Railroad Accident Report

Collision of Two Canadian National/Illinois

Central Railway Trains

Near Clarkston, Michigan

November 15, 2001

National 

Transportation 

Safety Board

Washington, D.C.

A

A

N TION

L TRA SPOR

ATIO

N

B OARD

SAF E T Y

N

T

E PLURIBUS UNUM 

NTSB/RAR-02/04

PB2002-916304

Railroad Accident Report

Collision of Two Canadian National/Illinois 

Central Railway Trains 

Near Clarkston, Michigan

November 15, 2001

NTSB/RAR-02/04

PB2002-916304 National Transportation Safety Board

Notation 7508 490 LíEnfant Plaza, S.W.

Adopted November 19, 2002 Washington, D.C. 20594
National Transportation Safety Board. 2002. Collision of Two Canadian National/Illinois Central

Railway Trains Near Clarkston, Michigan November 15, 2001. Railroad Accident Report NTSB/

RAR-02/04. Washington, DC.

Abstract: On November 15, 2001, about 5:54 a.m., eastern standard time, Canadian National/Illinois

Central Railway (CN/IC) southbound train 533 and northbound train 243 collided near Clarkston,

Michigan. The collision occurred on the CN/IC Holly Subdivision at a switch at the south end of a siding

designated as the Andersonville siding. Train 533 had been operating in a southward direction through the

siding and was traveling at 13 mph when it struck train 243. Signal 14LC at the turnout for the siding

displayed a stop indication, but train 533 did not stop before proceeding onto the mainline track. Train 243

was operating northward on a proceed signal on the single main track about 30 mph when the trains

collided. Both crewmembers of train 243 were fatally injured; the two crewmembers of train 533 sustained

serious injuries. The total cost of the accident was approximately $1.4 million.

In its investigation of this accident, the Safety Board examined one safety issue, the adequacy of rail

industry standards and procedures for identifying and reporting potentially incapacitating medical

conditions.

As a result of its investigation of this accident, the Safety Board makes safety recommendations to the

Canadian National Railway and the Federal Railroad Administration.

The National Transportation Safety Board is an independent Federal agency dedicated to promoting aviation, railroad, highway, marine,

pipeline, and hazardous materials safety. Established in 1967, the agency is mandated by Congress through the Independent Safety Board

Act of 1974 to investigate transportation accidents, determine the probable causes of the accidents, issue safety recommendations, study

transportation safety issues, and evaluate the safety effectiveness of government agencies involved in transportation. The Safety Board

makes public its actions and decisions through accident reports, safety studies, special investigation reports, safety recommendations, and

statistical reviews.

Recent publications are available in their entirety on the Web at <http://www.ntsb.gov>. Other information about available publications also

may be obtained from the Web site or by contacting:

National Transportation Safety Board

Public Inquiries Section, RE-51

490 LíEnfant Plaza, S.W.

Washington, D.C. 20594

(800) 877-6799 or (202) 314-6551

Safety Board publications may be purchased, by individual copy or by subscription, from the National Technical Information Service. To

purchase this publication, order report number PB2002-916304 from:

National Technical Information Service

5285 Port Royal Road

Springfield, Virginia 22161

(800) 553-6847 or (703) 605-6000

The Independent Safety Board Act, as codified at 49 U.S.C. Section 1154(b), precludes the admission into evidence or use of Board reports

related to an incident or accident in a civil action for damages resulting from a matter mentioned in the report. 
iii Railroad Accident Report

Contents

Acronyms and Abbreviations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . iv

Executive Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . v

Factual Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

The Accident . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

Train 533 Crewmembers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

Engineer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

Conductor . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

Postaccident Inspections and Tests . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

Toxicological Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

Meteorological Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

Obstructive Sleep Apnea . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

Fatigue Education at the CN/IC . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

Medical Examinations of Railroad Employees . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

Company-Mandated Medical Examinations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

Private Medical Examinations and Reporting Requirements . . . . . . . . . . . . . . . . . . . . 12

Medical Condition and Fitness-For-Duty Evaluations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14

Recorded Information for Postaccident Analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14

Analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16

The Accident . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16

General . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16

Train 533 Crewmembers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

Engineer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

Conductor . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18

CN/IC Fatigue Awareness Program . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20

Detection of Employeesí Conditions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21

Medical Examination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21

Reporting of Medical Conditions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22

Fitness-For-Duty Evaluations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24

Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26

Findings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26

Probable Cause . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27

Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28

Appendixes

A: Investigation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .29

B : Previous Safety Board Recommendations Concerning Sleeping Disorders 

and Other Related Issues Affecting Operator Fatigue . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
iv Railroad Accident Report

Acronyms and Abbreviations

ATSF Atchison, Topeka and Santa Fe Railway Company

CFR Code of Federal Regulations

CN/IC Canadian National/Illinois Central Railway

CPAP Continuous Positive Airway Pressure

ENT ear, nose, and throat

FAA Federal Aviation Administration

FMCSA Federal Motor Carrier Safety Administration

FRA Federal Railroad Administration

MARC Maryland Rail Commuter

NVIC Navigation and Vessel Inspection Circular

OSA obstructive sleep apnea

RSAC Railroad Safety Advisory Committee

SEPTA Southeastern Pennsylvania Transit Authority
v Railroad Accident Report

Executive Summary

On November 15, 2001, about 5:54 a.m., eastern standard time, Canadian

National/Illinois Central Railway (CN/IC) southbound train 533 and northbound train 243

collided near Clarkston, Michigan. The collision occurred on the CN/IC Holly

Subdivision at a switch at the south end of a siding designated as the Andersonville siding.

Train 533 had been operating in a southward direction through the siding and was

traveling at 13 mph when it struck train 243. Signal 14LC at the turnout for the siding

displayed a stop indication, but train 533 did not stop before proceeding onto the mainline

track. Train 243 was operating northward on a proceed signal on the single main track

about 30 mph when the trains collided. Both crewmembers of train 243 were fatally

injured; the two crewmembers of train 533 sustained serious injuries. The total cost of the

accident was approximately $1.4 million.

The National Transportation Safety Board determines that the probable cause of

the November 15, 2001, Canadian National/Illinois Central Railway accident in

Clarkston, Michigan, was the train 533 crewmembersí fatigue, which was primarily due to

the engineerís untreated and the conductorís insufficiently treated obstructive sleep apnea.

In its investigation of this accident, the Safety Board examined one safety issue:

ï The adequacy of rail industry standards and procedures for identifying and

reporting potentially incapacitating medical conditions.

As a result of its investigation of this accident, the Safety Board makes safety

recommendations to the Canadian National Railway (parent organization of the CN/IC)

and the Federal Railroad Administration.

1 Railroad Accident Report

Factual Information

The Accident

On November 15, 2001, about 5:54 a.m., eastern standard time,1 Canadian

National/Illinois Central Railway (CN/IC)2

 southbound train 533 and northbound

train 243 collided near Clarkston, Michigan. The collision occurred on the CN/IC Holly

Subdivision at a switch at the south end of a siding designated as the Andersonville siding.

Train 533 had been operating in a southward direction through the siding and was

traveling at 13 mph when it struck train 243. Signal 14LC at the turnout3 for the siding

displayed a stop indication, but train 533 did not stop before proceeding onto the mainline

track. Train 243 was operating northward on a proceed signal on the single main track

about 30 mph when the trains collided. Both crewmembers of train 243 were fatally

injured; the two crewmembers of train 533 sustained serious injuries. The total cost of the

accident was approximately $1.4 million. (See figure 1.)

1 All times in the report are eastern standard time.

2 The CN/IC is a subsidiary of the Canadian National Railway. The CN/IC operates one of the largest

railroad networks in the United States and Canada with 17,986 route miles covering 14 States and 8

Canadian provinces. The CN/IC network was created through the 1999 merger of the rail systems of the

Canadian National and the Illinois Central and the subsequent merger of this system with the Wisconsin

Central in 2001.

3 A turnout is a switch that allows two sets of parallel tracks (one siding track and one mainline track)

to merge together into one track.

Figure 1. Accident aftermath. (Train 243 is at the bottom of the picture and 

train 533 is at the top of the picture.)
Factual Information 2 Railroad Accident Report

The crew of CN/IC train 533 had gone on duty at Hamtramck, Michigan, at

7:30 p.m., November 14, 2001. Train 533 consisted of 2 locomotives and 90 loaded and 4

empty container platforms. The train was 6,193 feet long and weighed 4,791 tons. The

train departed the yard at 9:45 p.m., after the crew performed the required brake tests and

equipment inspections. The conductor was in the lead locomotive with the engineer. The

train proceeded without incident to Durand, Michigan, a distance of 67 miles, where cars

were to be set out and picked up. Train 533 arrived at Durand at 12:48 a.m., November 15.

In the meantime, the 2-person crew of CN/IC train 243 reported for duty at Flat

Rock, Michigan, at 8:00 p.m., November 14, 2001. Train 243 was to travel northward

from Flat Rock to Flint, Michigan. Train 243 departed Flat Rock about 9:15 p.m., heading

north, after its crew successfully completed the required paperwork and air brake tests.

