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rush2ny
post Nov 22 2002, 11:03 PM
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We have been discussing an accident in the Canadian forum which was attributed to sleep apnea. I wanted to repost the NTSB report here as well because it is a safety issue and symptoms are listed. Make your fellow railroaders aware!

Sleep Apnea Cited in Train Wreck

A Michigan train wreck that killed two men last year was caused by the fatigue of two crew members who were suffering from severe sleep apnea, the National Transportation Safety Board said in a report approved Tuesday.

Engineer Allen Yash and conductor Jesse Enriquez, who were operating a Canadian National freight train southbound toward Detroit, were diagnosed before the accident with obstructive sleep apnea by their private physicians. Neither had been successfully treated and their conditions were not listed in company medical reports, NTSB's investigation found.

The two men fell asleep while traveling in a wooded area near Clarkston, Mich., just before 6 a.m. on Nov. 15, 2001, and did not see a stop signal or the lights of an oncoming train, the report said. Their train was traveling at 13 miles per hour when it struck another Canadian National train going 30 mph northbound for Flint. The crash killed the 49-year-old engineer, Thomas Landris, and 58-year-old conductor, Gary Chase, of the oncoming train. Yash and Enriquez were hospitalized with serious injuries.

Obstructive sleep apnea, or OSA, causes a person to periodically stop breathing while asleep. Dr. Mitch Garber, a physician on the NTSB's investigation team, said people with the condition will feel extremely sleepy during the day and can drift off after a few minutes in a quiet or monotonous environment.

Sleep apnea also was blamed for a light rail crash at Baltimore-Washington International Airport on Aug. 15, 2000, injuring all 22 people aboard.

Garber estimated that 1 percent to 2 percent of the population has the severe form of OSA.

"It seems odd to have both members of a two-man crew with a similar condition," said board member John Hammerschmidt.

Steve Jenner, another investigator, said Yash had been diagnosed with the condition about a year before the wreck. Despite his doctor's warning that it could cause him to fall asleep on the job, he never followed the physician's instructions to attend a sleep clinic.

Enriquez had been diagnosed several years earlier and was treated at a sleep clinic and given an air-pumping mask to wear at night, but he still suffered from sleeplessness and snoring, so Jenner said it may not have been set at the right pressure. The report also said Enriquez had an irregular and unpredictable work schedule that may have added to his fatigue.

The NTSB recommended that the Federal Railroad Administration develop a standard medical form for railroad companies that would inquire whether operators suffered from sleep conditions. The board also recommended that the administration require that employees with incapacitating medical conditions tell their employer and stop working in safety-sensitive positions until they are successfully treated.

It also recommended that Canadian National require "fatigue awareness training" for its employees. The company offers its employees material on sleep problems, but does not require they read them or offer any classes on the topic.

Canadian National spokesman Jack Burke said the company will consider the recommendation. "I think their focus was appropriate that this was human error," he said.


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rush2ny
post Nov 23 2002, 10:59 AM
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Here's more to the story. It brings up a good question- Do you think that railroaders should have to disclose their medical history?
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The head-on train collision that killed two Shiawassee County men could bring changes in how the railroad industry deals with employee fatigue.

The National Transportation Safety Board - which Tuesday released a report blaming the crash on fatigue caused by sleep apnea - recommended federal officials force railroads to try to detect employee medical conditions that could result in fatigue.

The investigative body also recommended railroads be required to keep employees out of locomotives if their medical problems could affect safety.

There are no current federal requirements that railroads ask their employees whether they have sleep-related disorders or that workers disclose sleep problems.

Both the engineer and conductor on one of the trains involved in the collision likely were incapacitated by chronic fatigue caused by sleep apnea, the NTSB said in its report. As a result, the report said, engineer Allen Yash and conductor Jesse Enriquez didn't stop the train at a red signal, causing it to collide head-on with another train.

The two men in the other train, Gary Chase, 58, of Owosso Township, and Thomas Landris, 49, of Durand, were killed in the Sept. 15, 2001, crash, which occurred west of Clarkston near Andersonville and Big Lake roads.

Yash of Hartland Township and Enriquez of Detroit were seriously injured in the 5:54 a.m. crash.

"It's not a surprise, because I think sleep deprivation has been the dirty little secret of the railroad industry for quite some time," said Steven Kantor, an attorney who represents the Chase and Landris families. "To the extent that maybe some things will be changed as a result of this - that's a good thing."

Officials said federal regulations requiring the disclosure of sleep disorders could face opposition from the railroad industry, unions and privacy advocates.

"The recommendations are certainly something we'd take under advisement," said Jack Burke, spokesman for Canadian National Railway, the company that operated the two trains involved in the crash. "I can't say we won't end up at the same point because there could certainly be some resistance to going toward the path the National Transportation Safety Board laid out. It seems to me what we're talking about is a pretty basic and not unusual clash between two goals - safety on one hand and privacy on the other."

Burke said Canadian National doesn't ask engineers and conductors about sleep disorders because federal law doesn't require it. Without the weight of the law, he said, employees could refuse to answer the question.

All crew members involved in the collision were abiding by a federal law that prevents them from spending more than 12 consecutive hours on duty and requires them to have 10 hours off between shifts, Burke said.

But Kantor said those requirements are insufficient.

