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Safety Recommendation Details

Safety Recommendation R-13-021
Details
Synopsis: 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.
Recommendation: TO THE FEDERAL RAILROAD ADMINISTRATION: Develop medical certification regulations for employees in safety-sensitive positions that include, at a minimum, (1) a complete medical history that includes specific screening for sleep disorders, a review of current medications, and a thorough physical examination, (2) standardization of testing protocols across the industry, and (3) centralized oversight of certification decisions for employees who fail initial testing; and consider requiring that medical examinations be performed by those with specific training and certification in evaluating medication use and health issues related to occupational safety on railroads. [This recommendation supersedes Safety Recommendations R-02-24 through -26.]
Original recommendation transmittal letter: PDF
Overall Status: Open - Unacceptable Response
Mode: Railroad
Location: Goodwell, OK, United States
Is Reiterated: Yes
Is Hazmat: No
Is NPRM: No
Accident #: DCA12MR005
Accident Reports: Head-On Collision of Two Union Pacific Railroad Freight Trains
Report #: RAR-13-02
Accident Date: 6/24/2012
Issue Date: 8/14/2013
Date Closed:
Addressee(s) and Addressee Status: FRA (Open - Unacceptable Response)
Keyword(s):

Safety Recommendation History
From: NTSB
To: FRA
Date: 9/5/2018
Response: 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: NTSB
To: FRA
Date: 1/18/2018
Response: We note that you are working with medical organizations to develop training and informational materials on the unique needs of the railroad population, and that the informational materials will be made available to medical professionals who treat railroad employees. However, it has been 4 years since we issued Safety Recommendation R-13-21, and nothing in your response suggests that you are working to require railroads to systematically identify medical conditions or medication use among employees in safety-sensitive positions. Further, as mentioned above, we note that you have recently withdrawn your ANPRM on sleep apnea. Accordingly, Safety Recommendation R-13-21 remains classified OPEN--UNACCEPTABLE RESPONSE.

From: FRA
To: NTSB
Date: 3/30/2017
Response: -From Patrick T. Warren, Executive Director performing the duties of the Administrator: Thank you for your January 24, 2017, letter to the Federal Railroad Administration (FRA) regarding the National Transportation Safety Board's (NTSB) Safety Recommendations R-16-043 and R-16-044, as well as the reiterations of Safety Recommendations R-13-21 and R-12-16. FRA understands NTSB issued these recommendations as a result of its investigation of an August 17, 2014, accident, in which two Union Pacific Railroad (UP) freight trains collided at the UP Hoxie subdivision in Hoxie, AR. The enclosure responds to Safety Recommendations R-16-043 and R-16-044, and explains FRA's position on these recommendations as well as Safety Recommendations R-13-21 and R-12-16. FRA is actively working to achieve the intent of these recommendations and offer the attached description of action to inform you of our progress. FRA has a working group of the Rail Safety Advisory Committee (RSAC) tasked with the establishment of medical standards for employees in safety sensitive positions. Unlike other commercial transportation industries, the railroad industry does not have a pool of medical professionals trained in rail-specific health issues. FRA believes creating such a pool of medical professionals would not be cost effective, and would put an undue burden on the railroad industry and its employees. Furthermore, working group discussions revealed a strong preference from railroads and employees for safety-sensitive employees to receive rail-related examinations, and any needed continuing care, from the employee's personal physician or medical professional. As such, FRA is looking at ways to develop communication between the employee's personal physician and the employer consistent with the privacy rule set forth in the Health Insurance Portability and Accountability Act of 1996 (HIP AA; Pub.L. 104-191, 11 O Stat. 1936). FRA recognizes medical professionals who treat railroad employees need to have resources and training available to identify health issues, medications, risk factors, and concerns of the railroad population. FRA is working with several professional medical organizations to aid in developing training and informational materials on the unique needs of the railroad population. The resulting informational materials will be made available to medical professionals who treat railroad employees. This will enable an employee's personal physician or other medical professional to continue providing care, while also giving that medical professional the additional information needed when providing care to employees in safety-sensitive positions.

