Wednesday, April 11, 2018

NTSB cites fatigue in Roswell, N.M., accident

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NTSB cites fatigue in Roswell, N.M., accident NTSB

The National Transportation Safety Board (NTSB) named fatigue as the probable cause of a 2015 accident between two Southwestern Railroad trains in Roswell, N.M., that left one engineer dead and a conductor seriously injured.

The accident, which also derailed 11 locomotives and three empty hopper cars, occurred when a westbound Southwestern Railroad train traveled through a switch left in the reverse position at the east end of the Chisum siding and collided with Southwestern Railroad's Roswell Local, which was standing in the siding.

NTSB said not only did the fatigued conductor of the Roswell Local train fail to properly align the switch, but said the striking train crew's failure to perceive the misaligned switch in nonsignaled territory contributed to the accident.

Based on the results of its investigation the NTSB issued one new safety recommendation to the Federal Railroad Administration (FRA) 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.

"A train is an enormous machine that can injure or kill people, damage property or harm the environment," said NTSB Chairman Robert Sumwalt. "Given the stakes, image and audio recorders belong in train cabs. Yes, they help investigators but they also can help railroads ensure safer operations."

The NTSB's report reiterates three recommendations to the FRA including one requiring the installation of technology to warn trains of incorrectly lined main track switches and two addressing the installation of recorders to capture the actions of the crew.

NTSB explained the lack of inward-facing cameras in the locomotive prevented it from determining the actions of the crewmembers while operating the train, or even which crewmember was operating the train just prior to the accident.

While impairment is not considered a factor in the accident's probable cause, being able to view the actions of the crewmembers would have been helpful as the post-accident toxicological testing identified significant levels of tetrahydrocannabinol (THC) in the striking engineer's results.

NTSB said that the toxicological results along with the presence of rolling papers and pipes in the locomotive cab suggest the engineer smoked marijuana between 30 minutes and five hours before the accident, and, because the engineer had been on duty for almost 10 hours, he likely used marijuana while on duty and likely was under its influence while operating the train. NTSB could not, however, determine if the THC in the engineer's system affected his response to the misaligned switch.

The dispatcher on duty's test results were negative for drugs and alcohol and the Roswell Local conductor's results were positive for medications administered during his medical care and for oxycodone and its metabolite, oxymorphone, however, the results indicate the conductor most likely was not impaired at the time of the accident.

NTSB notes that FRA data shows the positive rate for post-accident drug testing declined in 2017 to 1.2 percent from 4.2 percent in 2016.