John WR BucyrusThe report addresses these issues on page 1-5. I see no explanation of how a person might be awake enough to manipulate the throttle and other equipment and then in somewhat over a minute be so sound asleep as to be totally unaware of his surroundings. I just don't see where that particular point is addressed. John
BucyrusThe report addresses these issues on page 1-5.
John
Well that point is not specifically addressed, and it may in fact be the case that the engineer failed to stop for the stopped train ahead for some reason other than falling asleep. But you seem to question the possibility of being awake and then falling asleep within one minute. Many people are probably not aware of that possibility because it is not a part of their normal routine. But I have had vivid experience of this while driving. Most people call it nodding off. You fall asleep and wake up a few seconds later with a startle. You tell yourself not to let it happen again, and in a few moments, you wake again with a startle. It can happen over and over again. With luck, you don't hit anything or go off the road during the lapse in consciousness.
jeffhergertBack when I was a conductor, I deadheaded out to our away from home terminal with Engr X, who's now retired.
Jeff
As a young man I spent a few years working in an operating suite. At times I had to work the night shift which as 11.pm to 7 am. I too tended to be less alert than I was when I worked a regular day shift.
Bucyrus,
I went back and re-read pages 1 to 5 including the event recorder chart. I see no explanation of how a person might be awake enough to manipulate the throttle and other equipment and then in somewhat over a minute be so sound asleep as to be totally unaware of his surroundings. I just don't see where that particular point is addressed.
John WR BucyrusI was referring to this as quoted from the accident report for the Iowa crash: Yes Bucyrus. And you go on to quote conclusion 4 to the effect that both the engineer and conductor had "fallen asleep due to fatigue." As I said above, I have no real expertise here and I don't like to shoot from the hip with a top of the head opinion. Yet for all of that it is hard for me to understand how, within 2 minutes, the engineer would move the throttle, push the button on the alerter and then "fall asleep" and so would not see and respond to a red signal. And the NTSB does not explain how just before missing the red signal actions would be taken that would require the engineer to be awake. John
BucyrusI was referring to this as quoted from the accident report for the Iowa crash:
Yes Bucyrus. And you go on to quote conclusion 4 to the effect that both the engineer and conductor had "fallen asleep due to fatigue."
As I said above, I have no real expertise here and I don't like to shoot from the hip with a top of the head opinion. Yet for all of that it is hard for me to understand how, within 2 minutes, the engineer would move the throttle, push the button on the alerter and then "fall asleep" and so would not see and respond to a red signal. And the NTSB does not explain how just before missing the red signal actions would be taken that would require the engineer to be awake.
Back when I was a conductor, I deadheaded out to our away from home terminal with Engr X, who's now retired. We deadheaded out in the morning, tying up about noon. Back then we only got 8 hours rest and they could call us 1 and 30 minutes prior to our 8 hours being up. That is they could call us after 6 hrs 30 mins to report for duty at the 8 hr mark. It appeared we would go on our rest and we did. I never got any sleep, not because I didn't try but because I wasn't tired enough to sleep. I spent at least 4 hours laying in bed but I never went to sleep. Engr X, who had a girlfriend out there (he wasn't married, although there are some who wouldn't let that status stop them) and he had spent the day with her. He didn't try to get any rest.
The first 50 miles or so was through a more populated area, quite a bit of artificial lighting. It wasn't that late through that area either. I was tired, but it didn't really hit me until we were out of that area and the time was approaching midnight. I was worried that I might doze off, no matter hard I tried to stay alert. As it turns out, I didn't have that problem after all. For as tired as I was, Engr X was worse. His lack of sleep hit him about the same time. He fell asleep a few times while blowing the horn for crossings. He would start the sequence and I would finish it with the button on the condr's side. A few times I blew the whole crossing.
We started down the one big hill we have on that end and I hollered over to him that he might want to set some air since we were getting close to the speed limit. He did but then I noticed an odor, like hot brake shoes. "You might want to bail them off." He had set air, but then dozed off before bailing off the independent. As we approached the bottom, he had dozed off again and I suggested he might want to release them, which he did. From there on he seemed to be a bit better, like he got his second wind or something. The middle part of the trip though, is one I won't forget. So yes, I can see someone under the right circumstances doing something and immediately dozing, zoning or spacing out.
