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Determinants of seafarers’ fatigue: a systematic review and quality

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Article  in  International Archives of Occupational and Environmental Health · November 2016

DOI: 10.1007/s00420-016-1174-y

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Int Arch Occup Environ Health
DOI 10.1007/s00420-016-1174-y
REVIEW
Determinants of seafarers’ fatigue: a systematic review
and quality assessment
Solveig Boeggild Dohrmann1 · Anja Leppin2 
Received: 11 May 2016 / Accepted: 12 October 2016
© Springer-Verlag Berlin Heidelberg 2016
Abstract  Conclusions  Realistic countermeasures ought to be estab-
Purpose Fatigue jeopardizes seafarer’s health and safety.
Thus, knowledge on determinants of fatigue is of great
importance to facilitate its prevention. However, a system-
atic analysis and quality assessment of all empirical evi-
dence specifically for fatigue are still lacking. The aim of
the present article was therefore to systematically detect,
analyze and assess the quality of this evidence.
Methods Systematic searches in ten databases were per-
formed. Searches considered articles published in schol-
arly journals from 1980 to April 15, 2016. Nineteen out of
98 eligible studies were included in the review. The main
reason for exclusion was fatigue not being the outcome
variable.
Results  Most evidence was available for work time-related
factors suggesting that working nights was most fatiguing,
that fatigue levels were higher toward the end of watch or
shift, and that the 6-h on–6-h off watch system was the
most fatiguing. Specific work demands and particularly the
psychosocial work environment have received little atten-
tion, but preliminary evidence suggests that stress may be
an important factor. A majority of 12 studies were evalu-
ated as potentially having a high risk of bias.
Electronic supplementary material  The online version of this
article (doi:10.1007/s00420-016-1174-y) contains supplementary
material, which is available to authorized users.
* Solveig Boeggild Dohrmann
sbdohrmann@health.sdu.dk
1 2004)—are associated with an increased risk of obesity,
Department of Public Health, Centre of Maritime Health
and Society, University of Southern Denmark, Niels Bohrs
Vej 9, 6700 Esbjerg, Denmark
2
Department of Public Health, University of Southern
Denmark, Niels Bohrs Vej 9, 6700 Esbjerg, Denmark
lished, e.g., in terms of shared or split night shifts. As inter-
nal as well as external validity of many study findings was
limited, the range of factors investigated was insufficient
and few studies investigated more complex interactions
between different factors, knowledge derived from stud-
ies of high methodological quality investigating different
factors, including psychosocial work environments, are
needed to support future preventive programs.
Keywords  Determinants of fatigue · Occupational health
and safety · Seafarers · Work-site prevention
Introduction
In an occupational context fatigue can be defined as ‘a state
of an organism’s muscles, viscera or central nervous sys-
tem, in which prior physical activity and/or mental process-
ing, in the absence of sufficient rest, results in insufficient
cellular capacity or system-wide energy to maintain the
original level of activity and/or processing by using normal
resources’; it is caused by sleep- and work-related factors
and can be restored by the right interventions like sufficient
rest or sleep (Soames-Job and Dalziel 2008).
Research has shown an association between fatigue
and endocrine dysfunction and metabolic abnormali-
ties (Kaltsas et al. 2010). Also sleep deprivation and sleep
disturbance—both recognized as risk factors for fatigue
(Balkin et al. 2008; Short and Banks 2014; Akerstedt et al.
diabetes, hypertension, irritability and an overall decrease
in motivation (Boivin and Boudreau 2014; Knutson 2010;
Zaharna and Guilleminault 2010). Furthermore, fatigue
has been identified as a risk factor for occupational safety.
13

Particularly in the transport industry, fatigue as a result
of sleep deprivation, poor quality of sleep, shift work and
long working hours is a recognized problem due to its
evident linkage to cognitive disengagement and lack of
concentration, resulting in an increased risk of accidents
(Philip 2005; Robb et al. 2008; Caldwell 1997; Cald-
well et al. 2009; Dorrian et al. 2007a, b; Williamson et al.
2011). Also in seafaring, where more than 90% of global
trade is carried, engaging about 1384.000 seafarers world-
wide (International Maritime Organization 2012), fatigue
and its potential impact on health and safety is increas-
ingly being acknowledged (Allen et al. 2008; Wadsworth
et al. 2008). Lewis and Wessely (1992) found that fatigue
prevalence presented in community surveys ranged from 7
to 45%, while rates from 38 to 76.3% have been reported
for the maritime industry (Allen et al. 2008; Sa˛lyga and
Kušleikaitė 2011; Sanquist et al. 1997). This might suggest
higher fatigue burden in the maritime population, but due
to a wide variety in operational definitions of fatigue, com-
parisons are problematic and conclusions premature.
Fatigue seems thus highly prevalent in the maritime
industry, possibly compromising vigilance on the job.
According to Härmä et al. (2008), 40.6% of the seafar-
ers surveyed in their study reported to have fallen asleep
at work at least once during the preceding 5 years. Fatigue
is therefore likely to be associated with the safety of the
crews, the passengers, the ship and the environment (Allen
et al. 2008; Maritime Accident Investigation Branch 2004;
Wadsworth et al. 2008). For instance, fatigue has been
assumed to have played a major role when the ferry MS
Herald of Free Enterprise foundered in 1987 in the Brit-
ish Channel causing 183 passengers and crew members to
drown (BBC 1987). Thus, to enhance health and well-being
of seafarers and to avoid accidents and disasters, preventing
fatigue is of great importance.
A starting point to preventive efforts in seafaring is knowl-
edge on what determines fatigue (Allen et al. 2007, 2008;
Smith et al. 2006). A range of factors, such as circadian
rhythms, sleep quality, shift schedules, watch systems, work
load, noise and environmental motion of the ship, have so far
been suggested as possible determinants of fatigue among
seafarers, but results so far have lacked consistency, as has
been pointed out by prior seminal reviews about seafarers’
fatigue (Allen et al. 2008; Oldenburg et al. 2010, 2013). As
occupations and activities undertaken in the maritime indus-
try are diverse, heterogeneity in fatigue profiles across occu-
pational groups is probable (Allen et al. 2007). Furthermore,
it seems as if initiatives at fatigue prevention in the maritime
domain have not had the desired effect, possibly because the
type and/or range of determinants addressed has been too
limited (Allen et al. 2007; Smith et al. 2008).
Thus, in order to obtain a systematic overview about
the determinants of fatigue in different groups of seafarers
13
Int Arch Occup Environ Health
the present article aims at systematically describing and
analyzing what is known about determinants of seafarers’
fatigue and to assess the quality of this evidence.
Method
A systematic review of the scientific literature was under-
taken by two reviewers. The process of the review was
directed by a protocol (available from sbdohrmann@health.
sdu.dk), and the Preferred Reporting Items for System-
atic Reviews and Meta-Analysis (PRISMA) was applied
as guidance for reporting (Liberati et al. 2009) excluding
items specific for meta-analysis which were not applicable
for this review.
Identification of studies
A two-step strategy was applied to identify relevant lit-
erature in terms of articles and conference papers to be
included in the review. As a first step, articles were iden-
tified by means of a systematic search in the sections of
title, abstract, topic and keywords in ASSIA, PsycARTI-
CLES, EMBASE, MANTIS, PsycINFO, PubMed, Sco-
pus, Sociological Abstracts and Web of Science, using the
terms ‘fatigue,’ ‘determinant,’ ‘seafarer’ and their respec-
tive MESH terms as search words (available from sbdohr-
mann@health.sdu.dk). Boolean operators were used
according to rules applicable for the specific databases.
In order to eliminate studies on fatigue among patients,
especially cancer patients, the command ‘NOT patient OR
cancer’ was built into the search string applied in PubMed
and in Scopus. The search was limited to articles includ-
ing an abstract and published in English in scholarly jour-
nals from 1980 to the last day of the search, i.e., April 15,
2016. The search was further limited to studies on human
adults (18 years+). As part of the first search phase con-
ference papers were identified by means of a systematic
search in Web of Science and the search engine ‘Summon’.
In Web of Science ‘fatigue,’ ‘determinant,’ ‘seafarer’ and
their respective MESH terms were used as search words.
In a second phase a snowball search was conducted in the
reference sections of all individual articles and papers so
far retrieved (Horsley et al. 2011) and webpages of known
ongoing fatigue-related research projects were checked for
relevant publications in a third and final phase.
Eligibility
Studies were considered eligible if (1) study participants
were seafarers engaged in occupational sailing, (2) one
or more research questions about factors associated with
seafarers’ fatigue were included, (3) fatigue was assessed
Int Arch Occup Environ Health

in terms of subjective ratings of fatigue, tiredness, etc., or
alertness and/or in terms of physiological fatigue measure-
ments, while studies relying exclusively on performance
measures as indicators for fatigue were not considered, (4)
quantitative data were provided, (5) articles were published
in English or Danish. Duplicate publications and publi-
cations with a sole focus on methodological issues were
excluded, as were studies with an exclusive focus on ergo-
nomic factors, such as type of seats installed on vessels.
The process of article selection is outlined in Fig. 1.

