at the wheel, he was certainly on autopilot - a situation I'd bet a lot of drivers have experienced but would be loath to admit. It's a sort of semi-asleep/semi-awake condition where time and miles pass that cannot be recalled. Many will have had moments where they realize they are at a certain place but can't remember getting there, or passing a certain landmark. I'm unaware of a technical definition for this condition, but I've been there, too.
I once worked for a carrier that regularly ran me on a grueling rotation of four 15-hour shifts (under the previous Canadian HOS rules) beginning at 4 on Thursday afternoon, ending at 8 on Monday morning. I'd stay awake the night before I began the rotation and sleep late trying to advance my circadian clock. I often grabbed a nap in the afternoon prior to beginning work, as well. Still, I started my week's work without the benefit of a solid period of core sleep, and as the workweek progressed, it got worse. Commuting to and from work, and trying to sleep during the daylight hours, left me with no more than 4-5 hours of decent sleep per off-duty period.
In many ways, that scenario was alarming similar to Creed's situation.
He had worked 23 days in 60 days prior to the crash, and was off the three days prior to the crash shift. On the day of the crash, Creed began work at 3 a.m., after what NTSB describes as no more than five hours of sleep. He had just came off three days at home, where he presumably would have slept at normal times during the night and remained awake at normal times during the day. He was just getting back into the nightshift groove.
The crash occurred at 1:20 p.m., 10 hours into his workday, and after fewer than eight hours behind the wheel. By hours-of-service standards, he was well within the law. However, a more immutable law was in effect here: Creed's circadian cycle. This is my supposition, not NTSB's official version of the story, but it seems likely that he was at a low point in his circadian cycle, and on a flat, straight, and featureless stretch of roadway with the cruise control on under hot sunny skies. With little in the way of external stimulation to keep him focused, Creed when into what I call autopilot.
My workshift, as described earlier, was worsened by the fact that the company frowned on napping during the shift. We had a 16-hour window in which to work 15 hours, and I usually worked every minute of those hours. Company policy prohibited drivers from exceeding 16 running hours in a shift because trucks were scheduled out with another driver, so whenever I napped and exceeded the company's 16-hour limit, I got a letter for violating company policy. That happened a lot. I kept napping and the letters kept coming, but for some odd reason they never fired me. Nor did the company adjust its policy, or my workshift.
I know what it's like to drive tired, and I'm not unique in that regard. Most drivers have been up against that wall at sometime in their careers. If Creed's situation played out as I described it, I'd have a hard time faulting him entirely for what happened. MANAGING FATIGUE
Fatigue is a very insidious thing. We tend to think we can stay awake even though all the cells in our bodies are screaming for sleep. We push on, turning up the radio, slapping our faces, doing mental arithmetic, whatever, to stay awake. Eventually, if pushed far enough, we fall asleep. As sleep experts and scientists all agree, it can happen in an instant and we won't even be aware of it, despite our efforts at staying awake.
Simply having available hours is not a good hedge against fatigue. One can be dead tired, but perfectly compliant at the same time. Unfortunately, available-hours means good-to-go, and that's just what most drivers do. Current HOS rules discourage napping, and missing an appointment or refusing a dispatch can have expensive and career-limiting consequences.
Fatigue management, in the truest sense of the word, would be a far better crash mitigation tool than HOS could ever be. Allowing drivers to govern their own work lives according personal needs for sleep, and arming them with a better understanding of the causes and effects of fatigue, would go a long way toward reducing incidents like the one at Miami, Okla. But fatigue management layered on HOS is kind of redundant. Legally defined minimums and maximums tend to become standards. Work shifts and delivery schedules are built around maximum driving availability and minimum rest periods. Turning from that to a program where drivers are encouraged and empowered to manage their time according to personal needs would could cost millions to implement and billions in lost productivity.
Still, I've been on aircraft where, following an unplanned delay, the crew has walked off the plane citing potential conflict with aviation HOS rules, leaving several hundred very angry passengers stranded while a replacement crew was found. Aviation regulations grant pilots the authority -- in fact, pilots are compelled to act accordingly -- to ground flights that may exceed their available duty hours, and they are protected by the regulations against company retribution.
I wish trucking regulations afforded drivers similar protection. It doesn't seem from the NTSB report that Creed was under any pressure to continue his run despite his tired state, but had he known more about the effects of fatigue and the physiology of sleep, he might have recognized an impending disaster and taken steps to avoid it. The only known cure for fatigue is sleep, and sleep is better taken in the bunk than behind the wheel.
May those 10 souls rest in peace. Read more about fatigue management in the November issue of
Heavy Duty Trucking magazine.
Author: Jim Park | Posted @ Friday, October 15, 2010 10:19 AM