More flying sorties based from the territorial United States, fewer overseas bases, less pre-positioning, volatile over-flight protocols, a greater reliance on airpower for power projection and enemy will-breaking—it all adds up to longer missions in the cockpit for today’s pilots. And longer missions invariably lead to greater individual fatigue. The Air Force has examined the paradigm and realizes that the human factor, the need for cockpit comfort, has never been more urgent.

Final Straws

“Using stimulants is the last tool in the toolbox for pilots,” explained Major Michael Jackson Jr., an Air Combat Command evaluator pilot for the B-1. Based at Dyess Air Force Base, TX, Jackson has flown many long missions and has had personal experience not just in the war on terrorism, but also in the permanent war on fatigue. “We have a lot of techniques and ways of dealing with long missions and the accompanying stress and exhaustion,” Jackson told Military Aerospace Technology. Jackson’s experiences indicate that pilots will be asked to endure more time in the cockpit, at greater levels of stress to complete far-flung missions.

Jackson copes with sleep deprivation and discomfort through diet, exercise, maximum crew rest before missions, music, talking and a slap of cold water in the face. “Fortunately in the B1 there is a little room in the aisle for one of us to get a little cat nap if we need one. We have four people on board which makes it a little easier,” observed Jackson.

“During Operation Enduring Freedom, we had a 22-hour flight with in-air refueling which can be very fatiguing. We’re trained to understand our circadian clock, which is very important in understanding the challenge. Our internal clock tells us we should be pretty sleepy between 3 and 5 a.m. and in the middle of the afternoon. Knowing this helps us to manage our sleeping habits. We’ve discovered ways of dealing with the energy drain, and the fatigue countermeasures are available if we think we’ll need them for a mission, again as a last resort to slow the impact of exhaustion.” Occasionally, pilots find themselves so out of cycle, Jackson explained, that it’s necessary to ask the flight surgeon for some medication to help sleep. “That can get you back into your circadian rhythm,” he added.

Doctor’s Call

Dr. John A. Caldwell of the Air Force Research Laboratory has conducted years of testing on “Go Pills,” the need for them and their side effects. “Increasingly, the military is looking at counter-fatigue medications because we have an increasing operational tempo and fewer overseas basing opportunities,” explained Caldwell. There are steps pilots can take to avoid the toolbox bottom-the use of sleep countermeasures like the amphetamine dextroamphetamine or Dexedrine. When possible, pilots can avoid stimulants by: controlling work schedules to factor in regular sleep; get regular crew rest after 12 hours of work; become educated about crossing multiple time zones and scheduling rest accordingly; staying fit; avoiding sleep-promoting food and drinks.

“The expression ‘Go Pill’ is really misleading,” said Caldwell. “Dexedrine slows the onset of fatigue. It’s given in 5 to 10 milligram doses, much less than is given to kids with attention deficit disorder in many of our schools,” explained Caldwell. “Pilots are ground tested with the drug in advance to ensure there will be no problems in the operational environment, and side effects which can include increased blood pressure and some difficulty resuming normal sleeping patterns are very pretty mild.” The Air Force’s approval of Dexedrine for pilots in single and dual-seated aircraft for up to 10 mgs at a time for some sustained missions indicates a widening acceptance that missions will probably keep getting longer.

Under study by the Air Force as a possible alternative or supplement to Dexedrine is another drug, Modafinil. Considered by some to be better suited for situations where a prescription medication is needed to sustain performance during prolonged periods of total sleep loss, Modafinil does not seem to manifest the side effect of slightly disturbing sleep after use, as is sometimes the case with Dexedrine (according to Caldwell’s March 2003 article, “Running on Empty” in the Air Force’s Flying Safety magazine).

Caldwell explained that Modafinil, sold under the brand name Provigil, was being used to control narcolepsy (uncontrollable daytime sleepiness) and has been used by some people outside the military for sustaining alertness during periods of sleep deprivation since 1998. The drug has been approved in France since 1993.

While the FDA has not yet recommended that the drug be used for fighting fatigue in sleepy but otherwise normal personnel, it is being closely examined by the Air Force medical community as a possible successor or alternative to Dexedrine. Cephalon, of Westchester, PA, produces Modafinil. Like Dexedrine, Modafinil is being used to treat the symptoms of narcolepsy, and it is being examined as a possible treatment for attention deficit/hyperactivity disorder.

“While we’re not issuing Modafinil yet, it wouldn’t surprise me to see it being used by the Air Force in the next year or so,” said Caldwell. “Provigil seems to be the kind of stimulant that entails very little risk of abuse, and that is why it is becoming increasingly popular. Also, research has shown that Provigil can maintain alertness without degrading the quality of subsequent sleep opportunities. We’ve heard that sometimes Dex makes it harder for pilots to sleep if it is taken too close to bed time.”

A Modafinil study has been conducted on helicopter pilots and one is being proposed for Air Force fighter pilots. “We found that Modafinil does promote alertness in sleep-deprived people,” remarked Caldwell. “But we’re not really sure how it stimulates the wake-control areas of the brain. We have observed that it doesn’t have the same side-effects as Dex, that it doesn’t seem to affect blood pressure or heart rate.” Caldwell, currently doing a sleep deprivation study on F-117 pilots, also found from his previous research that subjects didn’t feel particularly stimulated after using Modafinil, however, he was not willing to conclude that the drug is “better” than Dexedrine.