"These guys are getting maybe four, five hours of sleep a night," the attorney said. "They work four, five, six days in a row. They may work seven days in a row. The railroads push the limit.

"We would hope that both Canadian National and the industry will take a look at how they're working their workers and when they're working their work schedules and try to give them a more regular work schedule," he said.

People who suffer from sleep apnea periodically stop breathing while they sleep, causing them to awake. As a result, many people suffering from the condition doze off frequently during the day.

The NTSB said Enriquez had been unsuccessfully treated for sleep apnea and also suffered fatigue because of his irregular and unpredictable work schedule. The NTSB said Yash had sleep apnea, but hadn't been treated for it. Canadian National didn't know about their medical problems, the report said.

Dr. Venkat Rao, medical director of the Hurley Sleep Disorder Center in Flint, said about 5 percent of people have sleep apnea.

Anyone who snores and feels sleepy during daytime hours should be evaluated for sleep apnea, Rao said. The condition is easily treatable, and someone who has the disorder should be able to safely operate a vehicle or heavy equipment after successful treatment, Rao said.

Kantor said the Chase and Landris families did not want to comment on Tuesday's report.

"They're certainly glad that there's no mention of any responsibility on the part of Mr. Landris or Mr. Chase, but obviously, they feel not all their questions have been answered by the National Transportation Safety Board, and I'll be continuing with my investigation to try to get the families some answers," he said.

The Chase and Landris families have sued Canadian National over the collision. The case is still pending, as is a lawsuit Canadian National filed against Enriquez and Yash.

Kantor said blaming the crash on fatigue doesn't tell the entire story. He said NTSB officials ignored evidence that problems with equipment on the train could have contributed.

At the time of the crash, Kantor said, Yash was distracted by problems with a device that was supposed to signal whether the back of his train was off the main railway and on a siding track next to the main line.

But Burke said there was no problem with the equipment.

"The counter that he's talking about was tested by the railroad after the crash occurred, and we found it to be in working order," Burke said.

Neither Yash nor Enriquez has returned to work.

Allen Yash's wife, Sherry, said she's not sure if her husband will return.

"It's been a real long year," she said. "Al's doing OK. One leg got a lot of damage done to it. He has a hard time using it. ... He's got a couple of surgeries ahead of him."

Sherry Yash wouldn't comment on the NTSB report. She referred questions to Yash's attorney, who didn't return a telephone call. Enriquez's attorney also didn't return a telephone call.

The NTSB report said the Landris train was going 30 mph when the collision occurred, and the Yash train was going 13 mph. The Yash train was merging onto the main rail line from a siding rail at the time of the collision, the report said.

The report ruled out signal system failure as a possible cause of the crash.


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Tom
post Nov 16 2004, 08:56 PM
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Rush2NY,

Thank you for raising the problem of sleep apnea. Last year, I underwent a sleep study and was diagnosed with severe obstructive apnea. I have received treatment and cannot believe the difference it made in my life.

Over 12 million Americans have apnea. Most American health insurers cover the cost of sleep studies and treatment. Why? Because if untreated, sleep apnea can cause high blood pressure and other cardiovascular disease, memory problems, weight gain, impotency, and headaches. Moreover, untreated sleep apnea may be responsible for job impairment and tragedies such as those mentioned in your post.

Find out about the common symptoms to determine whether you may have apea at the American Sleep Apnea Association -- http://www.sleepapnea.org/asaa.html

Tom


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rockislandmike
post Nov 16 2004, 09:07 PM
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Yours truly has been diagnosed with it as well. How they expect one to sleep when they have all that crap strapped to them is beyond me - but I managed.


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polyjim
post Nov 17 2004, 11:47 AM
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Strange this subject comes up.
I am going thru the process right now. I had a serious breathing problem while at my Navy reunion in Branson late in Sept. Managed to get home and to the doctor's. Two weeks ago, a sleep disorder test with all them dumb wires attached resulted in a diagnosis of sleep apnea, hell I never slept at all. So, next week I get fitted for the mask and sent to sleep school. I don't think I have a problem, but my wife insists that I do, because, she says, I quit breathing at night. And life goes on.


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rush2ny
post Nov 17 2004, 07:13 PM
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Sleep apnea is quite common but not many folk are aware of it. My better half also tells me that I quit breathing at night Jim. I would never know it though. In fact , the only inclination that I have is that I am tired all the time because I never get into a full sleep. This is where it becomes a problem because most people that have apnea also become narcoleptic. A dangerous condition when you are operating a 70,000 lb locomotive!

Russ


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Tom
post Nov 25 2004, 06:50 AM
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"Union Pacific engineers: 'We struggle to stay awake'"
by Ken Rodriguez
San Antonio Express-News

Seven train derailments in Bexar County since May, five fatalities since June, and Union Pacific is literally asleep.

America's largest railroad opens a 24-hour safety command center here while some if its engineers say they doze off on locomotives.

UP increases walking inspections and re-instructs managers while some of its engineers claim they are working on two to three hours of sleep.

"I nodded off several times last night," one Texas engineer told me Saturday morning. "It was tough to stay awake."

The engineer fears he will be fired if he discloses his name, so we'll call him Michael. Michael says he rarely reports to work having slept more than four hours. One day in the spring, he became overwhelmed by exhaustion.

