Skip Ribbon Commands
Skip to main content
Safety Recommendation Details

Safety Recommendation R-16-045
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 BNSF RAILWAY, CANADIAN NATIONAL RAILWAY, CANADIAN PACIFIC RAILWAY, CSX TRANSPORTATION, KANSAS CITY SOUTHERN RAILWAY, NORFOLK SOUTHERN RAILWAY, INTERCITY RAILROADS, AND COMMUTER RAILROADS: Review and revise as necessary your medical rules, standards, or protocols to ensure you are informed of any diagnosed sleep disorders that employees in safety-sensitive positions must report and, when an employee makes such a report, perform periodic evaluations to ensure the condition is appropriately treated and the employee is fit for duty.
Original recommendation transmittal letter: PDF
Overall Status: Open - Await Response
Mode: Railroad
Location: Hoxie, AR, United States
Is Reiterated: No
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: Alaska Railroad Corporation (Open - Unacceptable Response)
Altamont Corridor Express (Open - Await Response)
Amtrak (National Railroad Passenger Corporation) (Open - Await Response)
BNSF Railway Company (formerly Burlington Northern and Santa Fe Railway Company) (Open - Unacceptable Response)
Canadian National Railway (Open - Await Response)
Canadian Pacific Railway (Open - Await Response)
Capital Metropolitan Transportation Authority (Open - Await Response)
Capitol Corridor Joint Powers Authority (Open - Await Response)
Central Puget Sound Regional Transit Authority (Open - Await Response)
CSX Transportation, Inc. (Open - Await Response)
Denver Regional Transportation District (Open - Await Response)
Kansas City Southern Railway Company (Open - Await Response)
Long Island Railroad (Open - Initial Response Received)
Massachusetts Bay Transportation Authority (Open - Initial Response Received)
Metra (Northeast Illinois Regional Railroad Corporation) (Open - Await Response)
Metro North Railroad (Open - Initial Response Received)
Nashville Metropolitan Transit Authority (Open - Await Response)
New Jersey Transit Corporation (Open - Await Response)
Norfolk Southern Corporation (Closed - Exceeds Recommended Action)
Peninsula Corridor Joint Powers Board (Open - Await Response)
Port Authority of New York and New Jersey (Open - Await Response)
Portland and Western Railroad (Open - Await Response)
Saratoga and North Creek Railway (Open - Await Response)
Sonoma-Marin Area Rail Transit Authority (Open - Await Response)
South Florida Regional Transportation Authority (Open - Await Response)
Southeastern Pennsylvania Transportation Authority (Closed - Acceptable Action)
Southern California Regional Rail Authority (Open - Await Response)
State of California, County of North, North County Transit District (Closed - Acceptable Action)
State of Connecticut, Department of Transportation (Open - Await Response)
State of Indiana, Northern Indiana Commuter Transportation District (Open - Await Response)
State of Maryland, Transit Administration (Open - Await Response)
State of Minnesota, Metro Transit (Open - Await Response)
State of New Mexico, Department of Transportation, Rail Runner Express (Open - Await Response)
State of Texas, County of Denton, Transportation Authority (Open - Await Response)
State of Utah, Utah Transit Authority (Closed - Acceptable Action)
SunRail (formerly Central Florida Commuter Rail) (Open - Await Response)
Tri-County Metro Transit District of Oregon (Open - Await Response)
Trinity Railway Express (Open - Await Response)
Virginia Railway Express (Open - Unacceptable Response)
Keyword(s):

Safety Recommendation History
From: NTSB
To: Alaska Railroad Corporation
Date: 8/1/2017
Response: Mr. Engebretson’s e-mail included a copy of ARRC Operating Circular (OC) No. 38, “Fatigue and Sleep Disorders—FRA [Federal Railroad Administration] Safety Advisory 2016 03,” which informs employees about the issues discussed in Safety Recommendation R 16 45. As the title suggests, OC 38 was developed in response to FRA Safety Advisory 2016-03 and contains information for ARRC employees on recognizing fatigue and sleep disorders. The OC also lets employees know that the cost of sleep disorder diagnosis and treatment is covered by your company’s medical insurance provider. This action to train and inform your employees about the risks to railroad safety posed by fatigue and sleep disorders is commendable and part of a robust overall fatigue management plan; however, OC 38 does not address the issue in Safety Recommendation R-16-45, which is the need for you to require your employees in safety-sensitive positions to inform you when they are diagnosed with any sleep disorder, and, when an employee reports a sleep disorder diagnosis, the need for you to perform periodic evaluations to ensure the condition is appropriately treated and the employee is fit for duty. Please inform us of the policies and procedures that you have in place to address this recommendation. Pending completion of the recommended action, Safety Recommendation R 16-45 is classified OPEN--UNACCCEPTABLE RESPONSE.

From: Alaska Railroad Corporation
To: NTSB
Date: 6/9/2017
Response: -From Doug Engebretson, Chief Operating Officer: Fatigue and Sleep Disorders—FRA Safety Advisory 2016-03 1. On December 5, 2016, the FRA issued Safety Advisory 2016-03, stressing to railroads the importance of taking actions to help mitigate human factor accidents, particularly with regard to various sleep disorders. The Safety Advisory is available here: https://www.federalregister.gov/documents/2016/12/05/2016-29013/mitigation-and-investigation-of-passenger-rail-human-factor-relatedaccidents-and-operations-in. This Operating Circular is the ARRC’s response to Safety Advisory 2016-03. 2. Sleep disorders range from fairly common disorders such as insomnia, to rare diseases such as narcolepsy (inappropriate and unnecessary sleep episodes). Railroad workers, particularly those who work an on-call extra board, can be especially vulnerable to circadian rhythm disorders, such as shift work sleep disorders. 3. One of the more common sleep disorders is obstructive sleep apnea (OSA), which is a respiratory disorder characterized by a reduction or cessation of breathing during sleep. Males are twice as likely to have sleep apnea as women. Women increase their risk when overweight. Risk factors for developing OSA include: obesity, advancing age, family history of OSA, large neck size, and an anatomically small throat. 4. The FRA has published an advance notice that it intends to issue regulations addressing the dangers of sleep disorders for railroad employees holding safety sensitive positions. In the meantime, it is important that you educate yourselves about the signs, symptoms, and effects of sleep disorders on your railroad duties. The website “Railroaders’ Guide to Healthy Sleep” contains links to many helpful resources that can help you and your families learn about sleep disorders and their effect on your work and health. There is also an anonymous tool for self-screening for sleep disorders, including OSA. The Guide may be found at www.railroadersleep.org. 5. Your ARRC health benefits can also help with the cost of screening, diagnosis, and treatment of sleep disorders. For further information about your health plan coverage and any questions you might have, call Premera Customer Service at 800-508-4722. 6. Should you believe that you are adversely affected by any sleep disorder that could incapacitate or otherwise seriously impair the performance of your safety-sensitive duties, you are strongly encouraged to seek medical attention.

From: NTSB
To: Alaska Railroad Corporation
Date: 1/23/2017
Response: On December 19, 2016, we adopted our 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 to the Federal Railroad Administration (FRA); and issued five new recommendations, including two to the FRA, one to UP, one to the Class I Railroads, and the following recommendation to BNSF Railway, Canadian National Railway, Canadian Pacific Railway, CSX Transportation, Kansas City Southern Railway, Norfolk Southern Railway Company, Intercity Railroads, and Commuter Railroads, including Alaska Railroad Corporation.

From: NTSB
To: Altamont Corridor Express
Date: 1/24/2017
Response: On December 19, 2016, we adopted our 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 to the Federal Railroad Administration (FRA); and issued five new recommendations, including two to the FRA, one to UP, one to the Class I Railroads, and the following recommendation to BNSF Railway, Canadian National Railway, Canadian Pacific Railway, CSX Transportation, Kansas City Southern Railway, Norfolk Southern Railway Company, Intercity Railroads, and Commuter Railroads, including Alaska Railroad Corporation.

From: NTSB
To: Amtrak (National Railroad Passenger Corporation)
Date: 1/24/2017
Response: On December 19, 2016, we adopted our 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 to the Federal Railroad Administration (FRA); and issued five new recommendations, including two to the FRA, one to UP, one to the Class I Railroads, and the following recommendation to BNSF Railway, Canadian National Railway, Canadian Pacific Railway, CSX Transportation, Kansas City Southern Railway, Norfolk Southern Railway Company, Intercity Railroads, and Commuter Railroads, including Alaska Railroad Corporation.