Train 533 left Durand at 4:49 a.m. on November 15 and proceeded south on the

single main track to the north end of the Andersonville siding where, according to signal

system event recorders, the signal was displaying a restricting indication. The train was

then diverted into the siding. The sidingís full length was about 7,140 feet, and it had a

ìclear spaceî distance of about 6,830 feet. By rule, the authorized maximum speed in the

Andersonville siding was 10 mph. The train 533 locomotive engineer had been qualified

over the territory where the accident occurred for 27 years, and he had previously operated

his train on the siding, as recently as a week before the accident. According to event

recorder data, while operating his train into the Andersonville siding on the day of the

accident, the engineer initially made several throttle control maneuvers that accelerated

the train to 16 mph while traveling in the siding. According to signal system event

recorders, signal 14LC at the south end of the Andersonville siding was displaying a

ìstopî indication.

No evidence was found that the train 533 engineer made any control maneuvers in

response to the stop indication, such as applying the brakes, during the last 2 minutes

before the accident.4

 The engineer told investigators that he had had no conversations with

the conductor during their trip up to and through the Andersonville siding; and there is no

evidence that the conductor attempted to activate the emergency brakes to stop the train.5

Train 533 passed the signal at the south end of the siding without stopping and,

about 5:54 a.m., entered the mainline track traveling about 13 mph and collided with the

right front corner of northbound train 243, which was operating about 30 mph on a

proceed signal. The collision occurred at a point about 163 feet past the stop signal. (See

figure 2.) The two crewmembers of train 243 were fatally injured, and the two

crewmembers of train 533 sustained serious injuries.

4 A locomotive engineer familiar with the Andersonville siding told Safety Board investigators that an

engineer would have needed to begin making brake applications about midway into the siding to safely stop

the train before it entered the main track.

5 This locomotive was equipped with a conductorís emergency brake valve, which the conductor could

use to initiate an emergency brake application.
Factual Information 3 Railroad Accident Report

Figure 2. Diagram of the main track and Andersonville siding, showing the approximate 

locations of the last throttle change for train 533 and the point of collision, based on the 

estimated times provided by event recorder data.

Main Track

Andersonville 

Siding

Stop Signal

163 ft.

Point of collision at

5:54:02 a.m.

7,140 ft.

Approximate location of the 

last throttle change of Train 

533 at 5:52:15 a.m.

Restricting Signal 
Factual Information 4 Railroad Accident Report

The chief of the Springfield Township Fire Department reached the area of the

accident by 6:10 a.m. He set up a command post and requested the assistance of the

Independence Township Fire Department. The engineer and conductor of train 533 were

trapped inside the lead locomotive immediately following the accident. Members of the

Independence and Springfield Township Fire Departments extricated them from the

locomotive. They were airlifted to separate hospitals.

As a result of the derailment, there was a fire. Out of concern for potential leaking

of hazardous materials, an area within a 1/2-mile radius and up to 1 mile downwind from

the accident scene was evacuated. The evacuation displaced persons from 263 residences,

38 businesses, and 2 schools (affecting about 1,570 people) for 3 1/2 hours.

In his first communication with Safety Board investigators after the accident

(through written responses to investigatorsí questions, provided via the engineerís

attorney), the engineer of train 533 indicated that shortly before the accident he had been

preoccupied with trying to pull the train into the Andersonville siding and trying to watch

the signals behind and in front of him. He also indicated that inclement weather impeded

the visibility of the signals in the siding and that some of the signals in the area were

malfunctioning. Subsequently, however, the engineer told Safety Board investigators that,

ìAs I was into the siding, I could see the red signalsÖ.î He also said the signals were

likely functioning properly.

The engineer did not indicate to Safety Board investigators that he had fallen

asleep before the accident. The conductor, who had sustained a head injury as a result of

the collision, said that he could not recall any of the events related to the accident.

Train 533 Crewmembers

Engineer

The engineer of train 533 began employment with the CN/ICís predecessor

railroad (Grand Trunk Western Railroad) on May 15, 1970. He was transferred to the

position of fireman on March 17, 1971, and was promoted to yard engineer on July 10,

1973. He became a locomotive engineer on October 1, 1974. His most recent qualification

on the operating rules took place on July 12, 2000, and he had last been re-certified on

December 29, 2000.

The engineer had worked 7 consecutive days prior to the accident trip. On these

daysand for most of his work during the prior monthhis on-duty time began at

7:30 p.m., and he would typically remain on duty for 12 hours and often remain in ìlimbo

timeî6

 for up to 2 hours beyond that. Except for one occasion during this 30-day period,

6 According to 49 United States Code 21103(b)(4), ìTime spent in deadhead transportation to a duty

assignment is time on duty, but time spent in deadhead transportation from a duty assignment to the place of

final release is neither time on duty nor time off duty.î The latter time is commonly termed limbo time.
Factual Information 5 Railroad Accident Report

each assignment he had worked during the last month was the same trip he was making on

the day of the accident.

Each day that the engineer worked, he would leave his house about 6:15 p.m.,

arrive at the terminal around 7:30 p.m., and go on duty at that time. The engineer was on

duty on November 11 from 7:30 p.m. until 8:40 a.m. the next morning. He was on duty

again that night (November 12) from 7:30 p.m. until 7:30 a.m., November 13. At

7:30 p.m., November 13, he went on duty and worked until 9:30 a.m., November 14. That

evening, he showered and ate before he left his house, about 6:15 p.m., for work. At

7:30 p.m., November 14, he went on duty at Hamtramck and worked until the accident

(which took place about 5:54 a.m., November 15).

The engineer stated that on the days leading up to the accident he would arrive

home between 8:30 and 9:00 a.m. He would be in bed within a half hour, get up between

4:00 and 5:00 p.m., and then clean up and eat before departing for work. He also indicated

that he received about 6 1/2 hours of sleep each day.

As a prerequisite to engineer certification, and in accordance with Federal

regulations, the engineer of train 533 underwent routine company physical examinations

to determine whether he met the standards for vision and hearing acuity prescribed in

49 Code of Federal Regulations (CFR) 240.121. The CN/IC, based on the results of his

last physical examination, performed on December 20, 2000, determined that the engineer

was fit to perform the duties required of a locomotive engineer. The engineer told Safety

Board investigators that, before the accident, his health was ìfairly good,î although he

stated that he had some minor health problems that he believed did not affect his job

performance. During his company physical examinations, he indicated that he had high

blood pressure and diabetes that were being treated with prescription medications. He had

specified these medications on his examination form. The CN/IC did not find either of

these medical conditions or the prescribed medications to be disqualifying. The engineer

did not indicate during his company physical examinations that he experienced any type

of chronic sleep problem, nor did the examination form request information about sleep

disorders.

Safety Board investigators examined the engineerís medical records from his

private physician. In April 1998, in response to the engineerís complaints about ìsnoring

with pauses,î his private physician referred him to an ear, nose, and throat (ENT)

specialist. The ENT specialist noted, in part, that the engineer was being evaluated for

ìchronic snoring with episodic awakening and daytime somnolence.î After his evaluation,

the ENT specialist concluded that the engineer likely suffered from obstructive sleep

apnea (OSA),7 a chronic sleeping disorder. The specialist had also indicated that he:

Warned [the engineer] of the risks of falling asleep while driving either his car or

the train. He appears to understand these risks. I also discussed treatment

optionsÖI requested that he have a sleep study performedÖ.

7 OSA will be discussed in detail later in this report.
Factual Information 6 Railroad Accident Report

The engineerís private physician was aware of the engineerís occupation and that

he likely suffered from OSA. On several occasions following the ENT specialistís

diagnosis, the last occasion occurring about a week before the accident, the private

physician explicitly warned the engineer that he should make an appointment at a sleep

clinic to undergo further evaluation and to learn about treatment options for possible OSA.

The private physicianís notes indicated that the engineer understood the need for further

medical treatment. The engineer did not seek additional medical treatment for this

condition. The engineer told Safety Board investigators that he believed he suffered from

OSA.

A CN/IC conductor who had worked with the train 533 engineer told Safety Board

investigators that on several occasions the engineer had fallen asleep while operating a

train and had to be awakened to respond to an upcoming signal or to blow the horn at a

grade crossing. Another conductor commented that the engineer ìalways looked tired.î

Conductor

The CN/ICís predecessor railroad hired the conductor of train 533 as a yard

brakeman on June 21, 1976. He was promoted to road brakeman and conductor on

October 13, 1980. His most recent qualification on the operating rules was on July 5,

2000.

According to CN/IC medical records, the train 533 conductorís last company

physical examination took place on July 27, 2001. The examining physician determined

that the conductor was fit to perform his duties, with the restriction that he wear hearing

protection. (There was evidence of ìslightî high frequency hearing loss for both his ears.)

The examination also indicated that the conductor had Type II diabetes, diagnosed 1 1/2

years previously, which was being controlled by diet. Nothing in the companyís medical

records indicated that the CN/IC was aware that the conductor had been diagnosed with,

and was being treated for, OSA.

In postaccident interviews with Safety Board investigators, the conductor stated

that some years earlier, his personal physician had referred him to a sleep clinic, where he

was diagnosed with severe OSA on June 6, 1997. Since then, he had been using a

Continuous Positive Airway Pressure (CPAP) device8

 to treat this condition. He did not

return to the sleep clinic for a CPAP titration9

 study to determine the effectiveness of the

CPAP device. The medical records for his last sleep examination at the sleep clinic

indicated that his Epworth Sleepiness Scale10 value was 4 (considered normal), but the

8 The CPAP device is considered the most effective non-surgical treatment for the alleviation of

snoring and OSA.

