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Safety Recommendation Details

Safety Recommendation R-09-010
Details
Synopsis: On May 28, 2008, about 5:51 p.m., eastern daylight time, westbound Massachusetts Bay Transportation Authority (MBTA) Green Line train 3667, traveling about 38 mph, struck the rear of westbound Green Line train 3681, which had stopped for a red signal. The accident occurred in Newton, Massachusetts, a suburb of Boston. Each train consisted of two light rail trolley cars and carried two crewmembers—a train operator at the front of the lead car and a trail operator in the second car. The operator of the striking train was killed; the other three crewmembers sustained minor injuries. An estimated 185 to 200 passengers were on the two trains at the time of the collision. Of these, four sustained minor injuries, and one was seriously injured. Total damage was estimated to be about $8.6 million.
Recommendation: TO 46 US RAIL TRANSIT AGENCIES: Review your medical history and physical examination forms and modify them as necessary to ensure that they elicit specific information about any previous diagnosis of obstructive sleep apnea or other sleep disorders and about the presence of specific risk factors for such disorders.
Original recommendation transmittal letter: PDF
Overall Status: Closed - Acceptable Action
Mode: Railroad
Location: Newton, MA, United States
Is Reiterated: No
Is Hazmat: No
Is NPRM: No
Accident #: DCA08MR007
Accident Reports: Collision Between Two Massachusetts Bay Transportation Authority Green Line Trains
Report #: RAR-09-02
Accident Date: 5/28/2008
Issue Date: 7/23/2009
Date Closed: 10/31/2017
Addressee(s) and Addressee Status: Bay Area Rapid Transit District (Closed - Reconsidered)
Capital Metropolitan Transportation Authority (Closed - Acceptable Action)
Central Arkansas Transit Authority (Closed - Acceptable Action)
Central Puget Sound Regional Transit Authority (Closed - Unacceptable Action - No Response Received)
Charlotte Area Transit System (Closed - Acceptable Action)
Chattanooga Area Regional Transportation Authority (Closed - Acceptable Action)
Chicago Transit Authority (Closed - Acceptable Action)
Commonwealth of Pennsylvania, County of Allegheny, Port Authority (Closed - Acceptable Action)
Commonwealth of Pennsylvania, County of Cambria, Transit Authority (Closed - Acceptable Action)
Dallas Area Rapid Transit Authority (DART) (Closed - Acceptable Action)
Detroit People Mover (Closed - Unacceptable Action - No Response Received)
Fort Worth Transportation Authority (Closed - Acceptable Action)
Galveston Island Transit (Closed--No Longer Applicable)
Greater Cleveland Regional Transit Authority (Closed - Acceptable Action)
Hampton Roads Transit (Closed - Acceptable Action)
Jacksonville Transportation Authority (Closed - Acceptable Action)
Kenosha Transit (Closed - Acceptable Action)
Massachusetts Bay Transportation Authority (Closed - Acceptable Action)
Memphis Area Transit Authority (Closed - Acceptable Action)
Metropolitan Atlanta Rapid Transit Authority (Closed - Unacceptable Action)
Metropolitan Transportation Authority New York City Transit (Closed - Acceptable Action)
Miami-Dade Transit Agency (Closed - Acceptable Action)
Nashville Metropolitan Transit Authority (Closed - Reconsidered)
New Jersey Transit Corporation (Closed - Acceptable Action)
New Orleans Regional Transit Authority (Closed - Acceptable Action)
Niagara Frontier Transit Authority (Closed - Acceptable Action)
Port Authority Transit Corporation (Closed - Unacceptable Action - No Response Received)
Portland Streetcar (Closed - Unacceptable Action - No Response Received)
Regional Public Transit Authority, Valley Metro Rail (Closed - Acceptable Action)
Regional Transportation District (Closed - Reconsidered)
Sacramento Regional Transit District (Closed - Acceptable Action)
San Diego Metropolitan Transit System (Closed - Reconsidered)
San Francisco Municipal Transportation Agency (Closed - Acceptable Action)
Santa Clara Valley Transportation Authority (Closed - Acceptable Action)
Seattle Monorail Services (Closed - Unacceptable Action - No Response Received)
Southeastern Pennsylvania Transportation Authority (Closed - Acceptable Action)
State of California, County of Los Angeles, Metropolitan Transportation Authority (Closed - Acceptable Action)
State of California, County of North, North County Transit District, Sprinter (Closed - Acceptable Action)
State of Maryland, Transit Administration (Closed - Acceptable Action)
State of Minnesota, Metro Transit (Closed - Acceptable Action)
State of Missouri, City of St. Louis, Metro Transit (Closed - Acceptable Action)
State of Texas, County of Harris, Metropolitan Transit Authority of Harris County (Closed - Acceptable Action)
State of Utah, Utah Transit Authority (Closed - Acceptable Action)
State of Washington, County of King, King County Metro Transit (Closed - Unacceptable Action - No Response Received)
Tri-County Metro Transit District of Oregon (Closed - Acceptable Action)
Washington Metropolitan Area Transit Authority (Closed - Acceptable Action)
Keyword(s): Fatigue

Safety Recommendation History
From: NTSB
To: State of Maryland, Transit Administration
Date: 3/6/2014
Response: We note that you have identified classifications of employees that require a Commercial Driver’s license and, as part of their medical evaluations, these employees are asked to self-certify their status regarding sleep disorders on the Medical Examination Report for Commercial Driver Fitness Determination Form 649-F (6045). As this form elicits the recommended information, Safety Recommendation R-09-10 is classified CLOSED—ACCEPTABLE ACTION.

From: State of Maryland, Transit Administration
To: NTSB
Date: 1/7/2014
Response: -Robert L. Smith, MTA Administrator: MTA Response: MTA Response: MTA has identified classifications that require a Commercial Driver's license (CDL). As part of the medical evaluations, the employee is asked to self-certify their status in regards to Sleep Disorders on the Medical Examination Report for Commercial Driver Fitness Determination Form 649-F (6045).

From: NTSB
To: State of Maryland, Transit Administration
Date: 11/22/2013
Response: We have never received a reply from the MTA regarding Safety Recommendation R 09 10 or -11; accordingly, both recommenations are currently classified OPEN—AWAIT RESPONSE.

From: NTSB
To: Regional Public Transit Authority, Valley Metro Rail
Date: 9/24/2014
Response: We are pleased that you established the recommended sleep disorder program, including guidelines for identifying, evaluating, and treating your light rail operators at risk for OSA. We understand that, as of May 1, 2014, your doctors administering the Department of Transportation (DOT) physicals must screen for OSA and, if it is suspected, further testing is required. Medical examiners question the operator about instances of daytime sleepiness, sleep-related distractions, and any previous sleep study or diagnosis of OSA. Medical examiners also record the operator’s body mass index, waist circumference, neck circumference, Mallampati score and Epsworth Sleepiness score. We note that 32 of your employees (22 operators and 10 supervisors) will have their DOT physicals recertified by the end of 2014, and the others will complete their DOT physicals according to their recertification schedules. These practices satisfy Safety Recommendations R-09-10 and -11, which are classified CLOSED—ACCEPTABLE ACTION.

From: Regional Public Transit Authority, Valley Metro Rail
To: NTSB
Date: 7/23/2014
Response: -From Ray Abraham, Chief Operations Officer: Valley Metro Rail operations contractor performed an audit of the current DOT physicals. The audit revealed that year to date, a total of 14 employees have had their DOT physicals recertified. All reports were submitted on proper forms. Under the Health History section on the forms, a box was checked indicating yes or no for sleep disorders, pauses in breathing while asleep, daytime sleepiness and loud snoring.

From: NTSB
To: Regional Public Transit Authority, Valley Metro Rail
Date: 6/13/2014
Response: In the 5 years since these recommendations were issued, you have not responded to us regarding them, despite our January 12, 2012, request for an update. We normally expect recommended actions to be completed within 3 to 5 years after a recommendation is issued. As we have received no reply from you for almost 5 years, despite our request for information, Safety Recommendations R-09-10 and -11 are classified CLOSED—UNACCEPTABLE ACTION/ NO RESPONSE RECEIVED.

From: NTSB
To: Regional Public Transit Authority, Valley Metro Rail
Date: 1/12/2012
Response: Although Safety Recommendations R-09-10 and -11 are over 2 years old, the NTSB has received no reply to date regarding actions that Valley Metro Rail has taken to address them. We are interested in knowing whether and how our recommendations are implemented, both to ensure the public is provided the highest level of safety and to identify creative solutions that might be shared with others. Accordingly, we would appreciate receiving specific information regarding your policies for mitigating the risks associated with unidentified and untreated sleep disorders among your operators. Other transit agencies receiving the same safety recommendations have completed actions and reported their accomplishments to the NTSB. Through their medical history and physical examination forms, their employee training programs, and their requirements for periodic medical examinations, they have identified operators who are at high risk for sleep disorders. Many of the transit agencies reported that they require operators to pass the U.S. Department of Transportation Physical Exam for Commercial Driver Fitness Determination (http://www.fmcsa.dot.gov/documents/safetyprograms/Medical-Report.pdf) every 1-2 years; this examination specifically addresses sleep disorders. Some agencies also administer the Epworth Sleepiness Scale (http://www.stanford.edu/~dement/epworth.html) to identify potential sleep disorders among their operators. In addition, many transit agencies now require their operators who exhibit risk factors for sleep apnea or other sleep disorders to undergo a diagnostic sleep evaluation. Common risk factors include the following: • excessive weight • a neck circumference greater than 17 inches • pauses in breathing while asleep • daytime sleepiness • loud snoring, dry mouth/throat upon awakening • morning headaches • insomnia • smoking If the operator is diagnosed with a sleep disorder and treatment is deemed necessary, these transit agencies require the individual to be reevaluated and to periodically provide proof of treatment compliance; for example, the consistent use of a continuous positive airway pressure (CPAP) machine for obstructive sleep apnea. To see the actions taken by specific transit agencies, please visit our safety recommendations website at http://www.ntsb.gov/safetyrecs/private/QueryPage.aspx and enter the safety recommendation numbers referenced above. A copy of the original safety recommendation issuance letter is posted on the NTSB’s website at http://www.ntsb.gov/doclib/recletters/2009/R09_10_11.pdf. The full report of the Newton, Massachusetts, accident investigation (Report Number RAR-09/02) is available on our website at http://www.ntsb.gov/doclib/reports/2009/RAR0902.pdf. We look forward to hearing about your agency’s actions to address the safety risks associated with transit operators who have sleep disorders.

From: NTSB
To: Chicago Transit Authority
Date: 8/19/2010
Response: The NTSB appreciates receiving the copies of the CTA forms that Ms. Kovalan provided as attachments to her e-mail. We note that the CTA has reviewed its medical history and physical examination forms and has added specific questions regarding a diagnosis of sleeping disorders/OSA, narcolepsy, and restless legs syndrome and that the forms also elicit specific risk factors-including body mass index, high blood pressure, and neck circumference-for such disorders. We also note that supervisors and managers are encouraged to report employees suspected of having a sleep disorder to the CTA medical department for a medical evaluation and possible sleep study and that employees needing a continuous positive airway pressure machine must periodically provide proof of its proper use. Accordingly, Safety Recommendation R-09-10 is classified CLOSED – ACCEPTABLE ACTION.

From: Chicago Transit Authority
To: NTSB
Date: 10/23/2009
Response: Letter Mail Controlled 11/3/2009 3:49:04 PM MC# 2090669 - From Richard L. Rodriguez, President: In response to the above referenced recommendations, submitted to the CTA in a letter dated July 23,2009, the CTA has taken the following actions. A review of the current medical history and physical examination forms was conducted. Specific questions regarding the presence of sleeping disorders were added. The CTA now asks the employee if they were ever diagnosed with sleep apnea/sleeping disorders, narcolepsy, and restless legs syndrome. Currently, supervisors and managers are encouraged to report any employees that are suspected to have a sleeping disorder to the CTA's medical department. Those employees are then referred for a medical evaluation which may include a diagnostic sleep study. Employees referred for medical evaluation are taken out of service until diagnosis is complete and treatment, if required, is under way. Employees found to require a continuous positive airway pressure (CPAP) machine must periodically provide the CTA with proof of device compliance.

From: NTSB
To: Commonwealth of Pennsylvania, County of Allegheny, Port Authority
Date: 10/30/2014
Response: We are pleased that your contracted CDL-certified medical examiners use the Commercial Drivers/Safety Sensitive Fitness Determination form and Sleep Evaluation Worksheet when examining safety-sensitive applicants (including all bus and light rail vehicle operators) that require a CDL physical examination for preemployment, rehire, reinstatement or for any other reason. We are aware that the form includes direct questions, completed by the patient, relating to sleep disorders and that the responses are reviewed by the medical examiner and followed up with a physical examination and discussion of the patient’s health history. We note that the medical examiner reviews the patient’s body mass index and other factors in completing the evaluation. The examiner typically refers an employee reporting or suspected of a potential sleep disorder to his or her personal physician for a sleep study and recommended treatment, and all employees returning to work after the prescribed treatment are evaluated by the contracted examiner to determine fitness for work. No such employee is returned to work until being cleared by a certified medical examiner. Finally, we note that these requirements have been incorporated into a comprehensive fitness-for-duty policy that you planned to finalize and issue to all safety-sensitive employees effective October 1, 2014. These combined actions satisfy Safety Recommendations R-09-10 and -11, which are classified CLOSED—ACCEPTABLE ACTION.

From: Commonwealth of Pennsylvania, County of Allegheny, Port Authority
To: NTSB
Date: 8/22/2014
Response: -From Michael J. Zamiska, Director, System Safety, Port Authority of Allegheny County: As discussed this morning, Port Authority is in receipt of your August 14, 2014 letter received August 20, 2014 by Port Authority CEO Ellen McLean. We apologize for the miscommunications, but recent organizational changes and e-mail configurations placed your last e-mail in the CEO’s spam/blocked folder. This has been corrected and it is Port Authority’s intention to respond and update our position regarding sleep apnea and fatigue. We are targeting early September for our response and will address to the Acting Chairman, Christopher Hart.

From: NTSB
To: Commonwealth of Pennsylvania, County of Allegheny, Port Authority
Date: 8/18/2014
Response: Because we had received no information from you regarding any actions that PAAC had taken to address Safety Recommendation R-09-10 or -11, our November 1, 2013, letter and our recent e-mail also requested information about your actions to address these recommendations. As stated above, we have received no response; therefore, we conclude that you have neither taken nor planned any actions to address Safety Recommendation R 09 10 or 11. Consequently, they are classified CLOSED—UNACCEPTABLE ACTION/ NO RESPONSE RECEIVED.

From: NTSB
To: Commonwealth of Pennsylvania, County of Allegheny, Port Authority
Date: 11/1/2013
Response: To date, we have received no information regarding any actions that PAAC has taken to address Safety Recommendations R-09-10 and -11. Normally, we expect action to address NTSB safety recommendations to be completed within 5 years. Because these recommendations are now 4 years old and we do not know of any actions taken to satisfy them, and because Safety Recommendation R-01-27 is nearly 12 years old and we have not heard from PAAC in over 8 years about completion of action to address it, we would appreciate receiving a reply within 90 days of the receipt of this letter regarding any actions that PAAC has taken or planned to address these important safety issues. We are interested in knowing whether and how our recommendations are implemented, both to ensure the public the highest level of safety and to identify creative solutions that can be shared with others. Pending our receipt of a reply to this request, Safety Recommendations R-09-10 and -11 remain classified OPEN—AWAIT RESPONSE.

From: Commonwealth of Pennsylvania, County of Allegheny, Port Authority
To: NTSB
Date: 9/3/2013
Response: -From Ellen M. McLean, Chief Executive Officer: Port Authority's Medical Examination Report for Commercial Drivers/Safety Sensitive Fitness Determination form and Sleep Evaluation Worksheet are utilized by Port Authority's contracted COL Certified Medical Examiners for safety sensitive applicants that require a COL for pre-employment, re-hire, reinstatement or upon request exams. This includes all Port Authority bus and light rail vehicle operator positions. Section 2 of the Commercial Driver Fitness form has direct questions relating to sleep disorders, which is completed by the individual, reviewed by the Medical Examiner and followed up with a physical examination and discussion of the individual's health history. The Medical Examiner also reviews the individual's BMI and other comments provided to complete their evaluation or require further assessment. Individuals who report or are otherwise suspected of potential sleep disorders are typically referred to their personal physician for sleep study and recommended treatment. All employees returning to work after the prescribed treatment are evaluated by the Authority's Certified Medical Examiners to determine return to work status, and these employees cannot be returned to work until being cleared to do so by a Certified Medical Examiner. The above requirements have been incorporated into a comprehensive Fitness for Duty Policy that Port Authority, after meeting and conferring with its labor union that represents its bus and light rail vehicle operators over the past year, is in the process of finalizing and issuing to all safety sensitive employees effective October 1, 2014. Last, please note that I did not receive NTSB's prior letter dated November 1, 2013 that previously sought a response and update from Port Authority concerning the above referenced recommendations and which I understand may have been sent to an incorrect e-mail address. I also did not realize that Mr. Marcus from the NTSB had sent me a follow-up e-mail concerning the November 1 letter in June of this year; unfortunately, it appears that e-mail was quarantined by Port Authority's spam filter and it was not located until Port Authority received your August 18, 2014 letter and began searching its records for the prior correspondence NTSB had indicated was sent in same. I do apologize for any miscommunication and prior lack of a response from Port Authority. I assure you that Port Authority's number one organizational goal is to maintain and continuously improve on the safety of its transportation system for the well-being of its employees and the public that we serve. We thus take any and all NTSB Safety Recommendations very seriously and strive to adopt practices and procedures that address same.

From: NTSB
To: San Diego Metropolitan Transit System
Date: 9/13/2012
Response: The NTSB notes that the San Diego Metropolitan Transit System (MTS) uses the California Department of Motor Vehicles Medical Examination Report for Commercial Driver Fitness Determination (DL 51), which is based on the Department of Transportation Medical Examination Report For Commercial Driver Fitness Determination (649-F), in examining MTS operators. We note that DL 51 includes questions in its “Health History” section regarding a history of sleep disorders, pauses in breathing while asleep, daytime sleepiness, and loud snoring. We further note that MTS physicians are trained in questioning and identifying operators who are at high risk for obstructive sleep apnea and other sleep disorders. In cases where sleep disorders are identified, MTS physicians take a variety of measures, including revoking the operator’s credentials during a period of further evaluation or permanently, if necessary. MTS physicians also have the ability to require more frequent medical evaluations for operators who have medical conditions, including sleep disorders, that may change over time and pose a safety risk. These procedures satisfy Safety Recommendations R-09-10 and R-09-11. Because the procedures were already in place before these recommendations were issued, the recommendations are classified CLOSED—RECONSIDERED. Thank you for your commitment to transit safety.

From: San Diego Metropolitan Transit System
To: NTSB
Date: 1/27/2012
Response: -From Paul C. Jablonski, Chief Executive Officer: The Agency employs a large number of Bus Operators who hold Commercial Driver's Licenses. 49 CFR 391.41 - 391.49 sets medical standards for such Commercial Drivers. The California Department of Motor Vehicles Medical Examination Report for Commercial Driver Fitness Determination (DL 51) is based on the Department of Transportation Medical Examination Report For Commercial Driver Fitness Determination (649-F), which you reference in your letter. All MTS Bus and Train Operators were already subject to evaluation based on the standards set forth in 49 CFR 391.41 - 391.49 before Recommendation R-09-10 was issued. Specifically, DL 51 requires that our Operators indicate in the "Health History" section whether they have suffered from "Sleep disorders, pauses in breathing while asleep, daytime sleepiness, loud snoring". Additionally, our physicians are trained in questioning and identifying Operators who are at high risk for obstructive sleep apnea and other sleep disorders. In cases where sleep disorders were identified, our physicians have taken a variety of measures to ensure the safety of our employees and the public including revoking the Operator's credentials during a period of further evaluation or permanently. Our physicians also have the ability to require more frequent medical evaluations for Operators who have medical conditions, including sleep disorders, which may change over time and pose a safety risk.

From: NTSB
To: San Diego Metropolitan Transit System
Date: 1/12/2012
Response: Although Safety Recommendations R-09-10 and -11 are over 2 years old, the NTSB has received no reply to date regarding actions that the San Diego Metropolitan Transit System has taken to address them. We are interested in knowing whether and how our recommendations are implemented, both to ensure the public is provided the highest level of safety and to identify creative solutions that might be shared with others. Accordingly, we would appreciate receiving specific information regarding your policies for mitigating the risks associated with unidentified and untreated sleep disorders among your operators. Other transit agencies receiving the same safety recommendations have completed actions and reported their accomplishments to the NTSB. Through their medical history and physical examination forms, their employee training programs, and their requirements for periodic medical examinations, they have identified operators who are at high risk for sleep disorders. Many of the transit agencies reported that they require operators to pass the U.S. Department of Transportation Physical Exam for Commercial Driver Fitness Determination (http://www.fmcsa.dot.gov/documents/safetyprograms/Medical-Report.pdf) every 1-2 years; this examination specifically addresses sleep disorders. Some agencies also administer the Epworth Sleepiness Scale (http://www.stanford.edu/~dement/epworth.html) to identify potential sleep disorders among their operators. In addition, many transit agencies now require their operators who exhibit risk factors for sleep apnea or other sleep disorders to undergo a diagnostic sleep evaluation. Common risk factors include the following: • excessive weight • a neck circumference greater than 17 inches • pauses in breathing while asleep • daytime sleepiness • loud snoring, dry mouth/throat upon awakening • morning headaches • insomnia • smoking If the operator is diagnosed with a sleep disorder and treatment is deemed necessary, these transit agencies require the individual to be reevaluated and to periodically provide proof of treatment compliance; for example, the consistent use of a continuous positive airway pressure (CPAP) machine for obstructive sleep apnea. To see the actions taken by specific transit agencies, please visit our safety recommendations website at http://www.ntsb.gov/safetyrecs/private/QueryPage.aspx and enter the safety recommendation numbers referenced above. A copy of the original safety recommendation issuance letter is posted on the NTSB’s website at http://www.ntsb.gov/doclib/recletters/2009/R09_10_11.pdf. The full report of the Newton, Massachusetts, accident investigation (Report Number RAR-09/02) is available on our website at http://www.ntsb.gov/doclib/reports/2009/RAR0902.pdf. We look forward to hearing about your agency’s actions to address the safety risks associated with transit operators who have sleep disorders.

