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Gregory, Kevin B.

Publications and source records attributed to Gregory, Kevin B..

At least 19 records

A Summary Of: Collecting Sleep, Circadian, Fatigue, and Performance Data in Complex Operational Environments

Sleep loss and circadian misalignment contribute to a meaningful proportion of operational accidents and incidents. Countermeasures and work scheduling designs aimed at mitigating fatigue are typically evaluated in controlled laboratory environments, but the effectiveness of translating such strategies to operational environments can be challenging to assess. This manuscript summarizes an approach for collecting sleep, circadian, fatigue, and performance data in a complex operational environment. We studied 44 airline pilots over 34 days while they flew a fixed schedule, which included a baseline data collection with 5 days of mid-morning flights, four early flights, four high-workload mid-day flights, and four late flights that landed after midnight. Each work block was separated by 3-4 days of rest. To assess sleep, participants wore a wrist-worn research-validated activity monitor continuously and completed daily sleep diaries. To assess the circadian phase, pilots were asked to collect all urine produced in four or eight hourly bins during the 24 h after each duty block for the assessment of 6-sulfatoxymelatonin (aMT6s), which is a biomarker of the circadian rhythm. To assess subjective fatigue and objective performance, participants were provided with a touchscreen device used to complete the Samn-Perelli Fatigue Scale and Psychomotor Vigilance Task (PVT) during and after each flight, and at wake-time, mid-day, and bedtime. Using these methods, it was found that sleep duration was reduced during early starts and late finishes relative to baseline. Circadian phase shifted according to duty schedule, but there was a wide range in the aMT6s peak between individuals on each schedule. PVT performance was worse on the early, high-workload, and late schedules relative to baseline. Overall, the combination of these methods was practical and effective for assessing the influence of sleep loss and circadian phase on fatigue and performance in a complex operational environment.

Arsintescu, Lucica

The Relationship between Workload, Performance and Fatigue in a Short-Haul Airline

Short-haul flights are associated with irregular work schedules and increased workload, due to frequent takeoffs and landings. We examined the relationship between pilot workload, performance and subjective fatigue during normal short-haul operations. Ninety airline pilots (8 female), mean age 33 (±8 years) completed a NASA-Task Load Index (NASA-TLX), a Psychomotor Vigilance Task (PVT; a reaction time test sensitive to sleep loss) and a Samn-Perelli (SP) fatigue scale, over a period of 20 duty days at top-of-descent on 2762 short-haul flights. The duty days included either 2 or 4 flights per day starting at different times as scheduled during normal operations. Workload was measured using the six NASA-TLX scales: mental demand, physical demand, temporal demand, effort, performance and frustration. Lapses (reaction times [RT] > 500ms) were calculated for the PVT. Spearman correlations were calculated to identify relationships between the NASA-TLX, PVT lapses, and SP. The six scales of NASA-TLX were positively correlated with the PVT lapses (p < 0.01) showing an increase in workload when lapses increased. There was a positive correlation between subjective fatigue as measured by the SP fatigue scale and each of the six scales of NASA-TLX (p < 0.001) suggesting that pilots reported higher workload when perceived levels of fatigue were higher. Of the six workload scales, mental demand and performance were rated the highest (mental: M = 40.99, SD = 20.32; performance: M = 41.61, SD = 20.71) and effort was rated the lowest (M = 15.59, SD = 8.98). Preliminary analyses suggest that high workload is associated with poorer PVT performance and increased self-reported fatigue in this population of short-haul pilots. Future studies should explore how other workload factors (i.e. flight hours, time of day) influence self-reported and objective fatigue measures.

TLX

Schedule Factors Associated with the Use of Controlled Rest in a Long-Haul Airline

