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Safety Recommendation Details

Safety Recommendation R-06-003
Details
Synopsis: On Wednesday, November 3, 2004, about 12:49 p.m., eastern standard time, Washington Metropolitan Area Transit Authority (WMATA) Metrorail train 703 collided with train 105 at the Woodley Park-Zoo/Adams Morgan (Woodley Park) station in Washington, D.C. Train 703 was traveling outbound on the Red-Line segment of the Metrorail system and ascending the grade between the Woodley Park and the Cleveland Park underground stations, when it rolled backwards about 2,246 feet and struck train 105 at a speed of about 36 mph. Train 703 was operating as a nonrevenue train; that is, it was not carrying passengers. Train 105, a revenue train, was in the process of discharging and loading passengers at the Woodley Park station. There were about 70 passengers on board train 105. Some passengers had exited the train just before or during the collision. The District of Columbia Fire and Emergency Medical Service transported about 20 persons to local hospitals. Estimated property damages were $3,463,183.
Recommendation: TO THE FEDERAL TRANSIT ADMINISTRATION: Require transit agencies, through the system safety program and hazard management process if necessary, to ensure that the time off between daily tours of duty, including regular and overtime assignments, allows train operators to obtain at least 8 hours of uninterrupted sleep.
Original recommendation transmittal letter: PDF
Overall Status: Open - Acceptable Response
Mode: Railroad
Location: Washington, DC, United States
Is Reiterated: No
Is Hazmat: No
Is NPRM: No
Accident #: DCA05MR003
Accident Reports: Collision Between Two Washington Metropolitan Area Transit Authority Trains at the Woodley Park-Zoo/Adams Morgan Station
Report #: RAR-06-01
Accident Date: 11/3/2004
Issue Date: 4/19/2006
Date Closed:
Addressee(s) and Addressee Status: FTA (Open - Acceptable Response)
Keyword(s): Fatigue

Safety Recommendation History
From: NTSB
To: FTA
Date: 2/13/2014
Response: CC# 201301266- ANPRM Response to Federal Transit Administration: ANPRM - The National Public Transportation Safety Plan, the Public Transportation Agency Safety Plan, and the Public Transportation Safety Certification Training Program; Transit Asset Management: Question 3: To what extent do these performance criteria categories sufficiently address the relevant safety information pertaining to public transportation agencies? Are there other safety performance categories that should be included? Performance criteria based on casualties are lagging measures and do not always result in improvement. It is important to measure casualties for trend analysis and development of enhanced strategies for improvement. However, the greatest emphasis should be placed on analytical data from close calls or near misses. Performance criteria in operations should be based on robust rules compliance programs, including emphasis on mentoring and coaching to improve human performance. Criteria also should guide and measure the inspection processes and accident review and analysis. Performance criteria should be developed that encompass right-of-way, bridges, signals, and all critical infrastructure. These criteria should include metrics for inspection and preventative maintenance that are linked to the transit asset management plan. Hazard analysis should be woven into these criteria to ensure conformance to industry standards, hazard identification and reporting, and job safety analysis programs. Additionally, the NTSB believes fitness-for-duty standards are vital to a safe organization. Performance criteria for organizational culture and human performance should be established to ensure safety is integrated fully into the overall business strategies that focus on the inclusion of resilience, reliability, and redundancy. Examples should include improved fitness-for-duty requirements, continual learning, training and competency assessment, and employee involvement. An example of this is the improved organizational culture at Union Pacific Railroad following the NTSB’s investigation of an accident that occurred in Goodwell, Oklahoma, on June 24, 2012. We note this ANPRM does not seek input on prescriptive standards. However, we wish to express our understanding that effective regulatory efforts require a balance between performance and prescriptive standards. The NTSB believes there will be a need for civil penalties to address noncompliance with certain regulations. Further, performance standards will often need to have some prescriptive elements. In some cases, a prescriptive minimum or floor should be established. Using track gage as an example, the minimum deviation needs to be established based on design gage and wheel width. In other cases, an appropriate existing standard may need to be referenced As well, in terms of performance standard, we wish to point out that there are perils to ensuring effective compliance oversight with such standards, as seen in NTSB investigations on pipeline ruptures in San Bruno, California, and Marshall, Michigan. Finally, there are physiological and psychological factors that logically lead to more specified standards. An example is the recognized need for adequate rest periods as found in the following NTSB recommendation to FTA. Require transit agencies, through the system safety program and hazard management process, if necessary, to ensure that the time off between daily tours of duty, including regular and overtime assignments, allows train operators to obtain at least 8 hours of uninterrupted sleep. (R-06-3) This recommendation is currently classified “Open—Acceptable Response.” Another example is the need to gauge the reaction time needed by roadway workers to detect and react to clear an approaching train. Pass–fail criteria are effective when balanced with robust and effectively implemented SMS.