From: FRA
To: NTSB
Date: 2/16/2017
Response: -From Karl Alexy, Director, Office of Safety Analysis: Thank you for your January 24, 2017, letter to the Federal Railroad Administration (FRA) regarding the National Transportation Safety Board's (NTSB) new recommendations R-16-043, R-16-044, and reiterated recommendations R-13-21, and R-12-16, in response to the August 17, 2014, Union Pacific Railroad accident in Hoxie, AR. FRA is working to respond to the recommendations in NTSB' s letter and will respond as soon as possible. Improving safety is FRA's top priority and FRA will continue to work to make rail travel as safe as possible. FRA is committed to working with NTSB to prevent future accidents and save lives. FRA welcomes and will consider all recommendations that will further that goal.

From: NTSB
To: FRA
Date: 1/24/2017
Response: From the Railroad Accident Report "Collision of Two Union Pacific Railroad Freight Trains, Hoxie, Arkansas August 17, 2014" published on January 24, 2017, Report Number: RAR-16-03. Adopted December 19, 2016, PB2017-100970: 2.5 Southbound Train Locomotive Engineer’s Medical Issues The southbound engineer’s postaccident urine toxicology testing identified 94 ng/ml diphenhydramine and citalopram/escitalopram in his urine, but no blood was available for testing. Although diphenhydramine is considered sedating, there is no accepted method for relating postmortem urine drug results for diphenhydramine to cognitive function impairment at the time of the fatal injury.19 Therefore, it cannot be determined if the engineer was impaired by this sedating antihistamine or its hangover effects at the time of the accident. Urine testing did not differentiate between citalopram and escitalopram, antidepressants commonly marketed with the names Celexa and Lexapro. Both are psychoactive medications and carry warnings about the risk of cognitive impairment in the mental and/or physical ability required for the performance of potentially hazardous tasks (such as, driving, operating heavy machinery). However, personal medical records revealed the southbound engineer had been using escitalopram for many years without reported performance problems. According to his personal medical records, between 2006 and 2014, the southbound engineer repeatedly reported feeling tired to his primary care physician. In 2010, the primary care physician considered the diagnosis of obstructive sleep apnea and obtained a polysomnography, also known as a sleep study, which was performed in a sleep laboratory. The results included an apnea-hypopnea index (AHI) of 19.3 episodes/hour, oxygen saturation ranging from 93-87 percent, and 29 periodic limb movements recorded with an index of 5.3 per hour.20 All of these measurements are considered abnormal. The sleep specialist diagnosed moderate sleep apnea and the possibility of restless leg syndrome.21 The southbound engineer returned to the sleep center for a trial of treatment with continuous positive airway pressure (CPAP). Following that trial, the sleep specialist recommended the “CPAP be placed at 7 cm/H2O. (No apneas, no snoring, no periodic limb movements).” The NTSB medical officer reviewed records from the sleep laboratory and sleep specialist, as well as the primary care physician, and interviewed the primary care physician. However, no follow-up visits or evidence of treatment initiation, maintenance, or review with the sleep specialist or the primary care physician were discovered. No evidence was found that the southbound engineer ever obtained or used a CPAP machine to treat his sleep disorder. The night before the accident, the southbound engineer’s work schedule required him to sleep away from home. He had checked out of his accommodation and did not have a CPAP device in his possession at the time of the accident. There is also no evidence that he obtained any other treatment for his sleep apnea, such as surgery or a customized mouthpiece. The NTSB concludes the southbound engineer was fatigued and likely asleep due to his diagnosed but inadequately treated moderate sleep apnea and operating the train in the early morning hours when he was predisposed to sleep. In September 2013, the southbound engineer was noted to be 6 feet, 3 inches tall and weigh 250 pounds. According to the body mass calculator from the National Institutes of Health, National Heart, Lung, and Blood Institute, his body mass index was 31.2 kg/mg2, which is considered obese.22 Although his body mass index was in the obese category, which increased the risk for sleep apnea, the southbound engineer’s weight was not known to directly cause it. The NTSB has investigated a number of previous railroad accidents where undiagnosed or inadequately treated sleep apnea or other sleep disorders in safety-sensitive employees caused or contributed to the accident. A head-on collision of two Canadian National/Illinois Central Railway trains occurred in Clarkston, Michigan, in 2001 that the NTSB determined was due to “…crewmembers’ fatigue, which was primarily due to the engineer’s untreated and the conductor’s insufficiently treated obstructive sleep apnea.” (NTSB 2002) As a result, the NTSB issued the following safety recommendation to the FRA: R-02-24 Develop a standard medical examination form that includes questions regarding sleep problems and require that the form be used, pursuant to [Title] 49 Code of Federal Regulations Part 240, to determine the medical fitness of locomotive engineers; the form should also be available for use to determine the medical fitness of other employees in safety-sensitive positions. In 2006, partly in response to this recommendation, the FRA created a Medical Standards Working Group as part of the Railroad Safety Advisory Committee (RSAC). Although the FRA has mentioned the RSAC and its Medical Standards Working Group in responses to NTSB recommendations on a number of occasions, it was disbanded after 5 years for being unable to reach consensus.23 On March 10, 2016, the FRA and the Federal Motor Carrier Safety Administration jointly published an advance notice of proposed rulemaking in the Federal Register (FR) regarding obstructive sleep apnea. (FR 2016, 12642) However, the notice primarily poses questions and asks for public comments on the topic. It does not provide information regarding any proposed rules. Currently, no public action has been taken by the FRA to develop guidelines or require screening, diagnosis, or treatment of sleep disorders among railroad employees. Following the investigation of a head-on collision between two UP freight trains in Goodwell, Oklahoma, in June 2012, the NTSB determined the probable cause of the accident was, in part, due to the conductor’s lack of engagement and the engineer’s inability to see and interpret signals due to a chronic illness and deteriorating eyesight. (NTSB 2013) As a result of this, the NTSB reclassified Safety Recommendation R-02-24 to the FRA as Closed?Unacceptable Action and superseded it with the following safety recommendation: R-13-21 Develop medical certification regulations for employees in safety-sensitive positions that include, at a minimum, (1) a complete medical history that includes specific screening for sleep disorders, a review of current medications, and a thorough physical examination, (2) standardization of testing protocols across the industry, and (3) centralized oversight of certification decisions for employees who fail initial testing; and consider requiring that medical examinations be performed by those with specific training and certification in evaluating medication use and health issues related to occupational safety on railroads. The FRA reported it had already created a new RSAC working group, the Fatigue Management Working Group, to develop standards for a railroad’s fatigue management plan.24 The NTSB did not view this reply as responsive to this recommendation and has, therefore, classified Safety Recommendation R-13-21 Open—Unacceptable Response. Like the previous medical working group, the fatigue working group has been operating for years without any publicly available output regarding medical conditions and fatigue. In the investigation of the April 27, 2011, rear-end collision in Red Oak, Iowa, discussed earlier in this report, the NTSB determined the collision occurred due to “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.” Among other ailments, the medical conditions included probable sleep apnea, restless leg syndrome, and chronic insomnia. (NTSB 2012) As a result of that investigation, the NTSB made the following safety recommendation to the FRA. R-12-16 Require railroads to medically screen employees in safety-sensitive positions for sleep apnea and other sleep disorders. In response to Safety Recommendation R-12-16, the FRA cited the Rail Safety Improvement Act of 2008 (RSIA) which requires, under section 103, that certain railroads develop a risk-reduction program (RRP).25 Section 103(d)(2) of the RSIA requires a railroad to include a fatigue management plan in its RRP. As part of the development of fatigue management plans, railroads will be required to provide opportunities for the identification, diagnosis, and treatment of any medical condition that may affect alertness or fatigue, including sleep disorders. The FRA, in response to Safety Recommendation R-12-16, stated, “Currently, FRA, in conjunction with a working group of members from the Railroad Safety Advisory Committee (RSAC), is developing a fatigue management regulation that will be responsive to the requirements set forth in the RSIA.”26 The recommendation was classified Open—Acceptable Response by the NTSB in October 2012. However, RSIA specified that this be carried out within 4 years of its implementation, which would have been October 16, 2012. However, as of October 2016, such a regulation has not been promulgated. On May 25, 2013, a UP railroad freight train collided with a BNSF freight train in Chaffee, Missouri, resulting in a total derailment of 24 cars and 2 locomotives, as well as a postimpact diesel fire and severe damage to a highway overpass. The two UP train crewmembers were injured and five occupants of motor vehicles on the bridge were transported to local hospitals. The NTSB determined that the probable cause of the accident was: …the failure of the UP train crewmembers to comply with wayside signals leading into the Rockview Interlocking as a result of their disengagement from their task likely because of fatigue-induced performance degradation. Contributing to the accident was the lack of: (1) a positive train control system, (2) medical screening requirements for employees in safety-sensitive positions for sleep apnea and other sleep disorders, and (3) action by the FRA to fully implement the fatigue management components required by the RSIA. Likely contributing to the engineer’s fatigue was undiagnosed obstructive sleep apnea. Also contributing to the accident was inadequate crew resource management. As a result of this accident investigation, the NTSB changed the classification of Safety Recommendation R-12-16 that was issued to the FRA to Open?Unacceptable Response. (NTSB 2014) The NTSB concludes that the continued occurrence of railroad accidents attributed to fatigue caused by sleep apnea are due in part to the failure of the FRA since 2002 to respond to the hazards posed by undiagnosed or inadequately treated sleep apnea. Therefore, the NTSB reiterates Safety Recommendations R-12-16 and R-13-21.