From: NTSB
To: Nashville Metropolitan Transit Authority
Date: 6/26/2014
Response: Although we have not received any information from you about your response to these recommendations in the 5 years since they were issued, we recently determined that you operate only bus transit vehicles. Because these recommendations were not issued to bus operators, Safety Recommendations R-09-10 and -11 are classified CLOSED—RECONSIDERED. The safety problems we discovered during our investigation of the May 28, 2008, accident in Newton, Massachusetts, associated with vehicle operators who have OSA or other sleep disorders likely affect bus operators as well as rail transit vehicle operators. If you do not currently have programs to identify and obtain treatment for your bus operators at risk for OSA or other sleep disorders, we believe that you could achieve safety benefits from implementing such a program.

From: NTSB
To: Nashville Metropolitan Transit Authority
Date: 1/12/2012
Response: Although Safety Recommendations R-09-10 and -11 are over 2 years old, the NTSB has received no reply to date regarding actions that the Nashville Metropolitan Transit Authority has taken to address them. We are interested in knowing whether and how our recommendations are implemented, both to ensure the public is provided the highest level of safety and to identify creative solutions that might be shared with others. Accordingly, we would appreciate receiving specific information regarding your policies for mitigating the risks associated with unidentified and untreated sleep disorders among your operators. Other transit agencies receiving the same safety recommendations have completed actions and reported their accomplishments to the NTSB. Through their medical history and physical examination forms, their employee training programs, and their requirements for periodic medical examinations, they have identified operators who are at high risk for sleep disorders. Many of the transit agencies reported that they require operators to pass the U.S. Department of Transportation Physical Exam for Commercial Driver Fitness Determination (http://www.fmcsa.dot.gov/documents/safetyprograms/Medical-Report.pdf) every 1-2 years; this examination specifically addresses sleep disorders. Some agencies also administer the Epworth Sleepiness Scale (http://www.stanford.edu/~dement/epworth.html) to identify potential sleep disorders among their operators. In addition, many transit agencies now require their operators who exhibit risk factors for sleep apnea or other sleep disorders to undergo a diagnostic sleep evaluation. Common risk factors include the following: • excessive weight • a neck circumference greater than 17 inches • pauses in breathing while asleep • daytime sleepiness • loud snoring, dry mouth/throat upon awakening • morning headaches • insomnia • smoking If the operator is diagnosed with a sleep disorder and treatment is deemed necessary, these transit agencies require the individual to be reevaluated and to periodically provide proof of treatment compliance; for example, the consistent use of a continuous positive airway pressure (CPAP) machine for obstructive sleep apnea. To see the actions taken by specific transit agencies, please visit our safety recommendations website at http://www.ntsb.gov/safetyrecs/private/QueryPage.aspx and enter the safety recommendation numbers referenced above. A copy of the original safety recommendation issuance letter is posted on the NTSB’s website at http://www.ntsb.gov/doclib/recletters/2009/R09_10_11.pdf. The full report of the Newton, Massachusetts, accident investigation (Report Number RAR-09/02) is available on our website at http://www.ntsb.gov/doclib/reports/2009/RAR0902.pdf. We look forward to hearing about your agency’s actions to address the safety risks associated with transit operators who have sleep disorders.

From: NTSB
To: Regional Transportation District
Date: 7/21/2010
Response: The NTSB is pleased to know that the RTD comprehensively addressed the issue of OSA and other sleep disorders before the issuance of these recommendations. We are satisfied that the medical history and physical examination forms used by RTD, its instructions to medical directors regarding OSA, individual questions asked about the presence of specific risk factors for OSA and other sleep disorders, and its use of the Federal Motor Carrier Safety Administration’s Medical Examination Report for Commercial Driver Fitness Determination form for operator candidates in the rail transit mode satisfy Safety Recommendation R-09-10, which is classified CLOSED -- RECONSIDERED.

From: Regional Transportation District
To: NTSB
Date: 10/13/2009
Response: Letter Mail Controlled 10/16/2009 12:21:44 PM MC# 2090640 - From David A. Genova, Assisant General Manager, Safety, Security, and Facilities: RTD requires light rail and bus operators to maintain a current Commercial Driver's License. As part of the license requirement, operators are required to physically qualify under 49 CFR 391.41 and obtain a medical examination certificate provided by a certified medical examiner every two years. As part of the medical examination, the operator must complete a comprehensive health history that specifically asks if the operator has any sleep disorders, pause in breathing while asleep, daytime sleepiness or loud snoring (refer to attached Medical Examination Report for commercial driver fitness determination form). Additionally, the medical examiner evaluates other physical fitness characteristics and sleep disorder risk factors such as weight, blood pressure, and diabetes. RTD will continue to use this specific job requirement to evaluate operators' risks for sleep disorders and risk factors associated with sleep disorders.

From: NTSB
To: Commonwealth of Pennsylvania, County of Cambria, Transit Authority
Date: 4/27/2010
Response: On December 29, 2009, NTSB staff contacted Mr. Parks for further clarification about CamTran’s fitness-for-duty physical. Mr. Parks indicated that the examination is performed on any employee who has not performed a safety-sensitive function for 90 consecutive calendar days as well as on any employee whose appearance or behavior indicates that he or she might be abusing drugs or alcohol or reporting to work in an impaired condition. In addition, Mr. Parks indicated all CamTran operator and conductor candidates, including those in the rail transit mode, undergo the pre-employment physical intended for commercial drivers. The NTSB is satisfied with the medical history and physical examination forms used by CamTran, instructions to medical directors regarding OSA, and individual questions asked about the presence of specific risk factors for OSA and other sleep disorders. CamTran’s use of the Federal Motor Carrier Safety Administration’s (FMCSA) Medical Examination Report for Commercial Driver Fitness Determination form (649-F [6045]) for its operator and conductor candidates in the rail transit mode constitutes an acceptable means of addressing this recommendation; accordingly, Safety Recommendation R-09-10 is classified CLOSED -- ACCEPTABLE ACTION.

From: Commonwealth of Pennsylvania, County of Cambria, Transit Authority
To: NTSB
Date: 8/11/2009
Response: Letter Mail Controlled 9/14/2009 4:52:31 PM MC# 2090519: - From James E. Parks, Director of Safety and Risk Management: Pursuant to the Safety Recommendation dated July 23, 2009, I have read and followed up on your recommendations. First of all, the Cambria County Transit Authority owns and operates an Inclined Plane and is the only rail service we operate. However, each Incline operator and conductor receive a DOT physical examine. The actual DOT form has a question on the form asking about sleep disorder. Should there be any checks to this question, they are referred to their family physician. Presently, there are no other follow-ups after completion of their physical. I have posted safety posters from time to time regarding sleep disorders. There are only three operators that operate the Incline Plane. Also, we do have a fitness for duty physical that is conducted should we discover an operator experiencing physical or emotional difficulties. I hope this is beneficial to your recommendations as described in your report.

From: NTSB
To: State of Minnesota, Metro Transit
Date: 9/14/2011
Response: The NTSB notes that Metro Transit contracts with NorthWorks Occupational Health to provide preemployment, fitness for duty, and annual physical examinations for its employees. The employee completes the health history section on the Medical Examination Report for Commercial Driver Fitness Determination (Federal Motor Carrier Safety Administration [FMCSA] form 649-F [6045]), and the contracted physician completes the remainder of the report. The NTSB is satisfied with both the contents of the health history section and the details of the physical examination related to diagnosing sleep disorders as they have been described to us. Metro Transit’s use of the FMCSA’s Medical Examination Report for Commercial Driver Fitness Determination and the Epworth Sleepiness Scale questionnaire for its light rail vehicle operators constitutes an acceptable means of addressing this recommendation; accordingly, Safety Recommendation R-09-10 is classified CLOSED—ACCEPTABLE ACTION.

From: State of Minnesota, Metro Transit
To: NTSB
Date: 6/10/2011
Response: CC# 201100229: - From Michael Conlon, Director of Rail and Bus Safety: Attached, please find two documents: 1. DOT physical form 2. Sample Metro Transit sleep apnea questionnaire The first has a question that goes to sleep disorders on the right hand side of section 2 – Health History. The second is a questionnaire that was developed by our Occupational Health Nurse in response to the NTSB recommendations referenced herein. Our operators undergo sleep disorder evaluations at any of three levels: a preemployment physical, a DOT physical, or a fitness-for-duty physical. Further, we attempt, as far as possible, to evaluate operators for fitness-for-duty when they report. This is accomplished consistently on rail, but bus mode has some operators who relieve, and who are relieved, on the street. Finally, be advised that fatigue (regardless of type) is considered in all of our incident investigations. We send operators for fitness-for-duty physicals when we recognize the possibility that fatigue may be playing a role in an operator’s performance. We may learn about the hazard from customer comments, incident investigations, and self reporting. We have considered our response to recommendations R-09-10 and R-09-11 closed for some time. It is possible that our progress was not communicated properly back to NTSB. Please do not hesitate to call, should you have questions or comments.

From: NTSB
To: Tri-County Metro Transit District of Oregon
Date: 6/14/2011
Response: The NTSB is pleased that TriMet’s light rail operators are required (1) to maintain a commercial driver’s license (CDL), which, in turn, requires them to undergo a biennial physical examination, and (2) to comply with 49 Code of Federal Regulations (CFR) Part 391.41(b)(5). This regulation further requires the evaluation and treatment of operators having a medical history of, or having been diagnosed with, a respiratory dysfunction that places them at risk for operating a commercial motor vehicle. We are also pleased that TriMet’s health services contractor uses the U.S. Department of Transportation (DOT) medical history and physical examination forms, which contain questions intended to diagnose sleeping disorders and identify the presence of their risk factors in employees’ physical examinations. These actions satisfy Safety Recommendation R-09-10, which is classified CLOSED – ACCEPTABLE ACTION.

From: Tri-County Metro Transit District of Oregon
To: NTSB
Date: 11/2/2009
Response: MC# 2090673 - From Shelly Lomax, Director Operations Support: TriMet requires light rail and bus operators to maintain a Commercial Drivers License. As you know in order to hold a CDL individuals are required to undergo a physical examination and carry a current DOT card. The examinations take place generally every two years, but can be required more frequently if directed by the physician. TriMet has reviewed medical evaluation forms used for the purpose of DOT examinations and finds that they elicit information related to sleep apnea and sleep disorders.

From: NTSB
To: Niagara Frontier Transit Authority
Date: 9/24/2014
Response: We are pleased to learn that all of your rail operators must meet prescribed physical requirements and must pass a New York Department of Motor Vehicles (DMV) examination using state DMV 19-A Pre-employment and Recertification physical assessment that includes an evaluation for OSA. We note that every operator is reassessed every 2 years, that operators diagnosed with OSA are reassessed annually, and that the assessment includes questions regarding fatigue. During your orientation for new employees, operators are given information regarding the dangers of fatigue, distraction, and the use of prescription and over the counter medications before and during equipment operation. We are also pleased that operators who are identified through a sleep study as having OSA are further evaluated by your health care provider, who determines whether the operator is complying with treatment. The procedures you describe satisfy Safety Recommendations R 09-10 and -11, which are classified CLOSED—ACCEPTABLE ACTION.

From: Niagara Frontier Transit Authority
To: NTSB
Date: 7/1/2014
Response: I am writing in response to your January 5, 2012, letter to Ms. Kimberly Minkel, Executive Director of the Niagara Frontier Transportation Authority (NFTA). I am the Medical Director for the NFT A and have been asked to report to you on the Medical Department's efforts to comply with the NTSB Safety Recommendations R-09-10 and R-09-11. R-09-10: Since I started acting as Medical Director in October of 2003, the NFTA has used the New York State Department of Motor Vehicles (DMV) "Medical Examination Report of Driver Under Article 19A" form DS-874 for all medical examinations on our drivers. While this form has been revised several times over the years, it has always included a "yes" or "no" question on "sleep problems" (see attachment A). Because the question on the DS-874 did not ask specifically about sleep apnea the NFTA began using a second questionnaire for the medical re-certifications asking specifically about "insomnia and use of sleeping pills," "sleep apnea," "narcolepsy" and "daytime sleepiness - difficulty staying awake" in April of 2006 (see attachment B). In January of 2009, The New York State DMV expanded the sleep question on the DS-874 to: "sleep disorders, pauses in breathing while asleep, daytime sleepiness, and. loud snoring" (see attachment C). There was no specific question about sleep apnea. In August of 2010 the DMV again revised the question on sleep to include "obstructive ·sleep apnea" (see attachment D). Each driver fills out both the DS-874 and the NFTA Medical questionnaire before employment and at the time of each medical re-'certification. Medical re-certification occurs · at least once every two years or on a yearly basis if there are any medical conditions that require more frequent follow-up (sleep apnea being one of those conditions). As Medical Director, I question each driver on any "yes" responses on the questionnaires to be sure there are no safety concerns as a result of a medical condition. 3 In August of 2009 Driver B was referred to the Medical Department because a passenger complained that he had dozed off behind the wheel of the bus at a stoplight. Driver B, also morbidly obese, denied falling asleep, denied excessive daytime sleepiness and scored a 3 on the Epworth Sleepiness Scale. Review of random bus videos over several days revealed no evidence of Driver B falling asleep while driving. No further action was taken. In September of 2010 Driver B rear-ended another vehicle after both vehicles had stopped at a traffic light. Bus video showed Driver B nodding off as his bus slowly moved forward to contact the rear bumper of the vehicle ahead of him. We sent driver B for a sleep medicine evaluation and he was diagnosed with severe obstructive sleep apnea. The experience with Driver B indicated that requesting voluntary information about sleep apnea symptoms was not effective in identifying drivers at risk for sleep apnea. This prompted review of screening criteria for sleep apnea and discussion with NFT A Management and the Amalgamated Transit Union Local 132. The NFTA Medical Department consulted with two sleep specialists in the community. Significant barriers to investigation of suspected sleep apnea had to be worked out between Management and the Union. Per a prior agreement, drivers removed from service because of suspected sleep apnea are to be paid their regular wages until a sleep study can be performed. In January of 2011 Driver C called dispatch reporting that his bus slid on black ice and hit the curb on the right side of the road. Review of bus video showed Driver C nodding off while driving at 30 miles per hour and neither steering nor braking the bus as it drifted left across the oncoming traffic lane, up the sidewalk on the opposite side of the street, went back across the lane for oncoming traffic and came to rest against the curb on the passenger side of the bus. No one was injured and only minor damage resulted from this accident. Driver C was sent for sleep studies and diagnosed with severe obstructive sleep apnea. Driver C was morbidly obese. Based upon these incidents of loss of control of the bus because of sleep apnea, the NFTA Medical Department and NFTA Management decided that a program was necessary to identify drivers at significant risk for sleep apnea and send them for evaluation by a sleep medicine specialist. Based upon our experience, all drivers involved in sleep apnea accidents were morbidly obese. A study by Lopez et al1 published in the September 2008 American Surgeon reported that the prevalence of sleep apnea in morbidly obese patients (BMI 40 to 40.9) presenting for bariatric surgery was 74 per cent while the prevalence in super-obese patients (BMI 50 to 60) is 77 per cent. Based upon this report and our past experience, the NFT A Medical Department began referring all drivers with a BMI of 40 or greater or other significant risk factors for sleep apnea (large neck size, loud snoring, witnessed apnea, small lower jaw, redundant posterior pharyngeal tissue, poorly controlled hypertension despite medication, Mallampati Class IV pharynx or complaints of excessive daytime somnolence) for evaluation by a sleep specialist.

From: NTSB
To: Niagara Frontier Transit Authority
Date: 6/13/2014
Response: In the 5 years since these recommendations were issued, you have not responded to us regarding them, despite our January 5, 2012, request for an update. We normally expect recommended actions to be completed within 3 to 5 years after a recommendation is issued. As we have received no reply from you for almost 5 years, despite our request for information, Safety Recommendations R-09-10 and -11 are classified CLOSED—UNACCEPTABLE ACTION/ NO RESPONSE RECEIVED.

From: NTSB
To: Niagara Frontier Transit Authority
Date: 1/5/2012
Response: Although Safety Recommendations R-09-10 and -11 are over 2 years old, the NTSB has received no reply to date regarding actions that the Niagara Frontier Transportation Authority has taken to address them. We are interested in knowing whether and how our recommendations are implemented, both to ensure the public is provided the highest level of safety and to identify creative solutions that might be shared with others. Accordingly, we would appreciate receiving specific information regarding your policies for mitigating the risks associated with unidentified and untreated sleep disorders among your operators. Other transit agencies receiving the same safety recommendations have completed actions and reported their accomplishments to the NTSB. Through their medical history and physical examination forms, their employee training programs, and their requirements for periodic medical examinations, they have identified operators who are at high risk for sleep disorders. Many of the transit agencies reported that they require operators to pass the U.S. Department of Transportation Physical Exam for Commercial Driver Fitness Determination (http://www.fmcsa.dot.gov/documents/safetyprograms/Medical-Report.pdf) every 1-2 years; this examination specifically addresses sleep disorders. Some agencies also administer the Epworth Sleepiness Scale (http://www.stanford.edu/~dement/epworth.html) to identify potential sleep disorders among their operators. In addition, many transit agencies now require their operators who exhibit risk factors for sleep apnea or other sleep disorders to undergo a diagnostic sleep evaluation. Common risk factors include the following: • excessive weight • a neck circumference greater than 17 inches • pauses in breathing while asleep • daytime sleepiness • loud snoring, dry mouth/throat upon awakening • morning headaches • insomnia • smoking If the operator is diagnosed with a sleep disorder and treatment is deemed necessary, these transit agencies require the individual to be reevaluated and to periodically provide proof of treatment compliance; for example, the consistent use of a continuous positive airway pressure (CPAP) machine for obstructive sleep apnea. To see the actions taken by specific transit agencies, please visit our safety recommendations website at http://www.ntsb.gov/safetyrecs/private/QueryPage.aspx and enter the safety recommendation numbers referenced above. A copy of the original safety recommendation issuance letter is posted on the NTSB’s website at http://www.ntsb.gov/doclib/recletters/2009/R09_10_11.pdf. The full report of the Newton, Massachusetts, accident investigation (Report Number RAR-09/02) is available on our website at http://www.ntsb.gov/doclib/reports/2009/RAR0902.pdf.

From: NTSB
To: Charlotte Area Transit System
Date: 9/25/2012
Response: We note that Charlotte Area Transit System (CATS) Bus Operations Division operators are required to possess a U.S. Department of Transportation medical certificate, which must be renewed every 2 years, and that operators of light rail vehicles must renew this certificate annually. To do so, operators must undergo a physical examination by a CATS contracted physician; the forms used for the examination include both (1) a medical history section that elicits information about sleep disorders and (2) a sleep evaluation worksheet that includes the Epworth Sleepiness Scale and addresses specific risk factors for sleep disorders, such as neck circumference and body mass index. Both the employee and the examining physician complete the forms, which satisfy Safety Recommendation R-09-10. Accordingly, the recommendation is classified CLOSED—ACCEPTABLE ACTION.

From: Charlotte Area Transit System
To: NTSB
Date: 4/20/2012
Response: -From Bryan Leaird, GM Safety and Security: This letter is Charlotte Area Transit System’s (CATS) response to the National Transportation Safety Board’s (NTSB) safety recommendations R-09-10 and R-09-11. The recommendations were issued as a result of the NTSB’s investigation of the Mary 28, 2008 collision of two Massachusetts Bay Transportation Authority Green Line trains in Newton, Massachusetts. The recommendations requested two actions: 1. Review medical history and physical examination forms and modify them as necessary to ensure that they elicit specific information about any previous diagnosis of obstructive sleep apnea or other sleep disorders and bout the presence of specific risk factors for such disorders. 2. Establish a program to identify operators who are at high risk for obstructive sleep apnea or other sleep disorders and require that such operators be appropriately evaluated and treated. CATS –Bus Operations Division (BOD) - operators are required to possess a DOT medical card. Operators must renew the medical card every two years. The physician is responsible for addressing sleep disorders and/or related risk factors. Employees identified as having risk factors have their DOT medical certification placed on a “medical hold.” The operator is placed out of work pending a follow up with their personal physician to arrange for a sleep study. If the sleep study determines a sleep disorder, the employee is placed on a continuous positive airway pressure (CPAP) machine. The employee must follow up with a CATS physician to determine if the employee meets the criteria for return to work and issuance of the DOT medical card. CATS – Light Rail Operations – operators receive DOT cards annually. DOT and pre-employment physicals are performed by Presbyterian Urgent Care. Employees are evaluated for sleep disorders as part of the physical. Any employee identified as having a sleep disorder is monitored for adherence to the prescribed treatment. Included with this response are copies of the “BOD -Medical Examination Report”, “LRV Physical Forms”, which specifically list sleep disorders, and the “Sleep Evaluation Worksheet” used by the CATS BOD physician.