John WR BucyrusHowever, having said that, I don’t see how sleep could be ruled out by the timing of the final alerter and throttle resets. Bucyrus, I do think the short amount of time between actions requiring the engineer be awake and passing the red signal does needs to be addressed. And yet the NTSP is silent on the issue. John
BucyrusHowever, having said that, I don’t see how sleep could be ruled out by the timing of the final alerter and throttle resets.
Bucyrus, I do think the short amount of time between actions requiring the engineer be awake and passing the red signal does needs to be addressed. And yet the NTSP is silent on the issue.
John,
The report addresses these issues on page 1-5.
In reading the report closely, I see that there was no failure of the striking train to comply with signals approaching the struck train. The only failure of the striking train was the failure to stop short of the struck train which was made visible by its end-of-train device.
At the time of the last recorded activity of the engineer of the striking train, the struck train was not yet in view of the striking train.
It was 1 minute 11 seconds from the last recorded activity of the engineer of the striking train to the point where the struck train came into view of the striking train.
Therefore, if the engineer of the striking train collided with the train ahead because he was asleep, he had 1 minute 11 seconds to fall asleep.
zugmannIf god forbid something ever happens to me out here, and some agency "concludes" what I was doing right before I met my end, then I would make sure to haunt them for the rest of their lives.
Zugmann, Judging by the little picture you post one problem you do not have is being overweight. I trust when your time comes you will leave us quite peacefully in your own bed in a way that is far to boring for any government agency to inquire into it.
edblysardBoth blood and urine sample were collected post mortem, neither the engineer nor conductor survived the initial collision, there was no survivable space in the cab.
Yes they were, Ed. And both drugs and alcohol were ruled out as related to the accident. And yes, the cab was crushed in the accident.
zugmann If god forbid something ever happens to me out here, and some agency "concludes" what I was doing right before I met my end, then I would make sure to haunt them for the rest of their lives.
If god forbid something ever happens to me out here, and some agency "concludes" what I was doing right before I met my end, then I would make sure to haunt them for the rest of their lives.
Thanks to Chris / CopCarSS for my avatar.
Between lighting and physical characteristics of the terrain, trains and signals - one's eyes can play tricks.
Several years ago my carrier had a rear end collision - train had a approach signal, complied with it - lost track that the next signal which should have displayed a Stop indication with number plate (restricting) was dark, came around a curve and observed a signal displaying Clear - what wasn't seen was the train ahead for whom the Clear signal was actually displayed for. The train ahead, was all bare table intermodal car - about 9000 feet of them - Overtaking crew totally overlooked the flashing EOT when the observed the Clear signal ahead.
Total man failure and sleep wasn't not involved - just PP railroading.
Never too old to have a happy childhood!
It's been fun. But it isn't much fun anymore. Signing off for now.
The opinions expressed here represent my own and not those of my employer, any other railroad, company, or person.t fun any
Ed,
I did not mean to suggest that I had concluded that the engineer missed the signal and collided with the leading train because he was asleep. As you and zugmann, I believe pointed out, he could have simply failed to see the standing train. Was he authorized to pass the red signal and stay at restricted speed? If so, the theory of sleeping past the red signal would not be needed to explain passing it. So that just leaves the standing train as the requirement for action.
However, having said that, I don’t see how sleep could be ruled out by the timing of the final alerter and throttle resets. He could have been sleeping between alerter resets, and become accustomed to falling asleep in a very short time after each reset. If so, he could have reset the alerter; and seven seconds later, reset the throttle; and then slept for the next 1 minute 53 seconds until impact. All we know for sure is that he was awake during the final alerter reset and final throttle change.
Both blood and urine sample were collected post mortem, neither the engineer nor conductor survived the initial collision, there was no survivable space in the cab.
2 minutes before the collision, the engineer reset the alerter, 1 minute 53 seconds before the collision, he performed a throttle setting reduction, two separate actions within 7 seconds….he wasn’t asleep.
