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On Sunday, June 24, 2012, at 10:02 a.m. central daylight time, eastbound Union Pacific Railroad (UP) freight train ZLAAH-22 and westbound UP freight train AAMMLX-22 collided head-on while operating on straight track on the UP Pratt subdivision near Goodwell, Oklahoma. Skies were clear, the temperature was 89°F, and visibility was 10 miles. The collision derailed 3 locomotives and 24 cars of the eastbound train and 2 locomotives and 8 cars of the westbound train. The engineer and the conductor of the eastbound train and the engineer of the westbound train were killed. The conductor of the westbound train jumped to safety. During the collision and derailment, several fuel tanks from the derailed locomotives ruptured, releasing diesel fuel that ignited and burned. Damage was estimated at $14.8 million. The National Transportation Safety Board determines that the probable cause of this accident was the eastbound Union Pacific Railroad train crew’s lack of response to wayside signals because of the engineer’s inability to see and correctly interpret the signals; the conductor’s disengagement from his duties; and the lack of positive train control, which would have stopped the train and prevented the collision regardless of the crew’s inaction. Contributing to the accident was a medical examination process that failed to decertify the engineer before his deteriorating vision adversely affected his ability to operate a train safely.
TO THE FEDERAL RAILROAD ADMINISTRATION: Require more frequent medical certification exams for employees in safety-sensitive positions who have chronic conditions with the potential to deteriorate sufficiently to impair safe job performance.
Original recommendation transmittal letter:
Open - Unacceptable Response
Goodwell, OK, United States
Head-On Collision of Two Union Pacific Railroad Freight Trains
Addressee(s) and Addressee Status:
FRA (Open - Unacceptable Response)
Safety Recommendation History
We point out that OSA is not the only chronic medical condition that can affect an employee’s performance. In the accident that led to these recommendations, the problem was ongoing loss of visual acuity and color vision, not OSA. Nothing in your response suggests that you are working to require railroads to develop a method for systematically evaluating medical conditions or medication use among employees in safety-sensitive positions. Similarly, you have not addressed the need to increase the frequency of medical evaluations when employees in safety sensitive positions have chronic medical conditions that may deteriorate and affect safety. As a result, Safety Recommendations R 13 20 and -21 remain classified OPEN--UNACCEPTABLE RESPONSE.
-From Sarah E. Feinberg, Administrator: FRA is addressing railroad employees' medical fitness for duty issues sequentially based on NTSB accident investigations of railroad accidents. For example, on March 10, 2016, FRA, with the Federal Motor Carriers Safety Administration (FMCSA), published an Advance Notice of Proposed Rulemaking (ANPRM) regarding obstructive sleep apnea. In this ANPRM, FRA and FMC SA request data and information concerning the prevalence of moderate-to-severe obstructive sleep apnea (OSA) among individuals occupying safety sensitive positions in highway and rail transportation and on its potential consequences for the safety of rail and highway transportation. FMC SA and FRA (collectively "the Agencies") also request information on potential costs and benefits from regulatory actions that address the safety risks associated with motor carrier and rail transportation workers in safety sensitive positions who have OSA. Once FRA has fully considered how to address obstructive sleep apnea, FRA will next consider strategies to address other medical conditions that are also contributing causes to accidents.
We understand that the Rail Safety Advisory Committee (RSAC) delegated this task to a Medical Standards Working Group (MSWG), which agreed to draft rule text and to create a Physicians Task Force to develop medical standards, but that, after 5 years of meetings, the MSWG was unable to reach consensus on either rule text or medical standards and was placed on hiatus. We appreciate that you are planning rulemaking that will reconsider vision and hearing standards for certified locomotive engineers and conductors, and that a new RSAC Fatigue Management Working Group is developing standards for a railroad fatigue management plan to consider sleep disorders and other medical conditions that could adversely affect a safety sensitive employee’s alertness. We note that you have also developed an online Railroaders’ Guide to Healthy Sleep and have issued rules limiting the work hours of passenger train operators and mandated implementation of Positive Train Control (PTC) systems that can reduce the probability of certain accidents, some of which may be due to fatigue. However, none of these efforts directly address the above recommendations, which include developing a comprehensive medical certification system rather than one limited to vision and hearing standards or focused solely on fatigue management. Nothing in your response suggests you are working to require railroads develop a structure to systematically identify medical conditions or medication use among safety-sensitive employees. Similarly, you have not addressed the need to increase the frequency of medical evaluations when employees in safety sensitive positions have chronic medical conditions with a possibility of deterioration, whether or not that deterioration might affect alertness. Because the FRA is not addressing these critical safety issues, pending full implementation of these recommendations, Safety Recommendations R 13-20 and -21 are classified OPEN—UNACCEPTABLE RESPONSE.
-Joseph C. Szabo, Administrator: In 2006, partly in response to superseded Safety Recommendations R-02-24 through R-02-26, the Railroad Safety Advisory Committee (RSAC) accepted a task to develop a program "[to] enhance the safety of persons in the railroad operating environment and the public by establishing standards and procedures for determining the medical fitness for duty of personnel engaged in safety-critical functions." The RSAC delegated this task to a Medical Standards Working Group (MSWG), which agreed to draft rule text and to create a Physicians Task Force to develop medical standards. The MSWG decided to focus on vision, hearing, and medical conditions such as obstructive sleep apnea that pose a risk of sudden incapacitation. After 5 years of meetings, the MSWG reported that it was unable to reach consensus on either rule text or medical standards and was placed on hiatus. Although consensus was not achieved, the MSWG meetings that were held over this period provided a forum for railroads, representatives of railroad employees, and other members of the RSAC to become better informed about medical fitness-for-duty programs and policies within the railroad industry and other transportation industries, as well as an opportunity to discuss their respective concerns about the benefits, fairness, and potential economic impact of such programs and policies. FRA believes that railroads and representatives of employees, working together, can use this information to develop risk reduction strategies on individual railroad properties that prevent accidents and improve railroad safety. In addition, FRA has since adopted a multipronged approach to address the fitness for duty of safety-sensitive employees. In a future rulemaking, FRA will reconsider its vision and hearing standards for certified locomotive engineers and conductors. A new RSAC working group, the Fatigue Management Working Group, is developing standards for a railroad fatigue management plan that must consider sleep disorders and other medical conditions that could adversely affect a safety-sensitive employee's alertness. Finally, FRA has developed a Web site, the Railroaders' Guide to Healthy Sleep, and has issued rules that limit the hours that a passenger train operator may work and also mandate the implementation of Positive Train Control (PTC) systems that reduce the probability of certain accidents, some of which may be due to fatigue.
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