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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 THE LONG ISLAND RAILROAD: Develop and implement protocols to routinely screen and fully evaluate your safety-sensitive employees for sleep disorders and ensure that such disorders are adequately addressed, if diagnosed.
Original recommendation transmittal letter:
Open - Acceptable Response
Addressee(s) and Addressee Status:
Long Island Railroad (Open - Acceptable Response)
Safety Recommendation History
Long Island 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."
Long Island Railroad
We note that the LIRR requires all safety-sensitive employees to report their medical history prior to being hired, when changing positions, and upon returning to work after an absence of 60 days or more. We also note that the form used to collect this information contains three questions addressing (1) obstructive sleep apnea (OSA), (2) use of a Continuous Positive Airway Pressure machine, and (3) fatigue, and that you use an employee’s responses to these questions to determine whether any followup is needed. We understand that you are also participating in MTA Metro-North Railroad’s pilot program to establish a screening and monitoring process for the treatment of employees with OSA, to help you mitigate potential fatigue-related problems. Please keep us informed as you move forward with these efforts. In the meantime, pending completion of the recommended actions, Safety Recommendation R-14-65 is classified OPEN—ACCEPTABLE RESPONSE.
Long Island Railroad
-From Patrick A. Nowakowski, President: At the LIRR, all Safety-Sensitive employees as part of the hiring/job change process complete our Medical History Record form, which contains three questions related to sleep issues. These questions address apnea, use of a Continuous Positive Airway Pressure (CPAP) machine, and fatigue. We determine follow up based upon each employee's responses to these questions. Safety-Sensitive employees also complete this form upon return to work after an absence of sixty days or more. LIRR is also participating in MTA Metro-North Railroad's (Metro-North) pilot program to establish a screening and monitoring process for the treatment of employees with obstructive sleep apnea. Through our work with Metro-North we will develop a medical protocol related to sleep disorders. Metro-North awarded a vendor contract to screen an identified at-risk population for obstructive sleep apnea. The screening is to be followed by appropriate treatment. LIRR will utilize the information gathered from MNR's pilot to develop enhanced medical protocols to screen our employees who may be most susceptible to sleep disorders. The goal is to mitigate potential fatigue related problems for both federally-regulated "hours of service" employees as well as other employees in critical safety positions. We thank the National Transportation Safety Board for its consideration. If additional information is required, please contact me.
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