From: NTSB
To: BNSF Railway Company (formerly Burlington Northern and Santa Fe Railway Company)
Date: 6/10/2019
Response: We note that you offer voluntary screening for obstructive sleep apnea (OSA) and other sleep disorders during health and wellness events, and that, for every employee in a safety-related position, you offer training on OSA that includes a voluntary OSA screening and sleep disorder questionnaire. We understand that employees who have elevated scores on this questionnaire are alerted that they may have a particular sleep disorder and are encouraged to seek further medical evaluation and treatment from their physicians. Although we believe educating employees on the dangers of OSA and other sleep disorders is important, doing so does not ensure diagnosis or treatment. In addition, as seen in the Hoxie accident, primary care doctors cannot be relied upon to ensure adequate treatment for railroad employees even when a diagnosis has been made. We note that the only formal OSA screening you conduct is prior to employment; therefore, numerous railroad employees that have been with BNSF for decades are exempt from screening as they age and their risk of developing a sleep disorder increases. Further, although you ensure adequate treatment for employees with sleep disorders who come to the attention of your medical and environmental health department, you have no information regarding treatment for those who did not have the disorder at the time you first employed them and who have not accumulated enough time off work to warrant a return-to-work evaluation. We believe that occupational medical oversight is necessary to ensure rail employees in safety-sensitive positions are adequately screened, diagnosed, and treated for sleep disorders. Therefore, until you revise your medical standards to properly screen for, diagnose, and treat sleep disorders in current employees in safety sensitive positions, Safety Recommendation R-16-45 is classified OPEN--UNACCEPTABLE RESPONSE.

From: BNSF Railway Company (formerly Burlington Northern and Santa Fe Railway Company)
To: NTSB
Date: 4/3/2018
Response: -From Ryan E. Ringelman, General Director System Safety: BNSF directly addresses medical conditions in its employee safety rules, BNSF Employee Safety Rule 1.2.11 - Medical Conditions (attachment A). The guiding principle of this rule is that employees are responsible for addressing personal medical conditions. This approach is respectful of employee privacy, but also reflects the reality that across a workforce of 40,000 employees, the employee and their personal physicians, medical professionals and healthcare providers are best positioned to identify and manage the employee's whole health and wellness. BNSF's rule, creates a clear requirement for the employee to ale11 their medical providers to job duties, and to actively engage the provider to ensure that the plan of treatment does not endanger the employee's ability to work safely. This rule applies to any medical condition that may endanger the employee's ability to work safely, including sleep disorders. In addition to the rule, BNSF supports employee safety with several programmatic approaches (consistent with responses in #DCA11FR002, Red Oak, Iowa) for identifying and mitigating employee medical conditions, including sleep disorders specifically. BNSF's medical screening for sleep disorders status in the pre-employment process. For the last 15 years, as part of its post-offer, pre-employment medical evaluation, BNSF has screened applicants in safety sensitive positions for potential risk of sleep disorders. This assessment identifies candidates at high risk for obstructive sleep apnea ("OSA"), who would then be required to take a formal sleep study for further evaluation. Candidates diagnosed with severe OSA are then required to demonstrate compliance with continuous positive airway pressure ("CPAP") therapy as prescribed by their treating provider. After initial employment (incorporating and reaffirming herein below, BNSF's responses provided to NTSB in accident docket #DCA11FR002), BNSF takes a programmatic approach to identify and mitigate sleep disorders as diagnosed in employees, including OSA, in its workplace. Since 2013, BNSF provides employees enhanced training on sleep disorders, including OSA through its annual training and certification programs. Beyond the formal training cycle requirement, this training program, as well as other web-based sleep resources, are always available to BNSF employees through BNSF's intranet. This training includes a screening questionnaire which employees may use to dete1mine their risk for sleep disorders. The employee can also use this questionnaire to increase their awareness on potential sleep concerns and to, confidentially, identify if additional follow-up or discussion with their medical professional is warranted (a copy of the latest version of that training was provided as an attachment to BNSF's Red Oak updated response letter dated February 9, 2018 ("February Letter"), as attachment A). To further support an employee's safety through medical wellness, throughout the year BNSF provides numerous opportunities for all employees to receive annual preventative health screenings, at no cost to the employee. These health screenings include assessments of heart rate, blood pressure, body mass index ("BMI"), neck circumference as well as providing an opportunity for a one-on-one discussion with a medical provider about potential risk factors or health concerns. As part of this annual employee health program, employees are also specifically provided an assessment/screening for OSA sleep disorders (February Letter, attachment B). And, the annual screening includes an opportunity for the employee to have a one-on-one discussion with on-site medical professionals. These professionals review the screening information and discuss areas of medical risk, concerning factors or potential concerns, including recommendations for additional follow-up screenings or studies as warranted. Lastly, BNSF has a medical return-to-work program for additional oversight in the event medical conditions are identified or an employee misses work due to a medical condition. If the identified medical condition may adversely affect the employee's ability to work safely, the Medical and Environmental Health Department ("MEH") may review the employee's medical fitness prior to the employee returning to work. If a sleep disorder is diagnosed or otherwise identified in an employee, the BNSF MEH team will provide medical oversight and conduct additional follow-up assessments as warranted. This follow-up includes employee monitoring to ensure compliance with the medically recommended treatment plan. BNSF's MEH uses the Medical Status Form: Sleep Disorders Review (February Letter, attachment D) to obtain a more robust assessment of the employee's condition and plan for medical treatment and as a vehicle to engage the employee's treating provider. As that provider is best positioned to assess the complete wellness of the employee, the provider is required to provide a signed confirmation, to ensure the employee is both compliant with the provider's plan of treatment and, most importantly, is able to safely perform required job duties, without medical restriction. MEH' s follow up will generally continue for a period of at least a year, so long as the employee maintains compliance with the medical treatment plan. Given BNSF's existing medical conditions rule, the extensive ongoing efforts both preemployment and post, including training, screening, health checks and the return to work process and monitoring of identified conditions as stated above, BNSF respectfully requests that this recommendation be classified as "Closed - Acceptable Alternate Response".

From: NTSB
To: BNSF Railway Company (formerly Burlington Northern and Santa Fe Railway Company)
Date: 1/24/2017
Response: On December 19, 2016, we adopted our 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 to the Federal Railroad Administration (FRA); and issued five new recommendations, including two to the FRA, one to UP, one to the Class I Railroads, and the following recommendation to BNSF Railway, Canadian National Railway, Canadian Pacific Railway, CSX Transportation, Kansas City Southern Railway, Norfolk Southern Railway Company, Intercity Railroads, and Commuter Railroads, including Alaska Railroad Corporation.

From: NTSB
To: Canadian National Railway
Date: 1/24/2017
Response: On December 19, 2016, we adopted our 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 to the Federal Railroad Administration (FRA); and issued five new recommendations, including two to the FRA, one to UP, one to the Class I Railroads, and the following recommendation to BNSF Railway, Canadian National Railway, Canadian Pacific Railway, CSX Transportation, Kansas City Southern Railway, Norfolk Southern Railway Company, Intercity Railroads, and Commuter Railroads, including Alaska Railroad Corporation.

From: NTSB
To: Canadian Pacific Railway
Date: 1/24/2017
Response: On December 19, 2016, we adopted our 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 to the Federal Railroad Administration (FRA); and issued five new recommendations, including two to the FRA, one to UP, one to the Class I Railroads, and the following recommendation to BNSF Railway, Canadian National Railway, Canadian Pacific Railway, CSX Transportation, Kansas City Southern Railway, Norfolk Southern Railway Company, Intercity Railroads, and Commuter Railroads, including Alaska Railroad Corporation.

From: NTSB
To: Capitol Corridor Joint Powers Authority
Date: 1/24/2017
Response: On December 19, 2016, we adopted our 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 to the Federal Railroad Administration (FRA); and issued five new recommendations, including two to the FRA, one to UP, one to the Class I Railroads, and the following recommendation to BNSF Railway, Canadian National Railway, Canadian Pacific Railway, CSX Transportation, Kansas City Southern Railway, Norfolk Southern Railway Company, Intercity Railroads, and Commuter Railroads, including Alaska Railroad Corporation.

