Travel Medicine and Infectious Disease (2005) 3, 8596

www.elsevierhealth.com/journals/tmid

Fatigue in aviation
John A. Caldwell*
Aviation Sustained Operations Team, Fatigue Countermeasures Branch, Air Force Research Laboratory,
2485 Gillingham Drive, Brooks City-Base, TX 78235, USA
Received 21 July 2004; accepted 26 July 2004
Available online 12 September 2004

KEYWORDS
Pilots;
Aircrews;
Crew rest;
Sleep;
Sleep deprivation;
Circadian rhythms;
Aviation accidents

Summary Pilot fatigue is a significant, but often under-reported problem in both

civilian and military aviation operations. Although estimates vary, official statistics
indicate that fatigue is involved in at least 48% of aviation mishaps, and surveys of
pilots and aircrew members reveal that fatigue is an important concern throughout
todays 24/7 flight operations. Regulatory efforts aimed at limiting flight hours and
ensuring at least minimal periods of crew rest have to some extent mitigated fatiguerelated difficulties in the cockpit, but it is clear that much remains to be done about
this insidious threat to air safety. Scheduling factors, sleep deprivation, circadian
disruptions, and extended duty periods continue to challenge the alertness and
performance levels of both short-haul and long-haul pilots and crews. Solutions for
these problems are not straightforward, but they can be developed through the
cooperative efforts of scientists, regulators, managers, and the pilots themselves.
Over the past 20 years, scientific understanding of human sleep, fatigue, and
circadian rhythms has expanded considerably. The thorough integration of this new
knowledge into modern crew-resource management practices will facilitate the
establishment of optimal crew scheduling routines and the implementation of valid
aviation fatigue countermeasures.
q 2004 Elsevier Ltd. All rights reserved.

Pilot fatigue is a significant problem in modern

aviation operations, largely because of the unpredictable work hours, long duty periods, circadian
disruptions, and insufficient sleep that are commonplace in both civilian and military flight
operations.1,2 The full impact of fatigue is often
underappreciated, but many of its deleterious
effects have long been known. Lindberg recognized
* Address: US Air Force Research Laboratory, 2504 Gillingham
Drive, Suite 25, Brooks AFB, TX 78235, USA. Tel.: C1-210-5368251.
E-mail address: john.caldwell@brooks.af.mil.

the detrimental consequences of long duty hours

(and long periods of wakefulness) on flight performance back in the 1920s, and scientists began
to appreciate the negative impact of rapid timezone transitions in the early 1930s.3 Such knowledge was no doubt pivotal to the formulation of
regulations such as the Civil Aeronautics Act of
1938, designed to manage aircrew duty hours and
flight times.
Unfortunately, there have been few changes to
aircrew scheduling provisions and flight-time limitations since the time at which they were first
introduced. Although scientific understanding of

1477-8939/$ - see front matter q 2004 Elsevier Ltd. All rights reserved.
doi:10.1016/j.tmaid.2004.07.008

86
fatigue, sleep, shift work, and circadian physiology
has advanced significantly over the past several
decades, current regulations and industry practices
have in large part failed to adequately incorporate
the new knowledge.4 Thus, the problem of pilot
fatigue has steadily increased along with fatiguerelated concerns over air safety. Accident
statistics, reports from pilots themselves, and
operational flight studies all show that fatigue is a
growing concern within aviation operations. In fact,
a group of internationally known sleep experts
recently indicated fatigue (sleepiness, tiredness) is
the largest identifiable and preventable cause of
accidents in transport operations (p. 395).5

Incident and accident statistics

A National Transportation Safety Board (NTSB)
study of major accidents in domestic air carriers
from 1978 to 1990 in part concluded that .Crews
comprising captains and first officers whose time
since awakening was above the median for their
crew position made more errors overall, and
significantly more procedural and tactical decision
errors (p. 75).6 Kirsch7 estimated that fatigue may
be involved in 47% of civil aviation mishaps, data
from the US Army Safety Center suggest fatigue is
involved in 4% of Army accidents,8 and statistics
from the Air Force Safety Center blame fatigue, at
least in part, for 7.8% of Air Force Class A
mishaps.9 Furthermore, 25% of the Air Forces
night tactical fighter Class A accidents were
attributed to fatigue between 1974 and 1992, and
12.2% of the Navys total Class A mishaps were
thought to be the result of aircrew fatigue from
1977 to 1990.10
At first glance, some of these percentages
appear rather inconsequential; however, it should
be noted that the cost of a single major civil
aviation accident can exceed $500 million in total
financial losses, while the costs in terms of personal
suffering are often inestimable.11 In addition, the
impact of a catastrophic mishap on the revenues of
an airline is severe. Although no concrete figures
are available, it is likely that substantial publicrelations fallout resulted from events such as the
crash of Korean Air flight 801 in which 228 people
died;12 the near crash of China Airlines flight 006 in
which 2 people were severely injured and other
passengers were traumatized;13 and the American
Airlines Flight 1420 mishap in which 11 people
died.14 In each of these cases, crew fatigue from
long duty periods and/or circadian factors was
implicated.

