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.
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.
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.
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