From: NTSB
To: Capital Metropolitan Transportation Authority
Date: 1/24/2017
Response: On December 19, 2016, we adopted our 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 to the Federal Railroad Administration (FRA); and issued five new recommendations, including two to the FRA, one to UP, one to the Class I Railroads, and the following recommendation to BNSF Railway, Canadian National Railway, Canadian Pacific Railway, CSX Transportation, Kansas City Southern Railway, Norfolk Southern Railway Company, Intercity Railroads, and Commuter Railroads, including Alaska Railroad Corporation.

From: NTSB
To: Central Puget Sound Regional Transit Authority
Date: 1/24/2017
Response: On December 19, 2016, we adopted our 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 to the Federal Railroad Administration (FRA); and issued five new recommendations, including two to the FRA, one to UP, one to the Class I Railroads, and the following recommendation to BNSF Railway, Canadian National Railway, Canadian Pacific Railway, CSX Transportation, Kansas City Southern Railway, Norfolk Southern Railway Company, Intercity Railroads, and Commuter Railroads, including Alaska Railroad Corporation.

From: NTSB
To: State of Connecticut, Department of Transportation
Date: 1/24/2017
Response: On December 19, 2016, we adopted our 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 to the Federal Railroad Administration (FRA); and issued five new recommendations, including two to the FRA, one to UP, one to the Class I Railroads, and the following recommendation to BNSF Railway, Canadian National Railway, Canadian Pacific Railway, CSX Transportation, Kansas City Southern Railway, Norfolk Southern Railway Company, Intercity Railroads, and Commuter Railroads, including Alaska Railroad Corporation.

From: NTSB
To: CSX Transportation, Inc.
Date: 1/24/2017
Response: On December 19, 2016, we adopted our 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 to the Federal Railroad Administration (FRA); and issued five new recommendations, including two to the FRA, one to UP, one to the Class I Railroads, and the following recommendation to BNSF Railway, Canadian National Railway, Canadian Pacific Railway, CSX Transportation, Kansas City Southern Railway, Norfolk Southern Railway Company, Intercity Railroads, and Commuter Railroads, including Alaska Railroad Corporation.

From: NTSB
To: State of Texas, County of Denton, Transportation Authority
Date: 1/24/2017
Response: On December 19, 2016, we adopted our 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 to the Federal Railroad Administration (FRA); and issued five new recommendations, including two to the FRA, one to UP, one to the Class I Railroads, and the following recommendation to BNSF Railway, Canadian National Railway, Canadian Pacific Railway, CSX Transportation, Kansas City Southern Railway, Norfolk Southern Railway Company, Intercity Railroads, and Commuter Railroads, including Alaska Railroad Corporation.

From: NTSB
To: Kansas City Southern Railway Company
Date: 1/24/2017
Response: On December 19, 2016, we adopted our 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 to the Federal Railroad Administration (FRA); and issued five new recommendations, including two to the FRA, one to UP, one to the Class I Railroads, and the following recommendation to BNSF Railway, Canadian National Railway, Canadian Pacific Railway, CSX Transportation, Kansas City Southern Railway, Norfolk Southern Railway Company, Intercity Railroads, and Commuter Railroads, including Alaska Railroad Corporation.

From: Long Island Railroad
To: NTSB
Date: 5/10/2018
Response: -From Joseph J. Lhota, Chairman: The MTA has centralized occupational health function into a headquarters-led program. This centralization permits a much greater degree of standardization of occupational medical evaluation across the MTA's operating agencies. All employees who receive medical examinations by MT A physicians are required to disclose medical conditions, treatment, and medication use. This includes being diagnosed with sleep disorders. Our screening procedures and questionnaires specifically address sleep disorders. When employees who are subject to OSA screening report that they have received a diagnosis outside our program, we place them into our compliance monitoring program, and monitor them accordingly. As valuable as self reported data are, our medical professionals are not dependent on employee-reported information. Our medical staff have received Continuing Medical Education focusing on sleep disorders with an in-depth segment on OSA. They are capable of assessing and using objective medical information to make informed OSA risk assessments. Any employee who is found to be at risk for OSA is referred, diagnostically assessed, and - if needed - treated in accordance with the MTA protocols described elsewhere in this letter. Because of the successful efforts across the MTA, we request that recommendation R-14-045 be classified as "Closed-Acceptable Action" with respect to both railroads.

From: NTSB
To: Long Island Railroad
Date: 1/24/2017
Response: On December 19, 2016, we adopted our 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 to the Federal Railroad Administration (FRA); and issued five new recommendations, including two to the FRA, one to UP, one to the Class I Railroads, and the following recommendation to BNSF Railway, Canadian National Railway, Canadian Pacific Railway, CSX Transportation, Kansas City Southern Railway, Norfolk Southern Railway Company, Intercity Railroads, and Commuter Railroads, including Alaska Railroad Corporation.

From: Massachusetts Bay Transportation Authority
To: NTSB
Date: 4/24/2018
Response: -From Ronald Nickle, MBTA, Chief Safety Officer: Based on a recent review with the Department of Public Utilities (DPU), we have learned the Massachusetts Bay Transportation Authority (MBTA) had not responded to Safety Recommendation R16-045 which had been directed to a previous General Manager. We would like to bring the NTSB up to date on MBTA’s actions related to this recommendation. We have been working with the FRA and Keolis on system mitigations and corrective actions as detailed in the attached supporting documentation. Please feel free to contact me should you have any questions.

From: NTSB
To: Massachusetts Bay Transportation Authority
Date: 1/23/2017
Response: On December 19, 2016, we adopted our report concerning the August 17, 2014, accident, in which two Union Pacific Railroad Company (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 to the Federal Railroad Administration (FRA); and issued five new recommendations, including two to the FRA, one to UP, one to the Class I Railroads, and the following recommendation to BNSF Railway, Canadian National Railway, Canadian Pacific Railway, CSX Transportation, Kansas City Southern Railway, Norfolk Southern Railway, Intercity Railroads, and Commuter Railroads, including Massachusetts Bay Transportation Authority.

From: NTSB
To: Metra (Northeast Illinois Regional Railroad Corporation)
Date: 1/24/2017
Response: On December 19, 2016, we adopted our 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 to the Federal Railroad Administration (FRA); and issued five new recommendations, including two to the FRA, one to UP, one to the Class I Railroads, and the following recommendation to BNSF Railway, Canadian National Railway, Canadian Pacific Railway, CSX Transportation, Kansas City Southern Railway, Norfolk Southern Railway Company, Intercity Railroads, and Commuter Railroads, including Alaska Railroad Corporation.

From: Metro North Railroad
To: NTSB
Date: 5/10/2018
Response: -From Joseph J. Lhota, Chairman: The MTA has centralized occupational health function into a headquarters-led program. This centralization permits a much greater degree of standardization of occupational medical evaluation across the MTA's operating agencies. All employees who receive medical examinations by MT A physicians are required to disclose medical conditions, treatment, and medication use. This includes being diagnosed with sleep disorders. Our screening procedures and questionnaires specifically address sleep disorders. When employees who are subject to OSA screening report that they have received a diagnosis outside our program, we place them into our compliance monitoring program, and monitor them accordingly. As valuable as self reported data are, our medical professionals are not dependent on employee-reported information. Our medical staff have received Continuing Medical Education focusing on sleep disorders with an in-depth segment on OSA. They are capable of assessing and using objective medical information to make informed OSA risk assessments. Any employee who is found to be at risk for OSA is referred, diagnostically assessed, and - if needed - treated in accordance with the MTA protocols described elsewhere in this letter. Because of the successful efforts across the MTA, we request that recommendation R-14-045 be classified as "Closed-Acceptable Action" with respect to both railroads.

From: NTSB
To: Metro North Railroad
Date: 1/24/2017
Response: On December 19, 2016, we adopted our 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 to the Federal Railroad Administration (FRA); and issued five new recommendations, including two to the FRA, one to UP, one to the Class I Railroads, and the following recommendation to BNSF Railway, Canadian National Railway, Canadian Pacific Railway, CSX Transportation, Kansas City Southern Railway, Norfolk Southern Railway Company, Intercity Railroads, and Commuter Railroads, including Alaska Railroad Corporation.