As to why they went by a red signal, as Zug pointed out, the only two folks who could tell us are dead, and while I could come up with a few reason, I will pass on speculation, as the NTSB has done enough of that for my taste.
23 17 46 11
When a person is very tired, it is possible to reset the alerter when being half asleep, and for the two minutes or so of alerter silence, a person can be fully asleep.
If they made alerters so a reset required the engineer to do 20 pushups, then it might do a better job of keeping a person awake. But you cannot add too much burden to resetting the alerter because it has to be reset so often in order to be effective.
I have a link somewhere to a collision caused by an engineer sleeping on the alerter. I will see if I can find it.
John, note my reposnse above to your question to me last night.
zugmannThe only people that know what happened are no longer with us.
That occurred to me, too, Zugmann. They did live long enough to allow for blood and urine tests to show that neither drugs nor alcohol were involved.
But, after reading the whole report, I don't think the NTSB is really saying they know what happened. I think they are saying that given the evidence, particularly the history of obesity, high blood pressure and diabetes, they cannot rule out the possibility of a sleep disorder.
John WR Quote from the NTSB accident report of the Iowa crash: "Therefore, the NTSB recommends that the FRA establish an ongoing program to monitor, evaluate, report on, and continuously improve fatigue management systems implemented by operating railroads to identify, mitigate, and continuously reduce fatigue-related risks for personnel performing safety-critical tasks, with particular emphasis on biomathematical models of fatigue." I think, Bucyrus, that this is the sentence you find particularly objectionable. John
Quote from the NTSB accident report of the Iowa crash:
"Therefore, the NTSB recommends that the FRA establish an ongoing program to monitor, evaluate, report on, and continuously improve fatigue management systems implemented by operating railroads to identify, mitigate, and continuously reduce fatigue-related risks for personnel performing safety-critical tasks, with particular emphasis on biomathematical models of fatigue."
I think, Bucyrus, that this is the sentence you find particularly objectionable.
That is not what I am referring to when I said something to the effect that they were reaching for conclusions without direct proof. I was referring to this as quoted from the accident report for the Iowa crash:
“The National Transportation Safety Board determines that the probable cause of the accident was the failure of the crew of the striking train to comply with the signal indication requiring them to operate in accordance with restricted speed requirements and stop short of the standing train because they had fallen asleep due to fatigue resulting from their irregular work schedules and their medical conditions.”
Now there is wiggle room in that statement. They use the term, “probable” as opposed to “definite.” But then with the term, “probable,” the statement becomes speculation, and I would expect an accident investigation to refrain from speculation. The NTSB cannot prove the crew was even asleep let alone sleeping due to sleep disorder. In terms of speculation, I would agree that the reason for passing the red signal was probably that the crew was asleep.
Now they don’t used the term, “sleep disorder.” They use the term, “fatigue,” and fatigue can be caused by simply failing to stay in bed long enough the day before. Fatigue has to be caused by something, so it is fair to speculate that it was caused by insufficient sleep before going on duty.
But then they go on to speculate that the fatigue was caused by irregular work schedules, and that linkage does make it a sleep disorder such as Shift Work Sleep Disorder by definition, thus taking the speculation on the crew being asleep to speculating that the sleep was caused by a sleep disorder caused by working irregular hours, even though not everyone who works irregular hours contracts a sleep disorder.
This is pure speculation used to advance an agenda under the guise of an objective, fact-based investigation.
Dead men tell no tales.
The only people that know what happened are no longer with us. For anybody or any agency to pretend like they know is just foolishness.
edblysardJohn, here ya go...
Thank you for the report, Ed. I read the whole thing except for the appendix.
As you point out, within two minutes before the accident the engineer adjusted the throttle and pressed the reset button so he was awake and alert enough to take those actions. Never the less, he did also pass a red signal. A fairly recent physical examination shows he did not have a vision impairment or color blindness.
