Analyse des incidents et des accidents

Was It Fatigue?

Analyse structurée après incident pour déterminer si la fatigue a contribué à un événement, et par quelle voie.

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Solution Risque et sécurité

Le problème

Les incidents graves doivent faire l’objet d’une enquête. Peu d’enquêtes examinent sérieusement la fatigue.

La fatigue est facile à invoquer et difficile à établir après coup. Les enquêtes ont tendance soit à la manquer, soit à lui attribuer la faute sans examiner les autres explications.

Was It Fatigue? donne à vos enquêteurs une façon cohérente et reproductible de poser la question, et un dossier qui montre que les autres explications ont été examinées.

See how Was It Fatigue? works Watch the video · 0:33

The size of the problem

National figures for Canada, from published research. They are modelled, not measured in your workforce.

13%of workplace injuries are linked to sleep problems2014
33%get less than 7 hours' sleep2017 (CHMS 2007-2013)
C$2 030lost productivity per affected employee each year

Sources

Uehli K, et al. Sleep problems and work injuries: a systematic review and meta-analysis. Sleep Medicine Reviews, 2014.
Chaput J-P, Wong SL, Michaud I. Duration and quality of sleep among Canadians aged 18 to 79. Health Reports (Statistics Canada), 2017.
Rosekind MR, et al. The Cost of Poor Sleep: Workplace Productivity Loss and Associated Costs. Journal of Occupational and Environmental Medicine, 2010;52(1):91-98, applied to average earnings in Canada (Statistics Canada, Survey of Employment, Payrolls and Hours, May 2026).

Cas

The biggest incidents fatigue played a part in

Findings from investigators, coroners and courts in Canada that fatigue contributed, the most harmful first.

Les cas sont présentés en anglais.

