NTSB: Railroad worker fatigue caused 2011 accident
The National Transportation Safety Board (NTSB) has determined that the probable cause of a rear-end collision between two BNSF Railway trains was the striking train crew’s fatigue. Both crewmembers had fallen asleep, which led to their failure to comply with the signal indication requiring them to operate at a
restricted speed and stop short of the standing train.
On Sunday, April 17, 2011, an eastbound BNSF coal train collided with the rear end of a standing BNSF maintenance-of-way equipment train near Red Oak, Iowa. The accident occurred at milepost 448.3 on the number two track on the Creston subdivision of the BNSF Nebraska Division. The collision resulted in the derailment of two locomotives and 12 cars. Both the engineer and conductor in the lead locomotive of the coal train were fatally injured.
“Once again, this investigation draws attention to the dangers of human fatigue,” said NTSB Chairman Deborah A. P. Hersman. “The human body is not designed to work irregular schedules, especially during the circadian trough, when our bodies are at their lowest alertness.”
Contributing to the accident was the absence of a positive train control system that identifies the rear of a train and stops a following train if a safe braking profile is exceeded.
“Humans are fallible and make mistakes and operational accidents can be prevented with positive train control,” Chairman Hersman said.
Also contributing to the severity of collision damage to the locomotive cab of the striking coal train was the absence of crashworthiness standards for modular locomotive crew cabs.
As a result of this accident investigation, the NTSB made safety recommendations to the Federal Railroad Administration, the Association of American Railroads, and the BNSF Railway.
The safety issues addressed by the recommendations include: train crew fatigue, BNSF Railway fatigue awareness training, positive train control regulations, design and crashworthiness of modular locomotive cabs, and survivability of electronic data.
A synopsis of the NTSB report, including the probable cause, findings, and a complete list of the safety recommendations is available on the NTSB website. The NTSB's full report will be available on the website in several weeks.