From: NTSB
To: State of Minnesota, Metro Transit
Date: 1/24/2017
Response: On December 19, 2016, we adopted our 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 to the Federal Railroad Administration (FRA); and issued five new recommendations, including two to the FRA, one to UP, one to the Class I Railroads, and the following recommendation to BNSF Railway, Canadian National Railway, Canadian Pacific Railway, CSX Transportation, Kansas City Southern Railway, Norfolk Southern Railway Company, Intercity Railroads, and Commuter Railroads, including Alaska Railroad Corporation.

From: NTSB
To: Southern California Regional Rail Authority
Date: 1/24/2017
Response: On December 19, 2016, we adopted our 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 to the Federal Railroad Administration (FRA); and issued five new recommendations, including two to the FRA, one to UP, one to the Class I Railroads, and the following recommendation to BNSF Railway, Canadian National Railway, Canadian Pacific Railway, CSX Transportation, Kansas City Southern Railway, Norfolk Southern Railway Company, Intercity Railroads, and Commuter Railroads, including Alaska Railroad Corporation.

From: NTSB
To: State of Maryland, Transit Administration
Date: 1/24/2017
Response: On December 19, 2016, we adopted our 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 to the Federal Railroad Administration (FRA); and issued five new recommendations, including two to the FRA, one to UP, one to the Class I Railroads, and the following recommendation to BNSF Railway, Canadian National Railway, Canadian Pacific Railway, CSX Transportation, Kansas City Southern Railway, Norfolk Southern Railway Company, Intercity Railroads, and Commuter Railroads, including Alaska Railroad Corporation.

From: NTSB
To: Nashville Metropolitan Transit Authority
Date: 1/24/2017
Response: On December 19, 2016, we adopted our 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 to the Federal Railroad Administration (FRA); and issued five new recommendations, including two to the FRA, one to UP, one to the Class I Railroads, and the following recommendation to BNSF Railway, Canadian National Railway, Canadian Pacific Railway, CSX Transportation, Kansas City Southern Railway, Norfolk Southern Railway Company, Intercity Railroads, and Commuter Railroads, including Alaska Railroad Corporation.

From: NTSB
To: New Jersey Transit Corporation
Date: 1/24/2017
Response: On December 19, 2016, we adopted our 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 to the Federal Railroad Administration (FRA); and issued five new recommendations, including two to the FRA, one to UP, one to the Class I Railroads, and the following recommendation to BNSF Railway, Canadian National Railway, Canadian Pacific Railway, CSX Transportation, Kansas City Southern Railway, Norfolk Southern Railway Company, Intercity Railroads, and Commuter Railroads, including Alaska Railroad Corporation.

From: NTSB
To: State of New Mexico, Department of Transportation, Rail Runner Express
Date: 1/24/2017
Response: On December 19, 2016, we adopted our 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 to the Federal Railroad Administration (FRA); and issued five new recommendations, including two to the FRA, one to UP, one to the Class I Railroads, and the following recommendation to BNSF Railway, Canadian National Railway, Canadian Pacific Railway, CSX Transportation, Kansas City Southern Railway, Norfolk Southern Railway Company, Intercity Railroads, and Commuter Railroads, including Alaska Railroad Corporation.

From: NTSB
To: Norfolk Southern Corporation
Date: 8/1/2017
Response: Dr. Litow provided extensive details of your comprehensive fatigue management program, particularly your efforts to identify safety-sensitive employees subject to obstructive sleep apnea (OSA) and to ensure that employees with OSA are monitored and receive appropriate treatment. Dr. Litow made the following points in her letter: 1) NS Safety Rule 917 states that employees “[a]re prohibited from reporting for duty or remaining at work if their ability to safely perform those duties is adversely impacted by their medical condition(s)” and “[m]ust notify NS Health Services promptly of a ‘reportable’ medical condition or medical event.” An accompanying document, “Medical Condition and Medication Guidance,” provides information regarding what medical conditions must be reported. After you received Safety Recommendation R 16 45, you revised “Medical Condition and Medication Guidance” to clarify that OSA is one of the medical conditions that must be reported. 2) You actively screen for OSA and you ensure that your employees with OSA are not permitted to perform safety-sensitive work until their condition is appropriately treated and stabilized. 3) You are exploring ways to identify job offerees and current employees who should be tested for OSA. During pre-employment physical examinations (for job offerees) or triennial Federal Railroad Administration required physical examinations (for current employees), you plan to assess individuals to determine whether they have OSA risk factors. If so, the employee will be required to either provide documentation that he or she has been tested for OSA and that any identified condition is controlled, or submit to an OSA test. If, as a result of this screening, an individual tests positive for OSA or was identified as having a record of untreated OSA, you would follow the same protocols presently used for individuals who self-report OSA: holding the individual out of service until he or she has produced medical documentation showing that his or her OSA is under control. The actions taken in items 1 and 2 satisfy Safety Recommendation R-16-45; however, the actions described in item 3 represent a comprehensive program to identify employees in safety sensitive positions who are subject to OSA and to ensure that they are being effectively treated and are fit for duty. We commend you on this program and note that it is more comprehensive than the action called for in Safety Recommendation R-16-45, which is classified CLOSED--EXCEEDS RECOMMENDED ACTION.

