July 12, 2006

The National Transportation Safety Board (NTSB) has determined that fatigue caused the recent failure of the engineer and conductor on a Union Pacific Railroad train to respond appropriately to wayside signals governing the movement of their train leading to a fatal collision with another train. The collision is now being used as case study in fatigue awareness to help other crews understand the importance of sleep.

“Get enough sleep—it sounds so simple and yet we continue to see accidents caused by fatigue,” said NTSB Acting Chairman Mark V. Rosenker. “How many more tragedies have to occur before employers and employees get the message that being well rested is critical to job performance?”

The accident occurred on June 28, 2004, near Macdona, Tex. A Union Pacific Railroad (UP) train was traveling westbound on the same mainline track as an eastbound BNSF Railway (BNSF) train. As the BNSF train was entering a parallel siding, the UP strain struck its midpoint. The collision derailed four locomotive units and the first 19 cars of the UP train, as well as 17 cars of the BNSF train.

As a result of the derailment, the 16th car in the UP train, a tank car loaded with liquefied chlorine, was punctured. The chlorine vaporized and engulfed the area surrounding the accident site. Three people (the UP conductor and two local residents) died from the effects of chlorine gas inhalation.

The Board’s investigation determined that sleep debt, disrupted circadian processes, limited sleep during the weekend preceding the accident, and long duty tours reduced the capacity of the UP engineer and conductor to remain awake and alert on the night of the accident. The Board also noted that the UP conductor’s consumption of alcohol on the evening before the accident likely added to his fatigue.

An examination of the UP engineer and conductor’s off-duty time revealed that neither made effective use of the time available to them to obtain adequate rest. Therefore, the Board determined as contributing factors:
1. The crewmembers’ failure to obtain sufficient restorative rest prior to reporting for duty because of their ineffective use of off-duty time.
2. UP train crew scheduling practices that created inverted crewmembers’ work/rest patterns.

The Board recommended that UP, the Brotherhood of Locomotive Engineers and Trainmen (BLET), and the United Transportation Union (UTU) use the Macdona accident as a case study in fatigue awareness training to illustrate the shared responsibility of rail carriers to provide opportunity for adequate rest and employees to understand the importance and obtain sufficient rest to perform at a safe level of alertness. Further, the Board recommended that the Federal Railroad Administration (FRA) require that railroads base their crew scheduling on scientific measures designed to reduce fatigue and to limit the railroads’ use of limbo time.