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Safety Recommendation Details

Safety Recommendation R-18-004
Details
Synopsis: The National Transportation Safety Board (NTSB) launched investigative teams to two very similar accidents within 13 weeks of one another. In both accidents, the engineers failed to stop their trains before reaching the end of a terminating track at a station. The September 29, 2016, accident on the New Jersey Transit commuter railroad at Hoboken, New Jersey, killed one person, injured 100, and resulted in major damage to the passenger station. The January 4, 2017, accident on the Long Island Rail Road (a subsidiary of Metropolitan Transportation Authority) at the Atlantic Terminal in Brooklyn, New York, injured 108 people. As the NTSB investigations progressed, it became apparent that these accidents had almost identical probable causes and safety issues. The NTSB also realized that these safety issues were not unique to these two properties, but exist throughout the United States at many intercity passenger and commuter passenger train terminals. The NTSB is issuing two new safety recommendations to the Federal Railroad Administration and two new safety recommendations to New Jersey Transit and the Metropolitan Transportation Authority. In addition, the NTSB is reiterating two safety recommendations to the Federal Railroad Administration.
Recommendation: TO NEW JERSEY TRANSIT AND METROPOLITAN TRANSPORTATION AUTHORITY: Ensure that operator impairment due to medical conditions, including obstructive sleep apnea, is part of the hazard management portion of your system safety program plan.
Original recommendation transmittal letter: PDF
Overall Status: Open - Initial Response Received
Mode: Railroad
Location: Hoboken, NJ, United States
Is Reiterated: No
Is Hazmat: No
Is NPRM: No
Accident #: DCA16MR011
Accident Reports: PRELIMINARY REPORT: RAILROAD DCA16MR011Railroad Accident Brief: New Jersey Transit Train Strikes Wall in Hoboken Terminal
Report #: SIR-18-01
Accident Date: 9/29/2016
Issue Date: 2/14/2018
Date Closed:
Addressee(s) and Addressee Status: Metropolitan Transportation Authority New York City Transit (Open - Initial Response Received)
New Jersey Transit Corporation (Open - Initial Response Received)
Keyword(s):

Safety Recommendation History
From: New Jersey Transit Corporation
To: NTSB
Date: 5/7/2018
Response: -From Kevin S. Corbett, Executive Director: NJ TRANSIT safety sensitive personnel are subject to periodic physical examinations. For example, although not legally required to do so, NJ TRANSIT has screened for obstructive sleep apnea (OSA) for well over a decade - since 2005. When American Passenger Transportation Association's (APTA) Commuter Rail Safety Management Program performed an audit in 2012, they commended NJ TRANSIT for its continuing efforts to improve system safety and specifically praised NJ TRANSIT for using the "Epworth Sleepiness Scale" to assist with screening for OSA during each safety-sensitive employee's annual physical exam. The form records weight, height, body mass index, and neck circumference, and poses a number of questions to gauge how likely the employee is to doze off or fall asleep during the day. APTA recognized that NJ TRANSIT had expanded its OSA program to include partnerships with certified sleep centers as a means to expedite the OSA assessment and corrective action process for employees. They described NJ TRANSIT's program as an "Industry Leading Effective Practice." Since 2014, if a safety-sensitive rail employee is diagnosed with OSA, NJ TRANSIT has removed the employee from service. The employee is not cleared to return to service until the employee provides documentation verifying that the sleep disorder has been treated. If an employee is diagnosed with OSA, NJ TRANSIT monitors treatment compliance on an annual basis. Subsequent to the Hoboken accident, NJ TRANSIT implemented a new Rail OSA procedure to further ensure OSA screening forms are completed, centrally reviewed, and safety sensitive employees meeting referral criteria are removed from service until appropriately tested and, if testing identifies OSA, successfully treated. This new Rail OSA procedure - including temporary removal from service - was implemented on October 1, 2016. NJ TRANSIT later adopted a new corporate-wide policy (CWP 3.34 Obstructive Sleep Apnea Policy-Rail Operations). As of September 30, 2017, all active locomotive engineers had been screened for OSA. In response to NTSB recommendation No. R-18-004, NJ TRANSIT reviewed the hazard management portion of its SSPP (Section 3), as well as the accident investigation and analysis portion (Section 4). More specifically, NJ TRANSIT reviewed the processes and mechanisms necessary for the inception and conclusion of an investigation, relying on technical data and analysis obtained by our professional engineers and other relevant staff. Such processes and mechanisms do not include an investigation into operator impairment due to medical conditions. As we understand the recommendation, we are asked to introduce an investigation for operator impairment due to medical conditions into those processes and mechanisms. Based on our understanding of federal law, such as the Americans with Disabilities Act (ADA) and the Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule, medical records are confidential and access and disclosure is limited. The release of medical information is strictly proscribed. NJ TRANSIT is interested in cooperating with the NTSB and in adopting safety conscious measures. Given the privacy ramifications of this second new recommendation, we will cooperate to the extent that the law allows. Safety is our top priority at NJ TRANSIT and we appreciate your input on steps we can take to improve.

