Friday, July 24, 2015

Statistics and Fatigue

In the late 19th Century, a former cricket player, English-born Henry Chadwick of Brooklyn, New York, was responsible for the “development of the box score, tabular standings, the annual baseball guide, the batting average, and most of the common statistics and tables used to describe baseball.” The statistical record is so central to the game’s historical essence that Chadwick came to be known as “Father Baseball.” As a result of the public’s interest in statistics, in the 1920s, American newspapers began devoting more and more attention to baseball statistics, initiating what journalist and historian Alan Schwarz describes as a tectonic shift in sports, as intrigue that once focused mostly on teams began to go to individual players and their statistics lines.  A major question here is – Do you know your personal fatigue error statistic line? 

The game of baseball places the individual player under intense scrutiny and pressure. Outcomes in baseball, unlike any other sport are totally dependent on the individual actions of each player. Scholar Michael Mandelbaum describes it this way, “It is impossible to isolate and objectively assess the contributions of each football team member makes to the outcome of the play... Every basketball player is interacting with all of his teammates all the time. In baseball by contrast, every player is more or less on his own! Baseball is therefore the realm of complete transparency and total responsibility. A baseball player lives in a glass house, and in a stark moral universe... Everything that a player does is accounted for and everything accounted for is either good or bad, right or wrong.” The accounting that Mandelbaum is discussing involves the keeping of statistics of the errors the individual makes.

In baseball statistics, an error is the act, in the judgment of the official scorer, of a fielder misplaying a ball in a manner that allows a batter or base runner to advance one or more bases, when such an advance would have been prevented given ordinary effort by the fielder. This facination with statistics in baseball produces a paradox for many in the field of error management and fatigue risk management. The paradox is this: Why do we have so much interest in baseball player statistics, yet frequently leave unexamined the personal safety statistics of operators in high risk industries, where human lives are often on the line?

Looking at the way in which the individual is held accountable in baseball may offer us some insight into how we should approach self- improvement and fatigue error reduction, or at a minimum, offer us some insight into what was going on that led to the error. Like any great athletic endeavor, each encounter with error or the error producing condition fatigue should be recorded and analyzed. Capturing what was happening, what you did or failed to do (or what someone else did or failed to do), and what happened as a result leads to an understanding of your error patterns and provides the path to the future and avoiding similar actions or conditions. The keeping of statistics on personal fatigue caused errors and analyzing them is a must if we are to improve performance and have an effect on personal and work safety.  Since there are systems in place and technology for monitoring available, there is essentially no excuse for not tracking our statistics when the error is attributed to fatigue. The only question here would be – Is your system and technology up to the task?

Note: Bob Novotney works as an Independent Consultant working with KOSTechnology, Inc. a producer of real-time fatigue monitoring systems. To learn more about KOSTechnology, please visit .

1. Mendelbaum, M. The Meaning of Sports. Why the Americans Watch Baseball, Football, and Basketball and What They See When They Do. New York, Public Affairs Books, 2004.
2. Kern, Tony. Blue Threat: Why to Err is Inhuman. Wage and Win the Battle Within. Woodland Park, Colorado, Pygmy Books, 2009.

Wednesday, July 8, 2015

Calculating Risk in Fatigue Risk Management

Explaining why insurance companies have a vested interest in ensuring the process works!

Fatigue is a common symptom with a reported prevalence in the population ranging from 7% to approximately 45%. Fatigue is a diagnostically nonspecific and associated with many health conditions. Broadly defined, the symptoms are described as a feeling of weariness, tiredness or lack of energy. Some Individuals experience a desire to sleep and may experience sudden onset of drowsiness or sleep.

Fatigue has been said to raise the risk factor for an accident by a factor of 50. In a study conducted by the Virginia Tech Transportation Institute, which was partly funded by the National Highway Traffic Safety Administration, it is suggested that driving fatigued is responsible for up to 20% of all reported auto crashes. This figure is up from the suspected 7% formally recognized as the number.

Fatigue doesn't just raise an individual’s chance of having an accident, it has been linked to health issues and it has a bottom line effect on the cost of conducting business. In a study, conducted by Judith Ricci, ET. Al. (JOEM, Vol. 49, Number 1, January 2007), it is suggested that fatigue costs employers $136.4 billion annually in health related LPT, an excess of $101.0 billion compared to workers without fatigue.

