Sad news: 2nd Washington Metro Track Inspector Dies

By Celeste Monforton

The transit workers in the Washington, DC region are suffering another loss. Matthew Brooks, 36, succumbed to the injuries he suffered after being struck by a Metro train on November 30. His fellow track inspector, Leslie Cherry, 52, died on the day of the accident. As the NTSB Chairman remarked, these deaths are unacceptable.

When the Washington Metro Area Transit Authority Board convenes next week for their monthly meeting, members of ATU Local #689 plan to make their voices heard. On the day of the meeting, they have a Safety Rally planned for the steps of WMATA headquarters. The message: Their lives are on the line. Mr. Brooks' and Mr. Cherry's families truly know that tragic fact.



SAFETY RALLY!

Thursday, December 14, 2006 11 a.m.
Metro Board Meeting
Jackson Graham Building
600 5th Street NW
Washington, DC

Time to send management a message: Too many injuries and deaths!

Bush's Highway Deregulation Kills

It's gotten to be an old story in this administration -- industry contributions flowing to Republican candidates, government oversight agency filled with appointees from the industry its supposed to regulate, relaxed regulations and continuing, but preventable deaths.

It's a familiar story, but it bears retelling over and over again, and Steve Labaton of the NY Times has done a masterful job describing how deregulation of "America’s most treacherous industry" -- the trucking industry -- has increased danger on the nation's highways. Almost 5,000 large trucks were involved in accidents in 2005, killing over 5,000 people -- both workers and "innocent" drivers and passengers. The direct cause of most of the accidents is driver fatigue.

But as Labaton points out, despite pleas to reduce the number of hours that fatigued truckers can spend behind the wheel, the Bush administration, caving in to lobbying and contributions from the trucking industry, actually rejected proposals to tighten drivers’ hours and instead relaxed the rules on how long truckers could be on the road.

The trucking industry is, of course, delighted; industry safety experts not so much:

But advocates of tighter rules say the administration’s record of loosening standards endangers motorists. The fatality rate for truck-related accidents remains nearly double that involving only cars, safety and insurance groups say. They note that weakening the rules has reversed a course set by the Clinton administration and has resulted in the federal government repeatedly missing its own targets for reducing the death rate.

“It is a frustrating disappointment that has led to a tragic era,” said David F. Snyder, an assistant general counsel at the American Insurance Association who follows the trucking industry closely. “The losses continue to pile up at a high rate. There has been a huge missed opportunity.”

In fact, the Bush administrations cave-in to industry influence was so egregious that even a Republican-appointed judge was appalled:

In July 2004, a three-judge panel from the federal appeals court in Washington issued a harsh opinion in a lawsuit brought by several safety organizations over the trucking work rules.

Judge David B. Sentelle, a conservative Republican appointed by President Ronald Reagan, wrote the opinion, faulting the Federal Motor Carrier Safety Administration for “ignoring its own evidence that fatigue causes many truck accidents.”

The opinion continued, “The agency admits that studies show that crash risk increases, in the agency’s words, ‘geometrically’ after the eighth hour on duty.” The judges said they could not understand why the agency had not estimated the benefits of electronic monitoring, saying the agency’s “passive regulatory approach” probably did not comply with the law. The panel struck down the hour and service rules.

But a year later, in August 2005, the agency issued virtually identical rules, which the safety groups and the Teamsters union are again challenging in court.

Despite Labaton's valuable description of how a powerful industry takes over a regulatory agency, I have a couple of problems with important omissions in the article. More than most workplace incidents, trucking accidents tend to get blamed on individual worker (driver) behavior. Truck drivers drive too much, they drive too fast, they falsify their logbooks, they take drugs to keep awake. The obvious solution is to drug test, monitor their driving (electronically), monitor the logbooks, and severely punish any who break the rules. But are those actually good solutions? Why do truckers cheat? Are they just a bunch of greedy bastards, thoughtlessly putting our families in danger in order to earn a few more pennies?

Actually, the answer lies more in the changing structure of the trucking industry than in the low morals of truckers. During the late 1970's the trucking industry was deregulated, making it easier to enter the trucking industry, increasing competition and reducing rates. Wages fell, particularly for non-union drivers. This led to the rise of the so-called owner-operator which has increasingly replaced unionized employees of large trucking companies. Whereas an employee of a company gets paid by the hour or is on a fixed salary, owner-operators who get paid by the trip are not compensated for waiting time, loading time, unloading time or time spent on maintenance. Combine these factors with increased competition in the deregulated industry that drives down their rates, and you have an industry where the only way you can earn a living is to cheat on the log books, speed from origin to destination and take drugs to keep awake.