Controlled Rest (CR) refers to a short, voluntary nap opportunity taken by pilots on the flight deck as a countermeasure to unanticipated sleepiness in flight. This study explores the profile of CR use in a long-haul commercial airline. Forty-four pilots wore actiwatches and filled in an application-based sleep/work diary for approximately 2 weeks. After merging sleep diary, actigraphy, and schedule data, complete records were analyzed from 240 flights. Sleep was estimated during CR intervals using the Philips Actiware 6.0.9 (Bend, OR) software with wake threshold set to medium. Timing of sleep periods and flight schedules were analyzed relative to home-base time. A mixed-effects binary logistics regression was used to analyze the impact of schedule factors on CR. Preliminary analyses revealed that CR was taken on 45% (n=107) of flights. Average sleep duration within these rest periods was estimated as 24.8 ± 16.1 minutes. CR was more frequent on return flights (arriving at home-base; 58%, n=69) vs. outbound flights (departing from home-base, 31%, n=38; p<0.001). There was no difference for direction of travel (eastbound: 49%, n= 56; westbound: 40%, n= 44; northbound/southbound: 50%, n=7; p=0.272). CR was more frequent on 2-pilot flights (62%, n=81) compared to augmented crew flights (24%, n=26; p<0.001). Of note, 21% (n=23) of augmented flights contained both CR and Bunk Rest. CR was more frequent on flights <10h duration (<10h: 59%, n=78; >10h: 27%, n=29; p<0.001). Flights departing between 12:00h-19:59h (25%, n=23; p<0.026) had the lowest frequency of CR. Data from this airline show that CR is most commonly used as a countermeasure to sleepiness on return, unaugmented, <10h duration, and nighttime flights. The direction of travel did not influence the use of CR. Future studies are required to determine generalizability of these results to other airlines.

Hilditch, Cassie

The Prevalence of Controlled Rest as a Countermeasure to Sleepiness on the Flight Deck

Despite the introduction of flight, duty, and rest time regulations to reduce the risk of sleepiness, airline pilots often encounter elevated sleepiness during flight. To combat this sleepiness, in some instances, pilots can take a short nap on the flight deck (controlled rest) to improve their alertness. Little is known, however, as to when and how often this countermeasure is used operationally.

sleepiness

San Francisco Bar Pilot Fatigue Study

The purpose of this study was to evaluate the extent of fatigue among San Francisco Bar Pilots (Maritime Pilots) and its potential impact on safety, and to make recommendations concerning how the risk of fatigue could be managed. Information was gathered via a literature review, observations of Bar Pilots at work, surveys, a task analysis, and an analysis of dispatch records.The work of San Francisco Bar Pilots involves an unusual mix of activities and job demands. Their work calls for situational awareness, reasoning, communication, and perceptual abilities comparable to those required by airline pilots and air traffic controllers. Errors can have severe consequences for public safety and the environment, as well as significant financial costs. Fatigue is increasingly recognized as a hazard that must be managed by the transportation industry. The reduced sleep quality and quantity experienced by personnel who work at night, in conjunction with human circadian rhythms can lead to an operationally significant level of cognitive impairment. The cognitive impact of fatigue includes functions that are critical to safe maritime piloting, such as vigilance, judgment, reaction time and communication. The surveys distributed to Bar Pilots did not uncover evidence of widespread fatigue. The survey results also suggested that fatigue was not a major concern of Bar Pilots. Bar Pilots had overall low scores on the subjective fatigue measures used in the survey, and generally assessed the safety risk due to fatigue as low. Compared to air traffic controllers, Bar Pilots gave significantly lower ratings on questions concerning the prevalence and impact of fatigue. The application of fatigue modeling software to Bar Pilot dispatch records identified that in most cases, pilot's cognitive effectiveness was predicted to be acceptable during their duty periods. However, these results could not be verified with objective data.The study identified a number of fatigue issues that deserve attention. These include Bar Pilot work periods that frequently infringe on the circadian low, consecutive work periods without a significant break, consecutive periods of night work, unpredictable work schedules, start time variability, the potential for sleep inertia, and the number of pilots on the board at any given time.

fatigue

NAPS as an Alertness Management Strategy

Today, 24-hour operations are necessary to meet the demands of our society and the requirements of our industrialized global economy. These around-the-clock demands pose unique physiological challenges for the humans who remain central to safe and productive operations. Optimal alertness and performance are critical factors that are increasingly challenged by unusual, extended, or changing work/rest schedules. Technological advancements and automated systems can exacerbate the challenges faced by the human factor in these environments. Shift work, transportation demands, and continuous operations engender sleep loss and circadian disruption. Both of these physiological factors can lead to increased sleepiness, decreased performance, and a reduced margin of safety. These factors can increase vulnerability to incidents and accidents in operational settings. The consequences can have both societal effects (e.g., major destructive accidents such as Three Mile Island, Exxon Valdez, Bhopal) and personal effects (e.g., an accident driving home after a night shift).

