November 15, 2001
NTSB Number RAR-02-04
NTIS Number PB2002-916304
Adopted November 19, 2002
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 crewmembers' fatigue, which was primarily due to the engineer's untreated and the conductor's insufficiently treated obstructive sleep apnea.
In its investigation of this accident, the Safety Board examined one safety issue:
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 investigators' 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.
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 railroad's designated physician determines that the employee can continue to work safely in a safety-sensitive position. (R-02-26)