9 The level of air pressure required to keep a personís airway open is determined through an overnight

sleep study with a nasal CPAP device; the study is called a CPAP titration. After an optimal pressure has

been determined, the patientís CPAP unit is set at that pressure for home use.

10 The Epworth Sleepiness Scale, a subjective measure of sleepiness, has a range of 0 to 24. Epworth

Scale values for a person without excessive sleepiness would be 10 or less, while values 11 through 24

indicate significant sleepiness.
Factual Information 7 Railroad Accident Report

records also indicated that he said he did not feel that the CPAP pressure was strong

enough, that he continued to snore, and that he was tired.

The conductor of train 533 had been assigned to the extra board,11 so he did not

work a regular assignment. As a result, both his on-duty and off-duty times varied from

assignment to assignment. He had not worked the train 533 job for at least a month prior

to the accident trip. His on-duty start times over the month before the accident were never

the same on consecutive days, and he had worked both daytime and nighttime shifts on an

irregular basis.

In the period immediately before the accident, he had first worked the night shift

for a few days. Then the conductor was off duty from about 7:00 p.m. on November 10

through November 12 (he indicated that he was ill). On November 13 at 11:30 p.m., he

went on duty and worked until 9:11 a.m., November 14. He went home about 11:00 a.m.

and rested/slept until 5:30 p.m., when he received a call from a CN/IC employee to go on

duty at 7:30 p.m. at Hamtramck. He remained on duty through the night and worked until

the time of the accident.

Postaccident Inspections and Tests

Postaccident inspection of the signals and train equipment indicated that they were

functioning properly.

Postaccident sight tests indicated that signal 14LC would have been visible to a

southbound train engineer for the entire length of the siding. Sight distance tests (which

were designed to take into account the relative speeds of the two trains) also indicated that

the headlight of train 243 would have been visible to the engineer of train 533 about

60 seconds before the collision occurred.

Toxicological Information

Pursuant to Federal Railroad Administration (FRA) postaccident toxicological test

requirements, as found in 49 CFR Part 219, each surviving crewmember involved in the

accident provided specimens that were tested for the presence of alcohol and drugs.12 Test

results were negative.

11 The extra board is a list of qualified employees available to fill assignments when the regularly

assigned employee is unavailable for duty.

12 The following drugs were tested for: cannabinoids, cocaine, opiates, amphetamines,

methamphetamines, phencyclidine, barbiturates, and benzodiazapines.
Factual Information 8 Railroad Accident Report

Meteorological Information

Meteorological reports for the accident area indicated that shortly after the

accident, winds were from the south-southwest at 8 mph with no precipitation.

No CN/IC crew operating in the area before the accident reported poor visibility

due to the weather conditions. Emergency responders who were on the scene minutes after

the accident reported clear visibility.

Obstructive Sleep Apnea

OSA is a common disorder in which breathing stops during sleep for 10 seconds or

more, sometimes more than 300 times a night, due to mechanical blockage of the airway.13

When a person with OSA falls asleep, muscles in the throat relax to a point at which the

airway collapses and becomes obstructed. As a result, breathing stops and the sleeper

awakens to open the airway. The American Sleep Disorders Association rates the average

number of OSA events per hour as a Respiratory Distress Index. A Respiratory Distress

Index of 0 to 5 is normal; 5 to 20 indicates mild distress; 20 to 40 indicates moderate

distress; and over 40 is considered to represent severe distress. Because of these

disruptions to normal sleep patterns, patients with OSA tend to suffer from excessive

daytime sleepiness, no matter how much sleep they obtain during any period. Patients

with OSA often complain of waking up feeling like they have not slept at all.

OSA is characterized by snoring and persistent fatigue, which are often

unrecognized, or considered mere annoyances rather than possible symptoms of a medical

condition. Consequently, those people with OSA who notice the symptoms frequently

dismiss them as insignificant. However, there is increasing recognition in the medical

community that OSA has other important consequences, leading to decrements in

attention and cognitive performance, as well as impaired quality of life. Persons with OSA

are at constant risk of experiencing dangerous events, such as falling asleep while driving,

and their fatigue may negatively affect workplace and personal relationships.14

13 According to the National Institute of Neurological Disorders and Stroke.

14 Source: William C. Dement, M.D., Ph.D., and Robert Koenigsberg.
Factual Information 9 Railroad Accident Report

Research has been conducted analyzing the impact of OSA on the health, sleep,

and alertness of railroad workers.15 The results showed that those railroad workers with

OSA indications16 reported receiving poor quality sleep, had more gastrointestinal

problems, and said they sometimes lost concentration and thought they might have missed

rail signals. The research further suggested that programs to identify and treat individuals

with OSA would improve health and safety in the workplace. Another study concluded

that the risk of developing cardiovascular disease is increased in middle-aged subjects

with untreated OSA. This study, however, found that efficient treatment of OSA was

associated with a significant risk reduction for cardiovascular disease incidence.17

Studies have shown an increased risk for motor vehicle accidents in patients with

OSA when compared with the general population. One study investigating the relationship

between sleepiness, driving, and accidents found that men with OSA were about three

times as likely as those without OSA to have had a recent traffic accident.18 At more

severe levels of OSA, people were seven times more likely to have had multiple traffic

accidents.

The reduction of human fatigue in transportation operations is one of the Safety

Boardís ìMost Wantedî transportation safety improvements. The Safety Board has a long

history of making safety recommendations concerning operator hours-of-service

requirements. The Safety Board has also made safety recommendations concerning

conditions (including sleeping disorders such as OSA) that may affect operator fatigue.

(See appendix B for a listing of relevant safety recommendations.)

The Safety Board has investigated other transportation accidents in which an

operator involved in the accident suffered from OSA.19 For instance, on August 15, 2000,

a light rail commuter train en route from Baltimore to the BWI Airport struck the

hydraulic bumping post at the terminus of track No. 2 at the BWI Airport Station and

derailed. The train operator did not apply the brakes to stop his train at the station. He said

15 A. Aguirre, A. Heitmann, U. Trutschel, K. Mathews, R. Khuri, P. Gerber, and M. Moore-Ede, ìSleep

Apnea as a Risk Factor in Railroad Operations.î Abstract contained in Shiftwork International Newsletter,

Vol. 14, No. 1, May 1997. The study is unpublished.

16 The authors determined that subjects exhibited indications of OSA based on the results of a sleep

apnea pre-screening questionnaire, which was based on the Sleep Disorders Questionnaire (SDQ) developed

by A. Douglass, R. Bornstein, K. Nino-Murcia, S. Keenan, L. Miles, V. Zarcone, C. Guilleminault, and W.

Dement, ìThe Sleep Disorder Questionnaire I: Creation and Multivariate Structure of SDQ.î Sleep, 17(2):

160-167 (1994).

17 Y. Peker, J. Hedner, H. Norum, H. Kraiczi, and J. Carlson, ìIncreased Incidence of Cardiovascular

Disease in Middle-aged Men with Obstructive Sleep Apnea.î American Journal of Respiratory and Critical

Care Medicine, Vol. 166; pp. 159-165 (2002).

18 T. Young, J. Blustein, L. Finn, and M. Palta, ìSleep-Disordered Breathing and Motor Vehicle

Accidents in a Population-Based Sample of Employed Adults.î Sleep, 20(8): 608-613 (1997).

19 See the following National Transportation Safety Board reports: Maryland Transit Administration

Light Rail Vehicle Accidents at the Baltimore-Washington International Airport Transit Station near

Baltimore, Maryland, February 13 and August 15, 2000, Railroad Special Investigation Report NTSB/SIR01/02 (Washington, D.C: NTSB, 2001); and Grounding of the Liberian Passenger Ship STAR PRINCESS on

Poundstone Rock, Lynn Canal, Alaska, June 23, 1995, Marine Accident Report NTSB/MAR-97/02

(Washington, D.C: NTSB, 1997).
Factual Information 10 Railroad Accident Report

that a restricting signal was the last thing he saw before he went ìoutî and that he was not

aware of anything until he returned to consciousness after the accident. The Safety Board

determined that the probable cause of the accident was the operatorís severe fatigue,

resulting from undiagnosed OSA, which caused him to fall asleep so that he could not

brake the train before it struck the bumping post. The Safety Board recommended fatigue

awareness training, including the risks posed by sleep disorders, for the rail transit

industry. (See appendix B, Safety Recommendation R-01-27.)

Fatigue Education at the CN/IC

The CN/IC has a fatigue awareness training program that includes a guidebook for

CN/IC employees and their families from Circadian Technologies, Inc., entitled ìLifestyle

and Fatigue Countermeasures.î The course material addresses many fatigue-related

issues, such as shift work, work-rest schedules, and proper regimens of health and diet, as

well as sleeping disorders, including OSA. The course is not part of a required CN/IC

training program, and the CN/IC does not document which of its employees have taken

the course. The train 533 engineer and conductor (as well as some CN/IC operating

crewmembers interviewed after the accident) could not recall having taken the course.

Medical Examinations of Railroad Employees

A railroad employeeís medical condition may be discovered through the companymandated physical examination or through an ìelectiveî medical examination conducted

by the employeeís private physician.

