Thomas J. Balkin, PhD, chief of the Department of Behavioral Biology at the Walter Reed Army Institute of Research and chairman of the National Sleep Foundation (NSF), has a firm grasp of drowsy driving issues not only in the United States but also overseas. Countries like Australia, according to Balkin, are leading the way in innovative approaches to managing fatigue among commercial drivers. Armed with this knowledge, Balkin has a better perspective on the need to modernize US laws and how to best bring the parties who influence such legislation to shared solutions. In an interview with Respiratory Therapy, Balkin shares specifics about how other countries are tackling the issue of drowsy driving, how the United States might adopt these approaches, and the role the NSF is playing in bringing drowsy driving awareness to the forefront.

RT: There has been plenty of recent discussion about steps some countries are taking to combat fatigue and drowsy driving among the general population and commercial drivers. What are some of these innovative approaches?

Thomas J. Balkin, PhD: Currently, the most innovative, and potentially effective, approach to managing fatigue in drivers is probably that represented by the Heavy Vehicle Driver Fatigue (HVDF) Laws implemented in South Australia (and much of the rest of Australia) on September 29, 2008. Central to the innovations represented by these laws are:

Accountability: An expanded, shared responsibility to ensure that professional drivers maintain a nominal level of alertness while on the road. Thus, in addition to the personal responsibility shouldered by the driver, responsibility now also accrues to the driver’s employer, the individual responsible for scheduling the driver and/or the delivery schedule of the load hauled by the driver, any individuals responsible for consignment of the load being transported, the supervisors responsible for overseeing the loading/unloading of the vehicle at both ends of the trip, as well as the individuals who actually do the loading and unloading of the vehicle. In other words, “driver alertness” has become a shared responsibility and any individual in the system who negatively impacts a driver’s ability to maintain a legal, safe schedule—and thus maintain a safe level of alertness—can be held legally responsible.

Flexibility: Recognizing that one-size-fits-all solutions are not likely to work equally well for all industries, the truckers in South Australia can now actually choose from among three options:

The Standard Hours (SH) option is the simplest and most straightforward, allowing for a maximum of 12 hours of work per day, with specified requirements for scheduled rest periods based on the duration of the work shift. Also, under this option 4 nights of rest (a minimum of 7 continuous hours taken between 10 pm and 8 am) during a 14-day period are mandated, and two of these nights must be consecutive. Therefore, these provisions appear to reflect an appreciation of the importance of obtaining sleep during the nighttime hours (when sleep duration and continuity are maximal, and the restorative value of sleep is therefore optimal) and an appreciation of the extent to which fatigue (time on task effects) can interact with sleep loss to impair driving performance.

Under the Basic Fatigue Management (BFM) option, the workday can be longer—up to 14 hours. BFM allows operators greater control over their work/rest schedules, with the requirement that extended workdays and nighttime driving are managed appropriately within the guidelines provided by the “36 Hour Rule,” in which the total number of nighttime driving hours plus extended driving hours (ie, beyond 12 in a single day) cannot exceed 36 over a 7-day period. Those wishing to operate under BFM must obtain official accreditation, a process that requires demonstrated competence and compliance with respect to scheduling and rostering, fitness for duty standards, fatigue knowledge and awareness, knowledge of responsibilities, an acceptable internal review process, and a satisfactory system of record-keeping and documentation.

The Advanced Fatigue Management (AFM) option allows greater flexibility than the SH or BFM options, with drivers allowed to operate up to 16 hours per day under special circumstances. AFM constitutes more of a “risk management” approach than SH or BFM, with less emphasis on hours of service regulations and more emphasis on accountability and demonstrated proficiency in management of fatigue-related risk.

These laws—although perhaps not yet perfect—appear to reflect a healthy collaboration between the government and the distinguished Australian “sleep and fatigue” scientific research community (the Australians have been a world leader in fatigue management research over the past three decades).

RT: How might the United States implement such approaches?