Rosekind, Mark R.

Crew Factors in Flight Operations XII: A Survey of Sleep Quantity and Quality in On-Board Crew Rest Facilities

Many aircraft operated on long-haul commercial airline flights are equipped with on-board crew rest facilities, or bunks, to allow crewmembers to rest during the flight. The primary objectives of this study were to gather data on how the bunks were used, the quantity and quality of sleep obtained by flight crewmembers in the facilities, and the factors that affected their sleep. A retrospective survey comprising 54 questions of varied format addressed demographics, home sleep habits, and bunk sleep habits. Crewmembers from three airlines with long-haul fleets carrying augmented crews consisting of B747-100/200, B747-400, and MD-11 aircraft equipped with bunks returned a total of 1404 completed surveys (a 37% response rate). Crewmembers from the three carriers were comparable demographically, although one carrier had older, more experienced flight crewmembers. Each group, on average, rated themselves as "good" or "very good" sleepers at home, and all groups obtained about the same average amount of sleep each night. Most were able to sleep in the bunks, and about two thirds indicated that these rest opportunities benefited their subsequent flight deck alertness and performance. Comfort, environment, and physiology (e.g., being ready for sleep) were identified as factors that most promoted sleep. Factors cited as interfering with sleep included random noise, thoughts, heat, and the need to use the bathroom. These factors, in turn, suggest potential improvements to bunk facilities and their use. Ratings of the three aircraft types suggested differences among facilities. Bunks in the MD-11 were rated significantly better than either of the B747 types, and the B747-400 bunks received better ratings than did the older, B747-100/200 facilities.

Rosekind, Mark R.

Crew Factors in Flight Operations: A Survey of Fatigue Factors in Corporate/Executive A Viation Operations - 8

Corporate flight crews face unique challenges including unscheduled flights, quickly changing schedules, extended duty days, long waits, time zone changes, and peripheral tasks. Most corporate operations are regulated by Part 91 FARs which set no flight or duty time limits. The objective of this study was to identify operationally significant factors that may influence fatigue, alertness, and performance in corporate operations. In collaboration with the National Business Aircraft Association and the Flight Safety Foundation, NASA developed and distributed a retrospective survey comprising 107 questions addressing demographics, home sleep habits, flight experience, duty schedules, fatigue during operations, and work environment. Corporate crewmembers returned 1,488 surveys. Respondents averaged 45.2 years of age, had 14.9 years of corporate flying experience, and 9,750 total flight hours. The majority (89%) rated themselves as 'good' or 'very good' sleepers at home. Most (82%) indicated they are subject to call for duty and described an average duty day of 9.9 h. About two-thirds reported having a daily duty time limit and over half (57%) reported a daily flight time limit. Nearly three-quarters (71%) acknowledged having 'nodded off' during a flight. Only 21% reported that their flight departments offer training on fatigue issues. Almost three-quarters (74%) described fatigue as a 'moderate' or 'serious' concern, and a majority (61%) characterized it as a common occurrence. Most (85%) identified fatigue as a 'moderate' or 'serious' safety issue.

Rosekind, Mark R.

Crew Factors in Flight Operations: A Survey of Fatigue Factors in Regional Airline Operations - 11

This report is the eleventh in a series on the physiological effects of flight operations on flight crews. A 119-question survey was completed by 1,424 flight crewmembers from 26 regional carriers to identify factors contributing to fatigue in regional airline operations. Eighty-nine percent of crewmembers identified fatigue as a moderate or serious concern with 88% reporting that it was a common occurrence and 92% reporting that, when it occurs, fatigue represents a moderate or serious safety issue. However, 86% reported they received no company training addressing fatigue issues. Identified fatigue factors included multiple flight segments, scheduling considerations, varying regulations, and others. The two most commonly cited fatigue factors regarded flying multiple (more than four) segments. Scheduling factors accounted for nine of the ten most common recommendations to reduce fatigue in regional operations. Differing requirements among regulations were cited as contributing to fatigue. Other identified factors were the flight deck environment, automation, and diet. The data suggested specific recommendations, including education of industry personnel about fatigue issues and examination of scheduling practices. Education plays a critical role in any effort to address fatigue. Analyzing scheduling practices and identifying potential improvements may result in reduced fatigue as well as other benefits to operations.

Co, Elizabeth L.

