WASHINGTON (AP) – A train crew rushing to finish its work late on Jan. 5 neglected to realign a hand-operated switch, causing the deadly collision of two trains that spread a toxic cloud over Graniteville, S.C., according to documents released Wednesday.

The conductor, brakeman and engineer were coming up against their legal work limits of 12 hours when they parked for the night on a spur next to a textile mill.

Hours later, a northbound Norfolk Southern train ended up on the spur because the switch that would have kept it on the main rail had not been moved back, investigators from the National Transportation Safety Board said.

The Norfolk Southern train slammed into the parked train. The crash ruptured a tank car, released chlorine gas. Nine people were killed, 250 injured and 5,400 were evacuated.

The conductor and brakeman on the local train told NTSB investigators that they thought the switch had been returned to its proper position after they left the siding for the night.

“In my mind I did,” brakeman Mike Ford told investigators, though he acknowledged, “I am not totally 100 percent sure.”

Conductor Jim Thornton described their rush to tie down the trains so the workers would not surpass their legal limit of 12 hours on the job.

At 6:57 p.m., Thornton looked at his watch and realized they would finish three minutes before they could no longer work legally.

“I said, ‘Lord, mission accomplished,”‘ Thornton told investigators.

Thornton admitted that he never touched the switch and did not remind the brakeman to do it, as required. Engineer Benjamin Aiken said he did not notice whether either man had realigned the switch.

Both Ford and Thornton continued working on paperwork that would clear the track for the next train to use it. They finished nearly an hour after they had worked beyond the legal limit of 12 hours.

Don Hahs, president of the Brotherhood of Locomotive Engineers and Trainmen, said fatigue played a big role in the Graniteville crash. Hahs said train crews cannot count time when they are stranded in a train yard or doing paperwork toward their 12-hour limit.

“It’s a historical issue in the industry – the limbo time,” Hahs said. “The crews are being asked to work beyond the hours of service.”

None of the train crew was tested for drug or alcohol use after the crash.

All three were fired a month after the crash.

According to the Federal Railroad Administration, misaligned switches are one of the leading causes of train wrecks.

The agency reported that between January 2001 and December 2003, there were 751 accidents where switches were not aligned properly and 74 where the switches were not locked.

Hand-operated track switches left in the wrong position caused eight other serious train wrecks since the Graniteville accident. Ten people died and more than 600 were injured in these crashes.

“A small number of particular human errors account for an inordinate number of human factor-caused accidents,” the NTSB concluded in its factual report.

Since the deadly Graniteville derailment, the FRA ordered all railroads to improve their manual track switching procedures or be liable for civil penalties up to $27,000.

The order, issued on Oct. 19, gave railroads until Tuesday to retrain and periodically test employees on procedures for operating a switch. It also requires workers to provide written documentation when a hand-operated switch is changed and locomotive engineers must confirm the switches are set correctly before operating the trains.

Several of the trainmen involved in the Graniteville accident had been disciplined before the crash for failing to properly secure a switch.

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On the Net:

NTSB documents can be seen at this link:

http://wid.ap.org/documents/ntsbrail/default.htm

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