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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: Revise your medical protocols for employees in safety-sensitive positions to include specific protocols on sleep disorders, including obstructive sleep apnea.
Original recommendation transmittal letter:
Open - Acceptable Response
Addressee(s) and Addressee Status:
Metro North Railroad (Open - Acceptable Response)
Safety Recommendation History
Metro North Railroad
-From Joseph J. Lhota, Chairman: As you are aware, the MTA has developed a very aggressive program to identify sleep disorders that screens, tests, and treats employees as necessary. A pilot program that screened all of MNR' s locomotive engineers was the basis for the "steady state" program now in place. To support this effort and ensure consistency in the screening program, a nationally-recognized sleep specialist was consulted and provided a Continuing Medical Education workshop for our physicians and occupational health services staff, focusing on sleep disorders with an in-depth segment focused on Obstructive Sleep Apnea (OSA). This workshop is available on video for any of our staff that wishes to refresh or for new staff to ensure consistency. All locomotive engineers at the MTA Railroads as well as train and bus operators at MTA New York City Transit are now screened routinely for sleep disorders. In addition, the MTA is in the process of extending the program to other safety sensitive positions and also will be educating all of its employees about the importance of adequate sleep as part of a broader wellness initiative. Those employees whose screening results indicate that they are at risk for Obstructive Sleep Apnea (OSA) are referred for a diagnostic sleep study. Employees who are diagnosed with OSA are required to demonstrate adherence to prescribed therapy. We are pleased to report that our program has screened all of the locomotive engineers at MNR and the LIRR (with the exception of a very small number of engineers who are in a non-work status). Because of our successful revision to our protocols and implementation of a robust sleep disorder, screening, testing and treatment program, we request that, recommendations (R-14-062, R-14-064 and R-14-065) be classified as "Closed-Acceptable Action."
Metro North Railroad
We note that you planned to take the recommended action in the near future as of last June; please inform us of the current status of this project. Pending timely completion of this effort, Safety Recommendation R-14-62 is classified OPEN—ACCEPTABLE RESPONSE.
Metro North Railroad
-From Joe Giulietti, President: While developing the pilot program described below, Metro-North enhanced our medical history questionnaire to significantly improve our ability to identify those individuals with sleep disorders. We concur that with the need to revise our medical protocols to include specific protocols on sleep disorders, including obstructive sleep apnea, and we plan to undertake such an effort in the near future.
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