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Safety Recommendation Details

Safety Recommendation H-01-020
Details
Synopsis: On May 9, 1999, about 9:00 a.m., a 1997 Motor Coach Industries 55-passenger motorcoach, operated by Custom Bus Charters, Incorporated (Custom), was traveling eastbound on Interstate 610 in New Orleans, Louisiana. The bus, carrying 43 passengers, was en route from La Place, Louisiana, to a casino approximately 80 miles away in Bay St. Louis, Mississippi. As the bus approached milepost 1.6, it departed the right side of the highway, crossed the shoulder, and went onto the grassy side slope alongside the shoulder. The bus continued on the side slope, struck the terminal end of a guardrail, traveled through a chain-link fence, vaulted over a paved golf cart path, collided with the far side of a dirt embankment, and then bounced and slid forward upright to its final resting position. Twenty-two passengers were killed, the busdriver and 15 passengers received serious injuries, and 5 passengers received minor injuries.
Recommendation: TO THE FEDERAL MOTOR CARRIER SAFETY ADMINISTRATION: Develop a comprehensive medical oversight program for interstate commercial drivers that contains the following program elements: Individuals performing examinations have specific guidance and a readily identifiable source of information for questions on such examinations.
Original recommendation transmittal letter: PDF
Overall Status: Open - Acceptable Response
Mode: Highway
Location: New Orleans, LA, United States
Is Reiterated: Yes
Is Hazmat: No
Is NPRM: No
Accident #: HWY99MH017
Accident Reports: Motorcoach Run-Off-The-Road
Report #: HAR-01-01
Accident Date: 5/9/1999
Issue Date: 9/10/2001
Date Closed:
Addressee(s) and Addressee Status: FMCSA (Open - Acceptable Response)
Keyword(s):

Safety Recommendation History
From: NTSB
To: FMCSA
Date: 6/3/2019
Response: We note that you continue to improve the quality and availability of medical information sources, including providing live webinars, issue-specific training, a call center, and ongoing availability of your Medical Programs Division staff. We are pleased to learn that you filled your chief medical officer position, ensuring a lead agency source for medical information. In addition, we are encouraged that you continue to move forward with rulemaking to update medical standards and that you are developing reference materials for medical examiners, including a medical topic reference table and an updated medical examiner’s handbook. We look forward to seeing these documents published when the National Registry website rebuild is finished later this year. Once complete, these efforts should address the intent of these recommendations and provide medical examiners with the reliable and consistent source of medical guidance they need when deciding whether to approve a certificate application. Accordingly, Safety Recommendations H-01-19 and 20 remain classified OPEN--ACCEPTABLE RESPONSE.

From: FMCSA
To: NTSB
Date: 1/18/2019
Response: -From Michael Jordan, Strategic Planning and Program Evaluation Division, Federal Motor Carrier Safety Administration: On August 8, 2018, and December 4, 2018, representatives from the Federal Motor Carrier Safety Administration (FMCSA) and National Transportation Safety Board (NTSB) met to discuss the status of 13 safety recommendations. This memorandum communicates the status updates discussed at those meetings. Source: Highway Accident Report (NTSB/HAR-01/01); New Orleans, Louisiana (1999-05-09) Current Classification: Open - Acceptable Response Requested Classification: Open - Acceptable Response Status Update: • FMCSA’s Medical Programs Division staff assist CMEs directly by answering medical certification and National Registry related questions by phone, e-mail, and letters received via the U.S. Postal Service. In addition, CME questions are also forwarded from other FMCSA Division offices and from FMCSA field staff for direct reply. • The Medical Programs Division recently established a Call Center dedicated to incoming medical inquiries and continues to staff a National Registry helpdesk. • FMCSA recently concluded a series of webinars to educate CMEs about how to conduct the physical qualification examination and complete the required driver examination forms, as well as a series of live question and answer sessions to answer specific medical questions from CMEs. For these question and answer sessions, CMEs submitted medical certification questions in advance that were organized by topic and answered during each live session. • As part of the compliance education materials currently being developed, FMCSA will include a quick reference table categorized by medical topic that contains links to the corresponding FMCSR, medical advisory criteria, evidence reports, and MRB recommendations. We anticipate this reference table to be available on the FMCSA and National Registry websites by the end of this calendar year. Due to the National Registry system being taken down on December 2017, this update has been delayed. • FMCSA tasked the MRB in September 2017 and again in June 2018 with developing recommendations for the Agency to consider regarding content for various parts of the Medical Examiner Handbook. • FMCSA is pleased to inform NTSB that Dr. Joseph Sentef has joined FMCSA’s Office of Policy as the new Chief Medical Officer. o FMCSA had previously encountered significant challenges in its recruitment efforts to fill the Chief Medical Officer position. The position was announced on three separate occasions and each time the Agency experienced recruitment barriers associated with salary. FMCSA coordinated with the Office of the Secretary of Transportation (OST) to obtain approval from the Office of Management and Budget (OMB) and the Office of Personnel Management (OPM) to increase the salary offer. Although OMB and OPM approved the salary range increase, it remains a capped offer. FMCSA advertised for this position again in September 2017 and revised the recruitment strategy to reach a broader community of qualified candidates that resulted in the selection of Dr. Sentef. • FMCSA requests NTSB maintain its classification for safety recommendation H-01-020 as Open - Acceptable Response.

From: NTSB
To: FMCSA
Date: 12/6/2017
Response: We note that you are working to improve the quality and availability of medical information sources. We previously noted that your Medical Programs Division remains available to provide guidance on the National Registry documents, and we understand that you have renewed your efforts to bring a medical doctor on staff. We are pleased that you are moving forward with rulemaking to update medical standards and that you are developing training and reference materials for medical examiners, including an updated medical examiner’s handbook. Once complete, these efforts should address the intent of these recommendations and provide medical examiners with the reliable and consistent source of medical guidance they need when deciding whether to approve a certificate application. Accordingly, Safety Recommendations H-01-19 and -20 are classified OPEN--ACCEPTABLE RESPONSE.

From: FMCSA
To: NTSB
Date: 9/6/2017
Response: -From Michael Jordan, Strategic Planning and Program Evaluation Division, Federal Motor Carrier Safety Administration: Report: Investigation - New Orleans, Louisiana (2009-05-09) Current Classification: Open - Unacceptable Response Requested Classification: Open - Acceptable Response • FMCSA’s Medical Programs Division staff assist medical examiners directly by answering medical certification and National Registry related questions by phone, emails, and letters via the U.S. Postal Service. In addition, medical examiner questions are also forwarded from other FMCSA Division offices and from FMCSA field staff for direct reply. • The Medical Programs Division recently established a Call Center dedicated to incoming medical inquiries and continues to staff a National Registry helpdesk. • FMCSA just concluded a series of webinars to educate medical examiners about how to conduct the physical qualification examination and complete the required driver examination forms, as well as a series of live question and answer sessions to answer specific medical questions from medical examiners. For these question and answer sessions, medical examiners submitted medical certification questions in advance that were organized by topic and answered during each live session. • As part of the compliance education materials currently being developed, FMCSA will include a quick reference table categorized by medical topic that contains links to the corresponding FMCSR, medical advisory criteria, evidence reports, and MRB recommendations. We anticipate this reference table to be available on the FMCSA and National Registry websites by the end of this calendar year. • FMCSA will be tasking the MRB in September with developing recommendations for the Agency to consider regarding content for various parts of the Medical Examiner Handbook. • FMCSA has encountered significant challenges in its recruitment efforts to fill the Chief Medical Officer position. The position was announced on three separate occasions and each time the Agency experienced recruitment barriers associated with salary. FMCSA coordinated with the Office of the Secretary of Transportation (OST) to obtain approval from the Office of Management and Budget (OMB) and the Office of Personnel Management (OPM) to increase the salary offer. Although OMB and OPM approved the salary range increase, it remains a capped offer. We anticipate advertising for this position again in September 2017 and have revised our recruitment strategy to reach a broader community of qualified candidates. • FMCSA requests NTSB reclassify safety recommendation H-01-020 as “Open – Acceptable Response.”

From: NTSB
To: FMCSA
Date: 6/5/2017
Response: We are disappointed that, despite your efforts to provide National Registry guidance to medical examiners, medical information sources continue to be lacking. We note that your Medical Programs Division is available to provide guidance on the National Registry documents; however, without a medical doctor on staff, and given the fact that the medical examiner’s handbook that you were developing has been removed from your website, medical examiners do not have sufficient guidance about how medical conditions, such as diabetes, affect a commercial driver, and they are forced to use their best judgment when deciding whether or not to approve a certificate application. In current investigations (San Jose, California; Laredo, Texas; Palm Springs, California; and Baltimore, Maryland), NTSB investigators continue to find that medical examiners use various approaches to deal with certifying commercial drivers with glucose issues. We continue to believe that medical examiners need a reliable and consistent source of medical guidance. Pending the development and availability of the recommended medical information, Safety Recommendation H 01-20 is classified OPEN--UNACCEPTABLE RESPONSE.

