Federal investigators on Tuesday blamed the Chicago Transit Authority for failing to prevent employee fatigue that they said was a factor in last year’s Blue Line crash that sent a train into an escalator at O’Hare International Airport.
The National Transportation Safety Board issued their findings and recommendations and approved a final report into the incident at a public meeting in Washington D.C.
“The layers of protection designed to protect such an accident failed,” Christopher Hart, chairman of the National Transportation Safety Board, said Tuesday at a hearing in Washington.
The Chicago derailment happened just before 3 a.m. on March 24, 2014, when the driver, Brittney Haywood, was on her 12th straight day of work. The Blue Line train she was driving did not slow down as it approached the dead-end center track at the O’Hare station. The runaway train jumped over a bump-stop designed to stop trains at speeds up to 15 mph — though the track’s speed limit was 25 mph, according to the NTSB. It then continued onto the platform and into an escalator. More than 30 passengers were hurt.
The NTSB issued several recommendations, including that the CTA install a transmission-based control system on all routes; such a system would automatically brake in times of emergency. The agency’s recommendation was extended to all transit agencies in the U.S. The agency also wants upgraded “event recorders” on each CTA car; those devices save certain information, such as the position of the controls, that investigators might want to know after an accident.
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Federal investigators also recommended the Federal Transit Administration develop work scheduling programs that take into account the science of fatigue and include evaluation of the risks of fatigue. The federal agency found Haywood “was likely sleep-deprived,” though a CTA spokesman on Tuesday said she was not “exhausted.”
Staff investigators for the NTSB said their investigation showed the middle track did not appear to have been originally intended to be used for arriving trains but had become commonly used for that purpose. That center track’s design, the NTSB found, “was not adequate to prevent a train from striking the bumping post near the end of the track.”
The NTSB found Haywood was experiencing the effects of “cumulative sleep debt” and was impaired by fatigue because of several factors. They included the challenges of her shift and what it called “her ineffective off-duty time management” — in other words, she didn’t rest enough during her time off.
“Chicago Transit Authority failed to effectively manage the operator’s work schedule to mitigate the risk of fatigue,” the NTSB said.
Since the crash, which sent 33 to hospitals, the CTA has implemented several changes, including lowering the speed limit of trains entering the station and moving the fixed trip stops — which halts trains manually when needed — further back.
Brian Steele, CTA spokesman, said the CTA is just learning of the federal recommendations for a transmission-based train control system. He said it’s too soon to know how that technology can be incorporated into CTA’s existing track and signal system.
The current system cuts the power to a train if an operator is speeding near a station: “If a train is exceeding that 15 mph, the system will stop the train. The signal system will stop the train.”
“That’s our existing system. The existing system that we had worked very well for decades. This March 24 incident was a combination of factors that hadn’t been seen before . . . the system worked but the trip arms were too close to the end of the platform.”
Since then the CTA has moved the trip arms back, so trains will be forced to stop much sooner.
The transit agency has also implemented several new employee scheduling policies.
“The CTA of course made numerous changes. We now have some of the most stringent scheduling guidelines among major U.S. transit agencies,” Steele said. “We have a 12-hour work limit, a minimum of 10 hours between shifts and are requiring one day off every seven days and a limit of real operating hours for employees with less than a year experience.”
Steele said the driver had 18 hours off before her shift in which the accident occurred and that she indicated she had between 8 to 9 hours of sleep.
“[There was] nothing about her shifts and her performance that suggested that fatigue would have played a role in this incident, but clearly it did,” Steele said.
Steele said the train in the crash had an event recorder on its underside, which was damaged in the crash. The other cars had event recorders that functioned. He said the CTA has modern event recorders on all its newer cars, which will replace the 500 old rail cars that are still in service by next year. The CTA will not install new event recorders on the old cars, but instead will switch them out with the more recently purchased 5000 or 7000 series cars, which are equipped with the new recorders, he said.
The CTA fired Haywood shortly after the crash, which was estimated at causing $9.1 million in damage.
An attorney for four people injured in the crash applauded the NTSB’s findings.
“Sadly, it often takes a disaster of some type to institute change. Thankfully, there were no deaths or catastrophic injuries that occurred in this case, but it did result in the NTSB recommending changes that, if instituted, could save many lives and other people from serious injuries,” attorney Jerry Latherow said in a statement.
Contributing: Associated Press
NTSB to Meet on 3/24/2014 Chicago Transit Authority Accident today at 9:30 am http://t.co/pxt4qkeNiN— NTSB (@NTSB) April 28, 2015
NTSB offers 11 adopted findings on how CTA can improve safety and equipment practices http://t.co/MqXcbtcqxL— Craig Newman (@craignewman) April 28, 2015
NTSB: probably cause is operator fatigue, CTA failure to mitigate fatigue and recognize viable stopping distance http://t.co/MqXcbtcqxL— Craig Newman (@craignewman) April 28, 2015
NTSB unanimously adopts report and findings in cause of CTA Blue Line derailment at O'Hare http://t.co/MqXcbtcqxL— Craig Newman (@craignewman) April 28, 2015
NTSB: There is no place in the US for a train operator falling asleep on the job http://t.co/MqXcbtcqxL— Craig Newman (@craignewman) April 28, 2015