From: NTSB
To: FTA
Date: 4/23/2013
Response: Notation 8486: On March 11, 2013, the US Chemical Safety and Hazard Investigation Board (CSB) published a request for public comment on a document released on its website titled “Draft Recommendations Evaluation for Public Comment: Fatigue Risk Management Systems (FRMS)” (CSB Evaluation). Subsequently, CSB staff invited the National Transportation Safety Board (NTSB) to share its experiences in investigating transportation accidents in which human fatigue was identified as a safety issue, and related NTSB safety recommendations. The NTSB is an independent federal agency charged with determining the probable cause of transportation accidents and issuing safety recommendations aimed at preventing future accidents. The NTSB has a long history of making recommendations to reduce fatigue and fatigue-related transportation accidents and, since its inception, has issued over 200 recommendations addressing fatigue in the aviation, highway, marine, railroad, and pipeline modes. We are pleased to share our experiences with the CSB. The CSB Evaluation comments on actions taken by the American Petroleum Institute (API) and the United Steelworkers International Union (USW) in response to Recommendation No. 2005-04-I-TX-7, issued by the CSB in 2005 to those organizations. The CSB recommendation was issued as a result of the March 23, 2005, Texas City, Texas, refinery explosion and fire. The portion of the CSB recommendation pertinent to this letter reads as follows: [D]evelop fatigue prevention guidelines for the refining and petrochemical industries that, at a minimum, limit hours and days of work and address shift work…. In April 2010, the API issued an American National Standards Institute-approved Recommended Practice titled Fatigue Risk Management Systems for Personnel in the Refining and Petrochemical Industries, First Edition (RP-755), and an accompanying technical report titled Fatigue Risk Management Systems for Personnel in the Refining and Petrochemical Industries, Scientific and Technical Guide to RP 755. The CSB Evaluation presents the results of a CSB staff review in which the CSB staff determined that RP-755 does not meet the intent of the CSB recommendation in several areas. The NTSB has reviewed RP-755 as well as the CSB Evaluation. With respect to human fatigue, the NTSB has specific experience with the following issues that are discussed in the CSB Evaluation: • The hours-of-service limits described in RP-755, which are more permissive than what is indicated by current scientific knowledge, and the suggestion that voluntary FRMS programs will compensate for the risk from excessive hours and days at work, and • The emphasis of RP-755 on voluntary efforts by industry and its lack of explicit requirements, especially with respect to elements of an effective fatigue management system. With respect to the hours-of-service limits, RP-755 describes “work sets” during normative conditions, which may include 12-hour day shifts or night shifts for 7 consecutive days, with the possibility of an additional “holdover period” beyond the duty day for training or safety meetings. The RP states that the “holdover period should not exceed 2 hours and, where possible, occur at the end of the day shift.” However, the use of the language “should” is not a requirement but is defined by the document as a “recommendation or that which is advised but not required in order to conform to the RP.” Therefore, a worker could, during a normal work set, work shifts of 14 hours or greater in a 24-hour period for several days. RP-755 also states that during planned or unplanned outages, workers may be called on to work 12-hour shifts for up to 14 consecutive days, with as little as 36 hours between 14-day, 12-hour work sets. Holdover periods of up to 2 hours are also allowed during outages. The RP also has provisions for extending work shifts up to 18 hours. In several of its accident investigations, the NTSB has recognized the relationship between long duty days and fatigue, both directly and through their effects on reduced sleep lengths during off-duty periods. For example, in the investigation of the October 2004 Corporate Airlines accident in Kirksville, Missouri, the NTSB determined that the probable cause of the accident was the pilots’ failure to follow established procedures and properly conduct an instrument approach at night, and that fatigue was one factor that contributed to the pilots’ degraded performance. The length of the pilots’ duty day (at the time of the accident, they had been on duty for 14 1/2 hours) was cited along with less-than-optimal overnight rest time, early reporting time for duty, the number of flight legs, and demanding flight conditions, as factors that resulted in the pilots’ fatigue. In the Kirksville report, the NTSB cited research showing that pilots who worked schedules that involved 13 or more hours of duty time had an accident rate that was several times higher than that of pilots working shorter schedules, and that airplane captains who had been awake for more than about 12 hours made significantly more errors than those who had been awake for less than 12 hours. As a result of the Kirksville investigation, the NTSB issued Safety Recommendation A-06-10 to the Federal Aviation Administration (FAA), which stated the following: A-06-10 Modify and simplify the flight crew hours-of-service regulations to take into consideration factors such as length of duty day, starting time, workload, and other factors shown by recent research, scientific evidence, and current industry experience to affect crew alertness. The NTSB reiterated Safety Recommendation A-06-10 in 2008 following its investigation of the April 2007 Pinnacle Airlines accident in Traverse City, Michigan. In that accident, the NTSB determined that the probable cause of the accident was the pilots’ poor decision-making as they prepared to land the airplane. The NTSB stated that “This poor decision-making likely reflected the effects of fatigue produced by a long, demanding duty day and, for the captain, the duties associated with check airman functions.” The pilots had been on duty for more than 14 hours at the time of the accident. The effectiveness of fatigue