For an excellent discussion of the industry, check out a recently published book, Working Disasters, edited by Eric Tucker. One chapter in the book: "Trucking Tragedies: The Hidden Disaster of Mass Death in the Long-Haul Road Transport Industry" by Michael Quinlan, Claire Mayhew and Richard Johnstone discusses the changes in the structure of the long-haul trucking industry mostly in Australia and New Zealand, although many of the conditions are similar to those in the United States. Quinlan et. al cite studies showing that such factors as earnings and regular contracts correlate with safer driving. And the number of unpaid hours (loading, maintenance, waiting) was the best predictor of unsafe speeds. Other studies found that drivers with higher earnings exhibited lower speeds. In fact, improving driver payment is the best way to improve safety. But they point out that under the current structure, "drug use in a long-term feature of the industry and is structured into the work process in a way found in no other occupation aside from prostitution. "

Of course, the fatigue issue is no secret. Since 1990, "Reduce Accidents and Incidents Caused by Human Fatigue" has been on the National Transportation Safety Board's list of Most Wanted Transporation Safety Improvements. NTSB has recommended that the Department of Transportation

Set working hour limits for transportation operators based on fatigue research, circadian rhythms, and sleep and rest requirements.

The NTSB says that progress on this objective is "progressing slowly."

Finally, take a look at workplace fatality statistics in the United States. 43 percent of workplace fatalities are transportation-related, 25% highway related. 993 1,428 workers died in highway incidents in 2005. drivers/sales workers and truck drivers were killed on the job, almost 70% on the road. But despite these numbers, trucking deaths are not really seen as occupational fatalities. In addition, the Occupational Safety and Health Administration has no authority over trucking safety. The Department of Transportation (DOT) preempts OSHA's jurisdiction. DOT regulates driving over public highways, the health and safety of drivers involving their use of drugs and alcohol, hours of service, and use of seat belts.

OSHA's absence from the highway safety debate is not a good thing. To a much greater extent than other occupational fatalities, trucking accidents are blamed on the drivers. Little attention is paid to the responsibility of employers (who, as Labaton documents, often encourage drivers to cheat on their logbooks), nor is attention paid to the structure of the industry which encourages employers to place unreasonable demands on drivers, in essence encouraging drug use and discouraging sufficient rest periods. Indeed, as Quinlan et. al. point out, when a trucker dies in a highway accident, "there is very seldom an investigation of possible corporate responsibility, let alone the launching of a prosecution. "

And leaving occupational health authorities and experts out of the the debate makes it impossible to address the problem successfully:

A regulatory approach that meerly focuses on individual crashes and the responsiblity of drivers for those crashes will routinely ignore the systemic causes of road injuries and death, and will persist in the isolation of each incident from its underlying causes and the tendency to understimate the disasterous nature of the road toll attributable to long-haul trucking.

With over 5,000 truck-related deaths on the highways each year, we have a slow motion disaster that the public only tolerates with because they happen a few at a time and are generally blamed on "bad" drivers. But the real story, the real blame, lies more in the structure of the industry, the overwhelming political influence of the trucking industry over those who control the regulatory agencies in this administration, and our tendency to deal only with the symptoms, rather than the underlying causes of these accidents. Only when people realize the root causes of the transportation toll can we begin to seriously reduce it.


Disclosures

Disclosure 1: Baywood Publishing, the publisher of Working Disasters (referenced above), is a Confined Space advertiser. Click on "Pathbreaking Collection" over on the right for more information on how to purchase the book.) I do not, unfortunately, profit from sales of the book (other than spiritually)

Disclosure 2: My entire family came close to being obliterated nine years ago on the Interstate outside of Allentown, PA when we were rammed from behind by a trucker who had probably fallen asleep. My kids still have nighmares. I still get shivers.

Bravo! NTSB Chairman

By Confined Space cub reporter, Celeste Monforton.


“Unacceptable.”

That’s the term used this week by Mark Rosenker, the Chairman of the National Transportation Safety Board (NTSB), upon learning that a third subway worker was struck and killed by a WMATA train. Mr. Leslie A Cherry Jr., 52, was inspecting the tracks with a co-worker on Thursday morning, when a 39 MPH-subway train hit them from behind. A co-worker said Mr. Cherry was "probably one of the most safety-conscious track walkers we had."

Two other veteran Washington Metropolitan Area Transit Authority (WMATA) subway employees were killed in the same way, one in October 2005 and another in May 2006. Three workers in 13 months is “UNACCEPTABLE.” With only 30 workers employed by WMATA to inspect the tracks, 3 out of 30 employees—a fatality rate of 10 percent--- is unacceptable, alarming and intolerable. Bravo! Chairman Rosenker for saying it.

But, WMATA Board member (and D.C. Councilman) Jim Graham strongly objected to Rosenker’s remark:

“This is not the proper role for the NTSB, taking potshots like this. We want them to go through a full, deliberative, unvarnished process of investigation and get to the bottom of this. This doesn't contribute to that type of investigation."

Baloney. Mr. Graham sounds just like other employers and their PR firms who, in the wake of employee deaths, try to elevate themselves above the raw situation. When the wounds of the deceased, their co-workers and families are naturally inflamed (and rightfully so) it’s more comfortable for employers and their defenders to insulate themselves and call for the methodical, “deliberative” and “unvarnished” process.

Well, sometimes, it’s justified for public officials to say, “Hey, I’m mad as hell” about this. Do such statements tarnish the investigation? No. It simply shows that the NTSB chairman is a human being, a sympathetic individual, and when people are injured or killed, or when management safety systems clearly aren’t working, he shows his emotion. Frankly, we need a few more like Mr. Rosenker in charge of investigatory agencies. Besides, the NTSB chairman merely said the WMATA situation is “unacceptable.” That’s a true statement. It is unacceptable.

