Good morning Chairman LaTourette, Ranking Member Brown, and Members of the Subcommittee. My name is Bob Chipkevich. I am the Director of the National Transportation Safety Board’s Office of Railroad, Pipeline and Hazardous Materials Investigations. The Safety Board’s Acting Chairman, Mark Rosenker, asked me to represent the Board today to discuss Human Factors Issues in Rail Safety.  The Acting Chairman is unable to be here today because the Board has a previously scheduled Sunshine Act meeting to deliberate on the probable cause of a marine accident.    

Since 2001, the National Transportation Safety Board has investigated 28 railroad and 3 rail transit accidents involving train collisions and over-speed derailments.  Most of these accidents occurred after train crews failed to comply with train control signals, failed to follow operating procedures in non-signaled (dark) territories, or failed to comply with other specific operating rules such as returning track switches to normal positions after completing their work at track sidings.  Our accident investigations have identified human performance failures related to fatigue, medical conditions such as sleep apnea, use of cell phones, use of after-arrival track warrants in dark territory, loss of situational awareness, and improperly positioned switches.   

Although the Safety Board has made numerous safety recommendations to address specific human performance issues, we have repeatedly concluded that technological solutions, such as positive train control systems, have great potential to reduce the number of serious train accidents by providing safety redundant systems to protect against human performance failures.  As a consequence, positive train control has been on the Safety Board’s most wanted list of transportation safety improvements for 16 years.

Fatigue

Fatigue is a human performance safety issue that crosses all modes of transportation.   Although fatigue has been identified as a safety issue in many railroad accidents over the years, the Safety Board most recently addressed this issue in its investigation of a collision between two freight trains at Macdona, Texas on June 28, 2004.  As a result of that accident, 3 people died from chlorine gas inhalation after a tank car was punctured. 

The Safety Board determined that the probable cause of the collision of the Union Pacific Railroad train with a BNSF Railway train at Macdona, Texas, was Union Pacific Railroad train crew fatigue that resulted in the failure of the engineer and conductor to appropriately respond to wayside signals governing the movement of their train.  Contributing to the crewmembers’ fatigue was their failure to obtain sufficient restorative rest prior to reporting for duty because of their ineffective use of off-duty time and Union Pacific Railroad train crew scheduling practices which inverted the crewmembers’ work/rest periods.  Contributing to the accident was the lack of a positive train control system in the accident location.  

The Safety Board concluded that the Union Pacific engineer had experienced microsleeps followed by a deeper descent into sleep and that the conductor was most likely asleep during most of the trip.  Admittedly, work as a train crewmember entails an unpredictable job schedule that can make it difficult for employees to effectively balance their personal and work lives.  During periods when the demand for crews exceeds the supply, the additional pressure on available crewmembers can make achieving such a balance particularly difficult.  The Board concluded in the Macdona report that the unpredictability of Union Pacific train crewmembers’ work schedules may have encouraged them to delay obtaining rest in the hope that they would not be called to work until later on the day of the accident. 

The Safety Board also found that the minimum rest periods prescribed by Federal regulations do not take into account either the rotating work schedules or the accumulated hours spent working and in limbo time.  Limbo time, the time when a crew is neither operating the train nor yet released from duty, is most often associated with a crew’s travel time to their final release point after the expiration of their 12-hour service limit.  The time spent awaiting that transportation can be significant and can lead to very long workdays.  For example, in June 2004, over 42 percent of the Union Pacific Railroad train crews in the San Antonio, Texas area spent greater than 12 hours on an assignment, over 24 percent spent greater than 13 hours, and 5 percent (or 760 train crews) spent greater than 15 hours.

As a result of the Macdona accident investigation, on July 20, 2006, the Safety Board recommended that the Federal Railroad Administration (FRA) require railroads to use scientifically based principles when assigning work schedules for train crewmembers, which consider factors that impact sleep needs, to reduce the effects of fatigue (R-06-14).  The Board also recommended that the FRA establish requirements that limit train crewmember limbo time to address fatigue (R-06-15). Further, the Board recommended that the Union Pacific Railroad, the Brotherhood of Locomotive Engineers and Trainmen, and the United Transportation Union use the Macdona accident as a fatigue case study to illustrate the responsibility of the carrier to provide an employee the opportunity for adequate sleep and the responsibility of the employee to acquire sleep sufficient to work at a safe level of alertness, and the options available if adequate sleep is not obtained (R-06-16 and 17).   As these safety recommendations have just recently been issued, they are classified “Open–Await Response.”