Company-Mandated Medical Examinations

Regulations and Requirements. FRA regulations require that an engineer be

certified as a qualified locomotive engineer at least once every 3 years.20 The medical

examination, which is a prerequisite to engineer certification, focuses on specific vision

and hearing acuity standards.21 The regulations do not provide guidance regarding general

or specific medical conditions that should be considered in the course of the examination.

The regulations require locomotive engineers to report deteriorating hearing and vision to

company officials whenever deterioration may occur, but neither the engineers nor their

private physicians are required to report a deterioration of any other medical condition that

might affect their performance. (Although not a Federal regulation, many railroads require

employees in safety-sensitive positions to notify a medical official of their use of

prescribed or over-the-counter medications.)

20 See 49 CFR 240.201.

21 See 49 CFR 240.121.
Factual Information 11 Railroad Accident Report

Medical Examination Forms. No standard medical examination form is used in

the U.S. railroad industry. The Safety Board reviewed a sample of the medical

examination forms used by Class I railroads and found that the typical medical

examination form does not include questions regarding sleep problems. Similar to the

other forms the Safety Board reviewed, the form used by the CN/IC had no questions that

specifically addressed sleeping problems or disorders.

The Safety Board examined the medical examination forms used in other modes of

transportation to determine the extent to which they request medical information about

sleep disorders.

In the maritime industry, the Merchant Marine Physical Examination/Certification

Report22 asks the examining physician if the applicant has or had suffered from

ìsleepwalking.î This is the only question on the form related to sleep. However, in

February 1998, the Coast Guard published a Navigation and Vessel Inspection Circular

(NVIC) to provide guidelines for evaluating the physical condition of an applicant for the

merchant marine license or document. The NVIC states, in part, that:

Without specific guidelines for conducting the examination, or without a general

familiarity with and appreciation for the rigors of employment in the maritime

environment, most medical personnel are unable to fully evaluate the applicantís

medical qualifications; therefore, this NVIC provides guidance to assist medical

personnel in conducting these examinations.

The NVIC prompts the examining physician to inquire about various sleep

problems, including narcolepsy and somnambulism, and: 

Any other diseaseÖmedication (side effects), sleep disorders or therapy which

would result in gradual deterioration of performance of duties, sudden

incapacitation or otherwise compromise shipboard safety, including required

response in an emergency.

In the highway industry, the driver undergoing a physical examination (used to

determine the physical qualification of commercial motor vehicle drivers operating in

interstate commerce) is to complete the health history section of the Federal Motor Carrier

Safety Administrationís (FMCSAís) revised medical examination form,23 and the medical

examiner is encouraged to discuss with the driver the severity of any problems the driver

reports. The formís history section requests that the driver answer ìyesî or ìnoî to a

variety of medical condition questions. Any ìyesî response requires further clarification

22 U.S. Department of Transportation Coast Guard form CG-719K (Rev. 7/01), required of an applicant

for certain merchant marine licenses or documents.

23 The updated medical examination form currently used was revised as of October 5, 2000, and appears

at 49 CFR 391.43(f). According to the FMCSA, the revised form has been organized to (1) gain simplicity

and efficiency, (2) reflect current medical terminology, and (3) be a self-contained document (that is, the

form will, to the extent possible, include all relevant information necessary to conduct the physical

examination and certification). Although the Safety Board supports the majority of the revisions to the form,

the Board has expressed some concern regarding such issues as the appropriate distribution of the form, the

lack of training for examiners, the lack of a tracking mechanism for the examinations, and other major flaws

in the commercial driversí medical certification process.
Factual Information 12 Railroad Accident Report

by the driver, including the onset date, diagnosis, treating physicianís name and address,

any current limitation, and any prescribed or over-the-counter medications used regularly

or recently. The history section specifically inquires about sleep problems, asking the

driver if he or she has experienced ìSleep disorders, pauses in breathing while asleep,

daytime sleepiness, loud snoring.î These symptoms, as discussed earlier, are indications

that the operator may have OSA.

In the aviation industry, the Federal Aviation Administration (FAA) does not have

any questions on its medical certification form specifically eliciting information regarding

sleep disorders, but guidance to FAA Aviation Medical Examiners in the Fall 2001

Federal Air Surgeonís Bulletin notes that:

[A]s for the medical certification of sleep apnea, the [Aviation Medical Examiner]

should defer the case to the Regional Flight Surgeon or the [Aerospace Medicine

Certification Division]Ö we will requireÖ a polysomnogramÖ operative notes

of any surgical proceduresÖ current status of the medical condition to include

any current treatment and whether the treatment has been successful. IfÖ

symptoms are persistent or not completely successful, we will require a

Maintenance of Wakefulness Test.Ö

CN/ICís Policy of Reporting Medical Conditions. The CN/IC indicated that it

has an established policy24 that, if an employee misses work due to a medical condition

that might affect the employeeís ability to work safely, the employee is required to report

the condition to company officials. The CN/IC, in a letter to the Safety Board, stated:

If an employee is off work due to that condition, our Medical Department

demands a statement from the treating physician that includes a diagnosis and a

medical opinion about the safety of the employee returning to his/her former

duties. The Medical Department will also send the employee for a ëfit for dutyí

physical, including the statement from the treating physician, and possibly a job

description. Unfortunately, under current laws designed to protect privacy rights,

the CN/IC cannot demand that a person divulge all medical issues if the person

and the physician see no reason that the condition would affect the ability of the

employee to perform their job. CN/IC is at the mercy of the employee and their

doctor to provide us with critical information. Most often, employees afraid of

losing their jobs will not voluntarily communicate protected, and/or privileged

medical information.

The CN/IC medical records for the engineer of train 533 show no evidence that the

engineer had ever missed work due to the effects of OSA. Because he had not missed any

duty time due to his OSA, the engineer did not violate any CN/IC rule requiring

documentation of a physicianís diagnosis of his condition.

Private Medical Examinations and Reporting Requirements

United States. In the United States, no Federal regulations for the railroad

industry require a private physician to report a patientís medical conditions to his

employer.

24 Included in CN/IC Substance & Alcohol Free Environment (SAFE) Policy B-2.
Factual Information 13 Railroad Accident Report

The Safety Board is aware of at least one transit company, the Southeastern

Pennsylvania Transit Authority (SEPTA), which has implemented a program whereby its

operating employees bring medical conditions requiring the use of prescribed medications

to the attention of SEPTAís medical department. Under the SEPTA program, if the

employee has been prescribed a medication that may affect the employeeís performance,

he or she is required to report such medication use to the SEPTA medical department

using a form provided by SEPTA that must be completed by the physician. The physician

may either return the completed form to the employee (who is to provide it to SEPTA) or

fax it directly to the SEPTA medical department. The form is designed primarily to report

medication use, but it does have a section in which the physician is to provide the patientís

diagnosis, enabling the SEPTA medical department to determine whether the condition

itself may affect the employeeís performance of safety-sensitive duties. (The SEPTA

medical director told Safety Board staff that he receives several of these forms each

week.)

Canada. Unlike U.S. Federal regulations, Canadian regulations require that a

physician or optometrist immediately disclose to the company any potentially hazardous

medical condition of a railroad employee that might affect the employeeís performance. In

September 2000, Bill C-58 of the Canadian Railway Safety Act25 came into effect,

discussing elements of the medical examinations for employees in safety-critical

operations. According to Transport Canada (the Canadian Government department with

responsibility for air, sea, and land transportation policy and regulation), the purpose of

this section is to ensure that persons in positions critical to safe rail operations are fit for

duty. This bill, in part:

ï Requires physicians and optometrists to notify the railway companyís medical

adviser if an employee has a medical condition that could be a threat to safe

railway operations (a copy of this notice is to be sent to the employee);

ï Places the responsibility on the patient to inform the physician that he or she

holds a designated position;

ï Allows the company to use information provided by a physician or optometrist

in the interest of safe railway operations;

ï Prohibits any legal, disciplinary, or other proceedings against a physician or

optometrist for such information given in good faith; and,

ï Prohibits further disclosure, or use as evidence, of such medical information,

except with the permission of the patient.

25 The Canadian Railway Safety Act was implemented in 1989 to address the many changes that had

taken place in the rail transportation industry in recent years. It was designed to achieve the objectives of the

national transportation policy relating to the safety of railway operations. The act gave direct jurisdiction

over safety matters to the Minister of Transport, to be administered by Transport Canada, where

responsibility for other federally regulated modes (that is, air, highway, and marine modes) resides.
Factual Information 14 Railroad Accident Report

Medical Condition and Fitness-For-Duty Evaluations

Federal regulations discuss the role of a treating medical practitioner or a

physician designated by the railroad in making a good faith judgment to determine if

employees taking prescribed or over-the-counter medications are fit to perform their

assigned duties safely.26 These regulations allow a company to disqualify an employee

from performing his or her duties if the medical practitioner or designated railroad

physician determines that the medications could affect the employeeís ability to perform

the job safely.

FRA guidance regarding medical certification is limited to regulations concerning

medications and minimum vision and hearing standards.27 There is no FRA guidance

regarding any general or specific medical conditions. No regulations require a medical

physician to disqualify an employee from performing duties based on a particular medical

condition (other than conditions that might affect vision or hearing), regardless of whether

that condition could incapacitate the employee or impair the employeeís performance.

