Direct link to the interim “Synopsis” of the report (see 2nd paragraph), being: “Board Meeting - Railroad Accident Report - Collision of BNSF Coal Train With the Rear End of Standing BNSF Maintenance-of-Way Equipment Train” - Red Oak, Iowa - April 17, 2011 - NTSB Number: RAR-12-02: http://www.ntsb.gov/news/events/2012/red_oak_ia/index.html
As the subsequent discussion here surmised, there appear to have been some issues with the crash-worthiness of the locomotive cab - see Conclusion 12. and following.
Also, why didn’t the locomotive alerter prevent this from happening ? See Conclusion 9.
But most surprisingly: Apparently the version of PTC that’s now being ‘rolled out’ would not have prevented this collision at “Restricted Speed”, nor the resulting fatalities ! See Conclusions 10. and 11.
Why such an apparently big gap between what the NTSB has been wanting, the Congress enacted, the FRA mandated, and what is now being implemented ?
I have looked at the 17 conclusions of the NTSB report, and I am amazed at how provocative and speculative some of them seem to be. Is the purpose of this accident report to discover and reveal the cause, or is it to advance an agenda?
Particularly interesting are the report’s massive speculations about the effect of irregular work schedules, sleep disorders, and fatigue.
The NTSB is usually, 99%, trying to advance an agenda. If it can do so based on fact that is all well and good. If the facts do not support the conclusion, then make up and twist the facts.
Even ICC accident reports had an “agenda” in that blame was to be found for an incident and direction given to avoid a recurrence. Maybe it was a rules violation or a bad or missaplied rule; a lack of supervision or proper supervision; an outdated rule; or anything else. Sometimes there were suggestions, sometimes there were directives, rarely did it appear to be an “act of God” or “just an accident”.
With speculation based on the same level of scientific ‘fact’ the report demonstrates - I’ll speculate that the crew of the hitting train was involved in a detailed and animated discussion on the merits of Iowa and Iowa State football players in the upcoming NFL draft.
What was published is among the worst NTSB reports of a incident that I have EVER seen.
Of course the NTSB has an agenda. Hint: it’s the S in NT_**S_**B.
In a case like this - all you can really do is speculate. Dead men tell no tales.
But did anyone read the footnote about the cab being turned 90 degrees and crushed? Possible design flaw? Maybe better go back to the drawing board on that design?
As far as being tired - probably more exhausted than tired. There’s thousands of scientific studies done by guys with more degrees on their walls than fries at McDonalds, and they all pretty much come to the same conclusion : humans need regular sleep and regular sleep schedules.
Probably will never be 100% possible in any type of 24.7 operation, but can a better effort be put forth? My prediction is that there will be a “landmark” type event that will force the government to come down on the railroads with the hammer of Thor regarding rest regulation. Although I hope my prediction is wrong. I really do.
“As far as being tired - probably more exhausted than tired. There’s thousands of scientific studies done by guys with more degrees on their walls than fries at McDonalds, and they all pretty much come to the same conclusion : humans need regular sleep and regular sleep schedules.”
Zug, you hit on two of the three terms people confuse as being the same thing. You mention “being tired” or lack of sleep and “exhausted” which denotes a major physical event or long time between awakening and being able to get to sleep again. The third term, fatigue, wasn’t mentioned but would be the next condition. Many, especially when young, can get by with periods of little sleep; some can be exhausted but bounce back after a good night’s sleep. But fatigue, the total of long periods of work and stress with little sleep between those periods and coupled with frequent exhaustion, the overall work and life pace pounding at one over weeks and months and years, is what causes the problems. You can catch up on short term loss of sleep, you can quickly amend exhaustion with one or two good night’s sleep, maybe with a few days off. But fatigue is infused with frequent lack of sleep and/or frequent exhaustion, uneven periods of work and sleep, job and personal stress, boredom, all combined over a period of time and which can cause a slowing or inability to perform at peak efficiency either physically or mentally. What has been elusive has been finding the right combination of work, time off, sleep, efficiency, and income that works for both the employee and the company. One would knows that a machine in tip top working order is most efficient and therefore earns the most money for the company. But figuring out how to apply that concept to humans is full of controversey. A guy who has a a family and wants to be home with them on a daily basis versus a guy who need to earn as much money to support the family are at odds with ea
What does this item #5 of the report’s conclusions mean? It says that had the emoplyees completed BNSF training, they would have been called out and sent to consult with a physician about a sleep disorder. And yet item #3 says that both employees had a medical history of sleep disorders. So if they had a medical history of the problem, why does the report conclude that BNSF’s fatigue training would have made any difference?
The larger question is, why were these two permitted to work on a job by an employer who knew that they could not perform the job safely due to a medical condition? Clearly, this NTSB report blames the crash squarely on the BNSF.
Had the two crewmembers on the striking coal train completed the BNSF’s fatigue training program, they would have had the opportunity to learn that they were at risk for sleep disorders, particularly obstructive sleep apnea, and the computer-based training program would have displayed a message advising them to consult with a physician.
I concur with zugman’s thoughts above on sleep deprivation issues. If the carriers don’t address it more proactively, then sooner or later it’ll ‘come back and bite them in the a**’ when the Feds do, same as with PTC over the last 20 years.
I used to really like getting a lead locomotive that had an ‘alerter’ system installed (back in my day few CNW locomotives had any such system). Having an alerter was like having a built-in snooze alarm–I knew I could nod off for 30-60 seconds and then the alerter would wake me. So if I knew I had no signals to look at or crossings ahead for a minute or two, it was micronap time!
