Rail Workers: Deadly Tired…but Still Working

By Georgetta Gregory

The rail business is an industry full of tired, stressed workers. It is an epidemic.

I know this first-hand because, before coming to the NTSB several years ago, I spent more than 30 years working in the freight railroad industry. While freight railroad managers and crews count on reliable schedules to make their shipments and make their customers happy, there is no routine schedule for the hundreds of thousands of crewmembers employed in this business. As a result, many railroad workers are literally walking and working in their sleep.

I was one of them.

One of my last jobs before coming to the NTSB was as a trainmaster for a major freight railroad. My duties included safely seeing the arrival and departure of trains in and out of terminals in California. I spent a large majority of my time reviewing train schedules and communicating with train personnel of arriving and departing trains. I coordinated the efforts of nearly 300 crewmembers, including yardmasters, dispatchers and engineers, to execute the transportation plan on my territory. Additionally, I was responsible for making sure all the work was done safely and in accordance with rules and regulations.

The job was very stressful and required long hours. It wasn’t unusual for me to work 80 hours a week. I often worked overnight, evenings, weekends and long hours.

Over time, I became chronically fatigued. I gained weight and began to lose my memory and other cognitive abilities. I had no routine schedule for sleep, because I worked irregular hours that were counter to my circadian rhythms. Eventually, I began to make mistakes at work and in my personal life – potentially dangerous ones.

Noting how my work and home life was suffering, I went to a sleep specialist. The doctor determined that I was fatigued at a dangerous level – to the point where the state of California took my driver’s license. Ironically, while I could no longer drive a car, I was still expected to carry out the meticulous details associated with managing rail yards.

I warned my bosses, but there was little help or response. I made suggestions for improvements, including encouraging the railroad to provide better lineups and opportunities for rest, but I felt unsupported and became concerned for the safety of my crews. Eventually, I left the railroad and began a new career.

My story is not unusual. And when I came to the NTSB as Chief of the Railroad Division, I quickly learned that the NTSB also realized the dangers of fatigue in the railroad business. As a result of our investigations in recent years, we have issued more than 25 recommendations related to managing fatigue—all still open, needing to be addressed.

Wreckage of BNSF train, including lead locomotive of striking train, at Red Oak, Iowa.

One accident, in particular, involving a freight train perhaps best highlights the danger the NTSB is attempting to eradicate. In April 2011, an eastbound BNSF Railway (BNSF) coal train traveling about 23 mph, collided with the rear end of a standing BNSF maintenance-of-way equipment train near Red Oak, Iowa. The collision resulted in the derailment of 2 locomotives and 12 cars. The lead locomotive’s modular crew cab was detached, partially crushed, and involved in a subsequent diesel fuel fire. Both crewmembers on the striking train were fatally injured.

We determined that the probable cause of the accident was the failure of the crew of the striking train to comply with the signal indication requiring them to operate in accordance with restricted speed requirements and stop short of the standing train because they had fallen asleep due to fatigue resulting from their irregular work schedules and their medical conditions.

As a result of that accident, we recommended that the railway require all employees and managers who perform or supervise safety-critical tasks to complete fatigue training on an annual basis and document when they have received this training, and that they medically screen employees in safety-sensitive positions for sleep apnea and other sleep disorders.

Both the conductor and the engineer had worked irregular schedules for several weeks leading up to the accident. During this time, work start times often varied significantly from day to day for both crewmembers. Changing work start and end times can make achieving adequate sleep more difficult, because irregular work schedules tend to disrupt a person’s normal circadian rhythms and sleep patterns, which in turn can lead to chronic fatigue.

Scene of the derailment of Metro North Train 8808.

More recently, we investigated an accident in New York where a Metro North Railroad locomotive engineer was operating a train with undiagnosed severe obstructive sleep apnea (OSA). The train, on its way toward Grand Central Station in New York, New York, had 115 passengers on board. The engineer headed into a curve with a 30 mph speed limit traveling at 82 mph, resulting in a derailment. Sixty-one people were injured, and 4 passengers died.

