Railroad Accident Report - Collision of Two Canadian National/Illinois Central Railway Trains

Near Clarkston, Michigan
November 15, 2001

NTSB Number: RAR-02-04
NTIS Number: PB2002-916304
Adopted November 19, 2002
PDF

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.

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 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:

  • 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.

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 performance impairing 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)