management is directly related to the availability of work schedules that allow a sufficient period of time between work shifts for the employee to obtain sufficient restorative sleep. The NTSB has investigated several accidents and serious incidents that provided clear and compelling evidence that air traffic controllers were sometimes operating in a state of fatigue because of their work schedules and poorly managed utilization of rest periods between shifts, and that fatigue had contributed to controller errors. Consequently, the NTSB issued Safety Recommendation A-07-30 to the FAA, which stated the following: A-07-30 Work with the National Air Traffic Controllers Association to reduce the potential for controller fatigue by revising controller work-scheduling policies and practices to provide rest periods that are long enough for controllers to obtain sufficient restorative sleep and by modifying shift rotations to minimize disrupted sleep patterns, accumulation of sleep debt, and decreased cognitive performance. The NTSB’s consideration of how long duty days affect fatigue and safety has not been limited to the aviation mode. Recently, in our investigation of the September 2010 collision of two freight trains near Two Harbors, Minnesota, the NTSB concluded that crew fatigue was a contributing factor in train crew errors that led to the collision. The train crewmembers who made the errors had been awake between 13 and 14 hours at the time of the accident, and the accident occurred during the final hour of a 12-hour shift. In its report, the NTSB cited a study showing that 12 hour work shifts have been associated with decrements in alertness and performance, compared to 8-hour shifts. Other studies of commercial drivers have found an exponential increase in crash risk with increasing driving times, especially for driving periods that extend beyond 8 or 9 hours. The NTSB has made numerous recommendations concerning hours of service across the transportation modes. A common theme of those NTSB recommendations has been an emphasis on establishing hours-of-service limits that are scientifically based, that set limits on hours of service, that provide predictable work and rest schedules, and that consider circadian rhythms and human sleep requirements. The second issue discussed in the CSB Evaluation with which the NTSB has experience concerns the lack of explicit requirements regarding essential elements of a fatigue management program. The CSB Evaluation remarks that The use of the word ‘should’ for most elements of a Fatigue Risk Management System (FRMS) in the RP means that they are optional, not required. In what is already a voluntary standard to begin with–employers can choose to conform to them, but they are not required by force of law to do so–‘should’ statements have very little force. The lack of required FRMS elements raises additional concerns because RP-755 states that its hours-of-service limits were “developed in the context of the existence of a comprehensive FRMS” and that “Consistently working at the limits shown is not sustainable and may lead to chronic sleep debt.” Hence, while RP-755 does not require the use of an FRMS, it does ostensibly allow operators to persistently schedule workers at the noted limits. The NTSB has recommended requiring the implementation of fatigue management programs. For example, as a result of its investigation of a June 2009 multivehicle accident near Miami, Oklahoma, in which a truck driver’s fatigue resulted in his failure to react to and avoid colliding with a slowing traffic queue, the NTSB emphasized the importance of comprehensive fatigue management programs. The report described the North American Fatigue Management Program (NAFMP), which is designed to address scheduling policies and practices, fatigue management training, sleep disorder screening and treatment, and fatigue monitoring technologies. In the report, the NTSB stated that “if the NAFMP guidelines remain voluntary—and are used by some carriers but ignored by others—this important safety tool might have only a limited effect in reducing fatigue-related highway accidents.” As a result of its investigation, the NTSB called on the Federal Motor Carrier Safety Administration to implement the following NTSB safety recommendation: H-10-9 Require all motor carriers to adopt a fatigue management program based on the North American Fatigue Management Program guidelines for the management of fatigue in a motor carrier operating environment. The NTSB has also made recommendations in the highway, railroad, and aviation modes to establish ongoing programs to evaluate, report on, and continuously improve fatigue management programs implemented by operators (NTSB Safety Recommendations H-08-14, R 12-007, A-06-11, and A-08-45). I hope that this information about the NTSB’s history of investigating fatigue-related accidents and the recommendations we have issued will be useful as the CSB moves forward with the evaluation of the API and USW responses to the fatigue-related CSB recommendation resulting from the Texas City investigation.

From: NTSB
To: FTA
Date: 9/29/2010
Response: The NTSB is aware that, on December 7, 2009, U.S. Secretary of Transportation Ray LaHood submitted to Congress draft legislation, titled “The Public Transportation Safety Program Act of 2009,” requesting the authority to promulgate regulations and issue orders for the safe operation of rail fixed guideway public transportation systems. We note that the FTA has also formed an advisory committee, the Transit Rail Advisory Committee for Safety (TRACS), to assist it in developing national safety standards for rail transit. The NTSB is pleased that the FTA has provided financial support to the American Public Transportation Association (APTA) to develop a voluntary Standard for Train Operator Hours of Service Requirements that limits shift length and hours of service as recommended. Pending the FTA’s receiving the authority it needs to require transit agencies to ensure that the time off between daily tours of duty, including regular and overtime assignments, allows train operators to obtain at least 8 hours of uninterrupted sleep, Safety Recommendation R-06-3 remains classified OPEN – ACCEPTABLE RESPONSE.