Not exactly the safest way to operate, but when one is so completely tired that one is falling asleep constantly, then the alerter is nice to have.
The crappy hours are the reason I left railroading back in '92. I had been working on-call for about 7 years, and it was really wearing me down. My wife would tell me that I looked cadaverous. I was falling asleep on the drive to and from work. I was, in short, not very safe to be around. I lived about 75 minutes from Proviso, 60 minutes from Milwaukee, and 90 minutes from Janesville–the three points I had to cover. And as the CNW only gave at most a 2-hour call…
A day in a railroader’s life:
*On duty 0900 at the away-from-home terminal after sitting there 20+ hours waiting for a return train;
*Off duty 2059 after a long, slow trip; (can’t make it a full12 actual hours on duty because the other crew members want to get out again in 8 hours; but what do they care–they get to sleep.
*Arrive home 2230
*Snack and shower and prepare the next day’s sandwiches,maybe a little tv, until 2330
*Sleep until the phone rings at 0500 for 0700 on duty
Repeat.
Or worse yet, is when you get home during the daytime hours when the wife/kids are awake and want your attention, or you need to get some chores done (go to the bank, dentist, etc); so instead of getting 5 hours sleep, you do your chores-THEN get called for another 12 hours on duty!
Do this for a few years and then see how you feel!
Find yourself on a slow train, ambling down the tracks at 25-30mph, the locomotive gentling roc
A pertinent excerpt from the David Schanoes “10-90” blog that I linked above [emphasis added - PDN]:
"The NTSB has determined that crew fatigue was the probable cause of the collision in Iowa, and I don’t doubt that. Nothing puts crew members to sleep faster than operating at 10-20 mph in daylight hours after being called to work in darkness. Used to be, railroads had rules against operating continuously at speeds between 12-22 mph [or in that area], a rule based on the possibility of triggering a harmonic rock-off derailments on jointed rail as 12-22 mph somehow reached the “natural frequency”-- the resonance causing the wheels of the cars to lift off the rail.
Then welded rail came along. Me? I still think that prohibition should be in the timetables, as 12-22 mph seemed to be the “natural frequency” for every locomotive engineer I ever worked with, putting him [they were all men] to sleep. I sure as hell know it was my natural frequency… so much so, that I would go outside the cab and sit on the porch of the locomotive to keep myself awake, so I could remember to go in and wake the engineer if something appeared wtihin half my range of vision. Trust me, I did exactly that, and I’m alive to prove it.
On my carrier the Harmonic Rock Off ‘rule’ applied only the ‘High Cube’ covered hoppers of 4700+ cubic foot capacity on 6 degree or greater curves. It was implemented as a Timetable Special Instruction and in general stated if a train contained those type cars, and if it could not maintain a speed greater than 25 MPH, then it must reduce sp
What are railroads companies supposed to do to address the issues of sleep problems being caused by irregular schedules? Do you assign everyone consistent schedules?
I used to really like getting a lead locomotive that had an ‘alerter’ system installed (back in my day few CNW locomotives had any such system). Having an alerter was like having a built-in snooze alarm–I knew I could nod off for 30-60 seconds and then the alerter would wake me. So if I knew I had no signals to look at or crossings ahead for a minute or two, it was micronap time!
Not exactly the safest way to operate, but when one is so completely tired that one is falling asleep constantly, then the alerter is nice to have.
The crappy hours are the reason I left railroading back in '92. I had been working on-call for about 7 years, and it was really wearing me down. My wife would tell me that I looked cadaverous. I was falling asleep on the drive to and from work. I was, in short, not very safe to be around. I lived about 75 minutes from Proviso, 60 minutes from Milwaukee, and 90 minutes from Janesville–the three points I had to cover. And as the CNW only gave at most a 2-hour call…
A day in a railroader’s life:
*On duty 0900 at the away-from-home terminal after sitting there 20+ hours waiting for a return train;
*Off duty 2059 after a long, slow trip; (can’t make it a full12 actual hours on duty because the other crew members want to get out again in 8 hours; but what do they care–they get to sleep.
*Arrive home 2230
*Snack and shower and prepare the next day’s sandwiches,maybe a little tv, until 2330
*Sleep until the phone rings at 0500 for 0700 on duty
Repeat.
Or worse yet, is when you get home during the daytime hours when the wife/kids are awake and want your attention, or you need to get some chores done (go to the bank, dentist, etc); so instead of getting 5 hours sleep, you do your chores-THEN get called for another 12 hours on duty!
Do this for a few years and then see how you feel!
Find yourself on a slow train, ambling down the tracks at 25-30mp
I would say that is exactly what this NTSB report is about. But what would it mean to employees? What does rest regulation require? I would guess it requires a lot more sign-off and logging of sleep periods. It would be a certified rest.
What does the NTSB mean when they refer to a computer showing whether or not you are rested?
This is a multi faceted issue for railroads, truckers, airline pilots, and a whole host of other professionals and skilled workers. Cost of an employee in terms of training, salary, benefits, etc. versus a return on that investment (how much work should you expect from him at that cost?) versus health of individual vs quality of work vs safety vs quality of life for individual vs cost of additional employees to cover times lost vs gain in quality of performance…it is a virtual round robin. Some workers don’t care about anything but getting home so they like short turn around times getting home and the need for money drives them back out on the road as soon as possible. But is that good for them in terms of their own health and longevity on the job? Or is it good for the employer or not? How about the public’s economic and safety? The list of questions and unresolved issues is endless.