Western Railroad Discussion > NTSB: Fatigue led to fatal train crash in New Mexico

NTSB: Fatigue led to fatal train crash in New Mexico

The National Surface Transportation Safety Board has determined that
a fatigued train conductor's failure to properly line a switch is the
probable cause for a 2015 collision of two Southwestern Railroad
freight trains near Roswell, New Mexico.

The engineer of the striking train died, and the conductor was seriously injured in the April 28, 2015, collision that derailed 11 locomotives and three empty hopper cars. The crash caused about $2 million in property damage, according to an NTSB press release.

The accident occurred when a westbound Southwestern Railroad train traveled through a switch left in the reverse position at the east end of the Chisum siding, just south of Roswell, and collided with Southwestern Railroad's Roswell Local, which was standing in the siding. The conductor of the standing Roswell Local train told a manager that he failed to line the switch for normal main track movement at the Chisum siding.

The striking train crew didn't perceive the misaligned switch in non-signaled territory and failed to stop before reaching it. As a result of its investigation, the NTSB issued one new safety recommendation to the Federal Railroad Administration (FRA) to develop a device or technique that would eliminate the possibility of employees failing to perform critical tasks such as lining a switch, lining a derail or ensuring cars are in the clear.

===========================================

This is exactly what happened to the Amtrak Silver Star, when it collided into a parked CSX freight train due to a switch not relined
for through traffic on the main track. In that wreck, the signals were suspended and not funcitioning. In New Mexico, the railroad was
unsignaled.

Oddly, or perhaps bowing to external pressure, NTSB notes blood tests on the engineer of the striking train which indicate he had probably been using marijuana while on duty...but did not point to that as a possible factor.

================================================
The engineer’s results identified significant levels of tetrahydrocannabinol (THC). These results, and the presence of rolling papers and pipes in the locomotive cab suggest the engineer smoked marijuana between 30 minutes and five hours before the accident, and, because the engineer had been on duty for almost 10 hours, he likely used marijuana while on duty and likely was under its influence while operating the train, the NTSB determined.

==============================================

This sounds like political correctness run amok.

The dispatcher and conductor of the striking train were also tested. The dispatcher tested clean; the conductor had traces of prescribed medications but was
probably not under their influence.


https://www.progressiverailroading.com/federal_legislation_regulation/news/NTSB-Fatigue-led-to-fatal-train-crash-in-New-Mexico--54408



Edited 2 time(s). Last edit at 04/11/18 10:12 by GenePoon.

GenePoon Wrote:
-------------------------------------------------------
> the NTSB issued one new safety
> recommendation to the Federal Railroad
> Administration (FRA) to develop a device or
> technique that would eliminate the possibility of
> employees failing to perform critical tasks such
> as lining a switch, lining a derail or ensuring
> cars are in the clear.

Mmmmmm, maybe something like not working crews into a stupor with random operation, working repeatedly to the maximum hours allowed (and then some), and no predictability of work hours? Nah! Let's look for more technology.

TAW

The claim of “probably not under the influence” does not match up with incidents I have seen where such a person had either acted or failed to act when a quick decision was necessary. Those blood tests were done by the coroner and were never in dispute. I can only imagine a worsening situation in railroading and elsewhere as the use of marijuana spreads.

Hey, even in the states where it's "legal", it's still against the law to drive while under the influence of alcohol, drugs (both prescription and illegal) and marijuana.
And I believe the various railroad rule books do ban being "under the influence" while on duty. So the NTSB does have a valid point.

What did the conductor's prior 7 day work schedule look like?

The Permian Basin has been hopping with oil, frac sand, new pipe, etc. If the guy was working immediately on his rest for weeks, the stupor could have been genuine old fashioned fatigue.

PHall Wrote:
-------------------------------------------------------
> Hey, even in the states where it's "legal", it's
> still against the law to drive while under the
> influence of alcohol, drugs (both prescription and
> illegal) and marijuana.
> And I believe the various railroad rule books do
> ban being "under the influence" while on duty. So
> the NTSB does have a valid point.

NTSB found he was probably using marijuana during his on-duty time, and they note "blood tests
on the engineer of the striking train which indicate he had probably been using marijuana
while on duty...but did not point to that as a possible factor."

THAT's odd and perhaps that conclusion was politically motivated.



Edited 1 time(s). Last edit at 04/11/18 10:26 by GenePoon.

