Your Captain Speaking: How the Airlines Manage Fatigue

“Samantha, EMS leaders try a lot of best-practice approaches, but I think we’re missing the forest for the trees with the problem of fatigue.”

“OK, explain. What’s the fatigue problem, and who has a good handle on it?”

There have been multiple studies on EMS and fatigue, and they all pretty much point to the same answer: We are fatigued more often than we’d like to admit while working, and when fatigued we make mistakes. A Department of Transportation study found EMS providers often run on empty with regard to sleep, averaging only six hours a night.¹ There are few people for whom that is enough.

We tend to blame individuals for not getting sufficient sleep, but it can be the fault of their system. Here’s an example: It’s a busy day, you’ve run hard for a 12-hour shift, and then 30 minutes before you’re cleared for 10-42 (return to base, you are now off duty), you are notified of a late trip. The dreaded late trip isn’t the patient’s fault, and they need the transfer, so you do what you always do and suck it up. Of course you are significantly delayed getting back to the base to go home.

Here’s where the problem can be compounded. Your next shift starts at 0700, so by the time you get home, get to bed, get up, and drive back to work, at best you will have only a few hours of sleep. That next day you will not be at the top of your game. Many of us have been there, and to my mind it’s the supervisor’s fault. When a schedule like this occurs, the EMT should not be penalized just because “that’s the way we’ve always done it.” In aviation there are minimum rest periods from end of duty—why not EMS?

Predictive Analysis

I can suggest, from backgrounds in both EMS and aviation, that there is a better way. Aviation reached a turning point when fatigue was identified as the cause of airline crashes, not just a contributing factor. It wasn’t easy, but we changed many things we’d done for a long time.

Now aviation management looks at scheduling to determine if it will contribute to a pilot being fatigued. Does their flight time remain within the mandated FAA limits? Are they getting enough time to rest? We knew a night-time out-and-back from Louisville to Newark and back could be done with the same crew for three nights in a row. If we tried to do it for a fourth night, it was an obvious problem when crews returned. All legal, but it was too much. As management, we had to know better. From my point of view, working four hard night shifts in a row is the same in flying as it is in EMS.

How about some predictive decisions, rather than being reactive? Here’s what is being done in a few airlines that is beyond the visible horizon in EMS. Schedules change, and many times I have asked for a “predictive fatigue analysis” for a set of flights. We input a pilot’s schedule and what time zone they are acclimated to when they start. Our program plots their normal circadian rhythms against their planned rest and work schedules. If the analysis shows fatigue becoming too great at any point, they don’t go! We change the schedule or change pilots, but we don’t knowingly assign the trip. Management has fatigue responsibility!

Personal Responsibility

What about the pilot’s responsibility to call fatigue? What I’m about to tell you may be beyond comprehension for EMS, but it’s what pilots do, and it works:

Before each flight, each pilot must sign the operational flight plan, attesting they “affirm and certify they are fit for duty.” This covers more than just fatigue—they can’t be sick, injured, or mentally unfit. Examples would be having the flu, a sprained ankle, or a death in the family that distracts the pilot from their duties.

Even after their report, the obligation to not fly fatigued remains. There are times when circumstances beyond the pilot’s or management’s control will cause a fatigue call. Mechanical problems can take hours to resolve, and crew members might call fatigue during long waits.

We don’t just let the system collapse if one person calls fatigue—we have backups. Sometimes a reserve pilot is on standby at the airport, but the time they can do this is limited to 4–6 hours. For longer coverage we put the crew at a hotel and require them to respond within 90 minutes. The point is, there is a backup plan.

Honestly, while there is some abuse, most of the time the crews are driven to fatigue through no fault of their own. The “late trip” example above is only one of many possibilities. Some scheduling plans are very brittle, and if there is a single hiccup, they fall apart. As supervisors we all want to have perfect results from our plans, but we live in a real world.

A fatigue program cannot exist without a well-defined policy. Retribution for calling fatigue, formal or informal, is not acceptable. When a pilot calls in to report fatigue, we make no attempt to pressure them, bargain, or talk them out of it. The scheduler reads a script, advises them they have a specific rest time, and to check back for their schedule when rest is complete. We try to identify and resolve the reason for the call with a fatigue panel. As an example, we saw a particular hotel had lots of noise and late-night disturbances. When we changed hotels the number of fatigue calls dropped significantly. That was not the fault of the pilots.

“Samantha, I shudder at how many mistakes and accidents might be occurring in EMS due to fatigue. I don’t think we have a handle on these numbers like they do in commercial airlines. Here’s something for sure: You do not want to be the person accepting a folded flag at a funeral, as I have.”

“Dick, it will take leadership and awareness on our part—and on everybody’s part.”

Reference

1. Patterson PD, Robinson K. Fatigue in Emergency Medical Services Systems (Report No. DOT HS 812 767). Washington, DC: National Highway Traffic Safety Administration, 2019.

Dick Blanchet (ret.), BS, MBA, worked as a paramedic for Abbott EMS in St. Louis, Mo., and Illinois for more than 22 years. He was also a captain with Atlas Air for 22 years and an Air Force pilot for 22 years.

Samantha Greene is a paramedic and field training officer for the Illinois Department of Public Health Region IV Southwestern Illinois EMS system, a paramedic and FTO for Columbia (Ill.) EMS, and a full-time paramedic at the St. Louis South City Hospital emergency department.