J.A. Caldwell

Pilots opinions about fatigue

and the causative factors
Surveys of aircrew members in both the civilian and
military aviation sectors suggest that from the
aviators standpoint, fatigue is an important issue.
International crews surveyed by Petrie and Dawson15 indicated that sleepiness and lethargy, cognitive slowness, concentration difficulties, and
irritability were common symptoms of aircrew
fatigue. In the long-haul (international) arena,
pilots frequently attribute their fatigue to sleep
deprivation and circadian disturbances associated
with time-zone transitions. Although long-haul
pilots are afforded in-flight sleep opportunities on
flights of 12 h or more, research has indicated that
the sleep is less restful than sleep at home, largely
due to noise, turbulence, temperature, lighting,
and other comfort factors.16 Short-haul (domestic)
pilots most frequently blame their fatigue on sleep
deprivation and high workload.17 Both long-haul
and short-haul pilots commonly associate their
fatigue with night flights, jet lag, early wakeups,
time pressure, multiple flight legs, and consecutive
duty periods without sufficient recovery breaks.
Corporate/executive pilots experience fatiguerelated problems similar to those reported by
their commercial counterparts as evidenced by
the fact that they most frequently cite scheduling
issues (multi-segment flights, night flights, late
arrivals, and early awakenings) as the most noteworthy contributors to operational fatigue. 18
Weather, turbulence, and sleep deprivation, in
combination with consecutive and lengthy duty
days, time-zone transitions, and insufficient rest
periods, are blamed as well. Three-quarters of the
corporate/executive pilots surveyed felt that fatigue was a moderate or serious concern, and 71% of
these pilots reported that they had, at some point,
nodded off during a flight. Similar results were
found in regional-air-carrier pilots where the
majority of aviators said that fatigue was a
moderate or serious concern. Like their cohorts in
other sectors, flight scheduling was felt to be the
most frequent contributor to the problem. In fact,
scheduling factors accounted for 90% of the
recommendations these pilots made to reduce
fatigue within their operational context.19
Despite the many differences between civilian
and military aviation operations, surveys of military
pilots generally support the findings obtained from
the commercial sector. Caldwell and Gilreath20
reported that Army helicopter pilots and crews
frequently blamed inadequate sleep and/or insufficient sleep quality for impaired on-the-job

Fatigue in aviation
alertness, and like their commercial counterparts,
they indicated that fatigue in general was a
significant problem. Respondents indicated that
noteworthy fatigue factors included scheduling
issues (frequently changing work/rest periods,
operating at night, etc.) and uncomfortable sleep
conditions in the field (leading to sleep deprivation). In some respects, these findings support an
earlier study in which Caldwell and Gilreath20 found
that 62% of helicopter pilots and crews complained
of insufficient sleep (i.e. less than 6 h per day) due
to non-standard (i.e. night) schedules. Eighty-two
percent of Navy fighter pilots deployed in Operation
Southern Watch in 1992 indicated that fatiguing
conditions were present during aircraft-carrier
flight operations. As a result, headaches, alertness
difficulties, falling asleep during briefings, and
general performance degradations were common.21
Apparently less-than-optimal sleep/wake scheduling and consequent truncations of sleep (ranging
from 0.4 to 1.6 h per day) were once again to
blame. Air Force F-15 pilots faced similar difficulties while conducting air-combat-patrol missions
during Operation Desert Storm.22 During the 40-day
air war, around-the-clock task demands, minimal
rest periods, consecutive duty days, circadian
disruptions, and sleep deprivation were commonplace. In fact, 2 of the pilots surveyed flew 20 h in a
single 24-h period. Clearly, sleep deprivation is an
issue for deployed military aviators, but extended
duty times are problematic as well.
Neville et al.1 demonstrated that both the recent
amount of sleep loss and the recent amount of flight
time were directly associated with the level of
subjective fatigue reported by Air Force C-141
pilots during Operation Desert Storm. Pilots who
had received 10 or fewer hours of sleep and those
who had accumulated 15 or more hours of flight
during the previous 48 h complained of the greatest
fatigue-related difficulties. No doubt, such circumstances lead pilots to seek fatigue-management
solutions that will permit continuous safe and
effective operations. Emonson and Vanderbeek23
found that during Operation Desert Shield and
Desert Storm, the pilots who were most heavily
tasked, working the longest hours, and obtaining
minimal crew rest more often relied upon amphetamines to sustain alertness (as authorized in
accordance with Air Force policy) compared to
aviators with less demanding schedules. Almost half
of these strained pilots were found to have been
working in excess of 14 h a day, and 86% were
obtaining less than 10 h of daily crew rest (which
no-doubt translated into far less than 8 h of
recuperative sleep). B-2 pilots in Operation Iraqi
Freedom similarly used dextroamphetamine to

