NTSB - Most Wanted

Importance
The Safety Board has long been concerned about the issue of operator fatigue in transportation and has stressed its concerns in investigation reports issued throughout the 1970s and 1980s. In 1989, the Board issued three recommendations to the Secretary of Transportation calling for research, education, and revisions to existing regulations. These recommendations were added to the Board’s Most Wanted List in 1990, and the issue of fatigue has remained on the Most Wanted List since then. The Safety Board’s 1999 safety study of DOT efforts to address operator fatigue continued to show that this problem was widespread. Operating a vehicle without the operator’s having adequate rest, in any mode of transportation, presents an unnecessary risk to the traveling public.

Safety Board recommendations on the issue of human fatigue and hours-of-work policies have had a substantial effect on encouraging the modal agencies to conduct research and take actions towards understanding the complex problem of operator fatigue in transportation and how it can affect operator performance.

Summary of Action
International
The Coast Guard played a major role in addressing fatigue at the International Maritime Organization (IMO) Convention, especially in the 1995 amendments to the International Convention on Standards of Training, Certification, and Watchkeeping for Seafarers (STCW), and in an IMO resolution calling attention to the variety of factors that contribute to fatigue. The new rules became mandatory for all mariners operating internationally in 2002.

Domestic
In the Coast Guard and Maritime Transportation Act of 2004, (1)Congress authorized the Secretary of the Department of Homeland Security to set maximum hours of service for towing vessel operators based on the results of the demonstration project that implemented Crew Endurance Management System (CEMS) (2) on towing vessels. The demonstration project was completed in 2005, and a report of the results was submitted to Congress on March 29, 2006. According to the report, the demonstration project was designed to evaluate the feasibility, effectiveness, and sustainability of CEMS in the towing industry. Although the report cautioned that the sample size of vessels that participated in the project was relatively small, and therefore might not generalize to a wider population, it asserted that, “when properly practiced, CEMS is effective in reducing fatigue-related risks.” Coast Guard staff indicated at a July 19, 2007, briefing that an increasing number of crews from vessels in the towing industry have received training on CEMS and that the Coast Guard is commencing efforts to promote CEMS in other industry segments. They also indicated that although the Coast Guard would likely consider regulatory changes to hours of service in the future, it had established no specific timeline for doing so.

Although the Coast Guard has made extensive efforts in developing and providing guidance in CEMS and in working with the towing industry, CEMS is a voluntary program, and all aspects of the program may not be implemented or properly implemented. For example, approximately half of the vessels involved in the demonstration project did not change their existing “6-on, 6-off” watch schedule. With such a schedule, it would not be possible for crews to obtain enough uninterrupted sleep to maintain alertness levels during working periods.

The Coast Guard played a role in the IMO’s 1995 amendments to the STCW and has taken action to address fatigue-related risk through its CEMS program; however, more than 9 years after the recommendation was issued—and 19 years after the Board asked the Department of Transportation to review and update hours-of-service regulations for all modes of transportation (I-89-3)—the Coast Guard has not initiated any rulemaking governing domestic operations.

Action Remaining
Issue hours-of-service regulations for all domestic operators, such as those referenced for towing vessel operators in the Coast Guard and Maritime Transportation Act of 2004.

Safety Recommendation
M-99-1 (USCG)
Issued June 1, 1999
Added to the Most Wanted List: 1999
Status: Open—Unacceptable Response
Establish within 2 years scientifically based hours-of-service regulations that set limits on hours of service, provide predictable work and rest schedules, and consider circadian rhythms and human sleep and rest requirements. (Source: Evaluation of U.S. Department of Transportation Efforts in the 1990s to Address Operator Fatigue [NTSB/SR-99-01])

October 2008

1. United States Department of Homeland Security, United States Coast Guard. (December 2005). Report on Demonstration Project: Implementing the Crew Endurance Management System (CEMS) on Towing Vessels.

2. CEMS is defined as “a system for managing the risk factors that can lead to human error and performance degradation in maritime environments.” Fatigue management is one of several factors that CEMS considers.