From: NTSB
To: Charlotte Area Transit System
Date: 1/12/2012
Response: Although Safety Recommendations R-09-10 and -11 are over 2 years old, the NTSB has received no reply to date regarding actions that the Charlotte Area Transit System has taken to address them. We are interested in knowing whether and how our recommendations are implemented, both to ensure the public is provided the highest level of safety and to identify creative solutions that might be shared with others. Accordingly, we would appreciate receiving specific information regarding your policies for mitigating the risks associated with unidentified and untreated sleep disorders among your operators. Other transit agencies receiving the same safety recommendations have completed actions and reported their accomplishments to the NTSB. Through their medical history and physical examination forms, their employee training programs, and their requirements for periodic medical examinations, they have identified operators who are at high risk for sleep disorders. Many of the transit agencies reported that they require operators to pass the U.S. Department of Transportation Physical Exam for Commercial Driver Fitness Determination (http://www.fmcsa.dot.gov/documents/safetyprograms/Medical-Report.pdf) every 1-2 years; this examination specifically addresses sleep disorders. Some agencies also administer the Epworth Sleepiness Scale (http://www.stanford.edu/~dement/epworth.html) to identify potential sleep disorders among their operators. In addition, many transit agencies now require their operators who exhibit risk factors for sleep apnea or other sleep disorders to undergo a diagnostic sleep evaluation. Common risk factors include the following: • excessive weight • a neck circumference greater than 17 inches • pauses in breathing while asleep • daytime sleepiness • loud snoring, dry mouth/throat upon awakening • morning headaches • insomnia • smoking If the operator is diagnosed with a sleep disorder and treatment is deemed necessary, these transit agencies require the individual to be reevaluated and to periodically provide proof of treatment compliance; for example, the consistent use of a continuous positive airway pressure (CPAP) machine for obstructive sleep apnea. To see the actions taken by specific transit agencies, please visit our safety recommendations website at http://www.ntsb.gov/safetyrecs/private/QueryPage.aspx and enter the safety recommendation numbers referenced above. A copy of the original safety recommendation issuance letter is posted on the NTSB’s website at http://www.ntsb.gov/doclib/recletters/2009/R09_10_11.pdf. The full report of the Newton, Massachusetts, accident investigation (Report Number RAR-09/02) is available on our website at http://www.ntsb.gov/doclib/reports/2009/RAR0902.pdf. We look forward to hearing about your agency’s actions to address the safety risks associated with transit operators who have sleep disorders.

From: NTSB
To: State of California, County of North, North County Transit District, Sprinter
Date: 8/18/2014
Response: We are pleased to learn that your contractor, Veolia Transportation, requires all its employees to meet California Public Utilities Commission’s (CPUC) class B licensing requirements and requires annual physical examinations that include evaluation for OSA and other sleep disorders. These policies satisfy the intent of Safety Recommendation R-09-10, which is classified CLOSED—ACCEPTABLE ACTION.

From: State of California, County of North, North County Transit District, Sprinter
To: NTSB
Date: 6/25/2014
Response: -From Matthew O. Tucker, Executive Director: The letter stated that North County Transit District had not provided a formal response to NTSB’s recommendations. I want to assure you that NCTD understands the importance of recommendations issued by the NTSB. It has been our practice to immediately respond to all NTSB requests for information. To that end, I have immediately requested that our staff review our records related to this NTSB request and we will commit to provide a formal close-out of this request by not later than June 30, 2014 in the event that we are not able to provide a copy of prior transmitted information related to the requests.

From: State of California, County of North, North County Transit District, Sprinter
To: NTSB
Date: 6/19/2014
Response: -From Matthew O. Tucker, Executive Director: This letter is in response to the following NTSB recommendations R-09-10 and R-09-11 for SPRINTER light rail operations. I have attached a copy of a letter and supporting documents received from our contractor for SPRINTER operations, Veolia Transportation, which are responsive and compliant with the recommendations of the NTSB. -From John H. Lee, General Manager-Sprinter: Although Veolia's Sprinter Operators are not required to meet the class B licensing requirements in physical examinations, we hold them to that standard. In addition, the California Public Utilities Commission requires bi-annual physicals on all current employees; however, Veolia exceeds this requirement by performing annual physicals on all employees. Attached you will find the Department of Motor Vehicles Medical Examination Report for fitness determination we use at Sprinter. As you review, I call your attention to 391.41 Physical Qualifications for Drivers, requirement #5 and Respiratory Dysfunction 391.41 (b) (5) of the form. It mandates that the medical professionals performing our physical exams must assess the health conditions of our Sprinter operators as outlined under these respiratory requirements, which includes sleep apnea and other related sleep disorders. In addition, you will find the attached Sleep Disorder Evaluation questionnaire administered by Veolia's Sprinter Operations medical provider "Concentra", which outlines the specific criteria and questions used in evaluating and documenting sleep apnea for our Operators during their annual physical exam.

From: NTSB
To: State of California, County of North, North County Transit District, Sprinter
Date: 6/16/2014
Response: On June 13, 2014, because we had received no reply from you regarding these recommendations in the 5 years since they were issued—despite our January 5, 2012, request for an update—Safety Recommendations R-09-10 and -11 were classified “Closed?Unacceptable Action/No Response Received.” We understand that you are reviewing your records of correspondence regarding these recommendations and will provide us further information by June 30, 2014. In the interim, Safety Recommendations R-09-10 and -11 remain classified CLOSED—UNACCEPTABLE ACTION/ NO RESPONSE RECEIVED.

From: NTSB
To: State of California, County of North, North County Transit District, Sprinter
Date: 6/13/2014
Response: In the 5 years since these recommendations were issued, you have not responded to us regarding them, despite our January 5, 2012, request for an update. We normally expect recommended actions to be completed within 3 to 5 years after a recommendation is issued. As we have received no reply from you for almost 5 years, despite our request for information, Safety Recommendations R-09-10 and -11 are classified CLOSED—UNACCEPTABLE ACTION/ NO RESPONSE RECEIVED.

From: NTSB
To: State of California, County of North, North County Transit District, Sprinter
Date: 1/5/2012
Response: Although Safety Recommendations R-09-10 and -11 are over 2 years old, the NTSB has received no reply to date regarding actions that Sprinter (North County Transit District) has taken to address them. We are interested in knowing whether and how our recommendations are implemented, both to ensure the public is provided the highest level of safety and to identify creative solutions that might be shared with others. Accordingly, we would appreciate receiving specific information regarding your policies for mitigating the risks associated with unidentified and untreated sleep disorders among your operators. Other transit agencies receiving the same safety recommendations have completed actions and reported their accomplishments to the NTSB. Through their medical history and physical examination forms, their employee training programs, and their requirements for periodic medical examinations, they have identified operators who are at high risk for sleep disorders. Many of the transit agencies reported that they require operators to pass the U.S. Department of Transportation Physical Exam for Commercial Driver Fitness Determination (http://www.fmcsa.dot.gov/documents/safetyprograms/Medical-Report.pdf) every 1-2 years; this examination specifically addresses sleep disorders. Some agencies also administer the Epworth Sleepiness Scale (http://www.stanford.edu/~dement/epworth.html) to identify potential sleep disorders among their operators. In addition, many transit agencies now require their operators who exhibit risk factors for sleep apnea or other sleep disorders to undergo a diagnostic sleep evaluation. Common risk factors include the following: • excessive weight • a neck circumference greater than 17 inches • pauses in breathing while asleep • daytime sleepiness • loud snoring, dry mouth/throat upon awakening • morning headaches • insomnia • smoking If the operator is diagnosed with a sleep disorder and treatment is deemed necessary, these transit agencies require the individual to be reevaluated and to periodically provide proof of treatment compliance; for example, the consistent use of a continuous positive airway pressure (CPAP) machine for obstructive sleep apnea. To see the actions taken by specific transit agencies, please visit our safety recommendations website at http://www.ntsb.gov/safetyrecs/private/QueryPage.aspx and enter the safety recommendation numbers referenced above. A copy of the original safety recommendation issuance letter is posted on the NTSB’s website at http://www.ntsb.gov/doclib/recletters/2009/R09_10_11.pdf. The full report of the Newton, Massachusetts, accident investigation (Report Number RAR-09/02) is available on our website at http://www.ntsb.gov/doclib/reports/2009/RAR0902.pdf. We look forward to hearing about your agency’s actions to address the safety risks associated with transit operators who have sleep disorders.

From: NTSB
To: Galveston Island Transit
Date: 5/13/2014
Response: We are aware that the Galveston Island Trolley has not operated since Hurricane Ike damaged the system on September 13, 2008. We recently checked to see whether the repairs were nearing completion and when operations were scheduled to resume, and learned that operations would not likely resume any time soon. Although you previously stated that you would incorporate our safety recommendations into your policies and procedures when operations resumed, because more than 5 years have passed since operations were suspended and the resumption of operations is not imminent, Safety Recommendations R-09-10 and -11 are classified CLOSED—NO LONGER APPLICABLE. If you are able to resume operations in the future, please implement the recommendations at that time.

From: NTSB
To: Galveston Island Transit
Date: 8/2/2012
Response: Your e-mail indicated that the Galveston Island Trolley has not operated since Hurricane Ike damaged the system on September 13, 2008, but that, once the trolley resumes operations, Galveston Island Transit will incorporate our safety recommendations into its policies and procedures for approval by the state of Texas. During a June 26, 2012, telephone discussion with NTSB staff, you stated that the Galveston Island Trolley is tentatively scheduled to be returned to service in late 2013. Thank you for your cooperation. Pending implementation of Safety Recommendation R-09-10 and -11 upon the trolley’s resuming operations, these recommendations are classified OPEN—ACCEPTABLE RESPONSE.

From: Galveston Island Transit
To: NTSB
Date: 1/18/2012
Response: -From Michael Worthy, Galveston Island Transit: Currently Galveston Island Trolley is not operable. It has not operated since Hurricane Ike September 13, 2008. However, we do plan to restore the system and have been informed by TXDOT and FTA that we must submit New System Safety and Security Plans prior to re-start. With that being said we will incorporate all NTSB Safety Recommendations into policy and procedures for State approval.

From: NTSB
To: Galveston Island Transit
Date: 1/12/2012
Response: Although Safety Recommendations R-09-10 and -11 are over 2 years old, the NTSB has received no reply to date regarding actions that Galveston Island Transit has taken to address them. We are interested in knowing whether and how our recommendations are implemented, both to ensure the public is provided the highest level of safety and to identify creative solutions that might be shared with others. Accordingly, we would appreciate receiving specific information regarding your policies for mitigating the risks associated with unidentified and untreated sleep disorders among your operators. Other transit agencies receiving the same safety recommendations have completed actions and reported their accomplishments to the NTSB. Through their medical history and physical examination forms, their employee training programs, and their requirements for periodic medical examinations, they have identified operators who are at high risk for sleep disorders. Many of the transit agencies reported that they require operators to pass the U.S. Department of Transportation Physical Exam for Commercial Driver Fitness Determination (http://www.fmcsa.dot.gov/documents/safetyprograms/Medical-Report.pdf) every 1-2 years; this examination specifically addresses sleep disorders. Some agencies also administer the Epworth Sleepiness Scale (http://www.stanford.edu/~dement/epworth.html) to identify potential sleep disorders among their operators. In addition, many transit agencies now require their operators who exhibit risk factors for sleep apnea or other sleep disorders to undergo a diagnostic sleep evaluation. Common risk factors include the following: • excessive weight • a neck circumference greater than 17 inches • pauses in breathing while asleep • daytime sleepiness • loud snoring, dry mouth/throat upon awakening • morning headaches • insomnia • smoking If the operator is diagnosed with a sleep disorder and treatment is deemed necessary, these transit agencies require the individual to be reevaluated and to periodically provide proof of treatment compliance; for example, the consistent use of a continuous positive airway pressure (CPAP) machine for obstructive sleep apnea. To see the actions taken by specific transit agencies, please visit our safety recommendations website at http://www.ntsb.gov/safetyrecs/private/QueryPage.aspx and enter the safety recommendation numbers referenced above. A copy of the original safety recommendation issuance letter is posted on the NTSB’s website at http://www.ntsb.gov/doclib/recletters/2009/R09_10_11.pdf. The full report of the Newton, Massachusetts, accident investigation (Report Number RAR-09/02) is available on our website at http://www.ntsb.gov/doclib/reports/2009/RAR0902.pdf. We look forward to hearing about your agency’s actions to address the safety risks associated with transit operators who have sleep disorders.

From: NTSB
To: State of Utah, Utah Transit Authority
Date: 9/5/2012
Response: We note that the UTA administers the U.S. Department of Transportation (DOT) physical exam to all its train operators every 2 years. The information specified is gathered through questionnaires and examinations of the operators’ physical characteristics. If an operator is prescribed treatment for obstructive sleep apnea or another sleep disorder and is under active treatment, the operator’s DOT medical certificate must be revalidated every 30 days. Once the condition has been stabilized, the operator is monitored via a yearly DOT exam. These practices satisfy Safety Recommendations R-09-10 and -11, which are classified CLOSED—ACCEPTABLE ACTION.

From: State of Utah, Utah Transit Authority
To: NTSB
Date: 7/6/2011
Response: CC# 201100259: - From Martin Cocker, Utah Transit Authority FrontRunner Rail Safety Administrator: This recommendation is captured in the Department of Transportation (DOT) physical exam that is administered to all train operators every two years. Specific information is gathered through questionnaires and physical characteristics examinations. In addition, if an operator is prescribed medication for obstructive sleep apnea or other sleep disorders and is under active treatment, then the DOT medical certificate is valid for 30 day periods. Once the condition has been stabilized the monitoring process and follow-up is included in a yearly DOT exam.

From: NTSB
To: Fort Worth Transportation Authority
Date: 8/2/2012
Response: The NTSB notes that Concentra Medical Center, which is contracted to provide medical services to the FWTA, uses the Federal Motor Carrier Safety Administration’s Medical Examination Report for Commercial Driver Fitness Determination when the center’s physicians conduct medical evaluations of FWTA personnel in safety-sensitive positions. The use of this form, which contains the recommended questions, satisfies Safety Recommendation R-09-10, which is classified CLOSED—ACCEPTABLE ACTION.

From: Fort Worth Transportation Authority
To: NTSB
Date: 1/24/2012
Response: -From Kelli Shields, PHR, Human Resources Leave Specialist: FWTA Actions: Concentra Medical Centers is utilizing the Medical Examination Report for Commercial Driver Fitness Determination, requiring those in a safety sensitive position to disclose sleep disorders, pauses in breathing while asleep, daytime sleepiness and loud snoring. All positive responses require the onset date, diagnosis, treating physician’s name and address and any current limitations. Also, a list of all medications taken (including over-the-counter).

From: NTSB
To: Fort Worth Transportation Authority
Date: 1/12/2012
Response: Although Safety Recommendations R-09-10 and -11 are over 2 years old, the NTSB has received no reply to date regarding actions that the Fort Worth Transportation Authority has taken to address them. We are interested in knowing whether and how our recommendations are implemented, both to ensure the public is provided the highest level of safety and to identify creative solutions that might be shared with others. Accordingly, we would appreciate receiving specific information regarding your policies for mitigating the risks associated with unidentified and untreated sleep disorders among your operators. Other transit agencies receiving the same safety recommendations have completed actions and reported their accomplishments to the NTSB. Through their medical history and physical examination forms, their employee training programs, and their requirements for periodic medical examinations, they have identified operators who are at high risk for sleep disorders. Many of the transit agencies reported that they require operators to pass the U.S. Department of Transportation Physical Exam for Commercial Driver Fitness Determination (http://www.fmcsa.dot.gov/documents/safetyprograms/Medical-Report.pdf) every 1-2 years; this examination specifically addresses sleep disorders. Some agencies also administer the Epworth Sleepiness Scale (http://www.stanford.edu/~dement/epworth.html) to identify potential sleep disorders among their operators. In addition, many transit agencies now require their operators who exhibit risk factors for sleep apnea or other sleep disorders to undergo a diagnostic sleep evaluation. Common risk factors include the following: • excessive weight • a neck circumference greater than 17 inches • pauses in breathing while asleep • daytime sleepiness • loud snoring, dry mouth/throat upon awakening • morning headaches • insomnia • smoking If the operator is diagnosed with a sleep disorder and treatment is deemed necessary, these transit agencies require the individual to be reevaluated and to periodically provide proof of treatment compliance; for example, the consistent use of a continuous positive airway pressure (CPAP) machine for obstructive sleep apnea. To see the actions taken by specific transit agencies, please visit our safety recommendations website at http://www.ntsb.gov/safetyrecs/private/QueryPage.aspx and enter the safety recommendation numbers referenced above. A copy of the original safety recommendation issuance letter is posted on the NTSB’s website at http://www.ntsb.gov/doclib/recletters/2009/R09_10_11.pdf. The full report of the Newton, Massachusetts, accident investigation (Report Number RAR-09/02) is available on our website at http://www.ntsb.gov/doclib/reports/2009/RAR0902.pdf. We look forward to hearing about your agency’s actions to address the safety risks associated with transit operators who have sleep disorders.

From: NTSB
To: Capital Metropolitan Transportation Authority
Date: 9/5/2012
Response: We note that Capital Metropolitan Transportation Authority has contracted with Herzog Transit Services, Inc. (HTSI), to operate and maintain its commuter rail lines and that HTSI uses the U.S. Department of Transportation (DOT) form in administering physical examinations, which all its locomotive engineers must pass. As this form elicits the recommended information, Safety Recommendation R-09-10 is classified CLOSED—ACCEPTABLE ACTION.

From: Capital Metropolitan Transportation Authority
To: NTSB
Date: 9/23/2011
Response: From Melvin Clark, Vice President, Rail Operations: Capital Metropolitan Transportation Authority began commuter rail operations on March 22,2010. Capital Metro contracts with Herzog Transit Services, Inc. (HTSI) to operate and maintain its commuter operation. All HTSI Locomotive Engineers are required to pass a Department of Transportation physical. Please note that Section 2 of the Medical Examination Report questionnaire for this physical (attached) includes questions that elicit specific information about any previous diagnosis of sleep apnea or other sleep disorders and the presence of risk factors for such disorders. HTSI strongly believes in monitoring and implementing fatigue management programs. Upcoming changes to the FRA Passenger Hours of Service Regulation will require railroads to utilize a computer program to monitor and address fatigue management through analyzing crew runs. HTSI is prepared to implement all appropriate programs dealing with fatigue management.

From: NTSB
To: Sacramento Regional Transit District
Date: 7/12/2012
Response: The NTSB notes that the SRT has reviewed the State of California Department of Motor Vehicles Medical Examination Report for Commercial Driver Fitness Determination medical history, as well as the examination forms that the SRT uses for transit operators, and has confirmed that they include questions intended to elicit information about sleep disorders, pauses in breathing while asleep, daytime sleepiness, and loud snoring. Contract medical services are required to screen employees and candidates for employment for OSA if they exhibit such risk factors. These actions and the others you describe that the SRT has taken satisfy Safety Recommendation R-09-10; accordingly, the recommendation is classified CLOSED—ACCEPTABLE ACTION.

From: Sacramento Regional Transit District
To: NTSB
Date: 6/23/2011
Response: CC# 201100258: - From Michael R. Wiley, General Manager/ CEO: Medical evaluation forms used when conducting pre-employment physicals and periodic physicals associated with maintaining a California Commercial Driver's License (COL) were reviewed and confirmed to contain specific questions to elicit information about sleep disorders, pauses in breathing while asleep, daytime sleepiness and/or loud snoring. A specific requirement was added to our medical services contract for screening employees and candidates for employment who exhibit a probability for having a sleep disorder. Additionally, specific information is provided to current employees about the impact of sleep disorders on their ability to maintain alertness while performing safety-sensitive duties. Specific information on certain risk factors, such as body mass index (BM I) which can lead to sleep disorders and/or sleep apnea was sent to all RT employees. Please see Attachment -3 (a copy of the initial employee notification about Fatigue Awareness and Safety that was distributed in February 2010).

From: NTSB
To: Detroit People Mover
Date: 6/13/2014
Response: In the 5 years since these recommendations were issued, you have not responded to us regarding them, despite our January 5, 2012, request for an update. We normally expect recommended actions to be completed within 3 to 5 years after a recommendation is issued. As we have received no reply from you for almost 5 years, despite our request for information, Safety Recommendations R-09-10 and -11 are classified CLOSED—UNACCEPTABLE ACTION/ NO RESPONSE RECEIVED.

From: NTSB
To: Detroit People Mover
Date: 1/5/2012
Response: Although Safety Recommendations R-09-10 and -11 are over 2 years old, the NTSB has received no reply to date regarding actions that the Detroit People Mover has taken to address them. We are interested in knowing whether and how our recommendations are implemented, both to ensure the public is provided the highest level of safety and to identify creative solutions that might be shared with others. Accordingly, we would appreciate receiving specific information regarding your policies for mitigating the risks associated with unidentified and untreated sleep disorders among your operators. Other transit agencies receiving the same safety recommendations have completed actions and reported their accomplishments to the NTSB. Through their medical history and physical examination forms, their employee training programs, and their requirements for periodic medical examinations, they have identified operators who are at high risk for sleep disorders. Many of the transit agencies reported that they require operators to pass the U.S. Department of Transportation Physical Exam for Commercial Driver Fitness Determination (http://www.fmcsa.dot.gov/documents/safetyprograms/Medical-Report.pdf) every 1-2 years; this examination specifically addresses sleep disorders. Some agencies also administer the Epworth Sleepiness Scale (http://www.stanford.edu/~dement/epworth.html) to identify potential sleep disorders among their operators. In addition, many transit agencies now require their operators who exhibit risk factors for sleep apnea or other sleep disorders to undergo a diagnostic sleep evaluation. Common risk factors include the following: • excessive weight • a neck circumference greater than 17 inches • pauses in breathing while asleep • daytime sleepiness • loud snoring, dry mouth/throat upon awakening • morning headaches • insomnia • smoking If the operator is diagnosed with a sleep disorder and treatment is deemed necessary, these transit agencies require the individual to be reevaluated and to periodically provide proof of treatment compliance; for example, the consistent use of a continuous positive airway pressure (CPAP) machine for obstructive sleep apnea. To see the actions taken by specific transit agencies, please visit our safety recommendations website at http://www.ntsb.gov/safetyrecs/private/QueryPage.aspx and enter the safety recommendation numbers referenced above. A copy of the original safety recommendation issuance letter is posted on the NTSB’s website at http://www.ntsb.gov/doclib/recletters/2009/R09_10_11.pdf. The full report of the Newton, Massachusetts, accident investigation (Report Number RAR-09/02) is available on our website at http://www.ntsb.gov/doclib/reports/2009/RAR0902.pdf. We look forward to hearing about your agency’s actions to address the safety risks associated with transit operators who have sleep disorders.

