Over the Long Haul, Fatigue Kills
Train accidents caused by human error are rising. Some experts blame
overworked crews, especially in the deadliest crashes.
By Dan Weikel
Times Staff Writer
April 24, 2005
When a Union Pacific freight train thundered into tiny Macdona, Texas,
just before dawn June 28, the engineer and conductor had clocked more than
60 hours in the previous week, working the long, erratic shifts that are
common in the railroad industry.
They flew through a stop signal at 45 mph and slammed into another freight
train that was moving onto a side track. No one even touched the brakes.
Chlorine gas from a punctured tank car killed the conductor and two
townspeople, while dozens of others suffered breathing problems and
burning eyes as the toxic cloud drifted almost 10 miles. Hundreds were
evacuated within a 2-mile radius of the accident.
Federal investigators suspect that both of the Union Pacific crewmen had
fallen asleep. In the weeks before the crash, each man's work schedule had
at least 15 starting times at all hours of the day.
The Macdona crash illustrates a grim fact of life for thousands of
engineers, brake operators and conductors who guide giant freight trains
across the country: Exhaustion can kill.
Two decades after federal officials identified fatigue as a top safety
concern, the problem continues to haunt the railroad industry, especially
the largest carriers responsible for moving the vast majority of the
nation's rail-borne freight.
"Engineers and conductors sleep on trains. Anyone who tells you different
is not being straight with you," said Diz D. Francisco, a veteran engineer
and union official who works out of Bakersfield for the Burlington
Northern Santa Fe Corp.
Tired crews have caused some of the deadliest and costliest freight train
wrecks of the last 20 years, a review of federal accident reports show.
And although the government doesn't track fatigue-related crashes, the
number of accidents caused by human error has increased 60% since 1996, a
surge that some safety experts suspect is at least partly the result of
weary crews.
"We have been talking about the same issues for more than 20 years," said
William Keppen of Annapolis, Md., a retired engineer, former union
official and past coordinator of Burlington Northern Santa Fe's fatigue
countermeasures program. "We made some progress in the 1990s, but the
whole thing is starting to go to hell. People are dying out there. The
risk is increasing again."
National Transportation Safety Board records show that entire crews have
nodded off at the controls of mile-long freight trains weighing 10,000
tons, some of them loaded with hazardous materials.
In a 1984 Wyoming crash, a Burlington Northern engineer had only 6 1/2
hours of sleep in the 48 hours before the accident; his conductor had five
hours of sleep.
Outside St. Louis in 2001, a Union Pacific engineer who had been up for 24
hours with only a short nap failed to heed three warning signals and
orders to limit his speed before triggering a chain-reaction crash
involving two other trains. The wreck injured four and caused $10 million
in damage.
A year later, in Des Plaines, Ill., a Union Pacific engineer fighting to
stay awake after more than 22 hours without sleep blew past warning
signals and broadsided another train, severely injuring two crew members.
After a Chicago & North Western train collision in March 1995, engineer
Gerald A. Dittbenner sued the railroad < and received a $500,000
settlement, his lawyers say < over his incessant 12-hour shifts and
irregular work schedules.
Dittbenner, 49, misread a stop signal after being awake almost 30 hours
and hit the rear of an empty coal train outside Shawnee Junction, Wyo.
Seconds before the impact, Dittbenner jumped from the locomotive and broke
his neck. Unable to do strenuous work because of persistent pain, he now
works as a locksmith in Scottsbluff, Neb.
At a freight terminal before the crash, Dittbenner wrote a prophetic
letter to the railroad company < but never got a chance to mail it.
"I said something like, 'We weren't getting enough sleep. The railroad is
always short-handed and working us to death. If nothing is done, someone
is going to get hurt,' " Dittbenner recalled in an interview. "That
someone was me."
U.S. Probes Few Crashes
Federal regulators believe that fatigue underlies many train accidents,
though the number of crashes related to the lack of rest is unknown.
The government investigates few crashes, leaving most of them to the
railroads to review. By law, those carriers submit reports to the
government. Under cause, the only fatigue-related category is "employee
fell asleep," which Federal Railroad Administration officials say doesn't
provide a full picture of the problem.
In 2004, the industry reported 3,104 significant accidents to the railroad
administration. About 1,250 were attributed to human factors such as poor
judgment, miscommunication and failure to follow operating procedures <
errors that experts say can be triggered by fatigue.
A 1997 survey of more than 1,500 freight crew members by the North
American Rail Alertness Partnership < a group of industry, government and
union officials < found that about 80% had reported to work while tired,
extremely tired or exhausted.
Though fatigue can affect passenger train crews, it is primarily a problem
for the 40,000 to 45,000 engineers, brake operators and conductors
assigned to unscheduled freight service.
Many put in 60 to 70 hours a week, sometimes more. They can be called to
work any time during the day or night, constantly disrupting their sleep
patterns.
