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Safety Recommendation Details

Safety Recommendation R-15-019
Details
Synopsis: About 2:49 a.m. on March 24, 2014, Chicago Transit Authority train No. 141 collided with the bumping post near the end of the center pocket track at O’Hare Station. The lead car rode over the bumping post and went up an escalator at the end of the track. The escalator provided public access to enter O’Hare International Airport from the platform in the station, but no one was using it at the time of the accident. About 50 people were on the train at the time of the accident. Thirty-three injured passengers and the injured train operator were taken to the hospital. The estimated damage was $11,196,796. The accident occurred in an underground station that was not impacted by weather conditions. The National Transportation Safety Board determines that the probable cause of the accident was the failure of the train operator to stop the train at the appropriate signal due to falling asleep as a result of fatigue, which was the result of the challenges of working shiftwork, circadian factors, and acute sleep loss resulting from her ineffective off-duty time management. In addition, Chicago Transit Authority failed to effectively manage the operator’s work schedule to mitigate the risk of fatigue. Contributing to the severity of the accident was Chicago Transit Authority’s failure to identify the insufficient stopping distance and inadequate speed restriction at the center pocket track at O’Hare Station.
Recommendation: TO THE FEDERAL TRANSIT ADMINISTRATION: Establish (through the state safety oversight program) scientifically based hours-of-service regulations that set limits on hours of service, provide predictable work and rest schedules, and consider circadian rhythms and human sleep and rest requirements.
Original recommendation transmittal letter: PDF
Overall Status: Open - Acceptable Response
Mode: Railroad
Location: Chicago, IL, United States
Is Reiterated: No
Is Hazmat: No
Is NPRM: No
Accident #: DCA14FR007
Accident Reports:
Preliminary Report Railroad DCA14FR007
​Chicago Transit Authority Train Collides with Bumping Post and Escalator at O’Hare Station
Report #: RAR-15-01
Accident Date: 3/24/2014
Issue Date: 5/13/2015
Date Closed:
Addressee(s) and Addressee Status: FTA (Open - Acceptable Response)
Keyword(s):

Safety Recommendation History
From: NTSB
To: FTA
Date: 3/29/2016
Response: We are pleased that you recognize the importance of developing criteria that address hours of service, managing personal fatigue risks, training personnel that develop work schedules for employees, and identifying training and certification necessary for work schedulers. We note that, in October 2014, in preparation for developing guidance in these areas, you tasked the Transit Advisory Committee for Safety (TRACS) with developing recommendations for establishing a fatigue management program for the bus and rail transit industry based on the principles of safety management systems. A member of my staff recently contacted Ms. Bridget Zamperini of the FTA’s Office of Transit Safety & Oversight for an update on the progress of this project. Ms. Zamperini informed us that you had received the final report from the TRACS panel of experts and that it includes specific recommendations regarding the management of personal fatigue risks, training for personnel that will assist with developing work schedules for employees, hours-of-service criteria that set limits on hours of service, and the training and certification of work schedulers, as anticipated. Ms. Zamperini further stated that you were currently evaluating the TRACS recommendations to determine a plan for moving forward. Accordingly, Safety Recommendations R-15-18 through -21 are classified OPEN—ACCEPTABLE RESPONSE pending our evaluation of your plan to proceed and the completion of the actions we recommended.

From: FTA
To: NTSB
Date: 8/10/2015
Response: -From Therese W. McMillan, Acting Administrator: The FTA recognizes the importance of developing of criteria that addresses hours-of-service, managing personal fatigue risks, training personnel that develop work schedules for employees and the identification of necessary training and certification for work schedulers that shape the safety of public transportation systems. To advance the research and analysis that is necessary to develop guidance in these areas, in October 2014, the FTA tasked the Transit Advisory Committee for Safety (TRACS) with developing recommendations for establishing a Fatigue Management Program for the Bus and Rail Transit Industry based on the principles of Safety Management Systems. In September 2015, the FTA expects to receive the final report from the TRACS panel of experts which will help guide our approach to addressing fatigue management in public transportation. We expect the final report of the TRACS panel on fatigue management to include specific recommendations regarding: management of personal fatigue risks, training for personnel that will assist with developing work schedules for employees, hours-of-service criteria that set limits on hours of service, and the necessary training and certification for work schedulers. The FT A will thoroughly evaluate those all of the recommendations that it receives from TRACS.