From: FMCSA
To: NTSB
Date: 1/27/2017
Response: -From Michael Jordan, Management and Program Analyst, Strategic Planning and Program Evaluation Division, Federal Motor Carrier Safety Administration: Report: Investigation - New Orleans, Louisiana (1999-05-09) Current Classification: Open – Acceptable Response Requested Classification: Closed Program Office: MC-PSP • National Registry Help Desk for technical support. • Medical Programs Division call line that allows callers to speak directly with the Medical Programs Staff. Approximately 100 calls per day. • FMCSA Medical e-mail box for questions that the Medical Programs Division staff respond to daily. • Federal Medical Exemptions Program help desk. • National Registry Resource Center that provides frequently asked questions, listserv messages, fact sheets, brochures, manuals for both training and testing organizations, and the Complete Guide to Medical Examiner Certification (https://nationalregistry.fmcsa.dot.gov/ResourceCenter/) • Formal training provided by training organizations that are accredited by a nationally recognized medical profession accrediting organization to provide continuing education units. • The FMCSA website provides access to a wealth of information for the ME to include the Medical Review Board recommendations, regulations, medical advisory criteria, medical conference reports, federal register notices, and forms/applications. • FMCSA requests NTSB close safety recommendation H-01-020.

From: NTSB
To: FMCSA
Date: 11/7/2016
Response: Reiterated in the Highway Accident Brief “School Bus Roadway Departure” Nohl Ranch Canyon Road, Anaheim, Orange County, California, April 24, 2014 Report Number: NTSB/HAB-16/06, published on November 7, 2016, Notation number 8782: The NTSB has previously recommended, in its Safety Recommendation H-01-20, a comprehensive medical oversight program for interstate commercial drivers that provides guidance and additional information to medical examiners to improve their certification decisions.19 As noted above, the FMCSA created a Medical Examiner Handbook that contained such guidance; however, that information is no longer available from the FMCSA. The link on the FMCSA webpage providing access to the handbook has been replaced with a message that states, “This document is in the process of being updated. A revised version will be published shortly.” This message has been in place for almost 2 years. Disease-specific guidance about certification could be particularly useful to certified medical examiners in cases of uncommon medical conditions, such as pulmonary hypertension. Therefore, the NTSB reiterates Safety Recommendation H-01-20 to the FMCSA.

From: NTSB
To: FMCSA
Date: 9/6/2013
Response: We are encouraged by the FMCSA’s recent progress in addressing these recommendations. The issuance of the 2010 final rule combining the medical certificate with the commercial driver’s license and the 2012 final rule establishing the National Registry, together with the ongoing efforts of the Medical Review Board to examine medical issues affecting commercial motor vehicle (CMV) drivers, are important steps toward the development of the comprehensive CMV driver medical oversight program that we envisioned when we issued these recommendations 12 years ago. When the National Registry becomes fully effective in May 2014, it should address the education and training of medical examiners to certify their compliance with FMCSA regulations and guidance. We emphasize that, in previous correspondence, the NTSB pointed out ongoing areas of deficiency in the FMCSA’s proposed National Registry rulemaking, including (1) the continuing potential for insufficiently qualified examiners, (2) the lack of a process to review and track medical certification exams or decisions, (3) the lack of reporting mechanisms between required exams, and (4) the lack of coordination between data collection processes. On May 10, 2013, the FMCSA published a notice of proposed rulemaking (NPRM) that proposes a new medical examination form and revisions to the system used by medical examiners for reporting the results of all completed commercial drivers’ physical examinations to the FMCSA and the state driver licensing agencies. The NTSB believes that a final rule based on these revisions should address most of the noted deficiencies, but we remain concerned with a few important issues that still exist: (1) the lack of a reporting system to capture the results of incomplete medical examinations and (2) the development of a system that would allow either the reporting or evaluation of adverse CMV driver medical conditions between required medical certification exams. In addition, we remain concerned that insufficiently qualified medical professionals may continue administering medical examinations. Consequently, we recently recommended in the Chesterfield accident report that the FMCSA require all persons applying for inclusion in the National Registry to have a thorough knowledge of pharmacology and current prescribing authority. We support the FMCSA’s efforts to develop a comprehensive medical oversight program, and we look forward to the full implementation of the National Registry system with the 2013 NPRM-proposed revisions. In the meantime, Safety Recommendations H-01-18 and -21 are classified “Open—Acceptable Response,” Safety Recommendations H-01-17, -19, and -20 remain classified OPEN--ACCEPTABLE RESPONSE, and Safety Recommendation H-01-24 remains classified “Open—Unacceptable Response” pending action to develop the recommended system.

From: NTSB
To: FMCSA
Date: 7/23/2013
Response: From the report of the School bus and truck collision at Intersection near Chesterfield, New Jersey, February 16, 2012. HAR-13-01, report adopted July 23, 2013, notation 8402A: 2.3.4.3 Anticipated Improvements in CDL Medical Examination Process. The Chesterfield crash investigation is not the first in which the NTSB has been concerned with the FMCSA medical examiner process, the certification of drivers with potentially disqualifying medical conditions and prescription medications, and the training and qualifications of medical examiners. In 2001, the NTSB issued numerous recommendations that called for a systemwide modification to the medical oversight of commercial drivers following a medical impairment-related motorcoach crash that occurred in New Orleans, Louisiana (NTSB 2001b). Included in these recommendations to the FMCSA were the development of a comprehensive medical oversight program for interstate commercial drivers that includes: (1) qualifying medical examiners and training them on driver occupational issues; (2) periodically updating medical certification regulations; (3) providing specific guidance and a readily identifiable source of information for those performing such examinations; and (4) preventing, or identifying and correcting, the inappropriate issuance of medical certification. Of these four program elements, Safety Recommendations H-01-17, -19, and -20, respectively, are currently classified “Open—Acceptable Response,” and Safety Recommendation H-01-21 is classified “Open—Unacceptable Response.” Since the NTSB made these recommendations, the FMCSA has created a Medical Division and continues to work toward an effective commercial driver medical oversight system, including publication of the Medical Examiner Handbook. New federal regulations will go into effect in May 2014 requiring CDL holders to obtain their medical examinations from trained and certified physicians. In April 2012, the FMCSA published a final rule establishing a National Registry of Certified Medical Examiners.114 The rule requires all healthcare professionals responsible for issuing medical certificates for interstate truck and bus drivers to complete a training course and to pass an examination to assess their ability to apply the rules and advisory criteria. In May 2013, the FMCSA published an NPRM proposing a new medical examination form and revisions to the system used by medical examiners to report the results of all completed commercial driver physical examinations to the FMCSA and state driver licensing agencies. Prior to 1992, only medical doctors and doctors of osteopathy were allowed to perform CDL medical examinations.115 Title 49 CFR 390.5 modified the regulations to allow certain state-licensed, -certified, or -registered health care professionals to perform examinations, including medical doctors, osteopaths, physician assistants, advanced practice nurses, and doctors of chiropractic. The federal regulations subject to compliance beginning May 21, 2014, will still allow the types of medical professionals listed above to issue medical certificates as long as they complete a training course, pass an examination test, and become listed on the National Registry of Certified Medical Examiners. In 2001, the NTSB expressed concern about the inability of most doctors of chiropractic—who may serve as examiners in many states—to assess the possible effects of prescription drugs, nonprescription drugs, and drug interactions on commercial vehicle operators (NTSB 2001b). The practice of chiropractic medicine specifically avoids the use of medications; doctors of chiropractic typically receive no formal training in pharmacology and are not licensed to prescribe medication. It is, therefore, unreasonable to expect that most doctors of chiropractic would know how certain medications affect driving performance. Similarly, other professionals who are permitted to perform physical examinations in the state in which they are licensed may not be permitted to prescribe medications, and thus would also have inappropriate backgrounds to make such determinations. Because the medical examiner remains the certifying authority, he or she must have sufficient background to analyze and evaluate medication effects. A brief training program for examiners cannot replace formal courses in pharmacology and current prescribing experience to the extent necessary for such evaluations. The NTSB remains concerned that the FMCSA is choosing to permit those whose backgrounds would not meet minimum requirements to make appropriate certification decisions to apply for inclusion on a registry of qualified examiners. The NTSB concludes that some medical professionals who are authorized to perform medical examinations and certify commercial drivers as fit to drive may lack the knowledge and information critical to certification decisions; consequently, drivers with serious medical conditions may not be sufficiently evaluated to determine whether their conditions pose a risk to highway safety. The NTSB recommends that the FMCSA require that all persons applying for inclusion on the National Registry of Certified Medical Examiners have both a thorough knowledge of pharmacology and current prescribing authority. Despite the numerous anticipated improvements in the CDL medical examination process expected with the recent rulemaking by the FMCSA, the NTSB maintains that more action is necessary to ensure a comprehensive medical oversight program. In a review of the circumstances of this crash and the issuance of medical certification to the school bus driver, NTSB investigators determined that the medical examiner did not have all of the information and guidance needed to make an informed decision regarding the applicant’s various medical conditions and prescription drugs. Furthermore, the system did not include a means to review the medical examiner evaluation and correct the possible inappropriate issuance of the certification. Safety Recommendations H-01-17, -19, -20, and -21, from the New Orleans crash investigation, addressed these concerns 12 years ago, and they remain in an open status. Therefore, the NTSB reiterates Safety Recommendations H-01-17, -19, -20, and -21 to the FMCSA.

