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Safety Recommendation Details

Safety Recommendation R-16-044
Details
Synopsis: On August 17, 2014, at 2:28 a.m. central daylight time, southbound Union Pacific Railroad (UP) freight train IMASNL-16 (southbound train) collided with northbound UP freight train IQNLPI-17 (northbound train) at milepost 228.6, while traversing the turnout at control point Y 229 on the UP Hoxie subdivision in Hoxie, Arkansas. Going north, the track in the area transitions from a single main track into two main tracks. As a result of the collision, the engineer and the conductor from the southbound train died, and the engineer and the conductor from the northbound train were seriously injured. The southbound train consisted of 2 locomotives and 86 cars; the northbound train consisted of 2 locomotives and 92 cars. The locomotives from both trains derailed and the second locomotive from the northbound train released diesel fuel, resulting in a fire. A total of 55 cars derailed, 41 cars from the southbound train and 14 cars from the northbound train. About 500 people within a 1.5-mile radius of the derailment were evacuated as a precaution. One tank car loaded with alcohol for human consumption breached and burned. The product posed no environmental hazard and emergency responders allowed the product to burn out. Damage was estimated by UP to be $10.7 million. The safety issues covered in this report include: fatigue and employee work schedules, medical issues, UP medical rules, automated systems that reset alertness devices, and positive train control. As a result of the investigation of this accident, the National Transportation Safety Board makes new safety recommendations to the Federal Railroad Administration; BNSF Railway, Canadian National Railway, Canadian Pacific Railway, CSX Transportation, Kansas City Southern Railway, Intercity Railroads, and Commuter Railroads; Class I Railroads; and Union Pacific Railroad. Further, the National Transportation Safety Board reiterates two recommendations to the Federal Railroad Administration.
Recommendation: TO THE FEDERAL RAILROAD ADMINISTRATION: Develop and enforce medical standards that railroad employees in safety-sensitive positions diagnosed with sleep disorders must meet to be considered fit for duty.
Original recommendation transmittal letter: PDF
Overall Status: Open - Unacceptable Response
Mode: Railroad
Location: Hoxie, AR, United States
Is Reiterated: Yes
Is Hazmat: No
Is NPRM: No
Accident #: DCA14FR011
Accident Reports: Railroad Accident Report: Collision of Two Union Pacific Railroad Freight Trains
Report #: RAR-16-03
Accident Date: 8/17/2014
Issue Date: 1/24/2017
Date Closed:
Addressee(s) and Addressee Status: FRA (Open - Unacceptable Response)
Keyword(s):

Safety Recommendation History
From: FRA
To: NTSB
Date: 6/28/2018
Response: -From Ronald L. Batory, Administrator: Please see the above response to Safety Recommendation R-12-16. FRA has no plans to pursue a separate rulemaking on medical standards for safety-sensitive employees diagnosed with sleep disorders. FRA believes its safety programs already in place and planned rulemaking addressing fatigue risk management are more appropriate measures for addressing the NTSB 's concern. Therefore, FRA respectfully requests that NTSB close Safety Recommendation R-16-44. I appreciate your interest in these important safety issues.

From: FRA
To: NTSB
Date: 2/26/2018
Response: -From Karl Alexy, Director, Office of Safety Analysis: Thank you for the report, End-of-Track Collisions at Terminal Stations, Hoboken, New Jersey, September 29, 2016, and Atlantic Terminal, Brooklyn, New York, January 4, 2017, which was sent to the Federal Railroad Administration (FRA) on February 14, 2018. In the "Safety Recommendations" section of the report, the National Safety Transportation Board (NTSB) issued Safety Recommendations R-18-01 and R-18-02 to FRA, as well as reiterated Safety Recommendations R-12-16 and R-16-44 to FRA. Improving safety is FRA's top priority, and we will continue to work to make rail shipments as safe as possible. We are committed to working with NTSB to prevent future accidents and save lives. FRA welcomes and will consider all recommendations that will further that goal.

