Regulation change · Jun 22, 2026
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Fatigue in the news
Findings, prosecutions and regulation changes on workplace fatigue in Canada, newest first.
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Stories and regulation changes
9 upcoming regulation changes
October 6, 2026
Ontario is expected to add further contraventions to its OHSA administrative penalty regulation; no date is set. Quebec employers have until 6 October 2026 to have a prevention program (20 or more workers) or action plan in place that addresses psychosocial risks, including heavy workload.
October 6, 2026
Quebec employers have until 6 October 2026 to have a prevention program (20 or more workers) or action plan in place that addresses psychosocial risks, including heavy workload.
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January 30, 2027
Federally regulated (extra-provincial) carriers must apply the thermal stress amendments (SOR/2026-10) from 30 January 2027. Transport Canada's 2026-2028 regulatory plan contains no change to commercial vehicle hours of service.
January 30, 2027
Federally regulated employers must apply the thermal stress amendments (SOR/2026-10) from 30 January 2027. A Canada Labor Code duty to adopt a disconnecting-from-work policy awaits a commencement date.
January 30, 2027
Federally regulated employers must apply the thermal stress amendments (SOR/2026-10), including the Aviation OHS Regulations, from 30 January 2027. Transport Canada plans to propose Canadian Aviation Regulations safety management system amendments (Canada Gazette Part I) in Fall 2027.
January 30, 2027
Federally regulated employers must apply the thermal stress amendments (SOR/2026-10), including the Maritime OHS Regulations, from 30 January 2027. Transport Canada plans to pre-publish new Marine Personnel Regulations in Fall 2026 for 60 days' comment; hours-of-rest content is unconfirmed.
January 30, 2027
Federally regulated employers, including those under the renamed Oil and Gas Occupational Safety and Health Regulations, must apply the thermal stress amendments (SOR/2026-10) from 30 January 2027. Quebec employers have until 6 October 2026 to address psychosocial risks in a prevention program.
January 30, 2027
Thermal stress duties (SOR/2026-10) apply from 30 January 2027; the new training regulations from 1 July 2028. Transport Canada targets proposed Railway Safety Management System amendments in Fall 2027; the 2022 Fatigue Management System proposal has no timetable.
Date not set
Manitoba's nurse ratio and mandatory overtime laws (assented 1 June 2026) start on a day fixed by proclamation, with ratios, benchmarks and compliance plans to follow by regulation. Quebec employers have until 6 October 2026 to have a prevention program addressing psychosocial risks.
June 2026
Regulation change · Jun 22, 2026
New Railway Personnel Training and Qualifications Regulations (registered 22 June 2026) require crew resource management training for operating employees and rail traffic controllers, in force 1 July 2028.
SourceRegulation change · Jun 1, 2026
Manitoba passed laws on 1 June 2026 to set nurse-to-patient ratios and benchmarks to eliminate mandatory nurse overtime by regulation.
Neither is in force until proclaimed.
Source
January 2026
Regulation change · Jan 30, 2026
If you are federally regulated, amendments registered 30 January 2026 add thermal stress duties - controls including work-rest cycles, worker training and committee consultation - in force 30 January 2027.
SourceRegulation change · Jan 1, 2026
In Ontario, OHSA administrative monetary penalties apply from 1 January 2026; the first prescribed breach concerns health and safety management systems in construction procurement (up to $100,000).
Source
October 2025
Regulation change · Oct 6, 2025
In Quebec, since 6 October 2025 every establishment must identify and analyze psychosocial risks, including heavy workload, in a prevention program (20+ workers) or action plan.
Source
September 2023
Story · Sep 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
- Safety
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.
Case CA-agriculture-09Report an issue
2023
Story · 2023 · Quebec, Canada
Arbitrator rules nurse ordered to work 31 hours in 39 was subjected to abuse of management rights
- Legal
A nurse in a regional Quebec public health service was ordered to work three consecutive shifts totalling more than 31 hours within a 39-hour period, and when she raised fatigue and said she could not continue, her manager threatened to call the police. The arbitrator found the practice went well beyond the limits generally accepted by the courts, that the employer had abused its management rights and created unreasonable working conditions, and ordered it to end all similar practices. The ruling reinforced earlier tribunal guidance that mandatory overtime should be used only in urgent and exceptional situations.
Case CA-healthcare-02Report an issue
November 2022
Story · Nov 2022 · Ontario, Canada
Captain with heavy sleep debt and 18 hours awake slips at 70 ft; passenger jet overruns runway
- Safety
A low-cost airline's narrow-body jet with 134 passengers overran the end of the runway at a regional airport at 6:25 am after the captain inadvertently pressed the go-around switch at about 70 feet, causing one engine to advance to near-maximum thrust during the landing roll. The Transportation Safety Board of Canada found the captain had built up a significant sleep debt over the previous week of night duties and had been awake for nearly 18 hours, at the end of the circadian low, and that this fatigue reduced his attention and made the slip more likely. The Board also found that when pilots do not monitor their own sleep debt, fatigue can go undetected and unmanaged.
Case CA-aviation-04Report an issue
September 2022
Story · Sep 2022 · Newfoundland and Labrador, Canada
Pilot boat deckhand on day 7 of 7, awake 18 hours, likely fatigued when he went overboard and died
- Safety
Near midnight, during a pilot transfer off a harbour entrance, the deckhand of a pilot boat went overboard while untethered and died. The Transportation Safety Board found that the tether system design and the vessel's limited recovery capability caused the death. It also found that the deckhand, on the last day of a 7-day shift and awake for 18 hours, faced multiple fatigue risk factors and was likely fatigued, and that crews on irregular schedules without effective fatigue risk management are at increased risk of impairment.
Case CA-maritime-18Report an issue
August 2021
Story · Aug 2021 · Nunavut, Canada
Gillnet crew awake over 21 hours after 21.5-hour work period; fatigued crew member entangled and pulled overboard
- Safety
Two crew members on a factory freezer fishing vessel were setting gillnets for turbot at about 03:00. They had started work at 05:30 the previous morning and worked 21.5 hours with one break of 1.75 hours, during which they did not nap. One crew member's arm became entangled in the buoy line and he was pulled overboard and died. The Transportation Safety Board found that both crew members had sleep-related fatigue that reduced their ability to stay alert to risks, and that this, with an adapted work method, led to the death.
Case CA-agriculture-08Report an issue
April 2021
Story · Apr 2021 · Nova Scotia, Canada
Snow crab crew awake 34 to 37 hours napping below; flooding missed and sleep inertia slows abandonment of capsizing boat
- Safety
On the opening day of the snow crab season, which began at midnight, the master of an open fishing vessel had been awake about 37 hours and the crew about 34 hours, with only short, poor-quality naps. To get needed sleep, all but one crew member were napping below while an inexperienced crew member steered, and water building up in the vessel went unnoticed until it capsized. The Transportation Safety Board found that sleep inertia likely affected the master's recognition of the danger and the abandonment. One crew member died and the master was not found.
Case CA-agriculture-07Report an issue
February 2021
Story · Feb 2021 · Ontario, Canada
Machine operator filmed asleep wins wrongful dismissal but is denied his job back
- Legal
- Financial
A mould operator at a mattress plant was caught on video sleeping during his shift and denied it, saying he was 'just relaxing'. The arbitrator found he was clearly asleep, but that dismissal was an overreaction for a worker with nine years' discipline-free service. Because trust had broken down, reinstatement was refused and the employer was ordered to pay about 11 weeks' notice plus a 15% top-up and benefits instead.