87
remain optimally alert in situations devoid of
adequate sleep or nap opportunities.24

Neurophysiological evidence of fatigue

in flight operations
In addition to the survey data described above,
studies have produced objective evidence that
fatigue/sleepiness is a serious, physiologicallybased problem on the flight deck. Crewmember
electroencephalographic activity has been monitored in several studies to determine the actual
biological cost of long-haul and night operations.
These studies have quantified the presence of slowwave EEG (which can be collected without interfering with the pilots primary duties) since this
offers a known objective marker for fatigue.25
Episodes of increased slow-wave brain activity
(often referred to as micro-sleeps or vigilance
lapses) have been associated with generalized
decrements on cognitive tasks26 as well as reduced
speed of responding to incoming stimuli.27
Several in-flight evaluations have shown that
micro-sleeps do in fact occur in cockpit crews.
Cabon et al.28 demonstrated that long-haul pilots
were particularly susceptible to vigilance lapses
during low-workload periods. Furthermore, it was
established that these lapses could simultaneously
appear in both crewmembers at the same time (an
obvious safety concern). In one of the crews that
were evaluated, both the pilot and the co-pilot
evidenced periods of increased slow-wave EEG
activity by the fourth and fifth hour of a westbound
flight from Paris to Winnipeg. Similar indications of
physiological drowsiness occurred at approximately
the same time during the eastbound return home
(although the co-pilot also experienced a vigilance
lapse 1.5 h into the return flight). Wright and
McGown29 found that pilot micro-sleeps tended to
occur most frequently during the cruise portion of
long haul operations (in the middle-to-late segments of the flight), and that micro-sleeps were
more than 9 times as likely during nighttime flights
compared to daytime flights. Of particular interest
was the fact that such lapses apparently went
unnoticed by the affected crewmembers. Thus, a
pilot may believe that he has successfully avoided
the physiological realities of severe fatigue when
actually, he has dozed off repeatedly. Samel,
Wegmann, and Vejvoda30 essentially confirmed
the EEG results from Cabon et al.28 and Wright
and McGown29 by showing that in general, spontaneous micro-sleeps increased with increasing
flight duration. Also, nighttime flights were again

88
found to be more problematic than daytime flights.
During the day, the average number of micro-sleeps
per pilot per hour increased noticeably from the 8-h
point (0.5 micro-sleeps per hour) to the end of the
flight (1.2 micro-sleeps per hour), whereas at night,
the average number of micro-sleeps reached
0.4 per hour as early as the third hour of flight and
subsequently escalated to an average of 1.9 microsleeps per pilot per hour by the end. Thus, vigilance
lapses should be expected during cruise; however,
this is not to say that they cannot occur elsewhere.
Rosekind et al.31 documented the presence of
physiological micro-events (slow brain activity and
eye movements) even during the last 90 min of long
haul flights-a time period of higher workload that
includes top-of-descent to landing. Eighty-seven
percent of the pilots in one group experienced at
least one micro-sleep greater than 5 s in duration,
and on average, the pilots experienced 6 microsleeps during the 90-min interval.
Simulation studies also have shown that sleepiness-related EEG episodes occur in pilots both
during long and short overnight flights. Neri
et al.32 found a statistically-significant increase in
the percentages of slow eye movements and slowwave EEG activity, particularly during the later part
of a simulated B-747 flight. Between 0540 and 0640
in the morning, there was physiological evidence of
sleepiness during 1115% of the designated assessment periods, and outright sleep episodes were
observed in 9 of 14 subjects during the later part
of the night. These findings are consistent with
Moore-Edes33 assertion that there is a dramatic
increase in the frequency with which pilots nod off
at the controls in the early morning hours as well as
Caldwell et al.s34 determination that there is a
significant increase in slow-wave EEG activity
(collected during F-117 flight simulations) as a
function of circadian factors and long periods of
continuous wakefulness.