From: FMCSA
To: NTSB
Date: 6/27/2013
Response: -From Anne S. Ferro, Administrator: I am pleased to provide the Federal Motor Carrier Safety Administration's (FMCSA) update on the National Transportation Safety Board's (NTSB) safety recommendations H-01-17 through H-01-21, and to respectfully request that NTSB reclassify these recommendations as "Closed-Acceptable." Recommendations H-01-17 through H-01-21 request FMCSA to develop a comprehensive medical oversight program for interstate commercial drivers that contains the following program elements: • Individuals performing medical examinations for drivers are qualified to do so and are educated about occupational issues for drivers. (H -01-17) • A tracking mechanism is established that ensures that every prior application by an individual for medical certification is recorded and reviewed. (H -01-18) • Medical certification regulations are updated periodically to permit trained examiners to clearly determine whether drivers with common medical conditions should be issued a medical certificate. (H -01-19) • Individuals performing examinations have specific guidance and a readily identifiable source of information for questions on such examinations. (H-01-20) • The review process prevents, or identifies and corrects, the inappropriate issuance of medical certification. (H-01-21) FMCSA believes the publication of its April20, 2012, final rule (77 FR 24103) concerning the National Registry of Certified Medical Examiners (the National Registry) and subsequent progress in putting into place the necessary information technology system, and network of training providers and testing organizations fulfills these recommendations. The National Registry provides a training, testing, and registration program to certify medical professionals as qualified to issue medical certificates for interstate truck and bus drivers based on FMCSA's physical qualifications standards. Current regulations require all interstate commercial drivers (with certain limited exceptions) to be medically examined by a licensed medical professional to determine whether these drivers meet FMCSA's physical qualification requirements. All drivers must carry a medical examiner's certificate as proof that they have passed this physical qualification examination. The Medical Examiners (ME) conducting physical examinations must retain copies of the Medical Examination Reports of all drivers they examine and certify. The Medical Examination Report lists the specific results of the various medical tests used to determine whether a driver meets FMCSA's standards under 49 CFR Part 391. Before the adoption of this rule, there was no required training program for the medical professionals who conducted driver physical examinations, although the Federal Motor Carrier Safety Regulations required MEs to be knowledgeable about the regulations (49 CFR 391.43(c)(l)). The former rules allowed any medical professional licensed by his or her State to conduct physical examinations to conduct interstate truck and bus drivers' medical certification examinations. No specific knowledge of the Agency's physical qualification standards were required or verified by testing. As a result, some of the medical professionals who conducted these examinations may have been unfamiliar with FMCSA physical qualification standards and how to apply them. These professionals also may have been unaware of the mental and physical rigors that accompany the occupation of commercial motor vehicle (CMV) driver, and how various medical conditions and the therapies used to treat them can affect the ability of drivers to safely operate CMV s. This rule establishes the National Registry to ensure that all MEs who conduct driver medical examinations have been trained in FMCSA physical qualifications standards and guidelines. In order to be listed on the National Registry, MEs are required to attend an accredited training program and pass a certification test to assess their knowledge of the Agency's physical qualifications standards and guidelines and how to apply them to CMV drivers. Upon passing the certification test and meeting the other administrative requirements associated with the program, MEs will be listed on the National Registry. Once this rule is fully implemented, all medical examination certificates issued on or after May 21, 2014, must be issued by medical professionals listed on the National Registry. As of May 9, 2013, 724 medical professionals had successfully completed the mandatory training and testing necessary to be listed on the National Registry. Another 105 medical professionals completed the mandatory training but failed their initial attempt to pass the test. In addition, 6, 790 individuals have completed the initial steps of enrolling on the National Registry website (http://nrcme.fmcsa.dot.gov/) to begin the process of training and testing. With the implementation of the National Registry and the requirement that each medical examimer submit reports to FMCSA for each individual who undergoes a medical examination, indicating whether the individual passes or fails the medical examination, FMCSA will have the means of monitoring the number of examinations being conducted by the healthcare professionals and the pass/fail rates to detect anomalies and make appropriate inquiries of the examiners. The Agency will also have the ability to detect suspected instances of "doctor shopping" by individuals failing a medical examination with one examiner but subsequently receiving a medical certificate from another examiner. The Agency can contact both medical examiners to request copies of the Medical Examination Reports to determine whether the driver should have been issued a medical certificate and to take appropriate actions if the driver should not have been certified as meeting the physical qualifications standards. Under certain circumstances, FMCSA may void a medical certificate issued to a truck or bus driver by a medical examiner that is either removed from the National Registry or found to have committed errors or omissions in performing the examination. Through the National Registry program, FMCSA can ensure that each medical professional conducting interstate truck and bus driver exams receives up-to-date information concerning changes in the medical standards and advisory criteria, and that the examiners have a readily available source of information for questions about the medical requirements. The Agency has completed a medical examiner handbook to assist medical professionals in understanding FMCSA's physical qualifications standards and the medical certification process, and this information is posted at the National Registry website. Furthermore, because the National Registry program includes requirements for refresher training every 5 years and recertification testing every 10 years, FMC SA has a means to ensure medical examiners are able to determine whether drivers with medical conditions covered by the updates to the rules and advisory criteria should be issued medical certificates. Based on the information provided, the Agency believes it has fully addressed safety recommendations H-01-17 through H-01-21 and requests that each recommendation be reclassified as "Closed-Acceptable."

From: NTSB
To: FMCSA
Date: 9/30/2010
Response: Notation 8248: The National Transportation Safety Board (NTSB) has reviewed the Federal Motor Carrier Safety Administration’s (FMCSA) Announcement of Public Listening Session and Request for Comment, which was published at 75 Federal Register 53015 on August 30, 2010. The notice announced that the FMCSA planned to hold a public listening session to solicit input on key challenges facing the motor carrier industry, issues facing stakeholders, and concerns that should be considered by the agency in developing its next 5-year Strategic Plan. NTSB staff attended the listening session and provided the FMCSA with a list of open recommendations that have been issued to the FMCSA. The FMCSA also invited written comments, suggestions, and recommendations from all individuals and organizations regarding the FMCSA’s mission, vision, and strategic objectives (goals) for the plan. This letter provides a more detailed history of the currently open recommendations the NTSB has made to the FMCSA (attached), a summary of the key safety issues the FMCSA should address to improve truck and bus safety as presented during the NTSB’s April 28, 2010, testimony before the U.S. Senate Committee on Commerce, Science, and Transportation, Subcommittee on Surface Transportation and Merchant Marine Infrastructure, Safety, and Security (attached), and responds to the questions most relevant to the NTSB’s mission for which the FMCSA is seeking input. Question 2. How can the FMCSA have a greater impact in the reduction of injuries and loss of life on our nation’s highways? The NTSB currently has 51 open recommendations that were issued to the FMCSA with the intent to improve safety on our highways. The implementation of these recommendations would allow the FMCSA to have both an immediate and lasting impact on reducing loss on our highways. We continue to believe that a plan to implement the recommendations on the NTSB’s Federal Most Wanted List of Transportation Safety Improvements (MWL) would significantly contribute to transportation safety. Question 5. How can the FMCSA balance driver-focused, vehicle-focused, motor carrier- focused compliance, interventions, and enforcement to achieve its safety mission? The NTSB has recommended that the FMCSA change the “balance” of its motor carrier oversight since 1999. The two most important factors related to safe motor carrier operations are the condition of the vehicles and the performance of the drivers. Current rules prevent the FMCSA from putting carriers out of service with an unsatisfactory rating in only one of the 6 rated factors. They must be unsatisfactory in at least 2 factors. In other words, they could be unsatisfactory in either the vehicle or driver areas and still be allowed to operate. The NTSB believes that an unsatisfactory in either category should be sufficient cause to place a carrier out of service. The NTSB recommended that the FMCSA do something relatively simple: change the safety fitness rating methodology so that adverse vehicle- or driver performance-based data alone would be sufficient to result in an overall “unsatisfactory” rating for a carrier. To date, the FMCSA has not acted on this recommendation. As a result, the NTSB added this recommendation to our Most Wanted List of Transportation Safety Improvements. The NTSB has been encouraged that the FMCSA is developing the CSA 2010 Initiative to include a greater emphasis on vehicle and driver safety. However, the NTSB is disappointed that the FMCSA did not make the incremental changes to the current safety system necessary to make either driver or vehicle deficiencies sufficient to affect the safety rating of a carrier. As such, the NTSB believes the FMCSA’s strategic plan should recognize the importance of getting carriers with unsafe drivers or unsafe vehicles off the road. Question 8. What technological changes could positively impact highway safety? The NTSB has recommended numerous technological improvements to both the FMCSA and the National Highway Traffic Safety Administration (NHTSA). Two technologies, forward collision warning systems (FCWs) and electronic onboard recording systems (EOBRs), are currently on the NTSB’s Federal MWL. Both of these technologies have been available for the last decade and could have improved highway safety. More recently, the NTSB has recommended to NHTSA technologies for driver fatigue detection, stability control for buses, event data recording, and lane departure warning for buses. The implementation of these recommendations would significantly improve highway safety. Question 9. How will technology affect driver behavior? Well designed technology can improve driver performance. Current research by the FMCSA on vehicle based collision warning systems found improved driver performance as a result of technology. However, technology not designed for use in vehicles, such as cell phones, can distract the driver from the road. That is why the NTSB supported the FMCSA’s ban on texting. Further, the NTSB has included restricting bus drivers from using a cell phone on its Federal MWL. The NTSB appreciates the opportunity to comment on this notice addressing concerns that should be considered in developing the FMCSA’s 5-year Strategic Plan. Many of the issues discussed here have been around for decades, and much is left to be done to improve highway safety. Prompt action is needed so that the trucks and buses that surround us on the nation’s highways are safely designed, maintained, and operated. We look forward to working with FMCSA in the near future to address the concerns presented in these comments.