From: FTA
To: NTSB
Date: 6/2/2010
Response: MC# 2100205: - From Peter M. Rogoff, Administrator: Congress will have to provide FTA with the authority to require hours of service limits for rail transit operators. FTA is proposing, however, adding a fatigue management section as part of the System Safety Program Plan in the next revision to 49 CFR Part 659. FTA has also provided financial support to the American Public Transportation Association (APTA), which developed and issued an industry standard for train operators addressing this recommendation.

From: NTSB
To: FTA
Date: 9/23/2008
Response: The Safety Board notes that the FTA is supporting the American Public Transportation Association (APTA) to develop a standard recommending 10 hours off duty between shifts to allow transit operators to obtain 8 hours of uninterrupted sleep. The FTA anticipates that the standard will also contain additional elements of a fatigue management program. The Safety Board further notes that the FTA is drafting a notice of proposed rulemaking (NPRM) revising Title 49 Code of Federal Regulations (CFR) Part 659, Rail Fixed Guideway Systems; State Safety Oversight” (SSO) to require that a fatigue management program section be included in the rail transit agency system safety program plan (SSPP). This added section will require each rail transit agency covered by 49 CFR Part 659 to identify in its SSPP its hours of service rules for rail transit operators and other safety critical personnel. Further, the section will require each agency to identify programs, techniques, and procedures it is using to address fatigue issues, including monitoring the alertness of rail transit operators and medical screening to identify sleep disorders in all safety critical personnel. The revised regulation will require the SSO agency to review and approve the elements of the fatigue management program and evaluate it as part of the SSO agency’s triennial safety review to determine whether the program is actually being implemented. The transit agency will be required, under the SSPP, (1) to review the program annually to determine whether it needs to be updated and (2) to incorporate the program into the rail transit agency’s internal safety audit process. The Safety Board also notes that the FTA will be revising Section 659.31, Hazard Management Process, to ensure that rail transit agencies provide their SSO agencies with an annual report that identifies each accident that occurred in which fatigue was a primary or contributing cause; the FTA is also considering including a provision requiring an analysis of rail transit operator work schedules by the rail transit agencies. The Board encourages the FTA to include that provision. The FTA expects to issue an NPRM by the end of 2008. The FTA’s efforts constitute an acceptable response to the recommendation; accordingly, Safety Recommendation R-06-3 is classified OPEN -- ACCEPTABLE RESPONSE.

From: FTA
To: NTSB
Date: 2/14/2008
Response: Letter Mail Controlled 2/21/2008 9:08:16 AM MC# 2080082: - From James S. Simpson, Administrator: In response to R-06-3, since October 2006, FTA has performed the following activities: In partnership with the Operating Practices Committee of the American Public Transportation Association (APTA) Rail Transit Standards Program, FTA is supporting the development of a standard to provide guidance limiting the hours of service of rail transit operators. O This standard, will recommend a minimum of 10 hours off duty between shifts to allow rail transit operators to obtain 8 hours of uninterrupted rest. We anticipate that this standard will also contain other practices to be implemented to support an effective fatigue management program, including approaches to: work scheduling and extra board management, employee pre-employment screening, fitness-for-duty checks, on-going dialogue with employees regarding their sleep habits, and managing employees with diagnosed sleep disorders. In partnership with the Transportation Safety Institute (TSI) and the National Transit Institute (NTI), FTA is providing training to State Safety Oversight (SSO) agencies and rail transit agencies that emphasize techniques for assessing fatigue as a probable cause or contributing factor in rail transit accidents. In the 2nd Quarter of Calendar Year 2008, TSI will begin revising its Advanced Rail Incident Investigation course to provide an in-depth module on investigating fatigue as a probable cause or contributing factor in rail transit accidents. FTA will initiate a rule revision process for 49 CFR Part 659 to require that a fatigue management program section be included in the rail transit agency System Safety Program Plan (SSPP). At a minimum, this new section will require each rail transit agency covered by 49 CFR Part 659 to identify or reference in its SSPP: Its hours of service rules for rail transit operators and other safety critical personnel, Its programs in place to help rail transit operators manage their behavior to ensure that they are well-rested and alert while on-duty, o Its techniques and procedures for managing work schedule and extraboard to ensure sensitivity to fatigue issues, o Its procedures and supporting training programs for supervisors to identify fatigue in employee fitness-for-duty checks and to administer discipline, o Its approach to identifying and deploying technologies available to monitor the alertness of rail transit operators, and o Its use of medical screening programs to identify sleep disorders in the recruitment of rail transit operators and other safety critical personnel. FTA will