From: Norfolk Southern Corporation
To: NTSB
Date: 4/24/2017
Response: -From Francesca Litow, Chief Medical Officer: In response to the 2014 collision of two Union Pacific trains in Hoxie, Arkansas, the National Transportation Safety Board (NTSB) issued a series of recommendations, two of which were directed to Class I Railroads such as Norfolk Southern Railway Co. ("NS"). The first recommendation suggested we "revise as necessary [our] rules ... to ensure you are informed of any diagnosed sleep disorders that employees in safety -sensitive positions" suffer, as well as "perform periodic evaluations [of employees diagnosed with sleep apnea] to ensure the condition is appropriately treated and the employee is fit for duty." (R-16-045). The second recommendation suggested we "[r]evise ... scheduling practices for train crews and implement science -based tools, such as validated biomathematical models, to reduce start time variability that results in irregular work -rest cycles and fatigue." (R-16-046) I have detailed below Norfolk Southern's current actions and planned additional steps as well as some brief background information: I. Background Information about Norfolk Southern A. Operations NS is a Class I railroad operating primarily in the eastern United States. NS has more than 28,000 employees and approximately 19,500 route miles of track. NS serves every major container port in the eastern United States, and it provides efficient connections with other rail carriers. NS operates the most extensive rail network in the East and is a major transporter of coal, automotive, and industrial products. B. Safety Training and Safety Culture NS takes numerous steps to enhance employee safety. NS provides all operations employees with regular rules training, in which they are trained on NS' safety and operating rules. NS has several safety rules relevant to the NTSB recommendations, including Safety Rules 917 (employees "[a]re prohibited from reporting for duty or remaining at work if their ability to safely perform those duties is adversely impacted by their medical condition(s)" and "[m]ust notify NS Health Services promptly of a 'reportable' medical condition or medical event"), 918 ("an employee must not engage in any outside activity that interferes with proper rest"), 919 ("employees must report for duty properly rested"), and 921 ("an employee called to report for service, who will not have legal rest at the indicated time to go on duty, must inform the caller before accepting the call"). Safety Rule 917 and its accompanying "Medical Condition and Medication Guidance" was revised recently to emphasize the importance of employees reporting dangerous medical conditions. However, upon review of NTSB recommendation R-16-045, we have decided to clarify our "Medical Condition and Medication Guidance" (which accompanies Safety Rule 917), in order to make clear that sleep apnea is one of the medical conditions that must be reported. Employees also receive regular one-on-one safety contacts with supervisors, in which the supervisor reviews an employee's safety record and discusses strategies for safe workplace practices, such as identifying and eliminating behaviors that could compromise safety. Employees also regularly engage in job safety briefings, in which crews discuss any unusual conditions or hazards and how to perform their assignments safely. There also are regular safety meetings for employees to attend, where supervisors summarize any recently reported accidents and discuss ways in which those accidents or injuries might have been prevented. NS' unwavering commitment to safety is further demonstrated through its comprehensive structure of proactive safety committees that operate at all levels of the company. For example, each of NS' operating divisions has its own safety committees, comprised of division -level managers and other company representatives. Each month, those committees discuss new ideas for proactively improving safety. NS also is careful to ensure that its safety programs both improve safety and comply with all laws protecting employee rights, including but not limited to the Americans with Disabilities Act, the Family and Medical Leave Act and the Hours of Service Act. For example, NS insists that an employee who reports an injury or a possible violation of law, rule, regulation or NS policy must not be harassed, intimidated, or disciplined for making the report. To emphasize this commitment, NS provides detailed training to its supervisors at all levels on their obligation to not retaliate against employees for engaging in legally protected activity. Il. NS Actively Screens for Sleep Apnea and Ensures that Employees with Sleep Apnea are Not Permitted to Perform Safety -Sensitive Work Until Their Condition is Appropriately Treated A. New Employees All job offers are contingent upon passing a drug test and medical review. The post -job offer medical exams include, among other things, express questions about past or current diagnoses of sleep apnea and other sleep disorders. Next, relevant follow-up questions and requests for all medical records are made, as appropriate, so that an applicant who reports a history of a sleep disorder will not be hired for a safety -sensitive job until the company's Chief Medical Officer can review all of the facts, including but not limited to reports from polysomnography or other sleep studies and data to support compliance with prescribed CPAP machines and any prescribed medications. Based upon the Apnea-Hypopnea Index and a review of all medically relevant information, the Chief Medical Officer makes a determination of medical fitness for duty for safety -sensitive positions. If there is insufficient information provided by a job offeree to support compliance with appropriate treatment, as well as stability and control of symptoms, NS will delay the hire of that individual. B. Current Employees Supervisors of employees in safety -sensitive positions receive training on how to recognize a potentially unsafe employee and how to report health concerns to the Chief Medical Officer. As a result, employees engaged in train and engine service undergo fitness -for -service medical examinations both periodically and whenever a reasonable concern about the employee's fitness has been raised. These examinations include a questionnaire that expressly asks about any past or current diagnosis of sleep apnea and other sleep disorders. C. NS Does Not Permit Individuals with Sleep Apnea to Perform Safety -Sensitive Duties Until the Condition has been Appropriately Treated and is Stable When the Chief Medical Officer learns that an employee performing a safety -sensitive job has been diagnosed with sleep apnea, the Chief Medical Officer will request information including documentation of the results of polysomnography or other sleep studies, physician evaluations, and data to support compliance with prescribed Continuous Positive Airway Pressure (CPAP) machines and any prescribed medications. If an employee with a diagnosed sleep disorder does not comply with a request for this information, and/or review of the information the employee provides indicates that the employee is noncompliant with treatment recommendations (including but not limited to CPAP and prescribed medications), the Chief Medical Officer will medically disqualify the employee until such time as the employee provides medical information that demonstrates compliance with prescribed treatment as well as stability and control of the sleep disorder. Ill. NS Takes Numerous Steps to Proactively Guard Against Employee Fatigue NS has invested in several new technologies to address and mitigate the risks of employee fatigue. For example, NS is working diligently on installing Positive Train Control (PTC). In addition, NS has implemented Movement Planner, Unified Train Control System (UTCS) and CrewVue to improve train scheduling and predictability throughout our network. These innovations allow NS to better balance crews at home and away terminals, improve the accuracy of train line-ups, and allow employees access to notifications by text or e-mail when they reach certain board or pool placements. To further enhance predictable work and rest cycles, NS has partnered with Interdynamics, a leading provider of risk management software, to develop an Assigned Service Planning Tool. This tool promises to aid NS in identifying opportunities to increase the number of assignments with scheduled on -duty times or calling windows as well as scheduled rest days. In addition to technological fatigue countermeasures, NS has adopted several new policies and collective bargaining agreements to mitigate potential fatigue. For example, NS has implemented a napping policy for select employees. Also, the 2015 Collective Bargaining Agreement between NS and the Brotherhood of Locomotive Engineers and Trainmen (BLET) provides a method - Predictable Workforce Scheduling - for engineers to more frequently and regularly change assignments to allow them to better respond to, and balance, work/life issues. While a significant number of our engineers have long been afforded scheduled rest days and/or reporting times in yard, local and assigned through freight service, the 2015 Agreement also provides a framework that affords every engineer in all classes of service, including extra boards and unassigned freight pools, access to predictable time off through scheduled (and consecutive) rest days. Similarly, NS has worked with International Association of Sheet Metal, Air, Rail and Transportation Workers (SMART -TD) to implement work/rest extra boards throughout our system. These arrangements enhance the predictability of work/rest periods, provide more consecutive rest hours, and offer the opportunity to reduce the amount of time an employee spends away from home during a given cycle, further increasing an employee's opportunity to manage work/life issues. In addition to these initiatives, NS complies with the Hours of Service Act. As you are aware, this Act addresses fatigue by controlling how many hours covered service employees may work, providing limitations on the consecutive -days of work and the cumulative monthly activity of train and engine service employees and prescribing uninterrupted rest between starts and after six consecutive starts. Finally, NS employees are afforded reasonable privileges to call off work (mark -off) in addition to collectively bargained and federally mandated time off. Scrutiny of employee attendance is not triggered by a single mark -off. Rather, our attendance policy focuses on extended and defined periods during which frequent, pattern and/or unexplained mark -offs occur. In cases where handling for absences during a given period is warranted under the attendance policy, the first step is always counseling. And, subsequent handlings for poor attendance do not result in unpaid suspension until an employee continues to demonstrate an unwillingness or inability to remediate his/her behavior. IV. Planned Efforts to Identify Undiagnosed Sleep Apnea U.S. rail regulators are regretfully behind both Australia (see Australia National Transport Commission, "National Standards for Health Assessment of Rail Safety Workers) and FMCSA in setting standards and specifying BMI thresholds for testing for sleep apnea. While we strongly encourage regulators to promptly take action in this regard, NS also is exploring ways to proactively identify job offerees and current employees who should be tested for sleep apnea. We currently envision this effort occurring during pre -employment physical examinations (for job offerees) or triennial FRA -required physical examinations (for current employees). During these examinations, NS would assess an individual to determine whether he/she possesses certain well -established sleep -apnea risk factors. If so, NS would require the employee either to: (1) provide documentation that he/she had been tested for sleep apnea and that any identified condition is controlled, or (2) submit to a sleep apnea test. If, as a result of this screening, an individual tested positive for sleep apnea or was identified as having a record of untreated sleep apnea, NS' plan would likely be to follow the same protocols that it presently uses for handling individuals who self -report sleep apnea, i.e., holding the individual out of service until he/she has produced medical documentation showing that their sleep apnea is under control. Safety is NS' number one priority, and we thank you for your recommendations and for your interest in these important safety topics. While NS continues to support implementation of federal safety standards that clearly address sleep apnea, we trust this response adequately details NS' full compliance with NTSB's recommended actions and we respectfully request that NTSB designate R-16-045 and R-16-046 as "Closed -Acceptable Action" with regards to NS.

From: NTSB
To: State of California, County of North, North County Transit District
Date: 4/25/2018
Response: We note your multifaceted approach to staying informed of employees’ changing medical conditions and ensuring that they are fit for duty. We further note that you have revised section 4.2 of your fatigue management plan, Employee Screening, which covers employee fitness for duty and states that employees must not perform any service while affected by a condition that could impair their ability to perform their duties properly, such as sleep disorders or undiagnosed medical conditions reported by the employee. You have also required all employees in safety-sensitive positions to pass a commercial driver’s license physical examination, during which a medical examiner checks for obstructive sleep apnea (OSA) warning signs and administers an OSA questionnaire. Any employee displaying symptoms or warning signs of OSA is provided a home screening test and, if needed, a prescription for sleep disorder treatment. The outcome of each examination is documented by the medical professional and tracked for ongoing compliance. Finally. we note that employees with changing medical conditions, such as sleep disorders, are evaluated and recorded to ensure that they are fit for duty. These actions satisfy the intent of Safety Recommendation R-16-45, which is classified CLOSED--ACCEPTABLE ACTION.