Recorded Information for Postaccident Analysis

For several years, the Safety Board has been a proponent of installing and using

locomotive cab audio recorders to help determine the cause of accidents. In the Clarkston

accident, audio recordings would have captured the voices of the train 533 crewmembers

if and when they discussed train operations and called out signal indications to one

another, as required by CN/IC operating rules. An audio recorder would have captured

any conversations between the engineer and the conductor, and this information could

have been used to determine how the crewmembers were interacting. Audio data might

also have indicated whether the crewmembers were fully alert and attentive as they

transited the Andersonville siding.

In its investigation of the February 16, 1996, accident in Silver Spring, Maryland,

involving the collision of a Maryland Rail Commuter (MARC) train and an Amtrak

passenger train,28 the Safety Board identified the need for train operating cabs to have

voice recording devices similar to the type installed in the cockpits of aircraft. The Board

noted that, although current locomotive event recorders had great utility in providing

mechanical response data, they could not answer some human performance questions

about the crewmembersí actions. In the case of the Silver Spring accident, the Safety

Board concluded that if the MARC locomotive had been equipped with an audio recorder,

investigators could have determined from the communications before the collision the

26 See 49 CFR 219.103.

27 The vision and hearing minimum standards relate only to locomotive engineers.

28 National Transportation Safety Board, Collision and Derailment of Maryland Rail Commuter

MARC Train 286 and National Railroad Passenger Corporation AMTRAK Train 29 Near Silver Spring,

Maryland, February 16, 1996, Railroad Accident Report NTSB/RAR-97/02 (Washington, D.C: NTSB,

1997).
Factual Information 15 Railroad Accident Report

factors that may have affected the MARC train operatorís actions. The Safety Board,

therefore, made the following recommendation to the FRA:

R-97-9

Amend 49 Code of Federal Regulations Part 229, to require the recording of train

crewmembersí voice communications for exclusive use in accident investigations

and with appropriate limitations on the public release of such recordings.

In a May 21, 2001, response to the Safety Board concerning this recommendation

(among others), the FRA indicated that although it had raised the issue of voice recorders

with its Railroad Safety Advisory Committee (RSAC), the RSAC declined to consider the

subject.

In its report on a collision of three Consolidated Rail Corporation freight trains

near Bryan, Ohio, during which a train crew was killed when the crewmembers failed to

comply with restrictive signal indications while operating in dense fog,29 the Safety Board

again noted that an audio recorder would have provided vital clues to the cause of the

failure to comply with signals. As a result of that investigation, on June 12, 2001, the

Safety Board reiterated Safety Recommendation R-97-9 to the FRA.

As the Safety Board stated in its September 19, 2001, letter to the FRA concerning

this safety recommendation (among others), the Board understands that the FRA told the

RSAC event recorder working group at its March 1998 meeting that the group would not

be handling voice recorders as part of its work because the FRA considered such recorders

too expensive to realistically include in a standard. The use of automatic information

recording devices is one of the Safety Boardís ìMost Wantedî safety improvements. In its

September 19, 2001, letter, the Board stated that it is disappointed with the FRAís position

and lack of progress on this issue and considers that there is more than enough experience

in the other modes of transportation for the FRA to begin the process leading to the use of

locomotive cab audio recorders. Accordingly, Safety Recommendation R-97-9 remains

classified ìOpenóUnacceptable Response,î pending implementation of the

recommendation.

29 National Transportation Safety Board, Collision Involving Three Consolidated Rail Corporation

Freight Trains Operating in Fog on a Double Main Track near Bryan, Ohio, January 17, 1999, Railroad

Accident Report NTSB/RAR-01/01 (Washington, D.C: NTSB, 2001).
16 Railroad Accident Report

Analysis

The Accident

On November 15, 2001, about 5:54 a.m., eastern standard time, CN/IC

southbound train 533 and northbound train 243 collided near Clarkston, Michigan. The

collision occurred on the CN/IC Holly Subdivision at a switch at the south end of a siding

designated as the Andersonville siding. Train 533 had been operating in a southward

direction through the siding and was traveling at 13 mph when it struck train 243.

Signal 14LC at the turnout for the siding displayed a stop indication, but train 533 did not

stop before proceeding onto the mainline track. Train 243 was operating northward on a

proceed signal on the single main track about 30 mph when the trains collided.

General

Postaccident investigation showed that the signal system had been operating

appropriately for the train movements at the time of the accident and that signal 14LC at

the south end of the Andersonville siding was showing a stop indication for train 533 as it

approached the signal. Consequently, the Safety Board concludes that the signal system

operation was not a factor in this accident.

Locomotive event recorder information indicated that the train 533 engineer did

not make any control maneuvers in response to the stop indication, such as applying the

brakes, during the last 2 minutes before the accident. In addition, the authorized maximum

speed for the Andersonville siding was 10 mph, and train 533 was recorded as reaching

speeds as high as 16 mph while on the siding. Even at the time of the collision, the train

was traveling at 13 mph, which was above the authorized speed by 3 mph.

The Safety Board attempted to determine what might have caused the crew of

train 533 to exceed the Andersonville siding speed limit and to fail to respond to the stop

signal indication.

Both crewmembers were experienced and had worked this route previously.

The engineer of train 533 first indicated (in responses to investigatorsí questions

provided via his attorney) that inclement weather had impeded the visibility of the signals

in the Andersonville siding. No other CN/IC crew operating in the area before the accident

reported poor visibility due to the weather conditions, and emergency responders who

were on the scene minutes after the accident reported clear visibility and no fog.

Meteorological reports for the area indicated that shortly after the accident, winds were

from the south-southwest at 8 mph with no precipitation. Postaccident sight distance tests

indicated that signal 14LC would have been visible to a train engineer for the full length of
Analysis 17 Railroad Accident Report

the siding (about 7,140 feet or 1.35 miles). Subsequently, during an interview with

investigators, the train 533 engineer changed his account and indicated that as he entered

the siding he had seen the red stop signal at its south end. Sight distance tests also

indicated that the headlight of train 243 would have been visible to the engineer of

train 533 about 60 seconds before the collision occurred. Consequently, the Safety Board

concludes that the engineer of train 533 should have been able to see the stop indication on

the signal at the south end of the Andersonville siding and the headlight of train 243

before the accident.

Postaccident toxicological drug and alcohol test results were negative, so the

Safety Board concludes that no evidence indicates that the engineer or the conductor of

train 533 had been under the influence of alcohol or illegal drugs at the time of the

accident.

Train 533 Crewmembers

Engineer

A CN/IC conductor who had worked with the engineer told Safety Board

investigators that on several occasions the train 533 engineer had fallen asleep while

operating a train and had to be awakened to respond to an upcoming signal or to blow the

horn at a grade crossing. Another conductor commented that the engineer ìalways looked

tired.î Safety Board investigators examined the train 533 engineerís work schedule and

found that in the days before the accident, he typically had the opportunity to sleep 7 to

8 hours between his assignments.

As a prerequisite to engineer certification, and in accordance with Federal

regulations, the engineer of train 533 underwent routine company physical examinations

to determine whether he met the standards for vision and hearing acuity prescribed in

49 CFR 240.121. The CN/IC, based on the results of the engineerís last physical

examination, performed on December 20, 2000, determined that, despite his having high

blood pressure and diabetes and using some prescription medications, the engineer was fit

to perform the duties required of a locomotive engineer. The engineer did not indicate

during his company physical examination that he experienced any type of chronic sleep

problem, nor did the examination form request information about sleep disorders.

Safety Board investigators examined the engineerís medical records from his

private physician. In April 1998, in response to the engineerís complaints about ìsnoring

with pauses,î his private physician referred him to an ENT specialist. The ENT specialist

noted, in part, that the engineer was being evaluated for ìchronic snoring with episodic

awakening and daytime somnolence.î After his evaluation, the specialist concluded that

the engineer likely suffered from obstructive sleep apnea (OSA), a chronic sleeping

disorder.
Analysis 18 Railroad Accident Report

The ENT specialist had also indicated that he warned the engineer about the risk of

the engineerís failing asleep while driving his car or a train. The ENT specialist told the

engineer that he should have a sleep study performed, but the engineer did not have such a

study conducted.

The engineerís private physician was aware of the engineerís occupation and that

he likely suffered from OSA. On several occasions after the ENT specialistís 1998

diagnosis, the last time about a week before the accident, the private physician warned the

engineer that he should make an appointment at a sleep clinic to further evaluate, and

provide treatment options for, possible OSA. The private physicianís notes indicated that

the engineer understood the need for further medical treatment, but the engineer did not

seek medical treatment for OSA. The engineer told Safety Board investigators that he

believed he suffered from OSA.

OSA is a common disorder in which, due to mechanical blockage of the airway,

breathing stops during sleep for 10 seconds or more, sometimes more than 300 times a

night. When a person with OSA falls asleep, muscles in the throat relax to a point at which

the airway collapses and becomes obstructed. As a result, breathing stops and the sleeper

awakens to open the airway. Because of these disruptions to normal sleep patterns, people

with OSA typically suffer from excessive daytime sleepiness, no matter how much sleep

they obtain.