From: NTSB
To: FMCSA
Date: 2/26/2010
Response: The FMCSA’s Medical Review Board (MRB) continues to hold quarterly public meetings, and its five members also work with research panels to examine medical issues affecting commercial motor vehicle (CMV) drivers for the development of new science-based standards and guidelines to ensure the physical qualification requirements for CMV operators. Current topics being reviewed by the MRB include vision and hearing, prescription medications, renal disease, injury, and psychiatric disorders, among others. The FMCSA is currently considering more than 60 recommendations from the MRB to determine whether the agency will initiate rulemakings to revise any of its medical standards. In addition to its work through the MRB, the FMCSA continues to develop a National Registry of Certified Medical Examiners (NRCME), an action required by the Safe, Accountable, Flexible, and Efficient Transportation Equity Act; A Legacy for Users legislation. The FMCSA published an NPRM on the NRCME in November 2008. The NPRM proposes to amend the Federal Motor Carrier Safety Regulations (FMCSRs) to establish and maintain an NRCME and to require that all medical examiners who conduct medical examinations of interstate CMV drivers complete certain training on physical qualification standards, pass a test to verify an understanding of those standards, and maintain competence by periodic training and testing. In its comments on the NPRM, the NTSB noted a number of continuing deficiencies in the FMCSA’s approach that do not show progress toward satisfying the intent of Safety Recommendations H-01-18, -21, and -24. These deficiencies include the continuing potential for insufficiently qualified examiners, the lack of a process to review or track medical certification examinations or decisions, a lack of reporting mechanisms between required exams, and a lack of coordination between data collection processes in this NPRM and in the final rule (further discussed below) merging the medical certificate with the commercial driver’s license (CDL). Assuming that these issues can be appropriately addressed as this rule moves forward, the rule will likely help to ensure that the individuals performing examinations are qualified to do so. On December 1, 2008, the FMCSA issued a final rule amending the FMCSRs to require interstate CDL holders subject to the physical qualification requirements of the FMCSRs to provide a current original or copy of their medical examiner’s certificates to their state driver licensing agency. The rule addresses the ability of enforcement authorities to identify invalid medical certification and to prevent uncertified drivers from driving until an appropriate medical examination takes place. Although many of the NTSB’s comments on deficiencies identified in the NPRM preceding this rule were not addressed, including the lack of (1) a process to establish the validity of a medical certificate, (2) a process for a state to downgrade a medical certification between required exams, and (3) a requirement or even permission for a state to maintain the completed examination forms, the NTSB believes that the rule is an important achievement because, at the roadside, law enforcement officials will be able to determine whether a driver possesses a current medical certificate and will be able to take appropriate action if the driver does not. As of October 26, 2009, the FMCSA has filled its newly created medical officer position to provide a high level of medical expertise in transportation issues as the agency moves forward in its efforts to address these recommendations. The hiring of a qualified individual to lead the FMCSA medical program places the FMCSA in a better position to address the development of the comprehensive medical oversight program recommended by the NTSB. A decade after the New Orleans, Louisiana, accident that precipitated the issuance of these recommendations, the NTSB is concerned that the pace of progress to establish an overall system of driver medical certification remains slow. Nevertheless, the MRB continues to meet regularly to discuss certification standards surrounding various important medical conditions and make recommendations to the FMCSA on medical standards, and rulemaking is underway to establish a national registry of certified medical examiners. The merging of the CDL and the medical certificate should help to improve driver oversight by the enforcement community. Although the initiatives completed at this time will not create the comprehensive medical oversight program for interstate commercial drivers that was envisioned in the NTSB’s recommendations nearly 8 years ago, the FMCSA has made some progress toward improving safety. Accordingly, Safety Recommendations H-01-17, -19, and -20 are classified OPEN -- ACCEPTABLE RESPONSE, and Safety Recommendations H-01-22 and -23 are classified Closed Acceptable Action as a result of the final rule merging the CDL with the medical certificate. Safety Recommendations H-01-18, -21, and -24 remain classified Open Unacceptable Response.

From: FMCSA
To: NTSB
Date: 10/2/2009
Response: Letter Mail Controlled 10/8/2009 8:40:30 AM MC# 2090625: - From Rose McMurray, Acting Deputy Administrator: More information on these actions can be found in the update for recommendation H-01-017 above. Currently, FMCSA’s medical program personnel at headquarters respond to an average of 1,000 inquiries from the medical examiner community and the public each week. In addition, the FMCSA Service Center and Division office personnel respond to numerous telephone inquiries on a daily basis. The Agency believes its current efforts to provide information to medical examiners have been effective and the planned improvements will greatly enhance our efforts in this area. FMCSA awarded a contract in September 2009 to create a physician work group for new program implementation and a new medical examiner communications campaign. This communications campaign initiative is projected to be completed by March 1, 2010. In addition, FMCSA has provided medical examiners with specific instructions and improved guidelines for performing examinations. The Agency has completed and posted online several modules of a medical examiner handbook with the entire medical examiner handbook projected to be available on the NRCME Web site by January 1, 2010. The handbook will support the training and certification components of the proposed NRCME. In addition, it serves as a resource to medical examiners about current FMCSA medical standards and guidelines.

From: NTSB
To: FMCSA
Date: 2/18/2009
Response: Notation 7381B: The National Transportation Safety Board has reviewed the Federal Motor Carrier Safety Administration (FMCSA) Notice of Proposed Rulemaking (NPRM), National Registry of Certified Medical Examiners (NRCME), which was published in 73 Federal Register 73129 on December 1, 2008. The NPRM proposes to amend the Federal Motor Carrier Safety Regulations to establish and maintain an NRCME and to require that all medical examiners who conduct medical examinations of interstate commercial motor vehicle drivers complete certain training on physical qualification standards, pass a test to verify an understanding of those standards, and maintain competence by periodic training and testing. The Safety Board has long had an interest in the link between commercial driver fitness and transportation safety. Following its investigation of a 1999 motorcoach accident involving a medically unfit driver, an accident that resulted in 22 fatalities, the Safety Board issued eight recommendations to the FMCSA outlining a comprehensive medical oversight program for interstate commercial drivers. These recommendations, listed below, have been on the Most Wanted List of Transportation Safety Improvements for over 5 years: Develop a comprehensive medical oversight program for interstate commercial drivers that contains the following program elements: Individuals performing medical examinations for drivers are qualified to do so and are educated about occupational issues for drivers. (H-01-17) A tracking mechanism is established that ensures that every prior application by an individual for medical certification is recorded and reviewed. (H-01-18) Medical certification regulations are updated periodically to permit trained examiners to clearly determine whether drivers with common medical conditions should be issued a medical certificate. (H-01-19) Individuals performing examinations have specific guidance and a readily identifiable source of information for questions on such examinations. (H 01-20) The review process prevents, or identifies and corrects, the inappropriate issuance of medical certification. (H-01-21) Enforcement authorities can identify invalid medical certification during safety inspections and routine stops. (H-01-22) Enforcement authorities can prevent an uncertified driver from driving until an appropriate medical examination takes place. (H-01-23) Mechanisms for reporting medical conditions to the medical certification and reviewing authority and for evaluating these conditions between medical certification exams are in place; individuals, health care providers, and employers are aware of these mechanisms. (H-01-24) Safety Recommendations H-01-17, -18, -21, -22, -23, and -24 are currently classified “Open—Unacceptable Response.” Safety Recommendations H-01-19 and -20 are currently classified “Open—Acceptable Response.” This NPRM, to a certain extent, addresses Safety Recommendations H-01-17 and -20. The NRCME would create a system whereby examiners are provided appropriate education and information to assist them in evaluating commercial driver medical qualifications. With regard to the proposed rule, however, the Safety Board notes the continued inclusion of individuals as “certified medical examiners” who may not possess the background necessary to evaluate common medical problems facing commercial vehicle drivers. In the report from which the above recommendations were derived, the Board noted: An example of this concern is the inability of most chiropractors, who may serve as examiners in many States, to assess the possible effects of prescription drugs, nonprescription drugs, and drug interactions on commercial vehicle operators. The practice of chiropractic medicine specifically avoids the use of medications; chiropractors typically receive no formal training in pharmacology and are not licensed to prescribe medication. It is therefore unreasonable to expect that most doctors of chiropractic would know how certain medications affect driving performance. Similarly, other individuals who are permitted to perform physical examinations in the State in which they are licensed may not be permitted to prescribe medications, and thus would also have inappropriate backgrounds to make such determinations. If the system were to be set up such that the examiner was merely gathering information for a separate certifying authority to reach a decision, this arrangement would not be a significant concern. However, because the examiner is also the certifying authority under both the current and proposed schemes, he or she must have sufficient background to analyze and evaluate medication effects. It seems extraordinarily unlikely that any brief training program for examiners would be able to replace formal courses in pharmacology and current prescribing experience to the extent necessary for such evaluations. It is unclear why the FMCSA would choose to permit individuals whose backgrounds would not meet minimum requirements to make appropriate certification decisions to apply for inclusion on a registry of qualified examiners. The Safety Board strongly suggests that, as an absolute minimum, only individuals who have prescribing authority be permitted to make certification decisions. If the FMCSA leaves those decisions in the hands of examiners, then they should be individuals whose States permit them to prescribe medications. The Safety Board is concerned that the regulatory initiatives thus far taken by the FMCSA, which include this NPRM, fall short of the comprehensive medical oversight program recommended by the Board. Specifically, neither this NPRM nor any other publicly announced FMCSA initiatives create a process to review or track medical certification examinations or decisions, as specified in Safety Recommendations H-01-18 and -21. The Board also notes that the NPRM does not include any sort of required action for listed examiners if they become aware, between required examinations, that a driver may not meet the requirements of the regulations. Safety Recommendation H-01-24 specifically calls for such mechanisms for all individuals who may have knowledge of a driver’s medical condition, and it seems that it would be of benefit to have a reporting and review mechanism in place at least for those professionals who will be responsible for evaluating drivers’ medical qualifications. The Board is convinced that a systematic approach addressing each of the issues in the eight recommendations is necessary to ensure the effectiveness of a commercial driver medical oversight program. The Safety Board is further concerned by the apparent lack of coordination among the various improvements to the medical oversight program. For example, the FMCSA has recently finalized a rule on merging the commercial driver’s license (CDL) and medical certificate by which certifying examination documentation is provided by an examiner to the driver, from the driver to the State licensing authority, and from that authority to an electronic format that can be queried through the Commercial Driver’s License Information System (CDLIS). The proposed NRCME rule requires examiners to electronically transmit information monthly to the FMCSA about each examination performed, including information for individuals who failed to meet the medical fitness standards. The NPRM does not explain what would be done with this information, except to state that it establishes the basis for implementation of other statutory requirements for monitoring medical examiner performance. The Board is disappointed that the FMCSA has chosen to delay the use of such essential data to monitor the performance of registered medical examiners. The Board is also disappointed that the FMCSA appears to be leaning toward creating two distinct databases that presumably contain similar medical information but are gathered by two separate means: 1) directly from the medical examiner, and 2) indirectly through two intermediaries, as established by the final rule merging medical certification requirements with the CDL. The information the FMCSA plans to gather directly from registered examiners would not only be useful in evaluating these examiners but also in identifying drivers who “doctor shop” or are in any other way inappropriately issued a medical certificate. Moreover, this information, if shared with the States, could be used to verify that a driver’s medical certificate was in fact certified by a member of the NRCME, something that is not currently possible. Unfortunately, under the current proposal, the Safety Board does not see how the FMCSA or the States will be able to use these data to their full potential. The Board does not see any advantage to establishing separate medical records databases and again urges the FMCSA to comprehensively address this problem. It is not at all clear that the finalized rule on CDL/medical merger and the proposed NRCME rule were developed to work in harmony; they seem to have been devised as completely independent programs, in spite of the significant overlap in functions. In conclusion, the Safety Board believes that the proposed rule, if adopted with the appropriate limitations on who may perform examinations, will likely make some progress toward improving safety. However, it will not, by itself, or considered together with initiatives completed at this time, create the comprehensive medical oversight program for interstate commercial drivers that was envisioned in the Board’s recommendations more than 7 years ago. The Board appreciates this opportunity to comment on the proposed rule and, accordingly, encourages the FMCSA to continue to develop a more robust framework for such oversight.