From: NTSB
To: FRA
Date: 5/31/2016
Response: The National Transportation Safety Board (NTSB) has reviewed the Federal Motor Carrier Safety Administration (FMCSA)-Federal Railroad Administration (FRA) advance notice of proposed rulemaking (ANPRM) and request for public comments, “Evaluation of Safety Sensitive Personnel for Moderate-to-Severe Obstructive Sleep Apnea,” published in the Federal Register, vol. 81, no. 47 (12642), March 10, 2016. The notice requests data and information regarding screening, diagnosis, and treatment for obstructive sleep apnea (OSA) among surface transportation vehicle operators. The NTSB has found inadequately diagnosed and treated sleep disorders among operators involved in accidents in both the highway and rail modes since 2000. In the past 16 years, OSA has been included in the probable cause of eight highway and rail accidents investigated by the NTSB.1 We have made two safety recommendations to the FMCSA and three safety recommendations to the FRA on this topic.2 We are pleased that the ANPRM addresses the important issue of OSA among operators performing safety-critical tasks. Although we agree that “OSA is a critical safety issue that can affect operations in all modes of travel in the transportation industry,” we maintain that further rulemaking is necessary to adequately address the need to screen, diagnose, and treat OSA among transportation operators in safety-sensitive positions. Footnotes: 1 (a) Motorcoach Run-Off-the-Road and Collision With Vertical Highway Signpost, Interstate 95 Southbound, New York City, New York, March 21, 2011, NTSB/HAR-12/01 (Washington, DC: NTSB, 2012). (b) Truck-Tractor Semitrailer Rear-End Collision Into Passenger Vehicles on Interstate 44 Near Miami, Oklahoma, June 26, 2009, NTSB/HAR-10/02 (Washington, DC: NTSB, 2010). (c) Work Zone Collision Between a Tractor-Semitrailer and a Tennessee Highway Patrol Vehicle, Jackson, Tennessee, July 26, 2000, NTSB/HAR-02/01 (Washington, DC: NTSB, 2002). (d) Collision of Union Pacific Railroad Freight Train With BNSF Railway Freight Train Near Chaffee, Missouri, May 25, 2013, NTSB/RAR-14/02 (Washington, DC: NTSB, 2014). (e) Collision of BNSF Coal Train With the Rear End of Standing BNSF Maintenance-of-Way Equipment Train, Red Oak, Iowa, April 17, 2011, NTSB/RAR-12/02 (Washington, DC: NTSB, 2012). (f) Collision Between Two Massachusetts Bay Transportation Authority Green Line Trains, Newton, Massachusetts, May 28, 2008, NTSB/RAR-09/02 (Washington, DC: NTSB, 2009). (g) Collision of Two Canadian National/Illinois Central Railway Trains Near Clarkston, Michigan, November 15, 2001, NTSB/RAR-02/04 (Washington, DC: NTSB, 2002). (h) Maryland Transit Administration Light Rail Vehicle Accidents at the Baltimore-Washington International Airport Transit Station Near Baltimore, Maryland, February 13 and August 15, 2000, NTSB/SIR-01/02 (Washington, DC: NTSB, 2001). 2 See Safety Recommendations H-09-15 and -16 from the Jackson, Tennessee, investigation; and Safety Recommendations R-13-21 (from Head-On Collision of Two Union Pacific Railroad Freight Trains Near Goodwell, Oklahoma, June 24, 2012, NTSB/RAR-13/02 [Washington, DC: NTSB, 2013]), R-12-16 from the Red Oak, Iowa, investigation, and R-02-24 from the Clarkston, Michigan, investigation.

