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Safety Recommendation Details

Safety Recommendation R-14-068
Details
Synopsis: 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.
Recommendation: TO THE METROPOLITAN TRANSPORTATION AUTHORITY: Develop an oversight and tracking process to ensure that the recommendations from the various investigations and reviews of Metro-North Railroad are coordinated, addressed, and resolved at all Metropolitan Transportation Authority properties.
Original recommendation transmittal letter: PDF
Overall Status: Open - Acceptable Response
Mode: Railroad
Location: United States
Is Reiterated: No
Is Hazmat: No
Is NPRM: No
Accident #: DCA14SS005
Accident Reports:
Report #: SIR-14-04
Accident Date: 4/2/2014
Issue Date: 11/24/2014
Date Closed:
Addressee(s) and Addressee Status: Metropolitan Transportation Authority New York City Transit (Open - Acceptable Response)
Keyword(s):

Safety Recommendation History
From: NTSB
To: Metropolitan Transportation Authority New York City Transit
Date: 11/8/2019
Response: On November 24, 2015, you told us that you had established a safety council to improve safety across your agencies and to monitor the progress of implementing third-party safety recommendations. We note that the council, comprised of safety leads from each of the MTA agencies, continues to meet on a regular basis to identify safety issues and trends and report them across all of your operating agencies. Establishment of the safety council is a positive step toward satisfying these recommendations. Please provide us with examples of the types of operational data the council has recently considered to identify safety issues and trends. We would also like to know what determinations the council has made regarding whether mitigations to address an identified issue on one of your properties was applicable to your other properties. Finally, please also describe the process the council uses to ensure that the recommendations from the investigations and reviews of MNR operations are coordinated, addressed, and resolved at all MTA properties. Pending our receipt and review of that information, Safety Recommendations R-14-66 through 68 remain classified OPEN--ACCEPTABLE RESPONSE.

From: Metropolitan Transportation Authority New York City Transit
To: NTSB
Date: 5/10/2018
Response: -From Joseph J. Lhota, Chairman: As an update, we continue to progress in the efforts mentioned previously in our November 24, 2015 letter to the NTSB. Our Safety Council comprised of safety leads from each of the MTA agencies continues to meet on a regular basis to identify any safety issues and/or trends and report them across all agencies, striving to identify and establish best practices. The Safety Council, along with MT A agency heads, meets in public session at least five times per year with the Safety Committee of the MTA Board to discuss trends and initiatives and obtain feedback from our highly engaged board members.

From: NTSB
To: Metropolitan Transportation Authority New York City Transit
Date: 5/18/2016
Response: We understand that, over the past 2 years, the MTA has established a Safety Committee and a Safety Council to improve safety across your agencies. We further understand that the Safety Council will monitor the progress of implementing third-party safety recommendations and will oversee the development of an authority-wide Safety Management System (SMS), including a systematic review of safety policies and practices among MTA agencies to ensure that you are sharing best safety practices. Although you did not discuss specific actions you plan to take to address each of the three recommendations, we believe that those actions you have initiated thus far, along with a fully implemented SMS, will address the issues. Accordingly, pending completion of all actions to satisfy Safety Recommendations R-14-66 through -68, the recommendations are classified OPEN—ACCEPTABLE RESPONSE.

From: Metropolitan Transportation Authority New York City Transit
To: NTSB
Date: 11/24/2015
Response: -From Thomas F. Prendergast, Chairman and Chief Executive Officer: As you know, last year I created the position of MTA Chief Safety Officer. The MTA's new Chief Safety Officer has been on the job reporting directly to me since December 1, 2014. He has convened and chartered a Safety Council. The charter for our new MT A Safety Council (copy enclosed) incorporates both the letter and spirit of the above three safety recommendations. The new council is hard at work monitoring progress of implementing third-party safety recommendations and overseeing the development of an authority-wide Safety Management System (SMS). This will include a systematic review of safety policies and practices among the MT A agencies to ensure that best safety practices are effectively shared across MTA agencies. The MTA board of directors established a Safety Committee in the spring on 2014. The Safety Committee held its first meeting in April2014, and has now met a total of nine times. The Safety Committee is providing oversight of a wide range of safety issues at all MT A agencies. By conducting board-level safety reviews, the MTA can identify other issues that would benefit from uniform treatment among all MT A properties. In summary, the work of the MTA Safety Council and the Safety Committee will enable the MTA to develop robust oversight and ensure continued self-improvement across the MTA agencies. To that end, we have embarked on a journey of safety excellence, which will include the development of an authority-wide SMS. I thank the NTSB for its consideration and request that these actions be considered acceptable to the above recommendations. If there is any additional information you need, we will be happy to provide it.