The NTSB argues fatigue was a factor in passing the red signal because the engineer and the conductor had risk factors for a sleep related disorder. However, they do not explain the discrepancy between taking actions that showed the engineer was awake and alert and passing the red signal. I personally am not inclined to comment about the validity of the NTSB's conclusion although I can see why you. with railroad expertise that I do not have, would question that conclusion. The only question I would ask you is if you would be able to comment on just why the engineer passed the red signal.
Randy Stahl I implanted a 12 pack of Miller beer in my abdomen and blanked out.................................
I implanted a 12 pack of Miller beer in my abdomen and blanked out.................................
tree68 Some researchers once proved, using accepted methods, that dimes cause cancer. Dimes were implanted into the abdominal cavities of research mice, and apparently enough cancer, or cancerous conditions, resulted that the researchers could make that claim. Since no one had an agenda to get rid of dimes the exercise ended as little more than a novelty, but research has proved...
Some researchers once proved, using accepted methods, that dimes cause cancer. Dimes were implanted into the abdominal cavities of research mice, and apparently enough cancer, or cancerous conditions, resulted that the researchers could make that claim.
Since no one had an agenda to get rid of dimes the exercise ended as little more than a novelty, but research has proved...
tree68 I think I figured out what the agenda is here - get rid of night-time trains. If there were no night trains, sleep cycles would not be disrupted, there would be no night-time noise issues/complaints, and there would always be daylight to work in (night operations, especially switching, are pretty dangerous). You may think this sounds silly, but the folks in the ivory towers have been known to come up with sillier ideas...
I think I figured out what the agenda is here - get rid of night-time trains. If there were no night trains, sleep cycles would not be disrupted, there would be no night-time noise issues/complaints, and there would always be daylight to work in (night operations, especially switching, are pretty dangerous).
You may think this sounds silly, but the folks in the ivory towers have been known to come up with sillier ideas...
I think the gist of the argument, such as it is, is more in line with "keep nighttime calls reserved for nighttime-compatible workers". And take whatever steps may be necessary to 'ensure sleep-wake cycle integrity' or whatever (a euphemism for intrusive monitoring to Make Sure The People Are In Bed On Time -- nanny-state at its finest flower.)
I would be interested to see the statistics for SWSD that are derived for continuous shift work (e.g., no rotation). That would give an average percentage for people who just can't get used to being up at night no matter what, and perhaps a percentage for people who have trouble with dark vs. light cycles. That will let railroads do sensible reasonable accommodation, and figure out exactly what they can run at night, and adjust their hiring policies and HR procedures accordingly...
Ramu is getting TIRED of the discussion.
LION is always tired. Him can curl up and go to sleep right next to any work that tries of involve him.
Bottom Line: They will automate the railroad long before they will be able to keep people from falling asleep, especially at night.
ROAR
The Route of the Broadway Lion The Largest Subway Layout in North Dakota.
Here there be cats. LIONS with CAMERAS
edblysard And I agree, part of the NTSB agenda seems to be doing away with night time railroading.
That does seem to be the case. The way they have framed the total problem of sleep disorders, eliminating nightshift work would probably be the cheapest solution.
It is interesting because the choice of eliminating night work versus the intrusiveness (and job insecurity) of employee monitoring would be as clear as a bell in terms of preference by labor.
I was wonder the same thing….given the rear of the work train was under the overpass, in a slight curve, and a flat car at that, by adding in the possibility that the engineer was “zoned out” he simply may not have recognized that what he was looking at was the rear of the other train. He quite simply might not have seen it for what it was. And I agree, part of the NTSB agenda seems to be doing away with night time railroading.
My mother (86, bless her soul) gave up driving some years ago because she discovered that she would "zone out" while driving - however, it had nothing to do with sleep. She would simply, occasionally blank out. She may have had an accident as a result - none of us really know for sure. I was never riding with her when it happened, but she was riding with me one time and announced, out of the blue, that she had just done so. I hadn't noticed anything, aside from the fact that she hadn't said anything for a brief, which was not unusual. As we have already discussed, it's entirely possible that a person could do some rote action, like clearing the alerter, while in such a trance.