The engineer experienced a dramatic work schedule change less than 2 weeks before the accident, with his wake/sleep cycle shifting about 12 hours. Previously, he had complained of fatigue but had not been tested or treated for sleep apnea. After the accident he had a sleep evaluation that identified excessive daytime sleepiness and underwent a sleep study resulting in a diagnosis of severe OSA. Following the study, he was treated successfully for OSA within 30 days of the diagnosis.

The NTSB issued safety recommendation to the Metro-North Railroad to revise its medical protocols for employees in safety-sensitive positions to include specific protocols on sleep disorders, including OSA.

We have issued numerous recommendations to the Federal Railroad Administration, as well, requiring it to develop medical certification regulations for employees in safety-sensitive positions that include, at a minimum, a complete medical history that includes specific screening for sleep apnea and other sleep disorders, a review of current medications, and a thorough physical exam. If such a recommendation had been implemented at the railroad for which I worked, my fatigue most likely would have been caught earlier and mistakes avoided.

(Note: As I was writing this blog, I was heartened to hear that, on March 8, the FRA announced it was seeking public input on the impacts of screening, evaluating and treating rail workers for obstructive sleep apnea.)

And while the railroads and the federal regulators are responsible for addressing this epidemic, so too must railroad workers recognize the dangers of working while fatigued. Yet many are compelled to make money and want to stay ready to react at any hour of the day to avoid missing the opportunity to get paid. To a certain extent, I understand this. And that’s why we must also work with labor unions to address this issue and provide workers the opportunity for sleep, while still allowing them the opportunity to get a paycheck and progress in their careers.

Fatigue in transportation is such a significant concern for the NTSB that it has put “Reduce Fatigue-Related Accidents” on its Most Wanted List of transportation safety improvements. It is not just an issue in rail, but an issue in all modes of transportation that must be addressed.

As a former railroad worker and now as a supervisor of railroad accident investigators, I can tell you we still have a long way to go to address this issue. Doing so will require the joint efforts of the regulator, the operator, and the employee. These efforts must be undertaken, because we can’t keep running down this dangerous track.

Georgetta Gregory is chief of NTSB’s Railroad Division.

Smithsonian Channel’s Alaska Aircrash Investigations Series

By Chris O’Neil

The NTSB is known for investigating large-scale air carrier accidents and other major transportation events. But a significant part of the agency’s daily workload is investigating general aviation and charter aircraft accidents across the country. There were 1,256 accidents involving general aviation and charter aircraft in 2014. Of these, 261 accidents resulted in the deaths of 439 people.

Charged with investigating them are 52 aviation safety investigators, or ASIs, based around the country, who often travel solo to a crash scene. While they may be the only NTSB investigators on scene, they are supported by the agency’s resources in Washington—ranging from our state-of-the-art laboratory to specialists in metallurgy and air traffic control.

A new television series on the Smithsonian Channel looks at the challenges and rewards of the NTSB’s ASIs in Alaska, who are charged with investigating airplane accidents in a state where weather and terrain make air travel a necessity.

The TV series, Alaska Aircrash Investigations, which debuted yesterday, follows our Alaska ASIs during the on-scene investigation of small airplane, or general aviation, crashes. The series provides a rare, behind-the-scenes look at the incredible work these men and women do.

The purpose of sending ASIs into the mountains and crevasses of Alaska to investigate crashes is to try and find out why the accidents happen and what can be done to prevent them from happening again. The show informs the public about the processes NTSB investigators undertake to find the probable cause of accidents. The series also highlights important messages about general aviation safety.

The series also sets into sharp focus some of the safety challenges throughout the general aviation community that the NTSB has been concerned about for years and that have been a mainstay on the NTSB’s yearly Most Wanted List of transportation safety improvements. In the 2016 Most Wanted List, we focus on loss of aircraft control by the pilot. Between 2008 and 2014, about 47 percent of fatal fixed-wing general aviation accidents in the United States involved pilots losing control of their airplane in flight, resulting in 1,210 fatalities throughout the United States. During the past 12 years, air fatalities dropped by 57 percent in Alaska. Based on accident investigations in Alaska in the past decade, the NTSB identified 32 different actions needed to improve aviation safety.