I decided to check the WMATA’s website to see what kind of information they have posted about the latest fatality. (Just like I check International Coal Group’s, BP’s and other company sites after workplace disasters at their facilities.) WMATA has a brief 230-word statement on their site, noting the “incident” is under investigation. The only real news in their press release is “the train operator, a Metro employee since 1999, was given routine drug and alcohol tests.” I’m sure that brought a smile to the face of advocates of mandatory worker drug-testing, like Congressman Charlie Norwood (R-GA) and the new head of WV’s Office of Miners Health Safety and Training, Ron Wooten. Pointing the finger of blame on the train operator will certainly be more palatable for WMATA’s Board of Directors than being forced to acknowledge their safety program is unacceptable.

Note: After Metro employee Jong Won Lee was killed last May, WMATA attempted to put the blame on Lee, himself. More on that here. The NTSB has not yet finished the Lee investigation. -- JB

Waiting On The NTSB: What Really Happened To my Daughter?

Some of you old-timers may recall February 2005 when I wrote about the National Transportation Safety Board (NTSB) investigation into the death of Denise Bogucki who was crushed against the nose of a plane in September 2003. The NTSB report essentially blamed Bogucki for her own death, stating that she had chosen to use the incorrect equipment to push back an airplane from a gate, causing the accident that pinned her against a plane.

The union objected, saying she had been using the only equipment available, and that she shouldn't have been working alone. Virginia OSHA cited the company, Northwest Airlines, and Northwest -- essentially admitting that there was a problem -- instituted changes, including requiring two people for pushbacks.

Several weeks after the report was released, the NTSB, citing "new information,"decided to take a second look at the Bogucki's death "due to new information."

Now, a year and a half later, Bogucki's mother, Jeanne Earley, is still waiting for that report.

"It's never going to end for me," said Earley, an executive assistant in the airport's administrative office. "But it would be nice to have this part of it over with and settled once and for all."

It doesn't help that a September issue of a Northwest newsletter referred to two recent accidents that resulted in "potentially life-threatening injuries" while doing the same job Bogucki was doing when she was killed.

Safety board spokesman Keith Holloway said last week that the investigation of Bogucki's death would be complete "before the end of the year, if not sooner." He added that the agency is not investigating the recent accidents.

Earley's heard it all before. About this time last year, the agency said it would finish by the end of 2005.

"I don't know if they're afraid to address it because of big business," she said. "We're just the little guys, and they're dragging her through the mud again."

The union is upset too

"It's like there's no value to human life," said Bob Bennek, safety and health director of the International Association of Machinists and Aerospace Workers Air Transport District 143, which includes Norfolk.

"You would think a fatality would get some type of resolution sooner than this," Bennek said. "The family deserves to have a resolution."

As for the other accidents where ground crew employees were injured, Airline spokesman Roman Blahoski says they weren't related. And although Northwest made changes after Bogucki's death, they are contesting the OSHA citation.

"Our investigation showed it to be an accident and not the result of a violation of OSHA standards," Blahoski said.

The two recent accidents mentioned in the Northwest newsletter also occurred "during the push-back of an aircraft." The newsletter said two employees "suffered injuries, one of which was serious."

Blahoski said the accidents, which occurred over the past few months, were different from Bogucki's because they injured ground crew members, not the driver of the push-back tug.

He said an internal investigation concluded that proper procedure was not followed in one case and that the other is still under review. (emphasis added)

Of course, experts who investigate the root causes of "accidents" generally will ask "why" procedures weren't followed and usually find that there are understandable reasons. (For example, understaffing, improper equipment, or the job just can't get done by following the rules.) And numerous "accidents," even if they appear "unrelated," generally mean that there's something seriously wrong with the management safety systems in the workplace.

Bennek, the machinists union's health and safety director, would like to see the safety board issue recommendations for making push-backs safer, including specifying push-back tractor designs, tow bar lengths and inspections criteria.

"They could make some findings that could forever change the industry," he said.

Meanwhile, Bogucki's mother waits:

Jeanne Earley checks a federal investigators' Web site daily, hoping for closure three years after her daughter was killed while working at the airport.

Every day, she longs to see that the inquiry has ended and to know, finally, what really happened.

Every day, she is disappointed.

Airport Ground Crews: Grind 'em Up And Spit 'em Out

Before you open up your book next time you get on a plane, take a look out the window and check out all the work being done on the tramac below you.

Keith L. Alexander of the Washington Post penned a great article today about the hazards faced by airport ground crews. It aint' pretty:

So far this year, four ground workers have been killed or seriously injured, according to data collected by The Washington Post. In one incident, a mechanic died in January when he was sucked into the engine of a Continental Airlines aircraft at El Paso International Airport. A month later, a baggage handler for Comair, a Delta Air Lines regional carrier, was killed when he was struck by a baggage cart at the Detroit airport. Three serious or deadly accidents occurred in 2005 and two in 2004.