GenePoon Wrote:
-------------------------------------------------------
> PHall Wrote:
> --------------------------------------------------
> -----
> > Hey, even in the states where it's "legal",
> it's
> > still against the law to drive while under the
> > influence of alcohol, drugs (both prescription
> and
> > illegal) and marijuana.
> > And I believe the various railroad rule books
> do
> > ban being "under the influence" while on duty.
> So
> > the NTSB does have a valid point.
>
> NTSB found he was probably using marijuana during
> his on-duty time, and they note "blood tests
> on the engineer of the striking train which
> indicate he had probably been using marijuana
> while on duty...but did not point to that as a
> possible factor."
>
> THAT's odd and perhaps that conclusion was
> politically motivated.

Sounds more like a statement of fact.

If the "striking engineer" saw the problem and applied the brakes in an appropriate/timely manner, the statement that his usage did not appear to impair his performance would be correct.

PHall Wrote:
-------------------------------------------------------
> And I believe the various railroad rule books do
> ban being "under the influence" while on duty.

It's in the CFR. Federal regulation. Zero tolerance.

Standing train conductor's mistake notwithstanding, perhaps if the stoned engineer of the other train hadn't been baked, he might have seen the mis-aligned switch and taken appropriate action in time. Speculation on my part but I detest people who use drugs on the railroad. They usually end up killing innocent bystanders.

Lackawanna484 Wrote:
-------------------------------------------------------
> What did the conductor's prior 7 day work schedule
> look like?
>
> The Permian Basin has been hopping with oil, frac
> sand, new pipe, etc. If the guy was working
> immediately on his rest for weeks, the stupor
> could have been genuine old fashioned fatigue.

If anyone is interested in facts instead of keyboard conjectures
the answer to this and other questions can be found in the NTSB Docket Items.
https://dms.ntsb.gov/pubdms/search/hitlist.cfm?docketID=58675&CFID=1644470&CFTOKEN=2bbf9eecbf3b1a09-1BE8D26C-9DA5-D0ED-46C82FD7190D94F9

As I have mentioned before the docket items contain the unfiltered interview transcripts and other information.
After reading the docket items knowledgable railroad people will often come to conclusions vastly different from the NTSB.
The NTSB "Final Report" is merely conclusions based on the direction of political winds.



From the docket items:

"As with the other three crewmembers, the engineer’ s statement that he went off duty at a time that exceeded
the Hours of Service regulations, on this day by one hour and forty-five minutes, includes limbo time.
Limbo time refers to a period oftime treated as neither time on duty nor time offduty in 49 U.S.C. 21 1 03 and 21 1 04,
and any other period ofservice for the railroad that does not qualify as either covered service or commingled service.
[see 49 CFR 228.5]. An example oflimbo time would be a railroad employee awaiting transportation from a duty assignment
to the place of final release. Thus, the engineer actually worked until 6: 00 p. m. , but accrued one hour and forty-five minutes
of limbo time resulting in a final release time of 7: 45 p. m. No crewmember exceeded their work time limitations imposed
by the Hours of Service regulations."

" The engineer of local switcher train LSWC-0021 27I:
At the time of the accident he had been awake for approximately 22 hours with the possible exception of a nap,
on duty for seven hours, and off duty for about twenty-three minutes."



Edited 3 time(s). Last edit at 04/11/18 11:52 by Englewood.

Seems like lately the NSTB will happily look the other way and throw out or deny the very obvious.

dcfbalcoS1 Wrote:
-------------------------------------------------------
> Seems like lately the NSTB will happily look the
> other way and throw out or deny the very obvious.

They are political appointees...

Englewood Wrote:
-------------------------------------------------------
> Lackawanna484 Wrote:
> --------------------------------------------------
> -----
> > What did the conductor's prior 7 day work
> schedule
> > look like?
> >
> > The Permian Basin has been hopping with oil,
> frac
> > sand, new pipe, etc. If the guy was working
> > immediately on his rest for weeks, the stupor
> > could have been genuine old fashioned fatigue.
>
> If anyone is interested in facts instead of
> keyboard conjectures
> the answer to this and other questions can be
> found in the NTSB Docket Items.
> https://dms.ntsb.gov/pubdms/search/hitlist.cfm?doc
> ketID=58675&CFID=1644470&CFTOKEN=2bbf9eecbf3b1a09-
> 1BE8D26C-9DA5-D0ED-46C82FD7190D94F9
>
> As I have mentioned before the docket items
> contain the unfiltered interview transcripts and
> other information.
> After reading the docket items knowledgable
> railroad people will often come to conclusions
> vastly different from the NTSB.
> The NTSB "Final Report" is merely conclusions
> based on the direction of political winds.
>
>
>
> From the docket items:
>
> "As with the other three crewmembers, the
> engineer’ s statement that he went off duty at a
> time that exceeded
> the Hours of Service regulations, on this day by
> one hour and forty-five minutes, includes limbo
> time.
> Limbo time refers to a period oftime treated as
> neither time on duty nor time offduty in 49 U.S.C.
> 21 1 03 and 21 1 04,
> and any other period ofservice for the railroad
> that does not qualify as either covered service or
> commingled service.
> . An example oflimbo time would be a railroad
> employee awaiting transportation from a duty
> assignment
> to the place of final release. Thus, the engineer
> actually worked until 6: 00 p. m. , but accrued
> one hour and forty-five minutes
> of limbo time resulting in a final release time of
> 7: 45 p. m. No crewmember exceeded their work time
> limitations imposed
> by the Hours of Service regulations."
>
> " The engineer of local switcher train LSWC-0021
> 27I:
> At the time of the accident he had been awake for
> approximately 22 hours with the possible exception
> of a nap,
> on duty for seven hours, and off duty for about
> twenty-three minutes."


