Working Together to. Understand Driver Fatigue: Report on Symposium Proceedings. Highway Safety Roundtable. Highway Safety Roundtable

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1 1 Highway Working Together to Understand Driver Fatigue: Report on Symposium Proceedings Working Together to Understand Driver Fatigue: Report on Symposium Proceedings Highway FEBRUARY

2 Highway 2 Table of Contents 3 Chair s Message Presentation Summaries 5 Introductory Session Driver Fatigue Literature: A Review, Dr. Leo Tasca, Ontario Ministry of Transportation 7 Session One Fatal and Injury Fatigue-Related Crashes on Ontario s Roads, Dr. Yoassry Elzohairy, Ontario Ministry of Transportation 9 Session Two Medical Perspective: Driver Drowsiness, Fatigue and Alertness, Dr. Henry Moller, University of Toronto 14 Session Three Countermeasures, Dr. Alison Smiley, Human Factors North Inc. 16 Session Four Policing Perspective, John Carson, OPP Deputy Commissioner 18 Closing Remarks: Hon. Donna Cansfield, Minister of Transportation Appendices: Presentations and Bibliography 19 Appendix A Drowsy Driving: An Overview of the Safety Research Literature, by Dr. Leo Tasca, Ontario Ministry of Transportation 28 Appendix B Fatal and Injury Fatigue-Related Crashes on Ontario s Roads: A 5-year Review, by Dr. Yoassry Elzohairy, Ontario Ministry of Transportation 35 Appendix C Medical Perspective: Driver Drowsiness, Fatigue and Alertness, by Dr. Henry Moller, University of Toronto 44 Appendix D Strategies for Reducing Fatigue-Related Crashes, by Dr. Alison Smiley, Human Factors North Inc. 50 Appendix E Driver Fatigue Bibliography, by the Strategies to Reduce Impaired Driving Sub- Group on Fatigue of the Canadian Council of Motor Transportation Administrators

3 3 Highway Chair s Message Driver fatigue is a deadly problem On May 16, 2007, Insurance Bureau of Canada, on behalf of the Highway and with the support of the Ontario Ministry of Transportation, sponsored a symposium in Toronto called Working Together to Understand Driver Fatigue. The symposium brought together about one hundred stakeholders including driver educators, fatigue experts, medical doctors, academics, police and political leaders. This report of the symposium proceedings includes an overview of the presentations made by four authoritative Ontario researchers, the Deputy Commissioner of the Ontario Provincial Police (OPP) and Ontario s Minister of Transportation. Notes and references from the presentations of doctors Tasca, Elzohairy, Moller and Smiley, along with a comprehensive bibliography of driver fatigue research, are included as appendices to this report. Mark Yakabuski President & CEO, Insurance Bureau of Canada Chair of the Highway Safety Roundtable The following are key points that were raised at the symposium: A Dr. Tasca: We have underestimated fatigue as a significant risk factor in crashes. A Dr. Elzohairy: A statistical model suggests 17.9%, a tragically high number, of all fatal crashes are fatigue-related. A Dr. Moller: Fatigue impairment is a disorder of information processing the more we understand information processing, the better able we will be to prevent the disorder. A Dr. Smiley: It is more effective for a driver to plan ahead and take countermeasures against fatigue before getting behind the wheel than to try to compensate for drowsiness while driving. A Deputy Commissioner Carson: Fatigue-related fatalities are senseless and can be prevented. With a concentrated effort, fatigue-related injuries and fatalities on our roads can be prevented.

4 Highway 4 The theme that recurred throughout the symposium was that driver fatigue is a very significant threat to road safety that needs much more attention from all levels of society. With a concentrated effort, fatigue-related injuries and fatalities on our roads can be prevented. On behalf of Insurance Bureau of Canada, I am proud to be part of the Highway Safety Roundtable, which is actively pursuing a number of initiatives put forward at the symposium, including working with the Ontario government to find ways to make Ontario s roads and highways safer. Mark Yakabuski President & CEO, Insurance Bureau of Canada Chair of the Highway February 2008 The Highway is composed of representatives from the following organizations: Brewers Association of Canada Canada Safety Council Canadian Automobile Association Insurance Bureau of Canada Railway Association of Canada Tourism Industry Association of Canada

5 5 Highway Introductory Session Driver Fatigue Literature: A Review Leo Tasca, Ontario Ministry of Transportation (For a full list of references cited in this summary, please see Appendix A.) Working Together to Understand Driver Fatigue: Report on Symposium Proceedings Leo Tasca, from the Ontario Ministry of Transportation, began the working sessions by giving an overview of fatigue impairment as documented in road safety research literature. Tasca reviewed the key fatigue impairment documents, beginning with the Commercial Motor Vehicle Driver Fatigue and Alertness Study (1997) conducted by the US Federal Motor Carrier Safety Administration and Transport Canada. The landmark study observed 80 commercial vehicle operators, aged 25 to 65, on 360 trips that covered a total of 200,000 miles. Tasca highlighted the following findings: Time of day was the single best predictor of decreased driving performance. 19 minutes out of the 244,667 minutes of video showed drivers falling asleep. A 13-hour drive with a night-time start was associated with the most sleep deprivation. There was little correlation between subjective and objective performance measures. Age was not a significant factor in fatigue. No collisions occurred during the study. In Development of Fatigue Symptoms During Simulated Driving (Nilsson et al. 1997) 80 young males were asked to drive for as long as they comfortably could. Subjects varied in how long they were able to continue driving, but they all had similar fatigue scores when they decided to stop. Nilsson and colleagues implied that it was better to teach drivers to recognize the signs of fatigue impairment than to tell them to rest after some specified number of hours of driving. An Australian study, Developing Measures of Fatigue Using Alcohol Comparison (Williamson et al. 2001), compared the effect of remaining awake for 28 hours with the effect of varying doses of alcohol (up to 1.0 BAC) on the same driver. Subjects were most affected after 17 to 19 hours of wakefulness, demonstrating performance similar to what they achieved with.05 BAC scores. Why Do People Have Drowsy Driving Crashes? (Stutts et al. 1999), a study conducted in North Carolina, was based on interviews with 1,403 drivers involved in crashes where police had coded the driver s condition as fatigued or asleep. The results of these fatigued and asleep groups were compared to two control groups consisting of drivers with no record of collisions and drivers involved in collisions not related to fatigue. Stutts and colleagues reported the following odds ratios (compared to the non-crash control). Night-shift worker 13.6 Sleeps less than 5 hours 7.0 Sleeps 5 to 6 hours 3.8

6 Highway 6 Working Together to Understand Driver Fatigue: Report on Symposium Proceedings Poor sleeper 12.1 Drives late at night 6.5 Slept less than 4 hours the night before 19.2 Awake 15 to 20 hours 10.4 Awake more than 20 hours 56.6 Epsworth Sleepiness Scale (ESS) score of ESS score of A study conducted in the UK, Driver Sleepiness and Risk of Serious Injury (Conner et al. 2002) was based on interviews of 571 drivers involved in serious collisions; 65% of these interviews took place within 48 hours of the collisions. The study found: an eight-fold increase in risk if drivers reported sleepiness; a five-fold increase in risk when driving between 2:00 a.m. and 5:00 a.m.; and a three-fold increase in risk when driving with less than five hours of sleep. Fatigue-Related Crashes (Australian Transport Safety Bureau [ATSB] 2002) was an analysis of fatigue-related crashes on Australian roads. The ATSB used its database of fatal accidents to analyse crashes in Australia. The study identified fatigue-impaired collisions in the database by first excluding all crashes where the database showed other factors were involved. Collisions involving the following were eliminated: BAC over.05 Pedestrian(s) Speed limit less than 80 km/h Unlicensed driver The ATSB took the remaining collision data and included the following types of collisions in their study: all single-vehicle collisions occurring between 12:00 a.m. and 6:00 a.m., and between 2:00 p.m. and 4:00 p.m.; and all head-on crashes where neither vehicle was passing. Using this selection process, the researchers found that 16.6% of fatal crashes were fatiguerelated. Tasca noted the study was not designed to find an absolute number of fatigue-related crashes, but to create an index of relative incidence. Drowsy Driving, a 2004 Traffic Injury Research Foundation survey of 1,209 Canadians, published in Road Safety Monitor, found the following:

7 7 Highway One in five drivers reported nodding off at the wheel at least once in the previous 12 months. Because of the lifestyle choices they tend to make, young people were at greater risk of drowsy driving. Working Together to Understand Driver Fatigue: Report on Symposium Proceedings Male drivers reported being more susceptible to fatigue than did female drivers. The authors of Subjective and Predicted Sleepiness While Driving in Young Adults (Smith et al. 2005) developed a model to predict sleepiness levels based on comparing sleep diary data with feelings of sleepiness as reported by subjects. Subjects recorded 2,518 driving trips. They reported being sleepy during 23% of the trips. Eighty-two trips (3.4%) occurred when subjects had been awake for more than 18 hours. There was not one instance where a subject chose not to drive because of sleepiness. An on-road study entitled, Fatigue, Sleep Restriction and Driving Performance (Philip et al. 2005), tested the performance of 22 healthy males aged 18 to 24. They drove 1000 kms on a divided highway in five 105-minute sessions. Subjects drove the route twice once with 8.5 hours of sleep the previous night and once with 2.5 hours of sleep the previous night. In the normal sleep condition (8.5 hours of sleep the previous night), drivers demonstrated a significant increase in risk by the fourth session. In the sleep-deprived condition, drivers demonstrated a significant increase in risk by the second session. Tasca concluded by noting that fatigue very definitely affects driving performance. He said we have, up until now, underestimated fatigue as a significant risk factor in crashes. After Leo Tasca s presentation, the symposium broke into two sessions. Session One Fatal and Injury Fatigue-Related Crashes on Ontario s Roads Yoassry Elzohairy, Senior Safety Research Advisor at the Ontario Ministry of Transportation (For a full list of references cited in this summary, please see Appendix B.) Yoassry Elzohairy, Senior Safety Research Advisor at the Ontario Ministry of Transportation, presented a review of fatigue-related crashes on Ontario s roads. Elzohairy noted that, according to police reports, less than 2% of all collisions are fatiguerelated. He observed that provided the drivers remain awake in cases where fatigue plays a factor, these cases are not generally recognized as fatigue-related. He noted that there is no straightforward fatigue-measuring device for police to use at the roadside. Elzohairy proposed a method for estimating the prevalence of crashes related to drowsy driving, based on a refinement of the Australian operational definition. Elzohairy considered a collision to be fatigue-related if it adhered to one or more of the following selection criteria: Vehicle condition: No apparent defect

8 Highway 8 Working Together to Understand Driver Fatigue: Report on Symposium Proceedings Driver did not exceed the speed limit or drive too fast for conditions Driver was not impaired by alcohol or drugs Driver had no medical or physical disability Crash occurred on dry pavement Driver initiated the crash Initial impact: Head-on collisions where neither driver was passing; rear-end collisions; or single-vehicle crashes Crashes involving pedestrians, unlicensed drivers or animals were excluded. Using this model, Elzohairy discerned the following: In 2004, 17.8% of all fatal crashes and 25.5% of crashes causing injury were fatigue-related. Men were involved in 65% of fatigue-related crashes. An average of more than 200 out of every 10,000 drivers aged 17 to 20 were involved in fatigue-related crashes. This is twice as many drivers as the 35 to 44 demographic. Bus drivers (Class C licences) were involved in fatigue-related crashes at a rate of 225 per 10,000 drivers, compared to 169 per 10,000 for school bus drivers (Class B), 146 per 10,000 for tractor trailer drivers (Class A) and 74 per 10,000 for other bus drivers (Class G). (At this point a participant in the symposium pointed out that Ontario collision reports did not provide the option of noting when, for instance, a bus driver is in a collision while driving his or her car.) 40% of all fatigue-related crashes occurred on roads where the speed limit was 50 km/h. The most common errors committed by fatigued drivers were following too closely (59%) and losing control (28%). Other points drawn from the model showed that most fatigue-related crashes occur between three and six in the afternoon and on Fridays. The Greater Toronto Area (GTA) has the highest rates of fatigue-related crashes and the summer months are the most dangerous. (At this point, several participants noted that if Ontario s data were related to kilometres driven, the conclusions drawn could be much sharper. A participant said Ontario s data need to be tied to Statistics Canada s Canadian Vehicle Survey.) All Symposium participants received a copy of Akilla, In the blink of an Eye: A drowsy driving handbook, the first driver education book about fatigue courtesy of Martin Jenkins. The Handbook is available at New Zealand Sleep Safety Limited P.O. Box 10386, The Terrace Wellington 6143 New Zealand