Through the busy summer season, ground workers have been under increased pressure to load and unload bags swiftly and to ensure that the aircraft are prepared for safe travel. Many financially strapped carriers have reduced their staffs, leaving more work for the remaining employees. Some airlines have been hiring ground workers at lower wages to cut costs.

I've spent some time working on health and safety issues with baggage handlers and other ground crew and it's pretty depressing. First, they fall in a gray area in terms of OSHA enforcement. Section 4(b)1 of the OSH Act prevents OSHA from enforcing its regulations if a working condition is regulated by another Federal agency such as the Federal Aviation Administration -- even if that agency is doing a lousy job. Safety conditions for flight attendants, for example, can't be enforced by OSHA, because the FAA claims jurisdiction. Baggage handlers and other ground crew, I learned when I was at OSHA, are in a gray area. If they're actually working on the plane, they're covered by the FAA. If they're on the ground, sometimes their OSHA's and sometimes their FAA's. When I first arrived at OSHA, the policy differed from Region to Region, although I believe it's been straightened out now.

The other problem is their working conditions. As the post describes:

They fix planes and load and unload heavy bags in sweltering heat and frigid cold. For many passengers, they are invisible, though they toil right underfoot. Airport ground workers do their jobs amid the deafening roar of aircraft engines and the arrival and departure of tanker-size jetliners. They must avoid stepping in oil slicks and watch out for baggage carts whizzing by.

***

While serious injuries and death occur, the most common injuries among ground workers result from heavy lifting, in many cases causing severe back strain. According to figures from the Bureau of Labor Statistics, there were 4.53 injuries and fatalities per 100 airport ground workers in 2004, the latest year for which data are available. By comparison, coal miners had a rate of 6.58 injuries and fatalities per 100 workers; in construction, the rate was 5.77.

When I was working at the AFL-CIO, I received a call from a disabled USAir ground employee who had seriously injured his back unloading bags. He worked on the smaller commuter planes where you have to lift the heavy luggage without being able to stand up in the luggage compartments -- not exactly proper lifting techniques. The company was fighting his workers comp claim. (Must have hurt his back bowling or playing tennis.) He couldn't believe that the company he had given his life to was treating him like garbage.

The reason for the article and the current attention to employee health and safety is a three day symposium that the airlines and the Federal Aviation Administration are co-hosting for the first time to focus on "improving safety on the tarmac at the nation's airports." All of the airlines quoted in the article claim that safety is a first priority. The families of those killed on the job disagree:

Yolanda Corbett, 32, was attracted to a subsidiary of the airline during an earlier hiring fare in 2005. She liked the free travel offered to employees and a chance to take her two young daughters to Disney World. The pay, about $9.75 an hour, was low, but it represented steady work for the single mother who had held such odd jobs as babysitting after being laid off from an accounting position at a local Welfare to Work office.

For two weeks, US Airways baggage handlers instructed the D.C. resident on the proper way to lift bags and navigate the busy runways of Reagan National Airport in a baggage-loading cart. She received a 100 percent accuracy rating in her training tests. In her third week on the job, Corbett was killed when she lost control of a baggage cart, which rammed the side of a regional jet, pinning her under the aircraft and severing her spine.

The NTSB attributed the accident to Corbett's inexperience with driving the cart.

Corbett's mother, Mary, said her daughter was trained to operate the baggage cart, but the day she was killed was the first time she had driven it by herself. "She wasn't trained properly. She wasn't ready to drive that vehicle. It just wasn't safe," she said.

Last year, the International Association of Machinists objected to a National Transportation Safety Board report on the death of Northwest Airline worker, Denise Bogucki, who was crushed against the nose of a plane in September 2003. The report essentially blamed Bogucki for her own death because of her "decision to use improper equipment" to push back an airplane from the gate. The union argued that she was using the only equipment Northwest provided to do the job and that she shouldn't have been working alone. Virginia OSHA cited the company and Northwest instituted changes, including requiring two people for pushbacks. The NTSB later agreed to reevaluate the investigation "due to new information." (Also check out the comment left by Bogucki's son.)

The unions want more oversight:

Paul Kempinski, director of ground safety for the International Association of Machinists & Aerospace Workers District 141, said unions have urged government agencies to more rigorously monitor ground operations. OSHA "only comes out when something happens," said Kempinski, who represents baggage handlers at United and Aloha airlines and US Airways. "Something needs to be done sooner. Someone needs to be in charge of oversight."

And ground crews aren't the only ones with problems.

By coincidence, I was wearing my OSHA NOW! t-shirt today, given to me by the Association of Flight Attendants (AFA) in 2000 after OSHA and the FAA signed an agreement directed the agencies to “establish a procedure for coordinating and supporting enforcement … with respect to the working conditions of employees on aircraft in operation … and for resolving jurisdictional questions." Unfortunately, under the Bush administration, the agreement was never implemented and last year the AFA filed a complaint in District Court against Secretary of Labor Elaine Chao and FAA Administrator Marion Blakely for their failure to ensure the health and safety of flight attendants and other employees working in the airline industry. And if you think their jobs are safe and easy, check out their health and safety website.

