In their report, NTSB investigators said they believed the conductor was too sleepy, startled or disoriented after he awoke to realize he needed to apply the brakes. They suggested a mechanical system that could sense an engineer’s lack of movement and rouse him in enough time to avert a crash.
No such system has been implemented.
Former NTSB managing director Peter Goelz said that under railways’ seniority system, veteran engineers get to select their schedules first and often choose to pack more hours into the workday so they can have more days off.
“They’re the guys with seniority, who are older, generally overweight, generally with health problems, generally with stuff going on in their lives,” Goelz said. “It’s exactly the wrong people you want on duty at that time.”
In the maritime industry, the NTSB has issued 21 fatigue-related recommendations. Nearly half have not been followed.
One of these is a 1988 recommendation that called for the U.S. Coast Guard to establish watch and duty time limitations for crew members on board ferries and other inspected passenger vessels.
Seven years after that recommendation was issued, a cruise ship ran aground off the Alaskan coast after its pilot erred while trying to guide the ship over a well-known and charted rock just before 2 a.m. Although he had been on duty for less than two hours, the pilot hadn’t slept longer than five-and-a-half hours the previous day.
When the entire vessel shuddered from the impact of hitting the rock, the pilot didn’t immediately realize the error.
“Under normal conditions, such an experienced pilot should have immediately deduced that he had not safely passed Poundstone Rock when he felt the vessel shudder,” the NTSB said. “A fatigued pilot, however, might not be sufficiently alert to realize that he had grounded.”
The pilot, who was later diagnosed with severe sleep apnea, suffered from “chronic fatigue,” according to the NTSB report.
Fatigue at sea can be a result of having no escape from the workplace.
“A lot of these crews, when they’re on watch, when they’re working, they’re on the vessel,” said David Deaver, a safety analyst at the U.S. Coast Guard’s investigations division. “When they’re done … they’re still on the vessel. They work and reside and live at this same place.”
Lack of Action
Virtually everyone — scientists, lawmakers, industry executives, safety advocates and even operators themselves — says that fatigue is an issue ripe for more attention.
“We’ve got enough evidence on fatigue now so we know how the human body responds broadly,” said Goelz, the former NTSB managing director. “We should be able to regulate and operate based on scientific evidence.”
But the regulatory process sometimes allows proposals to languish in bureaucratic purgatory, with no real action for decades, if at all.
Gerald Dillingham, director of civil aviation issues at the Government Accountability Office, published a report in 2001 that detailed the inefficiency of the FAA’s rulemaking. The report stated that between 1995 and 2000 the FAA completed 29 major rules, each averaging about 2.5 years, but six rules took 10 years or more to complete.