Case CA-manufacturing-02Report an issue
December 2020
Story · Dec 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
- Safety
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.
Case CA-agriculture-06Report an issue
Story · Dec 2020 · Quebec, Canada
Signal maintainer on 52-hour night weeks puts hi-rail unit on wrong track; passenger train hits it at nearly 83 mph
- Safety
A national railway's signal maintainer working long consecutive night shifts put his hi-rail track unit on the north main track when he meant to use the south track. An intercity passenger train struck the empty, stationary unit at nearly 83 mph and dragged it about 2,500 feet. The TSB found he had probably built up a sleep debt from many consecutive night shifts and daytime sleep, and warned that such schedules create high-risk situations.
Case CA-rail-30Report an issue
August 2019
Story · Aug 2019 · Ontario, Canada
Captain with three fatigue risk factors on a backward-rotating roster; regional jet starts takeoff without clearance as a wide-body jet crosses the runway
- Safety
A regional jet began its take-off roll at a major airport without a take-off clearance while a wide-body airliner was crossing the runway; the crew aborted the takeoff when they saw the other aircraft over the crest of the runway. The Transportation Safety Board of Canada found the captain had three fatigue risk factors - acute sleep disruption, chronic sleep disruption and circadian rhythm disruption from moving from late evening to early morning shifts - and was experiencing some fatigue, but could not determine whether fatigue contributed. It found as a risk that backward-rotating shift schedules raise fatigue risk when crews lack time off to adapt.
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January 2019
Story · Jan 2019 · Manitoba, Canada
Freight engineer fatigued by two nights of broken sleep reacts late to signals; freight trains collide
- Safety
A national railway's freight train ran past restrictive signals and side-collided with another of the railway's freight trains at 23 mph. The TSB found the locomotive engineer was fatigued after two nights of abbreviated and disrupted sleep, which together with low workload under the trip optimizer delayed his reaction and led to a poor braking choice. Two crew members jumped from the locomotive and were slightly hurt.
Case CA-rail-29Report an issue
June 2018
Story · Jun 2018 · Canada
National railway found in contempt and fined C$200,000 for keeping train crews on duty past rest limits
- Legal
- Financial
After an arbitrator ordered a national railway in 2018 to stop breaching collective agreement rules that require train crews who give rest notice to be relieved within 10 hours (12 hours otherwise), the union documented continuing breaches. The Federal Court found the railway guilty of contempt of court in 22 of 38 alleged incidents between 2018 and 2019, rejecting its argument that the breaches were beyond its control because it had achieved 99% compliance in some periods. The court described the rest provisions as inherently safety driven and later imposed a C$200,000 penalty.
Case CA-rail-11Report an issue
March 2018
Story · Mar 2018 · Ontario, Canada
Worker who refused night shifts citing disrupted sleep loses arbitration over dismissal
- Legal
A food plant maintenance worker repeatedly refused night-shift assignments, producing medical notes saying rotating shift work disturbed his sleep and caused headaches. The arbitrator found the notes only supported a need for steady shifts with minimal disruption, not a ban on night work, and that he had refused direct orders without first raising medical concerns. His termination under progressive discipline was upheld.
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November 2017
Story · Nov 2017 · Saskatchewan, Canada
Conductor's 'fatigued' unfit book-offs after rest days ruled pattern absenteeism; book-unfit clause 'not intended to serve as a shield'
- Legal
A national railway's conductor booked unfit on several occasions, including twice saying he was fatigued and not properly rested, once straight after two rest days. The railway dismissed him for patterned absenteeism, and the union argued the collective agreement bars discipline for booking unfit. The arbitrator agreed the book-unfit clause exists so employees are rested and fit and can be used without fear of discipline in appropriate circumstances, but held it is not a shield for a pattern of book-offs that extend weekends or days off. Given his long service, he was reinstated without compensation on strict attendance conditions.
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Story · Nov 2017 · Quebec, Canada
Yard helper with 4 hours' sleep in 38 sets wrong switch and is fatally struck
- Safety
A yard helper with a national railway was struck and killed by a reversing yard movement at a major rail yard at about 6 a.m. He had worked 7 of the previous 9 nights, was on his second consecutive night shift and had slept at most 4 hours in the previous 38. The Transportation Safety Board of Canada found his fatigue likely contributed to the incorrect alignment of a crossover switch that led to the accident, alongside the absence of a risk assessment and a task interruption.
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July 2017
Story · Jul 2017 · British Columbia, Canada
Tug mate falls asleep alone on watch; tug and cement barge strike channel bank
- Safety
At 0436 a tug towing a loaded cement barge made bottom contact in a coastal channel in British Columbia, damaging its hull and starboard propeller nozzle; there were no injuries or pollution. The Transportation Safety Board of Canada found the mate, alone on watch at night in confined waters, fell asleep, and that there were no strategies in place to mitigate crew fatigue.
Case CA-maritime-02Report an issue
April 2017
Story · Apr 2017 · Quebec, Canada
Survey pilots after almost 10 hours of low flying descend to 40 ft; mental fatigue a factor in fatal wire strike
- Safety
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.
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November 2016
Story · Nov 2016 · Yukon, Canada
Tanker driver and employer fined after rollover following days of five-hour breaks
- Safety
- Legal
- Financial
In his first week on the job, a tanker truck driver rolled his empty rig on a northern highway and suffered a broken neck and head injuries. Yukon commercial vehicle enforcement found he had averaged only about five hours off between shifts over the four nights before the crash, had driven more than 15 hours without rest and had worked more than 80 hours without a 24-hour break. Both the driver and his employer, a construction company, were prosecuted and pleaded guilty.
Case CA-transport-02Report an issue
October 2016
Story · Oct 2016 · British Columbia, Canada
Lone watchkeeper falls asleep; US tug grounds and spills diesel off British Columbia
- Safety
A US-registered articulated tug-barge struck a reef off the British Columbia coast, breaching the tug's hull and releasing about 110,000 litres of diesel; the tug sank. The Transportation Safety Board of Canada found the unit went aground after the second mate fell asleep while alone on watch at night, and issued two fatigue recommendations. The vessel and operator were American; the event and investigation were Canadian.
Case CA-maritime-01Report an issue
June 2016
Story · Jun 2016 · Alberta, Canada
Freight crew 2 to 3 hours short of sleep after a shifting call time strike the rear of a train; TSB flags unpredictable calls as a fatigue risk
- Safety
A national railway's freight train passed a restricting signal too fast and hit the tail end of another train at 18 mph, after the crew misheard a radio signal call and believed the train ahead was farther away than it was. The crew had gone to bed expecting to work at about 0100, woke near midnight to check, and were finally called at 0400 for a 0500 start; each had built up a sleep debt of 2 to 3 hours. The Transportation Safety Board of Canada could not establish whether the sleep debt affected the crew's decisions, but found as a risk that unpredictable call times can stop crews getting restorative sleep and increase the risk of fatigue. No one was injured.
Case CA-rail-27Report an issue
Story · Jun 2016 · Ontario, Canada
Long-haul trucker on two hours' sleep falsifies logbook; four killed in highway pile-up
- Safety
- Legal
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.