The factors responsible for pilot fatigue

Pilots and aircrew members are constantly confronted with long duty days, early departures, late
arrivals, and non-standard work hours that include
night duty and rotating schedules. Long-haul commercial pilots and many military pilots also make
frequent transmeridian crossings which contribute
to circadian disruptions and sleep difficulties. Thus,
it has been suggested that aircrew fatigue is a
function of scheduling and workload2-an assertion
that the previously-discussed pilot survey data
reinforce. In many ways, pilots face fatigue factors

J.A. Caldwell
similar to those encountered by industrial shift
workers except that pilots face many additional
complications. Akerstedt35 points out that when
work hours are in conflict with human biological
programming, alertness impairments often result.
The two primary components to be considered in
this programming are (1) the bodys circadian
timing system or the bodys internal clock, and
(2) the homeostatic mechanism or recent sleep
history (which includes the amount of time since
the last sleep period and the amount of prior sleep).
There is a high degree of interaction between the
circadian and homeostatic factors that influence
on-the-job alertness from one time period to the
next, as well as the quality of off-duty sleep that
underlies the ability to properly execute subsequent flight tasks.

Circadian factors
The effects of circadian rhythms on alertness,
physiology, and the subjective experience of
fatigue have already been mentioned. In summary,
there is a known biological propensity towards
sleepiness and inactivity at night, whereas arousal
and heightened activation more naturally occur
during the day. These physiologically-based
phenomena are controlled by the suprachiasmatic
nuclei of the hypothalamus which drives selfsustaining alertness and performance rhythms35.
These rhythms peak in the late afternoon (during
the day) and trough in the predawn or early morning
hours (at night). The body-temperature rhythm,
which in shift workers often coincides with performance rhythms,36 peaks at approximately 1700
and dips at around 0500. Conversely, melatonin
levels, which are inversely-related to alertness,37
tend to be lowest at 1600 and highest at 0400.
Similarly, there are a variety of other internal
rhythms that coincide with daytime alertness and
nighttime sleepiness. For instance, blood pressure
and plasma adrenaline levels are higher during the
day than at night while plasma growth hormone and
cortisol show the opposite pattern.38
As noted previously, surveys have revealed that
in-flight drowsiness is more problematic on night
flights compared to day flights, and electrophysiological evaluations have indicated that microsleeps in the cockpit are more frequent at night
than during the day. In addition, studies on pilots
have shown that attention lapses and flight-control
deviations are more frequent and more severe
when flights overlap the subjective nighttimes of
crewmembers. Dinges et al.39 found that lapses on
a probe vigilance task during long-haul flight

Fatigue in aviation
operations were approximately 5 times greater
during nighttime segments as during daytime segments. Furthermore, although vigilance deteriorated simply as a function of time on task and the
number of consecutive flight segments, the rate of
deterioration was steeper during night flights than
during day flights. Such results are congruent with
Lyman and Orladys40 finding that the majority of
fatigue-related flight incidents in one sample of
NASAs Aviation Safety Reports System occurred
between midnight and 0600 in the morning.
Furthermore, Klein et al.41 reported that simulator
flight performance at 0400 in the morning degraded
to 75100% below what was typical at 1500 in the
afternoon. Thus, the impact of circadian factors on
pilots engaged in what might be considered routine
shift work is clear.
These circadian factors are compounded by
extended periods of continuous wakefulness, but
even under conditions of moderate to severe sleep
loss, the impact of the circadian timing system
remains clear. Studies of flight performance in a
variety of sleep-deprivation experiments have
shown that steep increases in fatigue-related
degradations are clearly more problematic at one
time of day than another. Caldwell, Caldwell, and
Darlington42 for instance demonstrated that helicopter-pilot performance was in tact at 0100 (after
17 h of continuous wakefulness), but severely
degraded only hours later between 0500 and 1000
in the morning. Afterwards, despite continuing
sleep deprivation, performance actually tended to
improve, but never returned to baseline levels. This
temporary improvement was most likely because of
the circadian-mediated afternoon increase in arousal that preceded a subsequent worsening of
performance. Caldwell et al.43 demonstrated similar effects in sleep-deprived F-117 pilots, except
that the marked performance trough was 45 h later
in the day due to the fact that these pilots
habitually worked later schedules. Nonetheless, it
was clear that there was a point at which circadian
factors either multiplied the impairments from
sleep deprivation or partially (and temporarily)
attenuated or stabilized the impact of continuous
wakefulness.

Homeostatic factors
The homeostatic regulation of sleep and wakefulness is primarily a function of two factors. The first
is the amount (and quality) of sleep obtained prior
to a given period of performance; and the second is
the amount of continuous wakefulness prior to the
period of performance.

