April 2, 2012 | Mark Paradies

Monday Accident & Lessons Learned: Is Fatigue an Issue?

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I was reviewing an industry study on the causes of accidents and noticed that fatigue was nowhere on their list. Since other studies where people actually observed performance show that fatigue is a major issue in real world accidents, I wondered why fatigue did not show up on the industry sponsored list.

The easy answer is … If you don’t ASK about fatigue and look into fatigue as a potential cause, you will never find it.

That reminded me of an investigation into a barge crash. The operator couldn’t find a reason why the First Mate had gone “brain dead” and made a totally inappropriate approach to a bend in the river. It was very important to be lined up correctly because the river was running near flood stage and there was little room for error. But once he was lined up wrong, he had little choice. He tried to “power through” the turn and ended up crashing the barges into a bridge after the turn.

One of the questions I asked the investigator was, “Did you consider fatigue?” (The accident happened at about 5 AM and the tug and barges were on the second day of the trip.)

The reply was interesting … the investigator said:

“He was working a standard schedule.”

That seemed to be enough for him to dismiss fatigue as a cause.

I asked, “What is a standard schedule.” The answer, “6 on and 6 off.”

So the first mate would normally work from midnight to 6 AM, have six hours “off” to rest or work, then be back piloting from noon to 6 PM, get off, eat dinner, and go to bed and get back up to work from midnight to 6 AM again.

I asked if he knew if the First Mate had been well rested before starting the journey. The answer? “No, I didn’t ask about that.”

Even after this questioning, the investigator just couldn’t see that fatigue could be a potential cause that should be looked into. After all, the schedule was a standard industry practice.

That’s one of the reasons that I started adding sessions about fatigue to the TapRooT® Summit.

It’s also one of the reasons that we collaborated with Circadian Technologies to produce a tool for investigators to assess fatigue with a proved diagnostic tool call FACTS (Fatigue Accident/Incident Causation Testing System). (Click on the link to subscribe to the on-line system for free.)

It’s also why I recommend Circadian Technologies seminars on fatigue risk management and shift work scheduling.

If you are interested about learning more about fatigue, there are two seminars coming up that you should consider. The first is “Designing and Implementing an Effective Fatigue Risk Management System” and will be held in Salt Lake City on May 23-24. For more information, see:


The second is “Successfully Expanding from 5- to 7-Day Continuous Operation” and will be held in Chicago, IL on June 13-14. For more information, see:


We should not overlook fatigue as a potential cause. TapRooT® includes a question about fatigue as one of the 15 questions in the Human Performance Troubleshooting Guide on the front of the Root Cause Tree®. So you should consider fatigue for every human error. Ask about fatigue and perform an assessment using FACTS if there seems to be a potential for a fatigue issue. Don’t accept “standard industry practice” as ruling out fatigue as an issue.

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