CLINICAL REVIEWTransport and industrial safety, how are they affected by sleepiness and sleep restriction?
Introduction
For many years fatigue has been associated with an increased risk of accidents, but the causes were unclear. Extensive or nocturnal work or driving were associated with accidents but few reports differentiated fatigue, which is usually seen as due to driving time, from sleepiness, which is due to reduced sleep,1 extended time awake or and being awake at the circadian trough,2 or to drugs.
Drowsiness3, 4, 5 has been identified as the reason behind fatal road crashes and many industrial accidents.6 In recognition of this, the European Union aims to halve the number of road deaths by 2010, and a vast program of road safety has been initiated. To gain 20,000 life-years in Europe, we need to reach a better understanding of traffic accidents. Because professional traffic is going to increase by 50% in the next 10 years in Europe and many other continents, it is a major issue to identify new causes of accidents and new strategies to prevent them.
Much of the research has been focused on occupational driving and safety and far less is known about other areas of working life. Here we have, therefore, divided the material into “Occupational driving” and “Other kinds of work”. The latter includes traditional industrial work but also health care. Another subdivision that seems relevant is that of sleep disorders and rest/activity patterns. The latter includes shift work but also other reasons for deviating from traditional full nighttime sleep.
Section snippets
Safety and work-related driving risk
A series of studies by the National Transportation Safety Board (NTSB) in the USA, have pointed to the significance of sleepiness as a factor behind accidents involving heavy vehicles.7, 8, 9 In the 1995 study (which was very probing), NTSB came to the conclusion that 52% of 107 one-vehicle accidents involving heavy trucks were fatigue related; in 17.6% of the cases, the driver admitted to falling asleep. NTSB already referred in 1990 to fatigue as the most important cause (31%) of fatal
Sleep disorders and complaints
Several studies performed in the last 20 years show a clear relationship between sleep disorders and traffic accidents.10, 11, 12, 13, 14, 15, 16 Most of the professional accidents reported refer to the obstructive sleep apnea syndrome (OSAS). Several reasons can explain this high prevalence. First, in the general population the prevalence of obstructive sleep apnea syndrome is between 2% and 4%.17 In selected populations studied the prevalence of OSAS has been reported to range from 26%18 to
Drugs
Even if many publications41, 42, 43, 44, 45 associate central nervous system drugs and risk of accidents, very few data are available on accidents of occupational drivers.
Howard et al.46 measured the relationship between excessive sleepiness, sleep-disordered breathing, drug consumption and accident risk factors in 2342 respondents to a questionnaire distributed to a random sample of 3268 Australian commercial vehicle drivers. Another 161 drivers among 244 were invited to undergo
Sleep disorders and complaints
Most of the safety/fatigue data in the industrial sector derive from studies of sleep complaints or outright sleep pathology (as opposed to “merely” shortened sleep). One exception may be the epidemiological study by Kripke et al., which showed lowest mortality for individuals who slept 7 h per night.80
In another epidemiological study Åkerstedt et al.72 related fatal occupational accidents to a number of predictors measured previously. Both disturbed sleep and shift work had significant odds
Final comments
Sleepiness is clearly an important cause of accident in the transport sector. Programs to reduce the number of accidents need to focus on this topic, in addition to drugs and car safety measures. Clearly, the link between sleep restriction (or shift work) and safety is much better established in the transport industry than in other areas. The reason is, obviously, that driving a car or some other vehicle is a classical “tracking” task—the one most sensitive to reduced alertness.124 In industry,
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