The Safety Board also identified inadequate sleep as a safety issue in a recent rail transit accident.  On November 3, 2004, a Washington Metropolitan Area Transit Authority (WMATA) Metrorail train rolled backwards 2,246 feet and struck another train at a speed of about 36 mph at the Woodley Park-Zoo/Adams Morgan station in Washington, D.C.   The Board found that the train operator had become disengaged from some critical train operations and that his reduced alertness was likely due to inadequate sleep.  The Board found WMATA’s practice of allowing train operators to return to work after having as few as 8 hours off between shifts following prolonged tours of duty does not give train operators the opportunity to receive adequate sleep to be fully alert and to operate safely.   On April 19, 2006, the Board recommended that the Federal Transit Administration (FTA) require transit agencies to ensure that the time off between daily tours of duty, including regular and overtime assignments, allows train operators to obtain at least 8 hours of uninterrupted sleep (R-06-03).  

On June 6, 2006, the FTA responded that it shared the Safety Board’s concerns regarding the importance of adequate rest between shifts for train operators and is determining if it can require the action requested as a condition of grants or through other authority.  The Safety Board is evaluating the information provided by the FTA and the safety recommendation is classified “Open – Response Received.” 

Medical Conditions

Safety Board accident investigations have also identified inadequate requirements for identifying and addressing potentially incapacitating medical conditions of railroad employees who carry out safety sensitive duties.  The Safety Board found that the probable cause of a collision between two Canadian National (CN) freight trains near Clarkston, Michigan on November 15, 2001, was train crewmembers’ fatigue (for the train that did not stop for a stop signal), which was primarily due to the engineer’s untreated and the conductor’s insufficiently treated obstructive sleep apnea.  

Both crewmembers of the train that passed the stop signal had been told by their private physicians that they had (or likely had) obstructive sleep apnea, but neither employee informed the CN of his potentially incapacitating condition.  Company physical exams did not include questions about sleeping disorders or other chronic problems that might cause performance-impairing fatigue. FRA certification requirements for locomotive engineers focus on specific vision and hearing acuity standards but do not provide guidance regarding medical conditions that should be considered in the course of an examination.  The Board also found that no standard medical examination form exists in the railroad industry. 

On November 27, 2002, the Safety Board recommended that the FRA develop a standard medical examination form that includes questions regarding sleep problems and require that the form be used to determine the medical fitness of locomotive engineers, and that the form also be available for use to determine the medical fitness of other employees in safety-sensitive positions (R-02-24).   The Board also recommended that the FRA 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).  Further, the Board recommended that the FRA 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 railroad’s designated physician determines that the employee can continue to work safely in a safety-sensitive position (R-02-26). 

In response to these safety recommendations, in 2004 the FRA issued a safety advisory to highlight the relationships between medical conditions (particularly sleep problems) and impaired performance.  Further, a study completed by a contractor for the FRA on the need for and options for implementing medical standards was completed in January 2005 and presented to the Railroad Safety Advisory Committee.  The report concludes that there is a need for a consistent industry-wide medical standard program for railroad workers and recommends that the FRA expedite the development of a medical standard program for the industry.  The safety recommendations are classified “Open—Acceptable Response.” 

Use of Cell Phones           

On May 28, 2002, two BNSF Railway freight trains collided head-on near Clarendon, Texas.  The Safety Board determined that the probable cause of the accident was the coal train engineer’s use of a cell phone during the time he should have been attending to the requirements of the track warrant his train was operating under, and the unexplained failure of the conductor to ensure that the engineer complied with the track warrant restrictions.  Contributing to the accident was the absence of a positive train control system that would have automatically stopped the coal train before it exceeded its authorized limits.