The NASA Ames Fatigue Countermeasures Program: The Next Generation

Twenty-four hour, global aviation operations pose unique challenges to humans. Physiological requirements related to sleep, the internal circadian clock, and human fatigue are critical factors that are known to affect safety, performance, and productivity. Understanding the human operators' physiological capabilities, and limitations, will be important to address these issues as global demand for aviation activities continues to increase. In 1980, in response to a Congressional request, the National Aeronautics and Space Administration (NASA) Ames Research Center initiated a Fatigue/Jet Lag Program to examine the role of fatigue in flight operations. Originally established by Dr. John K. Lauber and Dr. Charles E. Billings, the Program was designed to address three objectives: (1) determine the extent of fatigue, sleep loss, and circadian disruption in flight operations; (2) determine how fatigue affected flight crew performance; and (3) develop strategies to maximize performance and alertness during flight operations.

Rosekind, Mark R.

Research on the Effects of Fatigue within the Corporate/Business Aircraft Environment

In 1980, responding to a Congressional request, NASA Ames Research Center created a program to examine whether 'there is a safety problem of uncertain magnitude, due to transmeridian flying and a potential problem due to fatigue in association with various factors found in air transport operations.' The NASA Ames Fatigue/Jet Lag Program was created to collect systematic, scientific information on fatigue, sleep, circadian rhythms, and performance in flight operations. Three Program goals were established and continue to guide research efforts to: (1) determine the extent of fatigue, sleep loss, and circadian disruption in flight operations; (2) determine the impact of these factors on flight crew performance; (3) develop and evaluate countermeasures to mitigate the adverse effects of these factors and maximize flight crew performance and alertness. Since 1980, studies have been conducted in a variety of aviation environments, in controlled laboratory environments, as well as in a full-mission flight simulation. Early studies included investigations of short-haul, long-haul, and overnight cargo flight crews. In 1991, the name of the program was changed to the Fatigue Countermeasures Program to provide a greater emphasis on the development and evaluation of countermeasures. More recent work has examined the effects of planned cockpit rest as an operational countermeasure and provided analyses of the pertinent sleep/duty factors preceding an aviation accident at Guantanamo Bay, Cuba. The Short-Haul study examined the extent of sleep loss, circadian disruption, and fatigue engendered by flying commercial short-haul air transport operations (flight legs less than eight hours). This was one of the first field studies conducted by the NASA program and provided unique insight into the physiological and subjective effects of flying commercial short-haul operations. It demonstrated that a range of measures could be obtained in an operational environment without disturbing the regular performance of duties. The Long-Haul study examined how long-haul flight crews organized their sleep during a variety of international trip patterns and examined how duty requirements, local time, and the circadian system affected the timing, duration, and quality of sleep. Duty requirements and local time can be viewed as external/environmental constraints on time available for sleep, while the internal circadian system is a major physiological modulator of sleep duration and quality. The Overnight Cargo study documented the psychophysiological effects of flying overnight cargo operations. The data collected clearly demonstrated that overnight cargo operations, like other night work, involve physiological disruption not found in comparable daytime operations.

Neri, David F.

Crew Factors in Flight Operations 7: Psychophysiological Responses to Overnight Cargo Operations

To document the psychophysiological effects of flying overnight cargo operations, 41 B-727 crew members (average age 38 yr) were monitored before, during, and after one of two typical 8-day trip patterns. During daytime layovers, the average sleep episode was 3 hr (41%) shorter than nighttime sleeps and was rated as lighter, less restorative, and poorer overall. Sleep was frequently split into several episodes and totaled 1.2 hr less per 24 hr than on pretrip days. Each trip pattern included a night off, which was an effective countermeasure against the accumulating sleep debt. The organization of sleep during daytime layovers reflected the interaction of duty timing with circadian physiology. The circadian temperature rhythm did not adapt completely to the inverted wake-rest schedule on duty days, being delayed by about 3 hr. Highest subjective fatigue and lowest activation occurred around the time of the temperature minimum. On duty days, reports of headaches increased by 400%, of congested nose by 200%, and of burning eyes by 900%. Crew members also reported eating more snacks. Compared with daytime short-haul air-transport operations, the overnight cargo trips included fewer duty and flight hours, and had longer layovers. Overnight cargo crews also averaged 5.4 yr younger than their daytime short-haul counterparts. On trips, both groups lost a comparable amount of sleep per 24 hr, but the overnight cargo crews had shorter individual sleep episodes and more broken sleep. These data clearly demonstrate that overnight cargo operations, like other night work, involve physiological disruption not found in comparable daytime operations.

