(The following column by Ken Rodriguez appeared on the San Antonio Express-News website on July 9.)
SAN ANTONIO, Texas — Fatigue, no doubt, played a pivotal role in the deadliest train wreck in Bexar County history.
Federal investigators say a crew aboard a Union Pacific train probably fell asleep.
Investigators also say UP failed to properly manage the schedules of its crew members, assigning them long shifts and erratic hours, making it difficult for them to get ample rest.
So who was more asleep: the nation’s largest rail carrier or the crew itself?
Two years after a derailment and toxic spill claimed five lives, Union Pacific isn’t saying much.
The company line is UP will wait until it reviews the National Transportation Safety Board’s full report.
Plenty of UP crewmen haven’t reviewed the report, either. But here’s what they’ve been saying for years: “We struggle to stay awake.”
Human error is a common cause of train accidents. Sleep deprivation is often behind such error. Ask any veteran engineer or conductor if they’ve ever nodded off. The honest ones often can’t recall how many times.
“In about one out of every four accidents,” says one recently retired engineer, “somebody falls asleep.”
A current crewman once told me, “There’s not an engineer out here who hasn’t fallen asleep.”
He recalled telling his wife: “I’m dreading going to work tonight. I’m afraid I’ll fall asleep and kill myself or kill somebody.”
That’s not an uncommon fear. No wonder federal investigators chastised UP in their accident report. NTSB acting chairman Mark Rosenker said: “It just seems amazing to me that we still, at this point in time, don’t have better management of employees’ schedules.”
UP engineer Art Cadena survived the accident. His fellow crewman did not. Was Cadena sufficiently rested the day of the crash?
In a Washington hearing last year, the following timeline was released: On the Friday before the accident, which was on a Monday, Cadena started work at 5:50 a.m. He finished at 4:15 p.m.
Less than 10 hours later, he resumed work at 2 a.m. and was released Saturday at 3:30 p.m.
Eight hours after that, he was back on the job. Cadena finished at 12:30 p.m. on Sunday, then returned at 2:45 a.m. Monday, the morning of the crash.
The Federal Railroad Association says Cadena was legally rested. FRA’s defense may hold up according to guidelines, but it crumbles before common sense.
In its report, the NTSB recommended the crash be used “as a case study in fatigue awareness training.”
Who was sleeping on the tracks?
The accident report contains striking contradictions. No crew member hit the brakes, but someone shifted the engine throttle. Nobody honked the horn when the train crossed two roads, but someone honked three times 40 seconds before the crash.
“We’ll never truly know what happened there,” says Russell Elley, vice chairman of the Brotherhood of Locomotive Engineers and Trainmen.
More would be known if voice recorders had been on the train. But the FRA rejected voice recorders in 2003. Too expensive, the association said.
The only crew member to survive the wreck remembers little. Two years ago, Cadena shared the few details he could remember with friends. Those friends passed them along to me on the condition they not be identified.
“Art told us that what he remembered was he honked the horn at the other train — three honks, that’s his trademark,” one friend said. “And the next thing he knows, they started hitting the other train, sparks started flying, and they rode the whole thing out.”
That recollection — provided to me in 2004 — squares with the NTSB report of three honks just before the crash. So how could Cadena be asleep and honk three times?
One possible explanation is that he dozed, only to be startled awake in time to sound warnings. Cadena’s lawyer rejects that theory. He says Cadena never fell asleep.
Cadena’s work schedule shows he wasn’t fully rested. Ditto for the second crewman, Heath Pape. And the train did speed past two warning signals at 45 mph before crashing.
Somebody somewhere wasn’t fully alert. But who carries more blame — the crew or Union Pacific for poorly managed work schedules?
The answer may have vanished in a haze of chlorine gas.