From: FRA
To: NTSB
Date: 3/23/2016
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.

From: NTSB
To: FRA
Date: 11/3/2015
Response: Reiterated in Railroad Accident Brief Locomotive Engineer Has Seizure While Operating Train in Arden, Nevada (RAB-15/07, DCA14FR010, 89861) published on November 3, 2015. The NTSB first highlighted the absence of comprehensive medical standards for train crewmembers more than 12years before this accident. As a result of NTSB safety recommendations following the head-on collision of two freight trains in Clarkston, Michigan, in 2001 (R-02-24 through R-02-26), the FRA created a Railroad Safety Advisory Committee (RSAC) working group on medical standards.21 When that group could not reach consensus after several years, it was disbanded and no changes were made to medical certification standards. The NTSB investigatedfour additional railroad accidents between 2011 and 2013 in which medical conditions caused or contributed to the accident.22 Despite these accidents and multiple additional recommendations from the NTSB, the FRA has taken no further action to address comprehensive medical evaluations. Following the Goodwell, Oklahoma, accident, where a key component of the probable cause was the predictable deterioration of the engineer’s eyesight as a result of a chronic condition, glaucoma, the NTSB issued the following safety recommendation to the FRA: (R-13-021) The recommendation is currently classified Open—Unacceptable Response. The NTSB concludes that if the FRA had implemented more comprehensive medical certification standards based on prior NTSB recommendations, UP would have been required to obtain and review the medications being used by the engineer in this accident. The NTSB therefore reiterates recommendation R-13-21 to the FRA.

From: NTSB
To: FRA
Date: 12/8/2014
Response: R-13-021 was reiterated in the report Collision of Union Pacific Railroad Freight Train with BNSF Railway Freight Train near Chaffee, Missouri on May 25, 2013. RAR-14-02, adopted November 17, 2014, notation 8507A, published December 8, 2014. Most recently, the NTSB investigated a head-on collision between two freight trains in Goodwell, Oklahoma, in 2012, which occurred as a result of the engineer’s inability to see and interpret wayside signals due to a chronic illness and deteriorating eyesight (NTSB 2013c). After that investigation, the NTSB classified the safety recommendation to the FRA from Clarkston (Safety Recommendation R-02-24, noted above), previously classified “Open—Acceptable Response,” as “Closed—Unacceptable Action/Superseded” by Safety Recommendation R-13-21 to the FRA on June 18, 2013. On February 24, 2014, the NTSB classified Safety Recommendation R-13-21 “Open?Unacceptable Response.” The NTSB therefore reiterates Safety Recommendation R-13-21.