Locomotive engineers commonly use the locomotive radio to communicate with the dispatcher or other railroad employees. At the same time, cell phones are becoming more prevalent, and all four crewmembers involved in this accident had personal cell phones with them.  The engineer of the coal train had used his cell phone for two personal calls the morning of the accident, one call for 23 minutes and then a second call for 10 minutes shortly before the accident.  The engineer was on the second call as he passed the location at which he should have stopped and waited for the arrival of another train.  The Safety Board concluded that the engineer’s cell phone use likely distracted him to the extent that he did not take proper note of the after-arrival stipulation imposed by a track warrant and thus was unaware of the need to prepare to bring his train to a stop. 

As a result of an unrelated collision on a different BNSF subdivision, the railroad issued instructions to operating employees on June 18, 2002, that prohibit locomotive engineers from using cell phones and laptop computers while operating the controls of a locomotive. 

Cell phone use interferes with the perception process during the performance of operational tasks.  A crewmember who is on a cell phone may miss information broadcast on the locomotive radio from a dispatcher, wayside defect detectors, or train crews from a passing train.  When used by either the engineer or conductor, a cell phone may distract the other crewmember or terminate the normal interaction between the two.  Further, one employee may wish to ask a question or offer a reminder but may choose to not disturb the employee who is using the phone. Additionally, an incoming call may be a significant distraction to a person who is engaged in a particular task at a critical time.
 
Federal regulations do not prohibit a locomotive engineer from using a cell phone while at the controls of a moving train.  On June 13, 2003, the Safety Board recommended that the FRA promulgate new or amended regulations that will control the use of cellular telephones and similar wireless communication devices by railroad operating employees while on duty so that such use does not affect operational safety (R-03-1). 

The FRA responded that by and large, railroads across the country have promulgated, or are promulgating, operating rules that prohibit or severely restrict cell phone use by employees moving equipment and in other situations, such as switching activities or when inspecting passing trains.  FRA noted that the railroad industry’s enforcement of its operating rules governing cell phone use is sufficient to address the issue without the need for Federal regulations.  However, the Safety Board does not share the FRA’s confidence that the railroad industry has taken sufficient steps to prevent the use of cell phones for personal matters when crewmembers should be attending to the operation of the train.  The Board is concerned that the risks of complacency and attention deficiencies associated with cell phone use are not sufficiently understood or recognized.  Unlike some other distractions to operating crewmembers, cell phone use has the potential to distract crewmembers for a considerable length of time, and is avoidable.  The FRA acknowledged concern and issued instructions to its staff to watch for use of cell phones, and has asked railroad members of the Railroad Safety Advisory Committee to provide information about their instructions for use of cellular phones before determining what actions, if any, the FRA should take.   The safety recommendation is currently classified “Open – Acceptable Response.”

After-Arrival Track Warrants in Non-Signaled (Dark) Territory

Non-signaled (dark) territory presents a unique problem for rail safety.  In dark territory there are no signals to warn trains as they approach each other, and the avoidance of collisions relies solely on dispatchers and train crews adhering to operating procedures.  Issuing after-arrival track warrants under these conditions exacerbates an already potentially tenuous and contingent work situation.  (An after-arrival track warrant is a conditional authority given to a train crew by a dispatcher. It authorizes the train crew to proceed ahead only after another specifically identified train that is en route to their location has arrived.)  While the railroad industry contends that after-arrival track warrants facilitate the expedient and efficient movement of trains, and the FRA has seen merit in the industry’s logic, ultimately, the role of human error and the cost of human casualties also must be considered in this equation.

The Safety Board has investigated a number of accidents involving after-arrival track warrants in non-signaled territory.  In 1996, in Smithfield, West Virginia, the Board investigated a head-on collision between two CSX Transportation freight trains operating under after-arrival operating procedures.  CSX Transportation subsequently discontinued the use of after-arrival authorities in non-signaled territory.  In 1997, the Board investigated a collision between two Union Pacific Railroad freight trains in Devine, Texas.  As a result of the Devine investigation, the Board recommended that the FRA permanently discontinue the use of after-arrival orders in non-signaled territory (R-98-27).  The safety recommendation was classified “Closed–Unacceptable Action” on June 29, 1999. 