Because he likely suffered from untreated OSA, the train 533 engineer almost

certainly had persistent fatigue. Therefore, on the basis of the available medical

information (and in the absence of any other likely cause), the Safety Board concludes that

the chronic fatigue the engineer of train 533 was experiencing due to untreated OSA likely

incapacitated him to the extent that he did not take any action to stop the train before the

collision.

Conductor

If he had noticed the engineerís failure to take appropriate action, the train 533

conductor could have alerted the engineer or used the conductorís emergency brake valve

on the train to initiate an emergency brake application. However, Safety Board

investigators found no indication that the conductor ever attempted to activate the

emergency brakes or to consult with the engineer about the excessive speed or the failure

to respond to the stop signal during the trip through and out of the Andersonville siding.

Investigation indicated that fatigue might also have incapacitated the conductor.

Some years before, the conductorís private physician had referred him to a sleep clinic,

where he was diagnosed with severe OSA on June 6, 1997. The conductor did not ever

inform the CN/IC that he was being treated for medically diagnosed OSA. (Nor was he

required or requested to do so.)

The conductor told investigators that he had been treating his OSA condition with

use of a prescribed Continuous Positive Airway Pressure (CPAP) device. However, he

had not undergone a CPAP titration study at the sleep clinic to determine the effectiveness
Analysis 19 Railroad Accident Report

of the CPAP device he was using. Such a study would have determined the appropriate

pressure setting for the CPAP device to keep the conductorís airway open during sleep.

Because the titration study was never performed, the degree to which the CPAP device

was effective in eliminating the impairing effects of the conductorís OSA cannot be

determined.

Although the conductorís medical records indicated that during his last sleep

examination at the sleep clinic his Epworth Sleepiness Scale value was 4 (out of 24),

which is considered normal, he had stated that he did not feel that the CPAP pressure was

strong enough, that he continued to snore, and that he was tired. Thus, even though the

conductor was receiving treatment for his OSA and told investigators that the treatment

had helped his condition, no study was done to determine the CPAP deviceís

effectiveness, and the conductorís complaints to his physician suggest that it did not

provide optimal treatment for his condition.

In addition, the effects of the train 533 conductorís work schedule may have

reduced his alertness on the day of the accident. The conductor had been assigned to the

extra board and therefore did not work a regular assignment. As a result, both his on-duty

and off-duty times varied from assignment to assignment, often with little notice.30 His onduty start times during the month before the accident were never the same on consecutive

days, and throughout the month he had worked both daytime and nighttime shifts on an

irregular basis. His schedule during the week leading up to the accident was particularly

irregular and demanding. He had worked the night shift for a few days, then he reverted to

a schedule during which he slept at night during the 3 days (more than 72 hours) he was

off with an illness, and then he rotated back to working the night shift, which he was

working when the accident occurred. The conductorís lack of a regular work schedule

resulted in irregular rest periods, a situation which has been identified as a prime cause of

fatigue.

The Safety Board has previously investigated accidents in the railroad industry in

which an operatorís irregular work schedule resulted in fatigue. One example is the

November 7, 1990, collision of the Atchison, Topeka and Santa Fe Railway Company

(ATSF) freight trains ATSF 818 and ATSF 891 on the ATSF Railway in Corona,

California.31 The Safety Board determined that the probable cause of the collision was:

The failure of the engineer of train 818 to stop his train at the stop signal because

he was asleep. Contributing to the accident was the failure of the conductor and

the brakeman to take action, probably because they too were asleep, to stop the

train. Also contributing to the accident were the irregular, unpredictable work

schedule of the engineer on train 818, the Atchison, Topeka and Santa Fe Railway

30 Several studies have documented an elevated prevalence of OSA in workers on irregular schedules.

See R. Stoohs, L. Bingham, A. Itoi, C. Guilleminault, and W. Dement, ìSleep and Sleep-disordered

Breathing in Commercial Long-haul Truck Drivers,î Chest 107(5): 1275-82 (Palo Alto, California: Stanford

Sleep Disorders Clinic and Research Center, 1995).

31 National Transportation Safety Board, Atchison, Topeka and Santa Fe Railway Company (ATSF)

Freight Trains ATSF 818 and ATSF 891 on the ATSF Railway, Corona, California, November 7, 1990,

Railroad Accident Report NTSB/RAR-91/03 (Washington, D.C: NTSB, 1991).
Analysis 20 Railroad Accident Report

Companyís lack of a policy or procedure for removing crewmembers from service

when they are not fit for duty because of a lack of sleep, and the inadequacy of the

Federal rules and regulations that govern hours-of-service.

The Safety Board noted that both the engineer and conductor on train 818 were

similarly subjected to the same irregularity and unpredictability of work schedules and, as

a consequence, likely suffered from sleep deprivation.32

In addition, the Safety Boardís investigation of a 1995 collision involving two

New York City subway trains on the Williamsburg Bridge, in Brooklyn, New York,33

concluded that the motorman of the striking train failed to take action to stop his train

because he likely fell asleep. The Board noted that the motormanís rotating schedule of

working nights during the week and sleeping at night on the weekends made it difficult for

his internal biological, or circadian,34 clock to change.35

In the case of the train 533 conductor involved in the Clarkston accident, the

conductorís existing fatigue, caused by his less than optimally treated OSA, appears to

have been exacerbated by the irregular schedule he was following as an extra board

employee. Therefore, the Safety Board concludes that the conductor of train 533 likely

was incapacitated by fatigue, caused by the combined effects of the less than fully

successful treatment of his OSA and his irregular and unpredictable work schedule.

CN/IC Fatigue Awareness Program

The CN/IC has a fatigue awareness training program that includes a guidebook for

CN/IC employees and their families from Circadian Technologies, Inc. The course

material addresses many fatigue-related issues, such as shift work, work-rest schedules,

and proper regimens of health and diet, as well as sleep disorders, including OSA. The

Safety Board commends the CN/IC for its development and use of such a program in

addressing the important safety consequences of fatigue. However, the program is not part

of a required CN/IC training program, and the CN/IC does not document which of its

employees have taken the course. Neither the engineer nor the conductor of train 533

could recall having taken the course. The Safety Board concludes that ensuring that all

32 See appendix B for Safety Recommendations R-91-41 and -42, which the Safety Board issued as a

result of the Corona accident.

33 National Transportation Safety Board, Collision Involving Two New York City Subway Trains on the

Williamsburg Bridge in Brooklyn, New York, June 5, 1995, Railroad Accident Report NTSB/RAR-96/03

(Washington, D.C: NTSB, 1996).

34 Circadian rhythms describe the regular recurrence, in cycles of about 24 hours, of biological

processes or activities, such as sensitivity to drugs and stimuli, hormone secretion, sleeping, and feeding.

This rhythm seems to be set by a ìbiological clockî that appears to be regulated by recurring daylight and

darkness. Also see M.R. Rosekind, Fatigue in Transportation: Physiological, Performance, and Safety

Issues. Prepared for the National Transportation Safety Board, Washington, D.C., April 1999.

35 See appendix B for Safety Recommendations R-96-20 through -22, which the Safety Board issued as

a result of the Williamsburg Bridge accident.
Analysis 21 Railroad Accident Report

railroad employees who carry out safety-sensitive duties receive training in fatigue

awareness will make these employees more aware of the dangerous and debilitating

effects of fatigue on performance and could reduce the incidence of fatigue-related

employee impairment. Therefore, the Safety Board believes that the Canadian National

Railway should require all its employees in safety-sensitive positions to take fatigue

awareness training and document when employees have received this training.

Detection of Employeesí Conditions

The Safety Board is concerned that in this case, both crewmembers of train 533

had been told by their private physicians that they had (or likely had) OSA, but neither

employee informed the CN/IC of his potentially incapacitating condition. Further, the

CN/IC did not detect the conditions through other means, such as medical examinations.

Medical Examination

The company physical examinations performed for the CN/IC did not include

questions about sleeping disorders or other chronic problems that might cause

performance-impairing fatigue.

FRA regulations require that engineers be certified as qualified locomotive

engineers at least once every 3 years.36 The medical examination, which is a prerequisite

to engineer certification, focuses on specific vision and hearing acuity standards.37 FRA

regulations do not provide guidance regarding general or specific medical conditions that

should be considered in the course of the examination. Many railroads use questionnairetype forms filled out by the employee in conducting these examinations.

No standard medical examination form is used in the U.S. railroad industry. The

Safety Board reviewed a sample of the medical examination forms used by Class I

railroads and found that the typical medical examination form does not include questions

regarding sleep problems. Similar to the other railroad forms the Safety Board reviewed,

the form used by the CN/IC had no questions that specifically addressed sleeping

problems or disorders. The Safety Board next evaluated the medical examination forms

used in other modes of transportation to determine the extent to which they request

medical information about sleep disorders.

In the maritime industry, the Coast Guard published an NVIC in 1998 to provide

guidelines for evaluating the physical condition of a merchant marine license (or

document) applicant. Among other guidance, the NVIC prompts the examining physician

to ask the applicant about various sleep problems, including narcolepsy and

somnambulism, and any other condition that could result in performance deterioration.