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March 2016
Story · Mar 2016 · Ontario, Canada
Track foreman with undiagnosed sleep apnea drives hi-rail truck into path of freight train
- Safety
A track maintenance crew from a national freight railway drove a hi-rail vehicle onto the main line without authority and travelled about 8 miles before a freight train struck it; the two workers got out just in time. The Transportation Safety Board of Canada found the foreman's fatigue, influenced by two mild sleep disorders (obstructive sleep apnea and periodic limb movement disorder, diagnosed only after the accident), a circadian low and a demanding schedule, contributed to the error. It warned that track workers in safety-critical roles are not subject to enhanced medical requirements, so sleep disorders can go undetected.
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February 2016
Story · Feb 2016 · Alberta, Canada
Engineer awake 23 hours, afraid to book off, derails 13 cars in rail yard
- Safety
A freight train run by a national railway derailed 13 cars in a major rail yard after the locomotive engineer applied too much power through a sharp curve. The Transportation Safety Board of Canada found the engineer was likely fatigued from two weeks of poor-quality sleep and being awake for at least 23 hours, which limited his working memory and vigilance. He had felt unfit when called for duty but feared discipline if he refused, and the board warned that fatigue procedures which do not let workers remove themselves from duty without fear of discipline increase the risk of fatigued employees reporting for work.
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2016
Story · 2016 · Quebec, Canada
Trucker driving 85-95 hours a week on two logbooks loses grievance as arbitrator rules fatigue cannot be self-managed
- Legal
A truck driver for a trucking company admitted working for other carriers, driving 85 to 95 hours a week and keeping two logbooks, and was dismissed in 2016. The arbitrator upheld the dismissal, finding that repeatedly and substantially exceeding the 70-hour weekly driving limit over many weeks was a serious fault, aggravated by the false logbooks and lies to the employer. The arbitrator rejected the argument that sleeping well, taking breaks and eating well reduced the risk, finding that driver fatigue is a biological state that cannot be controlled and that repeated excess hours build a sleep debt.
Case CA-transport-08Report an issue
September 2015
Story · Sep 2015 · Manitoba, Canada
Conductor 'on the job for some 18 hours' lets dangerous-goods train run at 62 mph in a 35 zone; fatigue refused as mitigation after he skipped booked rest
- Legal
A national railway's conductor on a train carrying special dangerous goods failed to warn the engineer that the train was traveling at 62 mph through a 35 mph restriction. He said he had been on the job for about 18 hours and that the limit slipped his mind through fatigue. The arbitrator refused to treat fatigue as a mitigating factor because the conductor had been able to book up to eight hours' rest before taking the assignment and chose not to, so his fatigue was his own decision. The 20 demerit marks were upheld.
Case CA-rail-26Report an issue
July 2015
Story · Jul 2015 · Ontario, Canada
Engineer's sleep apnea fatigue 'probably affecting his work' weighed in cutting dismissal to demotion after locomotive sparks lineside fires
- Safety
- Legal
A national railway's locomotive engineer placed a low-power, non-turbocharged locomotive on line with high-power units, contrary to the railway's operating instructions, and the train set fires along the line that firefighters had to put out. He was dismissed for accumulating demerits. The arbitrator found discipline was warranted but counted the engineer's sleep apnea, which had caused him fatigue during 2015 and probably affected his work, among the reasons discharge was too severe, while stressing that employees are responsible for making sure they are fit to work. He was reinstated on a last-chance basis, demoted from locomotive engineer.
Case CA-rail-25Report an issue
June 2015
Story · Jun 2015 · Ontario, Canada
Engineer found asleep in cab after working through lunch; sleeping alone 'might' merit less, but speeding record upholds dismissal
- Legal
A national railway's locomotive engineer was found asleep in his stationary locomotive at about 7:25am, at the end of a night shift in which the crew had worked through their lunch break to service a customer. Finding him asleep led the railway to pull the locomotive's event recorder data, which showed repeated speeding on the two previous night shifts. The arbitrator held that the extra scrutiny was justified because it was reasonable to ask whether the engineer was fatigued, and said the sleeping on its own might have warranted a lesser penalty. The dismissal was upheld because of the speeding and the engineer's prior discipline for a very similar offence.
Case CA-rail-24Report an issue
May 2015
Story · May 2015 · Saskatchewan, Canada
Semi driver later diagnosed with sleep apnea on 'autopilot' kills three teens in work zone
- Safety
- Legal
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'.
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April 2015
Story · Apr 2015 · Ontario, Canada
Tribunal finds waste truck driver's undiagnosed severe sleep apnea caused his crash; employer gets full cost relief
- Safety
- Legal
- Financial
A waste management truck driver lost consciousness at the wheel and crashed; afterwards he was diagnosed with severe obstructive sleep apnea and severe insomnia. The workers' compensation appeals tribunal accepted that the pre-existing sleep disorder caused the accident, noting medical advice that people with sleep apnea are two to three times more likely to have motor vehicle crashes. The worker's injuries remained compensable, but the employer was granted 100% cost relief from the provincial second injury fund because the sleep disorder, not the job, triggered the crash.
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February 2015
Story · Feb 2015 · Quebec, Canada
Snow-hauling truck driver awake more than 24 hours drives off with dump body raised and is killed; regulator faults employer's schedule management
- Safety
At about 4:25 am a dump-truck driver for a snow-removal contractor, hauling snow overnight, left a snow dump with the dump body still fully raised while talking on the phone; about a kilometre later it struck an overpass, the body was torn off and he was partly thrown from the cab and killed. The Quebec workplace safety regulator found he had been awake more than 24 hours and had worked 25 h 10 min within a 30 h 55 min work shift, which put him under a driving prohibition under the hours-of-service rules. It found that his hypovigilance, combined with the phone call, led him to forget to lower the dump body, and that the employer's failure to manage work schedules exposed him to hypovigilant driving.
Case CA-transport-07Report an issue
November 2014
Story · Nov 2014 · British Columbia, Canada
Intermodal train derails after fatigued crew misread a wheel-slip alarm
- Safety
A national railway's westbound intermodal train derailed a locomotive and eight flat cars in northern British Columbia after a seized locomotive axle slid for about 11 miles and struck a switch. The Transportation Safety Board of Canada found the crew were fatigued from circadian disruption caused by variable shift start times, which probably stopped them recognizing a wheel-slip alarm and an early detector announcement. No one was injured.
Case CA-rail-01Report an issue
October 2014
Story · Oct 2014 · Saskatchewan, Canada
Fatigued railway responders miss flaring risk after dangerous-goods derailment
- Safety
A national railway's freight train derailed 26 cars in rural Saskatchewan, and two petroleum distillate tank cars ruptured and burned; about 50 residents were evacuated. The Transportation Safety Board of Canada found that the railway's emergency responders, who had worked through the night and were likely fatigued, did not consider all the risks of a flaring operation. A flash fire sent a fireball toward two of them, who escaped unhurt.
Case CA-rail-02Report an issue
Story · Oct 2014 · Nunavut, Canada
Tanker master on 3 hours' sleep and overworked helmsman both fatigued; Arctic resupply tanker strikes bottom
- Safety
At 6:30 am in darkness, an oil and chemical tanker on a fuel resupply voyage struck bottom in confined waters near a remote Arctic community, cracking a ballast tank. The Transportation Safety Board of Canada found both the master and the helmsman were fatigued and showed performance lapses consistent with fatigue: the master had about 3 hours' sleep in the previous 24, and the helmsman, who had worked 106 hours in 7 days, was called out unexpectedly at 6 am after finishing work at 3 am. The Board found ineffective onboard fatigue management contributed.