9 9 Highway Session Two Medical Perspective: Driver Drowsiness, Fatigue and Alertness Dr. Henry Moller, Department of Psychiatry, University of Toronto (For a full list of references cited in this summary, please see Appendix C.) Working Together to Understand Driver Fatigue: Report on Symposium Proceedings Dr. Henry Moller, a physician-researcher and professor in University of Toronto s Department of Psychiatry, provided a medical perspective on driver drowsiness, fatigue and alertness. Moller demonstrated that fatigue impairment is not only confined to crashes resulting from drivers who fall asleep at the wheel; fatigue also dramatically affects the performance of drivers when they are awake, impairing the ability to process information. Moller began by citing a 1998 Lancet article that urged banishing the word accident from the road safety lexicon because the word denotes chance and unpredictability. He proposed a cybernetic model of driver performance based on four factors: 1. External environmental factors time of day, weather, duration of drive, etc. 2. Driver factors age, gender, driving experience, affective state, fatigue, etc. 3. Vehicle factors steering, brakes, tires 4. Distractions food, radio, cell phone, , passengers Dr. Moller stated that there was still debate around the operational definition of fatigue and he indicated that his research could inform that debate. From a medical-psychological standpoint, fatigue is characterized by a lack of alertness and reduced mental and physical performance. It is often accompanied by drowsiness. It manifests in forgetfulness, poor communication, impaired decision-making skills, slow reaction time, microsleep, mood disturbance and/or irritability. In relation to driving, Moller defined fatigue impairment as a disorder of information processing causing difficulty in human/vehicle or human/environment interaction. Driving requires different levels of cognitive activity. The lowest is skills-based behaviour and is automatic or effortless (sensory-motor perception), such as steering a vehicle. The next level of cognitive activity is rules-based and requires a driver to perform a prescribed manoeuvre to deal with changing circumstances (e.g., passing a slower car). The highest level of cognitive activity uses knowledge for problem-solving (e.g., when a rule-based manoeuvre is insufficient). Here, creativity is required from an individual in order to deal with complexity. While older models of fatigue and information processing (Rasmussen 1987) tended to focus on the effects of fatigue on the first level of cognition, Moller s research suggests that all three levels of cognition are affected by fatigue. Epidemiological studies have established circadian variation in the incidence of fatigue-related motor vehicle accidents, with the greater risk occurring in late-afternoon and late-night periods. In addition, typical circumstances/conditions of what Moller terms a Type I crash involving fatigue are: involvement of a single vehicle; lack of external stimulation; boredom/under-arousal, leading to a lowering of brain activity; and rural or long monotonous stretches of highway.

10 Highway Working Together to Understand Driver Fatigue: Report on Symposium Proceedings 10 However, when fatigue is seen as a disorder in information processing, crashes may occur with a set of completely different factors. Type II may involve: multiple vehicles; multi-tasking/ over-arousal on the part of a driver (over-stimulation results when mental tasks are excessively complex and sustained); an urban setting/intersection location; and heavier traffic volumes. Moller places drivers in the two types of motor vehicle accidents on a neurocognitive performance spectrum of fatigue. TYPE I CRASHES Under-Arousal Drowsiness Errors of Omission Sleep Mode TYPE II CRASHES Over-Arousal Cognitive Overload Errors of Commission Overload Mode Moller speculates that maladaptive driving behaviour may be fatigue-related. Road rage, for example, is thought to be purely volitional on the part of the driver. But changing socioergonomic factors impacts of sprawl, congestion, a three-fold increase in commute times since the 1970s may move the brain state from information underload to overload. Under these circumstances, fatigue-induced irritability transforms into rage. The use of mobile communications devices and social expectations (e.g., the demand for multi-tasking) are other variables in the driver-vehicle, driver-environment mix and are generally under-researched in terms of their impact on driver fatigue. Much of Dr. Moller s latest work has concentrated on brain function during task execution and the introduction of distractions. Brain imaging shows increased activation of the occipital (i.e., visual) cortex the simple visual tracking of distractions but also in the prefrontal cortex, where the brain works harder to process information. Cybernetic model of driver performance Four Factors: Driver External Environmental Distraction Vehicle

11 Moller s clinical practice with patients suffering from sleep disorders has given him specific insights into fatigue and crash risks. By far, the most common cause of fatigue is self-imposed sleep loss. However, some medical factors can also be at work. While it is true that sleep quality deteriorates with age, statistics bear out the fact that older drivers tend to be more sensible and risk averse. An area for investigation will be whether this holds true over the current demographic shift, i.e., baby boomers vs. their parents. 11 Highway Working Together to Understand Driver Fatigue: Report on Symposium Proceedings The most common medical disorder is untreated sleep apnea and is most prevalent in middleaged men (5% to 15%). A condition characterized by interrupted breathing, which starves the brain of oxygen, sleep apnea runs from mild (occasional occurrence during sleep) to severe (frequent occurrences). Narcolepsy is extremely rare (affecting 5 people in 1,000), but very dangerous because the brain is subject to sudden, unpredictable sleep attacks. Neurological disorders such as stroke, MS, Parkinson s, etc., can affect the brain physically (lesions), so impairment (and therefore risk) can be compounded when combined with sleep apnea. For patients with insomnia, it is questionable whether they have a higher risk of falling asleep when driving. Insomnia patients complain mostly of fatigue in carrying out daily tasks. Patients with psychiatric disorders are similar to insomnia patients in terms of the symptoms they report, but patients with psychiatric disorders who are treated with drug therapy may experience other symptoms or side effects. Practitioners must weigh the symptoms and side effects of treatments for psychiatric disorders in terms of a patient s overall ability to process information and safety operate a vehicle. Shift work is controversial in the medical community when it comes to sleep and sleep disorders. While one subject copes well with shift work, another does not. There are those who believe the latter has a disorder that can be treated. Others say that fatigue resulting from shift work is a social construct and should not be medicalized. It is possible that some people are simply better at adapting to shift work. The role of medication in fatigue can vary. Some medications may produce hangovers the following day. Antidepressants can have sedative effects, but can also improve brain function. In such cases, the job of evaluating the risk of allowing the patient to operate a vehicle would be left to a particular patient s doctor. Finally, Attention Deficit Disorder (ADD) a problem in the frontal lobe that affects the ability to process competing bits of information may increase the risk of fatigue in young people. The young, who already have four times the crash risk of the general population, are more prone to ADD and engage in more risk-taking behaviour. Recent research suggests interconnections between sleep disturbance and attention. Nevertheless, Dr. Moller warned against inferring too much without proper research and experimentation. Hospitals and clinics have been conducting sleep lab tests, which can be informative with regard to fatigue and driving. Overnight tests examine the brainwave activity of sleeping subjects. Daytime experiments with conscious subjects, such as the Multiple Sleep Latency Test (MSLT), look at how ready patients are to sleep on command. A more valuable daytime test is the Maintenance of Wakefulness Test (MWT) that tries to determine how likely a subject is to fall asleep in the absence of external stimuli when attempting to remain awake.

12 Highway Working Together to Understand Driver Fatigue: Report on Symposium Proceedings 12 What is not being done by hospitals and clinics to any great extent, and what Moller said the Ontario Ministry of Transportation (MTO) may want to consider undertaking, are simulated or actual road tests. The available daytime tests outlined above do not measure interaction with the environment, i.e., that which is pertinent to Type II crashes. This means that the experiments discussed above do not have good ecological validity, nor good sensitivity because they tend to look at impairment resulting from 15- to 30-second sleeps as opposed to 1- to 3-second microsleeps (Moller defined microsleep as an intrusion of sleep-related brainwave activity into waking consciousness). Recently, Moller conducted simulator tests at Toronto Western Hospital to assess driver performance and the occurrence of microsleeps. The tests simulated road position, varying speed, reaction time (using wind gusts) and crashes, over four circadian periods throughout the day, for a study published in the Journal of Psychosomatic Research (Moller et al. 2006). Data were gathered from 27 subjects with higher sleepiness scores, or those reporting having fallen asleep while driving at least once in the past year, and from 27 healthy subjects used as a control. The major findings showed that both groups were impaired during particular circadian periods (late afternoon, late night), which is consistent with previous studies. But there were also greater levels of impairment for those with disorders; their rate of crashes more than doubled in the late-afternoon period. The most robust finding of this study pertained to reaction times (sudden wind gusts) that went from 1 second to 1.5 seconds for patients with sleep disorders. Dr. Moller chose a three-second brainwave activity figure as constituting microsleep, based on the well-reported measure that it takes an unresponsive driver only three seconds to traverse a four-meter-wide highway shoulder at a speed of 100 km/h. Microsleep, the intrusion of sleep-related brainwave activity (alpha/theta) into waking consciousness, was examined. Microsleep episodes tended to increase with time awake. Moreover, subjects tended to be unaware that microsleep was occurring. Microsleep By far, the most common cause of fatigue is self-imposed sleep loss. Dr. Henry Moller May 16, 2007

13 precedes actual loss of consciousness and is a warning sign of the brain before it goes into sleep mode. Neither healthy subjects nor those with disorders had any sense of brainwave fluctuation throughout the day (subjects with disorders may have felt less alert but were, nonetheless, unaware). Moller suggests that a homeostatic model of a subjective state of fatigue is one where there is an adaptive response almost a healthy tendency to ignore the feeling when one is a little bit tired, irritable or fatigued (i.e., getting on with the day, even when one is tired, is a normal behaviour). 13 Highway Working Together to Understand Driver Fatigue: Report on Symposium Proceedings In Moller s study, before a subject was aware of a problem, both brain activity and performance had already begun to deteriorate. By the time the subject realized there was a problem, the subject s brainwaves had already been indicating some level of impairment. In terms of future research, Moller said there should be an effort to conduct some research outside hospitals and clinics, and greater cooperation among the medical, transportation and automotive fields. The need for evidence-based solutions to driver fatigue is a practical issue for medical professionals because, under the Ontario Highway Traffic Act, s. 203, physicians are responsible for communicating with the MTO about anyone whose driving skills may be affected by illness. Since medical testing isn t definitive in determining the degree to which an individual may be impaired by a disorder, there may be a place for the development of automotive systems, for example, that could lessen the burden of responsibility on the medical profession. Biometric monitoring is being explored through the use of instruments (mostly camerabased systems) measuring pupillometry, gaze analysis or head tracking. So far, these types of monitoring have proven subject to limitations; often by the time a problem is detected, it is too late. The systems are invasive as well, so public buy-in may be difficult to secure. The commercial industry is particularly interested, but Moller worries that things are moving too quickly and that purported solutions remain unvalidated. Researchers should therefore focus on empirical studies with standardized protocols while investigating simulation-type activities (intrinsic designs), including monitoring devices. Extrinsic designs of testing conditions (e.g., precise time of day, prolonged vs. shorter periods of time, night vs. day) and where testing is conducted (e.g., in simple research settings, clinical practices with better monitoring systems or even at MTO or licensing bureaus for screening of subjects) should all be considered carefully. Many look forward to the day when roadside tests are conducted using a sleepalyzer something analogous to breathalyzer instruments used to measure blood alcohol content but, Moller states, we simply are not there yet. Prevention will likely remain the focus of mitigation strategies. In April 2006, the Massachusetts legislature passed Law H.5378 mandating more education for young drivers because of their higher risk behaviour. The Sleep Research Society gave its endorsement for the law because it provides instruction about driver fatigue, in addition to the usual components emphasizing seatbelt use, and the dangers of alcohol and excessive speed. Dr. Moller felt that such legislation would prove useful in Ontario. In summary, the next steps in detection, prevention and screening should be more comprehensive, with a design combining in-hospital, in-vehicle and roadside research. Evidence-based, interdisciplinary knowledge dissemination should be central to education and public awareness. Public policies, strategies and law must involve members of the medical and law enforcement communities, as well as government and the automotive industry.

14 Highway Working Together to Understand Driver Fatigue: Report on Symposium Proceedings 14 Session Three Countermeasures: Strategies for Reducing Fatigue-Related Crashes Alison Smiley, President, Human Factors North Inc. (For a full list of references cited in this summary, please see Appendix D.) Alison Smiley, president of Human Factors North Inc., is a leading expert in traffic safety and driver behaviour. For Dr. Smiley, looking at factors involved in fatigue-related crashes is the best way to find measures that will prevent, or counter, fatigue-related crashes. For individuals, countermeasure that are pre-planned (i.e., measures taken before driving) are more effective than post-driving countermeasures (i.e., measures taken when a driver is already en route and requires a remedy for tiredness and fatigue). Smiley cited a number of studies with significant implications for fatigue-related crashes. The first, entitled Why Do People Have Drowsy Driving Crashes (Stutts et al. 1999), compared fatigue/sleep-related crashes with nonfatigue-related crashes. The study showed drivers on night shifts were approximately six times more likely to have a crash due to fatigue than to have a crash related to other causes. The likelihood of a crash caused by fatigue also related to length of time at the wheel, length of time awake and hours slept the night before. A French study (Arbus et al. 1991) of 110 male drivers aged 18 to 70 and subdivided into two groups of roughly 40% healthy and 60% with disorders, also showed that time of day was a very important factor in fatigue-related crashes. In the healthy group, 80% had experienced shortterm sleep deprivation, an almost identical figure (79%) for the crash time period from 2 a.m. to 6 a.m. (For the remaining 21% the average time was 4 p.m.) Comparative data (when alcohol is removed as a control) from Australia, the UK and Sweden corroborate that the 2 a.m. to 6 a.m. time period is the riskiest for single-vehicle crashes. Avoiding driving during this dangerous period should be a part of all drivers preparations. Commercial drivers (and their employers) often compelled to work overnight shifts should be especially conscious of this risk factor and plan accordingly. The need for evidence-based solutions to driver fatigue is a practical issue for medical professionals because under the Ontario Highway Traffic Act (s. 203) physicians are responsible for reporting to MTO anyone whose driving skills MAY be affected by illness.