The irregular shifts often place bleary-eyed crews at the controls between
3 and 6 a.m., when experts say the body's natural circadian rhythm
produces maximum drowsiness.
Engineers, brake operators and conductors liken on-the-job fatigue to
being in a constant state of jet lag.
"There is no set rest schedule. It changes all the time, and it is hard to
adjust," said Doug Armstrong of Huntington Beach, a veteran Union Pacific
engineer who often works 12-hour days, six days a week. "People have a
normal rest cycle, but a railroad is anything but normal."
Part of the problem is the federal Hours of Service Act, a 98-year-old law
that requires at least eight hours off after each shift. Crew members say
that often doesn't result in adequate sleep. Allowing for commutes, family
obligations, meals and getting ready for work, four to six hours of rest
is common, they say.
Moreover, it is legal under the act for engineers, conductors and brake
operators to work up to 432 hours a month. In contrast, truckers can drive
no more than 260 hours a month under federal law, while commercial pilots
are restricted to 100 hours of flying a month.
"It doesn't make scientific or physiological sense," said Mark R.
Rosekind, a past director of NASA's fatigue countermeasures program and a
former consultant to Union Pacific. "It calls for a minimum of eight hours
off, but people need eight hours of sleep a day on average."
Without adequate rest, engineers can significantly increase their risk of
an accident, according to research in the late 1990s by the Assn. of
American Railroads, the industry's trade organization and lobbying arm.
Donald G. Krause, then an analyst for the association, studied 1.7 million
work schedules and found that engineers who put in more than 60 hours a
week were at least twice as likely to be in an accident as those working
40 hours.
His work was intended to aid the industry in assessing the fatigue problem
and finding ways to reduce accidents. But in 1998, the association
canceled the research.
"They did not want this finding," said Krause, who once studied rail
safety for the federal General Accounting Office and is now a business
writer living outside Chicago. "The railroads fear it could lead to
restrictions on hours and government regulation, which could cost them
money. But something needs to be done. One of these days, they are going
to wipe out a town."
Association officials say Krause's research was halted because of budget
cuts, not out of a desire to bury the conclusions.
Not a New Problem
Exhausting schedules are nothing new in railroading. In 1863, long hours
contributed to the founding of the Brotherhood of Locomotive Engineers,
one of the nation's oldest unions.
Crew fatigue is even enshrined in American folklore. Engineer Casey Jones
was killed when he rear-ended another train in 1900 < near the end of a
double shift. The accident inspired a song, "The Ballad of Casey Jones."
Today's fatigue problem is the result of a variety of developments over
the last two decades, say union officials, railroad consultants, company
executives and train crew members.
Hiring has not kept pace with a steady increase in rail freight volumes,
about 4.4% a year on average since 1991, federal data show.
Corporate mergers and cost-cutting during the 1990s led to staff
reductions. In 2002, a change in pension rules led to 12,000 railroad
worker retirements, twice as many as the year before.
Since 1990, overall railroad employment has declined more than 25%.
Department of Labor statistics show that, until recently, the hiring of
engineers has been flat for years.
Railroad unions have at times resisted proposed solutions to the fatigue
problem if they threatened to limit the freedom of their members to work
long hours and maximize earnings. With overtime and high mileage, salaries
for engineers can reach $100,000 a year.
"It is a two-edged sword," said Brian Held, 47, a Burlington Northern
Santa Fe engineer for 10 years. "The company wants to save money and
doesn't hire what it needs to. Union members don't want the boards so full
of workers they can't make the money they want. It makes for a dangerous
situation."
Held said that fatigue led to a train collision April 28, 2004, in the
Cajon Pass of San Bernardino County, a long, tricky grade that requires
constant attention.
Federal records show that both the engineer and conductor of a Burlington
Northern Santa Fe train dozed off and struck a Union Pacific train at 5:15
a.m. Five cars derailed.
"There have been four or five fatigue-related incidents up there," Held
said. "We're lucky no one was killed."
Interest in fatigue as a safety problem intensified in the mid-1980s, when
the NTSB concluded that weary crews contributed to three collisions
involving Burlington Northern trains that left 12 dead.
But the railroad industry did not launch a major initiative until two
Santa Fe freight trains collided Nov. 7, 1990, in Corona, killing four and
causing $4.4 million in damage.
The fiery head-on crash occurred at 4:11 a.m., when a westbound train
ignored a stop signal and crept onto the main track from a siding. It
collided with an eastbound freight train going about 30 mph.
Crew members on the westbound train tried to run from the wreckage but
were consumed by a fireball. The brake operator on the other train was
killed; the engineer and conductor suffered serious injuries.
A year later, NTSB investigators concluded that the crew at fault had
probably fallen asleep. They noted that engineer Gary Ledoux and brake
operator Virginia Hartzell had not slept for almost 27 hours, making them
drunk with exhaustion. Conductor James Wakefield had no more than six
hours of rest the day before.
