20 fatigue prevention1

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Fatigue at Work

By: Safety Partnership Committee

Representatives from: Federal OSHA, Various State of Wisconsin and Federal Agencies, Insurance, Healthcare, and

Unions

Safety Partnership Mission

The Department of Workforce Development Safety Partnership is a formal alliance with the Wisconsin OSHA area offices. It is a signed agreement whereby DWD and OSHA work collaboratively to improve the safety and health of Wisconsin workplaces using non-enforcement means. That means education, training and other outreach activities. In the case of the alliances work on fatigue, we have also solicited the input of representatives from state agencies, employer and employee organizations and the insurance industry.

Air Traffic Controllers Asleep!!!

Safety and Security Risk!

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Bus Crash Kills 5

THURSDAY FEBRUARY 5, 2009 Last modified: Wednesday, February 4, 2009 10:43 AM CST

NTSB takes further steps in bus crash case On Oct. 16, 2005; Five people on board the bus carrying

members of the Chippewa Falls High School marching band died when the vehicle slammed into a Whole Foods Market semi truck that was overturned on Interstate 94 near Osseo.

The agency studied the crash and found truck driver Michael Kozlowski fell asleep at the wheel due to fatigue, leading to the vehicle overturning.

In particular, it appears that the program was not supported by management strongly enough to impress upon Whole Foods drivers the risks associated with driving while fatigued and the necessity of applying fatigue information to work and rest practices.

http://www.ntsb.gov/publictn/2008/HAR0802.pdf

Similar Accident 2008 MN

In the early morning darkness on April 5, Loren Ernst, the driver of one of two charter buses carrying Pelican Rapids High School band students home from Chicago, pulled into a rest stop in Menomonie, Wis.

Ernst asked Jake Blotsky, the driver of the second bus, if he'd noticed whether Ernst's bus had been "drifting" over the fog line.

When Blotsky said yes, Ernst, who had only had three hours of sleep in the 24 hours before embarking on the long drive, "said something to the effect of 'damn I'm getting tired,'" say felony charges filed Thursday in Wright County District Court.

Less than two hours later, shortly before 6 a.m., Ernst's bus left the road near the Albertville Mall and crashed in a ditch, killing 16-year-old Jessica Weishair and injuring dozens of others, most of them teenagers.

Ernst faces three counts of criminal vehicular homicide and two lesser driving-related felonies. The 69-year-old Moorhead man was driving 48 students and chaperones back from a spring band trip to Chicago.

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Goals and Objectives

Awareness of Risk Factors Associated with Long Work Hours

Site-Specific Evaluation of Risk Factors

Identify Control Measures

QUESTION ????

Lets assume that you are ESH (Environmental Safety & Health) Manager at a large facility and on this particular day, you are making a routine walk-around to see what operations are ongoing. You see an employee operating a large, costly piece of equipment. You ask the employee how he/she is doing.

The responds: Im OK, just a little tired.What is your reaction?

A. You say, OK just be safe.B. You ask the employee to take a short break.C. You ask the supervisor if the worker is OKD. You ask the supervisor to remove the worker

from the task the employee is performing

??????????????????????????????????????????????????????????????

WHAT IS FATIGUE ?

Fatigue the inability of a human

to perform reasonable and necessary physical or mental activity.

Muscular Fatigue a buildup of

Carbon Dioxide and Lactic Acid in muscle tissue due to overexertion and producing discomfort, pain and loss of strength

Mental Fatigue a condition in which activity in the brain is depressed resulting in diminished neurophysiologic performance

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SYMPTOMS OF FATIGUE

Irritability

Complex Decision

Making Suffers

Vigilance

Decreases

Tolerance for Errors and Risk Increases

Task Fixation

Reaction Time Increases

Inattentiveness

Communication is Impaired

Motivation Reduction

Short Term Memory

Deteriorates

Mood Deteriorates

Microsleeps Occur

WHY SHOULD WE WORRY?