Fig. 1  Flow diagram illustrat-

ing the process of selection of
359 articles and conference papers
articles and conference papers identified through systematic
searches in databases and search
query 25 duplicates removed

297 articles excluded based on title and abstract:

334 articles and conference papers
screened for eligibility
References from 37 articles and
conference papers reviewed to
identify those relevant
- Occupational injuries as outcome
- Fatigue as exposure
- Other occupational groups than
seafarers
- Catch quotas
- Non occupational sailing
- Article in Japanese
- Review articles
- Fatigue in steel and other metals
- Methodological study?
- Ergonomic factors as determinant
- Anecdotal material
- Qualitative study design

65 additional articles identified through a

snowball search conducted in the reference
102 articles and conference papers
screened for eligibility
83 articles excluded based on full text reading:
19 articles and conference papers
included in the final review
section of all articles and papers retrieved
- Health as outcome
- Sleep length/quality as outcome
- Burnout as outcome
- Results from neurobehavioral test as
outcome
- Ability to process complex
information as outcome
- Performance as outcome
- Rules and regulations about fatigue
- Mental work load as outcome
- Fatigue as an exposure
- Muscle fatigue as an outcome
- No detailed data presented
- Article not retreivable

13

Quality assessment
Methodological quality of the included studies was
assessed to allow for an informed evaluation of the validity
of the review results. ‘Risk of bias’ was used as indicator
of methodological quality and was assessed by means of
two tools: (1) The Quality Assessment Tool for Observa-
tional Cohort and Cross-Sectional Studies (QATOCCSS)
(National Heart, Lung, and Blood Institute 2014) was used
for observational studies, and (2) the Cochrane Collabora-
tion’s Tool for Assessing Risk of Bias (CCARB) (Higgins
and Altman 2008) was used for intervention studies.
Summary assessment for the overall risk of bias was
undertaken for each study with an exclusive focus on
fatigue as the outcome. This assessment was based on the
ratings assigned to each criterion or domain and a con-
sideration of the relative importance of each criterion or
domain (Higgins and Altman 2008). The overall assess-
ment was summarized into 4 categories, modifying the
originally suggested 3-tier system (good, fair and poor)
(National Heart, Lung, and Blood Institute 2014), by fur-
ther splitting the middle category into an upper and a lower
group, since results otherwise would have lacked differ-
entiation. The resulting categories were: ‘l = low risk of
bias’ (experimental studies or cohort/longitudinal studies
with low risk of bias), ‘2+ = low to moderate risk of bias’
(cohort/longitudinal studies with a low to moderate risk of
confounding), ‘2− = moderate to high risk of bias (cohort/
longitudinal studies with moderate to high risk of bias and
cross-sectional studies with statistical control of confound-
ers), ‘3 = high risk of bias’ (cross-sectional studies without
control of confounders, case studies/case series).
Results
As shown in Fig. 1, 102 eligible studies were initially
identified through systematic searches in the databases and
the reference search technique. Based on full-text read-
ing a total of 83 articles were excluded. The main reason
for exclusion was fatigue not being the outcome variable.
Thus, 19 articles were included in the final review and
these articles are marked with an asterisk in the refer-
ence list. As can be seen from Table 1, numbers of study
participants varied from n  = 6 in a small onboard study
with continuous sleep and alertness rating taken over sev-
eral days to n = 1855 in a large-scale cross-sectional mail
questionnaire. Fifty-three percentage of the studies were
based on small samples (n = 6–50). Merchant marine sea-
farers were the most commonly represented group (53%;
n = 10), while studies focusing on navy personnel (n = 4)
or fishermen (n = 2) were more rare. The samples of 42%
13
Int Arch Occup Environ Health
(n = 8) of studies consisted exclusively or predominantly
of officers.
The large majority of studies (74%; n = 14) were con-
ducted as on-board field studies where seafarers’ fatigue
was tracked over a longer or shorter period of time. Two
studies were experimental laboratory studies conducted in
a simulator on shore, and three studies were based on mail
questionnaire surveys.
In general, the most common focus in terms of possi-
ble determinants of fatigue was on workplace-related fac‑
tors (89%; n  = 17). More specifically, 58% (n  = 11) of
studies included work time factors, i.e., watch systems/
time into watch/time of day, 32% (n = 6) looked at voyage-
related factors, such as length of tour or time into tour, and
a further 32% (n = 6) included aspects of work demands,
such as length of work time or task demands. Only in 16%
(n  = 3) of the studies was the role of work environments
investigated, e.g., of noise or vibrations on board. Sleep-
related factors were focused on by 42% (n = 8), while 26%
(n = 5) and 21% (n = 4) of studies, respectively, included
individual determinants, mostly age, or psychosocial fac‑
tors, such as perceived stress.
As for fatigue measurement, most studies (74%) focused
directly on fatigue, while 26% (n  = 5) studies measured
alertness. While alertness was exclusively measured with
visual analogue scales, fatigue assessment varied widely.
Five studies used the Karolinska Sleepiness Scale, either
alone or in combination with other measures. Another five
studies employed other varying ratings of tiredness or need
for recovery. Complex multidimensional questionnaire bat-
teries like the Profile of Fatigue-Related Symptoms (PFRS)
or the Swedish Occupational Fatigue Inventory (SOFI)
were used by four studies, while three studies applied phys-
iological performance measures (e.g., eye movement meas-
ures, polysomnography).
Sleep‑related factors
As expected, sleep was consistently associated with fatigue.
All four studies reported results on sleep quality, and
among them two large-scale cross-sectional mail surveys
(Sa˛lyga and Kušleikaitė 2011; Wadsworth et al. 2008) and
two on-board longitudinal/process studies (Sanquist et al.
1997; Wadsworth et al. 2006) found significant results, as
did four of the five studies looking at effects of sleep quan‑
tity (Ferguson et al. 2008; Härmä et al. 2008; How et al.
1994; Sanquist et al. 1997), with only Wadsworth et al.
(2006) reporting no effect. Only two studies investigated
sleeping location, one of which found excessive sleepi-
ness in fishermen due to lack of sleep at sea as compared
to home (Gander et al. 2008), while the other did not detect
any location-related differences (Wadsworth et al. 2006).
 Table 1  Characteristics of reviewed studies
References Type of ship/shipping Sample size and sample Study purpose Fatigue measurement Determinants Main outcomes
sector characteristics