"I told my wife, 'I'm dreading going to work tonight, I'm afraid I'll fall asleep and kill myself or kill somebody,'" he says. "I worry about that all the time."

Michael's story is not uncommon, judging from the engineers I spoke with. They said they are sleep deprived. They receive no assigned days off. They often work 70 to 80 hours a week. Some say they've fallen sound asleep on the job.

Fatigue sometimes is cited as a contributing factor in rail accidents, and staffing levels long have been an issue between the railroad and the unions representing its workers.

Keith Pratt, 68, a retired UP engineer in La Grande, Ore., says he fell asleep once, and narrowly missed a head-on collision with another train.

"The night before, I didn't get much sleep," Pratt says, "Just two, three hours maybe."

One former West Coast UP engineer-in-training quit, fearing a job that would have put her on call seven days a week.

"I was told, 'You need to learn to go to work with sleep deprivation,'" the former UP employee recalls. "I couldn't believe it. I feared not only for my life, but I feared for my co-workers. I feared for the general public."

Union Pacific, of course, fears bad public relations. Third quarter profits, after all, are down. The last thing UP wants is a wave of negative publicity, but the truth stings when it strikes right between closed eyes.

And the truth is that nearly a dozen UP engineers and conductors across the country have told me they are fatigued, afraid and battling to stay awake.

"If anyone says he hasn't ever nodded off, he's lying," Michael says.

"That's absolutely right," adds one California conductor. "You are fatigued all the time."

"I nodded off a couple of nights ago," a California engineer admits. "It's frightening. I'm not a disgruntled employee. I like my job. But Union Pacific needs to pay more attention to fatigue."

Contrast these comments with a message on UP's Web site, which reads: "At Union Pacific, safety is No. 1."

Engineers never know when they will be called. Deciding when to sleep is often guesswork. And sometimes, right when they prepare to lie down, they're called in to work.

Here's the UP spin: Engineers are not allowed to spend more than 12 consecutive hours on the rails.

Here's the reality: After a 12-hour shift, some engineers wait hours for a ride to get home or to a hotel. That's when their official day ends, sometimes 15 or 16 hours after it begins.

One area engineer recalls working a 98-hour week.

"It was 14 hours a day, seven days in a row," he says.

Here's another UP spin: Its engineers are given a minimum of eight hours rest between shifts.

Here's the reality: Engineers spend much of those off hours catching up with spouses, playing with children, doing chores, showering and eating. Little time is left for sleep.

UP says engineers have ample opportunity for rest. The railroad has a chart showing that, in one recent 40-day work period, only four San Antonio rail employees worked more than 34 days. UP says the chart is typical of other systems in the country, though it did not provide supporting evidence.

Nor did it provide any evidence to counter the claim that sleep deprivation is a problem.

It is. The Federal Railroad Administration says fatigue was a possible factor in two local derailments. UP says it's working on the fatigue issue. How? It's conducting a long-term study with the FRA.

UP, how about studying this: Your engineers are dozing. Your trains are derailing. People are dying. Wake up before the next engineer falls asleep and gets someone killed.

Source: http://www.mysanantonio.com/global-include...d.77eb3bef.html
Web Posted: 11/21/2004 12:00 AM CST


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rush2ny
post Nov 25 2004, 06:01 PM
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Thanks for posting this Tom! This is a very poignant state of affairs that I am sure is vastly becoming the norm in America today. Companies are cutting the workforce all over and increasing productivity. Us poor schleps that have families to provide for put up with this kind of abuse just to feed our families. This article fully demonstrates the end result of such practices.

Russ


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Tom
post Dec 5 2004, 06:19 AM
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There is a very thoughtful essay on the subject of fatigue submitted on the Health and Safety bulletin board of RunningTrades.com. You can view it at http://www.runningtrades.com/modules.php?n...=737&highlight=


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Tom
post Dec 8 2004, 08:51 AM
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Australian device detects drowsy drivers
Last Updated Tue, 07 Dec 2004 17:53:33 EST

SYDNEY, AUSTRALIA - An Australian research team claims to have developed a device capable of identifying when a driver is too fatigued to operate a vehicle safely.

Researchers intend to test it on train engineers within a year, hoping to eventually cut down on the number of fatal traffic accidents caused by drivers falling asleep.

The system can read brainwaves to identify when a person is entering different stages of fatigue or even sleep, said Dr. Saroj Lal, a neuroscientist involved in the study.

For the experiment with train drivers, the device will likely be attached by means of a headband.

"We would be able to monitor the driver's attention levels and fatigue status immediately from his brain activity," she said.

"If he's in a fatigued state, he will be given an audible type of alarm.

"If all else fails, we hope to be linking to the train's control systems, give him an alarm through the train's system, also linked to the train's brake systems, and hopefully have the train stop."

The research project involves the University of Melbourne, a company called Integrated Vigilance Systems, and the University of Technology in Sydney.

In Canada, trucking industry statistics say fatigue is the most frequently cited probable cause of accidents (at 31 per cent), compared with the misuse of alcohol or other drugs, cited in just three per cent of cases.

Sleep deprivation has also been linked to accidents in the rail, aviation and marine sectors.

Young men aged 16-29, shift workers, and people with untreated sleep disorders are most at risk of being involved in fatal fall-asleep accidents.

