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Safety Recommendation Details

Safety Recommendation R-12-026
Details
Synopsis: On April 17, 2011, about 6:55 a.m. central daylight time, eastbound BNSF Railway (BNSF) coal train C-BTMCNMO-26, BNSF 9159 East, travelling about 23 mph, collided with the rear end of standing BNSF maintenance-of-way (MOW) equipment train U-BRGCRI-15, BNSF 9470 East, near Red Oak, Iowa. The accident occurred near milepost (MP) 448.3 on main track number two on the Creston Subdivision of the BNSF Nebraska Division. The collision resulted in the derailment of 2 locomotives and 12 cars. As a result of collision forces, the lead locomotive's modular crew cab was detached, partially crushed, and involved in a subsequent diesel fuel fire. Both crewmembers on the striking train were fatally injured. Damage was in excess of $8.7 million. The National Transportation Safety Board (NTSB) determined that the probable cause of the accident was the failure of the crew of the striking train to comply with the signal indication requiring them to operate in accordance with restricted speed requirements and stop short of the standing train because they had fallen asleep due to fatigue resulting from their irregular work schedules and their medical conditions. Contributing to the accident was the absence of a positive train control system that identifies the rear of a train and stops a following train if a safe braking profile is exceeded. Contributing to the severity of collision damage to the locomotive cab of the striking coal train was the absence of crashworthiness standards for modular locomotive crew cabs.
Recommendation: TO THE BNSF RAILWAY: Medically screen employees in safety-sensitive positions for sleep apnea and other sleep disorders.
Original recommendation transmittal letter: PDF
Overall Status: Open - Unacceptable Response
Mode: Railroad
Location: Red Oak, IA, United States
Is Reiterated: No
Is Hazmat: No
Is NPRM: No
Accident #: DCA11FR002
Accident Reports: Collision of BNSF Coal Train With the Rear End of Standing BNSF Maintenance-of-Way Equipment Train
Report #: RAR-12-02
Accident Date: 4/17/2011
Issue Date: 5/10/2012
Date Closed:
Addressee(s) and Addressee Status: BNSF Railway Company (formerly Burlington Northern and Santa Fe Railway Company) (Open - Unacceptable Response)
Keyword(s):

Safety Recommendation History
From: NTSB
To: BNSF Railway Company (formerly Burlington Northern and Santa Fe Railway Company)
Date: 7/17/2018
Response: We note that, for every employee in a safety-related position, you require training that includes a voluntary screening questionnaire for sleep apnea and other sleep disorders; however, this training is only required during the preemployment and return-to-duty stages and does not apply to current employees. Employees who have elevated scores on this questionnaire are alerted that they may have a particular sleep disorder and are encouraged to seek further medical evaluation and treatment (such as the use of a continuous positive airway pressure device) from their physicians. We note that, for these employees to be certified for duty by your medical examiner, they must prove they are complying with their physician-recommended treatment. Training employees on conditions such as sleep apnea is a step in the right direction, but training alone does not meet the intent of this recommendation, and screening new employees does not identify current employees who are likely to be at higher risk for sleep apnea. Until you test all of your employees in safety-sensitive positions for sleep apnea, Safety Recommendation R 12 26 is classified OPEN--UNACCEPTABLE RESPONSE.

From: BNSF Railway Company (formerly Burlington Northern and Santa Fe Railway Company)
To: NTSB
Date: 2/9/2018
Response: -From Ryan E. Ringelman, General Director System Safety: BNSF provides enhanced training on sleep disorders, including obstructive sleep apnea ("OSA") through its annual training and certification programs noted above. This training, as well as other web-based sleep resources, are always available to BNSF employees through BNSF's intranet. Provided as paii of this training is a screening questionnaire that employees may use to dete1mine their risk for sleep disorders. This questionnaire can be used to provide awareness on potential concerns and to confidentially identify if additional follow-up or discussion with a medical professional is warranted for the employee. A copy of the latest version of that training is included in the fatigue training attachment (attachment A, Part 3, beginning on page 34). For the last 15 years, as part of its post-offer, pre-employment medical evaluation, BNSF has screened applicants in safety sensitive positions for potential risk of sleep disorders. This assessment identifies candidates at high risk for OSA who would then be required to take a sleep study. Candidates with severe OSA are additionally required to demonstrate compliance with continuous positive airway pressure ("CP AP") therapy when prescribed by their treating provider. In addition to the more formal pre-employment screening and training programs, BNSF provides the opportunity for annual preventative health screenings to its employees through events held at designated locations across its system. These health screenings include assessments of heart rate, blood pressure, body mass index ("BMI"), neck circumference as well as providing an opportunity for a one-on-one discussion with a medical provider about potential risk factors or health concerns. As part of this annual employee health program, employees are also specifically provided an opportunity for additional assessment/screening for OSA sleep disorders (attachment B). This includes an opp01tunity for a one-on-one discussion with the on-site medical professionals of areas of medical risk factors or concerns, including recommendations for additional follow-up screenings or studies as warranted. Another formal approach BNSF uses in identification and mitigation of sleep disorders, is its medical return-to-work program. In the event an employee has missed work due to a medical condition that may adversely affect their ability to work safely, the employee's medical fitness must be reviewed by the Medical and Environmental Health Department ("MEH") prior to the employee returning to work (attachment C). If a sleep disorder is discovered as part of the return-to-work medical record review, additional review and follow-up documentation is required. Finally, in the event any of these programs or assessments provides info1mation that an employee is diagnosed with or treating for a sleep disorder, the BNSF MEH team will conduct additional follow-up assessments as needed and will additionally monitor that employee for compliance with the recommended treatment plan. The Medical Status Form: Sleep Disorders Review (attachment D) is utilized to obtain a deeper assessment of the employee's condition and treatment, as well as acting as a vehicle to provide Signed confirmation from the employee's treating provider that the employee is compliant with the plan of treatment and is able to safely perform job duties. This follow up will generally continue for a period of at least a year. Given the extensive ongoing eff01ts listed above with supporrting documentation, BNSF respectfully requests that this recommendation be classified as "Closed-Acceptable Response". Again, BNSF appreciates the opp01tunity to provide more inf01mation on its programs and approaches to the identified recommendations. We remain ready and willing to discuss these responses in greater depth with the NTSB team.