Allen et al. (2003) Passenger ferries 924 Crew members Investigation of levels of Fatigue Subscale of the Work demand factors: Multivariate analysis
High-speed passenger fatigue on different ves- Profile of Fatigue- Type of vessel (adjusting for age, gender
ferries sels at sea Related Symptoms  Passenger ferries and socioeconomic fac-
Freight ships (PFRS)  High-speed passenger tors):
Tankers General Fatigue Symp- ferries  Fatigue at work, fatigue
Dredgers toms (7 items measuring  Freight ships after work and PFRS-
Int Arch Occup Environ Health

e.g., extent of concen-  Tankers and dredgers Fatigue-subscale scores

tration loss, lethargy differed significantly
etc.) between crews of ship
Fatigue at work (3 items types
measuring feelings  Passenger ferry, high-speed
at work, e.g., feeling passenger ferry, and
sleepy, tired) freight vessel crews had
Fatigue after work (3 higher fatigue levels than
items measuring feel- those working on tankers
ings after work, e.g., and dredgers
physical and mental
tiredness)
Arulanandam and Tsing 1 Naval ship, Republic of 24 Crew members from Comparison of alertness Fitness Impairment Tester Work time factors: Mean saccadic velocity
(2009) Singapore the bridge and engine levels in crew working (FIT)-2000:  Variability of work hours measured after the 4th
room watch stations a rotating and a fixed  Saccadic velocity  Time into work period watch performed by
watch schedule (4-h  Pupil diameter at rest (four days) each watch group was
on–8-h off)  Latency (time: flash of  Time of watch significantly slower in
light to contraction) the rotating schedule
 Amplitude (amount of compared to the fixed
constriction) schedule suggesting that
fatigue level after about
36 h was higher in the
rotating schedule
In both the fixed and the
rotating schedules, there
were no differences in the
oculomotor parameters
between the 3 watches

13


Table 1  continued
References Type of ship/shipping Sample size and sample Study purpose Fatigue measurement Determinants Main outcomes
sector characteristics

13
Bridger et al. (2010) 7 Royal Fleet Auxiliary T1: 322 officers and Identification of work Need for Recovery Scale Work demand factors: Officers had higher NFR
ships from UK Royal ratings demands associated (NFR) Task load than ratings at T1 and T2
Navy Age: 19–61  with need for recovery  NASA Task Load Index NFR at T2 was significantly
M = 42.0 and to find out if recov-  Baecke Questionnaire higher than at T1
T2: 134 officers and rat- ery needs accumulate Voyage-related factors: Age was not associated
ings who had taken part over time and fatigue is  Time into tour with NFR
at T1 related to age Individual factors: Multivariate findings:
 Age Ratings: NFR was
 Rank positively associated with
high NASA frustration-
subscale scores and physi-
cal work demands
Officers: NFR was
positively associated with
NASA frustration-sub-
scale scores, dissatisfac-
tion with own perfor-
mance and high effort
NFR at T2 was significantly
higher than at T1 but did
not depend on age
Ratings: NFR change was
associated with T1 work
frustration and T2 tempo-
ral demands
Officers: NFR change was
associated with change in
temporal demands
Colquhoun et al. (1987) 1 Destroyer of the British 6 Watch keepers Investigation of perfor- Visual Analogue Scale for Work time factors: Alertness was lowest during
Royal Navy mance variations over Alertness Time of watch the two night watches
the first 4 days on a Time into watch Alertness was consistently
rotating watch system lower at the beginning
than at the end of watch
on the same day, inde-
pendent of prior sleep
Subsidiary analysis found
that after night watches
had disrupted sleep,
‘other than watch duty’—
alertness was lower than
after nights without night
watches
Int Arch Occup Environ Health
 Table 1  continued
References Type of ship/shipping Sample size and sample Study purpose Fatigue measurement Determinants Main outcomes
sector characteristics
Condon et al. (1988a) 5 Vessels: 50 Seafarers: Obtaining information on Visual Analogue Scale for Work time factors: Alertness was lowest dur-
 1 Fisheries research  25 watch keepers subjective alertness in Alertness  Time of watch ing night watches and
vessel  25 day workers watch keepers on the adaption of the circadian
 1 Oceanographic research Age: 4-h on/8-h off system rhythm was only partial
vessel Watch keepers
 2 Oil tanker M = 37.0
Int Arch Occup Environ Health

 1 Container ship (SD = 8.8)

Day workers
M = 38.8
(SD = 8.6)
Nationality:
In the initial total sample
(Condon et al. 1988a,
b): 75% German
Condon et al. (1988b) 3 Vessels, 2 of which Seafarers: Investigation of effects of Visual Analogue Scale for Voyage-related factors: Circadian rhythms in
were considered in the  9 watch keepers slow time zone crossing Alertness  Time zone crossing alertness adjusted fully
present analysis as they  22 day workers on alertness, including (eastbound versus on westward voyages but
did a full westward- Age*: interaction effects of westbound) only partially on eastward
eastward trip: Watch keepers: time change and unusual ones
 1 Container M = 32.9 work hours
 1 Refrigerator ship (SD = 7.6)
 Traveling westwards Day workers:
from Europe to the Gulf M = 36.2
of Mexico or the Carib- (SD = 10.5)
bean and then returning Nationality:
eastwards In the initial total sample
(Condon et al. 1988a,
b): 75% German
*Data for all 3 ships
initially included
Ellis et al. (2003) 7 vessels from short sea T1: 177 Examination of the Alertness was assessed as Work environment fac- There was a significant
shipping industry: Age: influence of noise and part of a mood measure tors: difference in alertness
 3 Small oil tankers M = 36.07 (11.4) motion on mood (meas- comprising 18 visual  Noise: CEL-460 Dosim- between high and low
 2 Passenger ferries Nationality: ured as alertness) analogue scales with eter motion vessels, but not
 1 Freight ferry 64% from British Isles, three factors, i.e., alert-  Ship motion: Seatex high and low noise ves-
 1 Fast ferry 34% other European ness, hedonic tone and MRU H.2 sels before and after work
T2: 142 anxiety on day 1 and day 7
Multivariate (only tested
for noise): There was a
significant effect of over-
all level of cabin noise on
change in alertness, i.e.,
high noise exposure led to
reduced alertness

13


Table 1  continued
References Type of ship/shipping Sample size and sample Study purpose Fatigue measurement Determinants Main outcomes
sector characteristics

13
Eriksen et al. (2006) 1 Bridge simulator with 3 12 Male navigators: Investigation of subjective Karolinska Sleepiness Work time factors: Time of starting watch had
bridges  6 Merchant marine sleepiness across and Scale (KKS)  Time of watch start (6.00 no effect on sleepiness
officers within the four possible versus 12.00) Sleepiness increased over
 6 Naval officers watches in a 6-h on/6-h  Time period of watch the span of watches,
 Age: 26–51  off system (morning, afternoon, except on the morning
 M = 39 evening, night watch (6.00–12.00)
 Time into watch Average level of sleepi-
ness was significantly
higher during the night
watch (0.00–6.00) than
during the afternoon
(12.00–18.00) and even-
ing (18.00–24.00) but
not the morning watch
(6.00–12.00)
Ferguson et al. (2008) Pilot boats operating in 17 Coastal marine pilots Examination of impact of Samn–Perelli Fatigue Voyage-related factors: Fatigue at the end (last two
the Great Barrier Reef Age: 38–74  brief, unscheduled naps Scale  Time into tour hours) of pilotage was
Marine Park Area, M = 56.8 (7.8) during work periods on Sleep-related factors: significantly higher than
Australia alertness and vigilance Sleep quantity/quality: at its beginning (first two
in coastal pilots  Wrist activity monitor hours)
 Sleep diaries Opportunistic naps
appeared to provide
adequate recovery
Gander et al. (2008) 3 Fresher vessels involved 20 Male deckhands Monitoring of sleep and Karolinska Sleepiness Sleep-related factors: Postsleep sleepiness ratings
in Hoki fishing, New sleepiness of commer- Scale (KKS)  Home periods versus were significantly higher
Zealand cial fishermen at home periods at sea working at sea than at home
and during extended in a 12-h on/6-h off
periods at sea system
How et al. (1994) 1 Naval ship, Republic of 20 Male gunners: recent Assessment of perfor- Stanford Sleepiness Scale Sleep-related factors: Sleepiness increased with
Singapore graduates from School mance patterns of naval (SSS)  Hours of sleep depriva- increasing duration of
of Naval Training seamen under sleep tion sleep deprivation, with
Age: 18–20 deprivation on board first peak after 36–42 h
and second peak after
80 h
Int Arch Occup Environ Health
 Table 1  continued
References Type of ship/shipping Sample size and sample Study purpose Fatigue measurement Determinants Main outcomes
sector characteristics
Härmä et al. (2008) Ships with registered 92 bridge officers Examination of the Karolinska Sleepiness Work time factors: Mean onboard sleepiness
members of the Finn- Age per watch system relationship between Scale (KKS)  Watch systems: (KSS) did not differ sig-
ish Maritime Officers’ (whole study): two watch systems and Skogby Excessive Day-   6-h on–6-h off nificantly between watch
Association 6/6: M = 45.1 (9.8) its impact on fatigue time Sleepiness Index   4-h on–8-h off systems
4/8: M = 36.9 (9.8) and sleepiness in bridge (SEDS)   Others Highest risk of sleepiness
Others: M = 42.9 (12.3) offers Epworth Sleepiness Scale  Time of day was during the early
Int Arch Occup Environ Health

