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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: Develop and implement a robust internal audit and oversight program, in coordination with your safety risk management process, to ensure that all employees and managers comply with your established safety procedures.
Original recommendation transmittal letter:
Open - Initial Response Received
Addressee(s) and Addressee Status:
Metro North Railroad (Open - Initial Response Received)
Safety Recommendation History
Metro North Railroad
-From Joseph J. Lhota, Chairman: All MNR departments participate in the audit effort as described in the newly-revised System Safety Program Plan (SSPP) with MNR's OSS providing oversight. OSS is responsible for auditing the SSPP, ensuring all departments implement the SSPP, and meet the requirements of the SSPP. To facilitate the audit, OSS Field Safety Managers (FSM) conduct facility, roadway worker, and station inspections as well as employee observations to identify and correct unsafe behaviors in all six MNR operating districts. All inspections require an inspection form to be completed. However, FSMs are not limited in their inspections to only the items on the inspection fonns. All safety issues found, regardless of whether they are identified as a category on the forms, are required to be fully described in the section provided. Tracking logs for each type of audit are maintained to manage identified deficiencies and ensure remediation. Departmental safety action plans, outlining operating department safety goals and strategies, are reviewed and audited by OSS annually to ensure plans are followed, any gaps are identified, and continuous improvement is achieved. MNR has developed a "Supervising for Safety" training program which provides supervisors with the tools needed to support the MNR System Safety Program Plan, foster a safe working environment, identify workplace hazards and promote a positive safety culture. The training covers the basic managerial and leadership skills to support MNR' s efforts toward accident investigation, corrective action implementation and continuously improving the safety environment for employees and customers. MNR has also implemented a training program in the first quarter of2017 to instruct the frontline supervisors, foremen and managers on incident investigation and reporting. The training focuses on completing key sections of MNR's Incident Reporting Forms IR1 and IR2, with an emphasis on identifying root causes, contributing factors, and corrective actions. Considering the above changes, we request that recommendations R-14-060 and R-14-061 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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