So, now you know all you never wanted to know about airport workers. They're not all glamorous pilots. So think about all of this again next time the airlines cut staff and ask ground workers to make concessions.

Transportation Safety Board Recommends Actions To Prevent & Reduce Impact Of HazMat Train Accidents

It's common practice following an industrial accident to blame the workers involved because they made mistakes or didn't follow proper procedures. And on a shallow surface level, this analysis is not wrong. Workers are human, and being human, they make mistakes.

But stopping with that superficial "blame the worker" analysis doesn't get to the real reason, or "root cause" of the incident. And if you don't address the root causes, similar accidents will continue to happen.In fact, it may make matters worse: punishing the workers involved may give management a false sense that the problem has been resolved.

On January 6th, 2005 a freight train carrying chlorine gas struck a parked train, puncturing the chlorine tanker. Nine workers died of chlorine inhalation: the train's engineer and eight workers in an adjacent factory. 5,400 people within a 1-mile radius were evacuated and 75 were admitted to a hospital for treatment.

The surface cause of the crash was the failure of the crew of the parked Norfolk Southern train to return a main line switch to the normal position after the crew completed work at an industry track, allowing the moving train to switch onto the wrong track and collide with the parked train.

Transportation Secretary Norman Mineta blamed the accident on "human error." Noting that is that type of human error is not addressed by Federal Railroad Administration regulations, he proposed a program that would provide more training and possible civil penalties. In the worst case, employees could be barred from certain train assignments.

Problems solved? Not quite.

The National Transportation Safety Board, which issued its report on the accident at the end of November, agrees that the railroads and the FRA need to look much deeper than just worker error as a cause, and punishing workers as the solution, as summarized by the New York Times.

The crew normally had a set routine of resetting the switch as they moved the train to the the siding that they had not planned to use. But on this night, the crew strayed from that normal routine because they were just coming off of a 12-hour workday, had a taxi waiting to take them back to their depot and were anxious about finishing before their work hours would violate federal rules.

In addition,

the tracks in the Graniteville area, near Aiken, S.C., were "dark," meaning that they had no electronic signals that would have allowed a dispatcher to realize that the first crew had forgotten to reset the switch. About 40 percent of the rail network is dark.

The second train, which was moving at 47 miles an hour in a 49-mile-an-hour zone, would have needed half a mile to stop but had less than an eighth of a mile, investigators said.

The engineer, who died in a hospital from chlorine inhalation, was doomed before he got there, they said.

To prevent similar accidents, the Board recommended

• A strobe light like those carried on some school buses, or a radio device that sent signals to beepers or cellphones, might have reminded the first crew to reset the switch when leaving the train for the night, investigators said. Where no automatic signals exist, trains should be operated at speeds that will allow them to be safely stopped in advance of misaligned switches


• Positioning cars carrying chlorine, anhydrous ammonia, and other liquefied gases that pose an inhalation hazard at the rear of the train and reducing speeds through populated areas


• Train employees should be provided with emergency escape breathing apparatus and training for all crewmembers on freight trains carrying hazardous materials that would pose an inhalation hazard.

As the Times article pointed out, "crashes caused by misaligned switches are common." And one member of the NTSB Board was not happy with the Federal Railroad Commission's response:

Debbie Hersman, a member of the safety board who accompanied the investigators to the scene in January, said that the Federal Railroad Administration had proposed fines for failing to reset switches, but questioned the effect.

"Do we think these things are going to change operating behavior?" she asked.

Like any workplace hazard, slapping workers on the wrist for being human isn't going to help. As the NTSB noted, there are other, more effective ways of preventing these accidents from re-occurring.

The NTSB Synopsis can be found here.

Related Stories

• Blaming Workers: In Texas City and On The Rails, May 18, 2005
• "Engineers and conductors sleep on trains. Anyone who tells you different is not being straight with you," May 9, 2005
• Deaths and Injuries at US Steel: Blame the Workers?, Feb 24, 2005
• Behavioral Safety Comes To The Railroads, November 15, 2004
• Blame the Worker: Chinese Style, January 3, 2004
• Worker Error Department (cont'd), April 14, 2003
• Worker Error Department, Part 2 April 11, 2003
• Worker Error Department, April 10, 2003

"Engineers and conductors sleep on trains. Anyone who tells you different is not being straight with you,"

It's late, I'm tired and I'm still writing. At least I'm not driving a train.

Here we have a story of well-known fatigue problems among workers responsible for carrying the 1.7 million carloads of the nation's hazardous materials every year, and the Association of American Railroads who would rather deny that obvious fatigue issues exist despite clear evidence to the contrary:

When a Union Pacific freight train thundered into tiny Macdona, Texas, just before dawn June 28, the engineer and conductor had clocked more than 60 hours in the previous week, working the long, erratic shifts that are common in the railroad industry.

They flew through a stop signal at 45 mph and slammed into another freight train that was moving onto a side track. No one even touched the brakes.

Chlorine gas from a punctured tank car killed the conductor and two townspeople, while dozens of others suffered breathing problems and burning eyes as the toxic cloud drifted almost 10 miles. Hundreds were evacuated within a 2-mile radius of the accident.

