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Dead Tired…Really

Everyone knows how busy air traffic is around Washington DC so it’s no surprise that two airliners, United Airlines #628 inbound from Chicago, and American Airlines #1012 from Dallas would be approaching each other from opposite directions, both intending to land at Reagan National Airport (DCA).  The problem was that neither pilot was able to reach anyone on the radio in the Reagan National Airport tower for landing instructions and traffic separation advisories.  The two flight crews were quite literally “in the dark” as it was just dead tired 1after midnight.  According to FAA and NTSB investigations, the pilots had made “numerous unsuccessful attempts to contact air traffic control from 12:04 AM to 12:28AM”.  After failing to contact the DCA tower, the American Airlines pilots executed a missed approach, climbed back into the night sky and contacted the Washington FAA center controllers for instructions.  The FAA personnel themselves made multiple attempts to contact the DCA tower via telephone and radio, but were “similarly unable to make contact.”  Ultimately the two airliners landed “as if at an un-towered airport” guiding themselves to the runway with no air traffic control.  The National Transportation Safety Board reported that the tower controller, who had worked at DCA for 20 years, “had fallen asleep during this period” and did not hear the airliners call in.  He told the FAA that he had been working his fourth consecutive all night shift (10PM to 6AM) and was alone in the tower.

This incident was a near miss that inconvenienced some folks but no one was injured.  As I have commented previously in this blog – errors repeat themselves and doom those who fail to learn its lessons.  The National Air Traffic Controllers Association appropriately commented that, “One person shifts late at night are unsafe”.  It is sad that the air traffic controller world had failed to learn from a real tragedy that occurred in the summer of 2006.  In that accident 49 people were killed when a single controller handling multiple duties in the early morning hours failed to notice a commuter airliner pilot mistakenly using the wrong runway.  It was too short and plane crashed into the ground after running off the end.  As the Australian road signs say, “Fatigue is Fatal”.

Charles Lindbergh

Charles Lindbergh

Maybe the best description of being “dead tired” comes from America’s most famous aviator, Charles Lindbergh, who pulled the ultimate all-nighter flying for 33½ hours alone in the cockpit of “The Spirit of St. Louis” with no relief, no rest, and no autopilot.  Early in the morning on May 20, 1927 Charles A. Lindbergh took off from Roosevelt Field near New York City.  Flying northeast along the coast then first over Nova Scotia and then Newfoundland he headed out over the Atlantic, using only a magnetic compass, his airspeed indicator, and luck to navigate across the Atlantic to Paris where he landed a day and a half later.

 “My mind clicks on and off.  I try letting one eyelid close at a time while I prop the other with my will.  But the effect is too much, sleep is winning, my whole body argues dully that nothing, nothing life can attain is quite so desirable as sleep.  My mind is losing resolution and control.  The nose is down, the wing is low, the plane is diving and turning.  I’ve been asleep with open eyes.  I kick the left rudder and pull the stick back.  My eye has jumped to the altimeter.  I’m at 1600 feet.  The turn indicator leans over to the left.  The air speed drops, the ball rolls quickly to the side.  My plane is getting out of control.  I’ve got to find some way to keep alert.  There’s no alternative but death and failure.” 

The high reliability literature dealing with human factors has repeatedly shown that fatigue is the number one cause of errors in high performance tasks.  Just look for proof at the time of almost every disaster that has been linked to human error.  The Chernobyl nuclear meltdown (26 April 1986 at 01:23 AM); the Union Carbide Bhopal cyanide gas leak that killed almost 8,000 people (3 December 1984 at 2:30 AM); the Titanic wreck (14 April 1912 at 11:40 P.M.); the Exxon Valdez struck Bligh Reef, spilling 10.8 million gallons of oil into Prince William Sound, Alaska (24 March 1989 at 12:15 AM) and on and on.  When our brain is tired it functions as if we were drunk.  A famous study (Dawson D, Reid K., Fatigue, Alcohol and Performance Impairment, Nature 1997; 388:235) equated 22 hours of being awake with dexterity and problem solving capability of a control group with blood alcohol levels of 0.09.  A blood alcohol level that high is enough to land you in jail if you got pulled over while driving home from the party. The National Transportation Safety Board says that in the last 15 years fatigue has been associated with over 250 fatalities in air carrier accidents that they have investigated and that there “are countless other general aviation accidents linked to fatigue” that are less well accounted.

Our brains and bodies work on a fixed circadian rhythm that lowers the body temperature, increases secretion of melatonin and block release of cortisol starting around 10 PM and peeks out after 4 AM when the cycle begins again with a spike in cortisol release.  If you think, just because we are surgeons and stayed up all night throughout our careers so “it’s OK”, think again.  The graph below will appear in a chapter I wrote for a new surgery textbook and plots these physiological factors on the same axis as time of day/night mortality for surgical cases*.

dead tired 3

There is just no way to get around the fact that the human brain goes into “sleep mode” as cortisol levels fall and melatonin levels rise.  The negative impact of fatigue on outcomes in surgery has been documented in this study and others that show higher mortality in late night surgical procedures.  Starting a case at night demonstrated a strong effect on morbidity and surgical start time has been shown to be an independent variable on mortality.  Numerous other studies can be found in the literature demonstrating diminished physician performance in other areas during periods of fatigue. As students and practitioners of the high reliability mindset we must respect our own physiological limitations during late night emergency surgery.  This needs to be reinforced by every surgeon and every surgical team and requires extra attention to “CRM skills”, communication and cooperation between the surgeon and team members.  Since hospitals are open 24 hours a day and patients always seem to get injured and sick during the early morning hours (probably because driving is also more dangerous at night) we must apply our high reliability mindset skills at these times.  We must always remind ourselves and our team members that late night and early morning hours are the most dangerous for our patients and we need to watch over each other, check and oversee each others’ actions and guard against error during these times as we battle our own physiology.  If you feel dead tired, remember that fatigue is fatal – really.

* Check out my references if you are in doubt:

(1) Kelz R, Timothy T, Hosokawa P. et al. Time-of-day effects on surgical outcomes in the private sector: a retrospective cohort study. J  Am Coll Surg 2009;209:434–45.

(2)Chan S, Debono M. Ther Adv Endocrinol Metab. 2010:1(3): 129–138.

(3) Rajaratnam SW, Middleton B, Stone BM,Arendt J. J Physiol. 2004 November 15; 561(Pt 1): 339–351.

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Posted in CRM, Fatigue, High Reliability Mindset, Human Factors.

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