36 See 49 CFR 240.201.

37 See 49 CFR 240.121.
Analysis 22 Railroad Accident Report

A driver undergoing a physical examination for commercial motor vehicle

licensing must complete the health history section of the FMCSAís medical examination

form, and the medical examiner is encouraged to discuss with the driver the severity of

any problems the driver reports. The formís history section requests that the driver answer

ìyesî or ìnoî to a variety of medical condition questions. Any ìyesî response requires

further clarification by the driver, including the onset date, diagnosis, treating physicianís

name and address, any current limitation, and any prescribed or over-the-counter

medications used regularly or recently. The history section includes a question specifically

inquiring about sleep problems, asking the driver if he or she has experienced ìSleep

disorders, pauses in breathing while asleep, daytime sleepiness, loud snoring.î

For the aviation industry, guidance to FAA Aviation Medical Examiners in the

Fall 2001 Federal Air Surgeonís Bulletin notes that:

[A]s for the medical certification of sleep apnea, the AME [Aviation Medical

Examiner] should defer the case to the Regional Flight Surgeon or the AMCD

[Aerospace Medicine Certification Division].Ö IfÖ symptoms are persistent or

[treatment is] not completely successful, we will require a Maintenance of

Wakefulness TestÖ.

The Safety Board considers that the U.S. rail industry, as well as the marine,

highway, and aviation transportation modes, should take into account the serious effects

that sleeping disorders could have on the performance of its employees who fulfill safetysensitive duties. The Safety Board concludes that because the U.S. rail industry does not

have a comprehensive medical examination form that includes questions about sleeping

disorders, railroads may find it difficult to identify employees at risk for fatigue

impairment due to the effects of sleeping disorders. Therefore, the Safety Board believes

that the FRA should develop a standard medical examination form that includes questions

regarding sleep problems and require that the form be used, pursuant to 49 CFR Part 240,

to determine the medical fitness of locomotive engineers; the form should also be

available for use to determine the medical fitness of other employees in safety-sensitive

positions.

Reporting of Medical Conditions

Aside from requiring regular engineer certification (involving medical

examination), Federal regulations provide little guidance concerning when, how, or if rail

employees should report medical conditions such as sleeping disorders to their railroads.

No Federal regulation requires that a railroad employee notify the railroad of a medical

condition, even if the employee considers that the condition could affect his or her

performance. (Although not a Federal regulation, many railroads require employees in

safety-sensitive positions to notify a medical official of their use of prescribed or over-thecounter medications.)

No Federal regulation for the railroad industry requires a physician to report a

patientís medical conditions to his employer. Federal regulations do require locomotive

engineers to report deteriorating hearing and vision to company officials whenever
Analysis 23 Railroad Accident Report

deterioration may occur,38 but neither the engineers nor their private physicians are

required to report a deterioration of any other medical condition that might affect their

performance. Consequently, unless the railroad employee is diagnosed with a particular

condition during his companyís required physical examination or voluntarily provides the

railroad with medical information from a private physician, the railroad may never learn

of a safety-critical employeeís potentially performance-impairing medical condition.

The CN/IC, in a letter to the Safety Board, stated:

Unfortunately, under current laws designed to protect privacy rights, the CN/IC

cannot demand that a person divulge all medical issues if the person and the

physician see no reason that the condition would affect the ability of the employee

to perform their job. CN/IC is at the mercy of the employee and their doctor to

provide us with critical information. Most often, employees afraid of losing their

jobs will not voluntarily communicate protected, and/or privileged medical

information.

In the rail transit industry, the Safety Board is aware of at least one company,

SEPTA, which has implemented a program under which its operating employees bring

medical conditions requiring the use of prescribed medications to the attention of

SEPTAís medical department. Under the SEPTA program, if the employee has been

prescribed a medication that may affect the employeeís performance, he or she is required

to report such medication use to the SEPTA medical department, using a form provided by

SEPTA that must be completed by the physician. The form is primarily designed to report

medication use, but it does have a section in which the physician is to provide the patientís

diagnosis, enabling the SEPTA medical department to determine whether the condition

itself may affect the employeeís performance of safety-sensitive duties.

Although the SEPTA program is a positive step with respect to ensuring that

transportation systems are notified of significant medical issues affecting their personnel

who fulfill safety-sensitive duties, the programís narrow focus on medications limits its

value. In the case of the Clarkston accident, for example, because people with OSA

typically are not prescribed medications for this condition, neither the train 533 engineer

nor the conductor would likely ever have been required, under the SEPTA program, to

report this condition. Therefore, had a reporting program identical to SEPTAís been

implemented by the CN/IC, the railroad would have been no more likely to have been

informed of the crewmembersí OSA.

Unlike U.S. regulations concerning medical reporting within the railroad industry,

Canadian regulations require a physician or optometrist to immediately disclose to the

company any potentially hazardous medical condition of a railroad employee that might

affect the employeeís performance. In September 2000, Bill C-58 of the Canadian

Railway Safety Act, which concerns elements of the medical examinations for employees

in safety-critical operations, became effective. The Canadian regulations, in part, require

38 See 49 CFR 240.121.
Analysis 24 Railroad Accident Report

physicians and optometrists to notify the railway companyís medical adviser if an

employee has a medical condition that could be a threat to safe railway operations.

Had the reporting system now being used in Canada been in effect in the United

States, the physicians who treated the two train 533 crewmembers would have been

required to report to the CN/IC any condition that they considered posed a threat to safe

railway operations. Consequently, the crewmembersí physicians might have been more

likely to inform the CN/IC that the two train 533 crewmembers had (or likely had) OSA.

The Clarkston accident demonstrates that a medical condition such as OSA, which

neither the employee nor the employeeís physician is currently required to report to the

railroad, can impair the performance of, or even incapacitate, an employee responsible for

safety-sensitive duties. OSA is widely recognized as a chronic condition that can cause

fatigue and excessive daytime sleepiness. Research has been conducted analyzing the

impact of OSA on the health, sleep, and alertness of railroad workers.39 With respect to

rail safety, the research found that those railroad workers with OSA indications reported

that they sometimes lost concentration and might have missed track signals. In the

Clarkston accident, a train engineer with indications of OSA and a conductor with less

than optimally treated OSA did miss a stop signal, resulting in a fatal collision.

Consequently, the Safety Board concludes that because current Federal regulations do not

require railroad employees who carry out safety-sensitive duties to report to the railroad

any medical condition that might result in incapacitation or significant impairment, such

employees are less likely to notify their railroads about medical conditions that could

negatively affect their performance of safety-critical tasks.

The Safety Board notes that medical conditions that might lead to incapacitation or

significant impairment cover a broad range of disorders, including, for example, heart

disease, seizure disorders, insulin-dependent diabetes, migraine headaches, psychiatric

disorders, severe asthma, etc., as well as fatigue-related conditions such as sleeping

disorders and chronic fatigue. Consequently, for a railroad to be able to proactively

safeguard its operations, the railroad must be notified whenever its employees in safetysensitive positions have any such medical condition at a level of severity likely to

incapacitate or significantly affect the performance of the employee. Therefore, the Safety

Board believes that the FRA should require that any medical condition that could

incapacitate, or seriously impair the performance of, an employee in a safety-sensitive

position be reported to the railroad in a timely manner.

Fitness-For-Duty Evaluations

Federal regulations discuss the role of a treating medical practitioner or a

physician designated by the railroad in making a good faith judgment of whether

employees taking prescribed or over-the-counter medications are fit to perform their

39 See ìSleep Apnea as a Risk Factor in Railroad Operations.î Abstract contained in Shiftwork

International Newsletter, Vol. 14, No. 1, May 1997.
Analysis 25 Railroad Accident Report

assigned duties safely.40 These regulations allow a company to disqualify an employee

from performing duties if the medical practitioner or designated railroad physician

determines that the medications could affect the employeeís ability to perform the job

safely. However, FRA guidance regarding medical certification is limited to regulations

concerning medications and minimum vision and hearing standards. (The vision and

hearing minimum standards relate only to locomotive engineers.)

No FRA guidance addresses medical conditions affecting railroad employees. No

regulations require the railroadís designated medical physician to disqualify an employee

from performing duties because of a particular medical condition (other than those

conditions that might affect vision or hearing or involve medication use), regardless of

whether the condition could potentially incapacitate the employee or impair the

employeeís performance.

In this accident, the train 533 crewmembers were incapacitated at least in part due

to the effects of the medical condition OSA, which their private physicians had either

detected or strongly suspected. Neither employee provided this medical information to the

CN/IC, nor did their physicians notify the CN/IC. However, under current Federal

regulations, even had the CN/IC-designated medical physician been aware of the

crewmembersí OSA, the CN/IC would not have been required to evaluate the

crewmembers for fitness for duty because of their OSA. That is, because the train 533

crewmembers were not taking medications for OSA and because it did not affect their

hearing or vision, this condition would not, under Federal law, necessarily have

disqualified them from operating a train. Under current regulations, therefore, railroad

companies decide for themselves if an employeeís existing medical condition will be

evaluated to determine whether the crewmember can safely perform his or her duties. The

Safety Board concludes that limiting a railroadís required medical regulation of

employees responsible for safety-sensitive duties to issues of vision, hearing, and

medication use fails to address a range of medical conditions that may negatively affect

employee performance.

As the Clarkston accident indicated, employees who carry out safety-sensitive

duties and who have potentially incapacitating or performance-impairing medical

conditions (such as OSA) may need to be medically assessed before they can be

considered fit for duty. Therefore, the Safety Board believes that the FRA should require

that, when a railroad becomes aware that an employee in a safety-sensitive position has a

potentially incapacitating or performance-impairing medical condition, the railroad

prohibit that employee from performing any safety-sensitive duties until the railroadís

designated physician determines that the employee can continue to work safely in a

safety-sensitive position.