(ESS) Sleep-related factors: morning hours (4.00–

van Leeuwen et al. (2013) 2 Simulator vessels: 30 Male bridge officers Identification of sleepi- Karolinska Sleepiness
 1 Coaster simulator Age: ness levels in seafar-
 1 Cargo simulator M = 30.0 (6.0) ers in a 4-h on/8-h off Polysomnography (PSG)
watch system and peaks
in sleepiness as well as
effects of mild overtime
work
 Sleep length 6.00)
Individual factors: Multivariate findings:
 Diurnal type Sleepiness (KSS) was
 Probable sleep apnea significantly associated
 Age with time of day and sleep
 BMI length/time spent awake,
but not age or diurnal type
Excessive sleepiness
(SEDS) was higher in
the 6-h on/6-h off watch
system, and related to
sleep apnea and diurnal
type (morning type less
sleepiness), but not inde-
pendently related to age,
BMI, sleep length
Work time factors: Sleepiness (KSS) was
Scale (KKS)  Time of watch higher during the morn-
 Time into watch ing watches of the day
Work demand factors: (0.00–4.00/04.00–8.00,
 Overtime work 8.00–12.00) than the
afternoon/evening
watches, but difference
was highest in the team
working 4.00–8.00
Sleepiness depended on
time into watch with
highest scores reached at
end of watch
Free watch disturbances
(overtime work) led to
higher sleepiness on the
following watch

13


Table 1  continued
References Type of ship/shipping Sample size and sample Study purpose Fatigue measurement Determinants Main outcomes
sector characteristics

13
Leung et al. (2006) 2 High-speed marine 93 Navigating officers Examination of fatigue Swedish Occupational Work time factors: Generally, night shift
crafts  Hydrofoil: 72 in Chinese high-speed Fatigue Inventory  Time of watch officers scored higher on
 1 Hydrofoil  Catamaran: 21 maritime craft officers (SOFI-Chinese version)  Time into watch physical exertion (PE)
 1 Catamaran operating Day shift: 35 working either a day-or Five subscales: Work demand factors: lack of energy (LE),
between Hong Kong and Night shift: 58 a night shift and to  Physical exertion (PE)  Perceived difficulty of physical discomfort (PD)
Macao Age: test the contribution of  Physical discomfort (PD) work: Scores on PE, PD, LE and
Day shifts: 6–7 1 h-voy- M = 46.8 (6.5) other work-related and  Lack of energy (LE)  9-Item-Perceived Diffi- sleepiness (S) were higher
ages over 11 h personal factors  Lack of motivation (LM) culty of Tasks Checklist on day 2 than day 1
Night shifts: 3–4 1 h-voy-  Sleepiness (S) (e.g., Visibility, Wind, Across all subscales, night
ages over 7 h Swell ) shift officers scored
Psychosocial work fac- higher on day 1, day shift
tors: officers on day 2
Job stress: Night shift officers showed
 8-Item Psychosocial a faster rate of increase
Status Checklist (incl. in fatigue than day shift
a 4-item measure of job officers
stress) Multivariate findings:
 Anxiety (State-Trait- PE and PD at the end of the
Anxiety-Inventory) 2nd day nightshift were
Individual factors: positively associated with
 Age length of work experience
 Length of experience and perceived voyage dif-
ficulty. PD was negatively
associated with age
S in the middle of the 2nd
day night shift was posi-
tively related to voyage
difficulty
LE during day 2 was posi-
tively related to job stress
There were no associations
with anxiety
Int Arch Occup Environ Health
 Table 1  continued
References Type of ship/shipping Sample size and sample Study purpose Fatigue measurement Determinants Main outcomes
sector characteristics
Lützhöft et al. (2010) 13 Swedish cargo vessels, 30 captains and nautical Examination of fatigue Karolinska Sleepiness Work time factors: Mean sleepiness levels did
among them bulk car- officers (29 males, 1 levels onboard using Scale (KKS) Watch systems: not differ significantly
riers, car carriers and female) both objective and Eye movement behavior  4-h on–8-h off versus between watch systems,
tankers Age: 27–60  subjective measures of (EOG)  6-h on–6-h off watch but there was a trend for
M = 45.8 (1.7) sleepiness: system more severe sleepiness on
Nationality: Those working on a 6-h  Time of watch the 6-h on/6-h off system
Int Arch Occup Environ Health

72% Swedish on/6-h off shift system  Time into watch There was no difference
22% Filipino are expected to experi- in mean blink duration
ence higher levels of between shift systems
fatigue than those on a Sleepiness increased with
4-h on/8-h off system time into watch in the 6-h
on/6-h off system but not
in 4-h on/8-h off system
Sleepiness, but not blink
duration, was higher at
night than during the day,
and this difference was
more pronounced in the
6-h on/6-h off system
Sa˛lyga and Kušleikaitė Sea transport, fishing and 932 Seafarers including Determination of factors 5 Questions about fatigue, Voyage-related factors: Multivariate findings:
(2011) local water transport, the following sectors: influencing fatigue among them a question  Length of tour Fatigue was significantly
Lithuania Management among seafarers about frequency of Work demand factors: positively associated with
 Mechanical ship service fatigue and a question  Employment in different long working hours and
 Deck crew about sleepiness at work ship sectors working for long hours
 Auxiliary  Length of work hours under harmful conditions
Age: Work environment fac- (vibrations/noise), work-
M = 40.0 (11.7) tors: ing in the auxiliary ship
 Noise sector, having high work
 Vibration requirements, experience
 Time of work under of psychoemotional strain
harmful conditions and poor sleep quality
Psychoemotional factors: Fatigue was significantly
 Psychoemotional strain inversely associated with
Sleep-related factors: age, having a non-man-
 Sleep quality agement occupation and
Individual factors: duration of work at sea,
 Age i.e., those working longer
 Rank times at sea reported less
fatigue

13


Table 1  continued
References Type of ship/shipping Sample size and sample Study purpose Fatigue measurement Determinants Main outcomes
sector characteristics