Of Ledoux's last 54 shifts, 35 had different reporting times at all hours.
The day before the crash, because of a last-minute shift change, Ledoux
had only 5 1/2 hours of sleep before guiding a freight train from Los
Angeles to Barstow, arriving at 12:40 p.m.
En route to Los Angeles, Ledoux exceeded speed limits 13 times. As he
neared Corona, he turned on the cab's dome light and opened the window in
an apparent attempt to stay awake.
Voluntary Solutions
The Corona accident prompted the formation of the Work Rest Task Force,
which stressed a voluntary approach by railroad companies and labor unions
to sponsor research and find solutions without government intervention. In
1996, the North American Rail Alertness Partnership was formed. The
Federal Railroad Administration also organized related efforts.
Today, a variety of fatigue countermeasures are partially in place or
under consideration at the nation's largest railroads, including
Burlington Northern Santa Fe, CSX Transportation, Norfolk Southern and
Union Pacific.
Some railroads have started voluntary work-rest cycles, though they are
not available to most of their freight crews. A typical arrangement is
seven days on and three days off. Educational materials are available,
crew lodgings at hotels have been upgraded and most major railroads, after
years of resistance, now allow short naps for those on duty.
Executives at some companies say they are moving to more regularly
scheduled freight service, which can make crew members' hours more
predictable.
At Burlington Northern Santa Fe, crew members are entitled to 14 hours of
undisturbed rest after working eight hours. At CSX, they can ask for
undisturbed rest for up to 10 hours, and fixed work-rest cycles are
available at several major hubs.
Officials at all of the nation's largest railroads say they are hiring
thousands of engineers and conductors to reduce crew shortages. The
companies, which handle about 90% of the nation's rail freight, added more
than 4,000 crew members in 2004, a 7% increase over 2003.
The Assn. of American Railroads contends that a voluntary effort is more
likely to succeed than a "one-size-fits-all" approach that government
regulation would create.
"We have made huge gains by working cooperatively," said Alan Lindsey,
general director of safety and rules for Burlington Northern Santa Fe. "We
have come a tremendous way as an industry."
Although accidents related to human error are increasing, the railroad
association cites federal data that deaths and injuries of railroad
workers from accidents are at record lows.
Fatigue "is not what I'd consider a major safety issue at this point, but
it is an issue we take seriously," said Robert C. VanderClute, the
association's senior vice president of safety and operations.
Industry critics, however, point to Union Pacific, the nation's largest
carrier, in asserting that the voluntary approach isn't working.
Understaffing and crew fatigue have persisted at Union Pacific despite the
railroad's participation in the Work Rest Task Force.
The largest team of safety inspectors ever assembled by the Federal
Railroad Administration descended on Union Pacific in 1997 after five
major crashes in eight weeks killed seven people.
Long hours, unpredictable work schedules and train crews that had worked
days on end without time off were partly to blame.
Since last May, the Federal Railroad Administration and the NTSB have been
investigating seven derailments and crashes involving Union Pacific trains
near San Antonio, including the Macdona wreck.
Crew fatigue is suspected in at least two of the accidents.
In December 2003, Union Pacific unsuccessfully sued a group of unionized
conductors alleging that they were taking too much time off during
weekends and holidays, disrupting commerce along a major Kansas line in
violation of the Railway Labor Act.
The United Transportation Union countered that the railroad was severely
understaffed in the area and many conductors were exhausted from working
for weeks < sometimes months < without a day off.
"We were running with a skeleton crew," said union official Greg Haskin.
"Guys were burned out and calling in sick. They were working 12- to
16-hour days up to 90 days straight. You can't expect people to work like
that and be safe."
Union Pacific declined to discuss the case.
The company has vowed to add 200 engineers and conductors in the San
Antonio area, where the Macdona crash occurred, and 2,500 this year across
its vast network.
The company also is experimenting with a two-days-on, two-days-off
work-rest cycle for engineers at its giant freight hub in North Platte,
Neb.
"Generations have been dealing with this problem," said John Bromley, a
Union Pacific spokesman. "There are not going to be any overnight
solutions."
Critics say the industry isn't doing enough voluntarily and that further
government regulation is needed. But when it comes to combating fatigue,
the wheels of reform turn slowly.
Bills requiring fatigue management plans and improvements to the Hours of
Service Act have failed repeatedly in Congress since 1998 because of
corporate and labor opposition.
Out of frustration, NTSB officials say they recently withdrew their
long-standing recommendation for revisions to the act.
Amending the law to reflect modern sleep science had been on the NTSB's
"10 Most Wanted List" of safety improvements since 1990.
George Gavalla, who headed the Federal Railroad Administration safety
office from 1997 to 2004, said trying to reduce the fatigue problem "was
one of my biggest frustrations."
"I'm disappointed we could not accomplish more," he added. "It is a huge
safety issue."