Fatigued people are less able to respond to unusual or emergency conditions. They are also more likely to take risks.

A Western Australian (WA) transport company has recently been fined $3500 for the failure to have a Fatigue Management Plan as required by WA Workplace Safety Laws.

The Baker Commission investigating the BP Texas City disaster in the US recommended to BP the development of a Fatigue Management Plan.

There have been several high-profile accidents where fatigue was identified as either a causal or contributing factor. eg. Three Mile Island, Chernoble and Exxon Valdez. It was also cited as a component of the flawed decision-making that contributed to the Challenger Disaster.

Work Schedules: Shift Work and Long Work Hours

Simon Folkard and David A. Lombardi

http://www.cdc.gov/niosh/topics/workschedules/abstracts/folkard.html

0

13

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10

15

20

25

30

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Risk of injury by Length (Hours)

Per Shift

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18.3

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05

1015

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3035

!st-

Day

2nd-

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Risk of Injury Per Time of 8 Hour

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Night

2nd

Night

3rd

Night

4th

Night

Risk of Injury for Successive Night

Shifts

Percent

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Workers Comp Cost vs. Degree of Fatigue

Shiftwork Practices 2007 Aguirre, A. and Moore-Ede, A. Circadian Information LP, Stoneham, MA www.circadian.com

Effects of Extending Hours on Nursing

Is associated with a 50-170% increase in musculoskeletal disorders. 1

Drowsy driving and increased risk of MVA2

Increased risk of needle stick injuries when working more than 13 hour shifts 3

References:

1. Work-schedule characteristics and reported musculoskeletal disorders of registered nurse. Scand J Work Environ Health. 2002 Dec; 28(6): 394-401.

2. The relationship between nurse work schedules, sleep duration, and drowsy driving. SLEEP. 2007 30 (12): 1801-1807.

3. Work schedule, needle use, and needlestick injuries among registered nurses. Infect Control Hosp Epidemiol 2007 28:156-164.

AN ANALYSIS OF FATAL EVENTS INTHE CONSTRUCTION INDUSTRY

2009 (OSHA & U-Tenn)

Table 4. Distribution of Fatal Construction Events by Hour, 2009 Hour Number of Events Percent 01 3 0.6 12 4 0.9 23 1 0.2 34 3 0.6 45 0 0.0 First 8 Hours: 7.8 % 56 3 0.6 67 5 1.1 78 18 3.8 89 37 7.9 910 51 10.9 1011 49 10.4 8-12 Hours = 37.7 % 1112 40 8.5 1213 33 7.0 1314 59 12.6 1415 62 13.2 WORST TIME BRACKET!!!!! 1516 29 6.2 1617 28 6.0 1718 13 2.8 1819 10 2.1 1920 3 0.6 2021 0 0.0 2122 9 1.9 2223 4 0.9 2324 6 1.3 ___ Total 470 100.0

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Contributing Factor to Injuries, Illness and Death

Impaired Judgment: Employee #1 was working on a highway bridge seismic retrofit

project. He was moving a gas welding cart to another location in the closed #1 lane, near the center line of the open lane, when he was struck by a north-bound automobile. Employee #1 suffered a dislocated hip and fractured leg. The cause of the accident was fatigue from working a double shift, which impaired Employee #1's judgment as to the proximity of the danger zone.

Ergonomics: Musculoskeletal Disorder increase with longer work shifts and less time between shifts for recovery.

Contributing Factor to Injuries, Illness and Death

Drugs-Medications

Cause Drowsiness

Pre-Existing Health Conditions

Sleep Apnea

Heat Stress-Dehydration

Working outside all day dehydrated and passes out during work

HOW BAD IS THE SLEEP PROBLEM ?

19% of adults report falling asleep at work.

18% of adults indicated that they have called in sick due to a poor nights sleep.

29% of adults indicated that they do not feel well rested when they get up for work.

27% of adults reported dozing off behind the wheel of an automobile.

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Studies on Alertness

Rotating shift workers get the least sleep of all people who shift work.