13
Sanquist et al. (1997) 8 Vessels (6–7 for alert- 141 Seafarers: Quantification of work Visual Analogue Scale for Work time factors: Alertness increased during
ness data):  Watch standers patterns that lead to Alertness  Time of watch watch in the first half of
 2 Tankers  Command personnel fatigue in mariners Retrospective Alertness Sleep-related factors: the day and decreased
 6 Freight ships  Day workers Inventory (RAI):  Sleep duration and sleep during watch in the sec-
on US West Coast runs  Stewards Critical fatigue measure: quality ond half of the day
Age:  Proportion of 24 h Watch standers on the
M = 43 (11.5) periods with total sleep 0.00–4.00 watch reported
≤4 h more periods with criti-
 Visual Analogue Scale cally low alertness than
Alertness score ≤3 those on other watches
Sleep quality and sleep
duration were signifi-
cantly related to alertness
but sleep quantity contrib-
uted only marginally to
explained variance
Wadsworth et al. (2008) Offshore support, short 1855 seafarers: Consideration of associa- Longer-term Fatigue: Voyage-related factors: Multivariate findings:
sea and deep sea ships  Deck or engineering tions between negative  Fatigue Subscale of  Tour length Shorter tour length, high
of the UK merchant officers: 85% occupational factors the Profile of Fatigue- Work time factors: job demands and high
shipping industry  Ratings, catering and and perceived fatigue to Related Symptoms  Shift schedule/Time into work stress, poor sleep
service personal: 15% establish a profile of risk (PFRS) to assess longer- shift quality were associated
96% male factors associated with term fatigue  Variability of work hours with higher scores on all
Age: 17–66  fatigue among seafarers Acute Fatigue: Work demands: subtypes of acute fatigue
M = 43.5  Fatigue at work  Job Demands Scale as well as longer-term
Nationality:  Fatigue after work  Hours worked per day fatigue
92% British  Symptoms of fatigue  Department Younger age, lack of sup-
at sea  Job security port, physical hazards,
Work environment fac- sleep disturbance and
tors: smoking were associated
 Physical hazards with longer-term fatigue
Psychosocial factors: as well as at least one of
 Work stress the acute fatigue measures
 Sleep-related factors: Longer time on shift, poorer
 Sleep quality job security, finding
 Sleep disturbance switching to port arrival
Individual factors: fatiguing, variable work
 Age hours and working more
 Education than 12 h per day were
 Rank associated with longer-
 Smoking term fatigue
A higher number of risk
factors were associated
with a higher odds ratio
for acute and longer-term
fatigue
Int Arch Occup Environ Health
 Table 1  continued
References Type of ship/shipping Sample size and sample Study purpose Fatigue measurement Determinants Main outcomes
sector characteristics
Wadsworth et al. (2006) Offshore, coastal and 203 seafarers: Description of daily Visual Analogue Scale for Voyage-related factors: Fatigue on waking but not
short sea as well as deep  Officers: 97% fatigue patterns among Tiredness  Length of tour on retiring increased
sea sectors of the UK Age: seafarers on a tour of  Port calls over the tour period,
shipping industry M = 46.1 (7.91) duty Work time factors: particularly over the first
 Night work versus day week, but this tendency
work was only significant for
Int Arch Occup Environ Health

Sleep-related factors: those on the shortest trips

 Sleep quality (7–12 days)
 Sleep quantity Night work was signifi-
 Sleep on leave time cantly positively related
versus tour time to fatigue during the first
week, particularly for
those continuously work-
ing nights
There was a nonsignificant
trend for more frequent
port calls being positively
associated with fatigue
for those on shorter tours
but negatively related
to fatigue for those on
longer tours
Multivariate findings:
Mean fatigue on waking
during first week of a tour
was predicted by sleep
quality, and night work
but not sleep length, tour
group or port calls

The characteristics are described exclusively in relation to those parts of the respective studies related to investigating fatigue
* Numbers refer to numbers from the ‘View Reference Checking Results’ list

13

Workplace factors
Voyage‑related factors
Three studies looked at time into tour, comparing fatigue
ratings at different points of time during the same tour, and
two at length of tour, making comparisons between fatigue
in seafarers on longer versus shorter trips. Bridger et al.
(2010), for instance, showed that officers and ratings indi-
cated higher need for recovery at a later measurement point
(1–2 month into tour) compared to an earlier assessment.
Similar results were reported from another small-scale on-
board study of coastal pilots (Ferguson et al. 2008) and a
longitudinal on-board mail survey, where such effects only
were observed for the group with the shortest tour length
(7–12 days) (Wadsworth et al. 2006).
Findings for tour length, i.e., between-group compari-
sons between seafarers on shorter and longer voyages,
which were reported from two large-scale cross-sectional
surveys, showed that those on longer trips reported less
fatigue (Sa˛lyga and Kušleikaitė 2011; Wadsworth et al.
2008). Condon et al. (1988b) looked at the influence of
time zone crossing in a cohort study including 50 watch
keepers and dayworkers employed on container/refrigerator
ships. Circadian rhythms of alertness fully adjusted to the
clock changes on westward voyages, but only partially on
eastward voyages.
Work time factors
All studies which investigated effects of time of watch
reported significant differences between night shifts (00–
4.00/4.00–8.00) and day shifts (Colquhoun et al. 1987;
Condon et al. 1988a; Härmä et al. 2008; Leung et al. 2006;
Lützhöft et al. 2010; Sanquist et al. 1997). Wadsworth et al.
(2006) found in their longitudinal on-board survey with
203 seafarers that night work was associated with greater
mean fatigue on waking only during the first week of
tour, and the highest levels were found in the group work-
ing every night. The two simulator trials reported similar
results but with slightly less clear boundaries. Eriksen et al.
(2006) found the mean level of sleepiness in 12 officers to
be higher during the night watch (00.00–06.00) than the
day (12.00–18.00) and the evening (18.00–24.00) watches,
but not the morning watch (06.00–12.00) (see also van
Leeuwen et al. 2013).
Five of the six studies which investigated time into
watch/shift found significant differences in terms of higher
sleepiness/fatigue toward the end compared to the begin-
ning of watch/shift, among them one of the large-scale
cross-sectional surveys (Wadsworth et al. 2008) and one
of the on-board longitudinal process studies (Leung et al.
2006) as well as both experimental simulator studies. van
13
Int Arch Occup Environ Health
Leeuwen et al. (2013) for instance, comparing sleepiness
within a simulated 4-h on/8-h off system over a 7-day
period in 30 officers, reported that sleepiness consist-
ently depended on time into watch with the highest scores
reached at the end of watch. Eriksen et al. (2006) reported
similar results except for the morning watch where sleepi-
ness levels remained stable. Lützhöft et al. (2010) in their
on-board longitudinal/process study on 30 officers found
such an increase for those on the 6-h on/6-h off system, but
not the 4-h on/8-h off system. Contrary to this, Colquhoun
et al. (1987) in a small-scale case process study on 6 sub-
jects reported alertness to be higher at the end than the
beginning of watch.
Both studies comparing watch systems found that com-
pared to the 4-h on–8-h off system, the 6-h on–6-h off
system was associated with higher sleepiness during night
watches compared to day watches (Lützhöft et al. 2010;
Härmä et al. 2008) and that the 6-h on–6-h off system
was also associated with higher risk of excessive sleepi-
ness than any of the other systems studied (4-h on–8-h
off, 4-h on–4-h off and 12-h on–12-h off). Another study
used a one-group crossover trial to compare rotating ver-
sus fixed watch schedules within the 4-h on–8-h off system
and found rotating shifts more fatiguing (Arulanandam and
Tsing 2009).
Work demands
Three studies, among them two cross-sectional mail sur-
veys and one of the laboratory simulator experiments,
investigated length of work time. Wadsworth et al. (2008)
found that seafarers working more than 13 h a day had
higher fatigue scores than those working fewer hours, while
in the other cross-sectional survey, experience of fatigue
was higher for those working long hours under harm-
ful conditions (high levels of noise and vibration) (Sa˛lyga
and Kušleikaitė 2011). van Leeuwen et al. (2013) reported
overtime work (measured as disturbance of free time) to be
related to higher sleepiness on the following watch.
Task demands were focused on in five studies, three
cross-sectional mail surveys and two on-board longitudinal/
process studies, all of which showed positive associations
with fatigue. Thus, Wadsworth et al. (2008) found scores
on a work demands scale measuring e.g., time pressure,
constant interruptions and high levels of responsibility to
be positively related to reports of fatigue (see also Sa˛lyga
and Kušleikaitė 2011; Allen et al. 2003). Also, in a longi-
tudinal survey it was found that temporal demands (time
pressure) and work frustration were the main variables
associated with an increase in need for recovery between
two points of measurements in both officers and ratings.
In ratings, a high need for recovery was further associated
with high physical demands (Bridger et al. 2010). Further,
Int Arch Occup Environ Health
the officers of high-speed crafts in the longitudinal study
by Leung et al. (2006) were more likely to report fatigue if
they perceived their trips as difficult.
Physical work environment
Findings from the cross-sectional mail survey by Sa˛lyga
and Kušleikaitė (2011) showed that both, noise and vibra-
tion, were positively associated with fatigue. Wadsworth
et al. (2008) similarly reported background noise and bad
weather to be related to acute fatigue in their cross-sec-
tional survey. Additionally, they found physical hazards,
like fumes and other harmful substances, to be associated
with longer-term fatigue. Ellis et al. (2003) found in an on-
board study over a one-week period that increase of fatigue
levels during the work day depended on vessel motion and
that cabin noise was predictive of changes in alertness over
the one-week period with high noise exposure leading to
reduced alertness.
Psychosocial work‑related factors
Only three studies investigated psychosocial reactions, and
all three of them found significant results for stress. Two
large-scale cross-sectional surveys (Sa˛lyga and Kušleikaitė
2011; Wadsworth et al. 2008) showed that those with higher
experience of psychoemotional strain and job stress were
also more likely to feel fatigued. Further, in a longitudinal
study with high-speed maritime craft officers, job stress
was related to sleepiness scores among night shift officers
and lack of energy for day shift officers (Leung et al. 2006).
Beyond stress, the only other psychosocial factors investi-
gated were anxiety, for which Leung et al. (2006) did not
find an effect, while lack of support and poorer job security
showed significant positive associations with fatigue in the
cross-sectional survey by Wadsworth et al. (2008).
Individual factors
Five studies included individual determinants, with a focus
mostly on age and/or rank. As for age, Wadsworth et al.
(2008) as well as Leung et al. (2006) showed that younger
age was associated with higher fatigue. Vice versa, how-
ever, Härmä et al. (2008) in their longitudinal study indi-
cated that older officers had higher sleepiness scores than
younger ones in the afternoon and at night in the 4-h on/8-h
off system, but not the 6-h on/6-h off system. No effect for
age was reported for need for recovery in the longitudinal
survey by Bridger et al. (2010).
Sa˛lyga and Kušleikaitė (2011) showed that those work-
ing in the management sector were more likely to expe-
rience fatigue compared to others. Similar results were
reported by Bridger et al. (2010). Wadsworth et al. (2008),
however, did not find a significant association between rank
and fatigue experience.
Only few studies have so far investigated lifestyle fac‑
tors. Wadsworth et al. (2008) found current smokers to
report higher fatigue, while no association was found
between BMI and excessive sleepiness in the survey by
Härmä et al. (2008).
Risk of bias
As can be seen from Table 2 only two experimental stud-
ies were categorized as being at low risk of bias/confound-
ing (11%). Five further studies (26%), four of which were
based on an on-board longitudinal/process design and one
study with a one-group crossover design, were classified as
having a low to moderate risk of bias, while the majority of
11 studies (58%) were evaluated as having a moderate to
high risk of bias—and one study (5%) as having a high risk
of bias. Among the ‘moderate to high risk’ and ‘high risk’
groups were all three cross-sectional studies, on-board lon-
gitudinal studies with a strong possibility for confounding
and one case process study. Beyond the problem of possi-
ble differential initial selection into the groups that were to
be compared, which affected all studies with higher risk of
bias, many of the longitudinal studies with a moderate to
high risk of bias reported substantial dropout rates and over
40% did not report any controlling for confounding, while
among those who did control for confounders often only
few potential influence factors were taken into account.
Studies with lesser risk of bias were focusing mainly
on work time factors (time into tour, time of watch, watch
systems), sleep-related factors (length of sleep) or work
demands in terms of work length, while all of the studies
investigating more complex work demands, work environ-
ments, psychosocial or individual factors were character-
ized by a moderate to high risk of bias.
A further prevalent methodological problem was con-
venience sampling and self-selection of ships and/or seafar-
ers in combination with often only moderate participation
rates. The reported range of initial participation (data for
11 studies) varied between 15 and 100% with a median of
47%. Over 50% of studies were based on samples with less
than 50 participants and thus had a risk of being underpow-
ered and providing estimates with limited precision.
Discussion
This review shows that the present literature supports the
existence of a range of determinants for fatigue. At the
same time it also clearly indicates that there is a distinct
lack of research on certain types of determinants such
as work demands and work environments, especially
13

