National Transportation Safety Board
Office of Public Affairs
Washington, DC - The National Transportation Safety Board determined today that crewmember fatigue led to the fatal November 15, 2001 railroad collision in Clarkston, Michigan. The fatigue, affecting both crewmembers of one of the trains, was primarily caused by the engineer's untreated and the conductor's insufficiently treated obstructive sleep apnea.
During its investigation, the Board also identified the lack of a railroad industry program requiring that all railroad employees' potential incapacitating medical conditions be reported to the railroad and included in fitness-for-duty evaluations.
On November 15, 2001 Canadian National/Illinois Central Railway southbound train 533 and northbound train 243 collided near Clarkston, Michigan. The collision occurred at a switch at the south end of a siding designated as the Andersonville siding. Train 533 was traveling at 13 miles per hour when it struck train 243. The signal 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 traveling about 25 miles per hour on a "proceed" signal on the single main track when the accident occurred. Both crewmembers on train 243 were fatally injured. The two crewmen on train 533 sustained serious injuries.
The Board found that both the conductor and the engineer of train 533 suffered from obstructive sleep apnea. Although the engineer was taking prescription medication for high blood pressure and diabetes and had been instructed by his private physician to seek further medical treatment for sleep apnea, his condition was not being treated at the time of the accident. The conductor's treatment was insufficient to successfully mitigate the affects of the condition, the Board found.
As a result of the accident, the Safety Board issued the following recommendations:
To the Canadian National Railway:
Require all your employees in safety-sensitive positions to take full fatigue awareness training and document when employees have received this training.
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-related positions;
Require that any medical conditions that could incapacitate, seriously impair the performance of, an employee in a safety-sensitive position be reported to the railroad in a timely manner; and
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 and safety-sensitive duties until the railroad's designated physician determines that the employee can continue to work safely in a safety-sensitive position.
A summary of this report is available now on the NTSB Web site at http://www.ntsb.gov, under "Publications"; the complete report will also be posted at that location in a few weeks. Soon afterwards, printed copies will be available for purchase through the National Technical Information Service.
NTSB Media Contact:
Terry N. Williams
The National Transportation Safety Board (NTSB) is an independent federal agency charged with determining the probable cause
of transportation accidents, promoting transportation safety, and assisting victims of transportation accidents and their families.