After investigating the 2002 head-on collision between two BNSF trains in Clarendon, Texas, the Safety Board recommended that the FRA limit the use of after-arrival orders in non-signaled territory to trains that have stopped at the location at which they will meet the opposing train (R-03-2).  The safety recommendation was classified “Closed–Unacceptable Action” on August 6, 2004. 

 On May 19, 2004, the Safety Board investigated yet another head-on collision between two BNSF freight trains near Gunter, Texas.  Again, the trains were being operated under track warrant rules on non-signaled territory. The Safety Board has concluded that informal communications between the dispatcher and train crews regarding authority limits, train names, and meeting or stopping points may lead to misunderstandings and errors.  In the opinion of the Board, the use of after-arrival track warrants for train movements in dark (non-signaled) territory creates an unacceptable risk of collision.   The Board also concluded that had the FRA required railroads to permanently discontinue the use of after-arrival orders in dark territory as advised in Safety Recommendation R-98-27, this accident would not have happened.  Further, the Board concluded that had a positive train control system with collision avoidance capabilities been in place and operational on the subdivision at the time of the accident, the collision would not have occurred.  On June 29, 2006, the Board again recommended that the FRA prohibit the use of after-arrival track warrants for train movements in dark (non-signaled) territory not equipped with a positive train control system (R-06-10).  The Board is awaiting a response from the FRA. 

Loss of Situational Awareness

The Safety Board has investigated accidents in which the loss of situational awareness was a factor.  In its investigation of the collision of an Amtrak train with a Maryland Rail Corporation (MARC) train in Baltimore, Maryland in 2002, the Safety Board concluded that a factor in the accident was the engineer’s unfamiliarity with equipment.  Specifically, the Amtrak engineer, with about 6 months of operating experience over the territory, had a train that was pulled by two locomotives of a type she had never operated.  In addition, she had had limited experience operating locomotives as multiple units.  As the engineer was approaching Baltimore station, she became overly concerned with and focused on maintaining her speed; as a result, she did not see either the cab or wayside signals indicating that she should stop.  She continued past the signals and collided with a MARC train near the station. 

On October 12, 2003, a Northeast Illinois Regional Commuter Railroad (Metra) train derailed in Chicago, Illinois at a speed of about 68 mph as it traversed a crossover from track 1 to track 2.  The maximum authorized speed through the crossover was 10 mph.  There were 375 passengers and a crew of 3 onboard; 47 passengers were transported to hospitals.  

During interviews with Safety Board investigators, the engineer discussed some operational concerns he had had soon after he began the trip.  None of the fundamental tasks (train handling, signal recognition, and operating rules) faced by the engineer on the day of the accident was beyond his capabilities.  However, when his belief that he was operating on clear signals was coupled with his unresolved concerns about the location of a work crew, when he would be crossed over, and other tasks, his ability to operate the train safely was affected.

The engineer was confronted with a number of tasks that he should have handled more effectively.  Training programs should help prepare students for “real-world” situations and teach them how to effectively prioritize conflicting tasks.  The Safety Board concluded that the cumulative operating concerns of the engineer likely diverted his attention from the safety-critical task of observing and complying with signal indications.  The Board also concluded that the Metra accident is another in a series of accidents that could have been prevented had there been a positive train control system at the accident location.   On November 23, 2005, the Safety Board recommended that the FRA develop guidelines for locomotive engineer simulator training programs that go beyond developing basic skills and teach strategies for effectively managing multiple concurrent tasks and atypical situations (R-05-9). 

On May 26, 2006, the FRA responded that it agreed that developing guidelines for locomotive skill development that contribute to good situational awareness is worthy of consideration, both as a further contribution to the quality of existing training programs and as a means of benchmarking the various programs. The FRA noted that while it did not currently have funding available to initiate this action, it would try to identify resources to undertake the work.  The safety recommendation is classified “Open – Response Received.”  