Case CA-maritime-07Report an issue
August 2013
Story · Aug 2013 · Northwest Territories, Canada
Air taxi pilot with acute sleep debt on 13th flight of the day departs in a damaged aircraft; fatal crash
- Safety
An air taxi pilot flying 15 planned lodge-support flights in one day damaged the aircraft's wing on trees and then took off again without an inspection; the aircraft lost control and crashed into a lake, killing the pilot. The TSB found that cumulative unmanaged stressors disrupted the pilot's processing of safety-critical information, and its analysis named fatigue from an acute sleep debt among those stressors, alongside illness, workload, time pressure and frustration.
Case CA-aviation-12Report an issue
November 2012
Story · Nov 2012 · Quebec, Canada
Pilot with untreated sleep apnea and shift work disorder likely microsleeps; bulk carrier runs aground
- Safety
At about 9:48 pm a river pilot with the conduct of a bulk carrier failed to make a planned course change, and the ship left the channel and ran aground. The Transportation Safety Board of Canada found fatigue was a likely factor in the pilot's reduced situational awareness, noted that a sudden stop in his activity suggested a possible microsleep on a dark, warm bridge, and that a sleep evaluation requested by the Board afterwards diagnosed obstructive sleep apnea and shift work disorder. The same pilot had been involved in an earlier grounding and had a sleep evaluation in 2007, but no feedback from it reached him or the pilotage authority.
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September 2012
Story · Sep 2012 · United States
Trawler mate on 3 to 4.5 hours' sleep a night leaves wheelhouse; collision sinks longliner, one crew member lost
- Safety
A Canadian whiting trawler and a US longliner collided before dawn in restricted visibility. The longliner was drifting with no lookout, and the trawler's mate was not keeping a proper watch and briefly left the wheelhouse unattended. The Transportation Safety Board found it highly likely that the mate's thinking was impaired by fatigue: he had slept 3, 4.5 and 3.5 hours on the three nights before. The longliner capsized and sank, and one of its deckhands was never found.
Case CA-agriculture-05Report an issue
June 2012
Story · Jun 2012 · Ontario, Canada
Micro-sleep direction over paratransit drivers' missing breaks rescinded for lack of evidence
- Legal
A municipal paratransit operator refused work after being on duty for over six hours without a break, saying the service did not provide adequate time for rest and meal breaks. A health and safety officer directed the city to act, stating that driving without breaks can lead to fatigue, including micro-sleep events, and to collisions. On appeal, the Occupational Health and Safety Tribunal Canada found that hours were within statutory limits and that no evidence showed fatigue had caused vehicle accidents. It treated the risk as a mere rather than reasonable possibility and rescinded the direction.
Case CA-transport-06Report an issue
January 2012
Story · Jan 2012 · British Columbia, Canada
Signal foreman called out at 2:30 am after little sleep takes wrong track; freight train hits his truck
- Safety
A lone railway signal maintenance foreman, who normally worked days, was called out at 2:30 am to repair a signal after getting to sleep only around midnight because of a cold. He drove his track unit onto the wrong main track and about 1.4 miles beyond his authorized limits, where a freight train struck and destroyed it; the foreman got clear in time. The Transportation Safety Board of Canada found his diminished alertness likely led to an erroneous mental model of which track he was on, and highlighted the extra risk for lone workers whose errors have no second line of defense.
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Story · Jan 2012 · British Columbia, Canada
Sleepless captain presses on with unstable approach; passenger jet overruns runway
- Safety
A jet airliner on a charter flight carrying 112 workers from Alberta to a remote town in northern British Columbia ran 230 feet off the end of the runway after an unstable, long landing; no one was hurt. Investigators found the captain had little or no sleep in the previous 24 hours because his accommodation was noisy and hot, and that he had considered calling in sick but felt it would not be viewed favourably. Fatigue likely caused attention lapses and a fixation on salvaging the approach instead of going around.
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October 2011
Story · Oct 2011 · Quebec, Canada
Precast-concrete truck driver with at most 7.5 hours' rest in 29 hours runs off the highway and is killed; regulator blames hypovigilance and schedule management
- Safety
A heavy-vehicle driver for a precast concrete manufacturer was driving back to the plant at about 4:20 am after an overnight bridge-beam delivery when his truck went straight on at a work-zone lane diversion on a highway and hit a fence; he died at the scene. The Quebec workplace safety regulator found that the driver's hypovigilance caused the run-off and that the employer's management of work schedules exposed him to the dangers of driving while hypovigilant. Over the 29 hours before the crash he had at most about 7.5 hours of sleep or rest, schedules were prepared without regard to the heavy-vehicle hours-of-service rules, and the employer had no fatigue management program or policy.
Case CA-manufacturing-03Report an issue
June 2011
Story · Jun 2011 · Alberta, Canada
Freight crew with 3.5 hours' and no sleep in 24 pass restricting signal and hit a stationary train
- Safety
A national railway's westbound freight train passed a restricting signal at about 37 mph and struck the rear of a stationary train at 25 mph shortly after 6 am. In the previous 24 hours the engineer had slept 3.5 hours and the conductor had not slept, and both had highly variable shift start times. The TSB found that the crew's thinking was likely impeded by reduced alertness, leading to inappropriate train control.
Case CA-rail-23Report an issue
Story · Jun 2011 · British Columbia, Canada
Gravel barge strikes river rail bridge after master awake about 22 hours
- Safety
At 0410 a tug towing a loaded gravel barge struck a railway bridge on a major river, putting the bridge out of service for about two months. The Transportation Safety Board of Canada found the master had been awake about 22 hours and was likely fatigued when he handed the con to an inexperienced mate, and that rest was left informally to crews.
Case CA-maritime-03Report an issue
April 2011
Story · Apr 2011 · Ontario, Canada
Night guard found reclined at a nuclear fuel site at 3.30am reinstated under last-chance terms
- Legal
During a 3.30am security audit at a nuclear fuel facility, a night-shift plant guard and supervisor was found fully reclined with his feet on the desk and his safety boots off, apparently asleep. The arbitrator accepted there was just cause for discipline and noted the 'potential catastrophic consequences' of a guard's inattention, but found the company's own policy and past practice treated sleeping on the job with warnings. The guard was reinstated to a lower position under a last-chance agreement rather than dismissed.
Case CA-security-01Report an issue
January 2011
Story · Jan 2011 · Over the North Atlantic
Sleep inertia after controlled rest: first officer pitches airliner down, 16 hurt
- Safety
During an overnight transatlantic flight on a wide-body airliner operated by a Canadian airline, the first officer woke from a 75-minute controlled rest, misjudged an oncoming aircraft as a collision threat and pushed the nose down; 14 passengers and two flight attendants were injured. The Transportation Safety Board of Canada found sleep inertia, a circadian low and fatigue contributed, and that fatigue training had not conveyed the risks.