From: NTSB
To: FMCSA
Date: 2/9/2009
Response: The Safety Board notes that the FMCSA’s Medical Review Board (MRB) continues to hold quarterly public meetings. The five members also work with research panels to examine medical issues affecting commercial motor vehicle (CMV) drivers, the results of which are provided to the FMCSA for the development of new science-based standards and guidelines to ensure that the physical qualification requirements for CMV operators are met. Current topics being reviewed by the MRB include vision and hearing, prescription medications, renal disease, and psychiatric disorders, among others. In addition to the MRB, the FMCSA continues to develop a National Registry of Certified Medical Examiners (NRCME), an action required by the Safe, Accountable, Flexible, and Efficient Transportation Equity Act; A Legacy for Users (SAFETEA-LU) legislation. The FMCSA published a notice of proposed rulemaking (NPRM) on the NRCME on December 1, 2008. The Safety Board notes that, prior to this NPRM, the agency completed a Role Delineation Study, the results of which should provide a blueprint for the medical examiner certification test and be used by subject matter experts to assist in the development of core curriculum specifications for medical examiner training. The FMCSA also continues to develop an online medical examiner’s handbook, the first completed sections of which are now available on the NRCME website. Approximately 6,000 medical examiners have registered to receive regular informational updates via e-mail; examiners can also obtain technical assistance through telephone services provided by the FMCSA headquarters office and certain field offices. Although these efforts offer interim solutions during the development of the NRCME, the Board is concerned that the information is not widely dispersed or easily available to examiners. The Board continues to believe that a final rule is necessary to establish a consistent and integrated program to identify and inform certified medical examiners. The Safety Board is further concerned that, although the FMCSA has made progress towards the development of a comprehensive oversight system, several areas still need attention. The Board has urged the FMCSA to address the issues of failed and denied medical forms and a tracking system to document driver status for verification by subsequent examiners. SAFETEA-LU Section 4116 contains provisions on medical certification requiring the FMCSA to periodically review a sampling of applications. On November 16, 2006, the FMCSA issued an NPRM to merge information from the medical certificate of commercial drivers into the commercial driver’s license process. If adopted, the proposed rule will, to a certain extent, address the ability of enforcement authorities to identify invalid medical certification and to prevent uncertified drivers from driving until an appropriate medical examination takes place; however, the Safety Board has commented on a number of deficiencies in the NPRM. The FMCSA published a final rule on this issue on December 1, 2008. The Board is considering the final rule and will address changes to the relevant safety recommendations in separate correspondence. Although the MRB continues to meet regularly to discuss certification standards surrounding various important medical conditions and make recommendations to the FMCSA on medical standards, and some progress has been made on establishing a national registry of certified medical examiners, as of the date of the Safety Board’s meeting, the FMCSA had not yet met the 2008 rulemaking publication dates for the two important rulemakings indicated in the United States Department of Transportation’s 2008 Annual Report to Congress and the National Transportation Safety Board on the Regulatory Status of Each Recommendation on the National Transportation Safety Board Most Wanted List. The Safety Board is concerned that, nearly a decade after the New Orleans, Louisiana, accident that precipitated the issuance of these recommendations, many issues in this area remain unaddressed, and the overall system of driver medical certification is no more effective this year than last. Accordingly, at the Safety Board’s October 28, 2008, meeting, Safety Recommendation H-01-20 was classified OPEN -- ACCEPTABLE RESPONSE and Safety Recommendations H-01-22 and -23 were classified Open Unacceptable Response. Safety Recommendation H-01-19 remains classified Open Acceptable Response, and Safety Recommendations H-01-17, -18, -21, and -24 remain classified Open Unacceptable Response. The Board voted that these eight recommendations would remain on the Most Wanted List in the issue area Prevent Medically Unqualified Drivers from Operating Commercial Vehicles.

From: FMCSA
To: NTSB
Date: 9/18/2008
Response: Letter Mail Controlled 9/25/2008 4:33:14 PM MC# 2080591: - From Karen Lynch, FMSCA: The FMCSA has submitted its NPRM concerning the establishment of a NRCME to OMB for review prior to publication in the Federal Register. This rulemaking would ensure that all medical examiners are qualified to perform medical examinations for CMV drivers and are educated about occupational issues that affect these drivers, When fully established, NRCME would provide a readily accessible list of medical examiners to CMV drivers that are certified to perform examinatio& and issue medical certificates according to the requirements of the FMCSRs. In the interim, FMCSA has established other channels of communication between the Agency and medical examiners to provide a readily identifiable source of information to them such as web pages, e-mail boxes they may use to submit inquiries, and a national e-mail notification system to which medical examiners may subscribe. To date, more than 6,000 medical examiners have subscribed to our notification system. The Medical Program has also created resources for examiners to receive in-depth technical assistance utilizing telephone services provided by our headquarters office and certain field offices. The Web site for the NRCME program is http://www.nrcme.fmcsa.dot.gov/. The research and developmental work to support the national registry project includes a RDS on the medical examination process. The RDS is complete and has been disseminated at a National Institute of Occupational Safety and Health meeting. Direct observational studies have begun to evaluate performance of different types of medical examiners while they are certifying drivers. In addition, FMCSA has provided medical examiners with specific instructions, advisory criteria, and improved guidelines for performing examinations. The Agency has completed several modules for a new CMV driver medical examiner handbook (on-line) as well as the preliminary core curriculum and certification testing materials for the NRCME program. Currently, FMCSA's medical program staff at headquarters responds to an average of 1,000 inquiries from the medical examiner community on a weekly basis. In addition, FMCSA Service Center and Division office personnel respond to numerous telephone inquiries on a daily basis. The Agency believes its current efforts to provide information have been effective and the planned improvements will greatly enhance our efforts in this area.

