The National Transportation Safety Board said Tuesday that while a violent accident involving a Chicago Transit Authority train at the O’Hare station was obviously caused by the motorman falling asleep, the CTA shared the blame for failing to manage the operator’s work schedule.
At least 33 people were injured during the pre-dawn hours last March 24, 2014 when the train rammed the end of the tracks in the O’Hare International Airport terminal, rocketing out of the track well and up an escalator. Motorman Brittany Haywood admitted falling asleep at the controls.
But in a final report issued Tuesday, the NTSB said the CTA had inadequately taken fatigue of its employees into account. In addition, investigators said antiquated safety systems failed to override the operator and bring the train to a stop.
"If this accident had occurred a few hours later during rush hour, it could have had far more tragic results," said agency chairman Christopher Hart. "Our investigation uncovered that the layers of protection, designed to prevent such an accident failed."
A spokesman for the CTA pointed out that numerous scheduling changes had been made within weeks of the crash.
The NTSB said the incident happened during a "known low in the circadian rhythm," the physiological clock human beings use to regulate sleep and fatigue. Nevertheless, investigators said the CTA, like many of its sister agencies, failed to take such fatigue factors into account in scheduling, and that the Federal Transit Administration likewise was lax in mandating such scheduling initiatives.
"In today’s 24/7 culture, a work shift that crosses this circadian low is not atypical, even in safety critical positions," Hart said. "It is vitally important that all transportation agencies incorporate fatigue science in scheduling their employees’ work shifts."
The NTSB chairman noted that at the time of the accident, Haywood was working her 12th straight day on duty, and investigators faulted the CTA for putting Haywood on a schedule where overnight shifts were interspersed with day duty.
"She would have still been trying to adjust to working at night, a time when humans traditionally sleep," said the agency’s Dr. Steve Jenner. "So the combination of the transit operator trying to adjust to an irregular night time schedule, the mismanagement of her off duty time, and the circadian factors that made it difficult to stay awake at night and sleep during the day, all likely contributed to her being fatigued and falling asleep moments before the accident."
While the Federal Rail Administration, which oversees heavy rail operators like Metra, mandates such scheduling issues, the Federal Transit Administration has no such rules for local transit agencies like the CTA. Board member Robert Sumwalt noted that in downtown Chicago, two different commuters, one on the CTA and one on Metra, were provided with "different levels of safety."
CTA spokesman Brian Steele noted that within days of the incident, the agency changed its scheduling policies, adopting new rules that were among the most stringent in the nation.
"Twelve hours of train operating in any day, and also a minimum of ten hours off between shifts," Steele said. "We require that all employees take at least one day off in a seven day period, and we’re limiting the time of train operations for CTA employees who have only been with the agency for a year."
One of the NTSB’s most costly findings stemming from the accident, was a recommendation that the CTA install high tech positive train control systems, designed to stop the train in events where the motorman fails to heed signals. Investigator Tim DePaepe said the O’Hare accident would have been prevented, had the CTA had such systems in place.
Such systems are hugely expensive. Metra is currently struggling to install a system mandated by the federal government, which is costing that agency hundreds of millions of dollars.
"Our existing systems have been in place for decades," Steele said. "And they’ve worked very efficiently."
The CTA operates about 2200 trains every weekday, serving some 700,000 riders. The O’Hare station handles about 2400 train trips a week.