That's interesting, thanks for the link.

Both guys had had two 24 hour periods off in the prior few days, yet each of them reported feeling "sorta tired" or "OK, but felt a little tired driving". Certainly sounds like they could have been fatigued.

Pages 7-9 https://dms.ntsb.gov/public/58500-58999/58675/590773.pdf

Lackawanna484 Wrote:

> Both guys had had two 24 hour periods off in the
> prior few days, yet each of them reported feeling
> "sorta tired" or "OK, but felt a little tired
> driving". Certainly sounds like they could have
> been fatigued.
>
> Pages 7-9
> https://dms.ntsb.gov/public/58500-58999/58675/5907
> 73.pdf


Happening to have 24 hours off work and knowing you will have 24 hours off work when you finish a shift are two very different things. Previous time off duty alone is worthless in determining the fatigue level of a crewmember.

smudgepot Wrote:
-------------------------------------------------------

> Happening to have 24 hours off work and knowing
> you will have 24 hours off work when you finish a
> shift are two very different things. Previous time
> off duty alone is worthless in determining the
> fatigue level of a crewmember.

Roger that! However that is the excuse for management that is found in virtually every accident report.

TAW

GenePoon Wrote:
-------------------------------------------------------
>
> NTSB found he was probably using marijuana during
> his on-duty time, and they note "blood tests
> on the engineer of the striking train which
> indicate he had probably been using marijuana
> while on duty...but did not point to that as a
> possible factor."
>
> THAT's odd and perhaps that conclusion was
> politically motivated.

Just say what you're trying to say without saying. What are you afraid of? Leave out the "perhaps" garbage.

Between this wreck and the one near Santa Rita, NM on their other operation, I don't think Southwestern will have to worry about winning a Harriman-style safety award anytime soon.

I believe the line where this wreck occurred has reverted back to being operated by BNSF.

CA_Sou_MA_Agent Wrote:
-------------------------------------------------------

> I believe the line where this wreck occurred has
> reverted back to being operated by BNSF.

Correct, on January 17, 2017.

As the railroaders here know well, I agree with smudgepot 24hrs rest means nothing in real life. When I worked on the "Chain gang" extraboard. We worked off our rest (8-10Hrs) under the old hours of service rules. It was easier on us because we worked, slept, worked and slept. We went to sleep at hotel at 2pm, got home to wife and kids at 7am. It didn't matter what you wanted to do, you had to sleep unless you booked off. For me the days we got an unexpected 20hrs off you had already got off went to sleep only to wake up on your own not the normal call to work from crew caller. Then you do stuff you have been putting off yard work, spending time with family normal person stuff. Then after being up 10 to 12 hours, you lay back down and boom the phone rings. Now your not rested, but not tired yet but that soon changes and when you get off you are dead tired, and the rotation continues. If that doesn't help the non railroaders on site it should.

In speaking of leaving the switches open on the Southwestern RR and on CSX recently with Amtrak. This has been going on for a long time. Throwing switches at wrong time, 2 times, or forgetting altogether, the industry has added so many steps and procedures and they continue. I've witnessed these myself, including today, and the person who did it just can't explain it. Throwing switches is a common activity, we may do it a hundred times a day and becomes a senseless activity. When it comes to mainline switches,that can't happen but it does. It gets so frustrating to hear that it happens again and again even after switch position awareness forms, Double Check Switch all that. What's the industry to do? I wish I knew I'd retire today.

> > cars are in the clear.
>
> Mmmmmm, maybe something like not working crews
> into a stupor with random operation, working
> repeatedly to the maximum hours allowed (and then
> some), and no predictability of work hours? Nah!
> Let's look for more technology.
>
> TAW


Kind of a dumb rant as it was due to what he was SMOKING not over work or didn't get enough sleep. Just stupidity and paid for it glad it was only him. Kind of took care of the gene pool. The best tech would not have helped much but keep the thoughts coming we need a good laugh.