Balkin: Here in the United States, changes in policies, rules, regulations, and laws relating to fatigue and driving will be helped by the convergence of three factors:

a. Over the past 20 years, scientific studies have greatly elucidated the extent and processes by which sleep loss, the circadian rhythm of alertness, “time on task,” various sleep disorders, and factors like monotony, weather, and visibility combine to impact alertness and driving performance.

b. There are currently several influential individuals working within relevant government agencies who have significant expertise in sleep and fatigue-related issues and who know how to work within the system to clear the hurdles that tend to slow or obstruct development and implementation of new rules, regulations, and laws. To name but a few: Stephen Popkin, PhD, director of the Human Factors Research and System Applications Center of Innovation at the Volpe National Transportation Systems Center, has been actively promoting sleep and fatigue research for the past 20 years; Debbie Hersman, President Obama’s selection to be the new chair of the National Transportation Safety Board (NTSB), has long championed the cause of improved fatigue management in transportation industries; and one of the newest NTSB board members, Chris Hart, is a former NSF board member.

c. Perhaps most critically, general public awareness of sleep-related issues—eg, the prevalence of sleep disorders and the overall importance of sleep for health and performance—has increased exponentially. For example, anyone who read, heard, or saw the various news reports about the crash of Continental Airlines Flight 3407 outside of Buffalo last February surely knows that pilot fatigue has been implicated as a causal factor. Similarly, “sleep apnea” has entered the general American lexicon. This increase in awareness of sleep-related issues (which is no doubt due, in part, to the public awareness efforts of the NSF) is now approaching the “critical mass” needed to spur lawmakers at the state and federal levels to take action.

RT: What is the NSF’s role in making those approaches a reality in the United States?

Balkin: The NSF’s primary mission is to disseminate accurate information to increase general public awareness of the importance of adequate sleep for health, safety, and well-being. Thus, NSF activities like “Drowsy Driving Prevention Week” and “National Sleep Awareness Week” are widely aimed at the public sector—although it is clear that lawmakers in Washington, DC and beyond also take note of these events, and are keenly aware of the extent to which sleep and fatigue-related issues constitute a significant concern in their home districts. The NSF also sponsors scientific meetings on sleep/health-related topics for which the target audience is narrower—ie, the sleep and fatigue research community, or primary care physicians. In addition, NSF board members have previously served as consultants in NTSB accident investigations, and have testified in Congress on sleep- and fatigue-related issues.

RT: What drowsy driving legislation is the NSF helping to push forward?

Balkin: While several states have active legislation, the most promising and comprehensive approach is taking place in Massachusetts where a special commission has been formed to make recommendations to the Governor. NSF has participated on this commission, which is looking at education, enforcement, and engineering solutions.

RT: At SLEEP 2009, there was much discussion about drowsy driving, OSA, and commercial drivers. The association between the commercial driving industry and the sleep industry seems to be an “us versus them” relationship. Truckers see increased demands and regulations as a threat to their livelihood whereas sleep professionals see themselves as pushing for patient advocacy/public safety. How can these two groups better communicate their goals with one another and come to better resolutions regarding drowsy driving, OSA, and commercial driving?

Balkin: I don’t think that these two groups—the sleep community and the commercial driving industry—are as far apart on the issues as some might think. Both communities, of course, are in favor of enhancing the safety, health, and general well-being of commercial drivers, and both would like to minimize fatigue-related accidents on the road.

However, commercial drivers are understandably concerned that “improved safety” can easily translate into “more restrictive hours of service regulations,” which, in turn, can mean reduced paychecks and an eroded standard of living for the drivers, and reduced profitability for the industry as a whole.

Such an outcome is not only undesirable from the driver’s financial standpoint, but it would be also self-defeating because the natural inclination would be for affected drivers to replace lost income by moonlighting—ie, taking a second (and usually lower paying) job that might very well increase the driver’s time pressure rather than reducing it, thereby reducing the driver’s total sleep time instead of increasing it!

Likewise, issues such as whether there should be mandatory sleep apnea screening for drivers need to be approached in a manner that addresses the concerns of all involved—ie, so that public safety is enhanced, operational efficiency is maintained, and the individual driver’s job/financial security is not threatened by a diagnosis of sleep apnea.

The challenge for the sleep community—in fact, the imperative for the sleep community—is to work together with the commercial driving industry and regulators to devise improved fatigue management practices, rules, strategies, and laws that not only avoid negative financial consequences, but actually improve profitability and take-home pay along with driver alertness and safety.

Based on advances in the science of sleep and fatigue management over the past two decades, this is an achievable goal. The hard part will be getting the laws and regulations to “catch up” with the science.

RT: What is the NSF doing differently this year with Drowsy Driving Prevention Week? What does the foundation hope to accomplish this year? And what are the foundation’s goals for the program in the future?

Balkin: NSF will continue to promote drowsy driving prevention through the media and the Internet to raise general awareness while providing materials for specific at-risk groups. NSF is currently building new partnerships to broaden the reach of its messages. One of these partnerships is with Mercedes-Benz. We hope to build this awareness event and build further partnerships, especially with other organizations, to reach specific at-risk groups.