89
Sleep restriction
Sufficient daily sleep, a key component in the
homeostatic regulation of alertness, is often one
of the first casualties in aviation operations. In
general terms, pilots suffer from work-related
sleep disturbances in the same manner as do
industrial shift workers who primarily complain
about their sleep (or the lack thereof).44 Needless
to say, insufficient sleep is central to the homeostatically-based drowsiness and inattention that
is known to be problematic in shift worker
operations.
Similarly, long-haul pilots and crews frequently
experience shortened sleep, reduced sleep efficiency, and/or changes in sleep architecture that
prevent full recovery during the layovers between
flight segments.4547 Furthermore, the sleep of
these individuals is often compromised by late
arrivals and early departures as well as by constant
schedule or time-zone changes. Sleep after eastward flights is particularly problematic48 in part
because the rate of circadian resynchronization is
50% slower following eastward transitions than
after westbound travel across multiple time
zones.49,50 Following eastward time-zone shifts,
sleep patterns are more variable and fragmented51
primarily because limited layover periods require
crew members to attempt sleep at an earlier than
normal biological time, which is difficult to accomplish. In addition, an earlier than normal rise time
on the following morning creates a significantly
shortened sleep period.
Short-haul pilots also experience duty-related
sleep difficulties. Rosekind et al.,52 reported that
while on trips, the sleep onset of these individuals
was delayed, the sleep period was shorter than
normal, and the wake-up time was almost an hour
and a half earlier than usual. Although the average
duty day for these domestic commercial pilots was
10.6 h, a third of the duty days was greater than
12 h, restricting the available time for sufficient
off-duty sleep. Regional airline pilots (with duty
periods averaging 11.3 h) and corporative/executive pilots (who average 9.9 h per day) also
routinely face this problem.18,19 As mentioned
earlier, while long-haul pilots associate their onthe-job fatigue primarily with night flights and jet
lag, short-haul pilots attribute their fatigue-related
problems more to prolonged duty periods and early
wakeup times.17
Military pilots suffer sleep disturbances or
truncated sleep because of the high demands
associated with operational missions. Paul, Pigeau,
and Weinberg53 for instance found that during the
days prior to some re-supply missions from Canada
to the former Yugoslavia, the sleep of Canadian

90
CC-130 pilots steadily decreased from 8.7 h per day
to 6.5 h per day before departure, largely because
the crews were required to report for duty in the
early morning hours. These same crews continued
to suffer from sleep deprivation immediately after
arrival due to sleep difficulties associated with
circadian factors. Boll et al.54 indicated that many
C-141 pilots slept only 6.7 h per day during Desert
Storm or 6.4 h per day during Desert Shield. Neville
et al.1 reported that during the final week of Desert
Storm, there were severe sleep deficits in at least
one sample of C-141 crews. Despite regulations
requiring a minimum crew rest period of 12 h,55
some pilots obtained no sleep at all during entire
24-h periods, and others obtained less than 10 h of
sleep across 48-h periods. Similarly, Bisson, Lyons,
and Hatsel56 found that C-5 crews during Operation
Desert Shield often reported for duty with less than
4 h of sleep in the previous 1216 h simply because
they were unable to sleep due to a combination of
circadian and environmental factors.
Lengthy duty periods
Long duty periods obviously contribute to sleep
deprivation, and working around the clock is
complicated by circadian factors. Simply remaining
awake and on the job for 18.521 h can produce
performance changes similar to those seen with
blood alcohol concentrations of 0.050.08%. 57
Goode58 found that the probability of a commercial
airline accident increases significantly as a function
of time on duty. Although only 10% of pilot duty
hours were found to exceed 10 h in duration, 20% of
all US commercial aviation mishaps appear to occur
at the 10th hour and beyond. Only 1% of duty time
exceeds 13 h or more, but 5% of the mishaps occur
within this time frame.
Such findings are disconcerting in light of the fact
that several investigators have reported continuous
wakefulness periods ranging from 19 to 22 h on
outbound international commercial flights.46,59,60
Also, as previously noted, duty days for domestic
commercial pilots often reach 1012 h or more.52
Regional airline pilots sometimes average 11.3 h
per day,19 and corporative/executive pilots have
been found to average 9.9 h per day.18 Long duty
cycles and consequent lengthy periods of continuous wakefulness also occur in sustained military
operations where duty days sometimes extend
beyond 20 h54 and the mission itself can be over
35 h in duration.24 Thus, in addition to circadian
disruptions and acute or cumulative sleep deprivation, prolonged periods of continuous wakefulness contribute substantially to pilot fatigue.

J.A. Caldwell

Recommendations for countering fatigue

in aviation
Clearly, scheduling demands and human physiological makeup are at the heart of fatigue-related
problems in aviation. The multiple flight legs, long
duty hours, limited time off, early report times,
less-than-optimal sleeping conditions, rotating and
non-standard work shifts, and jet lag that have
become so common throughout modern aviation
pose significant challenges for the basic biological
capabilities of pilots and crews. Humans simply
were not designed to operate effectively on the
pressured 24/7 schedules that often define todays
flight operations, whether these consist of shorthaul commercial flights, long-range transoceanic
operations, or around-the-clock military missions.
Because of this, a well-planned, science-based,
fatigue-management strategy is crucial for fighting
the acute sleep loss/sleep debt, the sustained
periods of wakefulness, and the circadian factors
that are primary contributors to fatigue-related
flight mishaps.61 First, educational efforts are
essential for ensuring a thorough understanding of
the causes and effects of aircrew fatigue, and
second, scientifically valid fatigue countermeasures are indispensable for matching human capabilities to increasingly-difficult job pressures.