(Wurtman, 2008)

Study examining rapidly rotating shift work significantly lower cognitive performance

slower speed on tasks

poorer memory recall (Rouch & Wild, et al, 2005.)

Employee Turnover

Absenteeism

Impaired Decision Making

Worksite Accidents

Injuries to Others

Liability and lost productivity through errors and omissions- rework and damaged goods

Healthcare Quality

Mental Health: Depression and Anxiety

What are the effects of fatigue due to long work hours ?

Background

Prior to government intervention no limit on length of work shifts or hours per week.

1886: Unions set a goal to establish a work day as 8 hours per day.

Fair Labor Standards Act in 1938: Required overtime to be paid for all hours after 40 in a week.

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COMPANY POLICY

Employers are left to set guidelines for their employees

What are safe shift intervals?

What constitutes a safe shift rotation schedule?

What length should a shift be?

What is a Work Day today?

Depends who you are!

5-8s

4-12s

5-4-9

24/48

Swing or Rotating Shifts

On Call

Disaster Responder

Self Scheduling

Flex Hours or Flex Scheduling

3 Perspectives

Employee

Business (Industry)

Employer/Human Resources

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Employee Perspective

Better Pay (Shift Differential)

Child or Adult Care Issues

More Daylight Hours for Recreation

Need Time to Attend School

Perception of Slower Pace on Night Shift

Perception of Less Direct Supervision

Employee Perspective

Commuting Costs

Gas Prices

Flex Scheduling: Personal Free Time

Secondary Employment

Work Overtime for Special Purchases

Mandated Job Requirement,

Midnight Sun or White NightsAlaska St. Petersburg

Extra daylight for outdoor projects, recreation, and travel.

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Business Perspective

We live in a 24/7 society

Technology makes it possible to do many things simultaneously, at any time of day/night

Operating expenses many industries must operate 24 hours/day to minimize overhead costs

Business need to provide services to accommodate the 24/7 society

Disaster Response

Storms, Power Restoration

Katrina, World Trade Center, I-35 Bridge Collapse

Business Perspective

Service Industries Retail Healthcare and Emergency Services

24/7 Mandated Emergency: Trauma

General Industry Continuous Processes Cyclical Operations (Peak Seasons)

Construction Night Road Work to Accommodate Traffic Turn Around Heavy Industry Deadlines: Penalties & Incentives

Employer/Human Resources

Appears to be inescapable fact of life Fast-paced society

Competitive economy

Productivity-Meeting Deadlines Limiting Employment Roster

Training Costs

Benefits Costs

Qualified Worker Available

Energy Costs

Off Peak Hours

Days of Operation

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Government Regulations

Most research Truckers and Sleep

Deprivation

Has translated into stricter laws governing the transportation industry Trucking

Aviation

Railroad

Law does little to guide design of industry work schedules to reduce stress and fatigue

Regulations

Transportation Industry (DOT, FAA, RR) Link between sleep restriction and safety is much better established in the transport industry than in other industrial areas

Driving a vehicle is a task with continuous demand for attention and immediate consequences for lapses

More a public safety issue(Phillip & Akerstedt, 2006)

Work schedules in business/industry Left up to individual company Subject to collective bargaining

Recognition of ProblemRecommendation of a Plan

Chemical Safety Board - BP Texas City Explosion: March, 2005 Develop a Fatigue Management Plan

http://www.csb.gov/completed_investigations/docs/CSBFinalReportBP.pdf pages 293-299

http://www.csb.gov/completed_investigations/docs/Baker_panel_report.pdf

The Mogford Report cites fatigue as one of the root causes of the Texas City accident:

Some employees had worked up to 30 days of consecutive 12-hour shifts. The reward system (staff remuneration and union contract) within the site encouraged this extended working period without consideration of fatigue. There were no clear limitations on the maximum allowable work periods without time off.

