It was 2:56 am on June 26, 2007. A bus traveling over a rural stretch of Interstate 65 in Kentucky ran off the road and struck an overpass support, killing two and injuring 65. A preliminary investigation found that the driver had apparently dozed off.

On May 18, 2007, at 6:40 am, an SUV departed from Interstate 40 in Oklahoma, crossed the median, then went airborne for 109 feet before crashing and killing seven. Police say the driver may have fallen asleep. "He never hit the brakes," one trooper said.

Tragic crashes such as these and additional near misses happen many times each day and thousands of times each year. Many of them are unreported or officially unexplained due to a lack of police training and objective roadside and postmortem tests for fatigue. Steps need to be taken to combat drowsy driving, and improvements will come only with legal action, awareness campaigns, and better data collection and reporting of fatigue-related crashes.

CRASH STATISTICS ARE PROBLEMATIC

While most people are aware of the dangers of driving while intoxicated, many are still in the dark about the dangers of driving while drowsy. However, like alcohol, fatigue slows reaction time, decreases awareness, and impairs judgment. According to the National Sleep Foundation (NSF) annual Sleep in America polls, more than one half of America's drivers (over 100 million people) admit to driving while drowsy, and nearly two out of five, or 32 million people, say they have actually fallen asleep at the wheel within the past year. Drowsy driving crashes are often very serious or fatal, especially when they occur at high rates of speed. Unlike a driver who is impaired by alcohol, a driver who has fallen asleep is unable to take any action to avoid a crash. In fact, one of the most common characteristics at a sleep-related crash scene is the lack of skid marks. Often, if the driver survives, they might remember being sleepy, but will not recall having nodded off for a couple of seconds.

Federal statistics related to drowsy driving and fall-asleep crashes are outdated and severely underestimate the full scope of the problem. National Highway Traffic Safety Administration (NHTSA) statistics, more than a decade old now, conservatively show that 100,000 drowsy driving crashes are reported to police each year, killing more than 1,500 Americans and injuring another 71,000. These crashes, injuries, and fatalities result in over $12.5 billion in diminished productivity and property loss. Yet, as startling as these figures may seem, most researchers and traffic safety officials believe that federal statistics significantly under-report the problem of driver fatigue.

For instance, there is some evidence to believe that a good portion of motor-vehicle crashes are not currently reported as sleep-related although they fit the profile of a typical fall-asleep crash—a single occupant driving off a two-lane road at night. However, even if more crashes were reported, they still might not be properly coded as fatigue-related because most police officers are not trained to investigate sleep as a causal factor.

Additionally, drowsiness also may play a role in crashes attributed to other causes. In 1991, there were more than 1.2 million police-reported single-vehicle roadway departure (SVRD) crashes, resulting in 15,533 fatalities. This group of crashes represents an area that has not been properly studied to determine causal factors such as fatigue.

NHTSA also estimates that 1 million crashes are caused by driver inattention. Clinical studies show that sleep deprivation and fatigue make some attention lapses more likely to occur. Research has shown that 17 hours of sustained wakefulness produces performance impairment equal to a blood-alcohol concentration (BAC) of 0.05%. After being awake for 24 hours, it is 0.10%.

Ironically, one of the basic properties of alcohol—the most studied and promoted cause of traffic crashes and fatalities—routinely gets overlooked. Alcohol is a sedating drug. When coupled with sustained wakefulness, time of day effects, and cumulative sleep loss, it can create a powerful, and deadly, combination. Research shows that the consumption of one beer or ounce of liquor, after a night with 4 hours of sleep, has the potential impact of several alcoholic drinks. It is believed that the interaction between alcohol and fatigue tends to be overlooked by investigators in determining crash causation. A fair number of "alcohol-related" crashes involve someone falling asleep at the wheel with a low BAC. Moreover, there are many over-the-counter medications and drugs that cause drowsiness, which impairs driving ability.

All of these circumstances are currently overlooked in state and federal statistics related to fatigued drivers. Until there are better data collection and reporting methods, driver fatigue will not receive the attention it deserves from state and federal agencies and law enforcement.

AVOID A CRASH

Tragically, those killed or injured are not only the drivers but those who have the misfortune to be on the road at the same time. Many of these crashes could have been avoided by understanding the impact of driving while fatigued and taking simple actions.

Often, untreated sleep disorders contribute to the risk of drowsy driving. Patients with undiagnosed sleep apnea are among the highest at-risk groups. It has been shown that OSA increases a person's risk of having a crash by two to seven times. Additionally, a recent study found that patients with OSA have a greatly increased risk of severe car crashes. Limited studies have demonstrated that once treated with continuous positive airway pressure, patients decrease their risk to the same level as in the general population. For these reasons, drowsy driving also needs to gain the attention of health care professionals in order to see that people are properly diagnosed and that OSA is treated as a chronic disease.

