By Dan Weikel
Times Staff Writer
April 24, 2005
When a Union Pacific freight train thundered into tiny Macdona, Texas, just before dawn June 28, the engineer and conductor had clocked more than 60 hours in the previous week, working the long, erratic shifts that are common in the railroad industry.
They flew through a stop signal at 45 mph and slammed into another freight train that was moving onto a side track. No one even touched the brakes.
Chlorine gas from a punctured tank car killed the conductor and two townspeople, while dozens of others suffered breathing problems and burning eyes as the toxic cloud drifted almost 10 miles. Hundreds were evacuated within a 2-mile radius of the accident.
Federal investigators suspect that both of the Union Pacific crewmen had fallen asleep. In the weeks before the crash, each man's work schedule had at least 15 starting times at all hours of the day.
The Macdona crash illustrates a grim fact of life for thousands of engineers, brake operators and conductors who guide giant freight trains across the country: Exhaustion can kill.
Two decades after federal officials identified fatigue as a top safety concern, the problem continues to haunt the railroad industry, especially the largest carriers responsible for moving the vast majority of the nation's rail-borne freight.
"Engineers and conductors sleep on trains. Anyone who tells you different is not being straight with you," said Diz D. Francisco, a veteran engineer and union official who works out of Bakersfield for the Burlington Northern Santa Fe Corp.
Tired crews have caused some of the deadliest and costliest freight train wrecks of the last 20 years, a review of federal accident reports show. And although the government doesn't track fatigue-related crashes, the number of accidents caused by human error has increased 60% since 1996, a surge that some safety experts suspect is at least partly the result of weary crews.
"We have been talking about the same issues for more than 20 years," said William Keppen of Annapolis, Md., a retired engineer, former union official and past coordinator of Burlington Northern Santa Fe's fatigue countermeasures program. "We made some progress in the 1990s, but the whole thing is starting to go to hell. People are dying out there. The risk is increasing again."
National Transportation Safety Board records show that entire crews have nodded off at the controls of mile-long freight trains weighing 10,000 tons, some of them loaded with hazardous materials.
In a 1984 Wyoming crash, a Burlington Northern engineer had only 6 1/2 hours of sleep in the 48 hours before the accident; his conductor had five hours of sleep.
Outside St. Louis in 2001, a Union Pacific engineer who had been up for 24 hours with only a short nap failed to heed three warning signals and orders to limit his speed before triggering a chain-reaction crash involving two other trains. The wreck injured four and caused $10 million in damage.
A year later, in Des Plaines, Ill., a Union Pacific engineer fighting to stay awake after more than 22 hours without sleep blew past warning signals and broadsided another train, severely injuring two crew members.
After a Chicago & North Western train collision in March 1995, engineer Gerald A. Dittbenner sued the railroad — and received a $500,000 settlement, his lawyers say — over his incessant 12-hour shifts and irregular work schedules.
Dittbenner, 49, misread a stop signal after being awake almost 30 hours and hit the rear of an empty coal train outside Shawnee Junction, Wyo. Seconds before the impact, Dittbenner jumped from the locomotive and broke his neck. Unable to do strenuous work because of persistent pain, he now works as a locksmith in Scottsbluff, Neb.
At a freight terminal before the crash, Dittbenner wrote a prophetic letter to the railroad company — but never got a chance to mail it.
"I said something like, 'We weren't getting enough sleep. The railroad is always short-handed and working us to death. If nothing is done, someone is going to get hurt,' " Dittbenner recalled in an interview. "That someone was me."
U.S. Probes Few Crashes
Federal regulators believe that fatigue underlies many train accidents, though the number of crashes related to the lack of rest is unknown.
The government investigates few crashes, leaving most of them to the railroads to review. By law, those carriers submit reports to the government. Under cause, the only fatigue-related category is "employee fell asleep," which Federal Railroad Administration officials say doesn't provide a full picture of the problem.
In 2004, the industry reported 3,104 significant accidents to the railroad administration. About 1,250 were attributed to human factors such as poor judgment, miscommunication and failure to follow operating procedures — errors that experts say can be triggered by fatigue.
A 1997 survey of more than 1,500 freight crew members by the North American Rail Alertness Partnership — a group of industry, government and union officials — found that about 80% had reported to work while tired, extremely tired or exhausted.
Though fatigue can affect passenger train crews, it is primarily a problem for the 40,000 to 45,000 engineers, brake operators and conductors assigned to unscheduled freight service.
Many put in 60 to 70 hours a week, sometimes more. They can be called to work any time during the day or night, constantly disrupting their sleep patterns.
The irregular shifts often place bleary-eyed crews at the controls between 3 and 6 a.m., when experts say the body's natural circadian rhythm produces maximum drowsiness.
