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NTSB Says Crew's Failure to Comply With Signals Caused Train Collision in Mississippi; Fatique A Possible Factor

Washington, D.C.- The National Transportation Safety Board today determined that the probable cause of a fatal train collision was the failure by the crew to comply with wayside signals requiring them to stop at North Anding. The crew's attention to the signals was most likely reduced by fatigue, the Board said, although other factors cannot be ruled out.

" This was an accident that could have been prevented," said NTSB Chairman Mark V. Rosenker. "We will continue to promote and reiterate the importance of having positive train control on our railroad system."

On July 10, 2005, two CN freight trains collided head on in Anding, Mississippi. The collision occurred on the CN Yazoo subdivision where the trains were being operated under a centralized traffic control (CTC) signal system on a single track. Signal data indicated that the northbound train continued past a stop (red) signal at North Anding and collided with the southbound train about ¬ mile beyond the signal. The collision resulted in the derailment of 6 locomotives and 17 cars. About 15,000 gallons of diesel fuel were released from the locomotives and resulted in a fire that burned for about 15 hours. There were two crewmembers on each train and all four were killed.

The Board stated that the northbound crew should have been able to see an approach signal and would have had ample time to slow down the train on the main track and be prepared to stop at the next signal. There was no indication that the northbound train slowed or that brakes were applied.

As part of its accident investigation, the Safety Board examined the work/rest cycles of the northbound train crew based on CN records and interviews with family members. A regularly deficient amount of sleep can impair human performance and alertness. Based on a review of the crew's 72-hour work/rest history prior to the accident, and the crew's previous 5-day work schedule, the Board believes that the train crew's short sleep periods likely led to their developing a cumulative sleep loss, or sleep debt. Sleep debt occurs when an individual does not obtain sufficient restorative sleep over time.

In previous accidents, the Safety Board has determined that crewmembers were inattentive to signals due to human factors other than fatigue, including distraction. In this case, the Safety Board concluded that the northbound train crew's attention to the signals was most likely reduced by fatigue; however, without a locomotive cab voice recorder or availability of other supporting evidence, it cannot be determined whether distraction or some other factor also contributed to the crew's failure to comply with the signals.

Contributing to the accident was the absence of a positive train control (PTC) system that would have stopped the northbound train before it exceeded its authorized limits. PTC technology is a safety redundancy that can prevent train collisions and overspeed derailments, when train crewmembers fail to follow signal indications.

The Safety Board has investigated many train collisions that could have been prevented through the deployment of a PTC system. Therefore, the Board concludes that had a PTC system been in place at Anding, it would have intervened by slowing and stopping the northbound train when the crew did not respond to the signals.

Also contributing to the accident was the lack of an alerter on the lead locomotive that may have prompted the crew to be more attentive to their operation of the train. Had the crew been incapacitated or not responded to an alarm, the alerter would have automatically applied the brakes and brought the train to a stop. The Board concludes that had an alerter been installed on the lead locomotive of the northbound train, it may have prevented the collision.

As a result of it's investigation, the Safety Board made recommendations to the Federal Railroad Administration, the Pipeline and Hazardous Materials Safety Administration, the Occupational Safety and Health Administration, CN and all Class I Railroads. Among the 8 recommendations are the following:

• That the FRA require railroads to ensure that the lead locomotives used to operate trains on tracks not equipped with a positive train control system are equipped with an alerter.
• That the FRA assist the Pipeline and Hazardous Materials Safety Administration (PHMSA) in developing regulations to require that railroads immediately provide to emergency responders accurate, real-time information regarding the identity and location of all hazardous materials on a train.
• That PHMSA require and verify that States and their communities that receive funds through the Hazardous Materials and Emergency Preparedness grant program conduct training exercises and drills with the joint participation of railroads and other transporters of hazardous materials operating within their jurisdictions as a means of evaluating State, regional, and local emergency hazardous materials response plans.
• That the CN develop and implement a positive train control system that includes collision avoidance capabilities on main line tracks, establishing priority requirements for high-risk corridors such as those where passenger trains operate.

A synopsis of the Board's report, including the probable cause and safety recommendations, is available on the Board's website, www.ntsb.gov, under "Board Meetings." The Board's full report will be available on the website in several weeks.

NTSB Media Contact:
Keith Holloway
(202) 314-6100
hollowk@ntsb.gov

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