require, that as part of the SSPP, the new fatigue management program section will be reviewed and approved by the SSO agency, reviewed annually by the rail transit agency to determine if it needs to be updated, and incorporated into the rail transit agency’s internal safety audit process (ISAP). FTA will also require, that as part of the SSPP, the new fatigue management program’’ section will be evaluated by the SSO agency as part of its Triennial Safety Review to determine if, in fact, it is being implemented. FTA also will revise the hazard management program specified in 49 CFR Part 659 to ensure that rail transit agencies provide their oversight agencies with an annual report that identifies each accident that occurred where fatigue was a primary or contributing cause. As part of this revision, FTA is also considering requiring an annual analysis to be performed by the rail transit agency on the work schedule developed for rail transit operators. This analysis may specify what percentage of rail transit operators are working more than 14 hours per day without one day off per week or may provide more detailed analysis regarding the number of hours worked per week or month by all rail transit operators. 0 FTA also has begun activity to revise the annual reporting requirements in 49 CFR Part 659 to ensure that SSO agencies submit to FTA copies of the annual reports prepared by the rail transit agencies identifying the accidents that occurred where fatigue was a primary or contributing cause and any analysis that may be performed on rail transit operator work schedules. FTA will provide NTSB with draft language regarding these Part 659 revisions prior to their publication in the Federal Register as part of a Notice of Proposed Rulemaking (NPRM). Based on our current schedule, we hope to have draft language to NTSB by the end of the 3rd Quarter of Calendar Year 2008. However, based on subsequent rule revision activity that may be required to address more recent NTSB recommendations from the July 11, 2006, derailment at CTA, this schedule is subject to change. FTA will keep NTSB updated regarding the draft language and the proposed publication schedule for the NRPM. FTA will also provide NTSB with any additional information collected on fatigue management issues as part of the rulemaking effort. Finally, in cooperation with the SSO agencies and rail transit industry, FTA will continue to investigate the need for legislation mandating an hours of service rule for safety sensitive personnel’’ in all modes of public transportation. FTA notes that Congress recently passed legislation to strengthen hours of service rules for freight and passenger railroads in the Federal Railroad Safety Improvement Act of 2007, H. R. 2095. While H.R. 2095 does not affect the rail transit industry, it does show a strong Congressional commitment to hours of service mandates in transportation.

From: FTA
To: NTSB
Date: 11/2/2007
Response: Letter Mail Controlled 11/7/2007 10:51:33 AM MC# 2070636: - From James S. Simpson, Administrator: Thank you for your letter dated October 5, 2007, responding to submissions made by the Federal Transit Administration (ITA) on June 6,2006 and October 20,2006, to address Safety Recommendations R-06-3 through R-06-6. These recommendations resulted from the National Transportation Safety Board (NTSB) investigation of a collision between two trains on November 3, 2004. at the Washington Metropolitan Area Transit Authority (WMATA). I especially appreciate receiving this letter in light of the recent hearing regarding NTSB investigation of the July 1 1, 2006, derailment at the Chicago Transit Authority (CTA) and our on-going legal correspondence related to R-02- 19 from an earlier series of accidents at CTA. FTA is committed to working with you and the Board to address critical safety issues in the rail transit industry. To ensure an effective partnership, it is important that we maintain ongoing communication. I have instructed my staff to make response to any communication from NTSB a top priority. We appreciate that NTSB has classified our response to R-06-4 as Closed -Acceptable Action and our response to R-06-3, R-06-5, and R-06-6 as Open -Acceptable Action. We look forward to working with you and the Board to ensure that all NTSB recommendations to FTA are ultimately classified as Closed -Acceptable Action. Over the last year since we submitted our October 20,2006, response to NTSB, we have moved forward to address the Board’s recommendations. In the coming month, I will provide you with an in-depth update of our activities, including a description of initiatives to develop consensus-based standards for hours of service, emergency features for rail transit cars, and procurement specifications for heavy and light rail vehicles. While implementation of these consensus-based standards is voluntary, we are working closely with the American Public Transportation Association to develop new strategies and incentives to encourage their wide-spread adoption in the rail transit industry. Also, I will provide a status update regarding FTA’s activities to revise 49 CFR Part 659 to address the activities we identified in our October 20, 2006, response regarding R-06-3 and R-06-6. Finally, I will describe FTA’s activities to provide on-going safety oversight to the Tri-State Oversight Committee and WMATA. Thank you again for conveying the Board’s classification of FTA’s response to Safety Recommendations R-06-3 through R-06-6. We look forward sharing our progress with you, and to continuing to work with you and the Board on rail transit safety issues.