From: NTSB
To: San Francisco Municipal Transportation Agency
Date: 3/24/2014
Response: We understand that, in 2009, you worked with the San Francisco Department of Public Health to establish strict guidelines, awareness programs, and testing protocols for employees who may be at risk for OSA. We note that you reviewed the medical records of all employees and that employees whose body mass index was over 30 were required to undergo further evaluation for OSA. In addition, during their required biannual Department of Transportation medical examination, all operators are evaluated for OSA, and those who have symptoms of OSA are referred for sleep studies and medical treatment. Employees who are found to have OSA are denied DOT medical certificates and are removed from driving status until their condition can be successfully treated. Your policies and procedures regarding OSA and other sleep disorders fully satisfy Safety Recommendations R-09-10 and -11, which are classified CLOSED—ACCEPTABLE ACTION.

From: San Francisco Municipal Transportation Agency
To: NTSB
Date: 1/22/2014
Response: -From Edward D. Reiskin, Director of Transportation: The following information responds to your letter dated December 18, 2013 regarding National Transportation Safety Board Safety Recommendations R-01-26, R-01-27, R-09-10, and R-09-11. Our organization, the San Francisco Municipal Transportation Agency (SFMTA), is very attentive to any recommendation issued by the NTSB, and does its best to respond to and implement such recommendations. In the case of these four, we have made considerable efforts, which I describe in this letter, to place programs into effect in response; however, after researching all the available internal records, we are unable to locate copies of any responses we may have sent your organization. When the first of these recommendations appeared in 2001, R-01-26, the San Francisco Municipal Railway (Muni) had already included the need for safety-sensitive employees to report both prescription and non-prescription drug use to their immediate supervisors. We first established such a program with the adoption of our first “Substance Abuse Program” in 1994. We have continued to refine and strengthen that policy with detailed entries in our operator rule book and specific forms and procedures applicable to employees’ use of all medications. In 2002, R-01-27, Muni developed its first Hours of Service policy and training program. In that training program, we covered sleeping disorders and their symptoms. That policy and corresponding training program has been revised and improved. Fatigue awareness, including sleep disorder awareness, is part of our new operator and annual refresher training programs. In 2009, in response to NTSB recommendations R-09-10 and R-09-11, Muni, working with the San Francisco Department of Public Health, established strict guidelines, awareness programs, and testing protocols for employees who may be at risk for sleep apnea. The medical records of all employees were reviewed and those employees who Body Mass Index was over 30 were required to undergo evaluation for sleep apnea. That sleep apnea program still remains in effect at this agency. Moreover, all operators who report for their biannual Department of Transportation (DOT) Medical Examination are mandatorily evaluated for sleep apnea. Those who have symptoms of sleep apnea are referred for sleep studies and medical treatment. Under the program, those employees who are found to have sleep apnea are denied DOT Medical Certificates and removed from driving status until their condition can be successfully treated. Attached are copies of various documents that demonstrate SFMTA’s implementation of these NTSB Safety Recommendations. If you have questions concerning our programs, please feel free to contact me.

From: NTSB
To: San Francisco Municipal Transportation Agency
Date: 12/18/2013
Response: In the more than 4 years since we issued these recommendations to Muni, we have received no information regarding action to address them. Currently, Safety Recommendations R-09-10 and -11 are classified “Open—Await Response.” We are interested in knowing whether and how our recommendations are implemented, both to ensure that the traveling public is provided the highest level of safety and to identify creative solutions that might be shared with others. Normally, we expect action to address our safety recommendations to be completed within 5 years. Given the ages of these four recommendations, we would appreciate receiving a response from you within 90 days indicating actions you have taken or plan to take to implement them, preferably electronically at the following e-mail address: correspondence@ntsb.gov. If a response, including attachments, exceeds 10 megabytes, please e-mail us at the same address for instructions. To avoid confusion, please do not submit both an electronic copy and a hard copy of the same response. Safety Recommendations R-01-26 and -27, and R-09-10 and -11 will retain their current classification pending our timely receipt of your reply. For your convenience, a copy of our letter issuing Safety Recommendations R-01-26 and -27 is available at http://www.ntsb.gov/doclib/recletters/2001/R01_26_27.pdf. The full report of the 2001 Baltimore accident is available at http://www.ntsb.gov/doclib/safetystudies/SIR0102.pdf. A copy of our July 23, 2009, letter issuing Safety Recommendations R-09-10 and -11 is available at http://www.ntsb.gov/doclib/recletters/2009/R09_10_11.pdf. The full report of the 2009 Newton, Massachusetts, accident is available at http://www.ntsb.gov/doclib/reports/2009/RAR0902.pdf. Thank you for your assistance in this matter.

From: NTSB
To: Metropolitan Transportation Authority New York City Transit
Date: 4/6/2011
Response: This letter addresses R-09-11, not R-09-10.

From: Metropolitan Transportation Authority New York City Transit
To: NTSB
Date: 11/4/2010
Response: CC# 201100025: - From Thomas F. Prendergast, President: This is in response to your letter dated September 28, 2010. Please let me assure you that New York City Transit (NYCT) is first and foremost concerned with the safety of our employees and customers. We provide service 24 hours per day and ridership on our system is approximately seven million daily - more than 2 billion annually. Past is not prologue but it should be noted that we have never had an accident where sleep apnea was deemed to have been a contributing factor. This is due in part to our aggressive Occupational Health Services Unit and its diligence in detecting sleep disorders before they become a safety issue. Currently we are working on updating our medical standards and job profiles to strengthen our efforts in this regard. It is appreciated that the National Transportation Safety Board has reviewed the enhancements in the medical questionnaires and examination forms and has found them to satisfy this Safety Recommendation.

From: NTSB
To: Metropolitan Transportation Authority New York City Transit
Date: 9/28/2010
Response: The NTSB is pleased that the NYCT modified its New York State Department of Motor Vehicles physical examination form and uses supplemental occupational health and safety questionnaires regarding snoring, tiredness during daytime, observed OSA, and high blood pressure to determine the medical condition of train operators. We note that these forms include prior history of OSA and other sleep disorders, as well as risk factors for those disorders; accordingly, Safety Recommendation R-09-10 is classified CLOSED – ACCEPTABLE ACTION.

From: Metropolitan Transportation Authority New York City Transit
To: NTSB
Date: 5/20/2010
Response: MC# 2100206 - From Thomas F. Prendergast, President: As indicated in the update letter dated January 26, 2010, the screening questions comprising the STOP questionnaire developed at the University of Toronto have been incorporated in the questionnaires completed by Train and Bus Operators at the time of their periodic examinations. Copies of these forms with sleep related questions highlighted are attached for your review. The form titled 19A Health Questionnaire contains questions from a medical examination form from the New York State Department of Motor Vehicles. This form (Examination to Determine Medical Condition of Driver Under Article 19-A) has been recently revised to include a question related to sleep problems. In addition, our Bus Operators must complete the Buses Periodic Health Questionnaire. Train Operators must answer the OHS Health Questionnaire. Their blood pressure is taken and body mass index calculated at each examination. Neck circumference is not currently being measured.

From: NTSB
To: Metropolitan Transportation Authority New York City Transit
Date: 4/28/2010
Response: The NTSB is pleased that New York City Transit (NYCT) is reviewing its medical questionnaires and that additional, more specific, questions will be added regarding risk factors for sleep disorders. Any NYCT operator who answers affirmatively to questions about sleep disorders during his or her periodic physical examination must undergo an evaluation by a sleep specialist. The NTSB is also interested in knowing whether NYCT’s physical examination forms or questionnaires contain any questions on the subject of previous diagnosis of OSA or other sleep disorders. In addition, are there individual questions about the presence of specific risk factors (for example, high blood pressure, body mass index, neck circumference) for OSA or other sleep disorders? Pending a further response to these questions, Safety Recommendation R-09-10 is classified OPEN -- ACCEPTABLE RESPONSE. The NTSB would appreciate receiving a copy of NYCT’s evaluation forms for review with your reply.

From: Metropolitan Transportation Authority New York City Transit
To: NTSB
Date: 1/26/2010
Response: Letter Mail Controlled 2/3/2010 2:07:59 PM MC# 2100041: - From Thomas F. Prendergast, President: New York City Transit (NYCT) has reviewed the current medical history and questionnaire forms in the electronic medical record system used by internal physicians in their assessments. After review of the medical literature, a screening questionnaire was identified that is easy for operators to answer and simple for physicians to score as being high risk or not for sleep apnea. The STOP questionnaire was developed and clinically vahdated by faculty at the Toronto Western Hospital, University of Toronto. The questions are being added to the questionnaires completed by Train and Bus Operators during their initial physical examination and their period examinations, which occur every two years. The NYCT physicians then rcview the questionnaires to determine if an operator is to he considered high risk for sleep disorders.

From: Metropolitan Transportation Authority New York City Transit
To: NTSB
Date: 9/10/2009
Response: MC# 2090604 - From Howard H. Roberts, Jr., President: Implementation of any program that involves such a large number of key operating personnel would adversely affect employee availability and budgetary constraints NYCT will have to develop a clinically responsible program that minimizes the impact on providing service to our customers. Sleep specialists and sleep testing centers participating in the medical insurance options of the operators must be identified. This initiative will also require the collaboration of the unions.

From: NTSB
To: Metropolitan Atlanta Rapid Transit Authority
Date: 8/19/2014
Response: On October 23, 2009, we received a letter from Mr. Timothy K. White, CSP, MARTA’s Acting Executive Director of Safety, describing actions you were taking in response to these recommendations. On July 21, 2010, we replied that, if the final medical history and physical examination forms you were using elicited information about the presence of specific risk factors (for example, high blood pressure, body mass index, neck circumference) and any previous diagnosis of sleep disorders, they would satisfy Safety Recommendation R-09-10. Accordingly, we classified that recommendation “Open—Acceptable Response” pending our review of MARTA’s completed evaluation forms. We classified Safety Recommendation R-09-11 “Open—Acceptable Response” pending finalization and approval of the planned identification and treatment programs for MARTA operators at high risk for OSA. We asked that you supply a detailed description of your programs for our review. In the 4 years since, we have received no further information from you, despite our December 20, 2011, letter requesting an update. Accordingly, we conclude that you have not finished the actions described in Mr. White’s October 23, 2009, letter. Consequently, Safety Recommendations R 09 10 and 11 are classified CLOSED—UNACCEPTABLE ACTION.

From: NTSB
To: Metropolitan Atlanta Rapid Transit Authority
Date: 12/20/2011
Response: Although Safety Recommendations R-09-10 and -11 are over 2 years old, the NTSB has received no reply to date regarding actions that the Metropolitan Atlanta Rapid Transit Authority has taken to address them. We are interested in knowing whether and how our recommendations are implemented, both to ensure the public is provided the highest level of safety and to identify creative solutions that might be shared with others. Accordingly, we would appreciate receiving specific information regarding your policies for mitigating the risks associated with unidentified and untreated sleep disorders among your operators. Other transit agencies receiving the same safety recommendations have completed actions and reported their accomplishments to the NTSB. Through their medical history and physical examination forms, their employee training programs, and their requirements for periodic medical examinations, they have identified operators who are at high risk for sleep disorders. Many of the transit agencies reported that they require operators to pass the U.S. Department of Transportation Physical Exam for Commercial Driver Fitness Determination (http://www.fmcsa.dot.gov/documents/safetyprograms/Medical-Report.pdf) every 1-2 years; this examination specifically addresses sleep disorders. Some agencies also administer the Epworth Sleepiness Scale (http://www.stanford.edu/~dement/epworth.html) to identify potential sleep disorders among their operators. In addition, many transit agencies now require their operators who exhibit risk factors for sleep apnea or other sleep disorders to undergo a diagnostic sleep evaluation. Common risk factors include the following: • excessive weight • a neck circumference greater than 17 inches • pauses in breathing while asleep • daytime sleepiness • loud snoring, dry mouth/throat upon awakening • morning headaches • insomnia • smoking If the operator is diagnosed with a sleep disorder and treatment is deemed necessary, these transit agencies require the individual to be reevaluated and to periodically provide proof of treatment compliance; for example, the consistent use of a continuous positive airway pressure (CPAP) machine for obstructive sleep apnea. To see the actions taken by specific transit agencies, please visit our safety recommendations website at http://www.ntsb.gov/safetyrecs/private/QueryPage.aspx and enter the safety recommendation numbers referenced above. A copy of the original safety recommendation issuance letter is posted on the NTSB’s website at http://www.ntsb.gov/doclib/recletters/2009/R09_10_11.pdf. The full report of the Newton, Massachusetts, accident investigation (Report Number RAR-09/02) is available on our website at http://www.ntsb.gov/doclib/reports/2009/RAR0902.pdf.

From: NTSB
To: Metropolitan Atlanta Rapid Transit Authority
Date: 7/21/2010
Response: The NTSB is pleased that MARTA has initiated action to address the recommendation by developing a draft form to assess operators’ risk for OSA. If the final medical history and physical examination forms elicit information about the presence of specific risk factors (for example, high blood pressure, body mass index, neck circumference) and any previous diagnosis of sleep disorders, they will satisfy the recommendation. Therefore, pending our review of MARTA’s completed evaluation forms, Safety Recommendation R-09-10 is classified OPEN—ACCEPTABLE RESPONSE.

From: Metropolitan Atlanta Rapid Transit Authority
To: NTSB
Date: 10/23/2009
Response: CC# 2090659: - From Timothy K. White, CSP, Acting Executive Director of Safety: We have had several meetings with the current medical services provider to discuss the recommendations and develop the necessary procedures to address the issue of sleep disorders, including obstructive sleep apnea. As a result of such meetings as well as internal discussions, a number of actions have been identified and are poised for implementation. Such actions include: R-09-10 1. Sleep Apnea Assessment Form is in final draft format and includes evaluation based on 6 criteria. R-09-11 2. Sleep Apnea Assessment to be incorporated into pre-employment physical exam. 3. Sleep Apnea Assessment to be incorporated into Operators' (Rail, Bus and Mobility) bi-annual exams and off-year medical briefing exam. 4. Program after assessment/screening has been identified 5. Budgetary/funding considerations completed 6. Identification of wellness programs to support diagnosis of or propensity to obstructive sleep apnea. Such programs to be incorporated into MARTA'S regular wellness programs. As of this date, we are finalizing these recommendations and will circulate them through the established approval protocols. Some of these actions have the potential to impact employees and represent a significant change to policy. In addition, recognizing that the workforce who will be subject to such screening is unionized, it will be necessary to discuss such with the union leadership prior to implementation. I will provide you with an update on the status of MARTA'S response to your recommendations within 90 days (by January 23, 2010). Please contact me if you require any additional information in the interim.

From: NTSB
To: Central Puget Sound Regional Transit Authority
Date: 6/13/2014
Response: In the 5 years since these recommendations were issued, you have not responded to us regarding them, despite our January 12, 2012, request for an update. We normally expect recommended actions to be completed within 3 to 5 years after a recommendation is issued. As we have received no reply from you for almost 5 years, despite our request for information, Safety Recommendations R-09-10 and -11 are classified CLOSED—UNACCEPTABLE ACTION/ NO RESPONSE RECEIVED.

From: NTSB
To: Central Puget Sound Regional Transit Authority
Date: 1/12/2012
Response: Although Safety Recommendations R-09-10 and -11 are over 2 years old, the NTSB has received no reply to date regarding actions that Sound Transit has taken to address them. We are interested in knowing whether and how our recommendations are implemented, both to ensure the public is provided the highest level of safety and to identify creative solutions that might be shared with others. Accordingly, we would appreciate receiving specific information regarding your policies for mitigating the risks associated with unidentified and untreated sleep disorders among your operators. Other transit agencies receiving the same safety recommendations have completed actions and reported their accomplishments to the NTSB. Through their medical history and physical examination forms, their employee training programs, and their requirements for periodic medical examinations, they have identified operators who are at high risk for sleep disorders. Many of the transit agencies reported that they require operators to pass the U.S. Department of Transportation Physical Exam for Commercial Driver Fitness Determination (http://www.fmcsa.dot.gov/documents/safetyprograms/Medical-Report.pdf) every 1-2 years; this examination specifically addresses sleep disorders. Some agencies also administer the Epworth Sleepiness Scale (http://www.stanford.edu/~dement/epworth.html) to identify potential sleep disorders among their operators. In addition, many transit agencies now require their operators who exhibit risk factors for sleep apnea or other sleep disorders to undergo a diagnostic sleep evaluation. Common risk factors include the following: • excessive weight • a neck circumference greater than 17 inches • pauses in breathing while asleep • daytime sleepiness • loud snoring, dry mouth/throat upon awakening • morning headaches • insomnia • smoking If the operator is diagnosed with a sleep disorder and treatment is deemed necessary, these transit agencies require the individual to be reevaluated and to periodically provide proof of treatment compliance; for example, the consistent use of a continuous positive airway pressure (CPAP) machine for obstructive sleep apnea. To see the actions taken by specific transit agencies, please visit our safety recommendations website at http://www.ntsb.gov/safetyrecs/private/QueryPage.aspx and enter the safety recommendation numbers referenced above. A copy of the original safety recommendation issuance letter is posted on the NTSB’s website at http://www.ntsb.gov/doclib/recletters/2009/R09_10_11.pdf. The full report of the Newton, Massachusetts, accident investigation (Report Number RAR-09/02) is available on our website at http://www.ntsb.gov/doclib/reports/2009/RAR0902.pdf. We look forward to hearing about your agency’s actions to address the safety risks associated with transit operators who have sleep disorders.

From: NTSB
To: Bay Area Rapid Transit District
Date: 9/4/2012
Response: We note that BART has reviewed the forms it uses in the hiring process and has confirmed that, since mid-2008, all candidates for positions as train operators are given a physical examination by a licensed physician who uses the Medical Examination Report for Commercial Driver Fitness Determination, California Department of Motor Vehicles Form DL51. This form includes a comprehensive health history and specific questions about sleep disorders, along with other questions about risk factors for sleep disorders such as weight, blood pressure, and diabetes. Because these practices, which satisfy Safety Recommendation R-09-10, were in place before the recommendation was issued, it is classified CLOSED—RECONSIDERED. We also note that BART incorporated a module on sleep disorders into its mandatory train operator recertification program, which includes a review of sleep disorders and their causes, effects, identification, and treatment and was completed by all operators in 2009 or 2010. Each operator was provided with tools and the time to complete a self-assessment during the session. These tools included the Epworth Sleepiness scale, a method to measure neck circumference, and a body mass index chart. Operators were then given information about treatment for sleep apnea and information about how life style choices can impact sleep quality and the development of sleep disorders. Finally, information about specific resources for treatment was provided. BART’s program consists of operator self-evaluation and self-referral to appropriate resources for corrective action. Additionally, transportation fore-workers have been trained on the signs, symptoms, and risks posed by sleep disorder as part of their recertification. BART has supplied its fore-workers with intervention techniques to engage an employee suspected by them as having a problem. However, your letter did not state the following information: • Whether train operators are required to complete physical examinations after hiring • If so, how often such examinations are administered • What steps you take to ensure that operators who are diagnosed with a sleep disorder are being treated and that such treatment has proven effective • Whether operators who are just beginning treatment, are not compliant with treatment, or for whom treatment has not proven effective are given certificates of limited duration or have their operating certificates revoked, if necessary These are all aspects of the programs of other transit agencies. We are concerned that self-evaluation, self-referral, and intervention by transportation fore-workers, who are not licensed physicians, may not be sufficient to ensure that operators who have a sleep disorder are adequately treated. Accordingly, pending our receipt of additional information regarding these issues, Safety Recommendation R-09-11 is classified “Open—Acceptable Response.”

From: Bay Area Rapid Transit District
To: NTSB
Date: 7/25/2011
Response: CC# 201100297: From Sherwood G. Wakeman, Interim General Manager: BART has received the subject recommendations and offers the following response. Regarding recommendation R-09-010, BART has reviewed the forms used in the hiring process and has confirmed that since mid 2008, the medical clinic responsible for conducting pre-employment physicals does a DMV commercial driver's license screening for all candidates for the train operator position despite the fact that BART train operators are not required to hold a commercial driver's license. The physician utilizes the Medical Examination Report for Commercial Driver Fitness Determination. (Attached). This form is completed by a qualified medical examiner and also includes the operator's comprehensive health history. Note that Section 2 of the California Department of Motor Vehicles form includes specific questions about sleep disorders along with other questions about risk factors for sleep disorders such as weight, blood pressure and diabetes.

From: NTSB
To: New Orleans Regional Transit Authority
Date: 1/29/2013
Response: The NTSB notes that the RTA system includes three streetcar lines and that Concentra Medical Centers (LA) is under contract to conduct physical examinations of RTA employees and complete employees’ medical examination reports. The contractor conducts pre-employment, fitness for duty, annual, and biannual physical examinations. Streetcar operators complete the medical history section of the Medical Examination Report for Commercial Driver Fitness Determination (similar to Federal Motor Carrier Safety Administration (FMCSA) form 649-F [6045]) and provide this information to the contracted physician, who then performs the physical examination and completes the remaining seven sections of the medical report. The NTSB is pleased that the medical history section of the form contains questions regarding whether the operator has experienced any sleep disorders, pauses in breathing while asleep, daytime sleepiness, or loud snoring. The testing sections include weight and height measurements for marked overweight, examination of the mouth and throat for irremediable deformities likely to interfere with breathing, and respiratory conditions that may interfere with oxygen exchange and may result in incapacitation, including OSA. These provisions satisfy Safety Recommendation R-09-10, which is classified CLOSED—ACCEPTABLE ACTION.

