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During the time period between May 2013 and March 2014, the National Transportation Safety Board (NTSB) launched investigative teams to five significant accidents on the Metro-North Railroad (Metro-North): (1) the May 17, 2013, derailment and subsequent collision in Bridgeport, Connecticut; (2) the May 28, 2013, employee fatality in West Haven, Connecticut; (3) the July 18, 2013, CSX derailment on Metro-North tracks in The Bronx, New York; (4) the December 1, 2013, derailment in The Bronx, New York; and (5) the March 10, 2014, employee fatality in Manhattan, New York. In combination, these accidents resulted in 6 fatalities, 126 injuries and more than $28 million in damages. The continued safe operation of Metro-North is vital to New York City and the tri-state area of New York, New Jersey, and Connecticut. As the NTSB investigations progressed, it became apparent that several organizational factors issues were involved in the accidents. The November 2013 NTSB investigative hearing on the Bridgeport and West Haven accidents (the NTSB hearing) explored the role of Metro-North and the Federal Railroad Administration (FRA) organizational factors in these accidents. The NTSB was not alone in observing that organizational factors were relevant to the series of Metro-North accidents. Subsequent actions by the FRA, which conducted a focused audit, and the Metropolitan Transportation Authority (MTA), which formed a Blue Ribbon Panel (BRP) to review safety and created an MTA Board Safety Committee to monitor safety, have reinforced the need to examine both the role of Metro-North and FRA organizational factors in relation to these five accidents. This special investigation report discusses all five of the recent Metro-North accidents investigated by the NTSB, examines some of the common elements of these accidents, and addresses the steps that Metro-North, the MTA, and the FRA have taken as a result of these investigations. The report also highlights lessons learned and provides recommendations to Metro-North, MTA, and several other entities to improve railroad safety on Metro-North and elsewhere.
TO METRO-NORTH RAILROAD: Require, as part of your risk management program, that representatives from all your divisions and labor organizations (1) regularly review safety and operational data from all divisions to identify safety issues and trends and (2) share the results across divisions.
Original recommendation transmittal letter:
Closed - Acceptable Action
Addressee(s) and Addressee Status:
Metro North Railroad (Closed - Acceptable Action)
Safety Recommendation History
Metro North Railroad
We note that you have reorganized your Office of System Safety (OSS) and created a data analysis unit to collect and analyze operational data so as to identify and mitigate adverse safety trends. Further, we note that you hold monthly meetings in each of your six districts to review safety concerns and develop solutions, as well as weekly meetings with department heads to review selected incidents. Your senior vice president of operations also holds a biannual district review with operations staff to discuss safety issues. We note that, based on these various meetings to review data retrieved from the OSS, you identify trends so you can prioritize risks and make recommendations for reducing hazards. Finally, we note that you review incidents on a weekly basis with the MNR’s department heads, and during these reviews, you discuss root causes, contributing factors, and corrective actions. These actions satisfy Safety Recommendations R 14 57 and -58, which are classified CLOSED--ACCEPTABLE ACTION.
Metro North Railroad
-From Joseph J. Lhota, Chairman: MNR has reorganized its Office of System Safety (OSS) and has fully implemented a data analysis unit to collect and analyze operational data to identify and mitigate adverse safety trends. The data unit is comprised of the following job titles: Deputy Director of Safety Analytics & Initiatives (Federal Reporting Officer), Manager of Analysis & Reporting, System Safety Analysts (2), Safety Education Program Coordinator, Manager of Administration, and a Chief Clerk. MNR's OSS issues a monthly safety performance report to all departments. The data are provided for MNR and broken down for individual districts and departments. The data are summarized to help identify trends that may be used to prioritize risk and make recommendations for reducing hazards. The report includes an operational data summary of major incidents such as trespasser strikes, grade crossing incidents, and derailments. Additionally, monthly, local, and district safety committee meetings are held in each of the six MNR districts to review safety concerns and develop solutions with the involvement of all stakeholders. Selected incidents are reviewed on a weekly basis with MNR's department heads and root causes, contributing factors, and corrective actions are discussed, to promote knowledge transfer to all levels of the organization. Also, MNR' s Senior Vice President of Operations holds a bi-annual district review with operations to discuss systemic trends and safety issues. And finally, in January 2018, MNR implemented a new safety data analysis system (Cority EHSQ Software), which is a centralized, state-of-the-art data repository and reporting. system for all MNR safety data. Considering the safety improvements described above, we request that recommendations R-14-057 and R-14-058 be classified as "Closed-Acceptable Action."
Metro North Railroad
To date, we have received no information from you on the status of action either taken or planned to implement Safety Recommendation R-14-57, -58, -60 or -61. Accordingly, these recommendations remain classified OPEN--AWAIT RESPONSE.
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