From: NTSB
To: FTA
Date: 10/5/2007
Response: Thank you for also providing a copy of the report titled Fatigue Management Survey Results: State Safety Oversight and Rail Transit Agencies Affected by 49 CFR [Code of Federal Regulations] Part 659 (September 2006). The Safety Board notes that the FTA surveyed 37 rail transit agencies and their 22 State safety oversight (SSO) agencies subject to 49 CFR Part 659, Rail Fixed Guideway Systems; State Safety Oversight. The survey provides information regarding current work scheduling practices in the rail transit industry, especially existing policies for hours off-duty and managing on-call/extraboard assignments, fatigue-related programs and training, and practices in place to ensure the alertness of rail transit operators. The survey found that, while few rail transit operators have policies that ensure the opportunity for at least 8 uninterrupted hours of sleep, 24 of the 37 surveyed agencies have daily work scheduling limits of 14 hours or less, providing at least 10 hours off-duty for rail transit operators between shifts. The Safety Board notes that the FTA has also determined that (1) it lacks the statutory authority to regulate safety operations at rail transit agencies; (2) it can only require specific safety policies, plans, programs, or activities as terms and conditions of grant-making, based on express delegations of authority from Congress, and (3) none of its existing safety programs, including the SSO program, has sufficient Congressional enabling authority to mandate hours-of-service requirements for rail transit operators. To develop and implement such a rule, the FTA would require additional authority from Congress. The Safety Board further notes, however, the FTA’s statement that requirements for the contents of rail transit system safety program plans (SSPPs) and the hazard management process could potentially be modified to address fatigue management issues. In addition, the FTA has proposed revising Part 659 to add fatigue management as a distinct section in the rail transit agencies’ SSPP. The FTA indicates that it will conduct additional research and industry outreach to focus on activities that do the following: • Use training and management techniques to help rail transit operators manage their behavior to ensure that they are well-rested and alert while on-duty • Address fatigue issues in the creation of the agency's work schedule • Address technologies available to monitor the alertness of rail transit operators • Identify screening programs to address fatigue issues in the recruitment of operators • Ensure that the investigation of accidents and hazards appropriately identifies and considers fatigue issues The Safety Board further notes that the FTA will propose revising the hazard management process specified in Part 659.31 to ensure that each rail transit agency submits an annual report to the FTA identifying every accident in which fatigue was a primary or contributing cause. The FTA will summarize the results in its annual report and provide additional guidance on evaluating fatigue issues through the hazard management process. We appreciate your commitment to continue to evaluate the need for congressional authority and your offers to provide the Safety Board with (1) draft language prior to beginning rulemaking and (2) copies of the Annual Report for the SSO Program. In the meantime, Safety Recommendation R-06-3 is classified OPEN -- ACCEPTABLE RESPONSE. Although the Board continues to believe that regulations will ultimately be needed, we are interested in the outcomes of the initiatives described above and would appreciate receiving updates as progress is made on these initiatives.

From: FTA
To: NTSB
Date: 10/20/2006
Response: Letter Mail Controlled 10/30/2006 11:33:44 AM MC# 2060532: - From James S. Simpson, Administrator: This letter has been prepared to update you on the progress made by the Federal Transit Administration (FTA) to address Safety Recommendations R-06-3 through R-06-6, officially transmitted to Deputy Administrator Sandra Bushue on April 19, 2006. Since becoming the Administrator of FTA last month, I have been fully briefed on the National 'Transportation Safety Board (NTSB) investigation of the November 3, 2004, collision at the Washington Metropolitan Area Transit Authority (WMATA). I have also reviewed Deputy Administrator Bushue's letter of June 6, 2006, which outlined our agency's activities to identify and evaluate options for addressing R-06-3 through R-06-6. I am pleased to report that, working with my staff, we have completed the initial activities identified in our letter of June 6, and now are proposing specific actions to respond to each recommendation. NTSB Recommendation R-06-3: Require transit agencies, through the system safety program and hazard management process if necessary, to ensure that the time off between daily tours of duty, including regular and overtime assignment, allows train operators to obtain at least 8 hours of uninterrupted sleep. During May and June of 2006, FTA completed an in-depth review of FTA’s current legal and statutory authorities to determine if FTA can require transit agencies to provide "at least 8 hours of uninterrupted sleep" for train operators. We also assessed the impacts of new provisions included in the Safe, Accountable, Flexible, Efficient Transportation Equity Act: A Legacy for Users (SAFETEA-LU) on our statutory authority. We determined that FTA lacks the statutory authority to regulate safety operations at rail transit agencies except for purposes of national defense or in cases of regional or national emergency. Based on express delegations of authority from Congress, FTA may require specific safety policies, plans, programs, or activities as terms and conditions of grant making. However, we found that none of FTA's existing safety programs, including the State Safety Oversight Program (49 CFR Part 659), has sufficient Congressional enabling authority to mandate hours-of-service requirements for rail transit operators. To develop and implement such a rule, FTA would require additional authority from Congress. However, SAFETEA-LU requires FTA to revise 49 CFR Part 659 to address two new provisions contained in Section 3029. Although we found that the enabling legislation for 49 CFR Part 659 is not sufficient to allow FTA to require hours-of-service as an element of the program to be enforced by State Safety Oversight (SSO) agencies, existing requirements for the contents of rail transit System Safety Program Plans (SSPPs) and the hazard management process could potentially be modified to address fatigue management issues. Any revision to Part 659 proposed by FTA, of