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Sleep apnea, boring job might have led to fatal trolley crash, not Unisom

NTSB investigators said this morning that they suspect Green Line trolley driver Terese Edmonds fell asleep as she drove out of Waban station, waking too late to stop the crash that took her life - and that the T is failing to do enough to keep workers alert on the job.

Investigators say a sleep-aid drug found in her urine likely did not interfere with her operation, because it was not found in her blood - which means her body had already metabolized it, basically gotten it out of her system. An autopsy ruled out any sudden incapacitation in the seconds before the crash.

Ultimately, however, NTSB acting Chairman Mark Rosenker blamed the MBTA for failing to install a signaling system that would have stopped Edmonds's train before it crashed. He said he is left "scratching his head" at the T's continued to failure to install such a system - a situation that will likely also be investigated as the NTSB looks at this past May's accident involving the texting trolley driver.

Instead, they say Edmonds likely suffered from undiagnosed obstructive sleep apnea, which would have kept her from getting enough restful sleep to stay fully alert on her boring job. They based this on the fact that Edmonds was significantly obese, which often contributes to the condition, in which the sufferer's air passage is blocked, leading to both snoring and inadequate oxygen flow.

Couple this with the lack of muscular activity and lack of mental stimulation in your typical Green Line operating job and the result could have been a "micro-sleep episode" just as Edmonds pulled out of Waban station - and headed around a curve on which another trolley had just stopped for a red light.

Board member Debbie Hersman said she is very concerned about sleep apnea, but urged caution in ruling sleep apnea the cause because there were no reports from partners or doctors about problems and because she had "no classic markers" for fatique, such as prolonged or irregular hours or serious stress in her personal life.

Investigators said they found the MBTA's programs for combating fatigue among workers inadequate. The T, for example, does not currently screen workers at risk for sleep apnea.

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Comments

Any word on what these program are / do?

Never heard of an employer being responsible for his employees getting enough sleep. now, if they knew about it, saw performance was lacking because of an employee constantly being tired, then they should fire them.

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A good place to learn about the issue.

Issues of sleep and work have been a huge factor in preventing road and industrial accidents for generations. While the problems with long-haul and long-shift drivers were early examples, there are numerous areas (such as manufacturing and healthcare) where rotating shifts and night shifts create safety problems.

The T is not 24/7, but they do offer a lot of "split shifts" that require that a person be awake early in the morning, work to mid-morning, leave work for several hours, return for a second half-shift in the afternoon/evening, and leave work in the early evening.

The idea that a company should fire somebody who isn't getting enough sleep because their shift schedules and work hours do not permit proper sleep is absolutely ridiculous. That's why there are limits on shift length in certain industries, and minimum amounts of time for rest in between. Where it has blown up in the last twenty years: hospitals working interns for dangerously excessive amounts of time.

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I under stand that, but I also understand that T operators, while even doing split shifts, have a minimum of 8 hours off a day and work 8 hour total shifts.

Unless the T is scheduling employees to work till 12:30am, then back at 6am, which I doubt, they have no liability.

I can't see this being a practice they encourage, let alone see as by the book.

Which is why I asked.

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That should immediately turn over (with difficulty) about 90% of their staff.

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Your logic is ironclad.

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n/t

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Board member Debbie Hersman said she is very concerned about sleep apnea, but urged caution in ruling sleep apnea the cause because there were no reports from partners or doctors about problems and because she had "no classic markers" for fatique, such as prolonged or irregular hours or serious stress in her personal life.

With all due respect to Ms. Hersman, the part about "classic markers" doesn't make sense. Sleep apnea by itself can cause fatigue. Stress and long working hours are not big contributors to sleep apnea; they are just other causes of fatigue.

To diagnose sleep apnea via autopsy, you would look for anatomical problems in the airway (large tongue, large tonsils, small airway, low-hanging soft palate, etc.) and for signs of respiratory disease (pulmonary edema, pulmonary hypertension). I don't know exactly who the article was referring to when it said "partners," but you would want to ask the victim's bed partner whether the victim snored or gasped while asleep, and you would also want to ask her work partners whether she had trouble staying awake on the job.

Hopefully this will all be clarified when the board releases the final report.

I am disappointed, but not surprised, to hear that the T doesn't screen for sleep apnea. I'm a skinny guy who got diagnosed with apnea in 2005. I probably had it for 10 years before that, and I had never even heard of it or suspected that I had it.

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Other sources seem to spell her name "Ter'rese" (including facebook and this memorial page on the carmen's union):

http://www.carmensunion589.org/special/edmonds/ind...

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But they are 100% confident that Edmunds ran a red light- they ruled out the possibility that her light might have been green while the one in front was "stuck on red"?

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They found evidence that could cause a light to show red, but no evidence that could cause a light to show green incorrectly.

The lights work by sending an electric current through the rail. When a train is on the rail, it interrupts the current and since the current is stopped, the light will show red behind that train. If there is no train, the current should go down the rail and come back, letting the light know that it should be green.

Rails expand and contract with the day's heat, etc. When they do, sometimes they don't directly touch and that would cause the current to stop as if there were a train. To avoid this for normal use, there are "bonds", which are strips of metal wire, between the rails to maintain the current connection even when two rails don't touch. On this particular rail, the bonds were broken and rusted. The investigators could demonstrate that this could cause the light to go red (as if there were a train when there wasn't one).

They didn't see evidence that it could go green if something were wrong. That would require either a train to be present or the bonds to have broken AND yet the electric current proceeded back to the light somehow (magic?). So, their interpretation is that the front train was stopping unnecessarily (yay, longer commutes due to faulty machinery!) due to a broken bond but that the second train went through a _functional_ red signal (where no bonds were broken).

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I might need a few more minutes with it before I comprehend it completely, but it looks good. :)

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I love to blame the T for everything that is wrong with the world but I can't see how they can pin a worker not getting enough sleep on the MBTA. Give me a break!

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This is one of the best examples of how today's society in America allows people to completely unaccountable for their actions. It is the T's fault that some fat T driver has sleep apnea and caused a crash because work is 'boring'? Does that mean that T drivers should sue for a more exciting ride? Hey, maybe they should use their cell phones and ... oh wait, that was another crash.

Bottom line, sleep apnea or no, saying "THE JOB IS BORING IS THE CAUSE" is one of the lamest things I've ever heard, and I read this crap site a couple times a week so I know of which I speak.

How about a weight limit for T drivers? How about an IQ test? Lets give them all GameBoys so they don't get bored.

My bank teller just caused a crash in the deposits department because she was bored with her job. OH NO!

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and preach about accountability, at least have the courage to give your name, you yellow dog.

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....dogs (yellow or otherwise).

This anon displays all the worst traits...

...of a _human_.

;~}

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Most dogs have more courage than anonymous commenters.

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