Gander, Philippa H.

Flight Schedule and the Circadian Clock Influence on Sleep Loss During Overnight Cargo Operations

Thirty-four flight crew members were monitored before, during, and after two 8-day overnight cargo duty patterns which involved multiple flights at night crossing no more than one time zone per 24 h. Rectal temperature, heart rate, and wrist activity were recorded every 2 min. Sleep quantity and quality, and nap timing, were noted in a logbook. To reduce the masking effects of physical activity on temperature, 0.28 C was added to each subject's raw temperature data whenever he reported being asleep. For both masked and unmasked data, daily temperature minima were estimated from the multiple complex demodulated waveform. The temperature minima did not show a progressive adaptation to night duty, which was interrupted by a night off after 5 nights on one trip pattern and after 3 nights on the other. On duty days, the average temperature minimum delayed by about 3 h, occurring near the end of the duty period. Daytime sleep episodes averaged 2.9 h shorter than nighttime sleep episodes, and were rated as lighter, less restorative, and poorer overall. Fifty-three percent of subjects slept more than once per 24 h while they were on night duty, compared to 17% when able to sleep at night. The total sleep per 24 h on duty days averaged 1.2 h less than pretrip. Twenty-nine percent of subjects lost more than 2 h of sleep per 24 h across the 8-day duty patterns. After night duty, subjects awoke around 1400 local time, even when they had slept 2-3 h less than a normal nocturnal sleep episode. Consequently, the duration of morning sleep episodes was correlated with the off-duty time (multiple r(sup 2)=0.44, F=37.23, p less than 0.0001). Anecdotally, crew members complained of being unable to sleep longer and not feeling well-rested. These wakeups were clustered 6 h after the temperature minimum, which suggests that they may have been a response to the circadian wakeup signal. Daytime layovers in which crew members were able to sleep again in the evening ended later (0200-0300) and were longer (average 19.2 h versus 14.8 h) than those in which they slept only once in the morning. Overnight cargo crew members are working around the time of the circadian nadir with an accumulating sleep debt. Two scheduling factors affect sleep loss during these operations: how long before the circadian wakeup signal crew members come off duty, and whether the layover lasts long enough to permit a second sleep episode in the early evening.

Gander, Philippa H.

Flight Crew Sleep in Long-Haul Aircraft Bunk Facilities: Survey Results

Modem long-haul aircraft can fly up to 16 continuous hours and provide a 24-hour, global capability. Extra (augmented) flight crew are available on long flights to allow planned rest periods, on a rotating basis, away from the flight deck in onboard crew rest facilities (2 bunks). A NASA/FAA study is under-way to examine the quantity and quality of sleep obtained in long-haul aircraft bunks and the factors that promote or interfere with that sleep. The first phase of the study involved a retrospective survey, followed by a second phase field study to collect standard polysomnographic data during inflight bunk sleep periods. A summary of the Phase I survey results are reported here. A multi-part 54-question retrospective survey was completed by 1,404 flight crew (37% return rate) at three different major US air carriers flying B747-100, 200, 400, and MD- 11 long-haul aircraft. The questions examined demographics, quantity and quality of sleep at home and in onboard bunks, factors that promote or interfere with sleep, and effects on subsequent performance and alertness. Flight crew reported a mean bunk sleep latency of 39.4 mins (SD=28.3 mins) (n=1,276) and a mean total sleep time of 2.2 hrs (SD=1.3 hrs) (n=603). (Different flight lengths could affect overall time available for sleep.) Crew rated 25 factors for their interference or promotion of bunk sleep. Figure I portrays the average ratings for each factor across all three carriers. A principal components analysis of the 25 factors revealed three areas that promoted bunk sleep: physiological (e.g., readiness for sleep), physical environment (e.g., bunk size, privacy), and personal comfort (e.g., blankets, pillows). Five areas were identified that interfered with sleep: environmental disturbance (e.g., background noise, turbulence), luminosity (e.g., lighting), personal disturbances (e.g., bathroom trips, random thoughts), environmental discomfort (e.g., low humidity, cold), and interpersonal disturbances (e.g., bunk partner).