It has not been possible for the Investigation Team to directly attribute actions or inactions of the operators and supervisors to fatigue. However, this extended working period clearly has the potential to contribute to a lack of attentiveness, and slowness to identify and respond to process upsets.

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FATIGUE MANAGEMENT POLICY

RESPONSIBILITIES OF EMPLOYERS AND EMPLOYEES

EMPLOYERS

1.Must ensure that employees are informed about fatigue risks.

2. Inform employees how to participate in controlling risks

3. Identify risks associated with fatigue

4. Monitor system for fatigue hazard identification

5. Assess the fatigue risk

6. Develop control measures

EMPLOYEES

1. Report problems with fatigue

2. Recognize and report fatigue symptoms

3. Help establish reporting systems

4. Help assess fatigue risks

5. Help design control measures

6. Cooperate with control measures

7. Help manage individual factors which affect fatigue e.g., ensuring adequate rest between shifts

Worksite Risk IdentificationDo you have a problem?

Trending/Tracking Indicators/Metrics OSHA 300 Log: TCR, DART, and DAWFII

First Aid

Near Miss Accident Investigations ( Did you ask? )

Quality Control: ISO perimeters

Productivity

Feedback Employee Surveys

Customer Complaints

Rejected Product

Production Decreases w/ TimeOvertime vs. Productivity

Source: Nevison, J., Overtime Hours: The Rule Of Fifty; 2003

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HAVE YOU ENTERED THE Drone Zone

Researchers have also documented a Drone Effectwhich describes individuals who become momentarilyfunctionally incapacitated, also known asmicrosleeps. These periods manifest as a fewseconds of open-eyed sleep, paralysis, blurred vision,or other effects of which the victim might be unawareexcept for a vague feeling of having missedsomething parts of a conversation or a section ofhighway. Traveling at 70mph (113kph), a ridercovers 103 feet (31 meters) per second thats thelength of a football (football) field in just 3 seconds.

SYMPTOMS OF FATIGUE WHILE RIDING MOTORCYCLE

Slow reaction time Braking hard to avoid a hazard Spilling drinks

Reduced awareness/vigilance Driving slower than normal Being surprised by a passing car Tailgating Not seeing deer or other road hazards

Impaired memory Passing a gas stop when low on fuel Forgetting your wallet after fueling Forgetting your spouses birthday call

Impaired decision-making Not stopping to rest when tired Taking an inappropriate route Inability to choose from a diner menu

Loss of situational awareness Failing to recognize a stop sign or signal Not putting the kickstand down Failing to put feet down when stopping Stopping in a high gear Failing to go when light changes Inserting eye drops while wearing glasses

Performance decrement Inability to calculate purchase amounts Inability to formulate routing plans Failing to communicate with riding buddies Fixating on a task

Some Signs & Symptoms of Fatigue

Tasks taking longer than normal

Difficulty with simple tasks:

Picking wrong tool or wrench

Slipping, tripping, falling

Taking shortcuts

Fixating on a task

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ASSESS FATIGUE RISKS

Are too many consecutive night shifts worked?

Is more than 8 hours required over night shift?

Are difficult tasks undertaken on the night shift?

Do night shift workers have difficulty getting

undisturbed sleep during the day?

Does one shift involve more than 12 hours in a day?


Do work hours exceed 50 hours in any 7 days? Do unplanned schedules result from call-outs? Is there enough time between shifts for adequate sleep?

Is the break between shifts less than 10 hours? Are breaks between shifts long enough for rest, refreshment and nourishment?

Do shifts start or finish between midnight and 6 am?

Are there split shifts?


Are difficult tasks required at the start or end of split shifts?

Do workers get sufficient notice of schedule changes?

Is Fatigue Management taken into account onschedule changes?

Do jobs involve repetitive or monotonous work? Is the work physically demanding? Is there time pressure due to a heavy workload?

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Is the work fast paced or intensive? Can workers vary work pace or work tasks? Do workers have input on work design?

Is high vigilance / or concentration required? Is significant travel to and from work necessary each day so that time for adequate sleep is reduced?

