The National Transportation Safety Board (NTSB) has completed an almost three-year-long investigation into an April 28, 2015, train crash in Roswell, New Mexico, and has found that the probable cause of the crash was a fatigued train conductor. It becomes one of several fatal train crashes in recent years linked to overtired workers.
The investigation also found that two of the Southwestern Railroad employees involved in the crash had drugs in their system, though officials will not say for certain if impairment was part of the probable cause for the collision between the two freight trains. Drug use, like fatigue, has been noted in other recent train crashes, leading to concerns amongst safety advocates.
Findings from the NTSB investigation lead the organization to issue a new safety recommendation to the Federal Railroad Administration (FRA), calling for improved technology that might reduce future fatal train crashes under similar circumstances.
Fatigued Conductor Failed to Properly Line a Switch Before Fatal Roswell Train Crash
At the core of the NTSB’s findings was a Southwestern Railroad Roswell Local train conductor who suffered from fatigue and had not properly aligned a switch on the morning of April 28, 2015. The oversight caused a separate Southwestern Railroad freight train to move through the switch and onto a siding track on which a Roswell Local train stood, crashing into it at approximately 6:20 a.m.
Forty-eight-year-old Jesse T. Coburn III, the engineer operating the train that went through the improperly aligned switch, died in the crash. Another employee aboard the train suffered injuries. The Roswell Local train was empty at the time of the Southwestern Railroad crash.
The fatigued train conductor who failed to properly align the switch later told a manager of his mistake. It was the main reason, according to the NTSB, that the crash occurred, but the fact that the train crew on the incoming train did not realize the switch was misaligned and stop the train was also a contributing factor. This begs the questions: what warnings did the crew have, either in the cab or along the right of way, that the switch was out of position? If they had adequate warnings, why were they not heeded?
Train Employee Toxicology Testing Finds Marijuana, Oxycodone and Oxymorphone
Another interesting—and concerning—finding was that two of the train crew members had drugs in their systems at the time of the Southwestern Railroad crash.
Post-accident toxicological testing was performed on the dispatcher on duty, the conductor and Coburn, the deceased engineer, according to the report. The testing found that only the dispatcher did not have any drugs in his system.
Coburn had “significant levels of tetrahydrocannabinol,” and both rolling papers and pipes were found in the locomotive cab. Investigators determined that he had likely smoked marijuana “between 30 minutes and five hours before the accident,” and that, since he had been on duty for nearly 10 hours, had both used marijuana while on duty and been under its influence while serving as the train’s engineer. Investigators hesitated to say whether that slowed his response to the misaligned switch.
Toxicology results from the conductor revealed the presence of both oxycodone and oxymorphone, but the report does not say whether the conductor had a prescription for those medications. It does go on to say that he was likely not impaired at the time of the crash.
Fatigue and Drug Use Cited as Factors in Other Recent Train Crashes
The NTSB’s findings have been unfortunately common in the last few years, with growing concerns about the use of drugs among train crews and of fatigue issues including long shifts and undiagnosed sleep apnea.
Both a January 2017 Long Island Railroad crash in Brooklyn and a fatal September 2016 New Jersey Transit crash in Hoboken were ultimately linked to engineers suffering from undiagnosed sleep apnea. Plans were underway to federally mandate sleep apnea testing for train engineers and truck drivers, but, in August of 2017, the government did away with the idea. The decision angered many safety advocates, who said putting the responsibility on individual companies to decide to test is not enough to protect passengers.
Meanwhile, officials discovered that the engineer involved in an April 2016 Amtrak crash in Chester, Pennsylvania, had marijuana in his system when the crash happened. Two men who had been working on the railway with a backhoe that the Amtrak train hit, died. They were also discovered to have drugs in their systems, in the form of cocaine, codeine, oxycodone, and morphine.
NTSB Issues New Safety Recommendation to Federal Railroad Administration
In light of the Southwestern Railroad crash investigation, the NTSB has made a new safety recommendation to the FRA, asking that they:
Require railroads to develop a device or technique to eliminate the possibility of employees failing to perform critical tasks such as lining a switch, lining a derail, or ensuring cars are in the clear.
They also reiterated a safety recommendation that the FRA:
Require the installation, in all controlling locomotive cabs and cab car operating compartments of crash- and fire-protected inward- and outward-facing audio and image recorders capable of providing recordings to verify that train crew actions are in accordance with rules and procedures that are essential to safety as well as train operating condition.
The lack of such technology on the Southwestern Railroad trains prevented investigators from seeing what actions (appropriate or not) the crews took before the crash, and even to verify who was serving in what capacity when the collision happened.
Positive Train Control Deadline Looming, Many Expected to Fail to Meet It
The technology exists, and has existed for decades, to do what the NTSB wants. Positive Train Control (PTC) uses radar and track sensors to enable computers to step in and control a train if the operator fails to properly do his job. Experts believe many collisions and derailments could be prevented by eliminating some of this potential for human error.
The system is so promising, in fact, that Congress issued a mandate requiring railroads to begin installing and using PTC, but the deadline to do so has been pushed back several times. It is now scheduled for December 31, 2018, but a recent report found that the vast majority of railroads are likely to fail to meet even that much-extended date.