Published November 20, 2002
WASHINGTON (AP) - A Michigan train wreck that killed two men last year was caused by the fatigue of two crew members who were suffering from severe sleep apnea, the National Transportation Safety Board said in a report approved yesterday.
Engineer Allen Yash and conductor Jesse Enriquez, who were operating a Canadian National freight train southbound toward Detroit, were diagnosed before the accident with obstructive sleep apnea by their private physicians. Neither had been successfully treated and their conditions were not listed in company medical reports, NTSB's investigation found.
The two men did not slow for a stop signal or the lights of an oncoming train while traveling in a wooded area in Oakland County's Springfield Township just before 6 a.m. on Nov. 15, 2001, the report said. Their train was traveling at 13 miles per hour when it struck another Canadian National train traveling 30 mph northbound for Flint.
The crash killed the 49-year-old engineer, Thomas Landris of Durand, and 58-year-old conductor, Gary Chase of Owosso, of the oncoming train. Yash and Enriquez were hospitalized with serious injuries.
Two nearby schools closed, and some residents were briefly evacuated as a precaution until officials determined no hazardous materials had leaked. The crash spilled about 3,000 gallons of diesel fuel and cost about $1.4 million, according to the NTSB.
Obstructive sleep apnea, or OSA, causes a person to periodically stop breathing while asleep. Dr. Mitch Garber, a physician on the NTSB's investigation team, said people with the condition will feel extremely sleepy during the day and can drift off after a few minutes in a quiet or monotonous environment.
Garber estimated that one percent to two percent of the population has the severe form of OSA.
"It seems odd to have both members of a two-man crew with a similar condition,"said board member John Hammerschmidt.
Steve Jenner, another investigator, said Yash had been diagnosed with the condition about a year before the wreck.
Despite his doctor's warning that it could cause him to fall asleep on the job, he never followed the physician's instructions to attend a sleep clinic.
Enriquez had been diagnosed several years earlier and was treated at a sleep clinic and given an air-pumping mask to wear at night, but he still suffered from sleeplessness and snoring, so Jenner said it may not have been set at the right pressure.
The report also said Enriquez had an irregular and unpredictable work schedule that may have added to his fatigue.
The NTSB recommended that the Federal Railroad Administration develop a standard medical form for railroad companies that would inquire whether operators suffered from sleep conditions.
The board also recommended that the administration require that employees with incapacitating medical conditions tell their employer and stop working in safety-sensitive positions until they are successfully treated.
It also recommended that Canadian National require "fatigue awareness training" for its employees. The company offers its employees material on sleep problems, but does not require they read them or offer any classes on the topic.
Canadian National spokesman Jack Burke said the company will consider the recommendation. "I think their focus was appropriate that this was human error," he said.
Attorney Steven Kantor, who is representing the Chase and Landris families, said fatigue is a problem across the railroad industry because workers are often forced to work long days and the government does not impose stricter restrictions on maximum working hours.
"Everybody knows that sleep deprivation has been a problem and the irregular schedules have been a problem, but it's kind of like a don't ask, don't tell," Kantor said.
"People are aware this is a problem, but no body wants to fix it until there is an accident, unfortunately."