From: NTSB
To: FRA
Date: 2/14/2018
Response: From the NTSB Railroad Special Investigation Report “End-of-Track Collisions at Terminal Stations Hoboken, New Jersey, September 29, 2016 and Atlantic Terminal, Brooklyn, New York, January 4, 2017” Report number SIR-18-01. Adopted on February 6, 2018 and published on February 14, 2018. The NTSB specifically addressed safety concerns resulting from sleep disorders in the investigation of the collision of two BNSF Railway (BNSF) trains in Red Oak, Iowa, on April 17, 2011. The accident occurred because the engineer and conductor had fallen asleep due to fatigue resulting from their irregular work schedules and their medical conditions. Those medical conditions were likely undiagnosed and untreated OSA. The NTSB made the following recommendation to the FRA: R-12-16 Require railroads to medically screen employees in safety-sensitive positions for sleep apnea and other sleep disorders (NTSB 2012a). The FRA responded on July 31, 2012, and stated that the RSIA requires that railroads develop a risk reduction program (RRP) that must contain a fatigue management plan. The FRA said that this action would address sleep disorders when implemented. In 2012, FRA said that they were also developing a fatigue management regulation responsive to the requirements set forth in until the FRA develops regulations directly addressing OSA screening and treatment. Safety Recommendation R-12-16 was reiterated to the FRA twice in 2014, in response to the investigations of two accidents: the collision of a Union Pacific Railroad (UP) train and a BNSF train near Chaffee, Missouri, on May 25, 2013, and a Metro-North derailment in Bronx, New York, on December 1, 2013 (NTSB 2014a; 2014b). On March 10, 2016, FRA, along with the Federal Motor Carrier Safety Administration (FMCSA), published an advance notice of proposed rulemaking (ANPRM) requesting data concerning the prevalence of moderate-to-severe OSA in individuals occupying safety-sensitive positions in rail transportation and the potential consequences for rail safety. The intent was to gather the data necessary to prepare a rulemaking that would develop regulations for sleep disorder screening. In its March 23, 2016, response regarding the reiteration of Safety Recommendation R-12-16, the FRA mentioned the ANPRM and concluded with the following proposal, “Once FRA has fully considered how to address obstructive sleep apnea, FRA will next consider strategies to address other medical conditions that are also contributing causes to accidents.” As a result of the investigation into the August 17, 2014, collision of two UP freight trains in Hoxie, Arkansas, the NTSB reiterated Safety Recommendation R-12-16, and issued a new safety recommendation to ensure that employees diagnosed with sleep disorders were fit for duty: R-16-044 Develop and enforce medical standards that railroad employees in safety-sensitive positions diagnosed with sleep disorders must meet to be considered fit for duty (NTSB 2016b). On February 16, 2017, the FRA responded to both Safety Recommendations R-12-16 and R-16-044 and said, “FRA is working to respond to the recommendations in NTSB’s letter and will respond as soon as possible.” FRA provided a second response on March 30, 2017, and said it was “actively working to achieve the intent of the recommendation.” The FRA added: FRA is currently developing a regulation, consistent with input from an RSAC working group, responsive to the RSIA’s FMP requirements. FRA, with the Volpe Center, fatigue researchers, and medical professionals, developed the Railroaders’ Guide to Healthy Sleep (RGHS) website at www.railroadersleep.org, as an educational resource. ?Unacceptable Action. However, on August 8, 2017, the FRA and FMCSA announced that they were withdrawing the 2016 ANPRM and would not continue developing a regulation to address sleep disorders by safety-sensitive railroad employees (Federal Register 2017e). This is particularly disappointing because the NTSB has recommended improvements to the medical screening and fitness-for-duty standards for railroad employees in reports since the investigation of the 2001 Clarkston, Michigan, accident. After 16 years, the railroad industry is still under no obligation to screen employees for sleep disorders. The NTSB concludes that the unwillingness of the FRA to address the issue of employee fatigue due to OSA and other sleep disorders, most recently evidenced by the August 2017 withdrawal of the ANPRM, jeopardizes public safety. In both of these accidents, the engineers were later diagnosed with severe OSA. The NTSB concludes that these accidents demonstrate the need for effective screening programs to reduce the risk of safety-sensitive employees with OSA operating trains. The NTSB further concludes that since the FRA did not implement Safety Recommendation R-12-16 or comply with the legislated time limit in the RSIA to require railroads to develop and implement fatigue management plans, NJT and LIRR were not required to have a screening and treatment program for OSA. Therefore, NTSB reiterates safety recommendations R-12-16 and R-16-044.