course, would require the opportunity for full public notice and comment in the Federal Register. To identify possible revisions to Part 659 to improve the rail transit industry's management of fatigue issues, FTA's Office of Safety and Security (TPM-30) conducted an in-depth survey of 37 rail transit agencies subject to Part 659 and their SSO agencies. The survey, which was administered as a periodic information request through the SSO program (49 CFR section 659.39(d)), was performed during the last two weeks of June and the month of July 2006. A report documenting the survey results is enclosed with this letter. This survey confirms earlier findings made by NTSB regarding work scheduling practices in the rail transit industry. However, FTA also determined that, while few rail transit agencies have official policies that ensure rail transit operators have the opportunity for at least 8 uninterrupted hours of sleep, 24 of the 37 surveyed agencies have daily work scheduling limits of 14 hours or less, providing at least 10 hours off-duty for rail transit operators between shifts. Also, FTA determined that for many agencies with less restrictive daily work limits, the length of the average overtime shift is four (4) hours, meaning that the majority of rail transit operators with overtime assignments are working 12 to 14 hours per days, providing at least 10 hours off in between shifts. In addition, innovative work scheduling practices are used at some of these agencies, which enable rail transit operators to select overtime assignments up to one week in advance, providing sufficient opportunity to ensure that they are well-rested prior to performing extended shifts. Some rail transit agencies are also providing "quiet rooms" and napping policies for rail transit operators when not on active duty. Additional, tools used in the industry to address fatigue include pre-employment screening for sleep disorders, fatigue management training programs, supervisor observations and "fitness for duty" evaluations, and strict discipline, including suspension and termination, for inattentive operators. Most significantly, as you will see in the enclosed report, survey results indicate that rail transit agencies and SSO agencies have not determined fatigue to be a major cause of accidents. Over the last three years, 73 percent of rail transit agencies have not experienced a single accident where fatigue was a primary or contributing cause. Of the remaining 27 percent of transit agencies, fatigue was a primary factor in 0.44 percent of all accidents to occur at these agencies during the last three years, and contributing factor in just two percent of accidents. Further, in outreach activities with affected SSO agencies and rail transit agencies, FTA learned that the majority of SSO agencies have not been given authority by their State or local jurisdiction to impose hours-of-service requirements. Rail transit schedulers, operations directors, and safety directors shared their opinions that while fatigue is a genuine concern with the potential for a catastrophic occurrence, the industry is making steady gains in addressing this issue through improved fatigue management programs. Both SSO agencies and rail transit agencies remain skeptical that the issue is of sufficient magnitude in industry to justify the expense of an hours-of-service rule. FTA Response to R-06-3 To address R-06-3, FTA proposes revising Part 659 to add fatigue management as a distinct section in the rail transit agency's SSPP. Based on additional research and outreach with industry, FTA will propose required contents of this section to focus on activities that: • Use training and management techniques to help rail transit operators manage their behavior to ensure that they are well-rested and alert while on-duty, • Address fatigue issues in the creation of the agency's work schedule, • Address technologies available to monitor the alertness of rail transit operators, • Identify screening programs to address fatigue issues in the recruitment of Operators; and • Ensure that the investigation of accidents and hazards appropriately identifies and considers fatigue issues. Rail transit agencies will be required to update this section annually, and to review their compliance with this section of the SSPP as part of their internal safety audit program. SSO agencies will be required to review rail transit agency compliance with this section of the SSPP during their three-year reviews. This will ensure on-going assessment of the rail transit agency's implementation of the fatigue management provisions in its SSPP. In addition, FTA will propose revising the hazard management process specified in Part 659 to ensure that an annual report is generated for each rail transit agency, which identifies each accident that occurred where fatigue was a primary or contributing cause. This report will be submitted to FTA annually, and the results will be summarized in FTA's Annual Report for the SSO Program. Based on this information collection, FTA will provide additional guidance on evaluating fatigue issues through the hazard management process and will focus this initiative on those rail transit agencies with the least restrictive work scheduling practices. FTA will provide NTSB with draft language prior to entering rulemaking. FTA will also provide copies of its Annual Report for the SSO Program directly to NTSB. FTA is also committed to performing other activities to support fatigue management in the transit industry. FTA is currently developing a set of accident notification and investigation guidelines in partnership with rail transit agencies and SSO agencies affected by Part 659. Questions and procedures to ensure that fatigue is adequately assessed as a component in each accident investigation will be considered. Through the National Transit Institute, FTA is also committed to providing training for rail transit agency safety personnel and SSO program managers on fatigue issues. Finally, in cooperation with NTSB and industry, FTA will continue to evaluate the need for Congressional authority mandating an hours-of-service rule for safety sensitive personnel in all modes of public transportation. FTA believes these proposed activities are reasonable given FTA's limited existing statutory authority, current opinion in industry regarding the appropriate level of resources to be devoted to fatigue management issues, and the potential for unintended consequences resulting from a dramatic change in policy. This proposed approach will also provide additional information to support further action in favor of an hours-of service regulation, should the annual data collected demonstrate the need.

