Why the TSB Investigates for Fatigue in Every Occurrence

By Clinton Marquardt - Sleep & Fatigue Specialist

September 29, 2015

fatigue, fatigue and transportation, TSB

I spent nine exciting years with the Human Factors (HF) investigation team of the Transportation Safety Board of Canada (TSB). During this career, I contributed to some major accident investigations that included:

  • First Air Flight 6560 Controlled Flight Into Terrain that killed 12 peopleTSB
  • Cougar Helicopters Collision with Water that killed 17 people
  • Air France Runway Overrun and Fire with 309 people on board
  • Queen of the North Ferry Boat Sinking with 101 people on board
  • Lac Megantic Runaway and Main-Track Derailment that killed 47 people


When I started with the TSB, investigation reports would rarely address fatigue. It was not for lack of trying. The modal investigators had some strong hunches that sleep-related fatigue was playing a role in safety, but they were having a hard time testing their hypotheses.

That’s where the HF team, and I like to think, my fatigue expertise, came in. After nine years of optimizing and refining the process to investigate for fatigue, the issue began to stick and turn up in many reports. The HF team did such a good job, that by the time I left the TSB, we were being asked to look at fatigue’s role in almost every occurrence.

I see now that the HF team has taken it a step further and they now look at fatigue every time an accident is investigated. My colleague, Dr. Rudin-Brown, with the TSB HF team wrote an article about Why the TSB Investigates for Fatigue in Every Occurrence….I just came across it as I was going through my In-Box. Here’s the link: http://www.bloguebst-tsbblog.com/2015/03/12/effects-fatigue-human-performance-tsb-investigates-fatigue-every-occurrence/#.Vgqq7LSd_60.

Shortly after I left the TSB, I was asked to write a book for them on how to investigate for fatigue. The TSB finalized the book in 2014 and released it in 2015. It is called the “Guide to Investigating Sleep-Related Fatigue”. I have been given permission to distribute the book in PDF format in both English and French. If you would like a copy, let me know.



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