15 Sleep quality/quantity is also a pertinent issue. A National Transport Safety Board (NTSB) study of commercial drivers and single-vehicle crashes where fatigue was involved, found that those drivers had, on average, 5.5 hours of sleep. For those crashes where fatigue was not a factor, the driver had 8 hours of sleep, on average. Eighty percent of all drivers in this study rated their sleep as good or excellent, implying that fatigued drivers were often unaware of their condition. 15 Highway Working Together to Understand Driver Fatigue: Report on Symposium Proceedings Unsurprisingly, shift workers are especially vulnerable to fatigue-related crashes. Smiley noted that North American work schedules are very inappropriate and should be redesigned. For example, she said shift workers should not be allowed to work overtime because it is difficult enough for individuals to cope with the physical stresses of shift-work schedules without adding overtime hours. As with commercial drivers, redesigning shift-work schedules may require the involvement of employers. (Later in the symposium, Smiley suggested this might be an area for Ministry of Labour involvement.) Treatment is an important countermeasure for drivers who suffer from sleep apnea. Those with this condition are nine times more likely to be involved in a single-vehicle crash than are healthy drivers. Fortunately, apnea treatment has a high rate of success. A final suggestion in the area of pre-planning is directed at individuals using medication, particularly sedative medication with side effects. Here, timing is very important because some sedative medications have lengthy hangover periods that can affect an individual s level of fatigue well after he or she feels the medication should have worn off. Smiley s discussion of post-driving remedies for fatigue began with discussion about the ubiquitous use of caffeine. She notes that caffeine can improve driver performance for 1 to 1.5 hours after consumption, but has limited effectiveness thereafter. Rest breaks are also initially effective. A study (Mackie and Miller 1978) of commercial drivers who took rest breaks every three hours showed that by the third break, there was no improvement in performance. Other studies of rest breaks also show their effectiveness has an ultimate limitation, and Dr. Smiley emphasized that when drivers reach that point they require something more than a break. A nap may be a restorative solution when a rest break is not enough. However, under certain circumstances even a nap is not enough. A 30-minute nap after a night of no sleep has no impact on driver performance. On the other hand, one experiment demonstrated that a 15-minute afternoon nap in the car after a driver consumed coffee, resulted in substantially improved performance. Further, a meta-analysis (of 12 studies) showed that a 15-minute nap can improve performance for up to 6.75 hours; a 2-hour nap can improve performance for up to 9.5 hours. Dr. Smiley emphasized that naps have an ultimate point of ineffectiveness when an individual requires nothing less than proper sleep. Studies of shift workers, for example, reveal naps effectiveness on the first night of a sequence of shifts, but effectiveness declines on subsequent nights. In terms of highway design, a number of countermeasures can be employed to reduce fatiguerelated crashes. For example, secure rest areas can encourage drivers to pull off the road to take naps. Roads with shoulder rumble strips have 18 to 21% fewer single-vehicle crashes. This is a huge number, says Smiley, who rates their cost-benefit ratio very high. Similarly, centre-line rumble strips show a 25% reduction of target injury (head-on) crashes.

16 Highway Working Together to Understand Driver Fatigue: Report on Symposium Proceedings 16 Clear zone improvements such as clearing roadside obstacles or creating a traversable slope significantly reduce the risk of crash injuries, should a driver leave the road. Intelligent technology systems (ITS) though these are still in the prototype stage are possible countermeasures to be used in the future. However, Dr. Smiley did mention some concerns with their possible effectiveness. In a Transport Canada study of subjects on sevenhour drives, devices that warned drivers when they were leaving the road had no effect on decisions to take voluntary breaks. Finally, the role of public education is essential in any strategy seeking to counter fatiguerelated crashes. Populations should be made aware that pre-planning before driving is the most effective way to avoid fatigue-related crashes and that while there are effective countermeasures for post-driving situations, these are subject to limitations. Provincial and municipal governments already have a number of options for the design of roads and highways that can help reduce the incidence of fatigue-related crashes. New and emerging technologies may also prove valuable in combatting fatigue-impaired driving, but their application lies in the future. Session Four The Policing Perspective John Carson, Deputy Commissioner, Ontario Provincial Police (OPP) OPP Deputy Commissioner John Carson is a member of both the Canadian Association of Chiefs of Police Traffic Committee and the International Association of Chiefs of Police s Auto Theft and Highway Safety Committee. Deputy Commissioner Carson began his remarks by stating that driving is high-risk behaviour and police officers understand this very well. Although many may think the greatest risk for police officers comes from violence directed toward their persons, police services lose far more personnel in traffic-related incidents and collisions than they do in violent situations. Therefore, the issue of highway safety in general, and fatigue-impaired driving in particular, is a matter of occupational health and safety for police officers. For individuals, countermeasure that are pre-planned (i.e., measures taken before driving) are more effective than post-driving countermeasures (i.e., measures taken when a driver is already en route and requires a remedy for tiredness and fatigue). Dr. Alison Smiley May 16, 2007

17 In Canada, the most likely cause of death for people between the ages of 3 and 35 is a motor vehicle crash. This is the unfortunate consequence of a highly mobile society. The OPP s traffic program is constantly looking at enforcement and the causes of motor vehicle collisions. The big three causes alcohol, lack of seatbelt restraints and aggressive driving remain a concern. With the addition of fatigue and distraction to any of these three causes of collisions, the regrettable result is a situation of disastrous proportions. 17 Highway Working Together to Understand Driver Fatigue: Report on Symposium Proceedings Carson said the OPP has conducted extensive education programs in schools. The OPP looks to its partners, such as public schools, to help them educate the public, to learn and to better understand the issues involved in road safety, enabling the OPP to make the best choices. There were 444 fatalities on OPP-enforced highways last year; 111 of the victims were vehicle occupants who were non-restrained. Carson argued that people seem to turn a blind eye to the obviously dangerous behaviours that cause traffic injuries and deaths. Traffic fatalities are treated relatively lightly by a society where one would think that, because the causes of death are so well known and preventable, there would be much more in the way of resources made available to combat these catastrophes. The Deputy Commissioner prefaced his comments with regard to collision investigation by stating that no motor vehicle collision is truly an accident and that no collision is unimportant because all collisions involve human beings. A significant number of collisions fall into the fatigue category. Fatigue-related collisions tend to exhibit specific patterns. For example, single-vehicle crashes tend to be fatigue-related. The single-vehicle crash presents problems because, frequently, the only witness is the driver who is obliged by law to give the investigating officer a statement. Most people who are not bound by law to give statements are reluctant to implicate themselves in a crash, especially when the outcome may be a ticket or a careless driving charge. Officers can and do chase down evidence; for example, police pursue independent witnesses when they exist. And officers who have been in the field for a couple of years easily recognize the signs and circumstances of fatigue-related crashes. In cases where the driver is the sole witness, time and again police hear similar stories about crashing to avoid hitting a black dog or a raccoon, or other stories that are impossible to substantiate. Moreover, even when there is sufficient evidence of driver drowsiness, it is often difficult to mount a successful prosecution. Prosecution takes a tremendous amount of effort and resources, and there are many competing interests and pressures within the policing community. Wrapping up a suspected case of fatigue-impaired driving then, is not simply a matter of conducting a proper interview. If enforcement, investigation and prosecution are problematic, prevention becomes an even more critical element in the work to find solutions to stop fatigue-related driving. Carson reiterated the importance of partnerships and cited the Driver Reviver stations organized by detachments in Bracebridge, Huntsville and South Georgian Bay during the summer season as an example of a successful partnership. Police departments also take an interest in highway design and are very supportive of the installation of rumble strips. More generally, Deputy Commissioner Carson noted that the Canadian Association of Chiefs of Police and its international counterpart are committed to the Road Safety Vision process. The Deputy Commissioner completed his observations by saying that the only surefire way to reduce the incidence of senseless fatalities behind the wheel is to find the social will to do what it takes to prevent such tragedies.

18 Highway Working Together to Understand Driver Fatigue: Report on Symposium Proceedings 18 Closing Remarks from Ontario s Minister of Transportation The Honourable Donna Cansfield, MPP Etobicoke Centre The minister began her address to the symposium by stating that the dangers of fatigueimpaired driving need to be at the centre of public concern, like drinking and driving. The challenge is to communicate the importance of being well rested before driving, and Cansfield added that this message must stress personal responsibility. Minister Cansfield stated that the problem of fatigue-impaired driving presents more difficulties than alcohol impairment. Police investigations of fatigue-related collisions are complicated by the fact that drivers have been shocked awake by the collision. And while there are some promising developments in the realm of technology for detecting fatigue, there is nothing at present that can match the precision of measuring blood alcohol content (BAC). Minister Cansfield made reference to Ontario s various initiatives that address the issue of driver fatigue. For example, reflecting federal regulations, Hours of Service regulations for drivers of commercial vehicles came into effect on January 1, The Ontario government has also taken note of Transport Canada studies that show driving for 19 hours results in performance levels equivalent to those achieved at a BAC level of Bus drivers and drivers of large commercial vehicles are a particular concern at MTO, and the Minister said it was hard to understand any reason, or more accurately excuse, for a driver to be behind the wheel for 16 hours. Fatigue impairment is being addressed in other areas, such as in the government of Ontario s peer-to-peer I Drive educational program aimed at young drivers, which has fatigue awareness content. The ministry can also promote awareness through its website and its driver handbook, and by ensuring that its highway safety partners include information about the dangers of drowsy driving in their road safety campaigns. The minister pointed out that there are 23 service centres along highways 400 and 401 (each about 1 hour or 84 kms apart), where drivers can rest and get essential services. In addition, there are approximately 200, mostly seasonal, rest areas on other provincial roads. In the north, especially along the Trans-Canada, the province is working to plow areas where truck drivers can pull over when they are fatigued. And rumble-strip installations along provincial roads will continue. Working with its jurisdictional partners in the Canadian Council of Motor Transport Administrators (CCMTA), the province will also rely on its other organizational partners to promote the various initiatives in the broader road safety framework. The minister mentioned specifically the RoadSafe alliance, comprised of Human Resources and Skills Development Canada, Insurance Bureau of Canada, the Ministry of Labour, the OPP, Transport Canada, the Transportation Health and Safety Association, and the Ontario Workplace Safety and Insurance Board. Minister Cansfield closed her speech by graciously thanking the Highway for its contributions to raising awareness of driver fatigue impairment and by inviting all those who were interested in road safety to work with Ontario s Ministry of Transportation.

19 19 Highway APPENDIX A Drowsy Driving: An Overview of the Safety Research Literature Leo Tasca, Ph.D. Safety Policy and Education Branch Ontario Ministry of Transportation

20 Highway APPENDIX A 20 Objectives A Survey research literature and identify key studies during the past decade A Provide some background regarding what we know about fatigue and sleep deprivation and how they may affect both driving performance and collision risk Commercial Motor Vehicle (CMV) Driver Fatigue and Alertness Study 1 A Landmark $4.45 million, 7-year over-the-road study on driver fatigue and alertness published in 1997 A Objectives: Measure relationships between driver activities and physiological and psychological indicators of fatigue and reduced alertness Identify and evaluate effectiveness of legal alertness-enhancing measures Provide scientific basis for evaluation of hours-of-service requirements A 80 properly qualified male CMV drivers aged 25 to 65 in U.S. and Canada A 4 different groups of 20 subjects drove under 4 contrasting driving schedules 10-hour daytime 10-hour rotating 13-hour night start 13-hour day start A The 4 schedules provided different amounts of time off between trips A 360 trips (200,000 miles) including about 4,000 hours of video data and 9,000 hours of physiological recordings A Strongest and most consistent factor influencing driver fatigue and alertness was time of day A Time of day a better predictor of decreased driving performance than hours spent driving A No difference in amount of drowsiness observed in video records of comparable daytime segments of 10-hour and 13 hour trips Study design did not provide for comparison of night time segments A Just over 19 minutes out of 244,667 minutes of driving analyzed were identified as instances of driver actually falling asleep A There were no crashes during the study A No significant relationships found between driver age and fatigue A 14% of the drivers accounted for 54% of the observed drowsiness episodes A 13-hour night start condition associated with most sleep deprivation A Little correlation between subjective ratings of drowsiness and objective performance measures 1 Driver Fatigue and Alertness Study, Federal Motor Carrier Safety Administration and Transport Canada, Technical Summary, 1997, (PB ) and the project final report (PB ), National Technical Information Service (NTIS), Springfield, Virginia.