From: State of California, County of North, North County Transit District
To: NTSB
Date: 2/23/2018
Response: -From Matthew O. Tucker, Executive Director: In response to the October 24, 2017 letter from the National Transportation Safety-Board's, (NTSB) related• to ·NCTO's: Fatigue- Management Plan (R-16-15) the Nort,h Country Transit District (NCTD) and its rail operations and maintenance contractor; Bombardier·Transportation (Holdings) USA, Inc. (Bombardier) have updated Section 4.2 Employee Screening of the Fatigue Management Plan with the NTSB's recommendations which states: " ... all ·employees in safety-sensitive positions are required to report any diagnosed sleep disorder". Once an employee reports a diagnosed sleep disorder, a program for medical follow-up will contain the following elements: • Verification of treatment plan and compliance with said plan. • Periodic monitoring program will be established to ensure compliance and fitness for duty. • All treatment plans and periodic monitoring exceptions will be reviewed and evaluated by the company's designated Medical Professional to ensure employees remain fit for duty • When an undiagnosed medical condition or sleep disorder is reported by an employee in a "safety, sensitive ,position, that could be potentially incapacitating. or performance-impairing, the employee is prohibited from performing, any safety-sensitive duties, and will be immediately referred to a medical professional for evaluation and treatment. NCTD and Bombardier will implement the approach provided below for the COASTER Engineer/Conductors and Dispatchers to further ensure that employees in safety sensitive positions receive proper screening via the following steps: • Require all safety-sensitive employees to have a Commercial Driver's License (CDL) physical completed once every three (3) years, including 240/242 hearing/vision requirements. • The COL physical has sleep apnea criteria: • Physical assessment (Height, Weight, BMI) • Personal history & responses to questions Current employees will complete COL physical at re-certification time . Applicants (new hires) will be subject to COL physical at time of hire . Home Screening Test (HST) for employees identified to have the prerequisite risk factors by the physician during COL exam. Continuous Positive Airway Pressure (CPAP) treatment for positive sleep apnea diagnoses from both the physical and HAST. Once an employee reports a diagnosed sleep disorder or one is identified through the steps taken above, a program for medical follow-up will contain the following elements: • Verification of treatment plan and compliance with said plan. • Periodic monitoring program will be established to ensure compliance and fitness for duty. • All treatment plans and periodic monitoring exceptions will be reviewed and evaluated by Bombardier's designated Medical Professional to ensure employees remain fit for duty. Additionally, when any undiagnosed medical condition or sleep disorder is reported by an employee in a safety sensitive position, that could be potentially incapacitating or performance-impairing, the employee is prohibited from performing any safety-sensitive duties and will be immediately referred to a medical professional for evaluation and treatment. The SPRINTER operators already participate in this testing protocol every two (2) years under the California Public Utilities Commission guidelines. NCTD and Bombardier remain committed to ensuring all employees are able to perform their job at the highest possible level to help prevent accidents and save lives.

From: NTSB
To: State of California, County of North, North County Transit District
Date: 10/24/2017
Response: In your April 18, 2017, letter to us about this recommendation, you described your fatigue management program and your response to Federal Railroad Administration Safety Advisory 2016-03. Much of your plan and response focused on educating your employees about the dangers of fatigue and how to avoid it. When we replied on August 1, 2017, we said that although the program you described was valuable, and training and raising awareness about fatigue are important components of a fatigue management strategy, your program did not address Safety Recommendation R-16-45. To satisfy this recommendation, you or Bombardier—your rail operations contractor—need to have medical rules, standards, or protocols in place requiring any employee in a safety-sensitive position who is diagnosed with a sleep disorder to report the diagnosis. Further, when an employee reports a sleep disorder, you or Bombardier must periodically evaluate the employee to ensure that the condition is appropriately treated and the employee is fit for duty. In response to our August 1, 2017, letter, you provided a copy of your fatigue management plan, which was adopted in May 2017. We reviewed the plan but did not see a requirement for employees to report a diagnosed sleep disorder; nor did we find any discussion of continuing medical follow-up to ensure that employees diagnosed with sleep disorders are effectively treated and remain fit for duty. Section 4.2 of the plan, “Employee Screening,” indicates that all locomotive engineers will be screened for sleep apnea during the employment testing process; however, the plan does not describe what will happen if an employee is identified as having sleep apnea, and it does not indicate if the employment offer will be withdrawn or if there will be some type of continuing medical follow-up. Pending revisions to your fatigue management plan to require all employees in safety sensitive positions to report any diagnosed sleep disorder, and a program for medical follow-up to ensure that such employees are effectively treated and remain fit for duty, Safety Recommendation R-16-45 remains classified OPEN--UNACCEPTABLE RESPONSE.

From: State of California, County of North, North County Transit District
To: NTSB
Date: 8/28/2017
Response: -From Matthew O. Tucker, Executive Director: The North Country Transit District (NCTD) is in receipt of the National Transportation Board's (NTSB) letter dated August 1, 2017, requesting that NCTD provide documentation evidencing its process for ensuring that diagnosed sleep disorders are reported for employees in safety-sensitive positions, and periodic evaluations and appropriate treatment are provided to ensure the employee is fit for duty. Attached hereto is a copy of NCTD and its rail operations contractor, Bombardier Transportation (Holdings) USA, lnc.'s (Bombardier) program plan, entitled Fatigue Management Plan, that was adopted in May 2017 to address these issues. NCTD and Bombardier are committed to ensuring that all employees are able to perform their job at the highest possible level to help prevent accidents and save lives. NCTD trusts that this document and its procedural requirements and processes sufficiently address the NTSB's concerns.

From: NTSB
To: State of California, County of North, North County Transit District
Date: 8/1/2017
Response: Your letter describes activities that Bombardier Transportation (Holdings) USA, Inc. (Bombardier), your contract operator for the COASTER commuter rail line, is taking regarding obstructive sleep apnea (OSA), including your response to the Federal Railroad Administration’s (FRA’s) Safety Advisory 2016-03 and briefing your operating crews on the contents of the advisory regarding sleep disorders’ effects on railroad operation safety. We note that you have also revised your training curriculum to guide your operating crews in identifying and treating sleep disorders and to inform them about sleep and fatigue as they relate to railroad operations. Further, Bombardier is currently developing a voluntary pilot sleep management program. These programs are valuable, and training and raising awareness about fatigue are important components of a fatigue management program. However, Safety Recommendation R 16-45 addresses the need for you (or Bombardier) to have medical rules, standards, or protocols in place that ensure that you are informed of diagnosed sleep disorders in your employees in safety-sensitive positions and that, when an employee reports a sleep disorder, you perform periodic evaluations to ensure the condition is appropriately treated and the employee is fit for duty. We did not see anything in your letter indicating you have such a program in place. Pending your providing us with information to the contrary, Safety Recommendation R-16-45 is classified OPEN--UNACCEPTABLE RESPONSE.

From: State of California, County of North, North County Transit District
To: NTSB
Date: 4/18/2017
Response: -From Matthew O. Tucker, Executive Director: The North County Transit District (NCTD) writes in response to the NTSB's letter of January 23, 2017 regarding Safety Recommendation R-16-045. Bombardier Transportation (Holdings) USA, Inc. (Bombardier), NCTD's contract operator for the COASTER commuter rail line, is taking a multi-faceted approach regarding Obstructive Sleep Apnea (OSA). NCTD's initial response to the Federal Railroad Administration (FRA) Safety Advisory 2016-03, released , on December 5, 2016, was to brief our operating crews on its contents, specifically related to the recommendations of FRA Safety Advisory 2004-04 regarding the effect of sleep disorders on the safety of railroad operations. Additional steps were taken to revise our training curriculum, which is predicated largely on the regulatory requirements pursuant to 49 CFR Part 228.411. Our training is intended to inform and guide our operating crews regarding the identification and treatment of sleep disorders, as well as general concepts about sleep and fatigue as they relate to railroad operations. During this training, employees are also provided with a pamphlet and brochure referencing the Railroaders' Guide to Healthy Sleep Web site (http://www.railroadersleep.org) and, as an interim measure, are strongly encouraged to take the voluntary self-screening assessment for sleep disorders located on the website. Presently, Bombardier, in concert with medical providers, is developing a voluntary pilot sleep management program, which will be implemented in a phased approach beginning with our operating crew personnel and extending to other safety-sensitive positions thereafter. Bombardier is also currently engaging other stakeholders in this process, including the International Association of Sheet Metal, Air, Rail and Transportation Workers (SMART), who collectively represent Bombardier operating crews on the COASTER Service. Bombardier is required to promptly advise NCTD of any subsequent completion or delays associated with the implementation of our voluntary pilot sleep management program. NCTD and Bombardier remain committed to ensuring that all employees are fit for duty to help prevent accidents and save lives.