From: NTSB
To: FRA
Date: 1/18/2018
Response: We note that you issued a joint ANPRM requesting data and information on the prevalence and consequences of moderate-to-severe obstructive sleep apnea among individuals in safety-sensitive positions in highway and rail transportation, yet neither you nor the Federal Motor Carrier Safety Administration have published any relevant medical literature addressing sleep apnea, nor have any medical standards been issued to railroad medical professionals to address sleep disorders for employees in safety-sensitive positions. You have, however, recently withdrawn your ANPRM for sleep apnea, as mentioned above. We continue to believe medical standards must be developed and enforced for railroad employees who have been diagnosed with sleep disorders. Pending that action, Safety Recommendation R-16-44 is classified OPEN--UNACCEPTABLE RESPONSE.

From: FRA
To: NTSB
Date: 3/30/2017
Response: -From Patrick T. Warren, Executive Director performing the duties of the Administrator: Thank you for your January 24, 2017, letter to the Federal Railroad Administration (FRA) regarding the National Transportation Safety Board's (NTSB) Safety Recommendations R-16-043 and R-16-044, as well as the reiterations of Safety Recommendations R-13-21 and R-12-16. FRA understands NTSB issued these recommendations as a result of its investigation of an August 17, 2014, accident, in which two Union Pacific Railroad (UP) freight trains collided at the UP Hoxie subdivision in Hoxie, AR. The enclosure responds to Safety Recommendations R-16-043 and R-16-044, and explains FRA's position on these recommendations as well as Safety Recommendations R-13-21 and R-12-16. FRA is actively working to achieve the intent of these recommendations and offer the attached description of action to inform you of our progress. On March 10, 2016, FRA and the Federal Motor Carrier Safety Administration (FMCSA), issued a joint Advanced Notice of Proposed Rulemaking (ANPRM) requesting data and information on the prevalence of moderate-to-severe obstructive sleep apnea (OSA) among individuals occupying safety-sensitive positions in highway and rail transportation, and its potential consequences for the safety of rail and highway transportation. The ANPRM also requested information on potential costs and benefits from regulatory actions that address the safety risks associated with motor carrier and rail transportation workers in safety sensitive positions who have OSA. In addition, FRA and FMCSA held three listening sessions in May 2016 to solicit feedback from the public regarding OSA and any possible regulatory actions. The listening sessions provided interested parties the opportunity to share their views and any data or analysis on this topic with FRA and FMCSA representatives. The meetings were webcast, and all comments were transcribed and placed in the docket. FRA is reviewing the comments received from the ANPRM and listening sessions to determine next steps given the input from rail industry, rail labor organizations, researchers, other stakeholders, and the public. FRA is preparing to release a Broad Agency Announcement (BAA) for spring 2017, to solicit research ideas on best practices for screening safety sensitive employees for OSA. FRA will use this research to inform future efforts in the identification and treatment of OSA in railroad employees in safety sensitive positions.

From: FRA
To: NTSB
Date: 2/16/2017
Response: -From Karl Alexy, Director, Office of Safety Analysis: Thank you for your January 24, 2017, letter to the Federal Railroad Administration (FRA) regarding the National Transportation Safety Board's (NTSB) new recommendations R-16-043, R-16-044, and reiterated recommendations R-13-21, and R-12-16, in response to the August 17, 2014, Union Pacific Railroad accident in Hoxie, AR. FRA is working to respond to the recommendations in NTSB' s letter and will respond as soon as possible. Improving safety is FRA's top priority and FRA will continue to work to make rail travel as safe as possible. FRA is committed to working with NTSB to prevent future accidents and save lives. FRA welcomes and will consider all recommendations that will further that goal.

From: NTSB
To: FRA
Date: 1/24/2017
Response: On December 19, 2016, the National Transportation Safety Board (NTSB) adopted its report concerning the August 17, 2014, accident, in which two Union Pacific Railroad (UP) freight trains collided on the UP Hoxie subdivision in Hoxie, Arkansas.1 Additional information about this accident and the resulting recommendations may be found in the report of the investigation, which can be accessed at our website, http://www.ntsb.gov, under report number RAR-16/03. As a result of this investigation, we reiterated Safety Recommendations R-13-21 and R-12-16; and issued five new recommendations, including one to BNSF Railway, Canadian National Railway, Canadian Pacific Railway, CSX Transportation, Kansas City Southern Railway, Norfolk Southern Railway, Intercity Railroads, and Commuter Railroads; one to the Class I Railroads; one to Union Pacific Railroad; and the following two recommendations to the Federal Railroad Administration (FRA).