Federal investigators suspect that both of the Union Pacific crewmen had fallen asleep. In the weeks before the crash, each man's work schedule had at least 15 starting times at all hours of the day.

The Macdona crash illustrates a grim fact of life for thousands of engineers, brake operators and conductors who guide giant freight trains across the country: Exhaustion can kill.

Two decades after federal officials identified fatigue as a top safety concern, the problem continues to haunt the railroad industry, especially the largest carriers responsible for moving the vast majority of the nation's rail-borne freight.

"Engineers and conductors sleep on trains. Anyone who tells you different is not being straight with you," said Diz D. Francisco, a veteran engineer and union official who works out of Bakersfield for the Burlington Northern Santa Fe Corp.

I've written about this incident before, but in the context of transporting hazardous cargo. Combined with hazardous material problems (like the train crash that killed nine in South Carolina several months ago), the incidents cited in this article are chilling:

National Transportation Safety Board records show that entire crews have nodded off at the controls of mile-long freight trains weighing 10,000 tons, some of them loaded with hazardous materials.

In a 1984 Wyoming crash, a Burlington Northern engineer had only 6 1/2 hours of sleep in the 48 hours before the accident; his conductor had five hours of sleep.

Outside St. Louis in 2001, a Union Pacific engineer who had been up for 24 hours with only a short nap failed to heed three warning signals and orders to limit his speed before triggering a chain-reaction crash involving two other trains. The wreck injured four and caused $10 million in damage.

A year later, in Des Plaines, Ill., a Union Pacific engineer fighting to stay awake after more than 22 hours without sleep blew past warning signals and broadsided another train, severely injuring two crew members.

After a Chicago & North Western train collision in March 1995, engineer Gerald A. Dittbenner sued the railroad — and received a $500,000 settlement, his lawyers say — over his incessant 12-hour shifts and irregular work schedules.

Dittbenner, 49, misread a stop signal after being awake almost 30 hours and hit the rear of an empty coal train outside Shawnee Junction, Wyo. Seconds before the impact, Dittbenner jumped from the locomotive and broke his neck. Unable to do strenuous work because of persistent pain, he now works as a locksmith in Scottsbluff, Neb.

As happens in so many other accident investigation, the root causes of these problems have been covered by conclusions that essentially blame the worker for falling asleep or "poor judgment, miscommunication and failure to follow operating procedures — errors that experts say can be triggered by fatigue."The root cause of the fatigue is not careless workers, but scheduling problems:

A 1997 survey of more than 1,500 freight crew members by the North American Rail Alertness Partnership — a group of industry, government and union officials — found that about 80% had reported to work while tired, extremely tired or exhausted.

Though fatigue can affect passenger train crews, it is primarily a problem for the 40,000 to 45,000 engineers, brake operators and conductors assigned to unscheduled freight service.

Many put in 60 to 70 hours a week, sometimes more. They can be called to work any time during the day or night, constantly disrupting their sleep patterns.

The irregular shifts often place bleary-eyed crews at the controls between 3 and 6 a.m., when experts say the body's natural circadian rhythm produces maximum drowsiness.

Engineers, brake operators and conductors liken on-the-job fatigue to being in a constant state of jet lag.

"There is no set rest schedule. It changes all the time, and it is hard to adjust," said Doug Armstrong of Huntington Beach, a veteran Union Pacific engineer who often works 12-hour days, six days a week. "People have a normal rest cycle, but a railroad is anything but normal."

And the problem here is antiquated laws, in this case, the 98 year old federal Hours of Service Act. The act requires train operators to have 8 hours off, but that doesn't allow for commuting, family obligations, meals -- as well as adquate sleep. In addition, it's legal for engineers, conductors and brake operators to work 432 hours a month, as opposed to truckers who are allowed to drive no more than 260 hours.

And it seems that no story of workplace -- or community -- hazard is complete without an industry association trying to deny that the problem exists. The Association of American Railroads (AAR), the industry's trade organization and lobbying arm, commissioned a study of the fatigue problem and finding ways to reduce accidents. But the study was canceled in 1998 when it found that "engineers who put in more than 60 hours a week were at least twice as likely to be in an accident as those working 40 hours."

"They did not want this finding," said [the former AAR analyst Donald]Krause, who once studied rail safety for the federal General Accounting Office and is now a business writer living outside Chicago. "The railroads fear it could lead to restrictions on hours and government regulation, which could cost them money. But something needs to be done. One of these days, they are going to wipe out a town."

Association officials say Krause's research was halted because of budget cuts, not out of a desire to bury the conclusions.

Yeah, I'm sure.

Among the reasons for the ARA to not want to see those results:

Hiring has not kept pace with a steady increase in rail freight volumes, about 4.4% a year on average since 1991, federal data show.

Corporate mergers and cost-cutting during the 1990s led to staff reductions. In 2002, a change in pension rules led to 12,000 railroad worker retirements, twice as many as the year before.

Since 1990, overall railroad employment has declined more than 25%. Department of Labor statistics show that, until recently, the hiring of engineers has been flat for years.