Fatigue is a universal issue that knows no boundaries in business and occupation.  In the world of aviation, fatigue has been on the National Transportation Safety Board’s most wanted list since the 1990s. Since being place on the list, new programs have been put in place such as Fatigue Risk Management Systems approach to managing fatigue. But what does it mean to manage risk? Especially fatigue risk?  We’ll start with a brief description of what risk management is…

Risk management is the process by which a company systematically identity, measure and manage the various types of risk inherent within their operations. The fundamental objectives of a sound risk management system are to manage the organization’s exposure to potential loss and to maximize the operational productivity while avoiding accidents, incidents and loss.  So, why should an insurance company insist that a company have a fatigue risk management system in place?

Insurance companies make money by managing various types of risk for individuals, municipalities and corporate entities – the risk of dying too young, experiencing a loss due to an accident or natural disaster, and so on. Where there is risk there is uncertainty, and where there is uncertainty, there is exposure to loss. Using traditional risk management approaches, no company can truly eliminate all exposure to risk. The primary benefit of the risk management approach lies in the fact that the company does have the opportunity to identify and quantify their risk, set tolerances, set standards and manage identified risk based on those standards and expectations.

Since insurance companies insure against loss they must have a vested interest in the risk management system of any company that they insure. Based on the prevalence of fatigue in the work place and the associated potential for loss, they should pay particular attention to the Fatigue Risk Management System.  They should require systems to be in place and be provided proof the system is being used and supported.

In return for compliance of the insured companies, the insurer should offer incentives to aid the company in further developing more active and real-time intervention systems. The incentives do not have to be huge. They can come in the form of modest discounts, safety magazines, aid with fatigue risk management system audits, and accident forgiveness where applicable systems strategies were in evidently in place. These incentives should be a reward with a focus on fostering an environment of fatigue safety and engagement at all levels of the insured company. 

Note: Bob Novotney works as a Consultant with KOSTechnology, Inc. a producer of real-time fatigue monitoring systems.  To learn more about KOSTechnology, please visit their website at:

Tuesday, July 7, 2015

Fatigue - The Causes, Hazards and Defenses: Connecting Fatigue Risk Management and Effectivene...

Fatigue - The Causes, Hazards and Defenses: Connecting Fatigue Risk Management and Effectivene...: It was around one o’clock in the morning on the turnpike in Mercer County, New Jersey when the driver of the tractor-trailer failed to ...

Connecting Fatigue Risk Management and Effectiveness

It was around one o’clock in the morning on the turnpike in Mercer County, New Jersey when the driver of the tractor-trailer failed to observe slow moving traffic ahead. At the last minute the driver swerved to try to avoid the Mercedes limo bus but struck it from behind, forcing the limo to rotate and overturn. The result was one person killed and four others taken to the hospital including comedian Tracey Morgan.

A report issued by the National Transportation Safety Board stated that the driver of the rig that slammed into the van was speeding after working for more than 13 consecutive hours, and driving for more than 9 hours and 37 minutes continuously leading up to the crash. Additionally, it is suspected that the driver had been awake for more than 24 consecutive hours, driving some 7 hours to the assigned pick up area for the rig where he began the trip. There seems to be a great deal of familiarity to this story. One has to ask, what was the role of the Fatigue Risk Management System (FRMS) in this tragic accident?

Before I get to deep into the subject, lets identify for those who are not familiar fatigue risk management and safety systems, just what a FRMS is.
In short, FRMS takes its roots from something know as Safety Management Systems (SMS). This involves a systematic approach toward operational risk management. Historically, SMS has been a largely reactive process. This means that incidents have been investigated and findings communicated together with appropriate controls to prevent reoccurrence - kind of like someone slapping you on the hand and saying don’t do that, it’s dangerous.  Additionally, SMS has incorporated the identification of risks involved in processes of the job. Traditionally, if the risk is too high then the plan gets changed to reduce the risk. In other words, you are working to avoid, trap or mitigate the errors brought on by the exposure to risk. This concept was greatly embraced in the field of aviation when James Reason published his book Human Error and continues to be embraced to this day.

FRMS has taken a similar approach but with a twist. In the field of FRMS they have added predictive modeling to the mix. FRMS’s claim to fame is that it is science based and supported by peer-reviewed science. Proponents of FRMS like their data in the system for what is called objective analysis. They also use system wide tools built into corporate safety and health management systems. An active FRMS is supposed to be under constant monitoring for ways to reduce risk using feedback, evaluation and modification of the system. Most companies that have an FRMS system will have a safety policy, a risk reporting system, perform incident investigations for more data, a training and education system, and perform audits on the FRMS system itself. An active FRMS system may look like the following:

-       Company Fatigue Policy
-       An active fatigue risk management information collection system such as questionnaires, surveys, a risk chart, and reports
-       A fatigue reporting system for the employee
-       Fatigue incident investigation system
-       Sleep disorder management
-       Fatigue education and training department/system

For all of this to work there must be buy-in from the employees and supported in the form of a top-down approach by company ownership and management. Otherwise, FRMS becomes a policy that sets on the shelf and becomes a reactive program to accidents or incidents.
Many of us involved in high-risk occupations have been exposed to the systems approach to fighting fatigue. I have always been a proponent of the systems approach for a couple of very straightforward reasons. First, it’s better than not having any approach at all. Second, it allows us to collect data and learn from it. My only thought that diminishes it from being the “end all - be all,” is that it is based on the presumption, in the words of Forest Gump, “shit happens”. The presumption that sometimes things just happen and there is nothing we can do about it, except record the data and identify risks, just doesn’t set well with me!

