CITIES: UNITED STATES: BOSTON, MASSACHUSETTS : TRANSPORTATION: DISASTERS: NTSB Cites Human Fatigue and Positive Train Control in 2008 Trolley Collision that Killed One

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CITIES: UNITED STATES: BOSTON, MASSACHUSETTS : TRANSPORTATION: DISASTERS: NTSB Cites Human Fatigue and Positive Train Control in 2008 Trolley Collision that Killed One

David P. Dillard
Administrator


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CITIES: UNITED STATES: BOSTON, MASSACHUSETTS :
TRANSPORTATION: DISASTERS:
NTSB Cites Human Fatigue and Positive Train Control
in 2008 Trolley Collision that Killed One



NTSB Cites Human Fatigue and Positive Train Control
in 2008 Trolley Collision that Killed One
FOR IMMEDIATE RELEASE: July 14, 2009
SB-09-37
<http://www.ntsb.gov/Pressrel/2009/090714a.html>



WASHINGTON, D.C. - The National Transportation Safety Board today
determined that the two-train collision on the Massachusetts Bay
Transportation Authority (MBTA) Green Line last year occurred as a result
of the trolley operator's failure to obey a signal indication likely
because she became disengaged from her environment consistent with
experiencing an episode of micro-sleep. The lack of a positive train
control system, which would have intervened to stop the train and
prevented the collision, was cited as a contributing factor.

At 5:51 PM EDT, on May 28, 2008, an MBTA Green Line train, traveling
westbound at about 38 mph, struck the rear of another westbound Green Line
train, which had stopped for a red signal. The operator of the striking
train was killed; three other crewmembers sustained minor injuries. Of the
185 to 200 passengers who were on the two trains at the time of the
collision, four sustained minor injuries and one was seriously injured.
Total damages were estimated to be about $8.6 million.

Post-accident toxicological testing indicated that the operator of the
striking train had recently taken the drug doxylamine, commonly found in
sleep aids, suggesting that she had trouble sleeping during at least one
of the nights leading up to the accident.  In addition, the operator had a
high body mass index (BMI), which is closely correlated with a higher risk
for sleep apnea, increasing the likelihood of a fatigued condition during
waking hours.

NTSB Acting Chairman Mark V. Rosenker highlighted the role a positive
train control system could have played in preventing the accident.
"Again, we've seen a situation where a positive train control system could
have prevented a tragic accident," said Rosenker. "We know that because
operators or equipment sometimes fail, redundancies like PTC systems can
be the difference between a fatal accident and an incident report. And
this is why we feel so strongly that transit systems like MBTA's should
have that crucial extra layer of safety that a PTC system provides."

Because the Safety Board concluded that the accident could have been
prevented had the MBTA been equipped with a positive train control system,
the NTSB recommended to the Federal Transit Administration that the agency
facilitate the development and implementation of positive train control
systems for rail transit systems nationwide.As a result of its
investigation of a transit system accident in Maryland in 2000, the Safety
Board recommended in 2001 that MBTA establish a fatigue awareness program
to addresses potential sleep disorders among its train operators.  While
the MBTA indicated that they had established and implemented such a
program, the Safety Board determined that their efforts were inadequate
and reiterated that safety recommendation.

In addition, the NTSB recommended to the Federal Transit Administration
(FTA) that they develop and disseminate guidance for operators, transit
authorities, and physicians regarding the identification and treatment of
individuals at high risk for obstructive sleep apnea and other sleep
disorders.

The Safety Board recommended to MBTA that train operators be required to
notify fellow crewmembers when a restrictive signal is encountered, and
the intended means of complying with the restriction.

And because MBTA operating rules do not require train operators to report
signals displaying red when the track is visibly clear, the NTSB has
concluded that this could allow possible problems in the signal system to
remain undetected and unrepaired, which could increase safety risks. Thus,
the Safety Board recommended to MBTA that train operators immediately
report all red signals they encounter when the track governed by that
signal can be seen to be clear of other trains.




A summary of the findings including the Board's report is available on the
NTSB's website at


<http://www.ntsb.gov/Publictn/2009/RAR0902.html>



The entire accident docket is available at


<http://www.ntsb.gov/Dockets/Railroad/DCA08MR007/default.htm>



NTSB Media Contact: Peter Knudson (202) 314-6100
[hidden email]





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David Dillard
Temple University
(215) 204 - 4584
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