From: NTSB
To: FMCSA
Date: 2/13/2007
Response: Notation 7381A: The National Transportation Safety Board has reviewed the Federal Motor Carrier Safety Administration (FMCSA) Notice of Proposed Rulemaking (NPRM), Medical Certification Requirements as Part of the [Commercial Driver’s License] CDL, which was published at 71 Federal Register 66723 on November 16, 2006. The NPRM proposes to amend the Federal Motor Carrier Safety Regulations to merge information from the medical certificate into the CDL process. The Safety Board’s has long had an interest in the link between commercial driver fitness and transportation safety. Following its investigation of a 1999 motorcoach accident involving a medically unfit driver that resulted in 22 fatalities, the Safety Board issued 8 recommendations to the FMCSA outlining a comprehensive medical oversight program for interstate commercial drivers. These recommendations, listed below, have been on the Board’s Most Wanted List for 3 years. Develop a comprehensive medical oversight program for interstate commercial drivers that contains the following program elements: • Individuals performing medical examinations for drivers are qualified to do so and are educated about occupational issues for drivers. (H-01-17) • A tracking mechanism is established that ensures that every prior application by an individual for medical certification is recorded and reviewed. (H-01-18) • Medical certification regulations are updated periodically to permit trained examiners to clearly determine whether drivers with common medical conditions should be issued a medical certificate. (H-01-19) • Individuals performing examinations have specific guidance and a readily identifiable source of information for questions on such examinations. (H 01-20) • The review process prevents, or identifies and corrects, the inappropriate issuance of medical certification. (H-01-21) • Mechanisms for reporting medical conditions to the medical certification and reviewing authority and for evaluating these conditions between medical certification exams are in place; individuals, health care providers, and employers are aware of these mechanisms. (H-01-22) • Enforcement authorities can identify invalid medical certification during safety inspections and routine stops. (H-01-23) • Enforcement authorities can prevent an uncertified driver from driving until an appropriate medical examination takes place. (H-01-24) Safety Recommendations H-01-17, -18, -20, -21, -22, -23, and -24 are currently classified “Open?Unacceptable Response.” Safety Recommendation H-01-19 is currently classified “Open?Acceptable Response.” This NPRM, to a certain extent, addresses two of the recommendations noted above: Safety Recommendations H-01-23 and -24. The NPRM would allow enforcement authorities to identify, during safety inspections and routine stops, those drivers who fail to submit either an original or a copy of their latest medical certificate to the State Driver Licensing Agency (SDLA), and, as currently written, would permit authorities to place out of service such drivers and those for whom 60 days had elapsed from the expiration date of their latest submitted certificate. However, the NPRM does not establish a comprehensive medical oversight program as recommended by the Safety Board. Specifically, neither this NPRM, nor any other publicly announced FMCSA initiatives, create a process to review or track medical certification examinations or decisions, as recommended in H-01-18 and -21 or to create a mechanism for reporting medical conditions identified between examinations, as recommended in H-01-22. The Safety Board is convinced that for any commercial driver medical oversight program to be effective, a systematic approach is necessary that addresses all of the issues conveyed in the eight recommendations. Accordingly, these deficiencies in the NPRM may limit its effectiveness. The following paragraphs discuss specific deficiencies in the NPRM. No Mechanism to Ensure Medical Certificate Validity. The Safety Board is concerned that, because the certificate form is not a controlled document, has no standard appearance, and may be freely reproduced, a means is needed for the SDLA to verify that forms submitted by drivers are issued in accordance with existing regulations. In at least one instance, an insulin-dependent bus driver who was involved in a single-vehicle, run-off-the-road accident possessed an expired medical certificate that had been altered to indicate that it was current (May 2001, Bay St. Louis, Mississippi, Safety Board accident number HWY01IH024). Additionally, because drivers are not prevented from visiting multiple examiners (“doctor shopping”) in their attempts to obtain medical certificates, the Safety Board believes that a means is necessary for the SDLA to establish that a driver has not previously been denied a medical certificate. The Safety Board also notes that the proposed rule does not include the commercial driver medical examiner’s phone number, currently included on the medical certificate, as one of the required CDLIS data fields, which may hinder authorities from calling medical examiners to confirm that they have actually issued medical certificates. Sixty-Day Period to Downgrade the CDL. The Safety Board is also concerned about the proposed 60-day window during which the CDL may not be downgraded for drivers who have received a medical certification status of “not-qualified.” The Board is aware that examiners may time-limit certificates to periods considerably shorter than 2 years, particularly when they find medical conditions that may change over a relatively short time, or when they are awaiting additional medical information from the driver. However, the proposed 60-day window would increase such a limitation by as much as 2 months, potentially thwarting the examiner’s intent to limit the certificate of a driver with a worrisome medical condition. Although the Safety Board supports the addition of driving while in a “not qualified” status during the 60-day window as a disqualifying offense (that is, by adding it to table 2 of §383.51(c)), the Board is concerned that such an addition would not automatically permit the authorities to take an unqualified driver out of service, which could allow an identified potential safety risk to persist for as long as 60 days. Unclear Employer Responsibilities. The Safety Board is concerned that the proposed rule contains no requirement for the SDLA to notify the employer if a driver’s CDL is downgraded due to an outdated medical certificate, and a motor carrier that is not maintaining medical certificates in driver qualification files will not know if a particular driver’s certificate has expired. As a result, the rule as proposed could hinder the FMCSA from holding carriers responsible for ensuring that all their drivers are qualified beyond the time of initial hire. A majority of a carrier’s employees could have outdated or invalid medical certificates, and the carrier would not be required to have timely knowledge of that situation. No Provision for State Revocation of CDL. The Safety Board is aware that several states have procedures for reporting and subsequently investigating CDL holders with medical conditions that would potentially prevent them from operating commercial motor vehicles safely, and if necessary, revoking their CDLs. However, the proposed rule does not provide for states to change the medical certification to “not qualified” when they learn that CDL holders have medical conditions incompatible with safe commercial vehicle operation. No Provision for States or Employers to Retain Long Form. The Safety Board is concerned that the proposed rulemaking does not specifically permit states and/or employers to require copies of the medical certificate or examination form (that is, the long form) to be provided and retained for review. The Safety Board therefore suggests that the rule require (as several states already do) that the entire long form (and not just the certificate) be submitted to and retained by the SDLA for review as necessary. At an absolute minimum, the rule should clarify that states and employers be expressly permitted to require submission of the long form and to retain the information indefinitely. No Provision for Medical Examiners to Retain Long Form. The Safety Board is concerned that the proposed rulemaking does not clarify that medical examiners are still required to retain the long form. This requirement currently exists only in the “Instructions for Performing and Recording Physical Examinations,” which follows 49 Code of Federal Regulations 391.43, and there are no other requirements for this form to be retained. If the long form is not retained, medical examiners, SDLAs, and accident investigation authorities are among those who would not be able to obtain the records necessary to document drivers’ known medical conditions, should the need arise. It is also unclear why the proposed rule allows examiners to routinely eliminate medical certificates from their records once they expire, making subsequent verification difficult or impossible. As in the example above from the Bay St. Louis, Mississippi, accident, a simple change of date might not be traceable because the original expired certificate would not be on file. No Requirement for Indefinite Retention of Certificate. Finally, although the NPRM has specified a 6-month period for retaining a copy or image of the medical examiners’ certificate, it is unclear to the Safety Board why the SDLA would not be required to maintain a copy of each submitted medical certificate indefinitely. Under current regulations, this might be the only historical record of these certificates. The Safety Board is disappointed at the length of time taken by the FMCSA to generate this NPRM. If modified to address the concerns noted above, the proposed rule may make some nominal steps towards improving safety, but it does not represent considerable progress toward the goal of a comprehensive medical oversight program for interstate commercial drivers that was envisioned in the Board’s recommendations on this topic. Accordingly, the Board encourages the FMCSA to develop a more robust framework for such oversight. The Safety Board appreciates the opportunity to comment on this NPRM.

From: NTSB
To: FMCSA
Date: 1/16/2007
Response: NMC# 102982: The Safety Board notes that the FMCSA is developing a National Registry of Certified Medical Examiners (NRCME), an action required by the Safe, Accountable, Flexible, and Efficient Transportation Equity Act: A Legacy for Users (SAFETEA-LU). The agency’s first step in this process is to conduct a national survey of 5,000 medical examiners who are qualified to perform medical examinations (doctors of medicine, doctors of osteopathy, physician assistants, advanced practice nurses, and doctors of chiropractic). The survey will gather data on the role of medical examiners and provide respondents with a means of participating in an assessment of the knowledge, skills, and abilities necessary for determining whether a commercial motor vehicle (CMV) driver’s health meets Federal physical qualification standards. The Board understands that the survey questionnaire was approved by the Office of Management and Budget and that the FMCSA has begun data collection. No other rulemaking action on the NRCME has been announced since the update of the November 2005 Most Wanted list. Although the FMCSA has made significant progress in addressing flaws in the current Federal CMV driver fitness system, particularly with regard to updating physical requirement standards, the Safety Board remains concerned with the very limited progress towards the congressionally mandated NRCME. The Board is also concerned that the FMCSA has not yet addressed the related issues of failed and denied medical forms or a tracking system to document driver status for verification by subsequent examiners. SAFETEA-LU Section 4116’s requirements regarding medical certification mandate the FMCSA to periodically review a sampling of applications. Although some of the FMCSA’s current initiatives may ultimately prove responsive to the Board’s recommendations, none of this activity has constituted measurable progress towards a comprehensive medical oversight system. Accordingly, at the meeting, Safety Recommendations H-01-17 and -20 were classified OPEN -- UNACCEPTABLE RESPONSE pending action to improve the medical certification process for CMV drivers. The Safety Board voted that these recommendations, along with H-01-18 and -19, and -21 through -24, would remain on the Most Wanted list in the issue area of Prevent Medically Unqualified Drivers from Operating Commercial Vehicles.