Are long distance commutes necessary at the beginning of a work cycle?

What Can Be Done?

Tips for Employers: Breaks

Allow frequent, short breaks (at least every 2 hours) for rotating shift workers.

Brief rest periods May reduce fatigue

Output actually not reduced

May increase output

Increases job satisfaction (American Academy of Sleep Medicine, 2002

Occupational Health, 2005

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Tips for Employers: Exercise

Provide exercise opportunities especially toward end of shift

We know exercise should be avoided before falling asleep because it keeps us awake

Advice used to advantage (American Academy of Sleep Medicine)

Tips for Employers: Environment

Keep the workplace well-lighted and the temperature cool

Air Quality:

Carbon Dioxide

Air Contaminates

Noise Levels

Shown to increase alertness at work

(American Acedemy of Sleep Medicine, 2002)

Tips for Employers:End of Shift Safety

Resident research

Restorative power of naps (even 15-20 min.)

Allow at end of shift?

Before ride home?

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Tips for Employers: The Ride Home

Much research available on drowsy driving

High risk for fatal crashes after night shift work Cab rides

Reward car pooling

Other transportation services

(Cavallo & Mallory, 2004)

Tips for Employers: Checks-Reviews

Peer Check

This collaborative technique involves asking others to observe or check the behavior of the worker performing a critical step or series of steps to verify correct performance. This technique takes advantage of a fresh set of eyes not trapped by the performers mindset and is similar to double verification.

VerbalizeState out loud your thoughts and intentions before acting to enhance ones attention and understanding of a RB or SB task and to allow coworkers the opportunity to challenge. In some cases verbalizing is accompanied by pointing to the device.

Fatigue vs. Blood Alcohol Level

Fatigue-Alcohol studies have been replicated by a variety of researchers who have shown that, although there are some specific differences in levels of performance on industrial tests, alcohol and fatigue produce similar levels of performance degradation

Fatigue in Naval Aviation, Capt. Nick Davenport, Contact, the Newsletter

Of the Society of U.S. Flight Surgeons, Vol 29, Nos. 2,3 & 4, April, July,

October, 2005, pg 3

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Tips for Employers:Education Opportunities

Part of safety meetings

Handout for employees

Supervisor Awareness

FATIGUE CONTROL MEASURESHierarchy of Controls

Hierarchy of Controls: Engineering, Substitution, Elimination

Work Practice-Administrative Controls Scheduling Work Activity

Scheduling Shifts

Scheduling Breaks-Rest Periods

Training

Guideline on Fatigue Management, Andrea Shaw, Australian Coal Association, Queensland, Australia, July 2003

FATIGUE CONTROL MEASURESEngineering, Substitution, Elimination

Eliminate or limit night work

Eliminate night shifts for particular jobs

Eliminate the use of extended hours

Eliminate repetitive, boring jobs

Increase outsourcing

Use alarms and monitors for those working alone

Use heating and cooling to control ambient temperatures to support alertness

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FATIGUE CONTROL MEASURESWork Practices: Scheduling Work Activities

Move as much activity as possible to day shift

Schedule complex tasks for daytime

Minimize administrative tasks done on night shifts

Improve the order, speed, duration and the

length of shift cycle rotation

Minimize work that has to be done between

midnight and 6 am.

FATIGUE CONTROL MEASURESAdministrative Controls: Scheduling Shifts

Limit the number of consecutive night shifts

Ensure adequate time off after night shifts Reduce working hours

Control the lengths of shifts

Limit the use of overtime, especially unscheduled overtime

Monitor hours of work

Reduce working hours

FATIGUE CONTROL MEASURESAdministrative Controls: Scheduling Shifts

Reduce the number of consecutive day shifts

Limit the use of standby and on-call duties

Keep shift changes from causing excessive hours

Schedule enough employees during peak times

and demands

Provide adequate resources to cover breaks

Reduce the use of split shifts

Dont start or finish between midnight and 6 am

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FATIGUE CONTROL MEASURESAdministrative: Breaks-Rest

