NTSB has released to the press and the public its docket on the December 1, 2013 derailment of Metro-North Railroad train 8808 at Spuyten Duyvil.
The docket is the "jacket" containing the documents, analysis, investigations, interviews that NTSB has established to this point in its inquiry in to the accident.
This was transparently a human factors incident. It was known to be a human factors caused accident within hours of its occurrence; actually within minutes, once you either were unfortunate enough to see the derailment in person, or observe photographs of the derailment.
As a consequence of this painfully evident cause, two documents are of particular interest to me: 1) the operational tests of the locomotives engineer's skill, efficiency and rules compliance conducted by the railroad's supervisor in the months prior to the accident and 2) the after incident medical report on the fitness of the locomotive engineer to discharge properly safety-critical obligations of controlling the speed of a train.
As for the first document, the record of tests performed, it comes as no suprise, but as a rather pointed indictment of the railroad's supervision that in 13 months prior to the accident, the locomotive engineer was observed and tested a total of 122 times and yet only one, 1, of those observations was of the individual complying with the authorized speed for a section of track. Only one. In 13 months.
What after all, is a locomotive engineer's singular, defining responsibility? It is to properly control the speed of his/her train.
Why are cell phones banned? Because the use of cell phones will interfere with the locomotive engineer properly controlling the speed of the train.
Why is the use of drugs and alcohol prohibited? Because such use interferes with the judgment necessary to control the speed of the train.
Why are locomotive engineers selected, trained, qualified, and licensed if you are not going to test them on the purpose of the training and licensing-- which is to control the speed of the train?
What is the point of testing an engineer if you don't, or won't, test that? There is none.
The NTSB's medical report is significant for it concludes, not with regard to the specific accident, but with regard to the fitness of the employee: "Post accident testing made an additional diagnosis of severe obstructive sleep apnea. No screening or evaluation for this diagnosis had been performed by any of his medical care providers prior to the accident."
A tragedy for sure. How could anyone have known? How could he have known? What a shame. Something that could happen to any human being. It snuck upon on him, and the railroad, without anybody's knowledge, right?
Nope, not right. Not hardly. Not even close. Sleep apnea is a common enough disorder; common enough that effective therapies have been developed. These therapies are available for use at home. These therapies can minimize the dangers, both medical and operating, that sleep apnea poses to those who drive cars, operate heavy equipment, or move locomotives.
Sleep apnea is so common that to think that locomotive engineers as a group would somehow be exempt from this malady is worse than ignorance, worse than stupidity. It's deliberate denial.
FRA is neither ignorant, nor stupid; nor does it engage in deliberate denial. For twenty years FRA has been urging, prodding, demanding that railroads develop programs that account for and mitigate employee fatigue. Sleep disorders are part of managing fatigue.
As a matter of fact in 2006, the Rail Safety Advisory Committee accepted as task 6-03 the charge from FRA to develop medical standards for assessing the fitness of those in safety-critical positions to actually perform those safety-critical functions, like controlling the speed of the train.
2006. That's before Chatsworth; before the RSIA of 2008; before Lac-Megantic; before crew consist; before securing a train; before Risk Reduction and Critical Incident. 2006. And?
And so where are we now? Where are we since June 25, 2009 when FRA's administrator Szabo told the RSAC meeting that railroads alone among the commercial modes of transportaton lacked a medical standard for determining the fitness of individuals to perform in safety-critical positions?
Well, a funny thing. Five years later, we're still about in the same place. A Medical Standards Working Group was formed (and might even still exist, although I can't find any record of presentations made by the MSWG in the RSAC minutes of its meetings since December 2011).
The Medical Standards Working Group was not able, you see, to reach consensus among its participants, which means frankly speaking, consensus between labor and railroad management. Going back to 2008, there was a recognition of no-census and so the MSWG handed back to FRA the matters upon which it could not reach consensus.
The MSWG went forward with the other work, including establishing a Physician's Task Force (PTF) to develop medical guidelines for the assessment of such disorders that can cause sudden incapacitaton. And what was/is number 1 on the doctor's list of disorders that can cause sudden incapacitation? Sleep apnea, you say? Correctomundo, buzzcock. You win the Jeep Wrangler, and the trip to Bermuda and the GE Frost Free Refrigerator Freezer with the built in ice dispenser.
(Here's some help for keeping track of this daisy chain of acronyms for committees, departments, administrations, working groups and task forces: DOT>>>FRA>>>RSAC>>>MSWG>>>PTF)
And? And nothing. The parties apparently are still at an impasse, unable to reach consensus, and FRA values consensus, at least in this case. We might say it overvalues consensus in this case because FRA has not taken upon itself to issue a NPRM on this issue of employee fitness; has not, to my knowledge prepared a draft of a NPRM on this issue to help persuade the parties to achieve consensus.
Is this a complicated issue. Yes. No. Yes it's complicated. No, it's not so complicated that guidelines cannot be established. After all, other commercial modes of transportation have established medical standards.
Moreover, FRA has demonstrated, and quite recently, that it certainly can move quickly when it is inclined to. In 2013 FRA convened the RSAC in an emergency meeting after the catastrophe at Lac-Megantic, Canada. FRA charged, and RSAC accepted the task of mandating crew size for trains as a mechanism to prevent the repetitition of this tragedy.
Back then FRA told the RSAC that "from the beginning FRA believes safety is enhanced through the use of multiple person crews...The starting point for our discussion is mandatory multiple person crews."
FRA also stated "while we believe that multiple person crews enhance safety and eliminate risk from our vast rail network, we also believe that there are instances in which multiple person crews may not be necessary. The starting point...is to identify what those exceptions might be."
Now that's what I call complicated, because you see the the landscape of US railroads is littered, literally, with the wreckage of trains where multiple person crews were in the operating cabs of the locomotives. There is not that much data about single person crew accident rates.
Now if there was any, any such evidence, I would expect FRA to extend and expand its "2nd person on the head end when a speed change is approaching" requirement in EO 29 to all railroads. It has not.
Without the data there was no basis for the RSAC to establish consensus on this question. In this instance, however, despite the lack of data regarding comparative safety of multiple and single person crews, despite the lack of consensus in the RSAC, FRA has announced that it will go forward with the rule-making by itself.
So...hmmm. This makes me go hmmm........and hmmm....and huh. Huh? Sleep apnea is a known condition with known risks. No action, apparently. Single person operating crews? Unknown risks, unassembled data. Quick action......hmmm....... makes me wonder...
Makes me wonder why, when the person in the safety-critical position is a risk to himself and others because of a medical condition for which there is testing and treatment, neither FRA nor the labor organizations are demanding testing for this disorder, proper treatment for those who are afflicted with this malady, and documentary evidence of the person's continued adherence to the therapy regimen.
Makes me wonder when there are no demands from the unions; no NPRM from FRA; no open letters from NTSB; no EOs; no deep dives; no belly flops; no press conferences; no newspaper articles; no nothing.
Railroad management has the responsibility for determining the guidelines of employee fitness. No other group has the obligation or the will. . Those who don't like that should feel free to seek other employment.
How many thousand of my poorest subjects
Are at this hour asleep!
O sleep, O gentle sleep,