Engineers, brake operators and conductors liken on-the-job fatigue to being in a constant state of jet lag.
"There is no set rest schedule. It changes all the time, and it is hard to adjust," said Doug Armstrong of Huntington Beach, a veteran Union Pacific engineer who often works 12-hour days, six days a week. "People have a normal rest cycle, but a railroad is anything but normal."
Part of the problem is the federal Hours of Service Act, a 98-year-old law that requires at least eight hours off after each shift. Crew members say that often doesn't result in adequate sleep. Allowing for commutes, family obligations, meals and getting ready for work, four to six hours of rest is common, they say.
Moreover, it is legal under the act for engineers, conductors and brake operators to work up to 432 hours a month. In contrast, truckers can drive no more than 260 hours a month under federal law, while commercial pilots are restricted to 100 hours of flying a month.
"It doesn't make scientific or physiological sense," said Mark R. Rosekind, a past director of NASA's fatigue countermeasures program and a former consultant to Union Pacific. "It calls for a minimum of eight hours off, but people need eight hours of sleep a day on average."
Without adequate rest, engineers can significantly increase their risk of an accident, according to research in the late 1990s by the Assn. of American Railroads, the industry's trade organization and lobbying arm.
Donald G. Krause, then an analyst for the association, studied 1.7 million work schedules and found that engineers who put in more than 60 hours a week were at least twice as likely to be in an accident as those working 40 hours.
His work was intended to aid the industry in assessing the fatigue problem and finding ways to reduce accidents. But in 1998, the association canceled the research.
"They did not want this finding," said Krause, who once studied rail safety for the federal General Accounting Office and is now a business writer living outside Chicago. "The railroads fear it could lead to restrictions on hours and government regulation, which could cost them money. But something needs to be done. One of these days, they are going to wipe out a town."
Association officials say Krause's research was halted because of budget cuts, not out of a desire to bury the conclusions.
Not a New Problem
Exhausting schedules are nothing new in railroading. In 1863, long hours contributed to the founding of the Brotherhood of Locomotive Engineers, one of the nation's oldest unions.
Crew fatigue is even enshrined in American folklore. Engineer Casey Jones was killed when he rear-ended another train in 1900 — near the end of a double shift. The accident inspired a song, "The Ballad of Casey Jones."
Today's fatigue problem is the result of a variety of developments over the last two decades, say union officials, railroad consultants, company executives and train crew members.
Hiring has not kept pace with a steady increase in rail freight volumes, about 4.4% a year on average since 1991, federal data show.
Corporate mergers and cost-cutting during the 1990s led to staff reductions. In 2002, a change in pension rules led to 12,000 railroad worker retirements, twice as many as the year before.
Since 1990, overall railroad employment has declined more than 25%. Department of Labor statistics show that, until recently, the hiring of engineers has been flat for years.
Railroad unions have at times resisted proposed solutions to the fatigue problem if they threatened to limit the freedom of their members to work long hours and maximize earnings. With overtime and high mileage, salaries for engineers can reach $100,000 a year.
"It is a two-edged sword," said Brian Held, 47, a Burlington Northern Santa Fe engineer for 10 years. "The company wants to save money and doesn't hire what it needs to. Union members don't want the boards so full of workers they can't make the money they want. It makes for a dangerous situation."
Held said that fatigue led to a train collision April 28, 2004, in the Cajon Pass of San Bernardino County, a long, tricky grade that requires constant attention.
Federal records show that both the engineer and conductor of a Burlington Northern Santa Fe train dozed off and struck a Union Pacific train at 5:15 a.m. Five cars derailed.
"There have been four or five fatigue-related incidents up there," Held said. "We're lucky no one was killed."
Interest in fatigue as a safety problem intensified in the mid-1980s, when the NTSB concluded that weary crews contributed to three collisions involving Burlington Northern trains that left 12 dead.
But the railroad industry did not launch a major initiative until two Santa Fe freight trains collided Nov. 7, 1990, in Corona, killing four and causing $4.4 million in damage.
The fiery head-on crash occurred at 4:11 a.m., when a westbound train ignored a stop signal and crept onto the main track from a siding. It collided with an eastbound freight train going about 30 mph.
Crew members on the westbound train tried to run from the wreckage but were consumed by a fireball. The brake operator on the other train was killed; the engineer and conductor suffered serious injuries.
A year later, NTSB investigators concluded that the crew at fault had probably fallen asleep. They noted that engineer Gary Ledoux and brake operator Virginia Hartzell had not slept for almost 27 hours, making them drunk with exhaustion. Conductor James Wakefield had no more than six hours of rest the day before.