Case CA-aviation-01Report an issue
October 2010
Story · Oct 2010 · Ontario, Canada
Engineer with under 2 hours' sleep in 24 derails 21 cars including LPG tank cars; homes evacuated
- Safety
A freight train derailed 21 cars, including loaded liquefied petroleum gas and fuel oil tank cars, and homes and businesses within 1.6 km were evacuated. The Transportation Safety Board of Canada found the locomotive engineer had slept only 1 to 1.5 hours before being called for work and had less than 2 hours' sleep in the previous 24 hours. It found he was insufficiently rested for safety-critical work, and that because workers decide for themselves whether they are fit to work, a fatigued employee facing lost wages or discipline is more likely to accept a shift.
Case CA-rail-07Report an issue
Story · Oct 2010 · British Columbia, Canada
Two paramedics die after ambulance driver likely falls asleep following short turnaround
- Safety
- Legal
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.
Case CA-emergency-01Report an issue
August 2010
Story · Aug 2010 · Alberta, Canada
Yard foreman on first night shift after days off misroutes shove; 43 cars derail including dangerous goods cars
- Safety
A national railway's yard crew shoved 55 cars into the wrong track at about 3.30 am without anyone protecting the leading end, striking a stationary cut of cars and derailing 43 cars, 21 of them carrying dangerous goods or residue. The foreman was on his first night shift after two days off and his body clock had not adjusted. The TSB found reduced alertness contributed to his decision to skip point protection and to the misrouting.
Case CA-rail-22Report an issue
February 2010
Story · Feb 2010 · Ontario, Canada
Night-shift aircraft maintenance chief prone to falling asleep wins danger ruling against regional airline
- Safety
- Legal
A regional airline's maintenance crew chief on 12-hour night shifts (17:30 to 05:30) had a medical condition made worse by night work, with excessive sleepiness and persistent fatigue. His doctor recommended he be taken off nights, and he refused to work when he was put back on them. A health and safety officer found no danger, but the Occupational Health and Safety Tribunal Canada found that a danger existed, because he was prone to falling asleep while moving aircraft and heavy machinery on the apron and could reasonably have expected to be injured. The tribunal held that a worker's personal medical condition must be taken into account when deciding whether a danger exists.
Case CA-aviation-11Report an issue
Story · Feb 2010 · Quebec, Canada
Passenger train enters siding at 64 mph; fatigue and likely undiagnosed sleep apnea in the cab
- Safety
At about 4:25 am a passenger train carrying 118 passengers entered a siding at 64 mph where the limit was 15 mph and derailed, injuring both locomotive engineers and five passengers. The Transportation Safety Board of Canada found that the crew's planning and reaction were likely degraded by fatigue, with the accident occurring in the early-morning circadian low. A post-accident medical evaluation concluded the operating engineer was most likely suffering from obstructive sleep apnea that had never been diagnosed, and the board found that medical information was not reliably passed on when safety-critical employees moved between railway companies.
Case CA-rail-06Report an issue
2010
Story · 2010 · Alberta, Canada
Locomotive engineer with suspected circadian sleep disorder barred from on-call service; tribunal upholds restriction as safety-critical
- Legal
A national railway's locomotive engineer in unassigned (on-call) service, with irregular start times, had growing trouble sleeping while waiting to be called. He booked off unfit 59 times in 2010 and told his doctor he had fallen asleep two or three times while driving a train. A sleep specialist suspected a circadian sleep rhythm disorder, and the railway restricted him from unassigned service and moved him to assigned day and afternoon shifts. The Canadian Human Rights Tribunal accepted that he could not safely operate trains overnight, found the restriction was a bona fide occupational requirement for a safety-critical job, and dismissed his disability and family-status complaints against the railway and the union.
Case CA-rail-21Report an issue
May 2008
Story · May 2008 · Ontario, Canada
Lake freighter master on 3 to 5 hours' sleep a night for five days grounds self-unloader on charted shoal
- Safety
At about 5:50 am a self-unloading bulk carrier grounded on a charted shoal near a small lakeside town while the master was conning the ship by eye using buoys. The Transportation Safety Board of Canada found the master had slept no more than five hours a day, and never more than 3.5 hours at a stretch, for the five days before, and that this lack of sleep made him fatigued and likely affected his performance, including shortcutting navigation tasks. The ship's hull was heavily buckled and three ballast tanks were holed.
Case CA-maritime-06Report an issue
October 2007
Story · Oct 2007 · Alberta, Canada
Freight engineer awake 22 hours loses track of location, passes stop signal and hits train entering siding
- Safety
At about 5 am a national railway's freight train passed a stop signal and struck the side of another of the railway's trains still entering the siding, derailing both locomotives and 27 cars. The engineer had lost track of where he was and believed he was about 13 miles away. The TSB found the crew was insufficiently rested for safety-critical work and that the railway's fatigue countermeasures were ineffective.
Case CA-rail-20Report an issue
August 2007
Story · Aug 2007 · Quebec, Canada
Watch officer on 3.5-hour sleeps and broken rest alone on bridge; passenger ship with 156 aboard strikes island
- Safety
A coastal passenger and supply vessel struck an island at night while approaching harbour with 156 passengers and 25 crew. The officer of the watch was left alone on the bridge at a critical turn, overshot it and did not check the ship's position. He had obtained 3.5 hours of sleep in each of his two six-hour rest periods in the previous 24 hours, and during his familiarisation week his rest had been broken at every port. The Transportation Safety Board found indications of fatigue in crew members and that, without a fatigue management plan, fatigue-induced errors become more likely.
Case CA-maritime-17Report an issue
June 2007
Story · Jun 2007 · Ontario, Canada
Prison wrong to apply 8-hour rest rule to bar officer from overtime; board says fitness must be judged case by case
- Legal
A federal prison refused a correctional officer an overnight overtime shift (23:00 to 07:00) because his scheduled day shift ended at 19:45, leaving only 3 hours and 15 minutes of rest. A manager said the concern was something happening at the institution because an employee was too tired or not alert enough. The labor board held that the collective agreement's 8-hour rest rule does not apply to overtime, and that the employer could not make a predetermined, subjective decision about fitness without speaking to the officer. It added that the employer keeps the full right to send an employee home without pay if it believes he is too tired to work.
Case CA-corrections-01Report an issue
March 2007
Story · Mar 2007 · Ontario, Canada
Railway trainmaster loses leg after 72 hours in six days; appeals officer rescinds fatigue-plan order for lack of evidence
- Safety
- Legal
A national railway's terminal trainmaster covering a shortage of operating crew on an evening assignment that started at 18:00 lost his footing at about 21:10 applying a handbrake on a moving car and lost his right leg. A Transport Canada health and safety officer concluded he had been fatigued after 72 hours of work in the preceding 144 hours and ordered the railway to adopt a fatigue management plan for supervisors doing operating work. On appeal, the Occupational Health and Safety Tribunal Canada rescinded that order, holding it was too vague, duplicated the railway's existing work-rest rules, and was not supported by any direct evidence that the supervisor was fatigued.
Case CA-rail-19Report an issue
December 2006
Story · Dec 2006 · International waters
Sail training deckhand awake most of the previous night on short-crewed watches likely fatigued when swept overboard and lost
- Safety
Three days into an offshore passage from Nova Scotia, a deckhand on a sail training barque was swept overboard in heavy weather, believed to be carrying out a ship check, and was not found. With trainees unable to help in the conditions, crew members were working during their off-watch periods, and the deckhand had been awake for all but two hours the night before and below deck for only three to four hours that day. The Transportation Safety Board of Canada found she was likely affected by fatigue and a loss of alertness at the time.