From: New Orleans Regional Transit Authority
To: NTSB
Date: 1/18/2012
Response: -From Derrick Breun, COO: I have been provided with a letter from Deborah Hersman, concerning an outstanding issue related to sleep disorders. The letter states that in mid-2009, RTA should have been in receipt of documentation from the NTSB in relation to sleep disorders recommendations. I am unaware of said document, but am more than willing to provide a response at this time. Response: All operators are required to perform standard DOTD Medical Examinations no less than every two years, and may not operate a vehicle without having an up to date DOTD physical. The medical history section of the physical form allows for commenting on sleep disorders, pauses in breathing while asleep, daytime sleepiness, and loud snoring specifically. The agency implemented Fatigue Awareness for all operators, and all operators have received approximately 90 minutes of fatigue specific training. Station clerks, as well as all supervisors, operations management, and maintenance management, all of which oversee the operators each morning prior to pull out have received comparable training, determining for what to look. Please let me know if you require more information.

From: NTSB
To: New Orleans Regional Transit Authority
Date: 1/12/2012
Response: Although Safety Recommendations R-09-10 and -11 are over 2 years old, the NTSB has received no reply to date regarding actions that the New Orleans Regional Transit Authority has taken to address them. We are interested in knowing whether and how our recommendations are implemented, both to ensure the public is provided the highest level of safety and to identify creative solutions that might be shared with others. Accordingly, we would appreciate receiving specific information regarding your policies for mitigating the risks associated with unidentified and untreated sleep disorders among your operators. Other transit agencies receiving the same safety recommendations have completed actions and reported their accomplishments to the NTSB. Through their medical history and physical examination forms, their employee training programs, and their requirements for periodic medical examinations, they have identified operators who are at high risk for sleep disorders. Many of the transit agencies reported that they require operators to pass the U.S. Department of Transportation Physical Exam for Commercial Driver Fitness Determination (http://www.fmcsa.dot.gov/documents/safetyprograms/Medical-Report.pdf) every 1-2 years; this examination specifically addresses sleep disorders. Some agencies also administer the Epworth Sleepiness Scale (http://www.stanford.edu/~dement/epworth.html) to identify potential sleep disorders among their operators. In addition, many transit agencies now require their operators who exhibit risk factors for sleep apnea or other sleep disorders to undergo a diagnostic sleep evaluation. Common risk factors include the following: • excessive weight • a neck circumference greater than 17 inches • pauses in breathing while asleep • daytime sleepiness • loud snoring, dry mouth/throat upon awakening • morning headaches • insomnia • smoking If the operator is diagnosed with a sleep disorder and treatment is deemed necessary, these transit agencies require the individual to be reevaluated and to periodically provide proof of treatment compliance; for example, the consistent use of a continuous positive airway pressure (CPAP) machine for obstructive sleep apnea. To see the actions taken by specific transit agencies, please visit our safety recommendations website at http://www.ntsb.gov/safetyrecs/private/QueryPage.aspx and enter the safety recommendation numbers referenced above. A copy of the original safety recommendation issuance letter is posted on the NTSB’s website at http://www.ntsb.gov/doclib/recletters/2009/R09_10_11.pdf. The full report of the Newton, Massachusetts, accident investigation (Report Number RAR-09/02) is available on our website at http://www.ntsb.gov/doclib/reports/2009/RAR0902.pdf. We look forward to hearing about your agency’s actions to address the safety risks associated with transit operators who have sleep disorders.

From: NTSB
To: Southeastern Pennsylvania Transportation Authority
Date: 4/27/2010
Response: The NTSB is satisfied with the medical history and physical examination forms used by SEPTA, its instructions to Medical Directors regarding OSA, and individual questions asked about the presence of specific risk factors for OSA and other sleep disorders. SEPTA’s use of the Federal Motor Carrier Safety Administration’s Medical Examination Report for Commercial Driver Fitness Determination form (649-F [6045]) for its operator candidates in the rail transit mode constitutes an acceptable means of addressing this recommendation; accordingly, Safety Recommendation R-09-10 is classified CLOSED -- ACCEPTABLE ACTION.

From: Southeastern Pennsylvania Transportation Authority
To: NTSB
Date: 8/26/2009
Response: MC# 2090579 - From James Fox, Director, System Safety and Risk Management: SEPTA has an in-house Medical Department staffed by one (1) Medical Director, two (2) physicians, and support personnel, whose duties include, but are not limited to new-hire physical examinations, return-to-duty medical exams, periodic physicals of regulated employee populations, wellness programs, drug & alcohol testing programs, and EAP. All new hires must complete the Medical Examination Report for Commercial Driver Fitness Determination form (Attachment 1). This medical history document -intended for commercial drivers -meets the requirements of 49 CFR 391.41 (Physical Qualifications for Drivers), and is completed by all SEPTA operator candidates including the rail transit modes. Report Section 2 -Health History - specifically asks the signatory whether they have, .Sleep disorders, pauses in breathing while asleep, daytime sleepiness, [and] loud snoring.. Additionally, SEPTA physicians physically examine each operator candidate - cognizant of apnea risk factors such as obesity; or other presentations that could disrupt the individuals sleep. Conclusion It is anticipated that this information should provide an acceptable response to these two (2) recommendations. Therefore, SEPTA requests that the NTSB consider recommendations R-09-10 and R-09-11 as, Closed - Acceptable Action.

From: NTSB
To: Hampton Roads Transit
Date: 9/2/2014
Response: We note that you require your light rail employees to have a current commercial operator’s license, as well as regular physical examinations conducted in accordance with Federal Motor Carrier Safety Administration (FMCSA) regulations by medical examiners listed on the FMCSA’s national registry. We also note that these examiners use the Department of Transportation’s (DOT) physical examination form and assess an operator’s medical history regarding sleep disorders, pauses in breathing while asleep, daytime sleepiness, and loud snoring. We further note that, after reviewing the employee’s medical history, the examiner determines whether additional evaluation is required and, if so, the employee is not permitted to operate one of your vehicles until he or she qualifies for DOT certification through treatment and management of the sleep disorder. These policies and practices satisfy Safety Recommendations R-09-10 and -11, which are classified CLOSED—ACCEPTABLE ACTION.

From: Hampton Roads Transit
To: NTSB
Date: 6/19/2014
Response: -From William E. Harrell, President and CEO: This letter is in response to your letter dated June 13, 2014, which I received yesterday (attached for easy reference). HRT has made your safety recommendations (R-09-1 0 and R-09-11) regarding monitoring of Light Rail employees for sleep apnea and other sleep related disorders. Our Light Rail employees (who are required to have a COL) must maintain a current DOT (Department of Transportation) physical. The DOT physical examinations are conducted in accordance with the Federal Motor Carrier Safety Administration (FMCSA) regulations and conducted by medical examiners listed on the National Registry with FMCSA. Our medical examiners use the DOT physical form provided by the FMCSA to ensure that Drivers meet the criteria to receive a DOT medical certification. An important element of the certification process is an assessment of the Driver's medical history regarding sleep disorders, pauses in breathing while asleep, daytime sleepiness and loud snoring. The medical examiner, after reviewing the employee's medical history, will make a determination as to whether further testing is required. If additional testing is required the Driver is not permitted to operate an HRT vehicle until they are able to obtain a DOT certification. HRT is committed to safety. The DOT medical certification is a crucial step in ensuring safe transportation for our customers and our employees. Please reconsider reclassifying safety recommendations R-09-10 and 11. Please let me know if you need additional information in order to make your decision. Thank you in advance for your assistance in this matter.

From: NTSB
To: Hampton Roads Transit
Date: 6/13/2014
Response: In the 5 years since these recommendations were issued, you have not responded to us regarding them, despite our request for an update on January 12, 2012. We normally expect recommended actions to be completed within 3 to 5 years after a recommendation is issued. As we have received no reply from you for almost 5 years, despite our request for information, Safety Recommendations R-09-10 and -11 are classified CLOSED—UNACCEPTABLE ACTION/ NO RESPONSE RECEIVED.

From: NTSB
To: Hampton Roads Transit
Date: 1/12/2012
Response: Although Safety Recommendations R-09-10 and -11 are over 2 years old, the NTSB has received no reply to date regarding actions that Hampton Roads Transit has taken to address them. We are interested in knowing whether and how our recommendations are implemented, both to ensure the public is provided the highest level of safety and to identify creative solutions that might be shared with others. Accordingly, we would appreciate receiving specific information regarding your policies for mitigating the risks associated with unidentified and untreated sleep disorders among your operators. Other transit agencies receiving the same safety recommendations have completed actions and reported their accomplishments to the NTSB. Through their medical history and physical examination forms, their employee training programs, and their requirements for periodic medical examinations, they have identified operators who are at high risk for sleep disorders. Many of the transit agencies reported that they require operators to pass the U.S. Department of Transportation Physical Exam for Commercial Driver Fitness Determination (http://www.fmcsa.dot.gov/documents/safetyprograms/Medical-Report.pdf) every 1-2 years; this examination specifically addresses sleep disorders. Some agencies also administer the Epworth Sleepiness Scale (http://www.stanford.edu/~dement/epworth.html) to identify potential sleep disorders among their operators. In addition, many transit agencies now require their operators who exhibit risk factors for sleep apnea or other sleep disorders to undergo a diagnostic sleep evaluation. Common risk factors include the following: • excessive weight • a neck circumference greater than 17 inches • pauses in breathing while asleep • daytime sleepiness • loud snoring, dry mouth/throat upon awakening • morning headaches • insomnia • smoking If the operator is diagnosed with a sleep disorder and treatment is deemed necessary, these transit agencies require the individual to be reevaluated and to periodically provide proof of treatment compliance; for example, the consistent use of a continuous positive airway pressure (CPAP) machine for obstructive sleep apnea. To see the actions taken by specific transit agencies, please visit our safety recommendations website at http://www.ntsb.gov/safetyrecs/private/QueryPage.aspx and enter the safety recommendation numbers referenced above. A copy of the original safety recommendation issuance letter is posted on the NTSB’s website at http://www.ntsb.gov/doclib/recletters/2009/R09_10_11.pdf. The full report of the Newton, Massachusetts, accident investigation (Report Number RAR-09/02) is available on our website at http://www.ntsb.gov/doclib/reports/2009/RAR0902.pdf. We look forward to hearing about your agency’s actions to address the safety risks associated with transit operators who have sleep disorders.

From: NTSB
To: Washington Metropolitan Area Transit Authority
Date: 10/23/2013
Response: We are pleased that WMATA now uses a form similar to Federal Motor Carrier Safety Administration (FMCSA) form 649F to record drivers’ medical histories and physical examinations, including information about high blood pressure and sleep disorders, pauses in breathing while asleep, daytime sleepiness, loud snoring, body mass index, and neck circumference. The procedures WMATA described satisfy Safety Recommendation R-09-10, which is classified CLOSED—ACCEPTABLE ACTION.

From: Washington Metropolitan Area Transit Authority
To: NTSB
Date: 6/6/2013
Response: -From James M. Dougherty, WSO-CSSD, Chief Safety Officer: I want to personally thank you for taking the time out of your schedule to meetwith members of my staff on May 23, 2013, to discuss the WashingtonMetropolitan Area Transit Authority's (WMATA), National Transportation SafetyBoard (NTSB) recommendations that are currently classified "Open AcceptableAction". It is my belief that the dialogue, along with the documentation that wasprovided to support the closure of several recommendations, will assist theNTSB in its evaluation of WMATA's progress and move these recommendationsto closure. Enclosed is a listing of all of the items in which closure documentation wasprovided during the meeting. WMATA would like to thank the NTSB for its consideration and support as wecontinue to demonstrate our goal of making safety a top priority for both ouremployees and patrons. We look forward to continued meetings with the NTSBwhere we can exchange technical information in support of our common goal. Provided copy medical review forms in accordance with the recommendation, but in consideration of HIPPA laws

From: Washington Metropolitan Area Transit Authority
To: NTSB
Date: 6/10/2011
Response: CC# 201100318: - From James M. Dougherty, WSO-CSSD, Chief Safety Officer: Consistent with the discussions held on May 3,2011 in a collective review of the Washington Metropolitan Area Transit Authority (WMATA) "Open Acceptable" National Transportation Safety Board (NTSB) recommendations, the attached documentation is provided to support the closure of recommendations R-09-010 and R-09-011. Attached, WMATA is providing a copy of the Medical Examination Report for Commercial Driver's Fitness Determination form. It is mandatory that this form be completed by the driver and WMATA medical examiner. The Health History section includes questions essential to the Obstructive Sleep Apnea process. In addition, all employees and applicants subject to Obstructive Sleep Apnea assessment receive a copy of the Federal Motor Carrier Safety Administration's Guideline 5, regarding the "Clinical Evaluation-Identification of Individuals with Undiagnosed Obstructive Sleep Apnea".

From: NTSB
To: Washington Metropolitan Area Transit Authority
Date: 4/28/2010
Response: The NTSB notes that Washington Metropolitan Area Transit Authority (WMATA) uses a Record of Periodic Medical Examination/Return to Duty Evaluation form requiring an operator to complete a Health History section that elicits information specific to the causes of sleep disorders. The NTSB is interested in knowing whether there are individual questions about the presence of specific risk factors (for example, high blood pressure, body mass index, neck circumference) for OSA or other sleep disorders. Pending the receipt of this information, Safety Recommendation R-09-10 is classified OPEN -- ACCEPTABLE RESPONSE. The NTSB would appreciate receiving a copy of WMATA’s Record of Periodic Medical Examination/Return to Duty Evaluation form for review with your reply.

From: Washington Metropolitan Area Transit Authority
To: NTSB
Date: 10/14/2009
Response: Letter Mail Controlled 10/20/2009 5:51:07 PM MC# 2090646: - From John B. Catoe, General Manager: WMATA currently has a "Record of Periodic Medical ExaminationIReturn to Duty Evaluation" form which requires an operator to complete the Complete Health History section. There are questions which will elicit information in reference to sleep disorders, pauses in breathing while sleeping, daytime sleepiness and loud snoring.

From: NTSB
To: State of Washington, County of King, King County Metro Transit
Date: 6/13/2014
Response: In the 5 years since these recommendations were issued, you have not responded to us regarding them, despite our request for an update on January 12, 2012. We normally expect recommended actions to be completed within 3 to 5 years after a recommendation is issued. As we have received no reply from you for almost 5 years, despite our request for information, Safety Recommendations R-09-10 and -11 are classified CLOSED—UNACCEPTABLE ACTION/ NO RESPONSE RECEIVED.

From: NTSB
To: State of Washington, County of King, King County Metro Transit
Date: 1/12/2012
Response: Although Safety Recommendations R-09-10 and -11 are over 2 years old, the NTSB has received no reply to date regarding actions that King County Metro Transit has taken to address them. We are interested in knowing whether and how our recommendations are implemented, both to ensure the public is provided the highest level of safety and to identify creative solutions that might be shared with others. Accordingly, we would appreciate receiving specific information regarding your policies for mitigating the risks associated with unidentified and untreated sleep disorders among your operators. Other transit agencies receiving the same safety recommendations have completed actions and reported their accomplishments to the NTSB. Through their medical history and physical examination forms, their employee training programs, and their requirements for periodic medical examinations, they have identified operators who are at high risk for sleep disorders. Many of the transit agencies reported that they require operators to pass the U.S. Department of Transportation Physical Exam for Commercial Driver Fitness Determination (http://www.fmcsa.dot.gov/documents/safetyprograms/Medical-Report.pdf) every 1-2 years; this examination specifically addresses sleep disorders. Some agencies also administer the Epworth Sleepiness Scale (http://www.stanford.edu/~dement/epworth.html) to identify potential sleep disorders among their operators. In addition, many transit agencies now require their operators who exhibit risk factors for sleep apnea or other sleep disorders to undergo a diagnostic sleep evaluation. Common risk factors include the following: • excessive weight • a neck circumference greater than 17 inches • pauses in breathing while asleep • daytime sleepiness • loud snoring, dry mouth/throat upon awakening • morning headaches • insomnia • smoking If the operator is diagnosed with a sleep disorder and treatment is deemed necessary, these transit agencies require the individual to be reevaluated and to periodically provide proof of treatment compliance; for example, the consistent use of a continuous positive airway pressure (CPAP) machine for obstructive sleep apnea. To see the actions taken by specific transit agencies, please visit our safety recommendations website at http://www.ntsb.gov/safetyrecs/private/QueryPage.aspx and enter the safety recommendation numbers referenced above. A copy of the original safety recommendation issuance letter is posted on the NTSB’s website at http://www.ntsb.gov/doclib/recletters/2009/R09_10_11.pdf. The full report of the Newton, Massachusetts, accident investigation (Report Number RAR-09/02) is available on our website at http://www.ntsb.gov/doclib/reports/2009/RAR0902.pdf. We look forward to hearing about your agency’s actions to address the safety risks associated with transit operators who have sleep disorders.

From: NTSB
To: Miami-Dade Transit Agency
Date: 4/14/2014
Response: We note that your medical contractor, Jackson Memorial Hospital, uses a medical questionnaire to elicit information regarding a previous diagnosis of OSA or other sleep disorders and that sleep disorder informational packets explaining risk factors are given to all MDT employees. As the form elicits the recommended information, Safety Recommendation R 09 10 is classified CLOSED—ACCEPTABLE ACTION.

From: Miami-Dade Transit Agency
To: NTSB
Date: 3/8/2012
Response: -From Ysela Llort, Director: The current County's medical contractor, Jackson Memorial Hospital, utilizes a medical questionnaire to capture information regarding a previous diagnosis of obstructive sleep apnea or other sleep disorders. Sleep disorder informational packets explaining the specific risk factors of sleep disorders is given to all Transit employees. The previous contractor, Mt. Sinai Hospital, also captured this information in questionnaires and distributed educational information. Copies of the questionnaires and informational packets from Mt. Sinai Hospital and Jackson Memorial Hospital are enclosed.

From: NTSB
To: Miami-Dade Transit Agency
Date: 1/12/2012
Response: Although Safety Recommendations R-09-10 and -11 are over 2 years old, the NTSB has received no reply to date regarding actions that Miami-Dade Transit Agency has taken to address them. We are interested in knowing whether and how our recommendations are implemented, both to ensure the public is provided the highest level of safety and to identify creative solutions that might be shared with others. Accordingly, we would appreciate receiving specific information regarding your policies for mitigating the risks associated with unidentified and untreated sleep disorders among your operators. Other transit agencies receiving the same safety recommendations have completed actions and reported their accomplishments to the NTSB. Through their medical history and physical examination forms, their employee training programs, and their requirements for periodic medical examinations, they have identified operators who are at high risk for sleep disorders. Many of the transit agencies reported that they require operators to pass the U.S. Department of Transportation Physical Exam for Commercial Driver Fitness Determination (http://www.fmcsa.dot.gov/documents/safetyprograms/Medical-Report.pdf) every 1-2 years; this examination specifically addresses sleep disorders. Some agencies also administer the Epworth Sleepiness Scale (http://www.stanford.edu/~dement/epworth.html) to identify potential sleep disorders among their operators. In addition, many transit agencies now require their operators who exhibit risk factors for sleep apnea or other sleep disorders to undergo a diagnostic sleep evaluation. Common risk factors include the following: • excessive weight • a neck circumference greater than 17 inches • pauses in breathing while asleep • daytime sleepiness • loud snoring, dry mouth/throat upon awakening • morning headaches • insomnia • smoking If the operator is diagnosed with a sleep disorder and treatment is deemed necessary, these transit agencies require the individual to be reevaluated and to periodically provide proof of treatment compliance; for example, the consistent use of a continuous positive airway pressure (CPAP) machine for obstructive sleep apnea. To see the actions taken by specific transit agencies, please visit our safety recommendations website at http://www.ntsb.gov/safetyrecs/private/QueryPage.aspx and enter the safety recommendation numbers referenced above. A copy of the original safety recommendation issuance letter is posted on the NTSB’s website at http://www.ntsb.gov/doclib/recletters/2009/R09_10_11.pdf. The full report of the Newton, Massachusetts, accident investigation (Report Number RAR-09/02) is available on our website at http://www.ntsb.gov/doclib/reports/2009/RAR0902.pdf. We look forward to hearing about your agency’s actions to address the safety risks associated with transit operators who have sleep disorders.

From: NTSB
To: Port Authority Transit Corporation
Date: 10/30/2014
Response: We note that you plan to respond to us regarding Safety Recommendations R-09-10 and 11 in other correspondence. Pending our timely receipt and review of detailed information regarding your actions or plans regarding these recommendations, they will retain their current classification, CLOSED—UNACCEPTABLE ACTION/ NO RESPONSE RECEIVED, which we assigned on August 13, 2014.

From: Port Authority Transit Corporation
To: NTSB
Date: 8/28/2014
Response: -From John D. Rink, General Manager: We will respond to these issues via separate correspondence.

From: NTSB
To: Port Authority Transit Corporation
Date: 8/27/2014
Response: Because we had not received a reply from you regarding actions either taken or planned in response to these recommendations since we issued them, they were classified “Closed?Unacceptable Action/No Response Received,” on August 13, 2014. We are encouraged that your August 21, 2014, e-mail states that you plan to respond in the near future to us regarding R-01-26 and -27; we would also welcome a response regarding your actions or plans concerning Safety Recommendations R-09-10 and -11. Because your reply did not include any substantive information, pending our timely receipt and review of detailed information regarding your actions or plans, Safety Recommendations R-01-26 and -27, and R-09-10 and 11, will retain their current classification.

From: Port Authority Transit Corporation
To: NTSB
Date: 8/21/2014
Response: -From John D. Rick, General Manager, PATCO: In regards to the attached letter, PATCO plans to respond in the near future.