From: BNSF Railway Company (formerly Burlington Northern and Santa Fe Railway Company)
To: NTSB
Date: 1/31/2013
Response: -From Mark A. Schulze, Vice President, Safety, Training, and Operations Support: Turning now to the specific recommendations, we acknowledge NTSB's classifications for R-12-25 and R-12-26, and will follow up with the appropriate Board staff to discuss our expectations for when the requested supporting documentation will be available.

From: NTSB
To: BNSF Railway Company (formerly Burlington Northern and Santa Fe Railway Company)
Date: 12/18/2012
Response: The NTSB notes that BNSF is requiring training for every safety-related employee, which includes a voluntary screening questionnaire for sleep apnea, restless leg syndrome, and other sleep disorders. Employees who choose to fill out this questionnaire and who have elevated scores on it are alerted that they may have a particular sleep disorder and should seek further medical evaluation from their physician. During the training, all employees are notified of two websites that provide additional information and screening tools for sleep apnea and other sleep disorders. We note that employee unions strongly objected to previous attempts by BNSF to require additional medical information about certain safety-related medical conditions, including sleep apnea, from its employees, and that charges filed by 10 of these unions with the Equal Employment Opportunity Commission regarding BNSF’s proposed requirements remain pending. The NTSB is aware that the FRA is writing guidelines for sleep apnea that would allow a safety-sensitive employee who has been diagnosed with the disorder, is undergoing treatment (such as the use of a continuous positive airway pressure [CPAP] device), and is complying effectively with that treatment, to be certified for duty by a medical examiner. We note that the FRA’s Medical Standards Railroad Safety Advisory Council (RSAC) is discussing this issue, and we are aware that union members are participating in drafting the RSAC guidelines. Until these guidelines are completed and BNSF implements a comprehensive program to screen employees in safety-sensitive positions for sleep apnea and other sleep disorders, Safety Recommendation is classified OPEN—ACCEPTABLE RESPONSE. We look forward to receiving a copy of BNSF’s screening procedures once they are complete.

From: BNSF Railway Company (formerly Burlington Northern and Santa Fe Railway Company)
To: NTSB
Date: 8/23/2012
Response: -From Mark A. Schulze, Vice President, Training and Operations Support, BNSF Railway: Medical Screening Safety Recommendation R-12-26 would require medically screening employees in safety-sensitive positions for sleep apnea and other sleep disorders. Under the Rail Safety Improvement Act of2008, a railroad's risk reduction program must include a fatigue management plan that is designed to reduce the fatigue experienced by safety-related railroad employees and to reduce the likelihood of accidents, incidents, injuries, and fatalities caused by fatigue. The FRA rulemaking proceedings for the risk reduction program and fatigue management component are underway. As outlined in the response to Safety Recommendation R-12-25, BNSF will require each employee to receive training on fatigue which will include sleep disorders. This training includes a voluntary screening questionnaire for sleep apnea, restless leg syndrome, and other sleep disorders. Employees with elevated scores are alerted that they may have a particular sleep disorder and should seek further medical evaluation from their physician. BNSF will also include the following resources in our communications to employees. • The "Railroaders' Guide to Healthy Sleep" (http://www.railroadersleep.orgl), is a new industry website that includes a screening tool along with extensive information about fatigue and sleep disorders and other conditions or activities that cause fatigue or interfere with restful sleep. • The screening tool, The Anonymous Sleep Disorders Screening Tool can be found at the following intemet address: https://sleepscreen.partners.orgluser/start. The screening tools include links to the American Academy of Sleep Medicine internet site for locating accredited clinics. Previous attempts by BNSF to require additional medical information about certain safety related medical conditions, specifically including attempts to obtain medical information on sleep apnea, met with stiff resistance from our labor organizations who alleged that these attempts to obtain medical information were in violation of various federal and state laws. Indeed, 10 unions filed charges with the Equal Employment Opportunity Commission alleging that the BNSF requirement violated the federal Americans with Disabilities Act. Those charges remain pending. Simply stated, until there are some federal standards on medical qualification for such conditions as sleep apnea, other sleep disorders or, medical conditions that affect an employee's ability to work safely, it will be difficult to obtain and use such information without facing a variety of legal challenges. BNSF believes such information may be lawfully used to improve safety without violating employee rights and is an active participant in FRA's Medical Standards Railroad Safety Advisory Council (RSAC) where this issue has been discussed. Based on the actions outlined above, I would request the NTSB close Recommendations R-12-25 and R- 12-26 as "Closed: Acceptable Action".