Guest Blog: NTSB Responds on Sleep Apnea

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In an AVweb Insider blog a month ago, we observed how the FAA got rapid and intense pushback on its proposal to require sleep apnea diagnosis for pilots with BMIs of 40 or higher. In this guest blog, the NTSB's Mark Rosekind explains that the agency has given this topic more than a passing glance. 

The National Transportation Safety Board mission is focused on enhancing safety and the agency’s interest in obstructive sleep apnea (OSA) is to address a known and established safety risk.  For example, on February 13, 2008, a go! airline flight in Hawaii overflew its destination airport by 18 minutes and 26 miles when both pilots fell asleep.  Based on its investigation, the NTSB identified excessive daytime sleepiness due to fatigue resulting from the captain’s undiagnosed sleep apnea as contributing to this incident.

Among the recommendations issued, the NTSB included three to address the safety risks specifically associated with sleep apnea and are directed to all pilots required to obtain an FAA medical certificate in every aviation class.  They are to: 

Modify the application for airman medical certificate to elicit specific information about any previous diagnosis of obstructive sleep apnea and about the presence of specific risk factors for that disorder (A-09-61).

Implement a program to identify pilots at high risk for obstructive sleep apnea and require that those pilots provide evidence through the medical certification process of having been appropriately evaluated and, if treatment is needed, effectively treated for that disorder before being granted unrestricted medical certification (A-09-62).

And third, develop and disseminate guidance for pilots, employers, and physicians regarding the identification and treatment of individuals at high risk of obstructive sleep apnea, emphasizing that pilots who have obstructive sleep apnea that is effectively treated are routinely approved for continued medical certification (A-09-63).

The full Safety Recommendation with extensive background information can be found here. These NTSB recommendations were issued to ensure the safety of the traveling public because sleep apnea leads to excessive daytime fatigue, increases the risk of accidents, impairs cognitive skills, elevates the likelihood of critical errors and falling asleep, and because many individuals who have the disorder do not know they have it.  With treatment, sleep can be improved, OSA symptoms reduced, and adverse effects reversed, leading to a return to normal duty for most civilian pilots.

Clearly, the NTSB has more than “opined” on the subject of OSA, its adverse effect on sleep, and the significant safety risks associated with human fatigue in transportation operations.  For more than 40 years, the NTSB has identified fatigue as a problem.  OSA is a common fatigue-inducing disorder that affects many pilots and it often remains undiagnosed, creating a hidden safety risk that can be managed effectively if identified.

Mark Rosekind has been a member of the NTSB since 2010 and is recognized as one of the world's foremost human fatigue experts. Prior to his joining the board, he was a consultant in human fatigue management.

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Read others' comments and add your own.

Comments (21)

Just substitute the word "cancer" for "obstructive sleep apnea." The resultant initiative would make as much (as little) sense. Being a parent of a newborn is "a known and established safety risk" for "excessive daytime sleepiness due to fatigue." Perhaps medicals should be withheld from such pilots, until their children no longer cause fatigue (that would be just after the parent's death). I guess we should prohibit acting as PIC after a full day's work, or after a hearty game of tennis. Too much fatigue, you know.

"Mark Rosekind... is recognized as one of the world's foremost human fatigue experts." And is a fine example of why - when you're a hammer - everything looks like a nail.

I've been teaching people how to fly for more than 30 years. I can safely say that almost all aircraft accidents are caused by a human pilot doing something that's truly stupid. I'm sure that fatigue has played a role in many an accident. But I've yet to see even Mr. Rosekind establish that fatigue induced by undiagnosed OSA was the primary cause of ANY accident.

To compare the fatigue-prone duties and typical workdays of an air-carrier crewmember with the typical GA pilot cockpit duty-cycle is woefully ignorant or purposefully malicious.

This OSA initiative is the most egregious act of bureaucratic tyranny I've seen in America in my six decades here.

Mr. Rosekind, please do us all the favor of finding a real problem to solve. Absent that, please provide us with incontrovertible EVIDENCE that undiagnosed OSA has been the primary cause of ANY aviation accident.

Posted by: Tom Yarsley | January 8, 2014 5:28 PM    Report this comment

As usual not only the FAA but now the NTSB is putting the "resolution" of this non-issue on the pilot instead of the air carrier or the FAA itself. The "fatigue prone" work duties of an air carrier pilot are due to the crazy time and duty rules that the FAA will not fix due to pressure from the airlines. Maybe the NTSB should concentrate its efforts there rather than encourage the FAA on its attempt to "fix" a non-issue that has not caused any accidents at all.

I wonder how long the air carriers are going to put up with pilots using extended disability because they were "diagnosed" with OSA. If this is as bad as the bureaucrats say it is then the airlines will lose a lot of crewmembers resulting in many more flight cancellations. And where are the pilots' unions on this?

Making the average GA pilot do this will just drive more pilots out of flying due to the unreasonable cost. Maybe that is the governments' objective anyway.

Maybe with more phony "safety" issues the FAA tries to regulate away, they will put themselves out of business along with the industry it is regulating!