There seems to be some dispute about the role of unions. According to the article, rail unions have supported the resulting overtime:

Railroad unions have at times resisted proposed solutions to the fatigue problem if they threatened to limit the freedom of their members to work long hours and maximize earnings. With overtime and high mileage, salaries for engineers can reach $100,000 a year.

"It is a two-edged sword," said Brian Held, 47, a Burlington Northern Santa Fe engineer for 10 years. "The company wants to save money and doesn't hire what it needs to. Union members don't want the boards so full of workers they can't make the money they want. It makes for a dangerous situation."

Although, on the other hand:

In December 2003, Union Pacific unsuccessfully sued a group of unionized conductors alleging that they were taking too much time off during weekends and holidays, disrupting commerce along a major Kansas line in violation of the Railway Labor Act.

The United Transportation Union countered that the railroad was severely understaffed in the area and many conductors were exhausted from working for weeks — sometimes months — without a day off.

"We were running with a skeleton crew," said union official Greg Haskin. "Guys were burned out and calling in sick. They were working 12- to 16-hour days up to 90 days straight. You can't expect people to work like that and be safe."

Union Pacific declined to discuss the case.

In 1999, the NTSB recommended that the Federal Railroad Commission

Establish within 2 years scientifically based hours-of-service regulations that set limits on hours of service, provide predictable work and rest schedules, and consider circadian rhythms and human sleep and restrequirements.

But, of course, we are faced with the usual debate in this administration about whether or not the railroads should be left to voluntary programs to reduce fatigue, or whether there should be regulations.

Guess which side is winning.

The FRA has announced that it

will continue to monitor the results from these various cooperative arrangements and research projects on fatigue and, as the need arises, take relevant regulatory action and/or recommend legislative action.

.

NTSB Takes Another Look At Death of Denise Bogucki

I wrote earlier this month of the National Transportation Safety Board's report on the death of Denis Bogucki. The report had blamed Bogucki for her own death, stating that she had chosen to use the incorrect equipment to push back an airplane from a gate, causing the accident that pinned her against a plane. The union objected, saying she had been using the only equipment available, and that she shouldn't have been working alone. Virginia OSHA cited the company, Northwest Airlines, and Northwest instituted changes, including requiring two people for pushbacks.

Now, citing "new information," the NTSB is taking a second look at the Bogucki's death. The board said on its Web page that the "investigation is currently being reevaluated due to new information." Board officials declined to comment further.

The report states that she used a tow bar that was too short for the tug she was driving.

But the union contends that she was using the only equipment Northwest provided to do the job.

"You don't put out false facts on an accident," said Bob Bennek, safety and health director of the International Association of Machinists and Aerospace Workers Air Transport District 143, which includes Norfolk.

Jeanne Earley, Bogucki's mother, told The Virginian-Pilot the report portrayed her daughter "like she was some dumb thing who didn't know what she was doing."

Before she died, Northwest workers had complained that staffing cutbacks were jeopardizing safety. Staffing was not mentioned in the federal report.

Shortly after the accident, Northwest began requiring two people for pushbacks. The airline also replaced the open-cab tug used in the accident with a closed-cab one.

Still, the union contends, conditions at Northwest's Norfolk operation have not improved significantly. The station is still understaffed, officials said, and despite having a new tug, the tow bars are still the same length.

The union said that the airline has begun installing protective roll bars on all of its tugs nationwide.

"I'd say that's the single biggest thing that could have prevented her death," Bennek said.

NTSB Blames Airline Worker For Her Own Death

I'm not quite sure what they were thinking over at the National Transportation Safety Board (NTSB)when they concluded that an Northwest Airline worker, Denise Bogucki, was to blame for her own death when she was crushed against the nose of a plane in September 2003.

According to the NTSB, the accident occurred because "Bogucki made a "decision to use improper equipment" to push back an airplane from the gate."

The report states there were two pushback tugs and two tow bars to choose from and that Bogucki used a tow bar that was too short for the tug she was driving. A tow bar is a long, straight bar that connects the tug to the airplane’s front-wheel assembly.

***

The accident occurred on the evening of Sept. 12, 2003, when Bogucki had connected one end of a tow bar to the airplane and was driving the tug slowly toward the other end, trying to attach it to the tug.

The NTSB report states that the tow bar buckled and the tug struck the nose of the plane. Bogucki, who was riding in the open-air cab of the moving tug, was pinned between the tug and the plane.

Why this "improper decision" was made, the report doesn't say. One thing is certain. Bogucki, 43 and the mother of two grown sons, was no novice. She had worked for Northwest for 13 years.

Unfortunately, the NTSB, unlike its sister agency, the US Chemical Safety and Hazard Investigation Board, does not always look for the "root causes" of such incidents. But by focusing more on the immediate cause, the agency fails to identify to underlying causes which, if addressed, can prevent similar accidents from happening in the future.

Again, I don't know what the NTSB was thinking, but we do know what the union, Virginia OSHA and Northwest Airlines were thinking.

The union contends she was using the only equipment Northwest provided to do the job. Union officials say Northwest had just one pushback tug, and that only one of the two tow bars would fit the DC-9 plane at the gate.

"She had no choice to make," said Bob Bennek , safety and health director of the International Association of Machinists and Aerospace Workers Air Transport District 143. He added that even if the other tow bar did fit the plane, it was shorter than the one Bogucki used....

