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Why we need to stop using the term human error in accident investigations

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Vancouver airport near miss

In April 2013, human error by an airport controller at Vancouver Airport mixed up the ID’s of two planes almost causing a serious accident. Luckily, the mix-up was solved and no one was killed. When investigating the cause of the incident at Vancouver Airport, the Transport Safety Board of Canada (TSBC), used our scientifically validated Fatigue Avoidance Scheduling Tool (FAST) to identify fatigue as the cause for human error. By reviewing the airport controllers actual schedule, FAST was able to identify that the controller did not obtain sufficient sleep before their shift and was therefore fatigued at the time of the incident.

By using objective data, TSBC now understands exactly what caused the human error and that ‘fatiguing schedules’ can greatly increase the likelihood of human error occurring.

So why are we still only referring to ‘human error’ as a cause?

In many accidents, investigators would run a series of investigations to establish that it was human error that was the cause.

A September 2012 study by the US Federal Aviation Administration (FAA) proves that self-reported studies, similar to the ones conducted to establish human error, are not accurate. The results showed that people do not normally feel fatigued until they lose 30% of their reaction time due to sleep loss. That is equivalent to the reaction time of people who are legally drunk at 0.08% blood alcohol.

Objective data is needed for 24/7 organizations to improve safety

In order for high-risk organizations such as aviation, air traffic control, healthcare or nuclear industry where reducing accident risk is imperative to the health, safety and wellbeing of their employees, objective data must be used to identify the root cause of human error in accidents.

The most accurate and validated way to improve safety is with our fatigue management technology – FAST and Readiband. This software is the “officially sanctioned” US Department of Defence fatigue analysis system.

FAST used to pinpoint the root of human error

FAST is our user-friendly scientifically validated software that has been developed for schedulers and planners to identify areas of fatigue risk in employee rosters. The data can then be used for objective comparisons and optimal schedules may be selected for proposed work periods or mission critical events. FAST is used by major accident investigators in North America and Australia including The US National Transportation Safety Board,  The US Federal Railroad Administration and the Transportation Safety Board of Canada.

Readiband is a proactive strategy to improve safety

On the other hand, Readiband can be used as a proactive strategy for organizations to improve workplace safety.  By wearing the Readiband, sleep data is collected and summarized in clear visual reports containing fatigue analytics that allow administrators to manage fatigue risk.

Global BC News: Sleep deprivation caused YVR near miss

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Global BC News,Ted Cherneki, reports on the level of fatigue the air traffic controller was suffering in 2011 when two Westjet flights nearly collided at YVR airport:

 

Westjet near accident: YVR fatigued air traffic controller

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Fatigue Science was asked to analyze how Fatigue contributed to the Westjet incident at Vancouver’s YVR Airport on April 15th, 2011.

Fatigue related accidents and close calls are completely preventable. Employers can be proactive and have their work schedules examined by the Fatigue Avoidance Scheduling Tool (FAST). This will tell them whether their schedules are creating dangerous periods of time when workers would be at a high risk of making a mistake or having an accident. It allows them to manage the risk to prevent the accidents from happening.

FAST was developed by the Walter Reed Army Institute of Research at the U.S. Army Medical Research Development Command to prevent fatigue related accidents and has been independently validated by the US Department of Transportation. FAST is used by many industries globally and is recommended by the world’s largest re-insurance company MunichRe.

Pilots of USA Airforce One use FAST to review schedule rosters before flight and ensure fatigue is not a risk factor.

The Canadian government and many Canadian industries are just beginning to address this important issue. Some have tried in the past but with FAST and Readibands they are now able to upgrade their fatigue management programs to a modern, evidence based system.

FAST used to identify fatigue as a factor in recent Vancouver airport incident

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Our Fatigue Avoidance Scheduling Tool (FAST), was recently used by The Transportation Safety Board of Canada (TSB) to identify fatigue as a factor in an April 2013 incident at Vancouver Airport. FAST identified that the airport controller did not obtain sufficient sleep before their shift. In addition, the airport controller’s schedule did not permit enough adaptation time, requiring the controller to sleep during the day in an attempt to be adequately rested for the night shift.

The report says the controller mixed up the ID of a 737 and the Jazz plane waiting to take off and ordered the 737 to take off from the same runway where the Jazz plane was waiting. The confusion set off a delay in getting the planes off the ground, which forced an incoming West Jet plane to circle the runway.

FAST for Retrospective Analysis

By uploading an employee’s schedule into FAST, users can identify if an employee’s schedule could have caused fatigue and increased the likelihood of an incident or accident.

Further, if the employee was wearing our Readiband technology before the incident/accident actual sleep data could be imported into FAST for a more comprehensive analysis.

How does FAST work? 

FAST is our user-friendly scientifically validated software that has been developed for schedulers and planners to identify areas of fatigue risk in employee rosters. FAST allows organizations to upload rosters and generates visual predictions of performance along with tables of estimated effectiveness scores. The data can then be used for objective comparisons and optimal schedules may be selected for proposed work periods or mission critical events.