With files from the Australian Broadcasting Corporation.

Written by CBC News Online staff
Source: http://www.cbc.ca/story/science/national/2...vers041206.html


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rush2ny
post Dec 9 2004, 03:24 PM
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Such a simple soulution Tom! I remeber that they were testing such devices as this for automotive use as early as the 70's. Why hadn't it occurred to use this before? Do these newer locomotives come equipped with the deadman pedal as they once had? If not why? Sometimes safety takes 4 steps backwards and everything old is new.

Happy railroading!

Russ


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Tom
post Apr 3 2005, 04:09 AM
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Millions Tired of Being Tired
Sleep Disorder Sufferers Look to Research Strides

By Jennifer Lenhart
Washington Post Staff Writer
Sunday, April 3, 2005; Page C01

Night falls on the Coleman household in Alexandria, and it's noisy. Startled cries come from a grandfather prone to World War II flashbacks, loud bouts of snoring bedevil the grandmother, shouts of "Quiet!" erupt from the bed-hugging teenage grandson. The family didn't exactly feel like springing forward today.

"I hate daylight saving time," said grandmother Ellen Coleman, a State Department employee who recently tested in an overnight sleep lab at Virginia Hospital Center. "I hate it for the morning after. . . . We have to turn the clocks ahead and we're plunged back into darkness."

Daylight saving time makes Coleman feel tired. She doesn't get enough sleep, and the sleep she does get is poor.

The same is true for most of her family and an estimated 40 million other Americans who have sleep disorders.

The nonprofit National Sleep Foundation, in its efforts to raise awareness of the hazards of bad sleep habits, released a poll last week reporting that Americans sleep almost two fewer hours a night than 40 years ago. The consequences of that can be dangerous: Studies show accidents rise in the days after the spring time change and drowsy drivers can be as impaired as drunken drivers.

Months-long waiting lists for rooms in sleep labs attest to the demand for solutions to sleep-related misery.

As the problem of sleep deprivation has worsened, sleep research has advanced. Scientists have identified genes involved in sleep and have figured out which sections of the brain are responsible for behaviors such as suddenly falling asleep or knowing when to wake up.

Scientists, medical industry leaders, military performance experts and inquisitive types are clamoring for more sleep research, and the National Institutes of Health in Bethesda is responding. NIH spent more than $110 million on sleep-related initiatives and doubled the amount awarded in sleep research grants in the last decade, according to a 2003 NIH sleep task force report announcing a major expansion of the effort.

A trickle of sleep research is flowing from academia into examining rooms, giving millions a chance to function better.

"There's been lots learned these last few years about the neurobiological basis of sleep," said Eric B. Sklar, a neurologist with Alexandria Fairfax Neurology and its SleepLab. "Now we're able to tell people who come in complaining of fatigue, memory loss, 'You're not crazy, you're not lazy, you don't have a problem that no one knows anything about. You have an actual medical condition.' And that alone means a lot."

Neurological research in all fields got a boost from the unlocking of the human genetic code and the development of magnetic resonance imaging devices that allow scientists to peek inside the brain while subjects do activities such as reading or looking at photographs meant to evoke responses. The sleep deprivation resulting from many sleep disorders shows up as a darkening of the section of the brain responsible for complex thinking and organizational tasks.

Sleep researchers harnessed these new technologies and put them to work in experiments that led to insights into the function and biology of sleep.

In Boston, a neurological researcher at Brigham and Women's Hospital discovered the location of sleep's on-off switch and dubbed it the "circadian pacemaker." In Palo Alto, Calif., a Stanford University research group identified the gene responsible for narcolepsy. Researchers found that sleep apnea, a potentially life-threatening condition in which airways clog, less oxygen gets into the blood and breathing often stops during sleep, is more common among obese people.

Medical researchers learned new things about established diseases, as well. For example, people with apnea have a higher risk for heart attacks and strokes. The death last year of former Green Bay Packers player Reggie White from complications related to apnea also raised awareness.

Shift-work sleep disorder, a disrupted sleep-wake cycle resulting from schedules that are at odds with the body's internal clock, became a diagnosable condition, and a medication with the trade name Provigil won Food and Drug Administration approval to treat it. Clinical proof that sleep disorders affect job performance caught the interest of businesses, the government and the public. The Army and NASA are now studying ways to translate clinical data into keeping astronauts and soldiers awake.

Soldiers on battlefields or routine patrols are more dangerous to themselves than to the enemy when they haven't slept enough, said retired Army Col. Gregory Belenky, who until recently was director of the neuropsychiatry division at Walter Reed Army Institute of Research.

Belenky debriefed soldiers involved in friendly-fire incidents in the Persian Gulf War and recorded symptoms characteristic of sleep deprivation. The sleep-deprived brain still sends signals for performing simple tasks, but it doesn't do as well with more complex tasks.

"So you had soldiers shooting straight, putting cross hairs on the target, but the problem was knowing and being oriented to the battlefield and knowing who was who and what was what," Belenky said. "That is more complex, and that appears to be degraded by sleep deprivation."

Belenky and other Army researchers are developing a sleep-monitoring program that will involve a small number of soldiers in Iraq wearing devices that will record whether the subject is asleep, total sleep time and, eventually, biomedical data.