21 Development of Fatigue Symptoms During Simulated Driving 2 A (Nilsson et al., 1997) used part-task simulator to obtain cumulative record of 80 young male subjects who discontinued driving as function of time 21 Highway APPENDIX A A Subjects accelerator position monitored continuously and their subjective fatigue level monitored every 20 minutes A Subjects varied in how long they were able to continue the driving task (range from 90 to 240 minutes; about three-quarters stopped by 180 minutes) A Remarkable similarity in fatigue scores when subjects did decide to stop A May be better to alert drivers to symptoms of fatigue, rather than suggest resting after a specified time 2 Nilsson et al., (1997) Development of fatigue symptoms during simulated driving, Accident Analysis and Prevention, Vol. 29, No. 4, pp Driver Performance: Fatigue and Alcohol Comparison 3 A Australian study (2001) compares effects on a driver of remaining awake continuously for 28 hours with how varying doses of alcohol up to 0.1 BAC affect the same driver A Objective is to assess relative sensitivity of 8 computerized performance tests known to be affected by fatigue and compare effects of fatigue with those of alcohol Alcohol is a useful benchmark because its performance effects are well-documented A Study also investigates individual abilities to cope with sleep deprivation A Computerized performance tests: Simple Reaction Time Unstable tracking Dual task Mackwork clock vigilance test Symbol digit coding Visual search task Sequential spatial memory Logical reasoning A Two types of test especially sensitive to fatigue: Monotonous or required passive concentration ( Mackworth clock vigilance test) Involved difficult visual discrimination (simple reaction time, unstable tracking and dual task) A Sleep-deprived subjects became most affected after hours of wakefulness A Showed performance similar to that found in the alcohol subjects at 0.05% BAC A Logical reasoning and visual search showed little or no fatigue effects after 28 hours of sleep deprivation A Alcohol was shown to impair performance on ALL tests Significant performance effects occurred between 0.05 and 0.1 BAC. 3 Williamson, Ann, M., et al. Developing measures of fatigue using an alcohol comparison to validate the effects of fatigue on performance, Accident Analysis and Prevention 33 (2001)

22 Highway APPENDIX A 22 North Carolina Case-control Study 4 A (Stutts et al., 1999) conducted first case-control study of drowsy driving crashes A Telephone interviews of 1,403 drivers A Cases were drivers involved in police-reported crashes who were coded as either asleep (n=312) or fatigued (n=155) A Two control groups: Drivers in non-sleep related crashes (n=529) Drivers not involved in crashes (n=407) > 10 times drowsy driving in past year Have ever fallen asleep while driving Sleep Crash Fatigue Drivers Crash Drivers Control Crash Drivers Non-Crash Drivers Fallen asleep while driving within past 2-3 years Column per cent 12 Category at risk Odds ratio 1 Category at risk Odds ratio 1 Night-shift worker Holds 2 jobs ESS ESS = Sleeps <5 hrs Sleeps 5-6 hrs Poor sleeper Driving late at night Slept < 4 hrs night before Awake hrs Sleep disorder 1.9 Awake > 20 hrs Compared to non-crash controls 2 Epworth Sleepiness Scale - subjective assessment of daytime sleepiness 13 4 Stuttset al., (1999) Why Do People Have Drowsy Driving Crashes?, American Automobile Association Foundation for Traffic Safety, Washington, D.C. Systematic Review of Epidemiological Studies A Systematic review of 19 scientific studies on driver fatigue (Connor et al., ) that met review criteria: included only studies with fatigue-related exposure measure, a crash or crash injury outcome measure and/or a comparison group A 18 studies were cross-sectional; 1 case-control study A 13 out of 19 studies report increase in risk of crash involvement or injury

23 A Many of these studies, however: Were poorly designed or had small sample sizes Did not test causal hypotheses adequately 14 of 19 studies focused on patients with sleep disorders not healthy drivers who were sleep-deprived for non-medical (lifestyle) reasons 23 Highway APPENDIX A A Identified a need for a well-designed, observational epidemiological study 5 Connor et al., (2001), The role of driver sleepiness in car crashes: a systematic review of epidemiological studies, Accident Analysis and Prevention, Vol. 33, pp Driver sleepiness and risk of serious injury to car occupants 6 A (Connor et al., 2002**) estimated collision risk associated with driver sleepiness A Conducted interviews and administered two sleepiness scales to 571 car drivers involved in crashes where at least one occupant admitted to hospital or killed 65% of interviews with crash-involved drivers done within 48 hours of crash A 588 drivers selected at random on public roads (controls) A Proxy interviews sought for drivers who were killed or seriously injured A Strong association reported between measures of acute sleepiness and risk of involvement in injury collision A Independent of effects of acute alcohol consumption and other confounding factors (eg. age and gender) A Eight-fold increase in risk if drivers reported sleepiness A Almost three-fold risk for drivers who drove with less than 5 hours of sleep A Five-fold risk for driving between 2 am and 5 am 6 Connor et al., (2002) Driver sleepiness and risk of serious injury to car occupants: population based case control study, British Medical Journal, Vol. 324, pp Australian Transport Safety Bureau (ATSB) Fatality Crash Databases Study 7 A (ATSB, 2002) conducted an innovative analysis of fatigue-related crashes on Australian roads in 1998 A ATSB used its Fatality Crash Databases (fatal crash data based on coroner and police reports) A Proposed operational definition based on crash characteristics A Not intended to measure absolute number of fatigue-related crashes A May provide index of relative incidence of fatigue-related crashes A Used stepwise selection process: First: exclude all crashes where the driver had a blood alcohol concentration (BAC) greater than 0.05g/100ml exclude all crashes involving any unlicensed drivers or unlicensed motorcycle riders

24 Highway 24 APPENDIX A exclude all crashes involving a pedestrian exclude all crashes where the speed limit is less than 80km/h Then: include all single vehicle crashes occurring between 12 a.m.-6 a.m. and 2 p.m.-4 p.m. include all head on crashes where neither vehicle overtaking A Selection process identified 251 of 1,511 (16.6%) fatal crashes as fatigue-related A Comparison of fatigue-related crashes identified by coroners/police to those identified by operational definition A 46 fatigue-related crashes identified by both operational definition and coroners/police A Additional 53 identified as fatigue-related only by coroners/police Mainly because crash occurred outside critical time period A 205 crashes identified as fatigue-related only by operational definition However, in 34.6% of these crashes, coroners/police identified drugs and/or alcohol or excessive speed as a factor ATSB Study Fatal Fatal Crashes Crashes With With Fatigue Fatigue Involvement Involvement Per Cent Number New South Wales 22.0 New South Wales 97 Victoria 15.6 Victoria 55 Queensland 16.7 Queensland 42 South Australia 13.1 South Australia 19 Western Australia 9.2 Western Australia 18 Northern Territory 16.9 Northern Territory 10 Tasmania 14.9 Tasmania 7 Capital Territory 15.0 Capital Territory 3 Fatal Crashes With Fatigue Involvement Per 100 Million Vehicle 1.5 Kilometers Traveled NSW Victoria Qnld S. Aust. W. Aust. NT Tas. ACT 7 Australian Transport Safety Bureau, (2002) Fatigue-related Crashes: An Analysis of Fatigue-related Crashes On Australian Roads Using An Operational Definition of Fatigue, Report No. OR

25 Drowsy Driving Survey 8 A 2004 Traffic Injury Research Foundation Road Safety Monitor featured Canada-wide survey results that focussed on drowsy driving 25 Highway APPENDIX A A 1,209 households responded to the survey data were weighted to ensure results were representative of the national population A There is a 95 per cent chance the percentages estimated by the survey are + or 2.8% of the actual population percentage A 57% of Canadian drivers believe drowsy driving is a serious or very serious problem A Over half of them report driving when tired or fatigued, at least occasionally A One in five Canadian drivers an estimated 4.1 million reported nodding off or falling asleep at least once while driving in the past 12 months A Falling asleep at the wheel varies as a function of age with younger drivers at greater risk due to lifestyle choices: 35% of drivers aged reported doing so compared to only 6% of drivers aged 65 and over A Male drivers are more likely than female drivers to report having nodded off at the wheel A Falling asleep at the wheel most commonly occurs late at night and during the afternoon A Drivers who report nodding off while driving are also more likely to report less than 8 hours sleep per night poor sleep quality greater daytime sleepiness 8 Traffic Injury Research Foundation, (2004) Road Safety Monitor: Drowsy Driving, Ottawa. 22 Subjective and predicted sleepiness while driving in young adults 9 A (Smith et al., 2005) assessed the relationship between predicted and perceived sleepiness while driving A Subjects ranged in age from 18 to 25 and completed both a sleep diary and driving diary over a 4-week period. A Weekly interviews to ensure compliance A Subjects pre-screened for sleep disorders, driving attitudes and driving behaviour A Sleepiness levels during study predicted by a model that incorporated the sleep diary data and compared to subjective sleepiness reported by subjects A Subjects recorded 2,518 driving trips during the 4-week period A They reported being sleepy during 23% of trips taken A 63 (2.6%) trips were identified as occurring at a critical level of alertness A 116 trips (4.7%) occurred when alertness was reduced A 82 (3.4%) trips occurred when subject had been awake for more than 18 hours

26 Highway 26 APPENDIX A A Not a single instance of a subject reporting they chose not to drive due to sleepiness. 9 Smith et al., (2005) Subjective and predicted sleepiness while driving in young adults, Accident Analysis and Prevention, Vol. 37, pp Fatigue, sleep deprivation and driving performance 10 A (Philip et al., 2005) tested the effects of sleep deprivation on 22 healthy male subjects ranging in age from 18 to 24 Prior testing confirmed none of the subjects had sleep disorders A Subjects drove 1,000 km on a divided highway maintaining posted speed limit over a 10- hour period consisting of five 105 minute driving sessions Cars equipped with dual controls and subjects accompanied by professional driving instructor A Subjects drove route twice: with 8.5 hrs of sleep the previous night with 2 hrs of sleep the previous night A Obtained measurements of: self-rated fatigue a video camera recording of driving sessions used to count the number of inappropriate line crossings while driving at each rest stop subjects simple reaction time was measured A Results confirm sleep deprivation affects performance A Key measure is the number of interventions by the accompanying driver: None during the rested condition 61 during the sleep-deprived condition A Sleep-deprived subjects who could not continue a session: One sleep-deprived subject had to be driven back to rest stop during 4 th driving session Another subject was driven back to rest stop during both the 2 nd and 4 th driving session A Sleep-deprived subjects driven back to rest stop were, after resting, able to complete the scheduled drive A Video recordings showed a significant increase in inappropriate line crossings 66 in normal sleep condition 535 in sleep-deprived condition A This means sleep deprivation increased risk of inappropriate line crossing 8.1 times A Relative risk of sleep-deprived drivers was higher for all driving sessions A When risk of line crossing compared to first morning session within each group: drivers with normal sleep condition saw significant increase in risk by 4 th session sleep-deprived drivers saw significant increase in risk by 2 nd session 10 Philip et al., (2005) Fatigue, sleep restriction and driving performance, Accident Analysis and Prevention, Vol , pp

27 performance Overall and and Per Per Period Period Inappropiate Inappropriate Line Crossings Line Crossings Driving Session Normal Sleep Sleep -deprived Relative Risk 27 Highway APPENDIX A Overall st Session nd Session rd Session th Session th Session Conclusions A We are underestimating the incidence of fatigue-related collisions A Fatigue and sleep-deprivation can significantly affect our performance on the road A Well-designed studies to estimate collision risk and/or adverse effects on driving performance are in short supply A Well-designed studies are essential for policy development and program spending justification

28 Highway 28 APPENDIX B Fatal and Injury Fatigue-Related Crashes on Ontario s Roads: A 5-year Review Yoassry Elzohairy, Ph.D., P.Eng. Senior Advisor Ministry of Transportation

29 Why do We Need An Operational Definition of Fatigue-Related Crashes A Cases where fatigue is a factor, but drivers remain awake are generally not recognized as fatigue-related collisions. 29 Highway APPENDIX B A Police are not provided with special training to identify sleepiness/fatigue as a contributing factor. Less than 2% of all fatal and injury police-reported crashes can be attributed to driver sleepiness or fatigue as a contributing factor. A Currently, there is no a straightforward fatigue-measuring device for roadside use by police. A There is also an absence of definitive criteria for establishing the level of fatigue that increases crash risk. A A method is needed to allow accurate estimates of the true prevalence of drowsy-driving crashes. Operational Definition of Fatigue-Related Crashes A Selection Criteria include crashes where Police or coroner identified fatigue as a contributing factor. Vehicle condition: No Apparent Defect Driver did not exceed speed limit and did not travel at speed too fast for condition at the time of the crash. Driver was not impaired by alcohol or drug. Driver has no medical or physical disability. Crash occurred on a dry pavement. Initial Impact Type (head-on collisions where neither vehicle was overtaking at the time of collision, rear-end collision and single vehicle collisions) Crashes that involve unlicensed drivers are excluded. Crashes that involve pedestrians or animals (wild or domestic) are excluded. Driver initiated the crash (i.e.; D01=1). Is Fatigue a Concern on Ontario s Roads?

