SCOTT COUNTY, MO (KFVS) - Fatigue was the likely cause of a catastrophic train crash in Scott County in May 2013. That's according to a report just released by the National Transportation Safety Board.
In a 50-page report, NTSB investigators conclude: "The probable cause of the accident was the failure of the Union Pacific Railroad train crew members to comply with wayside signals leading into the Rockview Interlocking as a result of their disengagement from their tasks likely because of fatigue-induced performance degradation."
The report states that on May 25, 2013, a BNSF railway freight train was moving through the Rockview Interlocking when the Union Pacific train struck the twelfth car behind the engine of the BNSF train causing 13 cars to derail and the two locomotives and 11 cars of the Union Pacific train to derail. The derailed cars struck the Highway M bridge supports and caused portions of the overpass to collapse.
Two vehicles that attempted to cross the bridge after the derailment crashed into the collapsed bridge span resulting in injuries to five occupants in two different vehicles.
The NTSB investigated the cause of the collision that resulted in an estimated $11 million in damage, finding crew fatigue a major factor.
The report states the Union Pacific train passed four signals within 3.7 miles telling the crew to slow and stop the train. Investigators say the train continued at 50 mph failing to follow the signals. Some of the signals included flashing lights that were found to have been operable at the time of the crash.
NTSB investigators learned that both of the Union Pacific crew members had been working erratic shifts in the days leading up the crash. On the day of the collision, the conductor of the train had been working a double shift which likely contributed to his fatigue.
The report also states that the Union Pacific train engineer had no memory of the crash or the minutes or hours leading up to it. The first thing he told investigators he remembered was "waking up" when the conductor shook him to get him out of the locomotive after the crash.
The report also examines the health condition of the engineer sighting issues of undiagnosed obstructive sleep apnea as a possible cause of fatigue that led to the crash.
The NTSB report states that the biggest safety challenge is human error, and that the installation of a positive train control system in the locomotive that take control of a train when crew members fail to follow signals would have prevented the crash entirely.
The report finds several things were not factors in the crash. The NTSB says both crew members were qualified, the train's mechanical systems were all in working order, the signal systems were functioning normally, crew members were not using portable electronic devices that could have distracted them and there was no alcohol or drug use by either Union Pacific crew member that could have contributed.
NTSB investigators recommend that the Federal Railroad Administration develop and use a standard medical evaluation form that includes questions regarding sleep problems to determine medical fitness for locomotive engineers. Investigators say had the engineer been found at high-risk of sleep disorders the crash may not have occurred.