36
wide fluctuations in scheduling
that
the other two crewmembers did, thus, she
probably
was
not suffering from chronic sleep deprivation
The crew caller notified her at 8.43 p m., allowing her a
maximum
of
43 minutes of sleep before her
fateful
trip. Other than those possible 43 minutes,
her last bed rest was 26 hours 41 minutes before the accident. She had been in the
engineer's company all day until about 8 p.m., when she went to her motel room
On
the
trip
from Barstow she was probably tired enough to succumb to the
neurological pressures to sleep. As were the others, she was working during her
circadian
nadir. Her body was demanding sleep while she nevertheless had to be
awake.
Coupled with the neurological
pressures
were the facts
that
she was on the
return portion of her first road
trip
and she was unfamiliar with night operations,
with the Corona siding, and possibly with what to do in an emergency situation
Although she had been trained to be aware of stop
signals,
it is possible
that
since
this was her first
trip
at night, she overlooked the stop signal. Or, she may have
been reluctant to act on what she observed
The Safety
Board
concludes
that
either she was asleep due to acute fatigue,
did not know what to look for in unfamiliar territory at night, or was reluctant to
take action when train 818 passed the stop signal
Behavioral
Acti
ons
of the Crew of Train 818 —When a crewmember completes
a tour of duty, he usually goes to bed shortly after coming off duty because he
knows
that
in 8 hours he will be subject to being called for another tour He is
particularly likely to go to bed at an away-from-home terminal, where a layover is
usually
short However, sometimes a layover at an away-from-home terminal
exceeds
8 hours.
When
the crewmembers arrived in Barstow at 12'40 p m , both the engineer
and the conductor called their
wives
Each
estimated
that
he would not go back on
duty until about 5am the following day The estimates were based on the line-up
of trains and on the number of crews in Barstow at the time and on the fact
that
a
traincrew was normally called at 5 a m. The Barstow terminal had computer
monitors
that
crewmembers used to find out the train line-up and crew
information entered into
VIPS
According to the crew's estimates, they had enough
time to have a meal before they went to bed. After eating, the conductor followed
standard practice and went to his room
The engineer took a
different
approach to getting his rest. He stayed up,
intending (as he told his wife) to go to bed later in the day and sleep until he was
called
for work Had he been able to follow his plan, the time between the end of
his
sleep and the beginning of his tour of duty would have been minimal and he
would have been as well rested as possible In theory, his approach was sound. But
because
the unexpected occurred, in practice, it
was
not.
When
the crew arrived in Barstow and checked the line-up, it did not show
any
pending deadhead moves.
Based
on
that
information, the engineer's and
conductor's
estimates of their
next
duty times were reasonably accurate During
the day the engineer had conversations with members of other crews
that
were in
Barstow,
and they were not aware of any pending deadheads If the deadhead
information had been available earlier in the day, it might have been entered in
VIPS,
and the engineer might have made a
different
decision about when to go to
sleep.
Since
the information about the deadheading of crews was not available to
the engineer, he probably wanted to take his sleep at the time he had been