Improperly Positioned Switches

One of the most serious hazardous materials train accidents in recent years occurred in Graniteville, South Carolina on January 6, 2005, after a Norfolk Southern Railway Company freight train, while traveling 47 mph, encountered an improperly positioned switch that diverted the train from the main line onto an industry track, where it struck an unoccupied, parked train.  The track through Graniteville was non-signaled (dark) territory.  Nine people died as a result of chlorine gas inhalation after a tank car was punctured during the accident. 

The investigation determined that the improperly lined switch had most recently been used by the crew of a local train about 8 hours before the accident. The crew had lined the switch for an industry track in order to place two cars at a local plant and then park their train.  No crewmember remembered relining the switch for the main line before they boarded a taxi and returned to the terminal.  The Safety Board concluded that the local train crew failed to reline the main line switch for one or more of the following reasons: (1) the task of relining the switch was functionally isolated from other tasks the crew was performing, (2) the crewmembers were rushing to complete their work and secure their train before reaching their hours-of-service limits, (3) the crew had achieved their main objective of switching cars and were focused on the next task of securing their equipment and going off duty, and (4) the switch was not visible to the crew as they worked, leaving them without a visual reminder to reline the switch. 

The Safety Board was concerned as early as 1974 about the issue of train speeds in areas not under a form of centralized traffic control.  As a result of its investigation of an accident in Cotulla, Texas involving a misaligned switch in non-signaled territory, the Board recommended that the FRA determine and assess the current risks of train accidents involving misaligned switches, collisions, broken rail, and other route obstructions on main track where automatic block signal systems do not exist, and to promulgate regulations that detail the major risks and controls assumed, set guidelines for safe operations below the maximum operating speed, and assign responsibility to the carrier for safe operations.  Because the FRA’ actions did not satisfy the Safety Board’s intent that new regulations specify circumstances that required that trains be operated below the allowable maximum speed, Safety Recommendation R-74-26 was classified “Closed – Unacceptable Action.” 

Measures beyond additional operating rules, forms, or penalties, are needed to ensure that accidents such as the one in Graniteville do not recur.  On December 12, 2005, the Safety Board recommended that the FRA require that, along main lines in non-signaled territory, railroads install an automatically activated device, independent of the switch banner, that will, visually or electronically, compellingly capture the attention of employees involved with switch operations and clearly convey the status of the switch both in day and in darkness (R-05-14).  In a letter dated June 30, 2006, the FRA acknowledged that additional actions are needed to protect the safety of trains in dark territory and that over time, positive train control will serve this function.  However, it noted concern that any system that requires power at the switch location will involve significant costs, simply because of the number of switches involved.  The letter advises that the FRA has initiated a project to evaluate a system that it believes will be able to detect and report switch point gapping for switches on main line tracks located within dark territories as an alternate action.  The safety recommendation is classified “Open–Response Received.”
 
The Safety Board also recommended that the FRA require railroads, in non-signaled territory and in the absence of switch position indicator lights or other automated systems that provide train crews with advance notice of switch positions, to operate those trains at speeds that will allow them to be safely stopped in advance of misaligned switches (R-05-15).  In its June 30, 2006, letter the FRA states that it does not believe the recommendation is feasible for operational and economic reasons and may also increase the risk of derailments.  The FRA hastened to add that there are undoubtedly certain situations where requiring trains to approach switches prepared to stop would be practical and an appropriate safety response, and that railroads should consider this option as they conduct risk assessments of their hazardous materials routes.  However, the FRA states that it is not aware of any means to describe how this strategy could be applied in a safe and cost-effective manner.  The FRA requested that the Safety Board classify the Safety Recommendation as “Closed–Reconsidered.”   The safety recommendation is currently classified as “Open–Response Received” and the Board is evaluating the information provided by FRA.

Summary

Actions need to be taken by the FRA to address train crew fatigue, to assess the medical fitness of train crews, to control the use of cellular phones, to prohibit the use of after-arrival track warrants in dark territory, to improve situational awareness training for train crews, and to prevent trains from being misdirected through improperly lined switches.  Most importantly, the FRA should take aggressive action to require railroads to install positive train control systems as soon as possible, so that train accidents caused by human factors can be prevented.  

           

Mr. Chairman, this completes my statement, and I will be happy to respond to questions at the appropriate time.