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A horrific Metro-North derailment in the Bronx — the deadliest of five accidents for the commuter railroad in a year — is being blamed on the engineer's undiagnosed sleep disorder and abrupt change in his shift. Officials blasted the railroad with the release of a National Transportation Safety Board report on the Dec. 1 crash and four others.
"The NTSB report represents a horror house of negligence resulting in injury, mayhem and even death," New York Sen. Charles Schumer said. "This would be almost a comedy of errors if it weren't so tragic..It's clear these mistakes were avoidable."
In the December derailment, investigators found engineer William Rockefeller fell asleep before the train roared into a 30 mph curve at a speed of 82 mph, with no automatic system in place to slow it down. Four people were killed — thrown from the train when the window glazing failed — and 61 were injured.
The report noted that even though the engineer had multiple risk factors for sleep apnea, which can cause daytime drowsiness and fatigue, the railroad's doctors failed to diagnose him with the condition, which was finally discovered and successfully treated only after the accident. In addition, less than two weeks before the crash, Rockefeller's shift changed from a start time of late afternoon to the pre-dawn hours.
"This would be almost a comedy of errors if it weren't so tragic."
"Given the substantial shift in work schedules and the varied sleep/wake times, it is likely that the engineer had not adjusted fully to the new work schedule at the time of the accident. The engineer’s [apnea] combined with his incomplete adjustment to a dramatic shift in work schedule most likely resulted in him being fatigued at the time of the accident," the report found.
After probing the four other Metro-North crashes in New York and Connecticut, the board found a lack of track maintenance and poor communication caused the death of two track workers and injury to 65 passengers.
"Seeing this pattern of safety issues in a single railroad is troubling," said NTSB Acting Chairman Christopher Hart. "The NTSB has made numerous recommendations to the railroad and the regulator that could have prevented or mitigated these accidents But recommendations can only make a difference if the recipients of our recommendations act on them."
Rockefeller's lawyer, Jeffrey Chartier, told NBC News that the NTSB conclusions "confirm that this tragic accident was not the result of any criminal of negligent acts" by his client. A spokeswoman for the Bronx District Attorney says a criminal investigation remains open and no decision on charges has been made.
In a statement, Metro-North President Joseph Giuletti said the railroad was a different organization than it was when the string of accidents began.
“Every decision and change that has been made since I became president last February has been made to advance safety," he said. "Our goal is to build a culture of safety where each employee is responsible for the safety of every customer and every other employee and no one is afraid to bring up safety concerns."
Railroad spokesman Aaron Donovan said Metro-North is working with its unions to set up a pilot program to screen employees for sleep apnea, a condition that affects 18 million Americans.