Once again, worker fatigue has proved deadly in a transportation incident.
A National Transportation Safety Board (NTSB) report says the probable cause of a collision between two BNSF Railway trains was the crew’s fatigue. Both crew members had fallen asleep, which led to their failure to comply with a signal requiring them to operate at a restricted speed and stop short of a standing train.
On April 27, 2011, a BNSF coal train collided with the rear of a standing BNSF maintenance train near Red Oak, Iowa. The crash caused the derailment of two locomotives and 12 cars. The engineer and conductor in the lead locomotive of the coal train were killed.
“Once again, this investigation draws attention to the dangers of human fatigue,” said NTSB Chairman Deborah Hersman. “The human body is not designed to work irregular schedules, especially during the circadian trough, when our bodies are at their lowest alertness.”
The circadian trough refers to the time (4:00 a.m.) when our bodies have the least energy and most likely want to rest. For most people, the circadian low occurs between midnight and 6:00 a.m.
The NTSB made several recommendations to the Federal Railroad Administration (FRA), Association of American Railroads and BNSF Railway in its report. Among the recommendations to the FRA:
- Require railroads to medically screen employees in safety-sensitive positions for sleep apnea and other sleep disorders
- Establish an ongoing program to monitor, evaluate, report on and continuously improve fatigue management systems implemented by operating railroads to identify, mitigate and continuously reduce fatigue-related risks for personnel performing safety-critical tasks, and
- Conduct research on new and existing methods that can identify fatigue and mitigate performance decrements associated with fatigue in on-duty train crews.
NTSB recommended BNSF require all employees who perform or supervise safety-critical tasks to complete fatigue training on an annual basis and document when they have received training.