From: FMCSA
To: NTSB
Date: 8/3/2006
Response: Letter Mail Controlled 8/7/2006 12:14:43 PM MC# 2060389: - David H. Hugel, Acting Administrator: I am pleased to provide the Federal Motor Carrier Safety Administration’s (FMCSA) response to the National Transportation Safety Board’s (NTSB) questions from our June 15,2006, Comprehensive Safety Analysis 2010 initiative briefing. Specifically, you asked how many motor carriers are included on our Safety Status Measurement System (SafeStat) A and B Lists annually, and how many of these carriers are subject to a Compliance Review (CR) annually. The FMCSA’s Safestat system is updated monthly, rather than annually, to identify new high-risk carriers in a timely manner and to reflect improved performance by carriers previously identified as high-risk. On average, there are approximately 5,500 motor carriers on FMCSA’s SafeStat A and B list in a given month. As of May 2006, there were 5,636 motor carriers on FMCSA’s SafeStat A and B Lists. During fiscal year 2005, FMCSA and its Motor Carrier Safety Assistance Program partners conducted a total of 12,596 CRs. Of those reviews, 6,004 were conducted on motor carriers that were included on FMCSA’s A or B list at the time the CR was conducted. Please note that not all SafeStat A and B motor carriers are considered an immediate priority for CRs, but only those which have not had a compliance review within the previous year. In many instances, motor carriers are listed on the SafeStat A and B list by virtue of the fact that violations were documented on a recent &e., conducted in the last 12 months) compliance review. Those A and B carriers are monitored to determine if they improve their safety performance or if an additional compliance review is warranted because sufficient improvement has not occurred. In addition to CRs on Safestat A and B carriers, FMCSA conducts CRs in response to Congressional inquiries, citizen complaints, significant fatal crashes, and significant hazardous materials incidents. We also conduct CRs to support our hazardous materials permitting program (carriers must have a satisfactory safety rating to obtain a hazardous materials permit). Moreover, Congress specifically directed FMCSA to require follow-up visits and monitoring of motor carriers with less-than-Satisfactory ratings in Section 216 of the Motor Carrier Safety Improvement Act of 1999 (MCSIA). FMCSA implemented a program to comply with this MCSIA requirement in fiscal year 2002. Since that time we have conducted more than 12,816 CRs on carriers with previous Conditional ratings and more than 3,822 reviews on carriers with previous unsatisfactory ratings. I hope you find this information useful. The FMCSA is working to continuously improve our safety oversight and follow-up activities, and we look forward to working with NTSB to fulfill our mutual transportation safety goals. If you need additional information or clarification, please do not hesitate to contact me or Dan Hartman, Associate Administrator for Enforcement and Program Delivery at 202-366-2525.

From: FMCSA
To: NTSB
Date: 6/7/2006
Response: Letter Mail Controlled 6/23/2006 8:55:41 AM MC# 2060281: - From David H. Hugel, Acting Administrator: I am pleased to provide an update from the Federal Motor Carrier Safety Administration (FMCSA) to the National Transportation Safety Board (NTSB) regarding milestones in our medical program. I appreciate NTSB's acknowledgement of the initiatives in progress, and I have enclosed a list of upcoming planned medical program activities with corresponding timelines. We believe it is crucial that FMCSA carry on a continuing dialogue with our partners and stakeholders as we continue to improve the medical program. FMCSA began this important work in 2004, and we were able to seek new authorities to support the medical program in the Safe, Accountable, Flexible, Efficient Transportation Equity Act: A Legacy for Users (Pub. L. 109-59, August 10,2005). FMCSA will soon announce details in the Federal Register about the first Medical Review Board deliberations, to be held in Washington, DC, on August 3 1. I hope that NTSB representatives will attend. We are also organizing a roundtable for Federal agencies and leading medical and scientific organizations to discuss occupational medical standards for transportation workers. Research to support our medical standards review and development work is in progress, and the survey to support the National Registry of Medical Examiners initiative is in the final review and approval stage. We have drafted the Notice of Proposed Rulemaking (NPRM) for the medical certification and commercial driver's license merger and this NPRM is in review. We have garnered significant interest in these activities from the medical examiner community, as indicated by our listserve community of more than 1,700 health care professionals representing the 5 1 jurisdictions and five medical examiner disciplines. Our agency remains committed to addressing NTSB safety recommendations. We are seeking diverse and expert advice in our endeavors to implement the complex medical oversight program. We are working to identify the most effective strategies for enhancing the fitness for duty regulations and policies for interstate truck and bus drivers. I hope that you find this information useful. FMCSA looks forward to working with NTSB to fulfill our mutual transportation safety goals. We would like to offer you and your staff a briefing on the medical program activities when we meet with you on June 15, on the Comprehensive Safety Analysis 201 0 initiative. If you need additional information or clarification, please do not hesitate to contact

From: FMCSA
To: NTSB
Date: 5/9/2006
Response: Letter Mail Controlled 5/10/2006 11:12:20 AM MC# 2060234 - From Warren E. Hoemann, Acting Administrator: I am pleased to provide the Federal Motor Carrier Safety Administration's (FMCSA) response to the National Transportation Safety Board's (NTSB) letter dated April 19,2006, regarding our Comprehensive Safety Analysis (CSA) 2010 Initiative. CSA 2010 reflects a new approach to how our Agency carries out its compliance and enforcement activities. Its goal is to enable FMCSA to have contact with more regulated entities through a broader array of compliance interventions that optimize Agency resources. I appreciate NTSB's acknowledgement of this major effort. In response to your request, I have enclosed a listing of major CSA 2010 activities with corresponding timeframes. The dates, of course, are for planning purposes and subject to change pending future budgetary constraints. We are also working with your staff to arrange a CSA 20 10 briefing for Board members. We believe it is crucial that FMCSA carry on a continuing dialogue with our partners and stakeholders as we continue the development of CSA 20 10. As you know, the Agency held a series of listening sessions in 2004 to solicit public input on the conceptual CSA 20 10 operational model. Based on that input, we completed the attributes of a proposed operational model. The CSA 2010 Team is currently working through the process of defining the technical requirements, pilot testing, validation, deployment and implementation issues associated with the draft operational model. We plan to conduct the first of a new series of listening sessions later this year. At that time, we hope to be in a better position to detail specific information. The dates and locations of the listening sessions will be announced in the Federal Register. I hope that NTSB representatives will attend. Additional outreach events are being planned to include announcement of the pilot test and the State partners that will be involved in the pilot. As FMCSA continues this major safety initiative, we will engage and solicit input from our partners and stakeholders. Our Agency has been, and remains, committed to addressing NTSB safety recommendations, either by implementing NTSB's recommended approach or by pursuing alternatives which we believe will achieve the intended result. We are not "deferring action" on any safety recommendations issued to FMCSA, but are working to identify the most effective strategies for enhancing motor carrier safety. We will continue to explore all potential countermeasures, including, but not limited to, CSA 20 10. I hope that you find this information useful. FMCSA looks forward to working with NTSB to fulfill our mutual transportation safety goals and to provide more information about our CSA 2010 initiative at the upcoming Board briefing currently being arranged by our staffs. If you need additional information or clarification, please do not hesitate to contact me.

From: NTSB
To: FMCSA
Date: 4/19/2006
Response: Six years ago, the Federal Motor Carrier Safety Administration (FMCSA) was launched as a new U.S. Department of Transportation agency charged with improving motor carrier safety in our nation. Then Secretary of Transportation, Mr. Rodney E. Slater, announced that the FMCSA's goal was to reduce truck and bus fatalities by 50 percent by 2010. At that time, there were more than 5,300 such fatalities every year. Five years later, the 2004 fatality count was 5,248, only slightly lower and far from approaching the FMCSA's 50 percent reduction goal. In fact, the death count in 2004 was higher than the 2003 count of 5,072, and the large truck fatality rate remained a constant 2.3 deaths per 100 million truck vehicle miles traveled. Today, there are 36 open safety recommendations that the National Transportation Safety Board issued to the FMCSA, 18 of which relate to the oversight of motor carrier operations and enforcement of regulations. The oldest of these recommendations dates back to 1993. The Safety Board is concerned that the FMCSA is not making timely progress toward meeting the intent of these recommendations. A list of the 18 recommendations, including the date and text of the last correspondence, is enclosed. Nine of these recommendations are currently on the Board's Most Wanted list. Two years ago, the FMCSA announced its Comprehensive Safety Analysis (CSA) 2010 Initiative, described as a top-to-bottom evaluation of the agency's motor carrier compliance review system. The FMCSA has said that this effort will address 15 of the outstanding recommendations, although the Safety Board has identified an additional 3 recommendations that may also be addressed by the initiative. Although the Board applauds the FMCSA's effort to undertake this comprehensive review, it is unaware of any public document outlining specific steps the agency plans to take and milestones it plans to meet to accomplish the review and implement necessary changes. In the 2 years since the announcement of the initiative, the FMCSA has not provided the Board with any specific information regarding implementation of the initiative or whether it will address any of the 18 open safety recommendations satisfactorily. Currently, an estimated 9 million people hold commercial drivers licenses in the United States, 3 million of whom are active drivers. These drivers operate on an aging highway system already crowded with an ever-increasing number of passenger vehicles. Protecting the safety of all these drivers and their passengers is of paramount concern today. Deferring action on these 18 safety-related recommendations until completion of the initiative in 2010 is not in the best interest of the motoring public and is therefore unacceptable to the Safety Board. The Safety Board would like to receive specific information about how the CSA 2010 Initiative will address the open safety recommendations cited in this letter. Further, the Board would appreciate receiving details about how the FMCSA plans to proceed with the CSA 2010 Initiative, including a proposed timetable and interim steps towards completing the initiative by its deadline. The Board would be pleased to meet with the FMCSA to further discuss the intent of the recommendations and the FMSCA's efforts toward improving the safety of motor carrier operations.

