Incident and Accident Analysis

Was It Fatigue?

Name: See how Was It Fatigue? works
Uploaded: 2026-10-29
Duration: 33 s
Description: Structured post-incident analysis of whether fatigue contributed to an event, and through which pathway.

Structured post-incident analysis of whether fatigue contributed to an event, and through which pathway.

Express interest Learn more

Risk & Safety solution

The problem

Serious incidents must be investigated. Few investigations ask properly about fatigue.

Fatigue is easy to assert and hard to establish after the fact. Investigations tend either to miss it or to blame it without testing the alternatives.

Was It Fatigue? gives your investigators a consistent, repeatable way to ask, and a record that shows the alternatives were tested.

**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 modeled, 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).

Stories

The biggest incidents fatigue played a part in

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

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
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
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
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.
Case CA-transport-01Report an issue
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
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'.
Case CA-transport-03Report an issue
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
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
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
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.
Case CA-aviation-13Report an issue

See all fatigue news

How it works

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 defense, after something has gone wrong, and feeds each finding back into the levels before it: rosters, sleep and in-shift controls.

The five levels of defense

Step 01
Event
An investigator opens an assessment against a specific incident.
Step 02
Was fatigue present?
The Fatigue Likelihood Score, from four questions: falling asleep immediately prior, behavioral symptoms in the preceding fifteen minutes, prior sleep and wake history, and sleep opportunity in the roster.
Step 03
Was it a fatigue-type error?
The Fatigue Error Likelihood Score tests alternative explanations at every level before attributing the error to fatigue.
Step 04
Combined finding
A Fatigue Attributable Likelihood Score on a 1–5 band with the pathway named, which feeds back into roster, sleep and in-shift controls.

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 PlattCo-founder and CEO

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.

What the client sees

Who sees what

Each record names the fatigue pathway and documents the alternatives tested. It is priced on investigation volume, not headcount: the only event-priced product in the suite.

Priced on prevalence, not headcount. How pricing works.

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

Evidence

What we can show

Its construction requires both the presence of fatigue and a fatigue-signature error, and tests alternative explanations throughout. That is what stops it inferring causation from fatigue alone.

It is the only product in the suite that looks across all levels, including roster adequacy, retrospectively after an event.

What it does not establish

It is retrospective. It does not predict an event, does not size a population, and one investigation does not establish a pattern. It is not a validated instrument and no validation claim is made for it. Records produced are discoverable.

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.

The science

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.

The science

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.

Trust and security Privacy policy Delete an account

Pathways