janv. 2004 · Ontario, Canada
Charter pilot on about 5 hours' sleep after cross-continent trip takes off iced and overweight; 10 killed
- Sécurité
- Financier
A single-engine turboprop on a charter flight took off from an island airstrip in freezing precipitation, about 15 percent over its maximum weight and with ice on the airframe, and struck the frozen surface of a lake, killing the pilot and all nine passengers. The Transportation Safety Board of Canada found the decision to take off was out of character for the pilot and was likely affected by stress and fatigue. The night before, he had returned from a trip to California across three time zones and could have slept at most 5 hours 15 minutes before reporting for duty at 4:45 am.
Cas CA-aviation-05Signaler une erreur
déc. 2020 · Nova Scotia, Canada
Scallop crew on 8-on, 4-off schedule without restorative sleep woken as vessel sinks; fatigue cuts survival chances, six lost
- Sécurité
A scallop dragger capsized and sank before dawn while returning from the fishing grounds with unshucked scallops on deck. The crew worked 8 hours on and 4 hours off, which the Transportation Safety Board found would not have allowed restorative sleep, and some were probably woken from sleep when the emergency began near the circadian low. The Board found that fatigue and being woken from sleep, together with cold water, darkness and hard-to-reach escape routes, significantly affected the crew's chances of survival. All six crew died or remain missing.
Cas CA-agriculture-06Signaler une erreur
oct. 2004 · Nova Scotia, Canada
Cargo jet crashes on take-off; investigators find crew fatigue a factor
- Sécurité
A large freighter jet operated by a cargo airline crashed on take-off from an international airport in Nova Scotia after the crew used take-off performance data carried over from the previous airport; all seven crew died. The Transportation Safety Board of Canada found crew fatigue likely increased the probability of error in calculating the take-off data and degraded the crew's ability to detect it, and contributed to lost situational awareness on the take-off roll.
Cas CA-aviation-02Signaler une erreur
juin 2016 · Ontario, Canada
Long-haul trucker on two hours' sleep falsifies logbook; four killed in highway pile-up
- Sécurité
- Juridique
A long-haul truck driver on a 28-hour run drove into stopped traffic on a major urban highway, causing an 11-vehicle pile-up that killed four people. The court found he had slept no more than about two hours after 13.5 hours of driving, had falsified his logbook to hide the missing rest, and was either distracted or falling asleep. He was convicted of criminal negligence causing death and jailed for eight years; the judge said a reasonable commercial truck driver would never have taken these risks.
Cas CA-transport-01Signaler une erreur
sept. 2023 · Quebec, Canada
Acutely fatigued trawler master who stayed at the helm through a 3-day redfish trip slow to respond as vessel sinks; three die
- Sécurité
The master of a stern trawler stayed at the helm for most of a three-day redfish trip with only occasional breaks, and gear failures disrupted his and the crew's sleep. About four hours after the crew stood down to rest, the overloaded vessel began to sink during the night. The Transportation Safety Board found that the master was acutely fatigued, which likely reduced his ability to recognize and respond to the emergency. Three of the six people on board died.
Cas CA-agriculture-09Signaler une erreur
mai 2015 · Saskatchewan, Canada
Semi driver later diagnosed with sleep apnea on 'autopilot' kills three teens in work zone
- Sécurité
- Juridique
A semi-trailer carrying insulation panels drove at about 84 km/h into a highway construction zone without slowing, killing three teenagers in a stopped vehicle and seriously injuring a flag person. The driver could not recall entering the zone or seeing any of the warning signs and described being on 'autopilot'; he was within hours-of-service limits and did not feel tired, but was diagnosed with mild sleep apnea after the crash. At sentencing the provincial superior court heard that he had likely fallen asleep or was on 'autopilot', and the case turned on whether he was reckless or 'just inattentive and sleep deprived'.
Cas CA-transport-03Signaler une erreur
août 1997 · Quebec, Canada
Outfitter pilot on 3 hours' sleep a night overloads floatplane; strikes power lines, two staff killed
- Sécurité
A hunting-camp operator flying his own twin-engine floatplane to carry two camp cooks and supplies took off overloaded from a remote lake, could not climb and struck high-voltage lines; the aircraft burned and both employees died, while the pilot was seriously injured. The Transportation Safety Board of Canada found he had not allowed enough time to prepare his camps for the season and was fatigued, having slept only about three hours on each of the two nights before the flight. The Board noted fatigue increases risk-taking, and he chose not to abort a second, overweight take-off.
Cas CA-aviation-10Signaler une erreur
oct. 2010 · British Columbia, Canada
Two paramedics die after ambulance driver likely falls asleep following short turnaround
- Sécurité
- Juridique
Two paramedics with a provincial ambulance service were called back to work at 2 a.m., less than five hours after their previous shift ended. Returning from a patient transfer before dawn, their ambulance left a highway, crossed a low barrier and fell 33 metres into a lake, killing both. The provincial coroner concluded that driver fatigue caused the crash and that the driver had likely fallen asleep at the wheel; the ambulance service later changed scheduling to ensure adequate rest.
Cas CA-emergency-01Signaler une erreur
juin 1994 · Manitoba, Canada
Medevac crew after long stand-by duty descend below approach altitude and hit beacon tower; 2 killed
- Sécurité
Just after midnight a twin turboprop returning from a medical evacuation flight descended below the mandatory altitude on approach to a northern regional airport, struck a navigation beacon tower and crashed, killing both pilots and seriously injuring the flight nurse. The Transportation Safety Board of Canada found the crew lost altitude awareness and listed probable pilot fatigue as a contributing factor. The first officer had been awake about 17 hours, had spent 180 hours on stand-by over the previous 14 days and had once been awake at least 36 hours straight in the days before.
Cas CA-aviation-07Signaler une erreur
avr. 2017 · Quebec, Canada
Survey pilots after almost 10 hours of low flying descend to 40 ft; mental fatigue a factor in fatal wire strike
- Sécurité
Two pilots flying a low-altitude aerial magnetometric survey struck a 69 kV power line after descending to between 100 and 40 feet on the way back, and both were killed. The crew had logged almost 10 hours of low-altitude flying in 12 hours that day. The TSB found that mental fatigue, sensation seeking and altered risk perception very likely contributed to the low flying.
Cas CA-aviation-13Signaler une erreur

Voir toutes les actualités sur la fatigue

Comment ça fonctionne

A structured answer to “was it fatigue?”

After an incident or near miss, investigators work through a structured method: was fatigue present, and was the error the kind fatigue produces once other explanations are tested? It sits at the last level of defence, after something has gone wrong, and feeds each finding back into the levels before it: rosters, sleep and in-shift controls.