"It will allow commanders to see, soldier by soldier, small unit by small unit, how topped off people are not just on fuel and ammunition, but also on sleep, and then use this information to decide who should go on a particular mission and who should take a break," Belenky said.

The habit of sacrificing sleep shows up among children, too. Jodi A. Mindell, author of "Sleeping Through the Night" and associate director of the Sleep Disorders Center at the Children's Hospital of Philadelphia, said that not getting enough sleep robs children of "all the really important things that you need to learn in school."

The Philadelphia center draws children diagnosed with attention deficit hyperactivity disorder whose parents want a second opinion. About 10 percent of such children "probably have an underlying sleep disorder that either leads to their daytime behavior problems or makes them worse," Mindell said.

In sleep centers around the Washington region, people are finding out they are not alone and that their sleep-addled memory problems don't signal a loss of intelligence.

A dozen members of a sleep apnea support group gathered in the SleepLab's waiting room in Alexandria one night last week, swapping tips on the latest equipment, as Beverly Burns, lab coordinator and support group organizer, gave advice.

Benny Pittman, a social policy consultant, tried to sit still as a technician applied about two dozen electrodes to his scalp, legs, chest and back for a sleep test. He came to the lab after his boss told him that Pittman's sleepiness was affecting his performance and said he should get help.

"I used to think it was a macho thing, you know, who can snore loudest," Pittman said. "People's attitudes are changing. My attitude's changing."


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chapmon
post Apr 3 2005, 07:04 AM
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Rush2NY:

I need to join this group, since I was also diagnosed with this illness. I have to use CPAP and Oxygen every night, so I can identify with it.

Best of health to all of you guys, we don't want to lose any of us!!

Wish me luck, since I've just started on a new diet med prescribed by my doctor. My goal is from 390 down to 220.

Chapmon[mband]


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polyjim
post Apr 3 2005, 11:00 AM
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I was diagnosed with sleep apnea last November or so and started with the half-mask CPAP. The doctor and others family members who were familiar with the problem said using the CPAP would vastly improve my sleep habits. Two weeks ago I had a follow-up sleep test. I went from the half-mask to a full face mask, because the half didn't cover my mouth and allowed me to breath thru my mouth instead of my nose.
As far as improving my sleep[zzz][zzz], I don't think so. I didn't think I had a problem before, but the first test showed I only got 17 minutes of sleep, all nite long. With the full mask I sleep better, but still don't have the results I expect for the incomvenience of the mask.
My primary care doctor says to lose weight, so I am now on a moderation diet.
Michael, is there a forum for us? I'd like to chat with others.


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rush2ny
post Apr 3 2005, 07:08 PM
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Jim, that is a good question. I have yet to come across a forum for us sleep deprived. My sleep apnea is caused in part by a slightly deviated septum and slight polyps. I am primarily a nose breather so I actually stop breathing several times a night because of this. To make matters worse, I also wake myself up with my snoring it gets so bad. Good thing that I have my wife to elbow me in the ribs every now and again to wake me up again. All I can say is thank heavens for caffeine. Anyway, let me know if you find a forum about apnea. I am looking for natural cures as I do not want surgery.

Russ


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Tom
post Apr 5 2005, 06:41 PM
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NTSB HIGHLIGHTS SAFETY ISSUES RELATED TO SLEEP DISORDERS


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Washington, D.C. - National Transportation Safety Board Acting Chairman Mark Rosenker today reemphasized the importance of medical screening for vehicle operators who may have undiagnosed sleep disorders. The remarks come at the beginning of National Sleep Awareness Week (March 28 - April 3), during which the NTSB hopes to raise public awareness of its ongoing concern about fatigue-related safety issues.

The U.S. Department of Health and Human Services estimates that sleep disorders such as insomnia, sleep apnea, and restless legs syndrome affect 50 to 70 million Americans. Sleep disorders were among the safety concerns addressed in the Board's Special Investigation Report, Medical Certification of Noncommercial Drivers, adopted in November 2004. The Board has recommended education for vehicle operators and their physicians about sleep disorders and how they may contribute to fatigue-related performance decrements, improved medical exams for commercial operators that include questions on sleep problems, and restrictions on the use of medicines that may cause impairment during vehicle operation.

The Board also addressed sleep disorders at a public hearing hosted by NTSB in March 2003 concerning factors that contribute to medically related highway accidents. Acting Chairman Rosenker stated that the Board has linked fatigue resulting from sleep disorders to numerous accidents. He noted, "In many cases operators are not aware that they suffer from a sleep disorder until after they have been involved in a crash."

By raising awareness about the importance of sleep and the need for operators to be screened and, if needed, treated for sleep disorders, the Board hopes to decrease the number of accidents attributable to fatigue. In an effort to further highlight and share information on the significant role fatigue plays in transportation safety, the Safety Board has developed a two-day course designed to bring together federal and commercial transportation officials, law enforcement officers, and other interested parties to discuss the topic at the NTSB Academy in Ashburn, Virginia.

Source: http://www.ntsb.gov/Pressrel/2005/050329a.htm


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post Apr 22 2005, 03:00 AM
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UP faces probe on human error
Web Posted: 04/19/2005 12:00 AM CDT
Patrick Driscoll
San Antonio Express-News Staff Writer

Federal officials probing June's deadly train crash in South Bexar County will grill Union Pacific on how it manages employees, including handling fatigue and testing for drugs and alcohol.