From: NTSB
To: State of Indiana, Northern Indiana Commuter Transportation District
Date: 1/24/2017
Response: On December 19, 2016, we adopted our 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 to the Federal Railroad Administration (FRA); and issued five new recommendations, including two to the FRA, one to UP, one to the Class I Railroads, and the following recommendation to BNSF Railway, Canadian National Railway, Canadian Pacific Railway, CSX Transportation, Kansas City Southern Railway, Norfolk Southern Railway Company, Intercity Railroads, and Commuter Railroads, including Alaska Railroad Corporation.

From: NTSB
To: Peninsula Corridor Joint Powers Board
Date: 1/24/2017
Response: On December 19, 2016, we adopted our 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 to the Federal Railroad Administration (FRA); and issued five new recommendations, including two to the FRA, one to UP, one to the Class I Railroads, and the following recommendation to BNSF Railway, Canadian National Railway, Canadian Pacific Railway, CSX Transportation, Kansas City Southern Railway, Norfolk Southern Railway Company, Intercity Railroads, and Commuter Railroads, including Alaska Railroad Corporation.

From: NTSB
To: Port Authority of New York and New Jersey
Date: 1/24/2017
Response: On December 19, 2016, we adopted our 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 to the Federal Railroad Administration (FRA); and issued five new recommendations, including two to the FRA, one to UP, one to the Class I Railroads, and the following recommendation to BNSF Railway, Canadian National Railway, Canadian Pacific Railway, CSX Transportation, Kansas City Southern Railway, Norfolk Southern Railway Company, Intercity Railroads, and Commuter Railroads, including Alaska Railroad Corporation.

From: NTSB
To: Portland and Western Railroad
Date: 1/24/2017
Response: On December 19, 2016, we adopted our 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 to the Federal Railroad Administration (FRA); and issued five new recommendations, including two to the FRA, one to UP, one to the Class I Railroads, and the following recommendation to BNSF Railway, Canadian National Railway, Canadian Pacific Railway, CSX Transportation, Kansas City Southern Railway, Norfolk Southern Railway Company, Intercity Railroads, and Commuter Railroads, including Alaska Railroad Corporation.

From: NTSB
To: Denver Regional Transportation District
Date: 1/24/2017
Response: On December 19, 2016, we adopted our 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 to the Federal Railroad Administration (FRA); and issued five new recommendations, including two to the FRA, one to UP, one to the Class I Railroads, and the following recommendation to BNSF Railway, Canadian National Railway, Canadian Pacific Railway, CSX Transportation, Kansas City Southern Railway, Norfolk Southern Railway Company, Intercity Railroads, and Commuter Railroads, including Alaska Railroad Corporation.

From: NTSB
To: Saratoga and North Creek Railway
Date: 1/24/2017
Response: On December 19, 2016, we adopted our 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 to the Federal Railroad Administration (FRA); and issued five new recommendations, including two to the FRA, one to UP, one to the Class I Railroads, and the following recommendation to BNSF Railway, Canadian National Railway, Canadian Pacific Railway, CSX Transportation, Kansas City Southern Railway, Norfolk Southern Railway Company, Intercity Railroads, and Commuter Railroads, including Alaska Railroad Corporation.

From: NTSB
To: Southeastern Pennsylvania Transportation Authority
Date: 7/13/2017
Response: We note your multifaceted approach to staying informed of employees’ changing medical conditions and ensuring that employees are fit for duty. Your Authority Standard Rule 4, which covers employee fitness for duty, states that employees must not perform any service while affected by a condition that could impair their ability to perform their duties properly, including sleep disorders. The rule goes on to say that employees must notify SEPTA’s medical department of any condition not already on record. Because SEPTA’s actions satisfy the intent of Safety Recommendation R-16-45, it is classified CLOSED ACCEPTABLE ACTION.

From: Southeastern Pennsylvania Transportation Authority
To: NTSB
Date: 4/17/2017
Response: -From Jeffrey D. Knueppel, General Manager, Southeastern Pennsylvania Transportation Authority: SEPTA's Authority Standard Rules (ASR) governs all employees and are intended to enhance consistency and the efficiency of SEPTA's operations. The Authority Standard Rules are standard rules of conduct that equally govern each SEPTA employee and were last revised in March 2012. Authority Standard Rule 4 - Fitness For Duty, includes rules governing Employee Injuries/Sickness, Policies on Drugs and Alcohol, Medical Examinations, Accident/Injury Prone Employees, and Corrective Lenses. ASR-4 Section A (Employee Injuries/Sickness) addresses the rules pertaining to the requirements of R-16-45. The rule reads in part: Employees must not perform any service while affected by any condition that could impair their ability to perform their duties properly. Such conditions include fatigue, use, and effect of over-the-counter medications, personal situations that affect alertness or one's ability to concentrate, etc. Employees must notify the Authority Medical Department of any condition not already on record that could impair their ability to perform their duties ... ... Physical ailments, including but not limited to, diabetes, heart condition, epilepsy, loss of hearing, sleep disorders, or eyesight, etc., which may affect an employee's ability to perform their duties or which may endanger themselves or others must be reported by an employee to the Authority's Medical Department as soon as such ailment is known to exist. Fitness For Duty issues, including sleep disorders, are also addressed through independent activities either performed by SEPTA or available to its employees through traditional health benefits and wellness programs. SEPTA's total human resource initiatives, in aggregate, provide both reasonable corporate knowledge of the employee population's fitness for duty; and individual employee awareness of their own health and fitness. SEPTA's Medical Department currently accesses personnel medical information sources in order to evaluate the medical fitness status of known at-risk SEPTA employees. These medical data sources include: • Sick Benefits • Employee reporting of medical restrictions imposed by personal physician • Directive Examinations • Return-to-Duty Medical Exams • Employee self-reporting of medications SEPTA monitors several source metrics to identify employees who would require fitness for duty monitoring and/or determinations. Specific categories of source protocols that monitor the fitness of SEPTA's workforce include: • New Hire Physicals o All New Hires (and current employee Transfers from non-safety-sensitive positions to Safety Sensitive jobs) • Prescribers Reports o Each employee is required to submit a prescriber's report listing medication/s she is taking. • Return to Work Evaluations • Medical Directives o Employees who are out on an extended leave, or denied FMLA are required to be seen by a doctor. • Sick Benefit Application o Any Non-Railroad employee assigned to SEPTA's transit modes and represented by Local 234 requesting sick pay must complete a sick benefit application - that shall include a diagnosis by the employee's personal physician. They are reviewed, and if they have certain identified "red flag" conditions, they are given to SEPTA's Medical Director. If necessary, SEPTA requests additional medical documentation. If appropriate, they are then entered into the applicable monitoring program • FMLA Medical Certifications o SEPTA's Third Party Administrator has been instructed to review all medical certifications to see if any employee has any of the "red flag" conditions. If so, the Third Party Administrator notifies SEPT A's medical department. • Weekly Sick Reports o Reports are run for Supervisory, Administrative, and Management personnel as well as several groups of represented employees that have been out for at least 2 weeks. FMLA paperwork is sent to those employees which in turn will either disclose a medical issue, or they will be subject to the medical directive process. Specific medical conditions presently monitored by SEPTA include: Blood Pressure Employees are required to report to SEPTA Medical periodically - ranging between every 3 months to annually - depending on their readings. If they miss an appointment, SEPTA's Medical Department advises the employee's manager. If an employee misses four appointments, SEPTA removes the employee from service. Diabetes Employees are required to submit current AlC reports every 3-6 months depending on their readings. If their numbers remain under nine, they are seen annually. Above, more frequent visits are required. Sleep Disorders Employees are required to submit documentation from their sleep specialist annually. Heart Employees are required to submit documentation from their cardiologist annually. Bi-Polar Employees are required to submit documentation from their mental health professional annually. Additionally, please note that SEPTA previously advised NTSB about Fatigue awareness initiatives incorporated into the Authority's Wellness and EAP Programs. The circa 2007 Fatigue Awareness Program previously forwarded to NTSB as evidence of the initiative was subsequently updated in 2014 and attached herewith in Attachment 1. Instead of relying solely on the Wellness Program to disseminate information about the effects of sleep disorders and fatigue, SEPTA initiated a proactive, formal Fatigue Awareness Training module that is delivered to all operating personnel. Training commenced in July 2014, and all affected employees completed their initial training in April 2016. This training includes advising employees about the signs and symptoms of sleep disorders and the necessity to report such conditions as soon as the employee becomes aware. Based on the information provided SEPTA requests that NTSB consider recommendation R-16-45 as "Closed - Acceptable Action".