From: NTSB
To: FRA
Date: 11/19/2014
Response: -From the Special Investigation Report Organizational Factors in Metro-North Railroad Accidents, NTSB/SIR-14-/04, adopted November 19, 2014: More recently, the NTSB investigated a head-on collision between two freight trains in Goodwell, Oklahoma, in June, 2012. The NTSB determined the collision was caused by the conductor’s lack of engagement and the engineer’s inability to see and interpret wayside signals due to a chronic illness and deteriorating eyesight (NTSB 2013). The NTSB reclassified R-02-24 Closed—Unacceptable Action and superseded it with Safety Recommendation R-13-21 to the FRA: Develop medical certification regulations for employees in safety-sensitive positions that include, at a minimum, (1) a complete medical history that includes specific screening for sleep disorders, a review of current medications, and a thorough physical examination, (2) standardization of testing protocols across the industry, and (3) centralized oversight of certification decisions for employees who fail initial testing; and consider requiring that medical examinations be performed by those with specific training and certification in evaluating medication use and health issues related to occupational safety on railroads. The FRA responded to the NTSB that it had already created a new RSAC working group, the Fatigue Management Plans Working Group, to develop standards for railroad fatigue management plans. However, like the previous medical standards working group, the fatigue management working group has not successfully produced a proposal for revised practices. FRA officials told NTSB investigators that they hope to publish a Fatigue Risk Management Program regulation in 2015. A regulation fatigue management plan is unlikely to address fitness-for-duty issues regarding medical conditions unrelated to fatigue. On February 24, 2014, the NTSB classified the recommendation Open?Unacceptable Response. In April 2011, a rear end collision occurred between a BNSF freight train and a maintenance-of-way equipment train near Red Oak, Iowa (NTSB 2012b). The NTSB determined the collision occurred due to: 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 the crew on the striking train had fallen asleep due to fatigue resulting from their irregular work schedules and their medical conditions. Among other issues, the medical findings included probable sleep apnea, restless leg syndrome, and chronic insomnia. The NTSB made two medical recommendations as a result of that investigation: that the BNSF Railway medically screen employees in safety-sensitive positions for sleep apnea and other sleep disorders (R-12-26), and that the FRA require railroads to medically screen employees in safety-sensitive positions for sleep apnea and other sleep disorders (R-12-16). The response to R-12-26 from BNSF Railroad included the following paragraph: 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. Essentially, BNSF told the NTSB that without related regulation, it is unable to comply with this recommendation. Safety Recommendation R-12-26 was therefore reclassified Open?Unacceptable Response. As discussed above, the NTSB is concerned the FRA is not making progress promulgating regulations requiring screening for OSA and other sleep disorders. Moreover, the NTSB is equally concerned some railroads may believe they are unable to adequately address the issue without FRA regulation. Further, the NTSB believes sleep disorders are part of a larger issue that the FRA is not addressing: medical fitness for duty. The NTSB recognizes the challenges organizations face with screening employees for sleep disorders or other medical conditions despite the fact that such screening, evaluation, and treatment will reduce the risk of catastrophic accidents and potentially improve the health and well-being of employees. The NTSB concludes that without evaluating safety-sensitive employees for sleep disorders or other medical conditions, increased risk to railroad employees, passengers, and the general public will remain, and the FRA has not adequately addressed the issue. Therefore, the NTSB recommends to the Association of American Railroads, the American Public Transportation Association, the American Short Line and Regional Railroad Association, the Brotherhood of Locomotive Engineers, and the International Association of Sheet Metal, Air, Rail and Transportation Workers collaborate to develop a model national labor agreement that supports effective programs for addressing sleep disorders and other medical conditions among safety-sensitive train operating personnel. In response to R-12-16, the FRA Administrator wrote to the NTSB citing the Rail Safety Improvement Act of 2008 (RSIA), which requires that certain railroads develop a Risk Reduction Program (RRP).61 Section 103(d)(2) of the RSIA (49 U.S.C. 20156) requires a railroad to include a Fatigue Management Plan in its RRP that meets the requirements of Subsection (f). 49 U.S.C. 20156(d)(2). As part of the development of Fatigue Management Plans, railroads will be required to provide opportunities for the identification, diagnosis, and treatment of any medical condition that may affect alertness or fatigue, including sleep disorders. The FRA Administrator went on to say, “Currently, FRA, in conjunction with a working group of members from the RSAC, is developing a fatigue management regulation that will be responsive to the requirements set forth in the RSIA.” The recommendation to the FRA was classified Open?Acceptable Response by the NTSB in October 2012. However, the RSIA specified a deadline of October 16, 2012, for this action and no action has yet been taken, nearly 2 years after the committed deadline. As a result, on November 17, 2014, NTSB reclassified Recommendation R-12-16 Open?Unacceptable Response. The NTSB concludes that had the FRA implemented NTSB recommendations R-02-24 and R-12-16, or complied with the legislated time limit in the RSIA to require fatigue management plans by railroads, Metro-North would have been required to appropriately screen, evaluate, and treat the engineer for obstructive sleep apnea prior to the December 1, 2013, derailment in The Bronx, and thus could have prevented the accident. Therefore, the NTSB reiterates R-12-16 and R-13-21.