Les cinq niveaux de défense

Step 01
Événement
Un enquêteur ouvre une évaluation liée à un incident précis.
Step 02
La fatigue était-elle présente?
Le Fatigue Likelihood Score (cote de probabilité de fatigue), établi à partir de quatre questions: endormissement juste avant l’événement, symptômes comportementaux au cours des quinze minutes précédentes, historique de sommeil et d’éveil antérieur, et possibilité de sommeil selon l’horaire de travail.
Step 03
S’agit-il d’une erreur de type fatigue?
Le Fatigue Error Likelihood Score (cote de probabilité d’erreur liée à la fatigue) examine les autres explications à chaque niveau avant d’attribuer l’erreur à la fatigue.
Step 04
Conclusion combinée
Un Fatigue Attributable Likelihood Score (cote de probabilité attribuable à la fatigue) sur une échelle de 1 à 5, avec la voie nommée, qui alimente les contrôles liés aux horaires, au sommeil et pendant le quart.

After an incident, fatigue is either missed or blamed without testing the alternatives. Neither helps the people involved, and neither tells you which control failed. I wanted investigators to have a consistent way to ask the question properly, and a record that shows they did.

Daniel PlattCofondateur et chef de la direction

Rollout

How we roll it out

Scope
Agree which events call for an assessment, and who investigates.
Set up
Investigator access, fitted to your existing incident process.
Train
Investigators learn the method and work a first case together with us.
Review
Findings feed back into roster, sleep and in-shift controls.

Ce que voit le client

Qui voit quoi

Chaque dossier nomme la voie de la fatigue et documente les autres explications examinées. Le prix est fondé sur le volume d’enquêtes, et non sur l’effectif: c’est le seul produit de la gamme tarifé par événement.

Un prix fondé sur la prévalence, pas sur l’effectif. Comment fonctionne la tarification.

Your investigators
The full record
- Every answer and score
- The alternative explanations tested
- The fatigue pathway named
The employer
One record per event
- A structured, repeatable investigation record
- Findings to feed back into roster, sleep and in-shift controls

Données probantes

Ce que nous pouvons démontrer

Sa conception exige à la fois la présence de fatigue et une erreur portant la signature de la fatigue, et examine les autres explications tout au long du processus. C’est ce qui l’empêche de conclure à un lien de causalité à partir de la seule fatigue.

C’est le seul produit de la gamme qui examine tous les niveaux, y compris le caractère adéquat des horaires, de façon rétrospective après un événement.

Ce que le produit n’établit pas

L’outil est rétrospectif. Il ne prédit pas d’événement, ne dimensionne pas une population, et une seule enquête n’établit pas une tendance. Ce n’est pas un instrument validé et aucune validation n’est revendiquée à son égard. Les dossiers produits peuvent faire l’objet d’une communication de la preuve.

In practice

Rail · North America

A Class I railroad uses Was It Fatigue? to determine whether fatigue contributed to an incident or near miss.

Its investigators ask the same structured questions after every event, so each record assesses how likely it is that fatigue was present and that the error was the kind fatigue produces, and shows which other explanations were tested.

FAQs

Questions we’re often asked

Who uses it?

Your investigators, who open an assessment against a specific incident or near miss.

How does it avoid blaming fatigue by default?

It requires both the presence of fatigue and an error of the kind fatigue produces, and tests alternative explanations at every level before attributing an error to fatigue.

What does the finding look like?

A Fatigue Attributable Likelihood Score on a 1–5 band with the fatigue pathway named, which feeds back into roster, sleep and in-shift controls.

Is it a validated instrument?

No, and no validation claim is made for it. It is a structured, repeatable method. It is retrospective: it does not predict an event, and one investigation does not establish a pattern. Records produced are discoverable.

How is it priced?

On investigation volume, not headcount: it is the only event-priced product in the suite.

How pricing works

How is investigation data protected?

The platform is certified to ISO/IEC 27001:2022.

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Parcours

Pour aller plus loin

Was It Fatigue? et la réglementation dans 33 secteurs (Canada)

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La réglementation nomme cette étape

Transport ferroviaire

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Soutient votre devoir général de diligence

Voyez comment Was It Fatigue? s’inscrit dans la réglementation de votre secteur, et par quoi d’autre nous commencerions.

Les 33 secteurs

Autres solutions liées à Was It Fatigue?

Niveaux 2 et 3

Fatiguefit4Duty

Repérez un risque élevé au début du quart, avant le prochain événement.

Par où commencer

Fatiguefit

Transformez les conclusions d’enquête en un portrait mesuré de toute l’organisation.

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Express interest Voyez le portrait de votre effectif

A Was It Fatigue? finding on a phone: a Fatigue Accident Likelihood Score of 3.2, between Possible and Likely, with how to record it.