Looking at each component of the system it looks as though FRMS cannot fail. But how does it happen that fatigue related accidents occur on a daily basis? I think my old friend Tony Kern struck gold with his assumption that the battle against error is a personal battle. This includes the battle against fatigue. If you haven’t had a chance to read any of Tony’s writings, I highly recommend his bookBlue Threat – To Error is Inhuman, Pygmy Book, Monument Colorado, 2009. In a very eloquent manner, he describes many personal reliability issues and countermeasures that may not be addressed in many SMS or FRMS. Now in getting back to where I was going, I think there are a couple of weaknesses in FRMS.

 First, if FRMS is not fully supported by management, it is doomed to fail. If ownership of the FRMS is from topside management, then topside management must wave the flag and be active in all the processes, not just give lip service because FRMS may be required to conduct business. Second, I feel that the systems approach has placed too much emphasis on the system of data collection and not enough on personal accountability. The system begins and ends with what the individual does and does not do, and therefore an acceptable level of responsibility and accountability must be present. Third and lastly, FRMS offers only limited intervention in real time and that intervention in its present form can be circumnavigated! Remember the Tracy Morgan story at the beginning of this article; all of these shortcomings were present and contributed to the accident.
 So what’s this missing link in FRMS that I’ve been hinting at throughout this article? I believe it to be real time intervention. I truly believe that no predictive model is ever going to actively intervene when someone is about fall asleep at his or her post, job or behind the wheel. What is needed is active monitoring, alerting and real time data collection for the support of the FRMS.
 The closest I’ve personally come to finding a fatigue monitoring device/system for real-time intervention comes from a company that I have done consulting and training work with – KOSTechnology.

KOSTechnology has developed a new fatigue risk worn bio-medical monitoring device that uses a measure of heart rate as a key indicator of the onset of fatigue related unwanted sleep events. Let’s take a look at the science behind the invention and how the device and system works.
As we approach sleep onset a couple of things begin to happen within our bodies. First of all, you don’t normally fall asleep all at once. Unless, you have been sleep deprived for a prolonged period of time. You actually enter into sleep in stages. Remember our discussion on sleep cycles? We described the early stages of sleep as preparatory stages, your brain actually starts to down shift from wakefulness to alpha wave to theta and so on and so on. Your physical body actually starts to downshift as well as you start to relax. Your body temperature will decrease slightly, your eyes may dilate, and your heart rate will decrease by as much as 5-8% of its normal resting state. This holds true for sudden onset sleep as well (even micro sleep), the heart rate drop is always present. This heart rate drop is a key indicator of your body’s propensity to fall asleep. KOSTechnology’s sensor uses this drop in heart rate and provides a warning to the wearer that unwanted sleep is about to occur.

The KOS Wearable device is very robust and performs multiple functions. The device automatically tracks the individual via GPS and can report independently. When a warning of unwanted sleep occurs there is an warning given to the wearer and simultaneously, a message is sent to a third-party such as a dispatcher, notifying them that a fatigue warning has occurred and to contact the wearer of the device. The third-party individual will know the exact location of the individual and can contact them with information, fatigue countermeasures and intervention, such as telling them to stop and take a break.

When coupled with the software suite that comes with the fatigue alerting device, a company can integrate the movement of the individual and heart rate data, as well as warning information into their company’s FRMS data collection portal. The company can then examine real-time historical data of events for future planning. They will be able to determine if a certain time period, event or route is a risk danger zone to their employee or operation, and actually be equipped to do something about it in real-time.

 KOSTechnology has also incorporated another aspect of what I consider to be a vital part of the risk equation and that is user training. They offer as a service of general fatigue and fatigue risk management training coupled with their bio-medical measuring device. I think that KOSTechnology has truly found the missing link in the FRMS equation – real-time monitoring and intervention coupled with focused training for the individual to bolster his or her role in the risk management system. No system is complete without the incorporation of the human element into the scheme of things.

 To learn more about KOSTechnolgy fatigue alerting systems, please visit