NTSB: Crew Fatigue Main Reason Behind Fatal 2014 Train Crash

Crew fatigue brought on by irregular work schedules and a moderate form of sleep apnea is the primary reason behind a middle-of-the-night train crash that killed two Union Pacific workers and injured two others in northern Arkansas, the National Transportation Safety Board said Tuesday.

The panel also blamed an automatic horn that improperly reset alarms and the railroad industry’s slow adoption of a system to stop trains automatically.

The conductor and engineer killed in the crash were likely sleeping in their southbound train as it sped through a stop signal Aug. 17, 2014, and hit a northbound Union Pacific train, the board found.

“This tragedy illustrates what can happen when identified weaknesses in safety protection are not addressed,” NTSB Chairman Christopher Hart said to open Tuesday’s hearing. “The crew of the train did not stop or slow their train in response to three restrictive signals. This action is indicative of fatigue, a problem that occurs so regularly it is on the most-wanted list of transportation safety improvements.”

The railroad said Tuesday it extends condolences to the families of conductor Roderick Hayes of McKinney, Texas, and engineer Chance Gober of White Hall, Arkansas, amid thoughts of the two injured workers from the northbound train.

“Safety is Union Pacific’s top priority and we look forward to examining the NTSB’s recommendations,” spokesman Jeff DeGraff said in an emailed statement.

Investigators found that, as the train approached Hoxie, a town of 2,700 near the Missouri border, the southbound crew activated an automatic horn that repeats blasts in a long-long-short-long sequence until being shut off. As each cycle started anew, it reset a device designed to ensure the crew is alert. Had it worked properly, the engineer and conductor would have been warned at least three times that something wasn’t right. If they didn’t respond to the warnings, the train would have applied its brakes automatically.

The investigators also found that either the conductor or the engineer disengaged the horn 44 seconds before the crash, but the board’s medical officer said it was likely just as a reflex.

“Have you ever hit the alarm, the snooze button on your alarm clock?” Dr. Mary Pat McKay told the board. “Automated responses can happen when you are not awake. We can explain the turning off of the horn.”

The conductor had worked an irregular schedule ahead of his final trip while the engineer had moderate sleep apnea that he was not required to report. Union Pacific required that only severe cases be disclosed.

After its 3-1 vote on the cause of the 2014 accident, the board unanimously recommended that railroads and government agencies screen for sleep apnea among transportation workers, citing its increasing role in accidents.

The condition has been implicated in a September crash in northern New Jersey that killed one person and a 2013 crash in the Bronx on the Metro-North Railroad Hudson Line that killed four. Crew fatigue was a factor in fatal train collisions in Red Oak, Iowa, in 2011, and Newton, Massachusetts, in 2008.

The board also renewed its call for “positive train control,” which uses GPS-based technology to monitor and control train movement.

NTSB vice chairman T. Bella Dinh-Zarr voted against the findings. She said that since the board has been advocating for a form of positive train control since 1970, it deserved greater attention so “there aren’t catastrophic results because of one simple human mistake.”

Most railroads face a December 2018 deadline to install the technology.

Link: http://abcnews.go.com/US/wireStory/automatic-horn-fatal-arkansas-train-crash-43999127

 

Wanda Lindsay’s Comments for FMCSA Sleep Apnea Listening Session

My name is Wanda Lindsay, and I am the founder of the John Lindsay Foundation and volunteer for the Truck Safety Coalition. I started the John Lindsay Foundation in my husband’s memory, after he was killed by a truck driver with severe sleep apnea, and began an effort to help educate the public and lawmakers on the dangers of sleep apnea in the trucking industry.

I appreciate the opportunity to submit comments about sleep apnea. I hope that the agency will promulgate a final rule that finally ensures truck drivers are adequately screened, tested, and treated for obstructive sleep apnea (OSA).

My husband and I were on our way to Kentucky to visit family on May 7, 2010, when we stopped for traffic on I-30 as we were coming into the west side of Texarkana, Texas. We were the last car stopped in a two-mile long, very visible line of traffic, in a well-marked construction zone when a Celadon tractor-trailer slammed into the rear of our car.

At almost the moment of impact, the truck was traveling 65 mph with the cruise control engaged. John died on Mother’s Day, May 9th, as a result of his extensive injuries. After the crash, my family and I learned that about two months prior to the collision the truck driver had been diagnosed with severe, uncontrolled sleep apnea, which among other health issues results in chronic, serious fatigue. Nevertheless, he was still allowed to drive a truck even though he was not being treated and monitored for his condition.

Obstructive sleep apnea is a sleep disorder that afflicts approximately 20 million Americans, 17 million of whom are undiagnosed. OSA causes the throat muscles to relax and block airways during sleep, which hinders a person’s ability to breathe. In turn, the deprivation of oxygen disrupts a person’s sleep. For truck drivers this translates to a health problem that contributes to driver fatigue, which has been recognized for more than 70 years as an industry-wide safety issue. Even the Federal Motor Carrier Safety Administration noted that OSA is “one of several respiratory dysfunctions that may be detrimental to safe driving as this condition may interfere with driver alertness and may cause gradual or sudden incapacitation.” And given that the FMCSA was established with the goal of reducing commercial motor vehicle crashes, injuries, and fatalities, I strongly believe that they should listen to their assessment of the problem and work tirelessly to craft a well-researched, data-based solution.

Moreover, OSA is a health problem that disproportionately affects CMV drivers compared to the general public. Based on conservative estimates, approximately five percent of the general population have obstructive sleep apnea, while another study estimated that 50 percent of commercial motor vehicle drivers were at risk for OSA based on a sample size of more than 3,000 driver. The FMCSA determined that nearly 1 out of three commercial drivers suffered from “mild to severe sleep apnea.” So it should come as no surprise that there is ample evidence demonstrating that OSA is a “significant cause” of fatigue-related commercial motor vehicle crashes.

Requiring companies to screen, test, and treat their drivers for OSA can help ensure that their drivers are healthy and adequately rested to operate a truck. When trucking company Schneider evaluated the safety performance and health care costs associated with truck drivers with sleep apnea their findings underscored the many benefits of screening, testing, and treating. Preventable crashes were reduced by 30 percent, median cost of crashes dropped by 48 percent, and health care costs decreased more than 50 percent, resulting in a health care savings of more than $500.00 per driver per month. Additionally, their retention rate improved by 60 percent over fleet average – a desirable quality in an industry that has a turnover rate above 90 percent. 

I am urging the FMCSA to fight back against fatigue, which continues to be a major factor in the unconscionably high number of yearly truck crashes and the resulting fatalities and injuries to truck driver as well as motorists, bicyclists, and pedestrians. From 2009 to 2014, truck crash fatalities increased by 15.5 percent, and truck crash injuries increased by 50 percent. These numbers underscore a dire need to reform the industry, and should remind all parties involved in trucking that we can do a much better job of saving lives. I look forward to seeing a final rule that would require all commercial motor vehicle drivers to be screened, tested, and treated for obstructive sleep apnea.

Wanda Lindsay

Sleep Apnea Comments for FMCSA Listening Session

Wanda Lindsay 2013 Press Conference in DC

The entirety of Wanda’s presentation at the press conference on May 7, 2013 in Washington, DC.

Wanda Lindsay 2013 Press Conference in DC