“Dexedrine has been thoroughly studied in the laboratory and the field, it has a good operational history, and there have never been any Air Force mishaps connected to this drug,” he said. Caldwell explained that while personnel have decreased by some 37 percent since the end of the Cold War, OPTEMPO has increased disproportionably. It is this situation that makes it critical that the Air Force research community investigate safe and effective fatigue countermeasures. In studying sustained wakefulness in cockpit simulators, Caldwell noted that untreated fatigue causes decreases in attention span, and increases in operational errors, but compounds such as Dexedrine significantly improved these areas by fending off fatigue and reducing discomfort. “I’d fly with someone on Dex rather than an untreated, fatigued pilot because I know it’s safe and effective,” said Caldwell.

In addition to pharmacological anti-fatigue strategies, Caldwell has recommended nonpharmacological strategies for countenancing fatigue to include exercise, naps and schedule adjustments. In addition, both the Air Force and the Army are exploring ways to ensure that personnel can make the most out of every sleep opportunity they get.

Whether pilot sleep is threatened by prolonged ground action and the accompanying adrenaline rush, or whether it suffers due to poor sleep environments or shift work, the military is looking to mitigate the problems with sleep-promoting drugs like, Zolpidem, Zaleplon and Temazepam. They are also trying to learn how to reduce poor performance in the early morning hours and in the afternoon by helping people reset their circadian clocks when they travel to new time zones or start working new shifts.

Colonel Thomas Hyde, chief of “Checkmate,” the Air Force Chief of Staff directorate for Air and Space Strategy Development has had personal experience with Dexedrine. Asked about media reports that have emphasized the use of amphetamines to counter the effects of sleep deprivation, Hyde emphasized that the decision to use any stimulant remains with the pilot and that all medication is strictly accounted for, the unused portion collected after the mission.

“The things to remember are that these countermeasures have had a long history of success. From 1977 to 1997 we found that fatigue was a factor in 105 or so flight incidents. Operational art and science both tell us that use of this medication of mission-critical flights is positive from both an operational and a pilot safety perspective,” said Hyde. Asked about side effects, Hyde added, “I’ve never personally experienced having a hard time falling asleep after using Dex and I’d feel confident knowing that Dex was being used on a prolonged mission. The amount of mistakes fall, reaction times are better, there is better attention span and coordination and we’ve seen that.”

The Air Force medical community has taken the lead role in strategizing the uses of medication for longer missions. Lieutenant Colonel (Dr.) Vincent Michaud, aerospace medical consultant to the Air Force surgeon general and chief of Aerospace Medicine Division discussed the “Go Pill” and the need for increasing cockpit comfort with MAT.

Michaud has both issued Dexedrine and managed pilots on longer missions who carried the medication. “Let’s remember that these pills are really a minor part of the overall program to counter fatigue in our pilots,” said Michaud. Asked about the possible replacement of Dexedrine by Modafinil, Michaud said, “Preliminary review indicates that Provigil holds a lot of promise for us. But like all these kinds of medications, they are just options for pilots, no one is forced to take any drug. The flight surgeons monitor the use of the amphetamines very closely and the pills are a controlled item. The unused portion is always collected after the long-duration mission. We’re still studying Modafinil,” he said.

Michaud went on to remark, “Charles Lindbergh was uncomfortable in the cockpit and even after 70 years of working hard on this, we’re still thinking about  the capability of the aircraft rather than the comfort of the pilot. That’s changing. The emphasis is coming back to the human asset. In fact, we’re so cognizant of the need for sleep, we’ll encourage it if it’s possible for one pilot to get a nap while his or her partner is awake,” he said.

There are other issues with comfort in the cockpit that most non-fliers rarely consider. For instance, most airframes aren’t designed to accommodate human waste that can be produced over long periods in the air, often extended by air refueling. Creature comforts are cut to make more room in the budget for airframes and their support. Another important comfort issue is the ejection seat.

“We know many of the ejection seats are not comfortable but they are necessary,” said Michaud. But the Air Force is using air conditioning and other technological changes to help pilots to be as comfortable and practicable. “We realize that the Air Force is very stringently against the use of drugs, but in this case we just don’t have the luxury to be 100 percent stimulant-free in some cases. In civilian airliners, there is no mid-air refueling, so you know your crew will get more rest. Also, pilots in combat are going to fatigue at a faster rate than civil air pilots,” Michau observed.

 Asked about the increasing number of women pilots and the steps taken to make them comfortable in the cockpit, Michaud was almost apologetic. “Only in the last decade or so have we started to really address making women more comfortable in fighter aircraft. For instance, ACC is reengineering some of the waste disposal techniques and devices available. There is now a uniform that helps women pilots and there are devices to help with the waste issue that they can try.”

Women simply had to make due, often coming up with their own techniques of either avoiding food and drink before flying missions or creating their own, private solutions. Asked about the delay in bettering women’s situation in the pilot seat, Michaud said that R&D fixes often take years to fully implement. “But we have become far more focused on this issue in recent years,” he said. Betty-Anne Mauger, the spokeswomen for the         surgeon general’s office added, “Advances are coming all the time to make both men and women more comfortable while performing their aerospace missions.”

Over the Long Haul

Sustained operations are increasing and so is the interest in making sure that pilots are both alert and as comfortable as possible to face mission demands on stamina. Partnering with the private sector has moved the military closer to effectively countering cockpit fatigue by redesigning the seating, headsets and body positioning.

Nevertheless, use of medication is increasingly an option given post September 11 realities that are asking more from today’s military pilots. Managerial awareness of the potential of exhaustion to degrade the mission and possibly cost a life or an expensive airframe has been expanding almost as quickly as the OPTEMPO.

If the current pace of missions is something of a permanent revolution in American military affairs, innovations in cockpit comfort and fatigue management will be coveted both by pilots and military leaders intent on aerospace dominance. The war on terrorism means a longer ride than ever for American and allied pilots—they may as well be comfortable!