Aviation in Alaska is central to sustaining communities, economies and the enjoyment of the wilderness of our nation’s last frontier. Two notable examples of safety improvements in Alaskan aviation include the use of weather cameras throughout Alaska and the FAA’s Capstone Project. The use of weather cameras in Alaska provides pilots real-time intelligence on flying conditions, allowing them to “see” the weather conditions they will encounter on their journey. The FAA’s Capstone Project is a GPS-driven system that gives pilots improved situational awareness by allowing them to see where their aircraft is in relation to terrain, and it allows small operators and dispatchers to provide real-time flight-following capabilities.

The Alaska Air Carriers Association, the Aircraft Owners and Pilots Association and the Medallion Foundation have all worked with the Federal Aviation Administration and the NTSB to advance safety in the general aviation community.

The work of the men and women of the National Transportation Safety Board is vital to the continuous improvement of safety across all modes of transportation. While the general public has access to all of the findings and results from NTSB accident investigations on its public docket, much of that day-to-day investigative work is conducted out of the public eye. Alaska Aircrash Investigations provides the public we serve a glimpse into the NTSB’s investigative process and the challenges our investigators face in our nation’s last frontier.

Chris O’Neil is the NTSB’s Director of Public Affairs.

Introducing … NTSB’s #MWLMonday

By Stephanie D. Shaw

If you have spent any time on social media, you’ve probably seen pictures and stories hash-tagged #TBT – for Throwback Thursday. Every Thursday in various social media channels (Facebook, Twitter, Instagram), people post photos and messages about memories from the past (good or bad), and people comment on those posts and offer memories of their own.

Taking a page from that popular trend, the NTSB introduces #MWLMonday. While we are known for our thorough investigative reports, you may not be aware of our many safety advocacy efforts. These efforts are directed primarily at raising awareness about the 10 safety issues identified on our Most Wanted List (MWL) of transportation safety improvements. Our MWL highlights safety issues that still need action, derived from our real-world accident investigations.

Each Monday, we will highlight one of these 10 safety issues; thus, #MWLMonday. On #MWLMonday, we will offer brief, shareable items for social media– we’ll also give you links to learn more. We’ll share the stories of NTSB investigations, and the stories of everyday people—all with a focus on a safety concern identified on our MWL.

Another goal of our #MWLMonday postings is to encourage dialogue and discussion. What we’d really like to see is people adding their own stories, comments, and pictures to the conversation. We want people to share those tweets and posts with their friends on social media.

To join the conversation every week or to just see how NTSB is communicating safety messages nationwide, look out for #MWLMonday on Facebook and Twitter, or check out the NTSB Safety Compass Blog. (Add us to your “favorites” and start following #MWLMonday on Twitter now!)

Going viral can help fight America’s epidemic of transportation deaths and injuries. Help us start with #MWLMondays!

For questions about our social media efforts or to suggest a blog topic or Twitter conversation, mail to: SafetyAdvocacy@ntsb.gov.

Stephanie Shaw is a Safety Advocate in the NTSB Office of Safety Recommendations and Communications.

Wake Up, America!

By Jeffrey Marcus

On February 29, 2016, the scientific journal Injury Prevention published “Fatigue in Transportation: NTSB Investigations and Safety Recommendations,” which I co-authored with former NTSB Board Member (and fatigue expert) Dr. Mark Rosekind. We reviewed all recent major NTSB investigations in all modes of transportation for the presence of fatigue in accidents.

Bottom line: fatigue was present in 20 percent of them as a probable cause, a contributing factor, or a finding. The presence of fatigue varied among the modes of transportation, ranging from 40 percent of highway investigations to 4 percent of marine investigations.

And this is after 109 years of federal government action to mitigate the risk of fatigue in transportation. Congress passed the Hours of Service Act on March 4, 1907. Fatigue regulations have been continually reviewed and revised as we learn more about the impact of fatigue; as recently as January 12, 2012, the FAA published a final rule substantially revising and improving the fatigue regulations governing commercial aviation.

However, the NTSB continues to see fatigue in transportation tragedies and incidents in investigations in all modes of transportation. Accordingly, we have issued safety recommendations to help prevent recurrences. Since the NTSB issued its first fatigue recommendation in 1972, we have issued 205 separate fatigue-specific recommendations.