The National Transportation Safety Board has scheduled a two-day public hearing in Washington that will start April 26.

The hearing will focus on human error, a suspected cause of the June 28 wreck in which a UP train slammed into a Burlington Northern Santa Fe train. Four locomotives and 35 cars derailed, including a tank car that spewed chlorine gas.

Four people died from inhaling the poisonous fumes and about 50 were injured.

Among witnesses called to testify at the hearing are representatives of UP, the Federal Railroad Administration, the United Transportation Union and the Brotherhood of Locomotive Engineers and Trainmen.

"I'm sure we'll be able to talk about their concerns," said UP spokesman Mark Davis.

Union representatives are ready to discuss problems with chronic fatigue, said Terry Briggs, chairman of the Texas legislative board of the Brotherhood of Locomotive Engineers.

"Everybody experiences fatigue at some time," he said.

Federal law requiring eight to 10 hours rest between train trips doesn't allow enough time for getting to and from home, eating, bathing and sleeping, Briggs said.

Also, sleep can be disturbed by a call up to three hours before a rest period ends to come back to work.

Another problem is imprecise scheduling of trains, which can keep crews waiting and awake for hours before starting a work shift, he said.

"A person can be in compliance with the law and still be tired," Briggs said.

Fatigue may have played a part in the wreck, FRA officials said in a letter late last year to Sen. Kay Bailey Hutchison, R-Texas.

The UP engineer failed to apply brakes despite passing two yellow warning signals, officials said in the days after the collision.

The engineer, who was injured, was dismissed from his job a couple of months later but UP officials declined to say why.

Also, the conductor, who died, had a slight amount of alcohol in his blood though not enough to be under the influence, FRA officials reported.

The FRA launched an investigation of UP operations last year and cited concerns about the company being understaffed and not properly training workers. Railroad officials signed a one-year agreement in November to fix the problems.

County officials said the hearing's emphasis on human factors appears to be on target.

"Those are great issues," said Seth Mitchell, chief of staff for the county judge. "Those are the kind of issues that we raised as well."

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pdriscoll@express-news.net
Source: http://www.mysanantonio.com/news/metro/sto....1ef265e11.html


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post Apr 23 2005, 06:06 AM
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Fatigue Stopping Crews Dead in Their Tracks: Overworked railroad staffs are a frequent cause of accidents, including some of the deadliest and costliest of the last 20 years.
By Dan Weikel
Times Staff Writer

April 24, 2005

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.

Tired crews have caused some of the deadliest and costliest freight train wrecks of the last 20 years, a review of federal accident reports show. And although the government doesn't track fatigue-related crashes, the number of accidents caused by human error has increased 60% since 1996, a surge that some safety experts suspect is at least partly the result of weary crews.

"We have been talking about the same issues for more than 20 years," said William Keppen of Annapolis, Md., a retired engineer, former union official and past coordinator of Burlington Northern Santa Fe's fatigue countermeasures program. "We made some progress in the 1990s, but the whole thing is starting to go to hell. People are dying out there. The risk is increasing again."

National Transportation Safety Board records show that entire crews have nodded off at the controls of milelong 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.

At a freight terminal before the crash, Dittbenner wrote a prophetic letter to the railroad company but never got a chance to mail it.

"I said something like, 'We weren't getting enough sleep. The railroad is always short-handed and working us to death. If nothing is done, someone is going to get hurt,' " Dittbenner recalled in an interview. "That someone was me."

U.S. Probes Few Crashes

Federal regulators believe that fatigue underlies many train accidents, though the number of crashes related to the lack of rest is unknown.

The government investigates few crashes, leaving most of them to the railroads to review. By law, those carriers submit reports to the government. Under cause, the only fatigue-related category is "employee fell asleep," which Federal Railroad Administration officials say doesn't provide a full picture of the problem.

In 2004, the industry reported 3,104 significant accidents to the railroad administration. About 1,250 were attributed to human factors such as poor judgment, miscommunication and failure to follow operating procedures errors that experts say can be triggered by fatigue.

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."

Part of the problem is the federal Hours of Service Act, a 98-year-old law that requires at least eight hours off after each shift.

Crew members say that often doesn't result in adequate sleep. Allowing for commutes, family obligations, meals and getting ready for work, four to six hours of rest is common, they say.

Moreover, it is legal under the act for engineers, conductors and brake operators to work up to 432 hours a month. In contrast, truckers can drive no more than 260 hours a month under federal law, while commercial pilots are restricted to 100 hours of flying a month.

"It doesn't make scientific or physiological sense," said Mark R. Rosekind, a past director of NASA's fatigue countermeasures program and a former consultant to Union Pacific. "It calls for a minimum of eight hours off, but people need eight hours of sleep a day on average."

Without adequate rest, engineers can significantly increase their risk of an accident, according to research in the late 1990s by the Assn. of American Railroads, the industry's trade organization and lobbying arm.

Donald G. Krause, then an analyst for the association, studied 1.7 million work schedules and 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.

His work was intended to aid the industry in assessing the fatigue problem and finding ways to reduce accidents. But in 1998, the association canceled the research.

"They did not want this finding," said 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.