From: NTSB
To: FRA
Date: 9/26/2014
Response: The National Transportation Safety Board (NTSB) has reviewed the Federal Railroad Administration’s (FRA) notice of proposed rulemaking (NPRM), “Control of Alcohol and Drug Use: Coverage of Maintenance of Way Employees, Retrospective Regulatory Review-Based Amendments (RRR)” published in the Federal Register July 28, 2014. We appreciate this opportunity to comment on the proposed rulemaking in response to Congress’ mandate in the Rail Safety Improvement Act of 2008 and are encouraged by the FRA addressing NTSB safety recommendations in these proposed fundamental revisions to this rule. This reliance on employees to manage medical conditions and medications without oversight has led to a number of fatal accidents including Secaucus, New Jersey, in 1996; head on collisions in Sugar Valley, Georgia, in 1990; Clarkston, Michigan, in 2001; and Goodwell, Oklahoma, in 2012; and a rear-end collision with a MOW equipment train in Red Oak, Iowa, in 2011. As a result, we issued a series of recommendations to the FRA, culminating most recently in R-13-021: Develop medical certification regulations for employees in safety sensitive positions that include, at a minimum, (1) a complete medical history that includes specific screening for sleep disorders, a review of current medications, and a thorough physical examination, (2) standardization of testing protocols across the industry, and (3) centralized oversight of certification decisions for employees who fail initial testing; and consider requiring that medical examinations be performed by those with specific training and certification in evaluating medication use and health issues related to occupational safety on railroads. This safety recommendation is currently classified “Open–Unacceptable.” The FRA does not propose any changes to this section; yet, we believe this section does not effectively address the safety concerns raised by individuals’ use of prescription and OTC drugs subject to Part 219. In addition, we believe the FRA, in its failure to address needed changes in this section, has missed a valuable opportunity to more fully speak to safety issues related to general health and medication effects in safety-sensitive railroad, including MOW, employees.

From: NTSB
To: FRA
Date: 2/24/2014
Response: 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.

From: FRA
To: NTSB
Date: 1/2/2014
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.