From: NTSB
To: Port Authority Transit Corporation
Date: 8/13/2014
Response: We have received no reply from you regarding actions you have taken or planned to take in response to these recommendations since we issued them, despite our February 13, 2003, and December 27, 2013, followup requests for such information regarding Safety Recommendations R-01-26 and -27. Our December 27, 2013, letter also requested that you update us about any actions you had taken or planned regarding Safety Recommendations R-09-10 and -11. Because we have received no reply from you to any of our requests, we conclude that you have not acted to date, nor do you plan to address these safety issues. Consequently, Safety Recommendations R 01 26 and 27 and R 09 10 and 11 are classified CLOSED—UNACCEPTABLE ACTION/ NO RESPONSE RECEIVED.

From: NTSB
To: Port Authority Transit Corporation
Date: 12/27/2013
Response: This letter addresses Safety Recommendations R-01-26 and -27, which the NTSB issued to the Port Authority Transit Corporation (PATCO), on January 23, 2002, as a result of our special investigation of the February 13 and August 15, 2000, Maryland Transit Administration light rail vehicle accidents at the Baltimore-Washington International Airport transit station near Baltimore, Maryland. We also issued Safety Recommendations R-09-10 and -11 to PATCO on July 23, 2009, as a result of our investigation of the May 28, 2008, collision between two Massachusetts Bay Transportation Authority Green Line trains near Newton, Massachusetts. To date, we have received no information regarding any actions that PATCO has taken to address Safety Recommendations R-01-26, R-01-27, R-09-10, or R-09 -11. Normally, we expect action to address an NTSB safety recommendation to be completed within 5 years. Because two of these recommendations are almost 12 years old and we do not know of any actions taken to satisfy them, we would appreciate receiving a reply within 90 days of the receipt of this letter regarding any actions that PATCO has taken or planned to address these important safety issues. We are interested in knowing whether and how our recommendations are implemented, both to ensure the public the highest level of safety and to identify creative solutions that can be shared with others. Pending our receipt of a timely reply to this request, Safety Recommendations R 01 26 and -27, and R-09-10 and -11 are classified “Open?Await Response.” A copy of our January 23, 2002, letter issuing Safety Recommendations R-01-26 and -27 is available at http://www.ntsb.gov/doclib/recletters/2001/R01_26_27.pdf. The full report of the Baltimore, Maryland, accident is available at http://www.ntsb.gov/doclib/safetystudies/SIR0102.pdf. A copy of our July 23, 2009, letter issuing Safety Recommendations R-09-10 and -11 is available at http://www.ntsb.gov/doclib/recletters/2009/R09_10_11.pdf. The full report of the Newton, Massachusetts, accident is available at: http://www.ntsb.gov/doclib/reports/2009/RAR0902.pdf. We encourage you to respond electronically to this letter at the following e mail address: correspondence@ntsb.gov. In your reply, please refer to the recommendation by number. If a response, including attachments, exceeds 10 megabytes, please e-mail us at the same address for instructions. To avoid confusion, please do not submit both an electronic copy and a hard copy of the same response. Thank you for your assistance in this matter.

From: NTSB
To: State of California, County of Los Angeles, Metropolitan Transportation Authority
Date: 6/20/2012
Response: The NTSB notes that LACMTA has reviewed the medical history and examination form “State of California Department of Motor Vehicles Medical Examination Report for Commercial Driver Fitness Determination,” which LACMTA uses for transit operators, and has confirmed that the form includes specific questions intended to elicit information about potential sleep disorders, chronic fatigue, pauses in breathing while asleep, daytime sleepiness, loud snoring and other questions about weight, blood pressure, and diabetes that can constitute risk factors for sleep disorders. We are pleased with the contents of the health history section and with the details of the physical examination as Mr. Chasnov described them. We are also pleased that candidates being considered for the position of operator, as well as operators seeking biannual recertification, are both questioned about, and examined for, potential sleep disorders; accordingly, Safety Recommendation R-09-10 is classified CLOSED—ACCEPTABLE ACTION.

From: State of California, County of Los Angeles, Metropolitan Transportation Authority
To: NTSB
Date: 6/20/2011
Response: CC# 201100252: - From Stefan E. Chasnov, C.P.A. (inactive), CCP, Deputy Executive Officer, Human Resources: Regarding recommendation R-09-010, LACMTA has reviewed its medical history and examination forms (please refer to the attachments) and confirmed that they specifically include questions to elicit information about sleep disorders, chronic fatigue, pauses in breathing while asleep, daytime sleepiness and loud snoring. The Medical Examination Report for Commercial Driver Fitness Determination is completed by a qualified medical examiner and includes an operator's comprehensive health history. This form includes not only the specific questions about sleep disorders (Section 2), but also other questions such as weight, blood pressure, and diabetes to evaluate other risk factors for sleep disorders. LACMTA also uses the Medical History Questionnaire as part of the initial screening process for candidates who are being considered for the position of Operator. This form also elicits questions specifically related to sleep disorders. Both these forms are also used in the bi-annual recertification of operators to reevaluate any changes in their medical condition since the previous evaluation.

From: NTSB
To: Kenosha Transit
Date: 9/19/2012
Response: We note that Kenosha Area Transit uses the U.S. Department of Transportation Commercial Driver medical form and requires that train operators undergo a physical examination when they are hired and annually thereafter. Every operator must respond to the form’s questions regarding sleep disorders and sleep apnea. These practices satisfy Safety Recommendation R-09-10, which is classified CLOSED—ACCEPTABLE ACTION.

From: Kenosha Transit
To: NTSB
Date: 1/24/2012
Response: -From Ron Piorkowski, Kenosha Transit: The Kenosha Transit Streetcar System is a 1.9 mile oval track that operates with one streetcar and a single operator on a daily basis. Each streetcar has a built in automatic dead man switch so if the Operator would lose consciousness the car would automatically stop. The operators are given a DOT/CDL physical exam when hired. The physical exam form has questions related to sleep disorders and sleep apnea that every operator must fill out. The City of Kenosha also has yearly health assessments that are given to all operators. The Kenosha Transit system shares a Nurse Practitioner that is available to all City of Kenosha employees. She is located on staff at our building and is available to help identify any operators medical concerns. We also have video cameras on the streetcar system that can help to identify or verify any potential operations concerns relating to any health issues. The route supervisor also does spot checks to review the Kenosha Streetcar operation. The procedures and policies listed for the Kenosha Transit Streetcar System do address the concerns of National Transportation Safety Board recommendations of R-09-10 and R-09-11.

From: NTSB
To: Kenosha Transit
Date: 1/12/2012
Response: Although Safety Recommendations R-09-10 and -11 are over 2 years old, the NTSB has received no reply to date regarding actions that Kenosha Transit has taken to address them. We are interested in knowing whether and how our recommendations are implemented, both to ensure the public is provided the highest level of safety and to identify creative solutions that might be shared with others. Accordingly, we would appreciate receiving specific information regarding your policies for mitigating the risks associated with unidentified and untreated sleep disorders among your operators. Other transit agencies receiving the same safety recommendations have completed actions and reported their accomplishments to the NTSB. Through their medical history and physical examination forms, their employee training programs, and their requirements for periodic medical examinations, they have identified operators who are at high risk for sleep disorders. Many of the transit agencies reported that they require operators to pass the U.S. Department of Transportation Physical Exam for Commercial Driver Fitness Determination (http://www.fmcsa.dot.gov/documents/safetyprograms/Medical-Report.pdf) every 1-2 years; this examination specifically addresses sleep disorders. Some agencies also administer the Epworth Sleepiness Scale (http://www.stanford.edu/~dement/epworth.html) to identify potential sleep disorders among their operators. In addition, many transit agencies now require their operators who exhibit risk factors for sleep apnea or other sleep disorders to undergo a diagnostic sleep evaluation. Common risk factors include the following: • excessive weight • a neck circumference greater than 17 inches • pauses in breathing while asleep • daytime sleepiness • loud snoring, dry mouth/throat upon awakening • morning headaches • insomnia • smoking If the operator is diagnosed with a sleep disorder and treatment is deemed necessary, these transit agencies require the individual to be reevaluated and to periodically provide proof of treatment compliance; for example, the consistent use of a continuous positive airway pressure (CPAP) machine for obstructive sleep apnea. To see the actions taken by specific transit agencies, please visit our safety recommendations website at http://www.ntsb.gov/safetyrecs/private/QueryPage.aspx and enter the safety recommendation numbers referenced above. A copy of the original safety recommendation issuance letter is posted on the NTSB’s website at http://www.ntsb.gov/doclib/recletters/2009/R09_10_11.pdf. The full report of the Newton, Massachusetts, accident investigation (Report Number RAR-09/02) is available on our website at http://www.ntsb.gov/doclib/reports/2009/RAR0902.pdf. We look forward to hearing about your agency’s actions to address the safety risks associated with transit operators who have sleep disorders.

From: NTSB
To: Massachusetts Bay Transportation Authority
Date: 8/19/2010
Response: The NTSB is pleased that the MBTA has reviewed and updated its medical history and physical examination forms and has implemented a sleep disorder screening questionnaire that employs the Epworth Sleepiness Scale to assist employees in determining their level of sleepiness. We are also pleased with the updated MBTA process that you describe for evaluating an employee's risk for OSA or other sleep disorders. The actions that the MBTA has taken to modify its forms and establish a program to address this issue satisfy Safety Recommendations R-09-10 and R-09-11, which are classified CLOSED – ACCEPTABLE ACTION.

From: Massachusetts Bay Transportation Authority
To: NTSB
Date: 10/23/2009
Response: Letter Mail Controlled 11/3/2009 12:24:17 PM MC# 2090664 - From William A. Mitchell, Jr., Acting General Manager: I am writing in response to the recommendations the National Transportation Safety Board (NTSB) issued on July 23,2009 to the Massachusetts Bay Transportation Authority (MBTA), in connection with the May 28,2008 accident that occurred on the MBTA's Green Line. On July 14,2009, the NTSB held a public hearing on the investigation regarding the collision of two MBTA Green Line light rail vehicles that occurred in May 2008. Subsequent to this hearing, the NTSB issued a report outlining both findings and recommendations arising from the investigation. Pursuant to your letter of July 23,2009, MBTA provides a response to each of the recommendations directed to the Authority. Let me begin by stating that the safety of our customers and employees is a priority to the MBTA. Additionally, we are committed to the implementation of sound technological advancements, as well as practical interventions to identify and mitigate any human factor that may have an adverse impact on our operations. The MBTA fully embraces the spirit of all recommendations issued by the NTSB. The Authority seeks to implement each recommendation because they will enhance the Authority's safety culture and performance. The MBTA implemented the following additional measures to put into service this recommendation. 1. Review and update our medical history and physical examination forms as appropriate, 2. Implement a medical screening tool for sleep disorders known as the "Epworth Scale" in its employment protocols. Any positive findings will result in further evaluation. 3. Upon hiring and during employment treatment protocols prescribed by treating physicians will be monitored for compliance every 90 days for the first twelve (12) months and then annually if compliant during the first twelve months. Furthermore, the MBTA has identified numerous other opportunities for the MBTA Medical Clinic to assess employees for sleep disorders. Examples of such opportunities include, but are not limited to, the following. - Biannual physicals performed until the age of 45 years. Annual physicals performed thereafter. - Promotion to a safety sensitive position. - "Return to Work" physical is required when any absence from work is longer than 32 days. - A "Fitness for Duty" physical exam can be requested by supervisory staff any time hetshe is concerned about an employee's medical status. - The Authority has a policy that requires employees to report their use of prescription and over the counter medications. - A physical exam is required as part of the "reasonable suspicion" drug and alcohol testing program.

From: NTSB
To: Seattle Monorail Services
Date: 6/13/2014
Response: In the 5 years since these recommendations were issued, you have not responded to us regarding them, despite our January 12, 2012, request for an update. We normally expect recommended actions to be completed within 3 to 5 years after a recommendation is issued. As we have received no reply from you for almost 5 years, despite our request for information, Safety Recommendations R-09-10 and -11 are classified CLOSED—UNACCEPTABLE ACTION/ NO RESPONSE RECEIVED.

From: NTSB
To: Seattle Monorail Services
Date: 1/12/2012
Response: Although Safety Recommendations R-09-10 and -11 are over 2 years old, the NTSB has received no reply to date regarding actions that Seattle Monorail Services has taken to address them. We are interested in knowing whether and how our recommendations are implemented, both to ensure the public is provided the highest level of safety and to identify creative solutions that might be shared with others. Accordingly, we would appreciate receiving specific information regarding your policies for mitigating the risks associated with unidentified and untreated sleep disorders among your operators. Other transit agencies receiving the same safety recommendations have completed actions and reported their accomplishments to the NTSB. Through their medical history and physical examination forms, their employee training programs, and their requirements for periodic medical examinations, they have identified operators who are at high risk for sleep disorders. Many of the transit agencies reported that they require operators to pass the U.S. Department of Transportation Physical Exam for Commercial Driver Fitness Determination (http://www.fmcsa.dot.gov/documents/safetyprograms/Medical-Report.pdf) every 1-2 years; this examination specifically addresses sleep disorders. Some agencies also administer the Epworth Sleepiness Scale (http://www.stanford.edu/~dement/epworth.html) to identify potential sleep disorders among their operators. In addition, many transit agencies now require their operators who exhibit risk factors for sleep apnea or other sleep disorders to undergo a diagnostic sleep evaluation. Common risk factors include the following: • excessive weight • a neck circumference greater than 17 inches • pauses in breathing while asleep • daytime sleepiness • loud snoring, dry mouth/throat upon awakening • morning headaches • insomnia • smoking If the operator is diagnosed with a sleep disorder and treatment is deemed necessary, these transit agencies require the individual to be reevaluated and to periodically provide proof of treatment compliance; for example, the consistent use of a continuous positive airway pressure (CPAP) machine for obstructive sleep apnea. To see the actions taken by specific transit agencies, please visit our safety recommendations website at http://www.ntsb.gov/safetyrecs/private/QueryPage.aspx and enter the safety recommendation numbers referenced above. A copy of the original safety recommendation issuance letter is posted on the NTSB’s website at http://www.ntsb.gov/doclib/recletters/2009/R09_10_11.pdf. The full report of the Newton, Massachusetts, accident investigation (Report Number RAR-09/02) is available on our website at http://www.ntsb.gov/doclib/reports/2009/RAR0902.pdf. We look forward to hearing about your agency’s actions to address the safety risks associated with transit operators who have sleep disorders.

From: NTSB
To: Santa Clara Valley Transportation Authority
Date: 1/31/2011
Response: The NTSB is pleased that the VTA uses the state of California Department of Motor Vehicles’ Medical Examination Report for Commercial Driver Fitness Determination, which follows Federal Motor Carrier Safety Administration regulations for physical qualifications for drivers, and that in its “Health History” section, the medical examination report asks whether the driver has a history of any sleep disorders, pauses in breathing while asleep, daytime sleepiness, or loud snoring. The VTA’s use of the described form satisfies Safety Recommendation R-09-10, which is classified CLOSED--ACCEPTABLE ACTION.

From: Santa Clara Valley Transportation Authority
To: NTSB
Date: 9/20/2010
Response: CC# 201000407: - From Michael T. Burns, General Manager: VTA does not have our own medical forms or a company doctor. All of our medical work is contracted out. In California applicants for commercial driver's licenses must pass an initial certification physical examination and then subsequent recertification physicals every two years. Attached is the California Department of Motor Vehicles information on the physical qualifications for commercial drivers, Instructions to the Medical Examiner and the Medical Examination report form. The references to sleep apnea are circled on the first and fourth pages of the attachment and on the first page of the medical examination report. These are the documents used by our physicians.

From: NTSB
To: Santa Clara Valley Transportation Authority
Date: 7/21/2010
Response: The NTSB is pleased that VTA is working with the two medical providers who test and certify most of its commercial drivers to review and enhance VTA's medical examination process and include specific questions and tests to identify sleep disorders. The NTSB is interested in knowing whether VTA's physical examination forms or questionnaires will contain any questions about a driver's previous diagnosis of OSA or other sleep disorders. In addition, will there be individual questions about the presence of specific risk factors (for example, high blood pressure, body mass index, neck circumference) for GSA or other sleep disorders? Pending a further response to these questions, Safety Recommendation R-09-10 is classified OPEN – ACCEPTABLE RESPONSE. The NTSB would appreciate receiving a copy of VTA's revised evaluation forms for review with your reply.

From: Santa Clara Valley Transportation Authority
To: NTSB
Date: 10/21/2009
Response: Letter Mail Controlled 10/26/2009 1:23:36 PM MC# 2090657 - From Michael T. Burns, General Manager: In California, applicants for commercial driver's licenses must pass an initial certification physical examination and then subsequent recertification physicals every two years. VTA is working with the two medical providers who provide the medical testing and certification for the majority of our commercial drivers to enhance the examination process to include protocol that asks specific questions and tests to identify sleep disorders. This plan is currently in place with our major provider, and we are working with the second one to implement the program as well.

From: NTSB
To: Memphis Area Transit Authority
Date: 12/17/2010
Response: The NTSB notes that MATA’s Medical Review Officer (MRO) conducts pre-employment, fitness-for-duty, and annual physicals. The MRO obtains the employee information from the medical history completed by the trolley car operators on the Medical Examination Report for Commercial Driver Fitness Determination (Federal Motor Carrier Safety Administration [FMCSA] form 649-F [6045]), performs the physical examination, and completes the remaining five sections of the report. The NTSB also notes that the form contains questions about the operator’s history of sleep disorders, pauses in breathing while asleep, daytime sleepiness, or loud snoring. It also has space for the physician to record the operator’s weight and height measurements (for individuals who are markedly overweight), results of an examination of the mouth and throat for irremediable deformities likely to interfere with breathing, and information about respiratory conditions that could interfere with oxygen exchange and result in incapacitation, including OSA. In addition, MATA uses the Epworth Sleepiness Scale (ESS) to determine the level of daytime sleepiness for its trolley car operators. This questionnaire asks the subject to rate his or her probability of falling asleep on a scale of increasing probability from zero to three for eight different situations. The scores for the eight questions are added together to obtain a single number. A number in the 0–9 range is considered to be normal; a number in the 10–24 range indicates that expert medical advice should be sought. MATA’s use of the FMCSA’s Medical Examination Report for Commercial Driver Fitness Determination form and the ESS for its trolley car operators satisfies this recommendation; accordingly, Safety Recommendation R-09-10 is classified CLOSED -- ACCEPTABLE ACTION.

From: Memphis Area Transit Authority
To: NTSB
Date: 9/23/2010
Response: CC# 201000365: - From William Hudson, Jr., President and General Manager: Annual employee re-certification is required by 101.3 Operator Certification and Identification. Employees must maintain a current DOT medical card. Additionally, all such employees must keep a current medical DOT card on their person while in service. The re-certification examination includes the review of sleep apnea and other sleep disorders. Based upon the findings of the appropriate risk factors, the employee will be referred for additional consultation or further diagnosis. The forms identified below are the same forms referenced in R-09-10. Forms: Medical Examination Report: sections 1 and 2 are completed by the employee; the remaining portions are completed by the physician. Epworth Sleepiness Scale, (sample of a determining factor). Physician Order Form. The consulting physician, specializing in sleep disorders, will report the employee’s exam results and treatment plan, if necessary, and send that information to attention to the company’s MRO. Depending upon the results the examining physician will deny a Medical DOT card or issue a Medical DOT card for a 3 month, 6 month, 1 year or 2 year period.

From: NTSB
To: Memphis Area Transit Authority
Date: 7/21/2010
Response: The NTSB is pleased that (1) MATA is modifying its medical exams for both pre-employment and annual physicals to include an assessment for sleep disorders; (2) the MATA Medical Review Officer's (MRO) review, as well as the forms, will indicate the patient's body mass index, neck size, and sleep synopsis scale results; and (3) employees that require additional screening or review will be referred to their personal physician for further diagnosis and treatment, if appropriate, prior to receiving clearance by the MRO. Pending MATA's revision of its medical history and physical examination forms, Safety Recommendation R-09-1 0 is classified OPEN – ACCEPTABLE RESPONSE. The NTSB would appreciate receiving copies of MATA's physical examination forms for review when they have been revised.

From: Memphis Area Transit Authority
To: NTSB
Date: 10/2/2009
Response: Letter Mail Controlled 10/9/2009 3:25:41 PM MC# 2090633 - From William Hudson, Jr., President and General Manager: MATA's current medic$ exams for both pre-employment and annual physicals shall be modified to include an assessment for sleep disorders. The company's MRO review shall include the patient's BMI, neck size and sleep synopsis scale results. Employees that require additional screening or review are referred to their personal physician for further diagnosis and treatment, if appropriate, prior to receiving clearance by the MRO.

From: NTSB
To: Portland Streetcar
Date: 6/13/2014
Response: In the 5 years since these recommendations were issued, you have not responded to us regarding them, despite our request for an update on January 12, 2012. We normally expect recommended actions to be completed within 3 to 5 years after a recommendation is issued. As we have received no reply from you for almost 5 years, despite our request for information, Safety Recommendations R-09-10 and -11 are classified CLOSED—UNACCEPTABLE ACTION/ NO RESPONSE RECEIVED.