Table 2  Risk of bias in studies concerning determinants of seafarers’ fatigue
References
13
Allen et al. (2003)
Arulanandam and Tsing
(2009)
Bridger et al. (2010)
Colquhoun et al. (1987)
Study design
Cross-sectional mail survey
On-board field pilot study;
One-group intervention
trial with a crossover
design including pre- and
postwatch measurements
from three watch groups
working first in a fixed 4-h
on–8-h off watch system
and then in an anticlock-
wise rotating 4-h on–8-h
off system (4 working
days—6 days for wash-
out—4 working days)
On-board field study; Personnel from 7 Royal
Longitudinal design
with two measurement
points 1–2 months apart
On-board field study;
Case process design with
2-h-measurements (excl.
sleep times) over a full
watch cycle of 4 days
Sampling Response/participation rate Loss of data in analysis Multivariate analysis and Risk of bias
compared to initial sample adjustment for potential
<15% confounders
Mail shot targeted at mari- 15–31.8% in different No Yes 2−
time union members and subsamples; no significant
crews of four purposively differences in response
sampled shipping compa- between subsamples
nies from different sectors
plus onboard distribution
of self-report question-
naires on ships of the four
companies
Crew members volunteered No information No information No information 2+
for participation
Response rate T1: 58% No Yes 2−
Fleet Auxiliary ships were Ratings: 53%
asked to sign up for par- Officers: 72%
ticipation in the study Response rate T2: 42% of
T1 sample
Responders and non-
responders did not differ
in T1 characteristics
Crew of one British Royal No information Yes (for main analysis) No 3
Navy destroyer was
targeted and 6 volunteers
recruited
Int Arch Occup Environ Health
 Table 2  continued
References Study design Sampling
Condon et al. (1988a) On-board field study;
Longitudinal/process design
over 6–13 consecutive
days, with 6 four-hourly
points of measurement
Purposive selection of 5
ships based on voyage
characteristics; all watch
keeping and day work
crew were targeted for
Response/participation rate Loss of data in analysis Multivariate analysis and Risk of bias
compared to initial sample adjustment for potential
<15% confounders
Fishery vessel: 30% No No 2−
Research vessel: 27%
Oil tankers: 50–73%
Container ship: 71%
Int Arch Occup Environ Health

during the day (excluding participation

sleep times)
Condon et al. (1988b) On-board field study; Purposive selection of 2 Refrigerator ship: 59% No No 2−
Longitudinal/process design ships based on voyage Container ship: 81%
with two 8-day periods characteristics; and all
from round trips, one watch keeping and day
involving a westward, one work crew were targeted
an eastward direction for participation
Ellis et al. (2003) On-board field study; Purposive selection of 7 T1: No information No information (bivariate Yes, for noise; 2−
Longitudinal design with ships of different type T2: 80.2% of T1 partici- analysis) No multivariate analysis
measurements before and within short sea ship- pants No (multivariate analysis) for motion due to small
after work shift on day 1 ping industry; all crew sample size
and day 7 members were targeted for
participation
Eriksen et al. (2006) Laboratory simulator study No information about N/a Yes No/N/a 1
Experimental design, com- recruitment procedure
paring two groups within
a simulated 6-h on/6-h off
system, one starting watch
at 6.00, one at 12.00,
with fatigue ratings each
30 min (except sleep time)
over a 3-day period
Ferguson et al. (2008) On-board field study; All coastal pilots working Nearly 33% of eligible Yes No 2+
Longitudinal/process design for a marine park service pilots
with 4-hourly recording of were contacted for partici-
sleep/wake and perfor- pation
mance data for
(a) two 14-day periods
(n = 3) or b) a single
28-day period (n = 14)
with
sleep diaries incl. a fatigue
measure after every sleep/
nap

13


Table 2  continued
References Study design Sampling Response/participation rate Loss of data in analysis Multivariate analysis and Risk of bias
compared to initial sample adjustment for potential

