Transportation Safety
Improvements
Federal Issues
Reduce Accidents and Incidents Caused by Human Fatigue
Objective
Importance
The Safety Board has long been concerned about the issue of operator fatigue in transportation and has stressed its concerns in investigation reports issued throughout the 1970s and 1980s. In 1989, the Board issued three recommendations to the Secretary of Transportation calling for research, education, and revisions to existing regulations. These recommendations were added to the Board’s Most Wanted List in 1990, and the issue of fatigue has remained on the Most Wanted List since then. The Safety Board’s 1999 safety study of DOT efforts to address operator fatigue continued to show that this problem was widespread. Operating a vehicle without the operator’s having adequate rest, in any mode of transportation, presents an unnecessary risk to the traveling public.
Safety Board recommendations on the issue of human fatigue and hours-of-work policies have had a substantial effect on encouraging the modal agencies to conduct research and take actions towards understanding the complex problem of operator fatigue in transportation and how it can affect performance.
Summary of Action
Over the years, the Safety Board has issued a number of recommendations to the Federal Railroad Administration (FRA) and to the railroad industry addressing the issue of operator fatigue. A recent accident illustrates the problem, and resulted in the Board’s issuing two new recommendations concerning fatigue. On June 28, 2004, a westbound Union Pacific Railroad freight train collided with a BNSF Railway Company freight train resulting in a subsequent derailment and hazardous materials release near Macdona, Texas. The Board determined that the probable cause of the collision was Union Pacific Railroad train crew fatigue that had 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. As a result, the Board asked the FRA to 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) and to establish requirements that limit train crewmember limbo time to address fatigue (R-06-15).
After review, the FRA responded as it had to a previous Safety Board recommendation (R-99-2), that it lacks the statutory authority to adopt the requirements contemplated by either of these recommendations, precluding the agency from making use of almost a century of scientific learning on the issue of sleep-wake cycles and fatigue-induced performance failures. The FRA further acknowledged that the existing hours-of-service law (HSL) is not designed to address the causes of fatigue. The Board indicated its willingness to work with the FRA in seeking the statutory authority it needed from Congress.
The Safety Board provided testimony on this issue before the U.S. House of Representatives Committee on Transportation and Infrastructure, Subcommittee on Railroads, Pipelines, and Hazardous Materials, on January 30, 2007, February 13, 2007, March 16, 2007, and May 8, 2007, and to the U.S. Senate Committee on Commerce, Science, and Transportation’s Subcommittee on Surface Transportation and Merchant Marine Infrastructure, Safety, and Security, on May 22, 2007. We are aware that the FRA has recently submitted a proposal to Congress that authority be given to the agency in its next reauthorization to revise railroad hours-of-service regulations, and Congressional legislation that will provide that authority is pending.
Action Remaining
Develop scientifically based principles when assigning work schedules for train crewmembers, which consider factors that impact sleep needs, to reduce the effects of fatigue and limit train crewmember limbo time to address fatigue.
Safety Recommendations
R-06-14 (FRA)
Issued July 20, 2006
Added to the Most Wanted List: 2007
Status: Open—Acceptable Response
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.
(Source: Collision of Union Pacific Railroad Train MHOTU-23 With BNSF Railway Company Train MEAP0TUL-126-D With Subsequent Derailment and Hazardous Materials Release, Macdona, Texas, June 28, 2004 [NTSB/RAR-06-03])
R-06-15 (FRA)
Issued July 20, 2006
Added to the Most Wanted List: 2007
Status: Open—Acceptable Response
Establish requirements that limit train crewmember limbo time to address fatigue.
(Source: Collision of Union Pacific Railroad Train MHOTU-23 With BNSF Railway Company Train MEAP0TUL-126-D With Subsequent Derailment and Hazardous Materials Release, Macdona, Texas, June 28, 2004 [NTSB/RAR-06-03])
November 2007
Most Wanted Highway | Most Wanted Home
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