Fatigue Reporting: Lessons from Reticent Doctors and Lax Parents

You are at work. Everything is humming along, a routine day. Then suddenly you become aware that something doesn’t seem right. You realize your colleague’s occasional yawning has become noticeable. And persistent. Should you say something? Should you report it?

Whether you are aware of it or not, if you work in a safety-sensitive role, you are constantly faced with micro-decisions about whether a given situation has crossed the threshold to become a potential safety hazard. Of course, you know you should speak up when you see something dangerous unfolding. But at the same time, some risk is always going to be present—it’s just part of the job.

Knowing where to draw the line on reporting safety hazards is crucial. It’s the difference between a successful and reliable air operation and one that is plagued with incidents, losing customers or worse. Many safety hazards are obvious: bad weather, complex terrain, mechanical issues and so on. These can readily be tackled with training and experience. Eventually, crew members just follow their well-honed instincts.

When it comes to fatigue, however, the hazards are more difficult to pin down. Trusting that crew members will follow their instincts is not enough. In addition to robust training, what’s needed is a just culture and an alignment of incentives. Here are two anecdotes from domains well outside aviation that illustrate how culture and incentives, handled poorly, can produce adverse outcomes.

Honesty and Its Limits

In the United Kingdom, doctors are bound by a “duty of candor” that requires them to tell patients when they have made a mistake causing a moderate degree of harm. This rule was introduced in 2014 in the wake of a scandal of poor care and subsequent cover-up. The idea was to force medical staff to come clean about their performance. Unfortunately, it didn’t work. A recent report on the performance of Nottingham University Hospitals Trust over a 12-year period since the policy was introduced paints a grim picture. The duty to report often wasn’t triggered because doctors routinely decided that incidents were below the “moderate” threshold requiring disclosure. A policy intended to stimulate truthful reporting instead caused reduced and dishonest reporting.

A Market-Based Solution That Doesn’t Work

The second anecdote is from Haifa, a city in Israel where several day care centers were annoyed with parents being late to pick up their children. So, the day care centers implemented a fine of about $3 for pickups more than 10 minutes late, thinking that the financial disincentive would shape the desired behavior. Unexpectedly, the rate of parents showing up late more than doubled, rising from 8 late pickups per week to 20.

As explained in a research paper about this social experiment by behavioral economists Aldo Rustichini and Uri Gneezy, the fine reframed lateness from a moral transgression into a simple paid service. Once parents could “purchase” the right to be late, they no longer had to pay the social cost of imposing on an inconvenienced teacher. The fine unintentionally encouraged the very behavior it was meant to deter!

Building a Strong Reporting Culture

Just as doctors can’t be compelled to tell the truth by passing new laws, or parents can’t be nudged into doing the right thing by charging them a fee for failing to do so, crew members in your air operation can’t be coaxed or corralled to report fatigue hazards. Instead, you need a strong framework for safety reporting. Such a framework has three essential elements: fatigue reports must be easy to access and fast to complete; there must be a clear policy of no reprisal for self-reporting fatigue; and leadership must demonstrate tangible engagement—seeking understanding and collecting data rather than assigning blame.

These are the foundations of a genuine just culture. When crew members trust the system, they report early. When they report early, you see patterns sooner. And when you see patterns sooner, you can intervene before fatigue becomes an incident, an accident or a headline.

Fatigue hazards rarely announce themselves; they must be revealed. A strong reporting culture is how you make that possible consistently, predictably and safely.