40 See 49 CFR 219.103.
26 Railroad Accident Report

Conclusions

Findings

1. The signal system operation was not a factor in this accident.

2. The engineer of train 533 should have been able to see the stop indication on the

signal at the south end of the Andersonville siding and the headlight of train 243

before the accident.

3. No evidence indicates that the engineer or the conductor of train 533 had been under

the influence of alcohol or illegal drugs at the time of the accident.

4. The chronic fatigue the engineer of train 533 was experiencing due to untreated

obstructive sleep apnea likely incapacitated him to the extent that he did not take any

action to stop the train before the collision.

5. The conductor of train 533 likely was incapacitated by fatigue, caused by the

combined effects of the less than fully successful treatment of his obstructive sleep

apnea and his irregular and unpredictable work schedule.

6. Ensuring that all railroad employees who carry out safety-sensitive duties receive

training in fatigue awareness will make these employees more aware of the dangerous

and debilitating effects of fatigue on performance and could reduce the incidence of

fatigue-related employee impairment.

7. Because the U.S. rail industry does not have a comprehensive medical examination

form that includes questions about sleeping disorders, railroads may find it difficult to

identify employees at risk for fatigue impairment due to the effects of sleeping

disorders.

8. Because current Federal regulations do not require railroad employees who carry out

safety-sensitive duties to report to the railroad any medical condition that might result

in incapacitation or significant impairment, such employees are less likely to notify

their railroads about medical conditions that could negatively affect their performance

of safety-critical tasks.

9. Limiting a railroadís required medical regulation of employees responsible for safetysensitive duties to issues of vision, hearing, and medication use fails to address a

range of medical conditions that may negatively affect employee performance.
Conclusions 27 Railroad Accident Report

Probable Cause

The National Transportation Safety Board determines that the probable cause of

the November 15, 2001, Canadian National/Illinois Central Railway accident in

Clarkston, Michigan, was the train 533 crewmembersí fatigue, which was primarily due to

the engineerís untreated and the conductorís insufficiently treated obstructive sleep apnea.
28 Railroad Accident Report

Recommendations

As a result of its investigation of the Clarkston, Michigan, railroad accident, the

National Transportation Safety Board makes the following safety recommendations:

To the Canadian National Railway:

Require all your employees in safety-sensitive positions to take fatigue

awareness training and document when employees have received this

training. (R-02-23)

To the Federal Railroad Administration:

Develop a standard medical examination form that includes questions

regarding sleep problems and require that the form be used, pursuant to

49 Code of Federal Regulations Part 240, to determine the medical fitness

of locomotive engineers; the form should also be available for use to

determine the medical fitness of other employees in safety-sensitive

positions. (R-02-24)

Require that any medical condition that could incapacitate, or seriously

impair the performance of, an employee in a safety-sensitive position be

reported to the railroad in a timely manner. (R-02-25)

Require that, when a railroad becomes aware that an employee in a safetysensitive position has a potentially incapacitating or performanceimpairing medical condition, the railroad prohibit that employee from

performing any safety-sensitive duties until the railroadís designated

physician determines that the employee can continue to work safely in a

safety-sensitive position. (R-02-26)

BY THE NATIONAL TRANSPORTATION SAFETY BOARD

CAROL J. CARMODY

Acting Chairman

JOHN A. HAMMERSCHMIDT

Member 

JOHN J. GOGLIA

Member

GEORGE W. BLACK, JR.

Member

Adopted: November 19, 2002
29 Railroad Accident Report

Appendix A

Investigation

The National Transportation Safety Board was notified of the Clarkston,

Michigan, accident about 8:45 a.m., eastern standard time, on November 15, 2001, and

dispatched a major railroad accident investigation team to the accident scene.

Investigative groups examined the operation, track, signals, radio communications,

mechanical, survival factors, human performance, and event recorder aspects of the

accident. No Board Member was on the scene during the on-site investigation.

Parties to the investigation were the Federal Railroad Administration, the

Canadian National/Illinois Central Railway, The Brotherhood of Locomotive Engineers,

the United Transportation Union, the Brotherhood of Railroad Signalmen, the Oakland

County Sheriff, and the Springfield and Independence Townships Fire Departments.

No public hearings or depositions were held in connection with this accident.
30 Railroad Accident Report

Appendix B 

Previous Safety Board Recommendations Concerning Sleeping 

Disorders and Other Related Issues Affecting Operator Fatigue

Accident Safety Recommendation Recipients Status

Railroad Special Investigation 

Report NTSB/SIR-01/02:

Maryland Transit Administration 

Light Rail Vehicle Accidents at the 

Baltimore-Washington 

International Airport Transit 

Station near Baltimore, Maryland, 

February 13 and August 15, 2000

R-01-27: Ensure that your 

fatigue educational awareness 

program includes the risks 

posed by sleeping disorders, 

the indicators and symptoms of 

such disorders, and the 

available means of detecting 

and treating them. 

U.S. rail transit 

systems (31) 

6 ClosedAcceptable 

Action

2 OpenAcceptable 

Response

23 OpenAwait 

Response

Marine Accident Report 

NTSB/MAR-97/02: Grounding of 

the Liberian Passenger Ship 

STAR PRINCESS on Poundstone 

Rock, Lynn Canal, Alaska, June 

23,1995

M-97-41: Advise pilots about 

the effect of fatigue on 

performance and about 

sleeping disorders such as 

sleep apnea.

U.S. Coast Guard ClosedAcceptable 

Action

M-97-42: Review, in 

consultation with experts in 

occupational health, your 

medical standards, guidelines, 

and examination forms to 

ensure that they require the 

disclosure and appropriate 

evaluation of the history or 

presence of any medical 

conditions, symptoms, or 

medication use that would 

affect an individualís fitness to 

pilot a vessel. 

U.S. Coast Guard OpenAcceptable 

Response

M-97-44: Advise pilots about 

the effect of fatigue on 

performance and about 

sleeping disorders such as 

sleep apnea.

State pilot 

commissions (26) 

17 ClosedAcceptable

1 Open-Await 

Response

8 ClosedUnacceptable

M-97-45: Review, in 

consultation with experts in 

occupational health, your 

medical standards, guidelines, 

and examination forms to 

ensure that they require the 

disclosure and appropriate 

evaluation of the history or 

presence of any medical 

conditions, symptoms, or 

medication use that would 

affect an individualís fitness to 

pilot a vessel.

State pilot 

commissions (26) 

14 ClosedAcceptable

1 Open-Await 

Response

11 ClosedUnacceptable
Appendix B 31 Railroad Accident Report

Railroad Accident Report 

NTSB/RAR-96/03: Collision 

Involving Two New York City 

Subway Trains on the 

Williamsburg Bridge in Brooklyn, 

New York, June 5, 1995

R-96-20: In cooperation with 

the American Public Transit 

Association, develop a fatigue 

educational awareness 

program and distribute it to 

transit agencies to use in their 

fitness-for-duty training for 

supervisors and employees 

involved in safety-sensitive 

positions.

Federal Transit 

Administration

ClosedAcceptable 

Action

R-96-21: Assist the Federal 

Transit Administration in 

developing a fatigue 

educational awareness 

program for transit agencies to 

use in their fitness-for-duty 

training for supervisors and 

employees involved in safetysensitive positions.

American Public 

Transit Association

ClosedAcceptable 

Action

R-96-22: Develop and 

disseminate a training and 

education module to inform 

train operators and other 

employees involved in safetysensitive positions about the 

hazards of performing their 

duties while fatigued.

New York City 

Transit

ClosedAcceptable 

Action

Railroad Accident Report 

NTSB/RAR-91/03: Atchison, 

Topeka and Santa Fe Railway 

Company (ATSF) Freight Trains 

ATSF 818 and ATSF 891 on the 

ATSF Railway, Corona, California, 

November 7, 1990

R-91-41: In cooperation with 

the operating unions, develop 

an educational and counseling 

program designed to improve 

crewmembersí knowledge of 

health and diet regimens and 

methods of avoiding sleep 

deficits and sleep deprivation. 

Atchison, Topeka 

and Santa Fe 

Railway Company

ClosedAcceptable 

Action

R-91-42: In cooperation with 

the Association of American 

Railroads and the operating 

unions, develop a policy that 

would allow the carrier to stop 

an employee from accepting 

assignments and that would 

allow an employee to report off 

duty when the employee is 

impaired by lack of sleep.

Atchison, Topeka 

and Santa Fe 

Railway Company

ClosedAcceptable 

Action

Railroad Accident Report 

NTSB/RAR-89/02: Head-End 

Collision of Consolidated Rail 

Corporation Freight Trains UBT506 and TV-61 Near 

Thompsontown, Pennsylvania, 

January 14, 1988

R-89-19: Cooperate with the 

Consolidated Rail Corporation 

and the other railroads in the 

implementation of voluntary 

education and counseling 

programs designed to improve 

train crewmembersí knowledge 

of proper health and diet 

regimens, as well as the 

necessity to avoid sleep 

deprivation.

Brotherhood of 

Locomotive 

Engineers

ClosedAcceptable 

Action