"This is the worst publication I’ve ever seen the NTSB put out," Bennek said. "They’re misstating the facts… I don’t get it. It very much upsets me."

***

Bogucki was trying to do a job alone that many in the industry say takes two to do safely.

Before she died, Northwest workers had complained that staffing cutbacks were jeopardizing safety. Staffing was not mentioned in the federal report.

Virginia OSHA probably didn't think much of the NTSB's conclusion either:

The Virginia Occupational Safety and Health Administration fined Northwest $6,300 for a "serious" violation of workplace safety laws. The maximum penalty for that violation was $7,000.

State safety officials wrote that Northwest failed to provide a work environment that was “free from recognized hazards that were causing or likely to cause death or serious physical harm.” They also stated that employees “were exposed to crushing hazards while conducting aircraft pushback operations.”

Northwest Airlines, which is contesting the OSHA penalty, made no statement about the NTSB report. But actions speak louder than words:

Shortly after the accident, Northwest began requiring two people for pushbacks. The airline also replaced the open-air tug at Norfolk with a vehicle with an enclosed driver’s cab that offers more protection.

Machinists leader Bennek said

he had hoped the NTSB findings would be strong enough to spur an industry-wide movement for eliminating open-air tugs and standardizing the length of tow bars.

"We were hoping to have a detailed finding to help the whole industry prevent this from ever happening again," he said.

That would have been nice.

As If That Wasn't Bad Enough...More on Rail Safety

New York Times reporter Walt Bogdanich who has been following the safety problems of the rail industry and weakened oversight by the Bush administration is giving us even more to worry about in the wake of the South Carolina rail accident and chlorine leak that has killed eight nine (or more?).

First, more than half of the nation's 60,000 pressurized rail tank cars did not meet industry standards:

Just how ruptured tank cars can endanger a community was underscored three years ago when a Canadian Pacific Railway freight train derailed just outside Minot, N.D. Five tank cars carrying a liquefied type of ammonia gas broke open, releasing toxic fumes that killed one resident and injured more than 300.

The National Transportation Safety Board, in a report on the accident released last year, said the steel shells on the five ruptured tank cars had become brittle, causing a "catastrophic fracture" that released clouds of toxic vapors. Those cars, the safety board found, were built before 1989 using steel that did not - as it does now - undergo a special heat treatment to make it stronger and less brittle. Tank cars built after 1989 use this specially treated steel.

***

The safety board warned that of the 60,000 pressurized tank cars in operation, more than half were older cars that were not built according to current industry standards, leaving them susceptible to rupture. And because these cars may remain in service for up to 50 years, some older ones could still be hauling hazardous materials until 2039.

Among the hazardous materials carried by the tank cars are liquefied ammonia, chlorine, propane and vinyl chloride. In most cases, the cars are owned by chemical or leasing companies, not the railroads.

And if that wasn't reassuring, it seems that more than three years after 9/11, the security of rail cars carrying highly hazardous chemicals is not much better than the security of chemical plants:

Federal authorities have been working with railroads and the chemical industry to improve security for trains. But there is still much to be done, particularly given the structural weaknesses of many tank cars, current and former federal officials say. George Gavalla, a former associate administrator for safety at the Federal Railroad Administration, said railroads had promised to beef up security when there was a credible terrorist threat.

So when such a threat arose a year ago in Las Vegas, Mr. Gavalla said, he sent an inspector there on New Year's Eve to assess the security measures in place. Those measures, he said, were virtually nonexistent.

When the inspector visited a rail yard 13 miles from the airport, he found no one watching over six tank cars with markings indicating that they might contain chlorine gas, according to a memorandum that he wrote about his visit. Two hours later, he visited another rail yard with four tank cars possibly carrying poisonous gas and they, too, were unguarded, the memorandum stated.

Finally, if all that's not bad enough, John Lowe over at Impact Analysis reveals that a request for comments on "the need for enhanced security requirements for the rail transportation of hazardous materials that pose a toxic inhalation hazard (TIH)," presented by the Departments of Transportation and Homeland Security last summer states that the agencies are considering whether to require the removal from rail tank cars used to transport TIH materials of identifying marks, names, stenciling, placards, or other markings that could help a terrorist or criminal identify a target.

Great idea, if you want every emergency responder in America to resign. The key to addressing hazardous materials accidents safely -- to protecting the lives of the emergency responders and the surrounding community -- is swift and accurate identification (preferably from a distance) of the material that has been released. Nothing would undermine the safety of the American people more than hiding the identify of the contents of the fleets of trucks and railcars carrying hazardous materials through our towns and cities every day.

Can the safety of rail cars be improved? Who's going to make sure its done and that it's effective. Is it really possible to have safe transport of highly hazardous substances? The best solution is, of course, right under our noses:

Rick Hind, a toxics specialist at Greenpeace, the environmental group, said that the best answer would be for industrial plants to substitute less toxic substances for chlorine and other hazardous materials.

Safer technologies have emerged in some areas, Mr. Hind said, and switching to them would reduce the sense that the plants and trains are "a target-rich environment."