From: NTSB
To: New Jersey Transit Corporation
Date: 2/14/2018
Response: The National Transportation Safety Board (NTSB) is an independent federal agency charged by Congress with investigating every civil aviation accident in the United States and significant accidents in other modes of transportation—railroad, highway, marine, and pipeline. We determine the probable cause of the accidents and issue safety recommendations aimed at preventing future accidents. In addition, we carry out special studies concerning transportation safety and coordinate the resources of the federal government and other organizations to provide assistance to victims and their family members affected by major transportation disasters. On February 6, 2018, the NTSB adopted its report End-of-Track Collisions at Terminal Stations, Hoboken, New Jersey, September 29, 2016, and Atlantic Terminal, Brooklyn, New York, January 4, 2017, SIR-18/01. The details of this special investigation report and the resulting safety recommendations may be found in the attached report, which can also be accessed at http://www.ntsb.gov. Among the safety recommendations are two issued to New Jersey Transit, which can be found on page 41 of the report. The NTSB is vitally interested in these recommendations because they are designed to prevent accidents and save lives. We would appreciate a response within 90 days, detailing the actions you have taken or intend to take to implement these recommendations. When replying, please refer to the safety recommendations by number. We encourage you to submit your response to correspondence@ntsb.gov. If it exceeds 20 megabytes, including attachments, please e-mail us at the same address for instructions. Please do not submit both an electronic copy and a hard copy of the same response.

From: Metropolitan Transportation Authority New York City Transit
To: NTSB
Date: 4/18/2018
Response: -From Joseph J. Lhota, Chairman: As you know, the LIRR implemented its System Safety Program Plan in 1986, and it has been regularly audited by third parties, updated by the railroad, and, in more recent years, certified and recertified by the New York Public Transportation Safety Board. This is also the case for MetroNorth Railroad and New York City Transit, both of which also maintain SSPPs. Going forward, the MTA will work with its agencies to ensure that, where necessary, the SSPPs and related controlling documents are revised in accordance with the above recommendations.

From: NTSB
To: Metropolitan Transportation Authority New York City Transit
Date: 2/14/2018
Response: The National Transportation Safety Board (NTSB) is an independent federal agency charged by Congress with investigating every civil aviation accident in the United States and significant accidents in other modes of transportation—railroad, highway, marine, and pipeline. We determine the probable cause of the accidents and issue safety recommendations aimed at preventing future accidents. In addition, we carry out special studies concerning transportation safety and coordinate the resources of the federal government and other organizations to provide assistance to victims and their family members affected by major transportation disasters. On February 6, 2018, the NTSB adopted its report End-of-Track Collisions at Terminal Stations, Hoboken, New Jersey, September 29, 2016, and Atlantic Terminal, Brooklyn, New York, January 4, 2017, SIR-18/01. The details of this special investigation report and the resulting safety recommendations may be found in the attached report, which can also be accessed at http://www.ntsb.gov. Among the safety recommendations are two issued to Metropolitan Transportation Authority, which can be found on page 41 of the report. The NTSB is vitally interested in these recommendations because they are designed to prevent accidents and save lives. We would appreciate a response within 90 days, detailing the actions you have taken or intend to take to implement these recommendations. When replying, please refer to the safety recommendations by number. We encourage you to submit your response to correspondence@ntsb.gov. If it exceeds 20 megabytes, including attachments, please e-mail us at the same address for instructions. Please do not submit both an electronic copy and a hard copy of the same response.