On August 17, 2014, at 2:28 a.m. central daylight time, southbound Union Pacific Railroad (UP) freight train IMASNL-16 (southbound train) collided with northbound UP freight train IQNLPI-17 (northbound train) at milepost (MP) 228.6, while traversing the turnout at control point (CP) Y-229 on the UP Hoxie subdivision in Hoxie, Arkansas.1 Going north, the track in the area transitions from a single main track into two main tracks. As a result of the collision, the engineer and the conductor from the southbound train died, and the engineer and the conductor from the northbound train were seriously injured.
The following safety issues are covered in the report:
- Fatigue and Employee Work Schedules: Regulatory requirements to use science-based tools, such as biomathematical models, are needed to reduce start time variability that results in irregular work-rest cycles and train crew fatigue
- Medical Issues: Regulatory requirements for screening, evaluating, and ensuring adequate treatment standards for sleep apnea and other sleep disorders for railroad employees in safety-sensitive positions
- Union Pacific Railroad Medical Rules: Union Pacific Railroad needs: (1) medical rules that would require railroad employees in safety-sensitive positions to report all diagnosed sleep disorders; and (2) to perform periodic evaluations to ensure the condition is appropriately treated
- Automated Systems that Reset Alertness Devices: An automatic horn sequencer prevented the operation of an electronic alertness device that was designed to help the southbound train crewmembers maintain vigilance in the locomotive cab by monitoring engineer activity and applying the train brakes should the device fail to detect activity for a predetermined period of time
- Positive Train Control: A functioning positive train control system would have prevented this accident.
We determined that the probable cause of the accident was the failure of the southbound train crewmembers to respond to the signal indications requiring them to slow and stop their train prior to control point Y-229 because they were fatigued and had fallen asleep due to (1) the locomotive engineer’s inadequately treated obstructive sleep apnea, (2) the conductor’s irregular work schedule, and (3) the train crew operating in the early morning hours when they were predisposed to sleep. Contributing to the accident was (1) the lack of a functioning positive train control system; (2) the use of an automatic horn sequencer that, when activated, negated the operation of an electronic alertness device; (3) the Federal Railroad Administration’s failure to promulgate rules regarding sleep disorders; and (4) the absence of federal regulations requiring freight railroads to use fatigue modeling tools for train crew work schedules.
As a result of the investigation of this accident, we made new safety recommendations to the Federal Railroad Administration; BNSF Railway, Canadian National Railway, Canadian Pacific Railway, CSX Transportation, Kansas City Southern Railway, Intercity Railroads, and Commuter Railroads; Class I Railroads; and Union Pacific Railroad. Further, the National Transportation Safety Board reiterates two recommendations to the Federal Railroad Administration.