Case CA-maritime-16Report an issue
April 2006
Story · Apr 2006 · Newfoundland and Labrador, Canada
Fatigued supervisor misses hazard; explosion on offshore oil shuttle tanker kills crew member
- Safety
A shuttle tanker carrying crude oil from an offshore oil field was at anchor while welders repaired a cargo tank. Oil residue had flowed back into the tank and the vapour exploded when welding began, killing one crew member and badly burning the welder. The Transportation Safety Board of Canada found that the officer overseeing the job had a heavy safety-critical workload and was working while fatigued, after days of continuous cargo and tank-cleaning work with disrupted sleep and less rest than required, and that the ship's safety manual did not treat fatigue as a risk.
Case CA-maritime-04Report an issue
2006
Story · 2006 · British Columbia, Canada
Night-shift carer who planned a nap beside a high-risk patient loses arbitration over dismissal
- Safety
- Legal
A night-shift nurse caring for a client with autism, a history of violence, seizures and a risk of wandering brought a quilt and an alarm clock to work intending to nap; the alarm failed and she slept. She then asked a colleague to cover for her. The arbitrator upheld her termination because the nap was deliberately planned, she tried to cover it up, she endangered the patient's safety and she showed no remorse.
Case CA-healthcare-01Report an issue
October 2005
Story · Oct 2005 · Ontario, Canada
Laker master who piloted a sister ship for 15.5-, 15- and 7.5-hour stints moves straight to another vessel and grounds it
- Safety
A self-unloading bulk carrier ran aground in a river channel less than two hours after its master boarded it straight from piloting another of the company's vessels. In the preceding three days he had piloted for 15.5 and 15 consecutive hours and had one rest period of only 4.5 hours, short of the regulated 6 consecutive hours in 24. The Transportation Safety Board of Canada found his work/rest schedule did not meet regulatory requirements and may have predisposed him to fatigue-related performance issues; the company had not built the rest rules into its procedures. The vessel was refloated with no damage or injuries.
Case CA-maritime-15Report an issue
May 2005
Story · May 2005 · Alberta, Canada
Possible fatigue in night crew's throttle and brake handling derails 26 units including ammonia tank cars
- Safety
A national railway's freight train derailed two locomotives and 24 cars, including three tank cars that had last carried anhydrous ammonia, after rapid throttle and dynamic-brake changes at about 1.25 am. The TSB found it possible that fatigue played a role in the train-handling errors, with difficult schedules compounded by a long period awake before the trip, and that the fatigue-management framework for train crews may not protect adequately.
Case CA-rail-18Report an issue
Story · May 2005 · Alberta, Canada
Regional airline captain on 3.5 hours' fitful sleep lets airspeed decay at 40,000 ft; stick shaker fires
- Safety
During cruise at 40,000 feet on a scheduled regional jet flight from Texas to Alberta with 64 passengers, the airspeed decayed below minimum drag speed while the crew worked on fuel calculations, and the stall warning stick shaker activated before the crew recovered by descending. The Transportation Safety Board of Canada found the captain was not well rested, having slept fitfully for only about 3.5 hours after arriving at his hotel at 3 am. It found fatigue likely degraded his concentration and drew his attention away from monitoring airspeed.
Case CA-aviation-06Report an issue
February 2005
Story · Feb 2005 · Ontario, Canada
Railway track foreman refuses overtime before 4-hour drive home; regulator seeks last-day work-hours policy
- Legal
A national railway's extra gang foreman, after working 12 or 13 hours a day all week, refused overtime on the last day of the week. He said he would be too tired for the four-hour drive home in winter. A federal health and safety officer found no danger because the railway had offered a hotel room to rest first, but noted that occupational health and safety 'cannot ignore human nature' and workers' wish to get home. The officer asked the railway for an assurance of voluntary compliance to develop, with its health and safety committees, a policy on hours of work on the last day of a work period that takes account of long trips home, and the worker withdrew his appeal on that basis.
Case CA-rail-17Report an issue
October 2004
Story · Oct 2004 · Nova Scotia, Canada
Cargo jet crashes on take-off; investigators find crew fatigue a factor
- Safety
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.
Case CA-aviation-02Report an issue
July 2004
Story · Jul 2004 · Quebec, Canada
River pilot on irregular early-morning assignments loses vigilance at a critical turn; container ship aground 11 days
- Safety
A river pilot had conduct of a container ship on a night downbound transit. Both of his recent assignments involved irregular early-morning hours, and his early-evening nap before boarding may not have been restorative, because it came at a time when his body clock would have favoured wakefulness. He did not order a timely course alteration and the ship grounded outside the channel; it was refloated 11 days later after 109 containers were removed. The Transportation Safety Board found that fatigue may have been a factor in the pilot's decreased vigilance.
Case CA-maritime-14Report an issue
January 2004
Story · Jan 2004 · Ontario, Canada
Charter pilot on about 5 hours' sleep after cross-continent trip takes off iced and overweight; 10 killed
- Safety
- Financial
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.
Case CA-aviation-05Report an issue
2004
Story · 2004 · Canada (federal jurisdiction)
Courier lead hand caught resting on shift has dismissal cut to demotion and suspension
- Legal
A lead hand with a courier company was found apparently asleep on shift with snacks and a drink beside him; he said he was only resting and stretching. The rail and transport arbitrator found he had been trying to get extra rest without intending to fall asleep, did not lie when caught, and had put no one's safety at risk. Termination was replaced with a demotion and a three-month suspension.
Case CA-transport-05Report an issue
July 2002
Story · Jul 2002 · Quebec, Canada
Bosun with 4 hours off duty in 24 on an under-crewed bulk carrier knocked overboard by a released lifeboat and drowned
- Safety
On a loaded bulk carrier sailing downriver in Quebec, the bosun was securing the port lifeboat when it suddenly released down its davit, struck him and knocked him into the river; he drowned. The ship was sailing with fewer deck ratings than its minimum safe manning certificate required, and in the 24 hours before the accident the bosun had had about four hours off duty. The Transportation Safety Board of Canada found, as a finding as to risk, that his judgment, reaction time and alertness would have been adversely affected by fatigue.
Case CA-maritime-13Report an issue
May 2002
Story · May 2002 · Ontario, Canada
Commuter train conductor's refusal over tired double-shift colleague fails for lack of objective fatigue evidence
- Legal
A conductor working on a commuter train for a national railway refused to continue because her assistant conductor had been on duty since that morning, had doubled onto a second assignment and was close to 12 hours of service. She believed he was too tired to be relied on in an emergency. The health and safety officer found no danger, and the Appeals Officer confirmed that decision. He found that the objective evidence did not show the assistant conductor was too fatigued, that the conductor had not met him face to face before refusing (she had only spoken with him by radio), and that none of her fatigue literature identified an objective test confirming a person cannot work safely.
Case CA-rail-16Report an issue
April 2002
Story · Apr 2002 · Canada
National postal operator ordered to pay damages for keeping supervisor with sleep disorder on 3.30am shift
- Legal
- Financial
A letter carrier supervisor at the national postal operator had a diagnosed sleep disorder and his doctor directed that he work regular day shifts only, not the 3.30am to 11.30am shift. The employer nevertheless assigned him to the early shift in 2001 and kept him there despite further medical directions in 2002, and his health worsened. The Canadian Human Rights Tribunal found disability discrimination because the employer did not properly assess accommodation or show undue hardship, and awarded lost wages for more than two years plus damages.