Not a New Problem

Exhausting schedules are nothing new in railroading. In 1863, long hours contributed to the founding of the Brotherhood of Locomotive Engineers, one of the nation's oldest unions.

Crew fatigue is even enshrined in American folklore. Engineer Casey Jones was killed when he rear-ended another train in 1900 near the end of a double shift. The accident inspired a song, "The Ballad of Casey Jones."

Today's fatigue problem is the result of a variety of developments over the last two decades, say union officials, railroad consultants, company executives and train crew members.

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.

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."

Held said that fatigue led to a train collision April 28, 2004, in the Cajon Pass of San Bernardino County, a long, tricky grade that requires constant attention.

Federal records show that both the engineer and conductor of a Burlington Northern Santa Fe train dozed off and struck a Union Pacific train at 5:15 a.m. Five cars derailed.

"There have been four or five fatigue-related incidents up there," Held said. "We're lucky no one was killed."

Interest in fatigue as a safety problem intensified in the mid-1980s, when the NTSB concluded that weary crews contributed to three collisions involving Burlington Northern trains that left 12 dead.

But the railroad industry did not launch a major initiative until two Santa Fe freight trains collided Nov. 7, 1990, in Corona, killing four and causing $4.4 million in damage.

The fiery head-on crash occurred at 4:11 a.m., when a westbound train ignored a stop signal and crept onto the main track from a siding. It collided with an eastbound freight train going about 30 mph.

Crew members on the westbound train tried to run from the wreckage but were consumed by a fireball. The brake operator on the other train was killed; the engineer and conductor suffered serious injuries.

A year later, NTSB investigators concluded that the crew at fault had probably fallen asleep. They noted that engineer Gary Ledoux and brake operator Virginia Hartzell had not slept for almost 27 hours, making them drunk with exhaustion. Conductor James Wakefield had no more than six hours of rest the day before.

Of Ledoux's last 54 shifts, 35 had different reporting times at all hours. The day before the crash, because of a last-minute shift change, Ledoux had only 5 1/2hours of sleep before guiding a freight train from Los Angeles to Barstow, arriving at 12:40 p.m.

En route to Los Angeles, Ledoux exceeded speed limits 13 times. As he neared Corona, he turned on the cab's dome light and opened the window in an apparent attempt to stay awake.

Seeking voluntary solutions

The Corona accident prompted the formation of the Work Rest Task Force, which stressed a voluntary approach by railroad companies and labor unions to sponsor research and find solutions without government intervention. In 1996, the North American Rail Alertness Partnership was formed. The Federal Railroad Administration also organized related efforts.

Today, a variety of fatigue countermeasures are partially in place or under consideration at the nation's largest railroads, including Burlington Northern Santa Fe, CSX Transportation, Norfolk Southern and Union Pacific.

Some railroads have started voluntary work-rest cycles, though they are not available to most of their freight crews. A typical arrangement is seven days on and three days off. Educational materials are available, crew lodgings at hotels have been upgraded and most major railroads, after years of resistance, now allow short naps for those on duty.

Executives at some companies say they are moving to more regularly scheduled freight service, which can make crew members' hours more predictable.

At Burlington Northern Santa Fe, crew members are entitled to 14 hours of undisturbed rest after working eight hours. At CSX, they can ask for undisturbed rest for up to 10 hours, and fixed work-rest cycles are available at several major hubs.

Officials at all of the nation's largest railroads say they are hiring thousands of engineers and conductors to reduce crew shortages. The companies, which handle about 90% of the nation's rail freight, added more than 4,000 crew members in 2004, a 7% increase over 2003.

The Assn. of American Railroads contends that a voluntary effort is more likely to succeed than a "one-size-fits-all" approach that government regulation would create.

"We have made huge gains by working cooperatively," said Alan Lindsey, general director of safety and rules for Burlington Northern Santa Fe. "We have come a tremendous way as an industry."

Although accidents related to human error are increasing, the railroad association cites federal data that deaths and injuries of railroad workers from accidents are at record lows.

Fatigue "is not what I'd consider a major safety issue at this point, but it is an issue we take seriously," said Robert C. VanderClute, the association's senior vice president of safety and operations.

Industry critics, however, point to Union Pacific, the nation's largest carrier, in asserting that the voluntary approach isn't working. Understaffing and crew fatigue have persisted at Union Pacific despite the railroad's participation in the Work Rest Task Force.

The largest team of safety inspectors ever assembled by the Federal Railroad Administration descended on Union Pacific in 1997 after five major crashes in eight weeks killed seven people.

Long hours, unpredictable work schedules and train crews that had worked days on end without time off were partly to blame.

Since last May, the Federal Railroad Administration and the NTSB have been investigating seven derailments and crashes involving Union Pacific trains near San Antonio, including the Macdona wreck.

Crew fatigue is suspected in at least two of the accidents.

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.

The company has vowed to add 200 engineers and conductors in the San Antonio area, where the Macdona crash occurred, and 2,500 this year across its vast network.

The company also is experimenting with a two-days-on, two-days-off work-rest cycle for engineers at its giant freight hub in North Platte, Neb.

"Generations have been dealing with this problem," said John Bromley, a Union Pacific spokesman. "There are not going to be any overnight solutions."

Critics say the industry isn't doing enough voluntarily and that further government regulation is needed. But when it comes to combating fatigue, the wheels of reform turn slowly.