30 Highway APPENDIX B 30 Severity of Injury in Fatigue-Related Crashes, Who is at RISK? 6 Fatigued Drivers: Who Are They?

31 31 Highway When Do Fatal and Injury Fatigue-Related Crashes Occur? APPENDIX B

32 Highway APPENDIX B 32 Fatal and Injury Fatigue-Related Crashes By Road Alignment Fatal and Injury Fatigue-Related Crashes By Road Jurisdiction 12

33 33 Highway Hotspots for Fatal and Injury Fatigue-Related Crashes 1. TORONTO 2. OTTAWA 3. LONDON 4. HAMILTON 5. MISSISSAUGA APPENDIX B Fatal and Injury Fatigue-Related Crashes By Speed Limit Fatalities and Serious Injuries By Involved Person

34 Highway APPENDIX B 34 Most Common Errors Committed by Fatigued Drivers

35 35 Highway APPENDIX C Medical Perspective: Driver Drowsiness, Fatigue and Alertness Henry Moller MD, MSc, FRCPC, DABSM University Health Network University of Toronto Sleep Research Unit henry.moller@uhn.on.ca

36 Highway APPENDIX C 36 Summary A Review of relationship between sleep-related driving impairment and crash risk A Focus on evidence-based medical review A Implications on public policy and education Background 1999 High profile vehicular manslaughter case involving elderly driver 2002 Inquest jury recommends the design of a diagnostic screening tool for doctors to identify drivers at risk Defining accidents better A 250,000 injuries 3000 deaths per year in Canada due to vehicle crashes A accident* (suggests role of fate, and implies unpredictability) vs. crash/collision A Fatigue, inattention and sleepiness implicated in major accidents in occupational/industrial context * Lancet (1998); O Neill Road Traffic Injuries-Global Burden A Recent 1 st UN / WHO Global Road Safety Week A Traffic fatalities leading cause of death among youth aged years A In high-income countries most young victims are novice drivers A Role of fatigue and inattention under-researched Traffic Fatalities: Established & Emerging Driver Risk Factors A Established Drinking Speeding/Risk-taking Seat-belt non-use A Emerging Distraction Fatigue and sleep-related Drowsy and Inattentive Driving: The Next Frontier in Public Awareness? A Public policy development analogy to drunk driving A Expanding knowledge of the medical science of sleep, fatigue and inattention

37 Including as preventable cause of driving impairment A Several recent high-profile studies have found sleep loss as impairing as alcohol intoxication (e.g. Arnedt et al., JAMA, 2006) 37 Highway APPENDIX C Quantifying Impairment A Difficult to measure impairment objectively (e.g. BAC for alcohol use) A Impairment= (medication effects) + (baseline medical condition) + (sleep deprivation) + (alcohol/ substance) A Legal/Categorical standards versus physiological parameters A Societal debate regarding thresholds of acceptability Cybernetic Model of Driving Performance What is fatigue? A Complex state characterized by a lack of alertness and reduced mental and physical performance, often accompanied by drowsiness A Signs and symptoms: Forgetfulness, Poor Communication, Impaired decision making skills, slow reaction time, microsleep, mood disturbance, irritability A disorder of information processing

38 Highway APPENDIX C 38 Information-processing model of driving behaviour (Rasmussen, 1987) A 3 levels of cognitive control for complex task performance (1) Skill-based behaviour automatic/effortless (sensory-motor perception) (2) Rule-based behaviour prescribed maneuver (e.g passing) to deal with changing driving circumstances (e.g. slower car) (3) Knowledge-based behaviour if rule-based maneuver not sufficient, conscious knowledge-based problem solving Drowsiness and Driving A Epidemiological studies have established circadian variation in the incidence of sleepinessrelated motor vehicle accidents Lavie, et al. Frequency of sleep-related traffic accidents and hour of the day. Sleep Research (1986) Two major crash categorizations define spectrum of collision related to fatigue A Type I Single vehicle Lack of external stimulation Boredom/underarousal, leads to lowering of brain activity Rural/Long mononotonous stretch of highway Circadian component A Type II Multi-vehicle Overstimulation results when mental tasks excessively complex and sustained Multi-tasking/overarousal Urban/intersection More often related to traffic volume Neurocognitive performance spectrum of fatigue Underarousal Drowsiness Errors of Omission TYPE I CRASHES Sleep mode Overarousal Cognitive Overload Errors of Omission TYPE II CRASHES Overload mode Type 3?: Road Rage A Relatively under-researched A Implication is that maladaptive driving behavior is volitional A Possible relationship to brain set shift between under- and overarousal driving scenarios A May be unmasked by fatigue, prolonged commutes

39 39 Highway Socioergonomic Factors A Increased Traffic Congestion/Urban Sprawl APPENDIX C A Increased trend towards Multi-tasking while driving: cell-phones, GPS, pagers, , etc. A The role of fatigue on these tasks is under-researched Effect of Distraction on Brain Function (Simulator task with visual distractions) A Increased activation of bilateral visual cortex (Area MT) (monitoring distracters) and prefrontal cortex A Implication: brain is working harder to stay focused under distracting conditions A (Drummond et al., 2005) Compensatory recruitment after sleep deprivation and the relationship with performance Drowsiness and crash risk A State (Sleep Loss) versus Trait (Sleep Disorder) A By far, most common cause is self-imposed sleep loss A Some Medical Factors: Aging Untreated Sleep Apnea Narcolepsy Neurological: Stroke, MS, Parkinson s, etc. Insomnia (?) Psychiatric (?) Shift-work, acute/chronic Role of medications Sleeping pills, antidepressants, analgesics, antihistamines, etc. Attention Deficit and Driving A Young drivers vs. Sociological trend? A Sleep disorders in teens may be present with ADD Link to decreased frontal cortex inhibition A 4X Crash risk (Reimer et al 2005), more frequent speeding, traffic citations (Barkley, 2004) Medicolegal: Physician s Perspective A Ontario Highway Traffic Act, S. 203 Each physician is required by law to report to the MOT any individual whose driving skills may be affected as a result of an illness or injury Sleep Disorders to be assessed in sleep lab

40 Highway APPENDIX C 40 How to assess drowsy driving risk? A Subjective Report A Physical Exam A Mental Status Exam A Sleep Laboratory Testing Overnight Sleep Study MSLT MWT A Neurological Tests: EEG, CT A Psychometric Tests A Simulator Tests A Road Tests Current Daytime Sleep Lab Tests A MSLT (Multiple Sleep Latency Test) 4 X 20 minute nap opportunities How readily are you able to go to sleep on command? A MWT (Maintenance of Wakefulness Test) 4 X 30 minute sessions How likely will you fall asleep sitting in a dark room? A Neither test interactive A Ecological validity vis a vis driving? A Sensitivity does not take into account microsleep Driving Performance and Microsleeps A Simulator Testing at 10:00/12:00/14:00/16:00 A Road Position A Speed A Reaction Time Moller et al. Simulator performance, microsleep episodes and subjective sleepiness: normative data using convergent methodologics to assess driver drowsiness. Journal of Psychosomatic Research, 2006

41 41 Highway Driving Impairment and Drowsiness Driving Impairment and Drowsiness 1.8 Mean Reaction Time per Simulation (Corrective Steering) Crashes On Repeat Simulated Drives APPENDIX C Normals Drowsers Mean Crashes/30 Minute Drive :00 12:00 14:00 16:00 MEAN Normals Drowsers 0 10:00 AM 12:00 AM MEAN Time of Day Time of Day How much sleep is too long while driving? A it takes an unresponsive driver only three seconds to traverse a four-meter-wide highway shoulder at a speed of 100 km/h and an angle of departure of three degrees Microsleep A Intrusion of sleep-related brainwave activity (alpha/theta) into waking consciousness A Increases with time awake, fatigue level and length of drive A Driver may be unaware A Precedes onset of actual loss of consciousness Insight into Impairment Insight into Impairment 1.6 Total Microsleeps per Simulation 9 Subjective Alertness Ratings (Visual Analogue Scale) ScaleScale) Microsleep s VAS Normals Drowsers :00 12:00 14:00 16:00 MEAN Time of Day :00 12:00 14:00 16:00 Mean Time of Day Drivers often unaware of impairment, report no change in subjective state A Drivers often unaware of impairment, report no change in subjective state

42 Highway APPENDIX C 42 2A Homeostatic Model of Subjective State A Adaptive response to ignore/discount fluctuations in internal states, at mild to moderate levels A Conscious Awareness of potential impairment arises at more extreme states of sleepiness A Objective evidence of impairment (performance/microsleeps) precedes conscious awareness Current Policy/Research Issues A Co-operation between Medical, and Transport and Automotive systems to develop evidencebased solutions A Medicolegal responsibility controversial A Clinic-based monitoring A Built-in auto-monitor A Graduated/Reverse graduated licensing A Road Design Biometric Monitoring A EEG monitoring A Blink/eyelid closure analysis (PERCLOS) A Pupillometry A Gaze analysis A Head tracking A Most of these involve camera-based systems A Unlikely public acceptance A Commercial Drivers Current Research Issues A Beware of unvalidated claims A Need for empirical research A Need for standardized protocols Simulator type (intrinsic) Testing conditions (extrinsic) A Where to test? Research Setting Routine Clinical MOT/Licensing Roadside sleepalyzer? In-car monitoring alert system

43 Massachusetts-Law H.5378 Massachusetts-Law H.5378 (April (April 2006) 2006) Driver Education and Junior Operator s s Licenses Driver Education and Junior Operator s Licenses 43 Highway APPENDIX C Summary A Fatigue is a state of impaired brain function often related to sleep loss may relate to medical factors that can be screened for difficult to measure/quanitify impairment strongly influenced by driver-environment interaction A Ontario physicians required to report if suspect underlying medical condition A However, no currently available reliable fatigue monitoring system to predict/prevent crashes makes this obligation controversial Next Steps in Reducing Collisions due to Fatigue and Inattention A Detection/Prevention/Screening In-hospital In-vehicle Roadside A Education Public Awareness Interdisciplinary knowledge dissemination Medical/Law-enforcement/Governmental/Auto Industry A Evidence-based Public Policy/Strategy/Law A Requires multidisciplinary research efforts Weighing the costs of prevention vs. treatment henry.moller@uhn.on.ca University Health Network Sleep Research Unit 4 th International Driving Symposium on Human Factors in Driving Assessment, Training, and Vehicle Design July 9-12, 2007 Stevenson, Wash, USA

44 Highway 44 APPENDIX D Strategies for Reducing Fatigue-Related Crashes Alison Smiley, PhD, CCPE Human Factors North Inc. Toronto, Ontario

45 45 Highway Fatigue-Related Crashes A 1403 drivers (407 nc, 529 cc, 467 fatc) APPENDIX D A Fatigue/sleep crash drivers vs. non-fatigue crashes: At wheel significantly longer before their crash Awake for longer that day A Drivers on night shift 6x more likely to have a crash due to fatigue vs. other causes A Fatigue crash likelihood related to length of time at wheel, length of time awake and hours slept the night before Stutts et al., 1999 A 110 male drivers aged A 38% healthy 80% short-term sleep deprivation 20% chronic insomnia 79% crash time 2 6 a.m. 21% average time 4 p.m. A 62% not healthy 16% sedating drugs 31% sleep apnea 10% narcolepsy 12% daylight sleepiness Unknown cause 47% other Arbus et al., 1991 Countermeasures A Pre-planning A Treatment for Sleep Disorders A Caffeine A Rest breaks A Naps A Highway design A ITS fatigue warning systems A Public Education Pre-Planning (1) High risk of single vehicle crashes in the 2 6 a.m. time period

46 Highway APPENDIX D 46 Crashes by Time of Day Risk ratio by time of day Risk ratio (to avg between hrs) Adapted from DiMilia, Australia, 1998 Adapted from Horne/Reyner, Great Britain, 1995 Kecklund/Akerstedt, Sweden, Time of day Pre-Planning (2) A Higher risk of crashes if inadequate prior main sleep period Inadequate Sleep and Crashes A 107 single vehicle nighttime crashes A 58% fatigue probable cause Fatigue related: A 5.5 vs. 8 hours previous sleep A 80% rated sleep good or excellent NTSB, 1995 NTSB, 1995 Sleep Apnea and Crashes A Car drivers with sleep apnea have 9x risk of single vehicle crash as compared to healthy drivers Haraldsson et al., 1990 Sleep Apnea and Performance A Sleep apnea patients performed similarly to drivers at 0.08% BAC A Treated patients performed similarly to healthy subjects George et al., 1996