Education
Education about the dangers of fatigue, the causes
of sleepiness on the flight deck, and the importance
of sleep and proper sleep hygiene is one of the keys
to addressing fatigue in operational aviation contexts. Ultimately, the pilots themselves and those
scheduling routes and missions must be convinced
that sleep and circadian rhythms are important and
that quality off-duty sleep is the best possible
protection against on the job fatigue. Recent
studies have made it clear that as little as 12 h
of sleep restriction almost immediately degrade
vigilance and performance in subsequent duty
periods.62,63 Thus, educational programs such as
those currently offered by the US Air Force
Research Laboratory and the NASA Ames Research
Center must continue to educate aircrews on the
following points: (1) fatigue is a physiological
problem that cannot be overcome by motivation,
training, or willpower; (2) people cannot reliably
judge their own level of fatigue-related impairment; (3) there are wide individual differences in
fatigue susceptibility that cannot be reliably predicted; and (4) there is no one-size-fits-all magic
bullet (other than adequate sleep) that can

Fatigue in aviation
counter fatigue for every person in every situation.
Aircrews and schedulers should be advised that it is
important to (1) make adequate off-duty sleep a
priority; (2) gain 8 h of sleep per day either in a
consolidated block, or in a series of naps, whenever
possible; and (3) adhere to good sleep habits to
optimize sleep quantity and quality.64

91
and effective for long-haul pilots.65 However,
cockpit napping has not yet been approved for US
commercial aviators despite the fact that the
general public in the US has indicated support for
cockpit napping as an in-flight fatigue-mitigation
strategy.66 Efforts are underway to address this
discrepancy and to make this proven anti-fatigue
strategy available to all long-haul pilots.

On-board sleep
Controlled rest breaks
One technique for minimizing the impact of sleep
loss and continuous duty is the implementation of
short out-of-cockpit sleep opportunities (known as
bunk sleeps). These sleep periods are extremely
helpful for sustaining the alertness and performance of long-haul crews. When in-flight bunk sleep
is implemented, one or more pilots retire(s) to a
specially-designated area in the passenger compartment for a sleep break while other qualified
crew members maintain control of the aircraft. For
commercial pilots in the United States, the Federal
Aviation Administration (FAA) requires augmented
crews (at least 3 pilots) and on-board rest facilities
for flights longer than 12 h so that pilots can
partially attenuate the homeostatic sleep drive
between take-offs and landings.18
Depending on the length of the flight and the
number of crew members on board, bunk-sleep
periods can range from 2 to 4 h in duration. They
are scheduled only during the cruise segment of the
flight since this is a time of relatively-low workload.
In some military operations, an out-of-cockpit sleep
strategy can be implemented in multi-crew aircraft. On B-2 bomber missions, which sometimes
last for over 30 continuous hours, one of the pilots
may sleep in a cot located behind the seats during
low-workload flight phases while the other pilot
maintains control of the aircraft. Such on-board
sleep should be considered an important aviation
fatigue countermeasure for any type of long-range
flight operation where an adequate crew compliment is available.

Cockpit naps
A strategy related to out-of-cockpit bunk sleep is
the cockpit nap. When cockpit naps are
implemented, one pilot actually sleeps in his/her
cockpit seat (rather than moving to another part of
the aircraft) while the other pilot flies the aircraft.
Many international airlines now utilize cockpit
napping on long flights, and cockpit napping is
sometimes authorized for US military flight
operations as well. A 1994 NASA study has shown
that naps of up to 40 min in duration are both safe

Tasks requiring sustained attention, such as monitoring aircraft systems and flight progress, can pose
significant problems for already-fatigued personnel.67 This is in part why pilots often implement
some type of work break strategy (chatting,
standing up, walking around, etc.) to help sustain
alertness during lengthy flights. There is evidence
from non-aviation studies that frequent rest breaks
can improve physical comfort and reduce eyestrain
during prolonged, repetitious tasks.68 More importantly, Neri et al.32 found that simply offering pilots
a 10-min hourly break during a 6-h simulated night
flight significantly reduced slow eye movements,
theta-band activity, unintended sleep episodes,
and subjective sleepiness ratings. Although positive
benefits were transient (1520 min), they were
noteworthy and particularly evident near the time
of the circadian trough. All of the reasons why rest
breaks are helpful are a matter for debate, but it
may be that their effectiveness is partially attributable to physiological factors as well as to the
temporary relief of mental boredom or physical
discomfort. Caldwell, Prazinko, and Caldwell69
found that simply assuming a more upright posture,
as opposed to remaining seated, reduced the
amount of slow-wave EEG activity and enhanced
performance on a 10-min vigilance task during the
later part of a 28-h sleep-deprivation cycle. Thus,
taken together with the results from Neri et al.32 it
appears that periodic breaks involving nothing more
than simply leaving the flight deck and conversing
with other crew members during long-duration
flights can help to sustain alertness in the cockpit.