From: FMCSA
To: NTSB
Date: 3/1/2006
Response: In its 3/1/2006 annual report to Congress, Regulatory Status of the National Transportation Safety Board's "Most Wanted" Recommendations to the Department of Transportation, the DOT wrote: Under SAFETEA-LU, FMCSA received funding from Congress for expanding oversight of the driver physical qualification program for commercial drivers. Specifically, SAFETEA-LU requires the establishment of a national registry of medical examiners and MRB, and FMCSA’s efforts are well underway in both those areas. In addition, FMCSA is developing a NPRM to link each driver’s medical certification to his or her CDL. The NR will provide a national database of medical examiners that have received specific training and are knowledgeable about driver qualifications and standards as well as the physical and mental demands involved in driving a CMV. The NR Web site is currently operational and a NR Role Delineation Study is underway regarding the roles of various types of medical professionals who conduct medical examinations of CMV drivers. The first observations for the study are complete and meetings are being held around the US. to gather data on medical examiner performance. The national survey plan for the study was published in the Federal Register on September 29, 2005.

From: NTSB
To: FMCSA
Date: 9/22/2005
Response: NTSB and FMCSA staff held a SWAT meeting on 9/22/05 to discuss Safety Recommendations H-01-17 through -24. FMCSA staff announced that Secretary Mineta has signed the Medical Review Board Charter and the Federal Register notice was published on October 3, 2005. NTSB staff mentioned that despite differences of opinion on specific procedures, they are pleased with FMCSA's overall work on medical certification. Safety Recommendations H-01-17, -19, and -20 are currently classified OPEN -- ACCEPTABLE RESPONSE. NTSB staff did not raise any questions about these recommendations and is satisfied with the work FMCSA has done so far to address these three recommendations. Safety Recommendations H-01-18, -21, -22, -23, and -24 are currently classified "Open-Unacceptable Response" and were the focus of this update on medical certification.

From: NTSB
To: FMCSA
Date: 3/25/2005
Response: The national registry being established by Axiom Resource Management, Incorporated, may provide for specific training and could be used to disseminate information to practitioners regarding new medical discoveries, policies or requirements relevant to the examinations. The Safety Board encourages the FMCSA to ensure that the national registry becomes a source of information for and provides guidance to all health care practitioners performing examinations on interstate commercial drivers. Pending the development of a national registry, Safety Recommendation H-01-20 is classified OPEN -- ACCEPTABLE RESPONSE.

From: FMCSA
To: NTSB
Date: 2/1/2005
Response: In its 2/1/2005 annual report to Congress, Regulatory Status of the National Transportation Safety Board's "Most Wanted" Recommendations to the Department of Transportation, the DOT wrote: Establishing a national registry of medical examiners will enable specific training and continuous national monitoring of medical examiners on the registry and can be used to disseminate information to practitioners regarding medical findings, policies, or requirements relevant to the examinations. A certification program will respond to NTSB’s recommendations to develop a comprehensive medical oversight program that ensures that medical examiners are qualified and educated about the occupational issues for drivers and have specific guidance and a readily identifiable source of information for questions on physical examinations. FMCSA believes that improving medical information, establishing a medical registry and examiner certification program and updating medical standards are critical activities to expand FMCSA oversight of the medical certification process and improve CMV safety. At the November 18,2003, NTSB board meeting, the NTSB Chairman and staff indicated that FMCSA’s completed and proposed actions in response to this recommendation were innovative, substantive, and comprehensive. These actions include the NPRM linking medical certification with the CDL; the already-established medical division within FMCSA; and the creation of a national medical registryicertification process and medical review board. Contracts to establish the national registry and medical review hoard were awarded in September 2004. The NTSB has expressed concern about the timeliness of Department action.

From: FMCSA
To: NTSB
Date: 8/31/2004
Response: Letter Mail Controlled 9/9/2004 10:25:06 AM MC# 2040553 - From Annette Sandberg, Administrator: Based on the Federal Motor Carrier Safety Administration's (FMCSA) April 11, 2002, initial response letter, NTSB classified four of the eight recommendations (-01 8, -021 -022, -023) "Open--Acceptable Response" and the remaining four (-017, -01 9, -020, -024) "Open--Unacceptable Response." Since that time, FMCSA has informally advised NTSB of a number of initiatives to address all eight recommendations in a comprehensive manner, such as organizing a medical division within FMCSA, publishing updated guidelines for medical examiners, developing a national registry of qualified medical examiners and a medical certification process, establishing a medical review board, and advancing a rulemaking to link the medical certification of drivers with the commercial driver's license process. We discuss these issues in detail in the enclosed summary.

From: NTSB
To: FMCSA
Date: 11/6/2003
Response: NTSB and FMCSA staff held a SWAT meeting on 11/6/03 to discuss Safety Recommendations H-01-17 through -24. Administrator Sandberg stated that the FMCSA was facing a FY04 budget dilemma because their budget has not yet been approved for the 2004 fiscal year. The Administrator stated that the FMCSA needed $9 million from Congress to fully fund the Medical Division and to properly carry out the mission of that Division. Administrator Sandberg requested that Chairman Engleman use the NTSB bully pulpit to favorably discuss the Medical Division and its mission with Congress, when appropriate. The Chairman stated that she strongly believed in the mission of the Medical Division and it's efforts to create a National Registry, and that while she could not lobby Congress, she would support the FMCSA's efforts in this regard. Chairman Engleman also suggested that the FMCSA reach out to other modes within the DOT for support.

From: NTSB
To: FMCSA
Date: 10/30/2003
Response: NTSB and FMCSA staff held a SWAT meeting on 10/30/03 to discuss Safety Recommendations H-01-17 through -24. In July 2003, the FMCSA created a separate Medical Division, which will take the lead in responding to these recommendations. The FMCSA is asking Congress for funding through the 2004 budget request and reauthorization request to create a National Registry of Physicians that will list those physicians who are qualified to provide an individual with approval for operating a commercial motor vehicle. The FMCSA has also asked Congress for money to create a Medical Review Board that will determine if and how medical standards need to be changed. The FMCSA also indicated that they have distributed new guidelines about medical conditions that should prevent a medically-impaired individual from operating a commercial motor vehicle. However, the NTSB pointed out that there is a big difference between guidelines and standards, and that it is the standards that ultimately determine the limitation of the person who is driving. The FMCSA agreed, but felt that the guidelines were a first step in the right direction. NTSB agreed to provide to the FMCSA a list of medical conditions that it feels should prevent a driver from operating a commercial motor vehicle. The FMCSA stated that as soon as its new Diabetes Program was up and running, it would have time to focus on other medical conditions. The FMCSA requested that the NTSB support their request of funding from Congress to create a National Registry. In addition, there will be further discussion about which health conditions should prevent an individual from operating a commercial motor vehicle.

From: NTSB
To: FMCSA
Date: 9/26/2002
Response: The Safety Board appreciates the development of the new medical examination form and notes the FMCSA's improved Web site with medical contact information. Although this information may be useful for individuals who perform medical examinations, the FMCSA has not indicated how its existence has been advertised or how often the Web site is accessed. Thus, it is not clear whether those who might benefit from them are aware that the new form and Web site exist. In our report, the Board indicated- Because these instructions and guidelines are not a required part of the medical examination form, the possibility still exists that not all examiners will benefit from having this information. In addition, the final rule published in October 2000 notes that "existing forms may be used until November 6, 2001." The old form is not as informative and the Safety Board is uncertain how this "sunset date" for the old form will be enforced, since no Federal requirement exists for anyone other than the examiner to see the form. The Safety Board is currently investigating an accident in which an Amtrak train struck a tractor-trailer at an unprotected grade crossing near Coosawhatchie, South Carolina, on May 14, 2002. The involved commercial driver's most recent medical certification examination was recorded on an old examination form, absent instructions, on March 8, 2002, 5 months after the federal regulation required conversion to the new form. The FMCSA has not indicated that it intends to provide either the new form or any other additional guidance or guidance sources to all potential medical examiners; therefore, Safety Recommendation H-01-20 is classified OPEN -- UNACCEPTABLE RESPONSE, pending action that meets the intent of the recommendation.

From: FMCSA
To: NTSB
Date: 4/11/2002
Response: Letter Mail Controlled 08/15/2002 6:20:08 PM MC# 2020418 - From Joseph M. Clapp, Administrator: The new medical examination form published on October 5,2000, includes information on the risk factors and demands on commercial drivers. The new medical form and materials have been updated and organized to reflect current medical terminology and examination components and include all relevant information necessary to conduct the physical examination and certification. Further, it contains the Federal standards, instructions to the medical examiner, and specific guidance to assist the medical examiner in determining the medical qualification status of commercial drivers. Web sites identified on the medical examination form direct medical examiners to FMCSA reports on specific medical conditions and commercial drivers. In addition, an FMCSA telephone contact number is provided for questions. FMCSA requests that the status of the Safety Recommendation H-01-20 be classified as "Closed -Acceptable Action."

From: NTSB
To: FMCSA
Date:
Response: At the November 18, 2003 Board meeting addressing the NTSB’s Most Wanted List of Transportation Safety Improvements (MWL), the Board voted to place Safety Recommendations H-01-17 through H-01-24 on the Federal MWL under the issue category “Prevent Medically Unqualified Drivers from Operating Commercial Vehicles.”