Posted by: matthew wagner | January 8, 2014 6:44 PM    Report this comment

Seems like OSA might present an equal or greater hazard for those that drive cars and trucks on the road. Why doesn't the NTSB tackle that problem? Maybe they think it's easier to take on a few pilots than take on 150,000,000 drivers?

Posted by: Stephen Phoenix | January 8, 2014 6:47 PM    Report this comment

Not sure I understand the point of the blog. Nothing said, as Thomas wrote, to link incontrovertably OSA as proven primary cause of any accident, nothing said of the effect on GA this will have and how governmental agencies are working to alleviate that stress, and nothing said of costs to pilots and taxpayers for such a huge undertaking.

Slamming Paul for using the word opined in his original blog when followup response blog is nothing but that - priceless.

Posted by: David Miller | January 8, 2014 7:19 PM    Report this comment

Dr. Rosekind,

Thank you for providing your side of the issue. Even though I, and I'm guessing most readers here, will disagree with you, I can assure you that we all appreciate your input and perspective.

That said, we must realize when any action, regulation, or restriction is appropriate, and when it is overbearing. I don't think anybody would doubt that there is some risk imparted by pilots flying with undiagnosed sleep apnea.

However, you point to one issue, on a scheduled airline flight, that would now justify thousands of dollars of expense for potential every third-class medical that will ever be issued. I know the current proposed metrics would only affect a small number of pilots, but the FAA openly stated they wanted to expand those numbers in the future.

We would all be much safer if we stopped flying small airplanes entirely. We've accepted the increased risk of flying them in exchange for the utility, challenge, and pleasure of flight. There's no reason to excessively burden tens of thousands of pilots to combat an issue that has not yet resulted in any appreciable number of incidents. Neither the FAA, nor the NTSB, has pointed to any statistics showing that sleep apnea has, or will, contribute to any incidents or accidents.

Getting Part 23 in order so that we can all install two-axis autopilots in our airplanes without going bankrupt will increase safety a thousandfold compared to making pilots submit to sleep studies and excessive medical treatment.

Posted by: Joshua Levinson | January 8, 2014 8:06 PM    Report this comment

So the captain had OSA--How come the first officer was also asleep. Is OSA contagious?

Posted by: Charles Haubrich | January 9, 2014 8:07 AM    Report this comment

The NTSB Probable Cause of the incident referred to by Mark Rosenkind:

The National Transportation Safety Board determines the probable cause(s) of this incident to be:

The captain and first officer inadvertently falling asleep during the cruise phase of flight. Contributing to the incident were the captain's undiagnosed obstructive sleep apnea and the flight crew's recent work schedules, which included several consecutive days of early-morning start times.

Posted by: Charles Haubrich | January 9, 2014 8:15 AM    Report this comment

Remove the autopilot and no one will ever fall a sleep again!

Posted by: VANCE BLAHNIK | January 9, 2014 8:28 AM    Report this comment

It is absurd to compare recreational GA operations with scheduled airline operations.

If we were forced to fly insane schedules like the airlines, then maybe Dr. Rosekind has a point, but we don't fly that way and never do...and that sir, is where you are dead-nuts wrong about painting the entire GA world with your part 121 brush. Please go find another small defenseless group to pick on.

Posted by: A Richie | January 9, 2014 8:54 AM    Report this comment

So the captain fell asleep for undiagnosed sleep apnea. What about the first officer? Did he have the turkey sandwich? Quick, let's pass a new regulation on what we can eat before we fly and test everyone for that during our medical.

Posted by: jay Manor | January 9, 2014 2:21 PM    Report this comment

With almost 30 million flights per year in the US alone, Dr. Rosenkind cites a single flight where one of two pilots who fell asleep during the flight suffered from undiagnosed OSA. Sounds like a call to action to me - or maybe just more regulatory overstep.

By the way, a significant percentage of people with OSA and other sleep disorders are not overweight.

Posted by: PHIL RYDER | January 9, 2014 2:40 PM    Report this comment

Seems to me that there was also a discussion about some medication (not clear whether it was prescription or over the counter) that the Captain was taking.

If there is a single incident that has a nebulous (at best) relation to sleep apnea, that does not seem to provide a scientific basis to launch a multi-million dollar expenditure to seek out undiagnosed cases of sleep apnea.

Even if there were many more cases associated with Sleep Apnea, it would seem controversial to used BMI as a screening tool.

Posted by: RAY DAMIJONAITIS | January 9, 2014 4:46 PM    Report this comment

As an Internist/Cardiologist who has probably diagnosed 3 or 4 cases of OSA per month for the last 30 years, and as an active pilot for 50 years and former USAF Flight Surgeon, I can say I agree with every comment written above. Further, the use of sleep laboratory assessment to screen for OSA is an inappropriate, expensive waste of medical and pilot resources. Screening for OSA is done with a good history and physical exam, not a $3000 "test".