47 47 Highway Sedating Drugs A Benzodiazepines such as valium impair driving performance for as much as 5 hours after 10 mg APPENDIX D Smiley, 1987 A Benzodiazepines increased crash risk by 1.5 times A Antidepressants (amitriptyline) increased crash risk by 2.2 times Ray et al., 1992 Caffeine A Improved performance on tracking, visual search and reaction time 1 hours after consumption Moskowitz and Burns, 1991 A Driving commenced 1.5 hours after consumption A Reaction time performance improved during first 1.5 hours over a 3-hour drive Lisper et al., 1990 Rest Breaks (1) A For rest breaks every 3 hours, 3 rd break did not result in improved performance or heightened arousal Mackie & Miller, 1978 Rest Breaks (2) A Rest breaks during night driving only reduced the frequency of eyelid closures for 12 minutes on average Vincent et al., 1998 Rest Breaks (3) A 12 drivers age A Start time 10:00 a.m. or 4:00 p.m. A 28 instances of microsleeps A After falling asleep once, mean time to fall asleep again: 24 minutes A After falling asleep 3 times, break and brisk walk, mean time to fall asleep again: 25 minutes Lisper et al., 1986

48 Highway APPENDIX D 48 Naps: Length and Effectiveness A 30-minute morning nap after night of no sleep ineffective Lenne et al., 2004 A 15-minute afternoon nap in the car after coffee substantially improved performance Reyner and Horne, 1997 A Meta-analysis of 12 studies showed that a 15-minute nap can improve performance up to 6.75 hours and a 2-hour nap up to 9.5 hours Driskell & Mullen, 2005 Naps: Timing and Effectiveness A Proactive naps are better than reactive naps: Lab study of 56 hours awake showed that even although sleep lighter, earlier 2-hour nap had stronger and longer lasting performance benefits than later nap Dinges et al., 1987 A Naps (proactive and reactive) appear to be most effective on the first night of a sequence of shifts Schweitzer et al., 2000; Purnell et al., 2002 Highway Design A Secure rest areas to nap A Shoulder-edge and centreline rumble strips A Forgiving roadside Shoulder Rumble Strips A 18-21% reduction in single vehicle crashes on freeways Centreline Rumble Strips A 25% crash reduction for target injury crashes Clear Zone Improvement A By 1.5m 13% reduction in crashes A By 6m 44% reduction in crashes ITS Countermeasure A Detection of loss of alertness through: Steering and other control movement changes Eyelid closures

49 A May have limited effectiveness: study of 7-hour drives showed warning signals had no effect on length or timing of voluntary breaks Vincent et al., Highway APPENDIX D Potential Public Education on Fatigue A Avoid driving during the early morning hours when crash risk is substantially increased A Be rested before long drives A Get treatment for chronic daytime sleepiness A Limit driving to under 8 hours per day A Pull off and nap when tired A Avoid taking drugs with sedating side effects within 2 3 hours of driving Summary A Pre-planning is the best countermeasure for fatigue: avoid driving 2 6 a.m. and start wellrested A Caffeine and rest breaks help for short periods, but once a driver gets sleepy, a nap is needed A Once a driver has been up for 16 to 18 hours, sleep is required A Sleep apnea treatment is effective A Shoulder edge rumble strips reduce run-off-road collisions by 15% A Centreline rumble strips reduce head-on collisions by 25% A A wide clear zone (>10m) is very effective in reducing crash severity A ITS countermeasures will soon be available and may reduce crash frequency A Public education is required

50 Highway 50 APPENDIX E Driver Fatigue Bibliography Produced by the Strategies to Reduce Impaired Driving by Fatigue Sub-Group of the Canadian Council of Motor Transport Administrators April 2007

51 51 Highway At Risk Groups A Young People APPENDIX E Carskadon MA. Adolescent sleepiness: increased risk in a high-risk population. Alcohol, Drugs and Driving. 1990;5(4)/6(1): Carskadon MA. Factors influencing sleep patterns of adolescents. In: Carskadon MA, ed. Adolescent Sleep Patterns: Biological, Social, and Psychological Influences. New York: Cambridge University Press, Carskadon MA. Sleepiness in adolescents and young adults. Proceedings of the Highway Safety Forum on Fatigue, Sleep Disorders and Traffic Safety. State University of New York, Institute for Traffic Safety Management and Research; 1993(a) Dec 1. Pp Carskadon MA et al. An approach to studying circadian rhythms of adolescent humans. J Bio Rhythms. 1997;12(3): Carskadon MA et al. Pubertal changes in daytime sleepiness. Sleep. 1980;2: Carskadon MA, Mancuso J. Sleep habits in high school adolescents: boarding versus day students. Sleep Research. 1988;17, 74. Wolfson AR, Carskadon MA. Sleep schedules and daytime functioning in adolescents. Child Dev Aug;69(4): A Commercial Drivers AAA Foundation for Traffic Safety. A Report on the Determination and Evaluation of Fatigue in Heavy Truck Accidents. Prepared by Transportation Research and Marketing. Falls Church, VA Beilock, R. Schedule-induced hours-of-service and speed limit violations among tractor-trailer drivers. Accident Analysis and Prevention. 1995;27: Braver, E. et al. Long hours and fatigue: A survey of tractor-trailer drivers. Journal of Public Health Policy. 1992;13: Expert Panel convened by the Federal Highway Administration. Potential Hours-of-Service Regulations for Commercial Drivers: Report of the Expert Panel on Review of the Federal Highway Administration Candidate Options for Hours of Service Regulations. Transportation Research Institute; Ann Arbor, MI Federal Motor Carrier Safety Administration. Docket No. FMCSA Hours of Service of Drivers; Driver Rest and Sleep for Safe Operations. Advanced Notice of Proposed Rulemaking. Washington, DC Federal Motor Carrier Safety Administration. Docket No. FMCSA Hours of Service of Drivers; Driver Rest and Sleep for Safe Operations; Final Rule. Washington, DC. Federal Register Vol. 68, No. 81, Monday, April 28, Keckland G, Akerstedt TA. Sleepiness in Long Distance Truck Driving. Ergonomics. Vol. 36. Sept Hakkanen J, Summala H. Sleepiness at work among commercial truck drivers. Sleep. 2000;1;23(1):49-57

52 Highway 52 APPENDIX E Harris W, Mackie R., et al. A Study of the Relationships Among Fatigue, Hours of Service, and Safety Operations of Truck and Bus Drivers. Report No. BMCS-RD Washington DC: U.S. Department of Transportation, Hertz R. Tractor-trailer driver fatality: The role of nonconsecutive rest in a sleeper berth. Accident Analysis and Prevention. 1988;20: Hertz R. Hours of service violations among tractor-trailer. Accident Analysis and Prevention. 1991;20(6): Insurance Institute for Highway Safety. Petition for onboard computers submitted to the Federal Highway Administration. Washington, DC: U.S. Department of Transportation Kecklund G, Åkerstedt T. Sleepiness in long distance truck driving: an ambulatory EEG study of night driving. Ergonomics. 1993;36: Lin T, Jovanis P, Yang C. Modeling the safety of truck driver service using time-dependent logistic regression. Transportation Research Record Washington, DC: Transportation Research Board McCartt AT et al. Factors associated with falling asleep at the wheel among long-distance truck drivers. Accid Anal Prev. 2000;32: McCartt AT et al. Study of Fatigue-Related Driving Among Long-Distance Truck Drivers in New York State: Volume 1, Survey of Long-Distance Truck Drivers. New York: Institute of Traffic Safety Management and Research McKane D. Three-state effort enforces hours of service regulations. The Guardian 1994;1(3):4-5. Mackie R, Miller J. Effects of Hours of Service Regularity of Schedules, and Cargo Loading on Truck and Bus Driver Fatigue. Report No. HS Washington, DC: National Highway Traffic Safety Administration Mitler M. et al. The sleep of long-haul truck drivers. New England Journal of Medicine. 1997;337(11): National Transportation Safety Board. Factors That Affect Fatigue in Heavy Truck Accidents. Washington, DC: PB , NTSB/SS-95/01;1995. National Transportation Safety Board. Safety Study: Fatigue, Alcohol, Other Drugs, and Medical Factors in Fatal-to-the-Driver Heavy Truck Crashes. Volume 1. Washington, D.C NTSB. [NTSB/SS/-90/01] Ouellet, L. The work lives of truckers. Pedal to the Metal. Philadelphia: Temple University Press Pack AI et al. A Study of Prevalence of Sleep Apnea Among Commercial Truck Drivers. Federal Motor Carrier Safety Administration. Publication NO. DOT-RT , Washington, DC, Ryder A. Driver fatigue: Part III. Logbooks or comic books? Heavy Duty Trucking 1991;70: Stoohs RA, Bingham LA, Itoi A, Guilleminault C, Dement WC. Sleep and sleep disordered breathing in commercial long haul truck drivers. Chest 1995;107(5): Stoohs RA, Guilleminault C, Dement WC. Sleep apnea and hypertension in commercial truck drivers. Sleep 16:S11-S14, 1993.

53 53 Highway Stoohs RA, Guilleminault, C, Itoi A, Dement WC. Traffic accidents in commercial long haul truck drivers: the influence of sleep disordered breathing and obesity. Sleep 17(7) , Wylie C. et al. Commercial Motor Vehicle Driver Fatigue and Alertness Study. (FHWA-MC ) Washington, DC: Federal Highway Administration APPENDIX E Vespa S. et al. Study of Commercial Vehicle Driver Rest Periods and recovery of Performance in an Operational Environment. Presented at the Third International Conference on Fatigue in Transportation, Fremantle, Western Australia, February 9-13, A People with Disorders Aldrich MS. Automobile accidents in patients with sleep disorders. Sleep. 1989;12: Broughton R et al. Life effects of narcolepsy in 180 patients from North America, Asia and Europe compared to matched controls. Can J Neurol Sci. 1981;8: Cassel W et al. Risk of traffic accidents in patients with sleep-disordered breathing: reduction with nasal CPAP. Euro Respir J 1996;9(12): Findley L, Unverzadt M, Suratt, P. Automobile accidents in patients with obstructive sleep apnea. American Review of Respiratory Disorders. 1988;138: Findley LJ et al. Driving performance and automobile accidents in patients with sleep apnea. Clin Chest Med Sep;13(3): Findley LJ et al. Treatment with nasal CPAP decreases automobile accidents in patients with sleep apnea. Am J Respir Crit Care Med Mar;161(3 Pt 1): George CF. Reduction in motor vehicle collisions following treatment of sleep apnoea with nasal CPAP. Thorax. 2001;56: George CF, Smiley A. Sleep apnea & automobile crashes. Sleep. 1999; 15;22(6): George CF et al. Sleep apnea patients have more automobile accidents. Lancet. 1987;1:447. Hanning C, Welch M. Sleepiness, snoring and driving habits. J Sleep Res 1996;5(1):51-4. Hansotia P. Sleep, sleep disorders and motor vehicle crashes. Wis Med J 1997;96(5):42-7. Haraldsson P et al. Clinical symptoms of sleep apnea syndrome and automobile accidents. ORL. 1990; 52: Haraldsson P et al. Driving vigilance simulator test. Acta Otolaryngol (Stockh) 1990;110: Haraldsson P et al. Long-term effect of uvulopalatopharyngoplasty on driving performance. Arch Otolaryngol Head Neck Surg 1995; 121(1): Masa JF, Rubio M, Findley LJ. Habitually sleepy drivers have a high frequency of automobile crashes associated with respiratory disorders during sleep. Am J Respir Crit Care Med Oct;162(4 Pt 1): Ohayon MM. Epidemiology of insomnia: what we know and what we still need to learn. Sleep Med Rev. 2002; 6: Ohayon MM, Roth T. Prevalence of restless legs syndrome and periodic limb movement disorder in the general population. J Psychosom Res. 2002; 53:

54 Highway 54 APPENDIX E Pierce RJ. Driver sleepiness: occupational screening and the physician s role. Aust N Z J Med. Oct, 1999;29(5): Teran-Santos J et al. The association between sleep apnea and the risk of traffic accidents. Cooperative Group Burgos-Santander. N Engl J Med Mar 18;340(11): Wu H, Yan-Go F. Self-reported automobile accidents involving patients with obstructive sleep apnea. Neurology. 1996; 46: Young T et al. The occurrence of sleep-disordered breathing among middle-aged adults. N Engl J Med. 1993; 328: Suratt P, Findley L. Effect of nasal CPAP treatment on automobile driving simulator performance and on self reported automobile accidents in subjects with sleep apnea. American Review of Respiratory Disorders. 1992;145:A169. Vorona RD, Ware JC. Sleep disordered breathing and driving risk. Curr Opin Pulm Med Nov;8(6): Review. A Shift Workers Åkerstedt, T. Wide Awake at Odd Hours Shift Work, Time Zones and Burning the Midnight Oil. Automotive Night Vision/Enhanced Driving Conference. June Åkerstedt T. Work hours, sleepiness and accidents: introduction and summary. J Sleep Res 1995(a);4(2):1-3. Åkerstedt T. Work hours, sleepiness and the underlying mechanisms. J Sleep Res 1995(b);4(2): Åkerstedt T. Work hours and sleepiness. Neurophysiol Clin 1995(c);25(6): Åkerstedt T et al. Sleepiness in shift-work: a review with emphasis on continuous monitoring of EEG and EOG. Chronobio Int. 1987;4: Bonnet MH, Moore SE. The threshold of sleep: perception of sleep as a function of time asleep and auditory threshold. Sleep. 1982;65: Co EL et al. Crew Factors in Flight Operations XI: A Survey of Fatigue Factors in Regional Airline Operations. NASA Technical Memorandum Moffett Field, Calif: NASA Ames Research Center; Cruz C et al. Effects of quick rotating shift schedules on the health and adjustment of air traffic controllers. Aviat Space Environ Med. 2000; 71: Harma M. Individual differences in tolerance to shift work: a review. Ergonomics 1993;36(1-3): Kessler E. Shift Work: Family Impact and Employer Responses, Special Report 32, Bureau of National Affairs. Washington, DC, 1992, pp Kurumatani, N. et al. The effects of frequently rotating shift work on sleep and the family life of hospital nurses. Ergonomics. 1994;37(6): Marcus C, Loughlin G. Effect of sleep deprivation on driving safety in housestaff. Sleep 1996;19(10):763-6.