Allow time for naps during night shifts

Increase the length of breaks between shifts

EXERCISE move around frequently during shift

Allow for recovery between work periods

Provide rest days

Allow for family and social commitments between shifts and shift cycles

Start work at long distance commutes on the day AFTER arrival and start travel home on the day AFTER the shift cycle is finished

Provide more and longer breaks within work periods

FATIGUE CONTROL MEASURESTraining

Provide training to allow multi-tasking and effective job rotation

Make supervisors aware and allow supervisors to reschedule tasks if fatigue becomes a problem

Ensure safe and efficient shift hand-over Improve job control and other risk factors associated with stress

Employees off duty time & sleep habits Improve communications

Employee Awareness -Responsibilities

Arrive to Work Fit for Duty

Off Duty Hours

Driving Home: Drowsy Driving

22-24% of all Crashes Related to Drowsiness

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Energy Drinks: Caffeine Content: WHERE and WHEN TO FIND IT, AND HOW TO AVOID IT

Helps & Hurts: Stay Alert-like it or not!

100 mg Caffeine Tablet Regulated by FDA w/ Warnings

500 mg Caffeine Drink Unregulated!!!

Concentration: mg/oz or ml Coffee: 77-150 mg/6 oz

Coca-Cola/Pepsi: 34.5-38 mg/can 12 oz

Energy Drinks: 50-505 mg/can or bottle

Energy Drinks: Caffeine

Postpone sleeps

Increased Heart Rate & Blood Pressure

Increased Tolerance to Caffeine

Diuretic Increase Dehydration

*** Strategic Use is Important ***

*** Young Individuals with SERIOUS

HEALTH ISSUES!!! ***

Where do we go from here?

Conduct Worksite Analysis

Survey to Assess if a Problem Exists & Extent

Develop a Strategy

Implement Appropriate Control Measures

Continue to Monitor Effectiveness of Program

Sharing Best Practices in a Variety of Industries and Situations

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Fatigue at WorkIs there a problem???

"Would you assist us in collecting information about workplace fatigue?

Please Take a Survey:

http://www.safetypartnership.blogspot.com/



Thru 10/31/09

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The Cost of Fatigue

The Cost of Fatigue

Excerpts from Comments

.... pushed a wrong button causing a roll to fall onto the floor

I have not been able to list fatigue as a primary factor in any incident, but it has been a contributing factor in more than half of our incidents. Drugs and alcohol have not been a factor in any incidents this year.

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Employee tired and took a short cut to save time. Hurt self.

Our maintenance personnel are required to plow snow. They come in up to 6 or 7 hours before their regular shift is to start and plow until around 7:00 am (regular shift start) and then work their regular shift.


Employee was working long hours and forgot to lock out a machine for simple maintenance.


Linemen working storm damage and after several days of working their attention and focus suffer and they start with slip, trips, and falls are the most common indicator that crews are exceeding their limits.

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just being tired and ending up running into things, dropping things, not seeing the issues

People run into things, are not as focused as they need to be.

Mistakes were made and accuracy was reduced. Loss of creditability followed.

Comment from Dairy Farmer

Know the Skill Set and Limitation of Employee

Long Hours

Unpredictable

Dont force Worker

past their limits

Commuting and Fatigue

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Excerpts from CommentsTraveling & Commuting

Commuting to jobs from home or temporary lodging adds

considerable time to the work day, which leads to fatigue.

Some members of management travel extensively, which puts them in the position of needing to drive in unfamiliar

places during extended work weeks.

An example is a crew in D.C travels 45 miles (1-2 hours) to

find affordable housing. When they work compressed

schedules, they may spend close to 14 hours working and traveling.

An employee just coming off the night shift apparently dozed, struck several

cars and a concrete pillar in the parking

structure.