Rosekind, Mark R.

Crew factors in flight operations 6: Psychophysiological responses to helicopter operations

Thirty-two helicopter pilots were studied before, during, and after 4-5 day trips providing support services from Aberdeen, Scotland, to rigs in the North Sea oil fields. Early on-duty times obliged subjects to wake up 1.5 hours earlier on trip days than on pretrip days. Consequently, they slept nearly an hour less per night on trips. They reported more fatigue on post-trip days than on pretrip days, suggesting a cumulative effect of duty-related activities and sleep loss. Fatigue and negative affect were higher, and activation lower, by the end of trip days than by the end of pretrip days. The earlier a subject went on duty, the lower his activation by the end of the day. Caffeine consumption increased 42 percent on trip days. The incidence of headache doubled, of back pain increased twelve fold, and of burning eyes quadrupled. In the aircraft studied, thermal discomfort and high vibration levels were common. The longer pilots remained on duty, the more negative their mood became.

Gander, Philippa H.

Fatigue in operational settings: Examples from the aviation environment

The need for 24-h operations creates nonstandard and altered work schedules that can lead to cumulative sleep loss and circadian disruption. These factors can lead to fatigue and sleepiness and affect performance and productivity on the job. The approach, research, and results of the NASA Ames Fatigue Countermeasures Program are described to illustrate one attempt to address these issues in the aviation environment. The scientific and operational relevance of these factors is discussed, and provocative issues for future research are presented.

Rosekind, Mark R.

Analysis of Crew Fatigue in AIA Guantanamo Bay Aviation Accident

Flight operations can engender fatigue, which can affect flight crew performance, vigilance, and mood. The National Transportation Safety Board (NTSB) requested the NASA Fatigue Countermeasures Program to analyze crew fatigue factors in an aviation accident that occurred at Guantanamo Bay, Cuba. There are specific fatigue factors that can be considered in such investigations: cumulative sleep loss, continuous hours of wakefulness prior to the incident or accident, and the time of day at which the accident occurred. Data from the NTSB Human Performance Investigator's Factual Report, the Operations Group Chairman's Factual Report, and the Flight 808 Crew Statements were analyzed, using conservative estimates and averages to reconcile discrepancies among the sources. Analysis of these data determined the following: the entire crew displayed cumulative sleep loss, operated during an extended period of continuous wakefulness, and obtained sleep at times in opposition to the circadian disposition for sleep, and that the accident occurred in the afternoon window of physiological sleepiness. In addition to these findings, evidence that fatigue affected performance was suggested by the cockpit voice recorder (CVR) transcript as well as in the captain's testimony. Examples from the CVR showed degraded decision-making skills, fixation, and slowed responses, all of which can be affected by fatigue; also, the captain testified to feeling "lethargic and indifferent" just prior to the accident. Therefore, the sleep/wake history data supports the hypothesis that fatigue was a factor that affected crewmembers' performance. Furthermore, the examples from the CVR and the captain's testimony support the hypothesis that the fatigue had an impact on specific actions involved in the occurrence of the accident.

Rosekind, Mark R.

Flight controller alertness and performance during MOD shiftwork operations

Decreased alertness and performance associated with fatigue, sleep loss, and circadian disruption are issues faced by a diverse range of shiftwork operations. During STS operations, MOD personnel provide 24 hr. coverage of critical tasks. A joint JSC and ARC project was undertaken to examine these issues in flight controllers during MOD shiftwork operations. An initial operational test of procedures and measures was conducted during STS-53 in Dec. 1992. The study measures included a background questionnaire, a subjective daily logbook completed on a 24 hr. basis (to report sleep patterns, work periods, etc.), and an 8 minute performance and mood test battery administered at the beginning, middle, and end of each shift period. Seventeen Flight controllers representing the 3 Orbit shifts participated. The initial results clearly support further data collection during other STS missions to document baseline levels of alertness and performance during MOD shiftwork operations. These issues are especially pertinent for the night shift operations and the acute phase advance required for the transition of day shift personnel into the night for shuttle launch. Implementation and evaluation of the countermeasure strategies to maximize alertness and performance is planned. As STS missions extend to further extended duration orbiters, timelines and planning for 24 circadian disruption will remain highly relevant in the MOD environment.

Kelly, Sean M.