Case CA-transport-04Report an issue
Story · Apr 2002 · Ontario, Canada
Tug crew on a work-rest schedule that prevented proper sleep strike a navigation light; tug and barge holed
- Safety
At about 10:30 pm a tug pushing a barge upbound in a major inland seaway struck and knocked over a navigation light structure, holing both vessels. The Transportation Safety Board of Canada found the crew's work-rest schedule did not allow proper rest and that their performance was likely affected by fatigue at the time, after insufficient restorative sleep in the preceding 24 hours. It also found that crews of small vessels such as tugs may work schedules that do not meet Canadian and international rules.
Case CA-maritime-10Report an issue
August 2001
Story · Aug 2001 · Ontario, Canada
Ferry pilot on duty over 20 hours after crossing six time zones crashes on night GPS approach
- Safety
A contract pilot ferrying a light single-engine aircraft across the Atlantic for an aircraft sales company crashed at about 2:20 am while attempting an improvised GPS approach to a northern regional airport in poor weather, and was killed. On the final day he had flown more than 1,900 nautical miles over about 19 hours, crossing six time zones, mostly single-pilot at night in cloud, after more than 20 hours on duty. The Transportation Safety Board of Canada found it likely that fatigue affected the pilot's performance and may have contributed to the accident.
Case CA-aviation-09Report an issue
November 1999
Story · Nov 1999 · Nova Scotia, Canada
Court of Appeal overturns compensation for tire-plant operator's sleeplessness on backward-rotating shifts
- Legal
A full-time operator at a tire plant worked a 28-day backward-rotating shift cycle for about seven years before developing severe sleeplessness that diminished his alertness, worst on night shifts. Nova Scotia's Workers' Compensation Appeals Tribunal upheld compensation for shift-work maladaptation syndrome in 2002, the first award of its kind in the province. Later that year the Nova Scotia Court of Appeal set the award aside, holding that the worker's intolerance of shift work was a personal characteristic and that there was no evidence the job caused or aggravated the condition.
Case CA-manufacturing-01Report an issue
Story · Nov 1999 · Quebec, Canada
Ship inspectors who said they could not sleep on 24-hour shifts aboard grounded vessel lose overtime claim
- Legal
Two federal marine surveyors took turns staying aboard a grounded cargo ship on 24-hour shifts, counted as 18 hours of work and 6 hours of rest. They said the rest never happened because conditions aboard were precarious and they were woken constantly, and they claimed overtime for all 24 hours each day. The federal labor board was not convinced that their duties had stopped them sleeping and put the problem down to conditions aboard the ship. It held that it was up to the surveyors to tell their manager the schedule was not working, and it dismissed the grievances.
Case CA-government-01Report an issue
August 1999
Story · Aug 1999 · Quebec, Canada
Commuter crew far over flight-time limits, first officer chronically fatigued; turboprop crashes on approach
- Safety
- Legal
A commuter turboprop on a scheduled night flight from an island community crashed one nautical mile short of the runway at a regional airport in fog, killing the captain and seriously injuring the first officer. The Transportation Safety Board of Canada found both pilots had exceeded their maximum monthly, quarterly and daily flight and duty times, and that the first officer had averaged 14-hour days for 30 days with one day off and had told the captain he was too tired and worn out. The national regulator was unaware of the exceedances and the company did not effectively supervise pilot duty times.
Case CA-aviation-08Report an issue
October 1998
Story · Oct 1998 · British Columbia, Canada
Crew awake 21 hours likely microsleeps past stop signal; two freight trains collide
- Safety
At about 4:40 am a freight train passed a stop signal and struck another freight train of the same railway as it entered a siding, derailing a locomotive and three cars. The Transportation Safety Board of Canada found both crew members were impaired by fatigue after more than 21 hours awake with no restorative rest, and had possibly experienced a microsleep as they passed the signal. The in-cab alerter did not rouse them beyond an automatic response, and the board found crews could be fully compliant with hours-of-service rules yet still not be rested.
Case CA-rail-08Report an issue
September 1998
Story · Sep 1998 · Alberta, Canada
Court rejects claim against livestock auction after worker on 19-hour day falls asleep driving home
- Safety
- Legal
A worker who had put in what the court called 'an amazing 19 hard and grueling hours' at a livestock auction, on top of his regular job, fell asleep at the wheel driving home at about 4am and was left paralysed. He sued the auction business, arguing it was responsible for his exhaustion. The Court of Queen's Bench dismissed the claim, finding that his decision to spend several hours drinking after work broke the causal link between the work-induced fatigue and the crash.
Case CA-agriculture-01Report an issue
December 1997
Story · Dec 1997 · British Columbia, Canada
Freight engineer with 2.5 hours' rest in 29 loses control on a steep mountain grade; runaway freight derails 66 cars
- Safety
A national railway's freight train ran away on a steep mountain descent and derailed 66 cars after a series of train-handling decisions depleted its air brakes. The locomotive engineer had had only 2.5 hours of rest in the previous 29 hours; he had chosen not to book rest after a short turn because he would have lost the pay for the trip. The Transportation Safety Board of Canada found his performance may have been affected by fatigue, impairing his ability to make critical operating decisions, and that pay and scheduling systems may push crews to work fatigued. The three crew members were not injured.
Case CA-rail-15Report an issue
September 1997
Story · Sep 1997 · British Columbia, Canada
Coast pilot awake 19.5 hours with 10-hour sleep debt turns early in fog; bulk carrier grounds
- Safety
At 1:36 am in fog, a forest-products bulk carrier grounded in a coastal strait after the coast pilot lost track of the ship's position and altered course early for a narrow passage, navigating without help from the ship's crew. The Transportation Safety Board of Canada found the pilot was probably fatigued: he had built up about 10 hours of sleep debt over three days, had been awake 19.5 hours, was near the end of an 80-day peak-season work cycle with irregular night assignments, and was seen by the second pilot looking tired with his head bowed. Neither the pilotage authority nor the pilots' organization had a regime to monitor pilot fatigue.
Case CA-maritime-09Report an issue
August 1997
Story · Aug 1997 · Quebec, Canada
Outfitter pilot on 3 hours' sleep a night overloads floatplane; strikes power lines, two staff killed
- Safety
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.
Case CA-aviation-10Report an issue
April 1997
Story · Apr 1997 · Nova Scotia, Canada
Scallop dragger crew on 20-hours-on, 4-off schedule; deckhand on watch likely falls asleep and vessel grounds
- Safety
A two-person scallop dragger had been fishing on a schedule of about 20 hours on duty and 4 hours off, during which the crew could sleep. On the run back to port the skipper handed the watch to the deckhand, and the vessel ran aground much closer to shore than intended. The Transportation Safety Board found that fatigue, made worse by the work/rest schedule, harmed the crew's performance, and that the deckhand probably fell asleep without meaning to. The vessel was declared a constructive total loss.