13
<15% confounders
Gander et al. (2008) On-board/at-home field Skippers from regional Hoki No information No No 2+
study fishery industry were con-
Longitudinal design with tacted, all of who agreed
sleepiness ratings before to participate;
and after each sleep for 3 ships from the overall
up to 3 sleep periods over population were selected
24 h on 4–13 days at home based on convenience and
and 5–9 days at sea crew members contacted
for participation
How et al. (1994) On-board field study No information No information Yes No 2−
Intervention trial with a
one-group pretest–posttest
design and measurement
points every 6 h
Härmä et al. (2008) On-board field study A representative sample of 31.6% for whole study, 92% Yes Yes 2−
Longitudinal/process design navigator members of the of who also participated
over 7 consecutive days at Finnish Officers Asso- in the sleep diary part
sea with sleepiness assess- ciation were mailed the (fatigue data)
ment every 2 h while on questionnaire
watch
van Leeuwen et al. (2013) Laboratory simulator study Paid volunteers were n/a Yes No/N/a 1
Experimental design recruited via a maritime
comparing sleepiness in recruitment agency and
three watch teams within website advertisements
a simulated 4-h on/8-h
off watch system over
a period of 7 days with
1-hourly recordings for
KSS and PSG during 6
selected watches from day
2 to day 6
Leung et al. (2006) On-board field study Purposive sampling of two No information Yes Yes 2−
Longitudinal survey with local companies operating
three measurement points, a certain type of vessel
at beginning, in the middle (high-speed ferries) and
and at the end of shift subsequent recruitment of
volunteers from group of
navigators
Int Arch Occup Environ Health
 Table 2  continued
References Study design Sampling Response/participation rate Loss of data in analysis Multivariate analysis and Risk of bias
compared to initial sample adjustment for potential
<15% confounders
Lützhöft et al. (2010) On-board field study Purposive sampling of 13 100% Yes No 2+
Longitudinal/process design ships representing differ-
with 7 sleepiness ratings ent types of cargo vessels
during each watch within (e.g., bulk carriers, car
6-h on/6-h off system and carriers, tankers)
Int Arch Occup Environ Health

5 sleepiness ratings during All watchkeeping person-

each watch on 4-h on/8-h nel from the participating
off system ships was approached for
participation
Sa˛lyga and Kušleikaitė Cross-sectional survey All seafarers who came in 88.2% No Yes 2−
(2011) design for their mandatory health
examination between
November–December
2007 were approached for
participation
Sanquist et al. (1997) On-board field study Purposive sampling of 67% No No 2−
Longitudinal/process design different types of ships (6
over 10–30 consecutive freight ships and 2 tank-
days with alertness meas- ers) representing different
ures taken before and after operational aspects and
three work periods plus work hour regulations
one daily retrospective All categories of on-board
24-hour measurement personnel were contacted
for participation
Wadsworth et al. (2008) Cross-sectional survey Mail shots targeted at mem- Average: 20% No information Yes 2−
design bers of seafarers’ unions Offshore support: 31%
and crews of purposively Short sea/coastal: 23%
sampled shipping compa- Deep sea: 10%
nies from different sectors
(offshore support, short
sea/coastal, deep sea) plus
questionnaires distributed
on board of vessels from
different sectors

13
 Int Arch Occup Environ Health

psychosocial aspects, individual differences and lifestyle

Risk of bias factors. According to this review most evidence is avail-
able for sleep-related and work time-related determinants.
2+
A similar tendency could already be recognized by Allen
et al. (2008) as well as the more recent systematic review
Multivariate analysis and

by Oldenburg et al. (2013) on stress and strain in seafar-

adjustment for potential

ers, where a focus on watch systems and physical stress-

ors, such as noise, was found. The range of empirical evi-
dence thus does not seem to have changed much over the
confounders

last decade despite the reiterated indication of a clear gap

in research.
Yes

Sleep‑ and work time‑related determinants

compared to initial sample

in initial Seafarers Fatigue No (multivariate analyses)

Yes (bivariate analyses)
Loss of data in analysis

First, unsurprisingly, for sleep quality and sleep length,

an association with fatigue was consistently supported,
which is in line with what has been reported by a prior
review on stress in seafarers (Oldenburg et al. 2013), and
for other lines of the transportation industry as well as
<15%

other branches (Dorrian et al. 2011; Härmä et al. 2002;

Roach et al. 2011, Vincent et al. 2015). Second, work-
Response/participation rate

20% completed tour diary;

Of 1008 who participated

ing night shifts is more fatiguing compared to day shift

18% completed tour plus
Questionnaire Study:

work, which also is a well-established fact in maritime

work (see Allen et al. 2008; Jepsen et al. 2015; Olden-
burg et al. 2013), other transportation industries (Dorrian
leave diary

et al. 2011; Härmä et al. 2002; Hartzler 2014; Pylkkonen

et al. 2015; Sallinen et al. 2003) and different occupa-
tional sectors (Niu et al. 2011; Akerstedt 1995, 2003).
Work carried out throughout the biological night seems
ticipate in an additional ‘at
unions plus questionnaires

pled from different sectors

participants in the original

sea/coastal, deep sea); All

survey were asked to par-

vessels purposively sam-

to create a misalignment in the circadian process which

at members of seafarers’

sea’ and ‘on leave’ diary

Initial mail shots targeted

(offshore support, short

distributed on board of

affects alertness levels on the job and the ability to rest

and sleep at home (Arendt 2010; Cajochen et al. 2010;
Van Dongen 2006).
Third, there was largely consistent evidence that fatigue
Sampling

increases over the watch period. While this does not nec-
essarily imply that it is always critically high levels of
fatigue which are reached, the finding warrants attention
since effects of time into watch can be expected to interact
Longitudinal survey design

of or into bed around the

main sleep period over a
time participants got out
with measurement each

tour and a leave period

with those of night shift work as well as certain types of

On-board field study

watch systems, which have been identified as more fatigu-

over 28–35 days

ing. Thus, rotating systems in general seem more problem-

Study design

atic than fixed ones, and the 6-h on–6-h off scheme is more
fatiguing than other watch routines—especially the 4-h
on–8-h off system (see also Allen et al. 2008; Jepsen et al.
2015; Oldenburg et al. 2013; Smith et al. 2003), which is
plausible, since the 6-h on–6-h off system allows for only
six hours of consecutive sleep, which is below the recom-
Wadsworth et al. (2006)

mended 7–9 h for adults (Abrams 2015). Interestingly, one

Table 2  continued

study also reported an interaction between time of watch

and watch systems in that the fatigue-increasing effect of
References

time into watch was relevant for the 6-h on–6-h off but
not other watch systems (Lützhöft et al. 2010). In view
of these findings it can be considered problematic that the