Bills requiring fatigue management plans and improvements to the Hours of Service Act have failed repeatedly in Congress since 1998 because of corporate and labor opposition.

Out of frustration, NTSB officials say they recently withdrew their long-standing recommendation for revisions to the act.

Amending the law to reflect modern sleep science had been on the NTSB's "10 Most Wanted List" of safety improvements since 1990.

George Gavalla, who headed the Federal Railroad Administration safety office from 1997 to 2004, said trying to reduce the fatigue problem "was one of my biggest frustrations."

"I'm disappointed we could not accomplish more," he added. "It is a huge safety issue."


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Copyright 2005 Los Angeles Times
http://www.latimes.com/news/local/la-me-fa...-home-headlines


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post Apr 26 2005, 04:24 PM
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FOR IMMEDIATE RELEASE: April 19, 2005 SB-05-13

SAFETY BOARD DETERMINES FATIGUE AS CAUSE OF A LOUISIANA MOTORCOACH ACCIDENT


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Washington, D.C. - The National Transportation Safety Board today determined that the probable cause of a fatal accident involving a 49-passenger motorcoach was the motorcoach driver's operation of the bus in a reduced state of alertness due to fatigue as a result of his chronic insomnia and poor quality sleep.

On October 13, 2003, a 1992 Neoplan USA Corporation 49 passenger motorcoach was traveling eastbound on Interstate 20 near Tallulah, Louisiana. As the motorcoach approached milepost 168, it drifted rightward from the travel lanes and onto the shoulder, where it struck the rear of a 1988 Peterbilt tractor semitrailer, which was stopped on the shoulder. Eight of the 14 passengers on board sustained fatal injuries. The motorcoach driver and six passengers received serious injuries. The Peterbilt driver was not injured.

The report states that the need for sleep varies among individuals. Losing as little as 2 hours of sleep a night can negatively affect alertness and performance, resulting in degraded judgment, decision-making, and memory; slowed reaction time; lack of concentration; fixation; and irritability. The Board found that this was a fatigue-induced accident although some facts are not typical of such a scenario.

For instance, the accident occurred in the late morning, not a time of day likely to induce sleepiness. The driver had not been on duty for an excessive length of time when the accident occurred. Also the driver's 72-hour history shows that he had the opportunity to obtain sufficient sleep during the three nights preceding the accident. Considering (a) the driver's preaccident behavior which was indicative of drowsy driving and (cool.gif documented medical conditions and sleep problems including chronic insomnia, chronic pain, mild obstructive sleep apnea, and a history of interrupted sleep, the Board concluded that the motorcoach driver's operation of the bus in a reduced state of alertness due to fatigue as a result of his chronic insomnia and poor quality sleep was the probable cause the accident.

Contributing to the cause of the accident was the failure of Alpha Trucking, Inc., to perform vehicle maintenance and to provide safety management controls, which resulted in the accident tractor semitrailer being parked on the interstate shoulder with a smoking brake. The report states that Alpha Trucking's vehicle maintenance was consistently deficient as evident by the habitual and progressive mechanical neglect found in roadside inspections and the Board's postaccident investigation. As a result, the Board found that Alpha Trucking, Inc., misused the motor carrier vehicle self-inspection program by failing to employ the services of a qualified inspector and by misrepresenting the completion of vehicle repairs, thereby compromising the safety of the traveling public. Accordingly, the Board recommended that the Federal Motor Carrier Safety Administration conduct a study on the safety effectiveness of the self-inspection and certification process used by motor carriers to comply with annual vehicle inspection requirements and take corrective action, as necessary.

During the Tallulah crash sequence, many passenger seats did not remain secure in their original positions in the passenger compartment, even in the space outside the impacted area. Consequently, the Board determined that inadequate seat anchorage hardware used by Neoplan USA Corporation failed during the accident and resulted in more severe injuries to passengers. The Board found that no performance standards are in place for motorcoach seat anchorages and some anchorage systems may be inadequately designed to withstand crash forces. As a result of the investigation, the Safety Board recommended that the National Highway Traffic Safety Administration develop performance standards for passenger seat anchorages in motorcoaches.

Another reason the seats did not remain in their original positions during the accident was that several of the T-bolts that fastened the seats to the stainless-steel floor track had been incorrectly installed and/or maintained. Improperly secured motorcoach passenger seats are not likely to be identified during commercial vehicle inspections because no criteria or procedures are available for the inspection of motorcoach passenger seating anchorage systems. Therefore the Board recommended that FMCSA and the American Association of Motor Vehicle Administrators develop a method for inspecting motorcoach passenger seat anchorages and revise their inspection standards and procedures.

A synopsis of the accident investigation report, including the findings, probable cause and safety recommendations, can be found on the "Publications" page of the Board's web site, www.ntsb.gov.


NTSB Media Contact: Keith Holloway, 202-314-6100
hollowk@ntsb.gov


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post May 8 2005, 05:59 AM
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Union Pacific plan allows crews to choose undisturbed rest time
BY STACIE HAMEL
WORLD-HERALD STAFF WRITER

Union Pacific Railroad began allowing more undisturbed rest time between shifts this week to cut fatigue among train crews.

Source: http://www.omaha.com/index.php?u_pg=46&u_sid=1402277


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