Case CA-agriculture-04Report an issue
October 1996
Story · Oct 1996 · Nova Scotia, Canada
Scallop deckhands on 9-on, 3-off rotation slept at most 18 hours in 72; fatigued decision ends in crushed foot
- Safety
After three days on a nine-hours-on, three-hours-off rotation, the deckhands on a scallop dragger had slept at most 18 hours in the previous 72. While the scallop rake was being hauled in, one deckhand tried to climb over the unguarded winch to reach its controls, slipped, and his foot was drawn onto the drum and crushed. The Transportation Safety Board found that the work/rest schedule most probably caused fatigue in the deckhands and affected their ability to make reasoned decisions.
Case CA-agriculture-03Report an issue
July 1996
Story · Jul 1996 · Quebec, Canada
Lone iron-ore railway engineer with 13 hours' sleep in 48 passes signal and rear-ends ore-line train
- Safety
An iron-ore railway's freight train, with a single crew member in the cab, ran past a governing signal and struck the rear of another train. The engineer had obtained about 13 hours of sleep in the 48 hours before the accident, partly in daytime, after a split schedule of calls. The TSB found that the possibility fatigue contributed to his decision not to comply with the signal could not be ignored.
Case CA-rail-14Report an issue
May 1996
Story · May 1996 · Ontario, Canada
Ferry master on new 10-hour shifts with little time to sleep leaves wheelhouse unattended; unmoored ferry drifts 45 m off the terminal while loading
- Safety
While a passenger-car ferry was loading passengers and vehicles, the master left the wheelhouse unattended with the ferry unmoored; a steering override failed and the ferry moved about 45 m off the terminal before the mate regained control. Earlier that year the operator had cut three positions and lengthened shifts from 8 to 10 hours, so the master, who lived on the mainland, had to catch a 0100 ferry to start work at 0530. The Transportation Safety Board of Canada found his judgment may have been affected by an accumulated sleep deficit caused by the schedule change. No one was injured.
Case CA-maritime-12Report an issue
October 1995
Story · Oct 1995 · British Columbia, Canada
Freight crew with 1 hour's sleep in 24 'impaired by fatigue' run stop signal in fog and hit oncoming train
- Safety
A national railway's freight train passed a stop signal in dense fog and struck another train; all four crew members were slightly hurt jumping clear. The engineer had about one hour of sleep in the previous 24 hours and the conductor none, although both complied with the hours-of-service rules. The TSB found the crew was impaired by fatigue from excessive waking hours and that the rules did not address cumulative sleep debt.
Case CA-rail-13Report an issue
February 1995
Story · Feb 1995 · Ontario, Canada
Engineer has probable sleep episode at 3:49 am; freight train runs into stationary train, two crew seriously hurt
- Safety
At 3:49 am a freight train ran past a restrictive signal at about 29 mph and struck the rear of a stationary train, pushing it into a third train; the two crew members of the moving train were seriously injured. The Transportation Safety Board of Canada found the locomotive engineer probably succumbed to fatigue and had a sleep episode, while the conductor was occupied with paperwork and did not provide backup. The board noted the crash happened in the 3 am to 5 am window of greatest sleepiness and that people are poor judges of their own fatigue.
Case CA-rail-09Report an issue
October 1994
Story · Oct 1994 · Ontario, Canada
Freight crew awake since the previous morning speed through the early hours and rear-end a stationary freight train
- Safety
At about 0440 a national railway's freight train traveling far above the permitted speed ran into the rear of a stationary freight train, derailing two empty hopper cars and the front wheels of the lead locomotive. Both crew members told investigators they were tired: the locomotive engineer had not slept since 0700 and the conductor since 1000 the previous day. The Transportation Safety Board of Canada found that reduced alertness from disruption of the normal sleep cycle probably contributed to the inappropriately high speed. No one was injured.
Case CA-rail-12Report an issue
June 1994
Story · Jun 1994 · Manitoba, Canada
Medevac crew after long stand-by duty descend below approach altitude and hit beacon tower; 2 killed
- Safety
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.
Case CA-aviation-07Report an issue
January 1994
Story · Jan 1994 · Newfoundland and Labrador, Canada
Airport firefighter refuses 34-hour triple shift; reviewing officer rules fatigue is not a 'danger' under federal law
- Legal
A federal airport firefighter refused a request to work a triple shift that would have kept him on duty for 34 consecutive hours. A safety officer agreed there was a risk of fatigue affecting performance and safety awareness, and directed the employer to act. On review, the Regional Safety Officer accepted that fatigue may affect performance but held that fatigue was not a 'danger' as federal workplace safety law then defined it, and rescinded the direction. He warned that, given the right conditions, excessive hours would likely become a safety issue, and invited the employer to resolve the problem by consulting the safety and health committee.
Case CA-emergency-02Report an issue
December 1993
Story · Dec 1993 · Ontario, Canada
Pilot on duty 22 hours without restorative sleep on third straight assignment; bulk carrier strikes moored tanker
- Safety
In the end-of-season rush before the shipping season closed, a marine pilot took a third continuous assignment after two trans-lake trips instead of the required 12-hour rest. Berthing a bulk carrier in strong stern winds, he failed to stop the ship in time and it struck a moored tanker and the barge alongside. The Transportation Safety Board found that he had been on duty about 22 hours without restorative sleep, which probably impaired his judgment, and recommended that mandatory rest be enforced in assigning pilots.
Case CA-maritime-11Report an issue
November 1993
Story · Nov 1993 · Nova Scotia, Canada
Lobster boat operator worn down by an 11-hour hauling day and poor health runs aground; operator drowns
- Safety
On the second day of the lobster season, the four-person crew of a small wooden lobster boat had been up since about 04:30 and had spent about 11 hours hauling, re-baiting and re-setting traps. Heading into harbour after dark, the operator made a navigational error and the boat grounded on a ledge. The Transportation Safety Board found that his performance was impaired by his poor health and by fatigue from the work. The operator, who was not wearing a flotation device, drowned.
Case CA-agriculture-02Report an issue
April 1993
Story · Apr 1993 · Quebec, Canada
Pilot asleep at the conn when loaded lake freighter touches bottom in a river
- Safety
At about 7:00 am a fully loaded bulk carrier touched bottom on the side of the channel in a stretch of river rapids while under the conduct of a river pilot. The Transportation Safety Board of Canada found the pilot was tired at the start of the assignment despite more than two days off, that his sleep habits during rest periods did not support his performance, and that he was asleep at the moment of bottom contact. It also found the pilotage authority had no guidance or education for pilots on fatigue and irregular schedules.
Case CA-maritime-08Report an issue
July 1966
Story · Jul 1966 · New Brunswick, Canada
Supreme Court holds mine worker who kept driving while sleepy fully liable for supervisor's death
- Safety
- Legal
After a 12-hour shift at a mine development and a night out, a mine worker drove his supervisor home in the early hours, felt sleepy and wanted to stop but dozed off before he could, and the car hit a culvert, killing his passenger. The lower courts dismissed the family's claim on the basis the passenger had accepted the risk. The Supreme Court of Canada reversed this, holding that knowingly continuing to drive while sleepy was conduct a passenger could not reasonably foresee, so the passenger bore no blame.
Case CA-mining-01Report an issue
See what sleep and fatigue mean for your workforce.
Tell us your industry and roughly how many people you employ. Your snapshot models how many are likely sleeping poorly and what it costs you. Then choose who you’d cover, and we’ll scope the right next step with you: a Fatiguefit Census where fatigue is a safety risk, or a proposal for a wellbeing program.