From: NTSB
To: Portland Streetcar
Date: 1/12/2012
Response: Although Safety Recommendations R-09-10 and -11 are over 2 years old, the NTSB has received no reply to date regarding actions that Portland Streetcar has taken to address them. We are interested in knowing whether and how our recommendations are implemented, both to ensure the public is provided the highest level of safety and to identify creative solutions that might be shared with others. Accordingly, we would appreciate receiving specific information regarding your policies for mitigating the risks associated with unidentified and untreated sleep disorders among your operators. Other transit agencies receiving the same safety recommendations have completed actions and reported their accomplishments to the NTSB. Through their medical history and physical examination forms, their employee training programs, and their requirements for periodic medical examinations, they have identified operators who are at high risk for sleep disorders. Many of the transit agencies reported that they require operators to pass the U.S. Department of Transportation Physical Exam for Commercial Driver Fitness Determination (http://www.fmcsa.dot.gov/documents/safetyprograms/Medical-Report.pdf) every 1-2 years; this examination specifically addresses sleep disorders. Some agencies also administer the Epworth Sleepiness Scale (http://www.stanford.edu/~dement/epworth.html) to identify potential sleep disorders among their operators. In addition, many transit agencies now require their operators who exhibit risk factors for sleep apnea or other sleep disorders to undergo a diagnostic sleep evaluation. Common risk factors include the following: • excessive weight • a neck circumference greater than 17 inches • pauses in breathing while asleep • daytime sleepiness • loud snoring, dry mouth/throat upon awakening • morning headaches • insomnia • smoking If the operator is diagnosed with a sleep disorder and treatment is deemed necessary, these transit agencies require the individual to be reevaluated and to periodically provide proof of treatment compliance; for example, the consistent use of a continuous positive airway pressure (CPAP) machine for obstructive sleep apnea. To see the actions taken by specific transit agencies, please visit our safety recommendations website at http://www.ntsb.gov/safetyrecs/private/QueryPage.aspx and enter the safety recommendation numbers referenced above. A copy of the original safety recommendation issuance letter is posted on the NTSB’s website at http://www.ntsb.gov/doclib/recletters/2009/R09_10_11.pdf. The full report of the Newton, Massachusetts, accident investigation (Report Number RAR-09/02) is available on our website at http://www.ntsb.gov/doclib/reports/2009/RAR0902.pdf. We look forward to hearing about your agency’s actions to address the safety risks associated with transit operators who have sleep disorders.

From: NTSB
To: Chattanooga Area Regional Transportation Authority
Date: 8/2/2012
Response: The NTSB notes that CARTA uses the U.S. Department of Transportation (DOT) physical examination form for commercial drivers, which includes the recommended questions. Accordingly, Safety Recommendation R-09-10 is classified, CLOSED—ACCEPTABLE ACTION.

From: Chattanooga Area Regional Transportation Authority
To: NTSB
Date: 2/24/2012
Response: -From Jeff Smith, Director of Human Resources: In response to the Safety Recommendations R-09-10 and R-09-11 please note that as a condition of employment, and continued employment, all of CARTA’s operators are required to pass the U.S. Department of Transportation (DOT) physical examination every 1–2 years. CARTA has a company physician who administers the DOT physical exam and identifies operators who are at high risk for obstructive sleep disorders. An operator who has been identified as having a sleep disorder is required to receive treatment and undergo monitoring before being permitted to drive a Commercial Motor Vehicle. Also, CARTA is raising awareness of fatigue and sleep disorders through flyers, posters, and driver training.

From: NTSB
To: Chattanooga Area Regional Transportation Authority
Date: 1/12/2012
Response: Although Safety Recommendations R-09-10 and -11 are over 2 years old, the NTSB has received no reply to date regarding actions that the Chattanooga Area Regional Transportation Authority has taken to address them. We are interested in knowing whether and how our recommendations are implemented, both to ensure the public is provided the highest level of safety and to identify creative solutions that might be shared with others. Accordingly, we would appreciate receiving specific information regarding your policies for mitigating the risks associated with unidentified and untreated sleep disorders among your operators. Other transit agencies receiving the same safety recommendations have completed actions and reported their accomplishments to the NTSB. Through their medical history and physical examination forms, their employee training programs, and their requirements for periodic medical examinations, they have identified operators who are at high risk for sleep disorders. Many of the transit agencies reported that they require operators to pass the U.S. Department of Transportation Physical Exam for Commercial Driver Fitness Determination (http://www.fmcsa.dot.gov/documents/safetyprograms/Medical-Report.pdf) every 1-2 years; this examination specifically addresses sleep disorders. Some agencies also administer the Epworth Sleepiness Scale (http://www.stanford.edu/~dement/epworth.html) to identify potential sleep disorders among their operators. In addition, many transit agencies now require their operators who exhibit risk factors for sleep apnea or other sleep disorders to undergo a diagnostic sleep evaluation. Common risk factors include the following: • excessive weight • a neck circumference greater than 17 inches • pauses in breathing while asleep • daytime sleepiness • loud snoring, dry mouth/throat upon awakening • morning headaches • insomnia • smoking If the operator is diagnosed with a sleep disorder and treatment is deemed necessary, these transit agencies require the individual to be reevaluated and to periodically provide proof of treatment compliance; for example, the consistent use of a continuous positive airway pressure (CPAP) machine for obstructive sleep apnea. To see the actions taken by specific transit agencies, please visit our safety recommendations website at http://www.ntsb.gov/safetyrecs/private/QueryPage.aspx and enter the safety recommendation numbers referenced above. A copy of the original safety recommendation issuance letter is posted on the NTSB’s website at http://www.ntsb.gov/doclib/recletters/2009/R09_10_11.pdf. The full report of the Newton, Massachusetts, accident investigation (Report Number RAR-09/02) is available on our website at http://www.ntsb.gov/doclib/reports/2009/RAR0902.pdf. We look forward to hearing about your agency’s actions to address the safety risks associated with transit operators who have sleep disorders.

From: NTSB
To: State of Missouri, City of St. Louis, Metro Transit
Date: 4/28/2010
Response: The NTSB is satisfied with the medical history and physical examination forms used by the Bi-State Development Agency Metro St. Louis (Metro), the instructions to its medical director regarding OSA, and individual questions asked about the presence of specific risk factors for OSA and other sleep disorders. Metro’s use of the Federal Motor Carrier Safety Administration’s Medical Examination Report for Commercial Driver Fitness Determination form (649-F [6045]) for its operator candidates in the rail transit mode satisfies this recommendation; accordingly, Safety Recommendation R-09-10 is classified CLOSED -- ACCEPTABLE ACTION.

From: State of Missouri, City of St. Louis, Metro Transit
To: NTSB
Date: 9/15/2009
Response: Letter Mail Controlled 9/25/2009 9:52:57 AM MC# 2090602: - From Raymond A. Friem, Chief Operating Officer: Metro agrees with and is in compliance with these recommendations. Metro requires all Light Rail Vehicle (LRV) operators to maintain a valid commercial Drivers License (CDL) and the accompanying Department of Transportation (DOT) Medical Examiners certificate. The certificate is renewed every two years (or in some cases more frequently) for all employees who operate an LRV in passenger service. Our medical screening process also includes the use of the Berlin Questionnaire (See Attachment A) where indicated. The results of that survey will determine if additional sleep study is necessary. Moreover, our current Occupational Vendor, Concentra, has provided guidelines and procedures (See Attachment B) for recognition, diagnosis, awareness, and treatment for Sleep Apnea and Obstructive Sleep Disorder. Finally, Metro has independently reviewed the methods and processes used by Concentra and I have attached a summary of these processes (See Attachment C). In addition to the foregoing, Metro also addresses the broader issue of operator fatigue in several ways. First, the State of Missouri Rail Safety Oversight rule includes provisions for hours of service (See Attachment D) for LRV operators. Metro complies with and enforces that rule in both Missouri and Illinois as part of the Joint State Safety &Security Oversight Program standard -MO and IL (July 2007). Finally, Metro provides Fatigue Recognition Training to all rail operations supervisors (See Attachment E). This training is derived from the fatigue management program developed by the FTA Office of Safety and Security.

From: NTSB
To: Jacksonville Transportation Authority
Date: 10/12/2016
Response: We note that the Jacksonville Transportation Authority uses the Florida Department of Transportation’s Medical Examination Report for Bus Transit System Driver to administer physical exams to all bus and Skyway personnel in safety-sensitive positions prior to their beginning employment, every 2 years thereafter, and more frequently if they are identified as having a medical condition that necessitates monitoring. Because this medical examination form includes the recommended questions intended to identify operators at high risk for sleep disorders, Safety Recommendation R-09-010 is classified CLOSED—ACCEPTABLE ACTION.

From: Jacksonville Transportation Authority
To: NTSB
Date: 4/15/2016
Response: -From Cami Haynes, Assistant VP. Chief Safety and Compliance Officer: As per your request, please find enclosed a copy of the form used by the JTA to collect specific information for diagnosing Obstructive Sleep Apnea (OSA) and other sleep disorders for our review (Attachment A)

From: NTSB
To: Jacksonville Transportation Authority
Date: 1/27/2016
Response: We understand that you require all control center operators to undergo physical examinations to ensure that they have not been diagnosed with OSA or any other sleep disorder and that your medical officer will continue to ensure that operators with a high risk for these disorders are appropriately evaluated and treated. We note that, as of September 23, 2015, all control center operators have undergone these physical examinations. However, we asked that you conduct a review of your medical history and physical examination forms and modify them as necessary. Please send us a copy of the form you use to collect specific information for diagnosing OSA and other sleep disorders for our review. Pending our receipt of this information, Safety Recommendation R-09-10 remains classified OPEN—ACCEPTABLE RESPONSE.

From: Jacksonville Transportation Authority
To: NTSB
Date: 10/22/2015
Response: -From Nathaniel P. Ford, Sr.: Please be advised that the Jacksonville Transportation Authority (JTA) has received your letter regarding Safety Recommendations R-09-10 and R-09-11. As you may know, over the past several years, the JTA has undergone a series of organizational changes in leadership. As a result, there was no record of the recommendations, nor was there any documentation that would suggest that the recommendations were adopted and/or formalized into the JTA's standard operating procedures. Upon receipt of your letter, JTA moved swiftly to implement the recommendations. Specifically, and as it pertains to R-09-10 and R-09-11, the JTA has mandated that all Control Center Operators submit to physical examinations to ensure that the Operators have not been diagnosed with sleep apnea, or any other sleep disorders. Likewise, the JTA will continue to utilize its Medical Officer to ensure that Operators with a high risk for obstructive sleep apnea or like disorders are appropriately evaluated and treated. I am happy to report that as of September 23, 2015, all of JTA's Control Center Operators have undergone the requisite physical examinations, aimed at identifying sleep apnea or like disorders. The JTA will continually require these examinations, and include the Control Center Operators in our ongoing monitoring efforts enforced for our Bus Operators. Should you have any questions, or require more information, please feel free to contact me.

From: Jacksonville Transportation Authority
To: NTSB
Date: 10/20/2015
Response: -From Nathaniel P. Ford, Sr., Chief Executive Officer: Please be advised that the Jacksonville Transportation Authority (JTA) has received your letter regarding Safety Recommendations R-09-10 and R-09-11. As you may know, over the past several years, the JTA has undergone a series of organizational changes in leadership. As a result, there was no record of the recommendations, nor was there any documentation that would suggest that the recommendations were adopted and/or formalized into the JTA's standard operating procedures. Upon receipt of your letter, JTA moved swiftly to implement the recommendations. Specifically, and as it pertains to R-09-10 and R-09-11, the JTA has mandated that all Control Center Operators submit to physical examinations to ensure that the Operators have not been diagnosed with sleep apnea, or any other sleep disorder. Likewise, the JTA will continue to utilize its Medical. Officer to, ensure that• Operators with a high risk for obstructive sleep apnea or like disorders are appropriately evaluated and treated. I am happy to report that as of September 23, 2015, all of JTA's Control Center Operators have undergone the requisite physical examinations, aimed at identifying sleep apnea or like disorders. The JTA will continually require these examinations, and include the Control Center Operators in our ongoing monitoring efforts enforced for our Bus Operators.

From: NTSB
To: Jacksonville Transportation Authority
Date: 9/16/2015
Response: Completing actions to address our safety recommendations usually takes recipients 3 to 5 years, and these recommendations are now more than 6 years old. Of the 46 addressees, JTA is 1 of 2 for which R-09-10 remains open, and 1 of 6 for which R-09-11 remains open. To date, we have received no information regarding your actions or plans for addressing Safety Recommendation R-09-10 or -11 since JTA’s January 12, 2012, letter. In our October 4, 2012 response, we explained that Safety Recommendation R 09 10 and 11 apply to all operators with safety related oversight responsibilities, including JTA trains’ control center operators; we encouraged JTA to act expeditiously to implement the recommendations for these operators. Our 2012 letter also included aspects of programs developed by other transit authorities to address these recommendations, should you find this information helpful in developing your own program. Pending your reply, Safety Recommendations R-09-10 and -11 were classified OPEN—ACCEPTABLE RESPONSE. As nearly 3 years have elapsed since then, we would appreciate receiving an update on your actions to satisfy these recommendations. We are interested in knowing whether and how our recommendations are implemented, both to ensure the public the highest level of safety and to identify creative solutions that can be shared with others. Although Safety Recommendations R 09 10 and -11 will retain their current classification pending your timely reply, unless we hear from you promptly, we may have to classify these recommendations in an unacceptable status.

From: NTSB
To: Jacksonville Transportation Authority
Date: 10/4/2012
Response: Safety Recommendation R 09-10 and -11 apply to all operators that have safety-related oversight responsibilities. Accordingly, although the train cars on the Automated Skyway Express operated by the Jacksonville Transportation Authority do not have onboard operators, the recommendations still apply to the train’s control center operators. Therefore, the NTSB encourages the Jacksonville Transportation Authority to act expeditiously to implement these recommendations for your control center operators. In establishing a fatigue management program, you may find it helpful to know some aspects of the programs developed by other transit authorities. Many other programs include the following practices: • Transit authorities or their contractors use the U.S. Department of Transportation (DOT) physical examination form 649-F when examining employees who occupy safety sensitive positions. The DOT exam questionnaire addresses sleep disorder history. • Safety-sensitive employees must undergo physical examinations prior to being hired and regularly thereafter (usually every year or every 2 years). • Physicians are trained in questioning and identifying operators who are at high risk for obstructive sleep apnea and other sleep disorders. • Physicians use standard criteria for identifying operators, such as body mass index and neck circumference measurements. • Physicians may use the Epworth Sleepiness Scale in evaluating employees. • If a potential sleep disorder is identified, the physician may refer the patient for a sleep study. Once referred, the patient does not operate trains until either a sleep disorder is ruled out or treatment has begun. • If treatment is prescribed, the patient is monitored for compliance. • The patient’s credentials are approved for limited periods (such as 3 months, 6 months, or 1 year) during treatment evaluation and may be revoked permanently if the disorder cannot be managed or the patient does not comply with treatment. • Physicians require more frequent medical evaluations for operators who have medical conditions, including sleep disorders, which can change over time and pose a safety risk. We look forward to hearing from you as you work to develop a fatigue management program for employees in safety-sensitive positions at the Jacksonville Transit Authority. In the meantime, Safety Recommendations R 09 10 and 11 are classified OPEN—ACCEPTABLE RESPONSE.

From: Jacksonville Transportation Authority
To: NTSB
Date: 2/3/2012
Response: -From Michael J. Blaylock, Executive Director/CEO: Thank you for your follow-up letter regarding our response to Safety Recommendations R-09-10 and -11 issued to us on July 23,2009. All recommendations from our transportation partners are carefully and seriously considered. Please be advised that the Jacksonville Transportation Authority's 2.5 mile Automated Skyway Express (ASE) train cars do not have on-board operators; they are controlled by our eight (8) Control Center Operators (CCO) located in our Operations and Maintenance Facility. We have two (2) CCOs on duty during our hours of operation. Our reading of the NTSB's Safety Recommendations R-09-10 and R-09-11 led us to believe that they only applied to those systems that have on-board train operators. If we are incorrect in our interpretation, please advise us so that we may implement appropriate processes to ensure compliance. Please accept our apology for not responding to your recommendations in a more timely fashion.

From: NTSB
To: Jacksonville Transportation Authority
Date: 1/12/2012
Response: Although Safety Recommendations R-09-10 and -11 are over 2 years old, the NTSB has received no reply to date regarding actions that the Jacksonville Transportation Authority has taken to address them. We are interested in knowing whether and how our recommendations are implemented, both to ensure the public is provided the highest level of safety and to identify creative solutions that might be shared with others. Accordingly, we would appreciate receiving specific information regarding your policies for mitigating the risks associated with unidentified and untreated sleep disorders among your operators. Other transit agencies receiving the same safety recommendations have completed actions and reported their accomplishments to the NTSB. Through their medical history and physical examination forms, their employee training programs, and their requirements for periodic medical examinations, they have identified operators who are at high risk for sleep disorders. Many of the transit agencies reported that they require operators to pass the U.S. Department of Transportation Physical Exam for Commercial Driver Fitness Determination (http://www.fmcsa.dot.gov/documents/safetyprograms/Medical-Report.pdf) every 1-2 years; this examination specifically addresses sleep disorders. Some agencies also administer the Epworth Sleepiness Scale (http://www.stanford.edu/~dement/epworth.html) to identify potential sleep disorders among their operators. In addition, many transit agencies now require their operators who exhibit risk factors for sleep apnea or other sleep disorders to undergo a diagnostic sleep evaluation. Common risk factors include the following: • excessive weight • a neck circumference greater than 17 inches • pauses in breathing while asleep • daytime sleepiness • loud snoring, dry mouth/throat upon awakening • morning headaches • insomnia • smoking If the operator is diagnosed with a sleep disorder and treatment is deemed necessary, these transit agencies require the individual to be reevaluated and to periodically provide proof of treatment compliance; for example, the consistent use of a continuous positive airway pressure (CPAP) machine for obstructive sleep apnea. To see the actions taken by specific transit agencies, please visit our safety recommendations website at http://www.ntsb.gov/safetyrecs/private/QueryPage.aspx and enter the safety recommendation numbers referenced above. A copy of the original safety recommendation issuance letter is posted on the NTSB’s website at http://www.ntsb.gov/doclib/recletters/2009/R09_10_11.pdf. The full report of the Newton, Massachusetts, accident investigation (Report Number RAR-09/02) is available on our website at http://www.ntsb.gov/doclib/reports/2009/RAR0902.pdf. We look forward to hearing about your agency’s actions to address the safety risks associated with transit operators who have sleep disorders.

From: NTSB
To: Dallas Area Rapid Transit Authority (DART)
Date: 2/15/2011
Response: The NTSB is pleased that Dallas Area Rapid Transit Authority’s (DART) review of its medical history and physical examinations forms confirmed compliance with Safety Recommendation R-09-10. DART’s contractor, U.S. HealthWorks Medical Group, uses a Medical Examination Report for Commercial Driver Fitness Determination, a modified version of the U.S. Department of Transportation’s physical qualification and examination form for commercial motor vehicle (CMV) drivers. We are aware that this form contains questions regarding sleeping disorders, pauses in breathing while asleep, daytime sleepiness, loud snoring, and other risk factors for sleep disorders. Accordingly, Safety Recommendation R-09-10 is classified CLOSED – ACCEPTABLE ACTION.

From: Dallas Area Rapid Transit Authority (DART)
To: NTSB
Date: 10/15/2009
Response: Letter Mail Controlled 11/3/2009 3:26:18 PM MC# 2090667 - From Gary C. Thomas, President/ Executive Director: This letter responds to the safety recommendations mentioned in your letter to all U.S. Rail Transit Agencies dated July 23,2009. A thorough review of medical history and physical examinations forms used by our contracted medical examiner for DART employees was initiated. The results of the review confirmed compliance with both safety recommendations [R-09-10 and R-09-12].

From: NTSB
To: State of Texas, County of Harris, Metropolitan Transit Authority of Harris County
Date: 10/31/2017
Response: We note that in October 2014, you implemented a new requirement that all of your rail operators complete and maintain a US Department of Transportation medical physical certification, which includes an assessment of the individual’s OSA risk. This action satisfies Safety Recommendations R 09-10 and -11, which are classified CLOSED--ACCEPTABLE ACTION.

From: State of Texas, County of Harris, Metropolitan Transit Authority of Harris County
To: NTSB
Date: 8/8/2017
Response: -From Thomas C. Lambert, President and CEO: Thank you for your letter dated July 26, 2017 that followed up on the National Transportation Safety Board's (NTSB) Safety Recommendation of R-09-10 and R-09-11. As stated in our letter dated July 1, 2014, METRO implemented a new guideline that required all Rail Operators (non-Commercial Drivers License [COL] holders) to complete a DOT Medical Physical and maintain a valid DOT Medical Physical Card. The guideline went into effect October 2014 and maintains in effect today. We appreciate your office following up on our original response to NTSB Safety Recommendations R-09-10 and R-09-11, and look forward to continued collective efforts of increasing safety in the transportation industry.

From: NTSB
To: State of Texas, County of Harris, Metropolitan Transit Authority of Harris County
Date: 7/26/2017
Response: Your most recent letter to us regarding these recommendations, dated July 1, 2014, said that all of your new rail operators must meet prescribed physical requirements and must pass a Department of Transportation (DOT) medical physical assessment, including an OSA evaluation. Those found to have OSA are further evaluated by your health care provider, who determines whether the applicant is complying with treatment. If no other issues exist, the rail operator candidate is issued a DOT medical physical card with an expiration date. You also said that, starting in October 2014, you would require all of your rail operators to complete and maintain a DOT medical physical. Pending full implementation of this new medical program for rail operators, Safety Recommendations R-09-10 and -11 were classified “Open—Acceptable Response.” We have not received any further information from you in the 3 years since your previous letter, despite a June 9, 2017, e-mail to Mr. Timothy Kelly asking for an update. Please tell us whether you have enforced the requirement that was scheduled to begin in October 2014 for all of your rail operators to complete and maintain a DOT medical physical. Based on this information, we may be able to close these recommendations.