LEGAL MATTERS

Just over 10 years ago, Maggie McDonnell, a 20-year-old college student, was killed in a head-on collision by a driver who admitted being awake for 30 hours after smoking crack cocaine in a local drug house. The driver was not intoxicated at the time of the crash, but he did state to the police that he stayed awake because he was afraid someone would steal the rest of his drugs. His lawyer successfully argued that New Jersey state law did not stipulate that fatigue constituted recklessness. Thus, the jury was barred from deliberating about the driver's admitted sleep deprivation, and he was only assessed a $200 fine. Following the verdict, Maggie's mother, Carole McDonnell, crusaded relentlessly along with the NSF to see that justice prevailed in her daughter's memory.

After working for 2 years with her state assemblyman and senator, the New Jersey State Senate passed legislation known as "Maggie's Law," on June 23, 2003. The law established fatigued driving as recklessness under the existing vehicular homicide statute. This legislation overwhelmingly passed both chambers of the state legislature and became the first law in the nation to specifically address the issue of drowsy driving.

However, Maggie's Law is not perfect. It narrowly defines "fatigue" as being without sleep for a period in excess of 24 consecutive hours. Maggie's Law did, however, address what is perhaps a more significant problem—a lack of awareness of the issue. The law gained national and international media attention and led McDonnell's congressman, Rep Rob Andrews, to work with NSF to draft and introduce the National Drowsy Driving Act of 2003 (also known as Maggie's Law). The legislation called for comprehensive education and training measures for drivers and police and rest area and road improvements such as rumble strips. While this bill never become law, its introduction, along with testimony and advocacy by Andrews and NSF, led to the inclusion of language calling for research and educational initiatives related to drowsy driving in the mammoth Safe, Accountable, Flexible, Efficient Transportation Equity Act (SAFETEA), which governs federal surface transportation spending through 2010.

The Andrews bill also served as a model for subsequent drowsy driving bills on the state level, the most significant of which was introduced in Massachusetts last year. That bill included many of the same provisions as the Andrews bill, plus it added an enforcement requirement that would allow the police to place any person who is incapacitated from sleep deprivation into "protective custody."

The Massachusetts bill failed on the floor, but certain provisions were incorporated into another law regarding driver education and junior operator's licenses. This law prevents teens from being on the road between the hours of 12 am and 5 am. It also requires the state of Massachusetts to implement a public awareness campaign for student drivers and parents with information on the major causes of accidents among new drivers, including sleep deprivation. Young people (ages 16 to 29), especially males, are the largest at-risk group for drowsy driving. The law also created a special commission to comprehensively study the impact of drowsy driving on highway safety and the effect of sleep deprivation on drivers. Its report is due in December 2007.

The problem of sleep deprivation and driver fatigue is complex and far-reaching. Complex, in that while there are many unanswered questions about the relationship between sleep, rest, and physical performance, sleep research has established that sufficient sleep is not optional. Far-reaching, in that NSF and others have identified several significant steps that need to be taken in the public health and traffic safety fields. Public education, physician and police training, school-based programs, workplace safety—these are some of the obvious program pieces that need to gain wide support. Just like with alcohol and drunk driving, sleep deprivation and drowsy driving will require a full-court press from the public and private sectors.

It is critical that the problem of drowsy driving be approached like other public health and safety issues. It is also important to note that laws related to drunk driving have been around almost since the first car hit the road, and there are still many individuals and groups calling for tougher legislation. The prevention of drowsy driving will have to take a similar evolutionary process rather than looking for any one element or component to successfully combat it.

Unfortunately, under our current social norms and laws, some do not view drowsy driving as risky behavior. The thinking goes something like this: Those who speed and drive drunk make a decision to act in a dangerous manner. Those who drive drowsy don't mean any harm. Their impairment is not deliberate, but an unavoidable fact of modern life.

We must change this thinking by equating drowsy driving with its dangerous consequences. We must provide the public with the tools to recognize the signs of fatigue and the countermeasures to ensure their safety. This will take a unique partnership of concerned health and safety organizations working with traditional government agencies and grassroots advocates.

DROWSY DRIVING PREVENTION WEEK

In an effort to reduce the number of fatigue-related crashes among the most inexperienced drivers, the NSF is declaring November 5-11 Drowsy Driving Prevention Week™, a national public awareness campaign designed to educate teen and college-aged drivers and their parents about the tragic consequences of driving while drowsy. Working with a variety of national and local partners, Drowsy Driving Prevention Week will comprise an online educational tool kit about the dangers of drowsiness behind the wheel, a "State-of-the-States" report outlining current drowsy driving public awareness and law enforcement activities taking place in all 50 states, and a "contract" between parents and young drivers—a pledge to honor safe driving practices and to be fully alert before driving as well as other ways for concerned individuals to get involved in raising awareness about this tragic killer.

For more information and to participate in the upcoming Drowsy Driving Prevention Week campaign, please visit www.drowsydriving.org.

Darrel Drobnich is chief program officer for policy, education, and research at the National Sleep Foundation (NSF), Washington, DC. He can be reached at .

John Rancourt is government affairs manager at the NSF. He can be reached at .