Posted by: warford johnson 11 | January 9, 2014 9:11 PM    Report this comment

Thank you Dr. Johnson, sanity is always nice, the voice of reason and experience is doubly welcome. Would you mind giving Dr. Rosekind a call? (I assume it is Dr. The intro never actually stated he is a Dr.)

Posted by: Richard Montague | January 10, 2014 7:39 AM    Report this comment

Its all about control from an ever increasing oppressive bureacracy. These jerks are not our elected government and we should all, I mean every one of us, contact our representatives and senators and DEMAND that they do something to make these idiot bueaucrats straighten up and fly right. While you are contacting them, ask them to demand that the FAA do away with the 3rd class medical.

Posted by: Richard Warner | January 10, 2014 10:04 AM    Report this comment

It would be nice if all of us were in the physical condition of Naval aviators, but that's not realistic. The ability to fly safely the sorts of airplanes we fly does not require that sort of conditioning. The issue that the NTSB and FAA are addressing is based on one incident of one pair of airline pilots who both nodded off at the controls on a short hop in Hawaii while the airplane was on autopilot, after flying for many hours and many take-offs and landings, more than 4 years ago. Only one of the pilots was portly, and he was later diagnosed with obstructive sleep apnea.

So on the basis of that one incident, in which only one of two airline pilots was found to have OSA, how does that justify requiring every single pilot whose BMI exceeds an arbitrary number or whose neck size exceeds an arbitrary circumference to go through expensive testing?

The issue is pilots falling asleep. That's hard to do unless the airplane is on autopilot, and the issue isn't why did he/she fall asleep, but how to keep him/her awake when the airplane is on autopilot.

The proposal is to require those with a BMI over 40 to undergo testing. But the writing is on the wall: First it's those over 40, then those over 35, then those over 30--or some other arbitrary number. The real question is this:

Will requiring all pilots with a BMI over any arbitrary number to go through OSA testing increase safety, at all?

Unfortunately, apparently neither the NTSB nor the FAA has answered that question before proposing the requirement.

I certainly don't purport to "practice medicine". But based on a lot of reading lately, I conclude that while a BMI over 40 is a serious medical issue, I have seen nothing which correlates OSA and a serious universal air safety problem.

Neither the NTSB nor the FAA is authorized to create a policy out of whole cloth. They must follow the rules of administrative procedure. They have no magic wand which allows either agency to change things, outside of the authority granted to them by the statutes and existing regulations, without going through the mandatory process to change those regulations. To justify changing the regulations, there must be a reasonable basis for doing so. And that's the fundamental problem.

The fundamental problem appears to be that a very few pilots occasionally fall asleep while piloting when the airplane is on autopilot. While OSA may be one of many contributors to falling asleep, addressing OSA itself regardless of the criteria used, doesn't adequately address the issue of pilots occasionally falling asleep when the airplane is on autopilot. Requiring all pilots whose BMI is above an arbitrary number to go through expensive testing is a draconian response to those few incidents in which pilots fell asleep--and it's not permitted to create that requirement without following the legal steps necessary to do so.

There may be ways to improve aviation safety; this is not one of them.

Posted by: Cary Alburn | January 10, 2014 11:06 AM    Report this comment

So I think the pilot community gets it that there are many factors that cause fatigue, sleep apnea being one factor. What was the second pilots excuse for sleeping through the same 18 minutes and 26 miles? As pilots we sign up to be medically responsible. You can't regulate responsibility so don't put the pilot community through the ringer because of an incidental lapse in responsibility.

Posted by: JAMES BENNETT | January 10, 2014 3:05 PM    Report this comment

Have a cup of coffee, and a shot of B12..... Seriously,the cause of fatigue is so variable it cannot possibly be regulated. For the FAA to even try exposes who they really are.

Posted by: Mike Maloney | January 11, 2014 9:35 AM    Report this comment

When your a carpenter (read fatigue expert) everything looks like a nail. I'm just saying!

Posted by: Harrel Crenshaw | January 11, 2014 6:12 PM    Report this comment

The FAA presumes,without evidence, that the captain was asleep because of sleep apnea. Thus,thousands and thousands of pilots require expensive and time consuming tests.

Curiously,the FAA seems to be awfully silent on the OTHER pilot who was also asleep.
Did he also have sleep apnea? Maybe he had gone ashore for lunch. That doesn't make much sense,but neither does the FAA.

Posted by: John Waters | January 18, 2014 6:14 PM    Report this comment

The NTSB presentation by Rosekind on OSA mentions Asiana 214 on page 24 and cites "flight crew fatigue" as a contributing factor. Isn't this conflating two issues? How would screening for OSA have done anything to have saved Asiana 214? Also, in the case of Go! 1002, even assuming the Captain had OSA, there is no proof linking that to the outcome of both pilots falling asleep. Again, isn't this conflating multiple issues? The presentation seems to make a reasonable argument in favor of better scheduling and sleep habits but makes absolutely no evidence based connection between OSA, pilot screening, and increased safety.

Posted by: FILL CEE | March 3, 2015 12:41 AM    Report this comment

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