Of Ledoux's last 54 shifts, 35 had different reporting times at all hours. The day before the crash, because of a last-minute shift change, Ledoux had only 5 1/2 hours of sleep before guiding a freight train from Los Angeles to Barstow, arriving at 12:40 p.m.
En route to Los Angeles, Ledoux exceeded speed limits 13 times. As he neared Corona, he turned on the cab's dome light and opened the window in an apparent attempt to stay awake.
The Corona accident prompted the formation of the Work Rest Task Force, which stressed a voluntary approach by railroad companies and labor unions to sponsor research and find solutions without government intervention. In 1996, the North American Rail Alertness Partnership was formed. The Federal Railroad Administration also organized related efforts.
Today, a variety of fatigue countermeasures are partially in place or under consideration at the nation's largest railroads, including Burlington Northern Santa Fe, CSX Transportation, Norfolk Southern and Union Pacific.
Some railroads have started voluntary work-rest cycles, though they are not available to most of their freight crews. A typical arrangement is seven days on and three days off. Educational materials are available, crew lodgings at hotels have been upgraded and most major railroads, after years of resistance, now allow short naps for those on duty.
Executives at some companies say they are moving to more regularly scheduled freight service, which can make crew members' hours more predictable.
At Burlington Northern Santa Fe, crew members are entitled to 14 hours of undisturbed rest after working eight hours. At CSX, they can ask for undisturbed rest for up to 10 hours, and fixed work-rest cycles are available at several major hubs.
Officials at all of the nation's largest railroads say they are hiring thousands of engineers and conductors to reduce crew shortages. The companies, which handle about 90% of the nation's rail freight, added more than 4,000 crew members in 2004, a 7% increase over 2003.
The Assn. of American Railroads contends that a voluntary effort is more likely to succeed than a "one-size-fits-all" approach that government regulation would create.
"We have made huge gains by working cooperatively," said Alan Lindsey, general director of safety and rules for Burlington Northern Santa Fe. "We have come a tremendous way as an industry."
Although accidents related to human error are increasing, the railroad association cites federal data that deaths and injuries of railroad workers from accidents are at record lows.
Fatigue "is not what I'd consider a major safety issue at this point, but it is an issue we take seriously," said Robert C. VanderClute, the association's senior vice president of safety and operations.
Industry critics, however, point to Union Pacific, the nation's largest carrier, in asserting that the voluntary approach isn't working.
Understaffing and crew fatigue have persisted at Union Pacific despite the railroad's participation in the Work Rest Task Force.
The largest team of safety inspectors ever assembled by the Federal Railroad Administration descended on Union Pacific in 1997 after five major crashes in eight weeks killed seven people.
Long hours, unpredictable work schedules and train crews that had worked days on end without time off were partly to blame.
Since last May, the Federal Railroad Administration and the NTSB have been investigating seven derailments and crashes involving Union Pacific trains near San Antonio, including the Macdona wreck.
Crew fatigue is suspected in at least two of the accidents.
In December 2003, Union Pacific unsuccessfully sued a group of unionized conductors alleging that they were taking too much time off during weekends and holidays, disrupting commerce along a major Kansas line in violation of the Railway Labor Act.
The United Transportation Union countered that the railroad was severely understaffed in the area and many conductors were exhausted from working for weeks — sometimes months — without a day off.
"We were running with a skeleton crew," said union official Greg Haskin. "Guys were burned out and calling in sick. They were working 12- to 16-hour days up to 90 days straight. You can't expect people to work like that and be safe."
Union Pacific declined to discuss the case.
The company has vowed to add 200 engineers and conductors in the San Antonio area, where the Macdona crash occurred, and 2,500 this year across its vast network.
The company also is experimenting with a two-days-on, two-days-off work-rest cycle for engineers at its giant freight hub in North Platte, Neb.
"Generations have been dealing with this problem," said John Bromley, a Union Pacific spokesman. "There are not going to be any overnight solutions."
Critics say the industry isn't doing enough voluntarily and that further government regulation is needed. But when it comes to combating fatigue, the wheels of reform turn slowly.
Bills requiring fatigue management plans and improvements to the Hours of Service Act have failed repeatedly in Congress since 1998 because of corporate and labor opposition.
Out of frustration, NTSB officials say they recently withdrew their long-standing recommendation for revisions to the act.
Amending the law to reflect modern sleep science had been on the NTSB's "10 Most Wanted List" of safety improvements since 1990.
George Gavalla, who headed the Federal Railroad Administration safety office from 1997 to 2004, said trying to reduce the fatigue problem "was one of my biggest frustrations."
"I'm disappointed we could not accomplish more," he added. "It is a huge safety issue."