13
Int Arch Occup Environ Health
6-h on–6-h off system is still commonly used as only two
watch teams are needed, which is why it is considered as
more cost-effective than, for instance, the 4-h on–8-h off
system, which requires three watch teams. Other research
has emphasized that shift work, including night shifts, has
a negative impact on work efficiency, vigilance, safety and
health (Boivin and Boudreau 2014; Knutsson 2003; Moser
et al. 2006; Niu et al. 2011; Szosland 2010; Touitou et al.
2014) and part of these effects may well be mediated by
buildup of fatigue.
Fourth, while fatigue tended to increase over the period
of a tour, comparisons between groups of seafarers on dif-
ferent vessels/tours indicated that a short time spent at sea
was experienced as more fatiguing than longer times. At
first glance this may seem counterintuitive as longer time
spent at sea implies longer exposure to fatigue-related risk
factors. However, length of time at sea may be associ-
ated with different types of vessels and work tasks. Allen
et al. (2003) reported that fatigue levels were notably
higher among those working on passenger vessels than, for
instance, tankers or dredgers. Ferry but also freight ship-
ping often involves short-term trips and tighter time sched-
ules as well as more port calls. Compared to routine activi-
ties and leisure time during sea passage, port calls usually
involve a higher task load and more time pressure, such as
frequent loading/unloading of goods or embarking/disem-
barking of passengers as well as documentation, adminis-
tration and controlling duties for officers. In comprehensive
field studies it is therefore necessary to distinguish between
occupational groups, type of vessel, voyage episodes and
shipping route as a precondition to develop specific inter-
vention strategies against fatigue.
Work demand factors as determinants of fatigue
Studies on the influence from the working environment
were surprisingly few—especially those explicitly deal-
ing with specific work demands and stress. Specific work
demands, e.g., experience of time pressure, physical
demands or work frustration, and stress were all reported to
be related to fatigue. It should be noticed though that all of
the respective studies were considered to be at higher risk
of bias due to, for instance, cross-sectional study designs,
and conclusions are therefore tentative at best. In particu-
lar work-related stress is considered an important factor
in other occupational areas (Sharpe and Wilks 2002) and
has been well researched in other occupational branches.
Therefore, the dearth of such studies in seafaring is aston-
ishing—not at least because in general seafaring is consid-
ered to be a potentially stressful occupation (Carotenuto
et al. 2012; Oldenburg et al. 2009; Rengamani and Muru-
gan 2012).
Tasks for future studies
First, beyond the underrepresentation of work environ-
ment and word demand factors in past and current research
on seafarer’s fatigue, a specific problem was a common
neglect of more complex relationships between differ-
ent types of factors, such as additive effects or interac-
tions. Lützhöft et al. (2010) investigated interaction effects
between watch systems and time of watch, and Wadsworth
et al. (2008), from a cross-sectional mail survey, reported
that a higher number of risk factors also meant a higher
level of fatigue experience, indicating a cumulative effect,
but these were exceptions. Second, a widening of the focus
toward aspects of work environment, specific types of work
demands and psychosocial issues as well as additive effects
and interactions between these factors and work time issues
or watch systems should thus be major issues for future
studies. Related to this is, third, the need to apply well-
established theoretical models about psychosocial work
environments and demands, such as Karasek’s Demand-
Control Model (Karasek 1979; Karasek and Theorell 1990;
Bultmann et al. 2002), Siegrist’s Effort-Reward Imbalance
Model (Siegrist 1996; Siegrist and Li 2016) or the use of
approaches focusing on interactions between professional
groups (Gittell 2005, 2009; Gittell et al. 2000, 2013). As
has been shown for onshore worksites, a systemic approach
to fatigue management and prevention which is needed to
design and implement successful programs requires knowl-
edge about a wide range of possible determinants (Dawson
and Mcculloch 2005; Dawson et al. 2012; Horrey et al.
2011).
Finally, it should be noted that the most important infor-
mation about fatigue comes from on-board field studies.
While time-consuming and personnel intensive, it is these
studies which best allow for a realistic assessment of the
working and living conditions likely to produce high lev-
els of fatigue and which therefore are needed in greater
numbers.
Risk of bias
In view of the fact that more than half of the included stud-
ies had to be considered as being at substantial risk for
biased findings due to potential confounding, more stud-
ies are needed which try to exclude extraneous influences
by using more compelling designs or at least make more
systematic attempts at assessing and statistically control-
ling such influences. It needs to be acknowledged though
that seafaring is inherently a challenging field for research,
since the range of work place influences is potentially larger
than on land, crews on individual ships are often small and
targets are moving and thus often difficult to recruit.
13

Another shortcoming relates to definition and measure-
ment of fatigue and the extent to which findings based on
different measures can be compared. There were no obvi-
ous differences in terms of detection of significant associa-
tions using different measures, but for a valid judgment on
these issue larger subgroups of studies being similar in all
other respects but measurement would be needed than were
actually available. This also links to the general question of
how fatigue was defined. Substantial differences and a lack
of coherence in definition have been noted in the more gen-
eral fatigue literature (Soames-Job and Dalziel 2008), and it
surely has implications whether the term fatigue is treated as
a synonym for (short-term) acute sleepiness, or if it reflects
a longer-term accumulated functional capacity reduction.
This, however, was rarely dealt with in the reviewed studies,
where only about half explicitly outlined a definition, and
where a clear rationale for the choice of measurement scale
was mostly lacking. Whether, however, alertness and fatigue
represent opposite ends of the same dimension or stand
for different dimensions altogether remains an open ques-
tion just as whether, for instance, the often-used Karolinska
Sleepiness Scale and the Patient-Specific Functional Scale
(PSFS) are functionally equivalent, since the latter has origi-
nally been developed to identify individuals with chronic
fatigue syndrome (Ray et al. 1992).
Regarding external validity, it needs to be noted that a
substantial group of studies focused on officers and/or
watch-keeping personnel from the merchant marine. Even
where other groups were included, systematic comparisons
in terms of age or rank were rarely conducted. Also, differ-
ent cultural backgrounds, which are common in seafaring,
seem not to have found much attention yet (see also Olden-
burg et al., 2013). Further, many studies used self-selection
or convenience sampling to recruit ships and/or/individual
participants and reported participation rates often were in
the low to moderate range only, all of which raises ques-
tions with regard to external validity. Thus, it appears
questionable if examined samples are representative for
the general seafaring population. While on the one hand,
ships with lesser fatigue problems on board might be over-
represented, it might vice versa be individuals with higher
fatigue problems who might have been more motivated to
participate in such studies.
Limitations of the review
While it would have been desirable to estimate average
effect sizes by meta-analytic techniques, the diversity of
study designs, samples, etc., and resulting small numbers
for comparable subgroups of findings as well as a presum-
able bias in many studies made pooling of effect estimates
non-feasible (Higgins and Altman 2008). In fact, it might be
13
Int Arch Occup Environ Health
argued that even a systematic review like the present one is
limited in its conclusions by the simultaneous variation of
types of study, study samples and fatigue measurement. In
the same vein, a more systematic and comprehensive link-
age of evidence quality with specific types of outcomes was
not possible since variations over different parameters made
subgrouping problematic. Further, the inclusion/exclusion
of studies based on a restricted fatigue definition/measure-
ment might be debated. As discussed above, concepts and
operationalizations varied widely and using narrower or
wider criteria (for instance by including performance crite-
ria) could be argued for or against. Finally, there is a pos-
sibility of publication bias in that it cannot be excluded that
the review overlooked studies which have not found their
way into the established documented publication outlets.
Conclusion
What was most striking in general, was the limited range of
factors that has so far been investigated and that the focus has
predominantly been on more ‘obvious’ issues such as sleep
and work time aspects, establishing in particular the relevance
of night shift work, length of shifts and watch system arrange-
ments. As the maritime business is a 24-h industry, night and
evening shifts are unavoidable. This means, however, that
realistic countermeasures ought to be established, e.g., in
terms of shared or split night shifts, longer or more frequent
breaks as well as an increased reliance on the 4-h on–8-h
off system, and also aiming at less than nine working hours
a day. Clearly this will raise demands for manning, which
puts a strain on budgets, thus jeopardizing the competitive-
ness of shipping companies which are operating under highly
competitive market conditions (Allen et al. 2007). However,
fatigue endangers the safety of the crews, the passengers, the
ship and the environment (Allen et al. 2008; Maritime Acci-
dent Investigation Branch 2004; Wadsworth et al. 2008), and
therefore realistic preventive programs must be initiated—
preferably supported by international regulations based on a
‘shared responsibility’ approach in order to promote fair con-
ditions across the industry (Allen et al. 2007).
Most importantly, to support development of effective
work-site prevention interventions which go beyond work
time regulations, further knowledge needs to be provided
from studies of high methodological quality including
larger samples which, in particular, broaden the scope by
including factors from a much wider range of influences on
fatigue than has so far been the case. This includes investi-
gations of the role of specific work demands, work climate,
psychosocial factors as well as collaborative processes,
which not at least also start focusing on the interplay
between these different types of fatigue determinants. To
support future research the development of a set of research
Int Arch Occup Environ Health
guidelines is strongly recommended and should be prior-
itized by the Maritime Research Society. Such guidelines
should, for instance, outline recommended study designs,
sampling methods and measurements instruments and
thereby not only help reduce risk of bias in future studies
but also enable comparability between study findings.
Acknowledgements  The funding was provided by Faculty of Health
Sciences, University of Southern Denmark.
Compliance with ethical standards  Arch Occup Environ Health 60:405–411
Conflict of interest  The authors declare that they have no conflict of
interest.
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