Optimum crew work-rest scheduling

Since scheduling factors are often cited as the
number one contributor to pilot fatigue, the
development and implementation of more human
centered work routines should be considered
paramount for promoting on-the-job alertness.
Unfortunately, crew scheduling practices in aviation have yet to incorporate the advanced knowledge of fatigue, sleep, and circadian rhythms that

92
has been gained over the past 20 years. Concerted
efforts must be made to develop schedules that
recognize (1) sleep as being essential for optimum
functioning, (2) breaks as being important for
preserving sustained attention, and (3) recovery
periods during each work cycle as being necessary
to ensure full recovery from fatiguing work conditions.4 In addition, crew schedules should include
weekly rather than monthly recovery days to ensure
recuperation from cumulative fatigue/sleep debt.
Furthermore, scheduling practices must take into
account the facts that (1) circadian factors influence both sleep and performance, (2) homeostatic
factors (continuous wakefulness) are similarly
important, and (3) under certain conditions these
two factors can interact to create sudden and
dangerous lapses in vigilance. Also, it must be
recognized that training, professionalism, motivation, and increased monetary incentives will have
little impact on the basic physiological nature of
circadian and homeostatic determinants of operator alertness. Finally, it is important to note that
flight crews are made up of individuals who are
differentially affected by sleep disruptions, long
duty periods, circadian rhythms, and other potentially problematic factors. Thus, one-size-fits-all
scheduling practices are almost certainly
inadequate. New computerized scheduling tools
such as the Fatigue Avoidance Scheduling Tool
(FAST)70 and the System for Aircrew Fatigue
Evaluation (SAFE)71 can ease the process of developing and implementing new schedules by allowing
planners to better appreciate the impact of fatigueinducing factors and the potential benefits of
appropriate counter-fatigue strategies. Once validated across a wide array of aviation applications,
these easy-to-use computerized scheduling tools
will no doubt contribute to successful aviation
alertness management.

Melatonin and bright light

Both melatonin administration and bright light
exposure may help to overcome jet lag and shift
lag in aviation operations involving rapid schedule
changes. With regard to melatonin, there is a
substantial amount of research which indicates that
appropriate administration of this hormone can
improve circadian adaptation to new time schedules.37 There also is evidence that melatonin
possesses weak hypnotic or soporific properties
that may facilitate out-of-phase sleep.72 Since
melatonin is not considered a drug, it is widely
available for use with few restrictions. Unfortunately, most potential users of melatonin possess

J.A. Caldwell
little knowledge about circadian rhythms and/or
endogenous melatonin secretion, and this could
lead to alertness and performance decrements
associated with improper use. For this reason,
Caldwell73 has concluded that melatonin use is
unacceptable for aviators (p. 243). It should be
noted that melatonin is not an approved substance
for use in military aviation.
Properly-timed bright light is an alternative
strategy for resynchronizing circadian rhythms
after schedule changes,7476 but the proper intensity, timing, and/or duration of bright light
exposures remains difficult to determine. Lewy
et al.77 discusses the complexities of using both
melatonin and light to adjust circadian rhythms.
However, the difficulties in appropriate timing of
both methods suggest that perhaps the safest selfadministered resynchronization strategy is to use
natural sunlight exposure, naps, and local zeitgebers such as local meal, activity, and sleep times to
facilitate adjustment to new time zones.78,79 While
pilots suffering from shift lag may not be able to
take advantage of a similar strategy, they can at
least be cautioned to avoid light exposure (or to
minimize it with very dark glasses) before a period
of daytime sleep.