From: FTA
To: NTSB
Date: 6/6/2006
Response: Letter Mail Controlled 6/20/2006 9:55:17 AM MC# 2060290: - From Sandra K. Bushue, Deputy Administrator: The Federal Transit Administration (FTA) shares your concerns regarding the importance of adequate rest between shifts for train operators. As you are aware, FTA has previously worked with NTSB, under Congressional direction, to develop a continuing program of technical assistance and training in fatigue awareness for transit operators. Major activities performed by FTA include development of Transit Cooperative Research Program (TCRP) Report 81: Toolbox for Transit Operator Fatigue (published in 2002), as well as a suite of fatigue management training courses at the National Transit Institute (NTI) and the Transportation Safety Institute (TSI). These courses are offered, free-of-charge, to rail transit agency and State Safety Oversight (SSO) agency personnel. In addressing R-06-3, FTA is taking several actions to ensure that we fully understand our options and authority, as well as the current practices in the rail transit industry, and the statutory authority of the SSO agencies. These actions include the following: FTA’s Office of Chief Counsel (TCC) is performing an in-depth review of FTA’s current legal and statutory authorities, to determine if FTA can require transit agencies to provide “at least 8 hours of uninterrupted sleep” for train operators as (1) a condition of grant-making: (2) through the SSO program (49 CFR Part 659); or (3) through some other authority In performing this review, TCC will also assess the impacts of new provisions included in the Safe, Accountable, Flexible, Efficient Transportation Equity Act: A Legacy for Users (SAFETEA-LU) signed into law on August 10,2005. Concurrent with this review FTA's Office of Safety and Security is conducting a detailed survey, through the SSO program, for each of the 43 rail transit agencies affected by 49 CFR Part 659. This survey will identify current practices regarding work scheduling for train operators, on- call/extraboard practices for managing train operator overtime assignments, required hours off between shifts (including overtime assignments) for train operators, any limitations placed on hours worked for rail transit operators (by day, week or month) and industry fatigue management practices. By conducting this survey through the SSO program, we can ensure independent review of the rail transit agency responses and also solicit additional information from the States regarding their authorities to mandate time off-duty for rail operators. Having this information will enable FTA to clearly identify (1) those rail transit agencies that allow operators to work without the opportunity for at least eight uninterrupted hours of sleep, and (2) model programs in place at either SSO agencies or rail transit agencies. Preliminary results from this survey will be introduced and distributed during an FTA-sponsored SSO Compliance Workshop in St. Louis, June 18-21,2006. This workshop will be attended by oversight agency program managers from States affected by FTA's State Safety Oversight Program. Mr. Robert Campbell, NTSB Rail Investigator will also be in attendance, both to make a presentation on R-06-3 and to observe the results of the workshop's fatigue management session. We believe that the workshop will provide an excellent opportunity for candid discussion regarding current work scheduling practices in the rail transit industry, strengths and limitations in existing fatigue-management tools and techniques and options for improvement through the SSO program. Also during this time frame, FTA will conduct a series of meetings with representatives from transit workers unions and the American Public Transportation Association (APTA) to solicit their input and suggestions regarding R-06-3. For some rail transit agencies, the distribution of overtime is an element of collective bargaining agreements with unions. Therefore, it is important to make sure that the labor and industry are provided the opportunity to comment to FTA on the NTSB recommendation. Based on the results of the above-listed activities, FTA anticipates identifying a number of possible options for responding to R-06-3. To support our efforts in reviewing these options, we may find it necessary to request a SWAT ("Safety with a Team") meeting with NTSB. We understand that SWAT meetings with other Department of Transportation modal administrations have been very successful in addressing similarly complex issues. If FTA determines that such a meeting is necessary, we anticipate requesting it for sometime in July 2006. While these activities are being performed, we will also make additional efforts to offer NTI and TSI fatigue management training to SSO agencies and rail transit agencies, including a training session at the 10th Annual SSO Meeting in Salt Lake City, September 17-21, 2006.