From: NTSB
To: State of Texas, County of Harris, Metropolitan Transit Authority of Harris County
Date: 8/18/2014
Response: We understand that all your new rail operators must meet prescribed physical requirements and must pass a Department of Transportation (DOT) medical physical assessment, including an OSA evaluation. Those found to have OSA are further evaluated by your health care provider, who determines whether the applicant is complying with treatment. If no other issues exist, the rail operator candidate is issued a DOT medical physical card with an expiration date. We are encouraged that, starting in October 2014, you will require all rail operators to complete and maintain a DOT medical physical. Pending full implementation of this new medical program for rail operators, Safety Recommendations R 09-10 and -11 are classified OPEN—ACCEPTABLE RESPONSE.

From: State of Texas, County of Harris, Metropolitan Transit Authority of Harris County
To: NTSB
Date: 7/1/2014
Response: -From Thomas C. Lambert, President and Chief Executive Officer: First, on behalf of the Metropolitan Transit Authority of Harris County (METRO), sincerely apologize that we did not respond in a timely manner to the NTSB issued Safety Recommendations R-09-1 0 and 11. METRO takes the safety of our passengers and employees very seriously, and we value any Safety Recommendation issued from the NTSB and just wanted you to know that we include as part of our pre-employment process the following: • All qualified, candidates for a Rail Operator position must meet physical requirements•which include a DOT Medical. Physical Assessment, all applicants are given a sleep apnea evaluation • Applicants determined to have sleep apnea are required to provide proper documentation to METRO's health care provider. Upon review of documentation the health care provider determines if the applicant. Is compliant with the issued CPAP and no other issues exists, the rail operator candidate is issued a DOT Medical Physical Card with an expiration date. In 2012 METRO implemented a guideline requiring all COL holders to maintain valid DOT Medical Physicals. Starting in October 2014 the agency will have a revised guideline that will require all Rail Operators to complete a DOT Medical Physical and maintain a valid DOT Medical Physical card.

From: NTSB
To: State of Texas, County of Harris, Metropolitan Transit Authority of Harris County
Date: 6/13/2014
Response: In the 5 years since these recommendations were issued, you have not responded to us regarding them, despite our January 12, 2012, request for an update. We normally expect recommended actions to be completed within 3 to 5 years after a recommendation is issued. As we have received no reply from you for almost 5 years, despite our request for information, Safety Recommendations R-09-10 and -11 are classified CLOSED—UNACCEPTABLE ACTION/ NO RESPONSE RECEIVED.

From: NTSB
To: State of Texas, County of Harris, Metropolitan Transit Authority of Harris County
Date: 1/12/2012
Response: Although Safety Recommendations R-09-10 and -11 are over 2 years old, the NTSB has received no reply to date regarding actions that Metropolitan Transit Authority of Harris County has taken to address them. We are interested in knowing whether and how our recommendations are implemented, both to ensure the public is provided the highest level of safety and to identify creative solutions that might be shared with others. Accordingly, we would appreciate receiving specific information regarding your policies for mitigating the risks associated with unidentified and untreated sleep disorders among your operators. Other transit agencies receiving the same safety recommendations have completed actions and reported their accomplishments to the NTSB. Through their medical history and physical examination forms, their employee training programs, and their requirements for periodic medical examinations, they have identified operators who are at high risk for sleep disorders. Many of the transit agencies reported that they require operators to pass the U.S. Department of Transportation Physical Exam for Commercial Driver Fitness Determination (http://www.fmcsa.dot.gov/documents/safetyprograms/Medical-Report.pdf) every 1-2 years; this examination specifically addresses sleep disorders. Some agencies also administer the Epworth Sleepiness Scale (http://www.stanford.edu/~dement/epworth.html) to identify potential sleep disorders among their operators. In addition, many transit agencies now require their operators who exhibit risk factors for sleep apnea or other sleep disorders to undergo a diagnostic sleep evaluation. Common risk factors include the following: • excessive weight • a neck circumference greater than 17 inches • pauses in breathing while asleep • daytime sleepiness • loud snoring, dry mouth/throat upon awakening • morning headaches • insomnia • smoking If the operator is diagnosed with a sleep disorder and treatment is deemed necessary, these transit agencies require the individual to be reevaluated and to periodically provide proof of treatment compliance; for example, the consistent use of a continuous positive airway pressure (CPAP) machine for obstructive sleep apnea. To see the actions taken by specific transit agencies, please visit our safety recommendations website at http://www.ntsb.gov/safetyrecs/private/QueryPage.aspx and enter the safety recommendation numbers referenced above. A copy of the original safety recommendation issuance letter is posted on the NTSB’s website at http://www.ntsb.gov/doclib/recletters/2009/R09_10_11.pdf. The full report of the Newton, Massachusetts, accident investigation (Report Number RAR-09/02) is available on our website at http://www.ntsb.gov/doclib/reports/2009/RAR0902.pdf. We look forward to hearing about your agency’s actions to address the safety risks associated with transit operators who have sleep disorders.

From: NTSB
To: New Jersey Transit Corporation
Date: 9/13/2012
Response: The NTSB notes that New Jersey Transit administers three light rail systems within the state of New Jersey: the Newark Light Rail (NLR), the Hudson-Bergen Light Rail Transit System (HBLR), and River LINE (RVL), and that New Jersey Transit has reviewed these systems’ programs for addressing potential sleep disorders in its operators. We also note that operators are examined every 2 years by a licensed physician using the U.S. Department of Transportation form, which includes the recommended questions regarding symptoms of sleep disorders. As part of the physical, each operator completes a health history form that elicits information about symptoms of sleep disorders, and the examining physician identifies operators at risk for sleep apnea. In some cases, operators are also rated using the Epworth Sleepiness Scale. These procedures satisfy the requirements of Safety Recommendation R-09-10, which is classified CLOSED—ACCEPTABLE ACTION. The NTSB notes that any operator determined to have a sleep disorder may not operate a New Jersey Transit light rail vehicle until cleared by a physician. Followup treatment for such conditions includes counseling and referral to a family physician for treatment. Efficiency checks and undercover programs also help ensure that sleep disorders are not going undetected or untreated. This policy satisfies Safety Recommendation R-09-11, which is classified “Closed—Acceptable Action.”

From: New Jersey Transit Corporation
To: NTSB
Date: 3/13/2012
Response: -From John F. Squitieri, Deputy General Manager, Light Rail Operations: These two recommendations have resulted from NTSB's investigation of the May 28,2008 collision of two Massachusetts Bay Transportation Authority Green Line trains in Newton, MA. In NTSB's letter of January 12, 2012, NTSB enquired in knowing about whether and how their recommendations have been implemented by NJ Transit. NTSB is requesting NJ Transit for specific information regarding policies for mitigating risks associated with operators' unidentified and untreated sleep disorders. NJ Transit administers three light rail systems within the state of New Jersey. NJ Transit owns and operates Newark Light Rail (NLR). Hudson-Bergen Light Rail Transit System (HBLR) and River LINE (RVL) are contracted out for operations and maintenance to URS Corporation and Southern New Jersey Light Rail System, respectively as part of Design-Build-Operate and Maintain contract. NTSB states in their letter of January 12, 2012 that other transit agencies have implemented NTSB recommendations through agencies' medical history and physical examination forms, employee training programs, and requirements for periodic medical examinations and have identified operators who are at high risk for sleep disorders. NJ Transit has reviewed the programs of NLR, HBLR and RVL, concerning sleep disorders in regard to their operators. Every operator in each transit system is given a DOT physical every two (2) years, at a minimum, by a licensed "Medical Examiner". As part of the physical, each operator has to complete a 'Health History' form that requires information on sleep apnea. During this physical, the Medical Examiner identifies operators at risk for sleep apnea. They counsel the individual(s) and provide them with informational handouts. The individual is then referred to their family Physician. In some cases, NJ Transit also screen operators using "Epworth Sleepiness Scale. The Medical Examiner provides a "medical certificate" for the DOT physical. Any operator deemed to have a sleeping disorder is not permitted to operate a Light Rail Vehicle until cleared by the Medical Examiner. In addition, to informational handouts, each operator is given fatigue and sleep apnea training. In this training symptom(s) of sleep apnea, sleep disorders and fatigue are discussed along with recommendations to receive medical assistance for sleep apnea. Efficiency checks and under cover programs also assist NJ Transit in identifying operators with sleep disorders. If you need any further information regarding NJ Transit's programs, please contact me directly.

From: New Jersey Transit Corporation
To: NTSB
Date: 1/23/2012
Response: -From John F. Squitieri, Deputy General Manager, Light Rail Operations: New Jersey Transit has received the NTSB's January 12, 2012 letter addressed to Mr. Joseph North, General Manager Light Rail, One Penn Plaza East, Newark, NJ 07105. This letter refers to previous correspondence that was sent to New Jersey Transit on July 23, 2009. Unfortunately, we have made a thorough search of our documents and did not find any communication from NTSB to New Jersey Transit, dated July 23, 2009. As a further complication, please note that Mr. Joseph North, the person your letter was addressed to, retired from New Jersey Transit later that year, in 2009. New Jersey Transit is requesting that your office kindly address all future correspondence, to the following: Mr. John F. Squitieri Deputy General Manager, Light Rail Operations NJ TRANSIT One Penn Plaza East Newark; NJ 07105 In the meanwhile, New Jersey Transit is present1y in the process of reviewing the safety recommendations from the NTSB and will report our progress under separate cover. Thank you for your help with this request. If you need any further information or documentation regarding our programs, please contact me at the above address.

From: NTSB
To: New Jersey Transit Corporation
Date: 1/12/2012
Response: Although Safety Recommendations R-09-10 and -11 are over 2 years old, the NTSB has received no reply to date regarding actions that New Jersey Transit has taken to address them. We are interested in knowing whether and how our recommendations are implemented, both to ensure the public is provided the highest level of safety and to identify creative solutions that might be shared with others. Accordingly, we would appreciate receiving specific information regarding your policies for mitigating the risks associated with unidentified and untreated sleep disorders among your operators. Other transit agencies receiving the same safety recommendations have completed actions and reported their accomplishments to the NTSB. Through their medical history and physical examination forms, their employee training programs, and their requirements for periodic medical examinations, they have identified operators who are at high risk for sleep disorders. Many of the transit agencies reported that they require operators to pass the U.S. Department of Transportation Physical Exam for Commercial Driver Fitness Determination (http://www.fmcsa.dot.gov/documents/safetyprograms/Medical-Report.pdf) every 1-2 years; this examination specifically addresses sleep disorders. Some agencies also administer the Epworth Sleepiness Scale (http://www.stanford.edu/~dement/epworth.html) to identify potential sleep disorders among their operators. In addition, many transit agencies now require their operators who exhibit risk factors for sleep apnea or other sleep disorders to undergo a diagnostic sleep evaluation. Common risk factors include the following: • excessive weight • a neck circumference greater than 17 inches • pauses in breathing while asleep • daytime sleepiness • loud snoring, dry mouth/throat upon awakening • morning headaches • insomnia • smoking If the operator is diagnosed with a sleep disorder and treatment is deemed necessary, these transit agencies require the individual to be reevaluated and to periodically provide proof of treatment compliance; for example, the consistent use of a continuous positive airway pressure (CPAP) machine for obstructive sleep apnea. To see the actions taken by specific transit agencies, please visit our safety recommendations website at http://www.ntsb.gov/safetyrecs/private/QueryPage.aspx and enter the safety recommendation numbers referenced above. A copy of the original safety recommendation issuance letter is posted on the NTSB’s website at http://www.ntsb.gov/doclib/recletters/2009/R09_10_11.pdf. The full report of the Newton, Massachusetts, accident investigation (Report Number RAR-09/02) is available on our website at http://www.ntsb.gov/doclib/reports/2009/RAR0902.pdf.

From: NTSB
To: Greater Cleveland Regional Transit Authority
Date: 9/13/2012
Response: The NTSB notes that all Greater Cleveland Regional Transit Authority (GCRTA) bus and rail operators are required to pass a physical examination prior to being hired and every 2 years (or, in some cases, more often) thereafter. The current “Medical Examination Report for Commercial Driver Fitness Determination” requests health history information related to sleep disorders, pauses in breathing while asleep, daytime sleepiness, and loud snoring. If any of these symptoms is checked or the patient indicates that he or she has been diagnosed with a sleep disorder, the examining physician obtains detailed information regarding treatment and compliance. We note that the GCRTA has also developed and is using a new form created to identify operators at high risk for obstructive sleep apnea or other sleep disorders. The following risk factors are used in making this determination: • Body mass index of 35 or greater • Neck circumference greater than 17 inches for men, 16 inches for women • Hypertension (new, uncontrolled, or uncontrollable with fewer than two medications) • Previously diagnosed sleep apnea, and compliance with CPAP (continuous positive airway pressure) treatment claimed, but no compliance data available for immediate review When it has been determined that an operator is at high risk (that is, he or she has two or more of the listed factors), the operator is certified for only a 3-month period, is referred to his or her personal physician, and is required to submit a letter from that physician indicating that the appropriate tests have been administered and the operator is compliant with the treatment plan. An operator who has been diagnosed with sleep apnea and is not compliant with a physician's treatment plan will be removed from duty until after a physician can confirm compliance. These procedures satisfy Safety Recommendations R-09-10 and R-09-11, which are classified CLOSED—ACCEPTABLE ACTION. Thank you for your cooperation.

From: Greater Cleveland Regional Transit Authority
To: NTSB
Date: 1/19/2012
Response: -From Joseph A. Calabrese, CEO, General Manager, Secretary-Treasurer: Medical History and Physical Examination All GCRTA Bus and Rail Operators are required to pass a physical examination prior to hiring and every two years (or in some cases more often) thereafter. The current "Medical Examination Report for Commercial Driver Fitness Determination" requests health history information related to sleep disorders, pauses in breathing while asleep, daytime sleepless and loud snoring (see Attachment 1). If any of these symptoms or diagnosis is checked the examining physician will obtain detailed information regarding treatment and compliance. Identify Employees at High Risk A new form was created to determine drivers who are at high risk for obstructive sleep apnea or other sleep disorders. If an operator has 2 or more of the following risk factors, the driver will be issued a 3-month card: 1. BMI greater than or equal to 35 Kg/ms. 2. Neck circumference> 17 inches for men and 16 inches for women. 3. Hypertension (new, uncontrolled or uncontrollable with less than 2 medications). 4. Previously diagnosed sleep apnea, C-PAP compliance claimed but no compliance data available for immediate review. Requirements When it is determined that an operator is at high risk, the operator will be issued a 3-month card, referred to their physician and required to submit a letter from their physician indicating that the appropriate tests have been administered and they are compliant with the treatment plan. Operators who have been diagnosed with sleep apnea and are not compliant with their physician's treatment plan will be pulled from duty and unable to drive until after their physician can confirm compliance. Operator Training - Fatigue Awareness All GCRTA Operators are required to attend a Fatigue Awareness Seminar. The seminar covers signs and symptoms of fatigue, factors that affect fatigue, sleep disorder symptoms and strategies and countermeasures to fatigue. The seminar is conducted as part of the Biennial Operator Training. The following documents are used to monitor/train operators on sleep apnea/fatigue awareness and are attached: 1. Medical Examination Report for Commercial Driver Fitness Determination (Attachment 1) 2. Sleep Apnea Risk Factor Assessment Form (Attachment 2) 3. Fatigue Awareness Seminar Slides (GCRTA Training Department) (Attachment 3) The GCRTA implemented these recommendations in 2009 and have been actively using them in our daily activities to ensure that our agency is working proactively to remain a safe system.

From: NTSB
To: Greater Cleveland Regional Transit Authority
Date: 1/12/2012
Response: Although Safety Recommendations R-09-10 and -11 are over 2 years old, the NTSB has received no reply to date regarding actions that the Greater Cleveland Regional Transit Authority has taken to address them. We are interested in knowing whether and how our recommendations are implemented, both to ensure the public is provided the highest level of safety and to identify creative solutions that might be shared with others. Accordingly, we would appreciate receiving specific information regarding your policies for mitigating the risks associated with unidentified and untreated sleep disorders among your operators. Other transit agencies receiving the same safety recommendations have completed actions and reported their accomplishments to the NTSB. Through their medical history and physical examination forms, their employee training programs, and their requirements for periodic medical examinations, they have identified operators who are at high risk for sleep disorders. Many of the transit agencies reported that they require operators to pass the U.S. Department of Transportation Physical Exam for Commercial Driver Fitness Determination (http://www.fmcsa.dot.gov/documents/safetyprograms/Medical-Report.pdf) every 1-2 years; this examination specifically addresses sleep disorders. Some agencies also administer the Epworth Sleepiness Scale (http://www.stanford.edu/~dement/epworth.html) to identify potential sleep disorders among their operators. In addition, many transit agencies now require their operators who exhibit risk factors for sleep apnea or other sleep disorders to undergo a diagnostic sleep evaluation. Common risk factors include the following: • excessive weight • a neck circumference greater than 17 inches • pauses in breathing while asleep • daytime sleepiness • loud snoring, dry mouth/throat upon awakening • morning headaches • insomnia • smoking If the operator is diagnosed with a sleep disorder and treatment is deemed necessary, these transit agencies require the individual to be reevaluated and to periodically provide proof of treatment compliance; for example, the consistent use of a continuous positive airway pressure (CPAP) machine for obstructive sleep apnea. To see the actions taken by specific transit agencies, please visit our safety recommendations website at http://www.ntsb.gov/safetyrecs/private/QueryPage.aspx and enter the safety recommendation numbers referenced above. A copy of the original safety recommendation issuance letter is posted on the NTSB’s website at http://www.ntsb.gov/doclib/recletters/2009/R09_10_11.pdf. The full report of the Newton, Massachusetts, accident investigation (Report Number RAR-09/02) is available on our website at http://www.ntsb.gov/doclib/reports/2009/RAR0902.pdf. We look forward to hearing about your agency’s actions to address the safety risks associated with transit operators who have sleep disorders.

From: NTSB
To: Central Arkansas Transit Authority
Date: 9/13/2012
Response: We note that, on behalf of CATA, the Baptist Medical Center Occupational Health Group uses the U.S. Department of Transportation (DOT) form to administer physical exams to all CATA’s bus and rail operators prior to their beginning employment, every 2 years thereafter, and more frequently if they are identified as having a medical condition that dictates such action. The DOT form includes the recommended questions intended to identify operators at high risk for sleep disorders. Accordingly, Safety Recommendation R-09-10 is classified CLOSED—ACCEPTABLE ACTION. We note that operators are referred to their personal physicians for treatment and monitoring of identified sleep disorders before they are certified for bus or train operation. This practice, in combination with the more frequent physical examinations for such operators, satisfies Safety Recommendation R-09-11, which is classified “Closed—Acceptable Action.” Thank you for your cooperation.

From: Central Arkansas Transit Authority
To: NTSB
Date: 1/10/2012
Response: -From Betty Wineland, Executive Director: In reference to your recent letter concerning sleep disorders among transit vehicle operators, the Central Arkansas Transit Authority (CATA) follows these procedures: All applicants for bus and rail operator positions, and all maintenance applicants who will drive transit vehicles in the course of their employment, are required to pass a pre-employment physical, the U. S. Department of Transportation Physical Exam for Commercial Driver Fitness Determination. Once employed, each individual is required to pass the exam every two (2) years or more often if there are indications that a problem may exist. This examination addresses sleep disorders. The exams are administered by the Baptist Medical Center Occupational Health Group. If there is evidence of a disorder that may place the employee at risk, including sleep disorders, the employee is referred to his or her family physician for further examination. Until the Occupational Health Group receives verification from the family physician that the examination has occurred and treatment prescribed, if indicated, the employee cannot receive certification. In addition, CATA provides informational materials on health care, including high-risk conditions such as high blood pressure and sleep disorders through health and workers compensation insurance providers.

From: NTSB
To: Central Arkansas Transit Authority
Date: 1/5/2012
Response: Although Safety Recommendations R-09-10 and -11 are over 2 years old, the NTSB has received no reply to date regarding actions that the Central Arkansas Transit Authority has taken to address them. We are interested in knowing whether and how our recommendations are implemented, both to ensure the public is provided the highest level of safety and to identify creative solutions that might be shared with others. Accordingly, we would appreciate receiving specific information regarding your policies for mitigating the risks associated with unidentified and untreated sleep disorders among your operators. Other transit agencies receiving the same safety recommendations have completed actions and reported their accomplishments to the NTSB. Through their medical history and physical examination forms, their employee training programs, and their requirements for periodic medical examinations, they have identified operators who are at high risk for sleep disorders. Many of the transit agencies reported that they require operators to pass the U.S. Department of Transportation Physical Exam for Commercial Driver Fitness Determination (http://www.fmcsa.dot.gov/documents/safetyprograms/Medical-Report.pdf) every 1-2 years; this examination specifically addresses sleep disorders. Some agencies also administer the Epworth Sleepiness Scale (http://www.stanford.edu/~dement/epworth.html) to identify potential sleep disorders among their operators. In addition, many transit agencies now require their operators who exhibit risk factors for sleep apnea or other sleep disorders to undergo a diagnostic sleep evaluation. Common risk factors include the following: • excessive weight • a neck circumference greater than 17 inches • pauses in breathing while asleep • daytime sleepiness • loud snoring, dry mouth/throat upon awakening • morning headaches • insomnia • smoking If the operator is diagnosed with a sleep disorder and treatment is deemed necessary, these transit agencies require the individual to be reevaluated and to periodically provide proof of treatment compliance; for example, the consistent use of a continuous positive airway pressure (CPAP) machine for obstructive sleep apnea. To see the actions taken by specific transit agencies, please visit our safety recommendations website at http://www.ntsb.gov/safetyrecs/private/QueryPage.aspx and enter the safety recommendation numbers referenced above. A copy of the original safety recommendation issuance letter is posted on the NTSB’s website at http://www.ntsb.gov/doclib/recletters/2009/R09_10_11.pdf. The full report of the Newton, Massachusetts, accident investigation (Report Number RAR-09/02) is available on our website at http://www.ntsb.gov/doclib/reports/2009/RAR0902.pdf. We look forward to hearing about your agency’s actions to address the safety risks associated with transit operators who have sleep disorders.