Sleep-promoting compounds
When sleep opportunities are available but compromised due to operational factors, the hypnotics
temazepam, zolpidem, and zaleplon should be
considered. Although the use of prescription
(and over-the-counter) hypnotics and sedatives is
discouraged throughout aviation, they are sometimes authorized to enhance pre-mission or recovery sleep on the ground (hypnotics are never
authorized for the promotion of in-flight naps or
rest periods). In the US, the Federal Air Surgeon
recently approved the ground use of zolpidem as
long as it is not administered more than twice a
week or within 24 h of flight; however, zolpidem
cannot be used to aid in overcoming circadian
disruptions. In military aviation, the use of hypnotics is slightly more liberal, and in this context,
temazepam, zolpidem, and zaleplon are all three
occasionally authorized. Choosing the best hypnotic
for each situation requires consideration of a
variety of factors. From a strictly pharmacological
standpoint, temazepam is best for maintaining
sleep for relatively long periods during the night
and/or for optimizing the daytime sleep of nightworking personnel. Caldwell, Prazinko, Rowe,
Norman, Hall, and Caldwell80 reported that the
facilitation of daytime sleep with temazepam

Fatigue in aviation
resulted in improved performance during subsequent nighttime simulator flights. Zolpidem and
zaleplon are better for promoting an earlier-thanusual sleep onset (in preparation for early-morning
wakeups) or for inducing and maintaining short
naps. Since both compounds have shorter half lives
than temazepam, the probability of post-sleep
sedation is reduced. Caldwell and Caldwell81
found that both mood and performance during a
sustained period of wakefulness was bolstered more
by a zolpidem-induced prophylactic nap than by a
natural nap or a simple rest period. Zolpidem
prolonged the sleep during the 2-h sleep opportunity by almost 30 min. In general, hypnotics can
help to minimize sleep disruptions associated with
circadian factors (jet lag and shift lag), and with
proper planning, they can be used without undue
concern about post-sleep hangover effects. The
choice of compound depends on when the new
sleep opportunity becomes available and whether
there is a high probability that the sleep period will
be unexpectedly truncated (as is sometimes the
case in military operations). An effort should be
made to balance the need to improve sleep with the
need to avoid residual effects, taking into account
that sleep disruptions associated with the avoidance of hypnotics may be far more problematic
than a hangover following a restful hypnoticinduced sleep. Since it is sometimes difficult to
make such determinations, it is not surprising that,
with the exception of some military applications,
the use of hypnotics is discouraged or often
completely banned within the aviation context.

Alertness-enhancing compounds
When, despite everyones best intentions, sleepiness becomes a problem in the flight environment,
caffeine is often used as the first line pharmacological fatigue countermeasure in both civil and
military aviation. Numerous studies have shown
that caffeine increases vigilance and improves
performance in sleep-deprived individuals,
especially those who normally do not consume
high doses of caffeine.82 In commercial aviation,
caffeine (generally in the form of coffee, tea, or
soft drinks) and some dietary supplements are
the only alertness-enhancing substances allowed,
whereas in military aviation, prescription alertness-enhancing medications are periodically authorized, particularly for lengthy missions during
continuous and sustained operations. The most
widely used prescription stimulant within military
aviation contexts is dextroamphetamine, a
compound with powerful, reliable, and safe

93
alertness-sustaining effects.42 Properly-administered dextroamphetamine has been shown to
sustain pilot performance at near well-rested
levels for over 5055 h without sleep. It is for this
reason that the US military has authorized the use
of Dexedrinew at various times since World War II.
More recently, modafinil has been introduced into
limited aviation operations. In December of 2003
modafinil was authorized for use in extended Air
Force dual-crew bomber missions. Although modafinil has not been as well-tested in operational
contexts as dextroamphetamine, two studies to
date have shown that it is capable of significantly
attenuating fatigue-related decrements in pilot
performance throughout 3040 h of continuous
wakefulness. The attractiveness of modafinil over
dextroamphetamine is that it has relatively low
abuse potential, and it produces few cardiovascular side effects. However, both medications can be
life-saving in sustained aviation operations devoid
of sleep opportunities. Both modafinil and dextroamphetamine are carefully regulated by trained
physicians (flight surgeons), and they are used only
when all other counter-fatigue strategies have
been exhausted.

Summary
Countering fatigue is a challenging proposition in
complex aviation operations. However, with appropriate planning, one or more of the previouslymentioned strategies can contribute significantly to
pilot alertness and flight safety. With proper
training and education, crews, schedulers, and
leadership can design safer crew schedules and
effectively utilize on-board rest opportunities,
cockpit napping, controlled rest breaks, and other
techniques to optimize alertness on the flight deck.

Conclusions
Aviation is a critical component of the transportation system, our national defense network, and
the world economy. As technological advancements
in terms of airframe speed, range, payload, and
ease of operation continue to improve, there is
little doubt that societys dependence on this
important asset will continue to grow. As a result,
pilots and crews will face escalating challenges to
effectively staff the complex and often difficult
schedules that characterize modern 24/7 flight
operations. As long as technological and economic
factors strain available personnel resources and
basic human capabilities, fatigue will continue to

94
be an aviation risk factor. However, systematic
fatigue education; cooperative dedication among
airlines, crews, and governments; and the
implementation of scientifically-based scheduling
practices and fatigue countermeasures will optimize the safety and well-being of crews, passengers, and payloads everywhere.

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