55 National Institute of Occupational Safety and Health. NIOSH Alert: Preventing Worker Injuries and Deaths from Traffic-Related Motor Vehicle Crashes. DHHS Publication No Washington, DC. July Highway APPENDIX E Novak R, Auvil-Novak S. Focus group evaluation of night nurse shiftwork difficulties and coping strategies. Chronobiology International (6): Richardson GS et al. Impaired driving performance in shiftworkers: the role of the circadian system in a multifactorial model. Alcohol, Drugs and Driving. 1990;5(4): U.S. Congress, Office of Technology Assessment. Biological Rhythms: Implications for the Worker, OTA-BA-463. Washington, DC: U.S. Government Printing Office, September, Vila B. Tired cops: the importance of managing police fatigue. Washington, DC: Police Executive Research Forum, Countermeasures Åkerstedt T. et al. Fatigue and irregular duty patterns - a review of causes and countermeasures Å kerstedt T. Readily available countermeasures against operator fatigue. In Managing Fatigue in Transportation. Rockville, MD: Government Institutes, Inc., Cummings P et al. Drowsiness, counter-measures to drowsiness, and the risk of a motor vehicle crash. Inj Prev. 2001;7: Horne JA, Foster SC. Can exercise overcome sleepiness? Sleep Research. 24A Reyner L, Horne, J. Caffeine combined with a short nap effectively counteracts driver sleepiness (Abstract). Sleep Research. 1997;2 6:625. Horne JA, Reyner LA. Counteracting driver sleepiness: effects of napping, caffeine, and placebo. Psychophysiology 1996; 33: Reyner LA, Horne JA. Evaluation of in car countermeasures to driver sleepiness: cold air and radio. Slee p. 1988;21: Rosekind MR et al. Crew Factors in Flight Operations XIII: A Survey of Fatigue Factors in Corporate/ Executive Aviation Operations. NASA Technical Memorandum Moffett Field, Calif: NASA Ames Research Center; Rosekind MR. Managing Fatigue in Operational Settings1: Physiological Considerations and Countermeasures. Behavioral Medicine. Vol Rosekind MR. Physiological Considerations of Fatigue. Fatigue Symposium Proceedings. Nov. 1-2, Rosekind M, Neri. D, Dinges DF. From laboratory to flightdeck: Promoting operation alertness. Fatigue and Duty Time Limitations-An International Review. London: The Royal Aeronautical Society Williamson A. et al. Strategies to Combat Fatigue in the Long-Distance Driver Road Transport-State I: The Industry Perspective. CR 108. National Occupational Health and Safety Commission. Canberra, Australia: Federal Office of Road Safety Nguyen LT, Jauregui B, Dinges DF. Changing Behaviors to Prevent Drowsy Driving and Promote Traffic Safety: Review of Proven, Promising, and Unproven Techniques. Washington, D.C.: AAA Foundation for Traffic Safety

56 Highway APPENDIX E 56 Caffeine Griffiths et al. Low-Dose Caffeine Discrimination in Humans. J. Pharm. Exper. Therapuet. Vol ; Horne JA, Reyner LA. Beneficial effects of an "energy drink" given to sleepy drivers. Amino Acids. 2001;20:83-9. Lorist M et al. Influence of caffeine on selective attention in well-rested and fatigued subjects. Psychophysiology 1994;31: Regina EG. Effects of Caffeine on Alertness and Simulated Automobile Driving. J. App. Psychol. Vol Reyner LA, Horne JA. Efficacy of a functional energy drink in counteracting driver sleepiness. Physiol Behav Mar;75(3): Continuous Shoulder Rumble Strips Federal Highway Administration, Wyoming Division. Shoulder Rumble Strips-Effectiveness and Current Practice. Online Posting. April Gårder P. The Efficacy and Use of Continuous Shoulder Rumble Strips: Engineering a Solution. National Summit to Prevent Drowsy Driving, Washington, DC, Nov 20-21, Gårder P, Alexander J. Fatigue related accidents and continuous shoulder rumble strips. Presented at the Transportation Research Board s 74 th Annual Meeting; 1995 January Hickey J. Shoulder Rumble Strip Effectiveness, Drift-Off-Road Accident Reductions on the Pennsylvania Turnpike. Transportation Research Record 1573, National Research Council National Sleep Foundation. Use of Continuous Shoulder Rumble Strips: A consensus report of the National Sleep Foundation. Washington, DC, Perrillo, Kerry. The Effectiveness and Use of Continuous Rumble Strips. Federal Highway Administration, Online Posting, Washington, DC Environmental Improvements Czeisler C et al. Exposure to bright light and darkness to treat physiologic maladaption to night work. N Engl J Med 1990;322(18): Rosa R. Editorial: factors for promoting adjustment to night and shift work. Work & Stress 1990;4: Legal Aspects and Public Policy AAA Foundation for Traffic Safety. Nationwide survey of highway patrol officers. AAA Foundation for Traffic Safety press release, May 23, Desai AV, Ellis E, Wheatley JR, Grunstein RR. Fatal distraction: a case series of fatal fall-asleep road accidents and their medicolegal outcomes. Med J Aust Apr 21;178(8): Review. Ellis E, Grunstein RR. Medico-legal aspects of sleep disorders: sleepiness and civil liability. Sleep Med Rev Feb;5(1):33-46.

57 National Sleep Foundation. Drowsy Driving: A State of the State s Response. Survey conducted as part of the Drive Alert Arrive Alive program. Washington, DC, Mitler M, Carskadon M et al. Catastrophes, sleep, and public policy: consensus report. Sleep 1988;11(1): Highway APPENDIX E Napping Mahowald MW, Schenck CH. Medical-legal aspects of sleep medicine. Neurol Clin May;17(2): Mehlman M. Employee/employer interactions and responsibilities with special reference to genetically related sleep disorders. Sleep Breath Sep;5(3): Rajaratnam SM. Legal issues in accidents caused by sleepiness. J Hum Ergol (Tokyo) Dec;30(1-2): Waller P. A graduated licensing system for beginning drivers. In: National Highway Traffic Safety Administration: provisional licensing programs for young drivers. Washington, DC; 1989; Caldwell J, Caldwell J, Colon J. Recovery alertness following sleep deprivation: the effects of zolpidem nap or placebo nap versus forced sleep. Sleep. 1998;21:229. Dinges DF. Adult Napping and Its Effects on the Ability to Function in: C Stampi (Ed). Why We Nap. Birkhauser, Boston. 1992; Dinges DF et al. Temporal placement of a nap for alertness: contributions of circadian phase and prior wakefulness. Sleep 1987;10: Lavie P. To nap, perchance to sleep Ultradian aspects of napping. In Dinges DF, Broughton RJ, eds. Sleepiness and Alertness: Chronobiological, Behavioral, and Medical Aspects of Napping. New York: Raven Press Rosekind M et al. Alertness management: strategic naps in operational settings. J Sleep Res 1995;4(2): Public Education Flatley D, Reyner LA. A Survey of Public Education Literature Regarding Driver Sleepiness. Report for the Department of the Environment, Transport & Regions. Loughborough, Leicestershire, United Kingdom, National center on Sleep Disorders research and Office of Prevention, Education, and Control. Educating Youth About Sleep and Drowsy Driving: Strategy Development Workshop Report. U.S. Department of Health and Human Services, Washington, DC, September Available Online at Nelson TS, Isaac NE, Graham JD. Development and Testing of Countermeasures for Fatigue Related Highway Crashes: Focus Group Discussions with Young Males, Shift Workers, and Shift Work Supervisors. Harvard School of Public Health. Prepared for the National Highway Traffic Safety Administration. No. DTNH22-96-H Available online at drowsy_driving1/listening/title.htm#title. New York Governor's Traffic Safety Committee Sleep Task Force, Public Information and Education Subcommittee. Drowsy driving focus group study: final report. August, 1994.

58 Highway APPENDIX E 58 Rest Areas Federal Highway Administration. Commercial Driver Rest Area requirements: Making space for safety. Report No. FHWA-MC Prepared by Trucking Research Institute; Apogee Research, Inc; and Wilbur Smith Associates. Federal Highway Administration: Washington, DC, Federal Highway Administration. Report to Congress: Study of Adequacy of Parking Facilities. Washington, DC. June Technological Devices Dinges DF. The promise and challenges of technologies for monitoring operator vigilance. Proceedings of the International Conference on Managing Fatigue in Transportation. American Trucking Associations Foundation, Tampa, FL, 1997; Dinges DF. et al. Federal and Private Initiatives in the Evaluation and Management of Sleepiness-Related Fatigue in Transportation. (10 th Annual APSS Meeting), May 29, Filliatrault DD, Cooper PJ, King DJ, Siegmund GP, Won PKH. Efficiency of vehicle-based data to predict lane departure arising from loss of alertness due to fatigue National Highway Traffic Safety Administration. Evaluation of Techniques for Ocular Measurement as an Index of Fatigue and the Basis for Alertness Management. DOT HS Washington, DC, Skipper J. Drowsy Driver Detection Using Discriminant Analysis. Human Factors. Vol. 28. Oct Weirwille et al. Research on vehicle-based driver status/performance monitoring: development, validation, and refinement of algorithms for the detection of driver drowsiness. Final Report. Washington, DC: US. Department of Transportation, National Highway Traffic Safety Administration. Dec Economic Costs Hossain JL, Shapiro CM. The prevalence, cost implications, and management of sleep disorders: an overview. Sleep Breath Jun;6(2): Review. Leger D. The cost of sleep-related accidents: a report for the National Commission on Sleep Disorders Research. Sleep Feb;17(1): Review. Leger D. The cost of sleepiness: a response to comments. Sleep, 1995;18(4): Webb WB. The cost of sleep-related accidents: a reanalysis. Sleep May;18(4): General Overview Documents Brown ID. Driver fatigue. Hum Factors Jun;36(2): Review. Brown ID. Driver Fatigue and Road Safety. Behavioral Factors that Determine Accident Rates Symposium Santa Monica, California. Alcohol Drugs & Driving. Vol 9. July Dinges DF. An Overview of Sleepiness and Accidents. Journal of Sleep Research. Vol 4. Suppl ;4-14.

59 Expert Panel on Driver Fatigue and Sleepiness, National Center on Sleep Disorders Research/National Highway Traffic Safety Administration. Drowsy Driving and Automobile Crashes. Washington, DC: National Highway Traffic Safety Administration Highway APPENDIX E Fagerstrom K. Sleepy Drivers. Accident Analysis & Prevention. Vol 10. Sept. 1978; Fell D. The road to fatigue: circumstances leading to fatigue accidents. In Laurence Hartley, ed., Fatigue and Driving. Bristol PA: Taylor & Francis, Inc Horne JA, Reyner LA. Sleep-related accidents: a review. Occup Environ Med May;56: Review. Institute for Traffic Safety Management and Research. New York State Task Force on Drowsy Driving. Status Report. Albany, NY. May Institute for Traffic Safety Management and Research. Proceedings of the Highway Safety Forum on Fatigue, Sleep Disorders and Traffic Safety. Albany, NY. December Lyznicki, J. et al. Sleepiness, driving, and motor vehicle crashes. Journal of American Medical Association. 1998;279(23): NCSDR/NHTSA Expert Panel on Driver Fatigue and Sleepiness. Drowsy Driving and Automobile Crashes, Report No. DOT HS , National Center on Sleep Disorders Research, National Heart, Lung, and Blood Institute, and National Highway Traffic Safety Administration, Washington, D.C. April 1998, 30 pp. Staysafe 28 Sleep Disorders, Driver Fatigue and Safe Driving. (Edited transcripts of a Seminar Held at Parliament House, Sydney). November Transportation Research Board. NCHRP Synthesis 287. Sleep Deprivation Countermeasures for Motorist Safety; A Synthesis of Highway Practice. A report by the National Cooperative Highway Research Program. National Academy Press, Washington, DC, General Traffic Safety Miller TR, et al. The costs of highway crashes. Urban Institute, Contract No. DTFH61-85-C-00107, report No. FHWA-RD June Treat J et al. Tri-level study of the causes of traffic accidents: final report. Volume I: Causal factor tabulations and assessments. Institute for Research in Public Safety, Indiana University; DOT Publication No.: DOT HS Alcohol Interactions and Comparison with Fatigue Arnedt JT et al. How do prolonged wakefulness and alcohol compare in the decrements they produce on a simulated driving task? Accid Anal Prev. 2001;33(3): Arnedt JT et al. Simulated driving performance following prolonged wakefulness and alcohol consumption: separate and combined contributions to impairment. J Sleep Res. 2000;9(3): Dawson D, Reid K. Fatigue, alcohol and performance impairment. Nature. Jul ;388(6639):235. Huntley M, Centybear T. Alcohol, sleep deprivation and driving speed effects upon control use during driving. Hum Factors 1974;16:19-28.