We also can't rule out the possibility of simple daydreaming. I've done it myself - get so wrapped up in whatever I'm thinking about that I realize that I have no recollection of passing a certain point, or something similar. In all likelihood, "the cap" would not alert on that situation - the brain would be showing waking activity.
Even a well-rested person could get so wrapped up in their thoughts that they would lose touch with their surroundings, all the while doing what had to be done (resetting the alerter, making control adjustments, etc). If they are very familiar with the line they are running, and there are no operational distractions (ie, train handling badly), the situation would be that much worse.
Larry Resident Microferroequinologist (at least at my house) Everyone goes home; Safety begins with you My Opinion. Standard Disclaimers Apply. No Expiration Date Come ride the rails with me! There's one thing about humility - the moment you think you've got it, you've lost it...
In the report, I recall that the alerter was nearly at the end of its quiet interval, and was scheduled to sound something like 7 seconds after the time of impact. So the timing of the circumstance was relatively unfavorable by allowing almost the maximum quite cycle ahead of the point where the engineer’s action was called for. It is just a matter of chance, but a different position of the alerter cycle in relation to the crash might have prevented the crash.
It will be interesting to see how much time transpired between the last alerter reset and the time of impact in the Goodwell, Oklahoma collision. One would expect a relatively long time interval. What would the NTSB conclude if the alterter was reset 5-10 seconds before impact?
BucyrusTherefore, the NTSB recommends that the FRA establish an ongoing program to monitor, evaluate, report on, and continuously improve fatigue management systems implemented by operating railroads to identify, mitigate, and continuously reduce fatigue-related risks for personnel performing safety-critical tasks, with particular emphasis on biomathematical models of fatigue.
I see it a little differently than you do. The NTSB says it will do nothing but it thinks someone else -- in this case the FRA -- should do something about the problem. However, the FRA sets its own agenda so whether or not is will is another question. In any event, the NTSB indicates no interest and what the FRA does or does not do.
You know more about this than I do. I have never heard of a "fatigue management system." Do you know what they mean?
I am about to retire to my own personal fatigue management system. I call it going to bed. I hope you don't loose any sleep over it.
The following is a quote from the accident report of the Iowa crash. It gives a lot of insight into the concern of the NTSB. From work load to cognitive demand; and from lighting, temperature, noise level, caffeine, to adrenaline changes due to stressors; and from time pressure, social friction to monotony and repetitive motion-- the NTSB is leaving no stone unturned.
The NTSB is aware, however, of some general limitations regarding the use of these models. For instance, in general, biomathematical models have been calibrated to represent a population average rather than real-time fatigue levels of a specific NTSB Railroad Accident Report 50
individual.62 It is unclear how individual differences (such as age, sex, and operating experience) may affect the output of these models. Additionally, biomathematical fatigue models predict risk factors for an average healthy person; thus, the output may not accurately predict the risks to a crewmember who may have medical conditions or otherwise not be fully fit for duty. The NTSB further recognizes that biomathematical models may not consider all factors affecting fatigue such as workload (mental or physical, high or low cognitive demand), the operating environment (including lighting, temperature, and noise level), and pharmacological agents, for example, caffeine and changes in adrenaline levels due to stressors. Other factors that may not be represented in biomathematical models include stressors in the workplace (that is, time pressure, social friction) and aspects of the work (such as monotony and repetitive motion).63 Studies have pointed out the need for additional research to determine whether one or more of these work-related factors are important alone or in interaction with sleep/wake cycles and circadian dynamics, especially for risk-focused models.64 The NTSB notes that several studies have concluded that fatigue model predictions cannot be the sole means upon which fatigue risk management operational decisions are made.65 The NTSB concludes that because biomathematical models of fatigue are relatively new to the railroad industry, the use of this technology should be evaluated for its effectiveness within the context of railroads‘ fatigue management plans through independent scientific peer review. Therefore, the NTSB recommends that the FRA establish an ongoing program to monitor, evaluate, report on, and continuously improve fatigue management systems implemented by operating railroads to identify, mitigate, and continuously reduce fatigue-related risks for personnel performing safety-critical tasks, with particular emphasis on biomathematical models of fatigue.
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