Excerpts from CommentsTraveling & Commuting

When we had 3 day 12 hour work shift week, several employees would take a nap in their parked cars before driving home because they felt so fatigued. This was one of the reasons we ended the 12 hour shift schedule.

There are days that I don't remember the drive home

We work at remote locations and although our employees are allowed to stay over - some chose to drive back. They are not worth much the next day. Errors become a problem throughout the day

Excerpts from CommentsStrategies Being Used

More Advanced Notice for Extra Hours

Staff lounge has recliners for rest naps. That action is not discouraged.

More Scheduled Breaks (however, not always possible), Get up & Walk Around

Increased Training and Awareness: On and Off the Job, Newsletter, Articles, etc

Carpooling, Staying Shift to Rest, Pull over

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Excerpts from CommentsStrategies Being Used

In periods of hot or very cold weather we have work-rest cycles that we follow.

It is mandated that no worker shall work more than 12 hours during a 24 hour period. Furthermore any worker who has worked their 12 hours must rest for at least 12 hours before reporting back to work.

EXERCISE, EAT HEALTHY, AND GET 8 HRS OF SLEEP!

References

Fatigue in Naval Aviation, Capt. Nick Davenport, Contact, the Newsletter Of the Society of U.S. Flight Surgeons, Vol 29, Nos. 2,3 & 4, April, July, October, 2005, pg 3

National Sleep Foundation website: www.sleepfoundation.org

Semi-Bus Accident: Osseo, WI October 16, 2005

http://www.ntsb.gov/Pressrel/2008/080916b.html

Guideline on Fatigue Management, Andrea Shaw, Australian Coal Association, Queensland, Australia, July 2003

American Academy of Sleep Medicine http://www.aasmnet.org/

Kerin, A. (2004). Shiftwork practices 2004. Circadian Technologies, Lexington , MA .

NIOSH: http://www.cdc.gov/niosh/topics/workschedules/

References

Chemical Safety Board BP Texas City Explosion: March, 2005

http://www.csb.gov/completed_investigations/docs/CSBFinalReportBP.pdfpages 293-299

http://www.csb.gov/completed_investigations/docs/Baker_panel_report.pdf

The Mogford Report cites fatigue as one of the root causes of the Texas City accident:

Some employees had worked up to 30 days of consecutive 12-hour shifts. The reward system (staff remuneration and union contract) within the site encouraged this extended working period without consideration of fatigue. There were no clear limitations on the maximum allowable work periods without time off.

It has not been possible for the Investigation Team to directly attribute actions or inactions of the operators and supervisors to fatigue. However, this extended working period clearly has the potential to contribute to a lack of attentiveness, and slowness to identify and respond to process upsets.

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Contributing Members

OSHA Occupational Safety and Health Administration,

DWD-Worker Compensation, State of Wisconsin

DOA- Dept. of Administration, State of Wisconsin

DHS-Dept. of Health Services, State of Wisconsin

WisCon State Consultation,

115th Fighter Wing

WHA-Wisconsin Hospital Association

Jim Lombardo, Audiologist

SEIU,

AFL-CIO,

Johnson Insurance,

American Family Insurance,

Special Thanks To:

Mary Beatty, Nurse Practitioner

Saints Health Services for Business

an affiliate of St. Michael's Hospital

R. E. McClay CSP 724-388-6661

[email protected]

Contact Person: Mary Bauer, 715-832-9019

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Revision / Modification History

10-18-08: Original Generic 2-18-09: Chicagoland Construction

Added Survey Results Band Bus Crash Intro

3-10-09: Website Version Updated Survey Info from Chicagoland Conference

5-11-09: VPPPA Updated Survey and Comments Peer/Verbal Review as Tips

Revision / Modification History

7/31/09: Updated Survey for WSC Presentation.

11/29/09: Updated Survey for Prevention Presentation.

4/26/10: WSC

6-1-10: VPPPA: Circadian Cost Slide; added production, white nights, clip art, caffeine slides.

6-1-11: VPPPA: Air Traffic Controllers

20 fatigue prevention1

Documents