Dr. Rosekind and I divide these recommendations into seven subject categories. We list the number of recommendations in each category, both overall and by transportation mode. We also analyze the types of organizations that received the recommendations, whether the recommended actions have been taken, and the NTSB’s evaluation of whether the actions taken satisfied a given recommendation.

Of the seven subject categories, scheduling policies and practices account for 40% of all fatigue recommendations. Other subject categories included Education/Raising Awareness; Organizational Strategies; Medical issues affecting sleep; Vehicle and Environmental Strategies and Technologies; Research and Evaluation; and Fatigue Management Plans.

Overall, 54 percent of NTSB fatigue safety recommendations were issued to federal agencies, but this percentage varied among modes, with 86 percent of all aviation fatigue recommendations being issued to federal agencies, and only 30 percent of rail recommendations issued to these agencies. Other types of organizations receiving recommendations included transportation operators (both government and private companies), labor unions, and professional associations.

In the more than 40 years since our first fatigue recommendation, the scientific knowledge related to fatigue, sleep, circadian rhythms and sleep disorders has grown enormously, and there has been a parallel increase in investigators’ recognition of fatigue as a causal or contributory factor. In addition, investigative techniques (such as collection of a 72-hour history) are now standard components of major investigations. These advancements in science, recognition, and investigative techniques have resulted in fatigue findings that previously might not have been identified.

The more we know about fatigue, the more clearly we learn that proper sleep is foundational to all human functioning – including in the operation of vehicles in transportation.

Jeffrey Marcus is a Transportation Safety Specialist in the Office of Safety Recommendations & Communications

Sleep Awareness Week: Resolve to Improve Your Sleep and Avoid Drowsy Driving

By Dr. Jana Price

January 27, 2014, crash in Naperville, Illinois. Crash scene photo looking showing the vehicles at final rest. (Source: Illinois State Police)

March 6-13, 2016, is National Sleep Awareness Week, which is a great time to think about improving our sleep habits for both our health and our safety.

Sleepiness while driving can have serious consequences. A lack of sleep slows reaction time and makes us more susceptible to forgetting or overlooking important tasks. Drowsy drivers may also experience microsleeps—brief episodes of sleep that may only last a few seconds—without being conscious that they are occurring. A few seconds is all it takes to drift out of the lane or to miss a stopped vehicle ahead.

The NTSB has investigated numerous crashes in which driver drowsiness played a role. Last month, the NTSB met to discuss a January 27, 2014, crash involving a truck-tractor semitrailer that collided with stopped vehicles that were providing assistance to a broken-down truck-tractor semitrailer in the right lane of Interstate 88 near Naperville, Illinois. As a result of the collision, an Illinois State Toll Highway Authority worker died and an Illinois State Police trooper was seriously injured in a postcrash fire. The Board concluded that the driver of the striking truck was impaired by fatigue due to his lack of adequate sleep—estimated as less than 4.5 hours in the 37 hours prior to the crash—which resulted in his delayed response to the vehicles stopped ahead of him.

On the day of the crash, and on several prior occasions, the driver had not complied with the federal rules governing hours of service and had falsified his logbook.

In the Naperville crash, the driver knew how much rest was required, but did not adhere to the rules. A recent AAA Foundation study showed that many drivers who understood the risks of drowsy driving did so nonetheless. Specifically, the AAA survey found that 97 percent of drivers see drowsy driving as a serious threat and a completely unacceptable behavior. However, among that same group, nearly 1 in 3 admitted to driving when they were so tired that they had a hard time keeping their eyes open.

Although it’s not always possible to predict when you will become drowsy behind the wheel, there are several steps you can take to help avoid this risk:

• Get 7-9 hours of sleep per night.
• Take rest breaks during longer drives.
• Avoid driving during early-morning hours, when the brain is wired to be asleep.
• Talk to your doctor if you have trouble sleeping or are sleepy during the day.
• Check medicine labels to understand how they may affect your driving.
• Never drive while you are drowsy; pull over to rest or change drivers at the first sign of drowsiness.

The NTSB is concerned with the issue of fatigue in all modes of transportation and has included “Reduce Fatigue-Related Accidents” on its 2016 Most Wanted List of transportation safety improvements.

Jana Price, PhD, is Chief of the Report Development Branch in NTSB’s Office of Highway Safety.