60 Highway 60 APPENDIX E Lumley et al. Ethanol and Caffeine Effects on Daytime Sleepiness Alertness. Sleep. Vol ; Peeke S et al. Combined effects of alcohol and sleep deprivation in normal young adults. Psychopharmacology 1980;67: Powell NB et al. A comparative model: reaction time performance in sleep-disordered breathing versus alcohol-impaired controls. Laryngoscope. 1999;109(10): Roehrs T et al. Sleepiness and Ethanol Effects on Simulated Driving. Alcohol Clin. Exp. Res. 1994;18: Wilkinson R. Interaction of alcohol with incentive and sleep deprivation. J Exp Psychol. 1968;76: Williams A, Feyer A. Moderate sleep deprivation produces impairments in cognitive and motor performance equivalent to legally prescribed levels of alcohol intoxication. Occup Environ Med. 2000;57(10): Medications and Performance Ceutel C. Risk of traffic accident injury after a prescription for benzodiazepine. Annuals of Epidemiology. 1995;5(3): Gengo F, Manning C. A review of the effects of antihistamines on mental processes related to automobile driving. J of Allergy Clinical Immunology. 1990;86: Kerr et al. Separate and combined effects of the social drugs on psychomotor performance. Psychopharmacology 1991;104: Kozena L et al. Vigilance impairment after a single dose of benzodiazepines. Psychopharmacology (Berl) 1995;199(1): Leveille et al. Psychoactive medications and injurious motor vehicle collisions involving older drivers. Epidemiology. 1994;5: Neutel CI. Risk of traffic accident injury after a prescription for a benzodiazepine. Annals of Epidemiology (3): New South Wales Road Safety Bureau. Problem Definition and Countermeasure Summary: Fatigue O'Hanlon FJ, Vermeeren A, Uiterwijk MMC, van Veggel LMA, Swijgman HF. Anxiolytics' effects on the actual driving performance of patients and healthy volunteers in a standardized test. Neuropsychobiology. 1999;31: O'Neill D. Benzodiazepines and driver safety. The Lancet. 1998;352(9137): Ray et al. Psychoactive drugs and the risk of injurious motor vehicle crashes in elderly drivers. Am J Epidemiol. 1992;136: Schweitzer P. Drugs that disturb sleep and wakefulness, in Principals and Practices of Sleep Medicine. ed. Kryger, Roth, and Dement. (New York: W. B. Saunders Company, 2000), pp Van Laar M et al. Acute and subchronic effects of Nefazodone and imipramine on highway driving, cognitive functions, and daytime sleepiness in healthy adult and elderly subjects. Journal of Clinical Psychopharmacology. 1995;15(1):30-40.

61 Scope and Nature Gallup Organization. National Survey of Distracted and Drowsy Driving Attitudes and Behaviors: Volume 1-Findings Report. Conducted for the National Highway Traffic Safety Administration. Mar Highway APPENDIX E Glaze AL, Ellis JM. Pilot Study of Distracted Drivers. Prepared for the Transportation and Safety Training Center, Center for Public Policy, Virginia Commonwealth University by Survey and Evaluation Research Laboratory, Richmond, VA, January, Itoi A, Cilveti R, Voth M, Dantz B, Hyde P, Gupta A, Dement WC. Can drivers avoid falling asleep at the wheel? Washington, D.C.: AAA Foundation for Traffic Safety Knipling RR, Wang WS. Crashes and fatalities related to driver drowsiness/fatigue. Research Note. U.S. Department of Transportation, National Highway Traffic Safety Administration, Washington, DC, Knipling RR, Wang SS. Revised estimates of the US drowsy driver crash problem size based on General Estimates System case reviews. 39 th Annual Proceedings, Association for the Advancement of Automotive Medicine, Chicago, Lauber JK, Kayten PJ. Fatigue, alcohol and drug involvement in transportation accidents. Alcohol, Drugs and Driving. 1989;5(3): National Commission on Sleep Disorders Research. Wake Up America: A National Sleep Alert. National Center on Sleep Disorders Research, National Heart, Lung, and Blood Institute, Washington, DC, National Sleep Foundation. Sleep in America Poll: Washington, DC, National Sleep Foundation. Sleep in America Poll: Washington, DC, National Sleep Foundation. Sleep in America Poll: Washington, DC, National Sleep Foundation. Sleep in America Poll: Washington, DC, National Sleep Foundation. Sleep in America Poll: Washington, DC, National Sleep Foundation. Sleep in America Poll: Washington, DC, Pack AI et al. Characteristics of crashes attributed to the driver having fallen asleep. Accid Anal Prev. 1995;27: Powell NB, Schechtman KB, Riley RW, Li K, Guilleminault C. Sleepy driving: accidents and injury. Otolaryngol Head Neck Surg Mar;126(3): Shafer J. The decline of fatigue related accidents on the NYS Thruway. New York State Task Force on Drowsy Driving. Proceedings: Highway Safety Forum on Fatigue, Sleep Disorders and Traffic Safety, Albany New York, December Stutts JC et al. Driver risk factors for sleep-related crashes. Accid Anal Prev. 2003; 35: Stutts JC et al. Why Do People Have Drowsy Driving Crashes? Input From Drivers Who Just Did. AAA Foundation for Traffic Safety, Washington, DC, December Wang JS et al. The role of driver inattention in crashes; new statistics from the 1995 crashworthiness data system. 40 th Annual Proceedings, Association for the Advancement of Automotive Medicine, Vancouver, British Columbia, Oct 7-9, 1996.

62 Highway APPENDIX E 62 Scope and Nature International Studies DiMilia L. Sleepiness, Single Vehicle Accidents and Policy Performance. Presented to The Third International Conference on Fatigue and Transportation, Fremantle, Western Australia, February 9-13, Fell DL, Black B. Driver fatigue in the city. Accident Analysis and Prevention. 1997;29(4): Garbarino S, Nobili L, Beelke M, De Carli F, Ferrillo F. The contributing role of sleepiness in highway vehicle accidents. Sleep Mar 15;24(2): Erratum in: Sleep 2001 May 1;24(3):preceding table of contents. Horne JA, Reyner LA. Sleep Related Vehicle Accidents. British Medical Journal. Vol 310. March 1995; Horne JA, Reyner LA. Driver Sleepiness. Journal of Sleep Research Vol 4. Suppl Horne JA, Reyner L A. Falling Asleep at the Wheel. Report for UK Department of Transportation. 1995b. Kecklund G, Akerstedt T. Time of day and Swedish road accidents. Shiftwork International Newsletter. 1995;12(1):31. Lavie P et al. Frequency of sleep related traffic accidents and hour of day. Sleep Res 1986;15:175. Lisper H et al. Relation between time to falling asleep behind the wheel on a closed track and changes in subsidiary reaction time during prolonged driving on a motorway. Ergonomics 1986;29(3): McCartt AT, Ribner SA, Pack AI, Hammer MC. The scope and nature of the drowsy driving problem in New York State. Accident Analysis and Prevention. 1996; 28(4): Maycock G. Sleepiness and driving: the experience of UK car drivers. J Sleep Res. 1996;5(220): Maycock G. Sleepiness and driving: the experience of U.K. car drivers. Accident Analysis and Prevention. 1997; 29(4): Philip P et al. Fatigue, alcohol, and serious road crashes in France: factorial study of national data. Brit Med J. 2001;322(7290): Sagberg F. Many drivers fall asleep at the wheel. Institute of Transport Economics, Norway: Nordic Road and Transport Research, No. 3, 1998;16. Sleepiness and Performance Åkerstedt T, Gillberg M. Subjective and objective sleepiness in the active individual. Int J Neurosci 1990;52: Bonnet, M. Sleep deprivation. In Kryger MH, Roth T and Dement WC, Principles and Practice of Sleep Medicine, Second Editio n. Philadelphia, PA: W.B. Saunders Company Carskadon M. Evaluation of excessive daytime sleepiness. Neurophysiol Clin 1993(b);23: Carskadon M, Dement WC. Cumulative effects of sleep restriction on daytime sleepiness. Psychophysiology 1981;18: Carskadon M, Dement WC. Daytime sleepiness: quantification of a behavioral state. Neurosci Biobehav Rev 1987;11:

63 Carskadon M, Roth T. Sleep restriction. In Monk T, ed. Sleep, sleepiness and performance. Chichester: John Wiley & Sons; 1991; Carskadon M et al. Guidelines for the Multiple Sleep Latency Test: a standard measure of sleepiness. Sleep 1986;9: Highway APPENDIX E Dinges D et al. Cumulative sleepiness, mood disturbance, and psychomotor vigilance performance decrements during a week of sleep restricted to 4-5 hours per night. Sleep 1997;20(4): Dinges DF, Kribbs N. Performing while sleepy: effects of experimentally-induced sleepiness. In Monk T, ed. Sleep, sleepiness, and performance. New York: John Wiley & Sons; 1991: Hamilton P et al. A study of four days partial sleep deprivation. In Colquhoun W, ed. Aspects of human efficiency. London: English Universities Press, Ltd.; 1972: Hublin C et al. Daytime sleepiness in an adult, Finnish population. J Intern Med 1996;239: Kribbs N, Dinges DF. Vigilance decrement and sleepiness. In Harsh J, Ogilvie R, eds. Sleep onset mechanisms. Washington, DC: American Psychological Association; 1994: Johnson D et. al. The effects of partial sleep deprivation on psychomotor vigilance. Sleep. 1998;21:236. Martikainen K et al. Daytime sleepiness: a risk factor in community life. Acta Neurol Scand. 1992;86(4): Naitoh P. Minimal Sleep to Maintain Performance: The Search for the Sleep Quantum in Sustained Operations. In: C. Stampi (Ed) Why We Nap. Birkhauser, Boston. 1992: National Commission on Sleep Disorders Research. Wake up America: a national sleep alert. 1993;1. National Sleep Foundation. Survey: sleepiness in America Roehrs T, Timms V, Zwyghuizen-Doorenbos A, Roth, T. Sleep extension in sleepy and alert normals. Sleep. 1989; 12: Roehrs T, Shore E, Papineau K, Rosenthal L, Roth T. A two week sleep extension in sleepy normals. Sleep ;19: Rosenthal L et al. Level of sleepiness and total sleep time following various time in bed conditions. Sleep 1993(a);16: Roth T, Roehrs TA, Carskadon MA, Dement WC. Daytime sleepiness and alertness. In Kryger MH, Roth T and Dement WC, Principles and Practice of Sleep Medicine, Second Edition. Philadelphia, PA: W.B. Saunders Company Sharpley A. Impact of daytime sleepiness underrated. Lancet 1996;338:71. Williams H et al. Impaired performance with acute sleep loss. Psychol Monogr 1959;73:1-26. Circadian Rhythms Czeisler, C. et al. Stability, precision, and near-24-hour period of the human circadian pacemaker. Science. 1999;284:1-5. Richardson GS, Miner JD and Czeisler CA. Impaired driving performance in shiftworkers: the role of the circadian system in a multifactorial model. Alcohol, Drugs and Driving. 1990; 5(4):

64 Highway APPENDIX E 64 Sleepiness Indicators & Measurement Buysse D et al. The Pittsburgh Sleep Quality Index: a new instrument for psychiatric practice and research. Psychiatry Res. 1989;28: Hoddes E et al. Quantification of sleepiness: a new approach. Psychophysiology. 1973;10: Johns MW. A new method for measuring daytime sleepiness: the Epworth Sleepiness Scale. Sleep. 1991;14: Mitler M et al. Maintenance of wakefulness test: a polysomnographic technique for evaluating treatment efficacy in patients with excessive somnolence. Electroencephalogr Clin Neurophysiol. 1982;53: Mitler M, Miller J. Methods of testing for sleepiness. Behav Med. 1996;21: Rosenthal L et al. The Sleep-Wake Activity Inventory: a self-report measure of daytime sleepiness. Biol Psychiatry 1993(b);34: Torsvali L, Åkerstedt T. Extreme sleepiness: quantification of EOG and spectral EEG parameters. Int J Neurosi. 1988;38(3-4): The Highway gratefully acknowledges the support of the Road Safety Community Partnership Program of the Ontario Ministry of Transportation.

65 65 Highway

66 The Highway is composed of: Brewers Association of Canada Canada Safety Council Canadian Automobile Association Insurance Bureau of Canada Railway Association of Canada Tourism Industry Association of Canada