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NTSB blames crew fatigue for deadly UP train crash

The August 2014 collision of two Union Pacific freight trains that claimed the lives of an engineer and a conductor was likely the result of both workers being asleep due to fatigue and sleep apnea, according to the National Transportation Safety Board.

   The August 2014 collision of two Union Pacific freight trains in Hoxie, Ark. that claimed the lives of two UP employees and injured two more, was likely the result of worker fatigue, according to a recent report from the National Transportation Safety Board (NTSB).
   The incident, which took place at 2:28 a.m. central daylight time on Aug. 17, 2014, involved a southbound UP train that failed to stop at a signal and collided with a northbound train that was traversing the turnout. Both the engineer and conductor of the southbound train were killed in the incident, and the engineer and conductor of the northbound train were seriously injured as well.
   The NTSB said in its report the southbound train did not respond to three restrictive signals and, as a result, took no action to slow or stop prior to the collision. The northbound train, on the other hand, was complying with traffic control signals, but had no indication of the impending collision and, therefore, did not have enough time to apply its emergency air brakes in order to prevent the crash.
   According to the report, both the engineer and conductor on the southbound train were likely asleep at the time of the incident. The NTSB said the train conductor was fatigued due to the variability of his shift start times and the circadian desynchronization he experienced from operating the train in the early morning hours when he was predisposed to sleep. The NTSB also said the locomotive engineer likely fell asleep “due to his diagnosed but inadequately treated moderate sleep apnea and operating the train in the early morning.”
   The report also found that if provisions in the hours of service requirements for commuter and passenger trains had been applied to freight operations, “the southbound train conductor would not have been allowed to work such a highly variable schedule because of its high risk for causing fatigue.”
   In addition, the NTSB pointed a finger at the Federal Railroad Administration (FRA) and Union Pacific for not requiring rail employees to regularly demonstrate adequate, ongoing treatment for conditions like sleep apnea before obtaining medical clearance for duty.
   “The lack of minimum standards for medical rules among Class I, intercity, and commuter railroads poses an unnecessary risk for employees in safety-sensitive positions who are diagnosed with sleep disorders,” the board wrote in its report.
   The NTSB also noted that a properly functioning positive train control (PTC) system would have prevented the collision entirely. PTC is a wireless braking system that can override a conductor to slow or stop a train in the event of a potential accident. Congress in 2008 mandated implementation of PTC for all U.S. railroads, but progress on implementation by freight railroads has been slow and uneven, according to a recent report from the FRA.
   As a result of its investigation, the NTSB recommended the FRA require freight railroads to use validated bio-mathematical fatigue models, similar to those used by passenger railroads, to develop work schedules that do not pose an excessive risk of fatigue, as well as develop and enforce medical standards for railroad employees in safety-sensitive positions that have been diagnosed with sleep disorders.
   The board recommended that all the Class I railroads review and revise their medical rules with regard to sleep apnea, and revise their scheduling practices for train crews and implement “science-based tools, such as validated biomathematical models, to reduce start time variability that results in irregular work-rest cycles and fatigue.”