From: NTSB
To: Sonoma-Marin Area Rail Transit Authority
Date: 1/24/2017
Response: On December 19, 2016, we adopted our 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 to the Federal Railroad Administration (FRA); and issued five new recommendations, including two to the FRA, one to UP, one to the Class I Railroads, and the following recommendation to BNSF Railway, Canadian National Railway, Canadian Pacific Railway, CSX Transportation, Kansas City Southern Railway, Norfolk Southern Railway Company, Intercity Railroads, and Commuter Railroads, including Alaska Railroad Corporation.

From: NTSB
To: South Florida Regional Transportation Authority
Date: 1/24/2017
Response: On December 19, 2016, we adopted our 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 to the Federal Railroad Administration (FRA); and issued five new recommendations, including two to the FRA, one to UP, one to the Class I Railroads, and the following recommendation to BNSF Railway, Canadian National Railway, Canadian Pacific Railway, CSX Transportation, Kansas City Southern Railway, Norfolk Southern Railway Company, Intercity Railroads, and Commuter Railroads, including Alaska Railroad Corporation.

From: NTSB
To: SunRail (formerly Central Florida Commuter Rail)
Date: 1/24/2017
Response: On December 19, 2016, we adopted our 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 to the Federal Railroad Administration (FRA); and issued five new recommendations, including two to the FRA, one to UP, one to the Class I Railroads, and the following recommendation to BNSF Railway, Canadian National Railway, Canadian Pacific Railway, CSX Transportation, Kansas City Southern Railway, Norfolk Southern Railway Company, Intercity Railroads, and Commuter Railroads, including Alaska Railroad Corporation.

From: NTSB
To: Trinity Railway Express
Date: 1/24/2017
Response: On December 19, 2016, we adopted our 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 to the Federal Railroad Administration (FRA); and issued five new recommendations, including two to the FRA, one to UP, one to the Class I Railroads, and the following recommendation to BNSF Railway, Canadian National Railway, Canadian Pacific Railway, CSX Transportation, Kansas City Southern Railway, Norfolk Southern Railway Company, Intercity Railroads, and Commuter Railroads, including Alaska Railroad Corporation.

From: NTSB
To: State of Utah, Utah Transit Authority
Date: 10/24/2017
Response: We note that, since you commenced commuter rail operations in 2008, you have required all employees in safety-sensitive positions to pass a US Department of Transportation (DOT) physical examination, and that, as part of this examination, a DOT-certified medical examiner checks for obstructive sleep apnea (OSA) warning signs and administers an OSA questionnaire. Any employee displaying symptoms or warning signs of OSA is referred for an overnight sleep study for proper diagnosis and, if needed, a prescription for sleep disorder treatment. The outcome of each examination is documented by the medical professional and tracked for ongoing compliance. We further note that employees with changing medical conditions such as sleep disorders are evaluated and recorded to ensure that they are fit for duty. These actions satisfy the intent of Safety Recommendation R-16-45, which is classified CLOSED--ACCEPTABLE ACTION.

From: State of Utah, Utah Transit Authority
To: NTSB
Date: 8/11/2017
Response: -From Bruce Cardon, Commuter Rail General Manager, UTA FrontRunner: I received your letter of August 1, 2017. In response to the two additional questions, please see below: "Is the US DOT p hysical examination a recurring requirement, or is it administered only for new hires? If the physical examination is not a recurring requirement, do you have procedures or programs that require employees in safety-sensitive positions to report when they have been diagnosed with sleep disorders and ways to ensure that their condition is being treated effectively?" DOT certification cards are issued for a period not to exceed two years, if the employee is in good health. For those with identified medical concerns (including sleep apnea) the cards are issued for shorter periods of time. In the case of serious sleep apnea, DOT cards cannot be issued for a period longer than one year. Additionally when an individual with sleep apnea is renewing a DOT card they must provide a CPAP print out showing that they are actively using the machine. "Is reporting required for all diagnoses of OSA, or is it limited to only severe cases?" Any UTA employee that is identified as having sleep apnea, severe or moderate, is reported through our medical examiner to UTA. It is then tracked through our HR department to ensure the employee receives follow up care and meets the requirements which accompany the condition. We appreciate your concern on this matter and take this issue very seriously. We hope this information answers your questions and you are able to close out the recommendation. However, if there is any additional information needed, please don't hesitate to let us know.

From: NTSB
To: State of Utah, Utah Transit Authority
Date: 8/1/2017
Response: We note that, since you commenced commuter rail operations in 2008, you have required all employees in safety-sensitive positions to pass a US Department of Transportation (US DOT) physical examination, and that, as part of this examination, a US DOT-certified medical examiner checks for obstructive sleep apnea (OSA) warning signs as well as administers an OSA questionnaire. Any employee displaying symptoms or warning signs of OSA is referred for an overnight sleep study for proper diagnosis and, if needed, a prescription for sleep disorder treatment. The outcome is documented by the medical professional and tracked for ongoing compliance. You appear to have established a program that satisfies this recommendation; however, before we can close the recommendation, we request you answer two questions: 1) Is the US DOT physical examination a recurring requirement, or is it administered only for new hires? If the physical examination is not a recurring requirement, do you have procedures or programs that require employees in safety-sensitive positions to report when they have been diagnosed with sleep disorders and ways to ensure that their condition is being treated effectively? 2) Is reporting required for all diagnoses of OSA, or is it limited to only severe cases? Pending the answers to those questions, Safety Recommendation R-16-45 is classified OPEN--ACCEPTABLE RESPONSE.

From: State of Utah, Utah Transit Authority
To: NTSB
Date: 4/21/2017
Response: -From Bruce Cardon, Commuter Rail General Manager, UTA FrontRunner: The Utah Transit Authority (UT A) strives to take the safest course possible in providing service to our customers. We recognize that sleep apnea is a serious concern within the industry, and has been linked as a contributing factor in recent incidents. The standard UT A established, when commuter rail operations commenced in 2008, includes a requirement for all safety sensitive employees to pass a USDOT physical exam. As part of this physical, US DOT-certified medical examiners check for sleep apnea warning signs as well as administer a sleep apnea questionnaire. Any employee displaying symptoms or warning signs are referred for an overnight sleep study for proper diagnosis and, if needed, prescription for treatment of sleep apnea. The outcome is documented by the medical professional and tracked by UTA for ongoing compliance. We appreciate your concern on this matter. Please contact us if there is any additional information needed.

From: NTSB
To: Virginia Railway Express
Date: 10/13/2017
Response: We note that you currently contract with Keolis Rail Services Virginia, LLC (KRSV) to provide commuter rail train operations. In response to this recommendation, you asked KRSV to summarize its approach to ensure it is aware of the diagnosed sleep disorders that employees in safety-sensitive positions must report and that, when employees report having a sleep disorder, they are periodically evaluated to ensure the condition is appropriately treated and that they are fit for duty. You included in your letter a copy of an April 11, 2017, letter from Mr. John Kerins, General Manager, KRSV, to Mr. Richard Dalton, VRE’s Deputy Chief Executive Officer and Chief Operating Officer, identifying the actions KRSV has taken or is planning to take in regard to employee fatigue mitigation; particularly those actions recommended by Federal Railroad Administration Safety Advisories 2004-04 and 2016-03. Although Mr. Kerins’s letter describes KRSV’s activities to notify and train its crews regarding fatigue as a safety issue and how to recognize and treat it, we did not find any evidence that you or KRSV are informed of diagnosed sleep disorders in your safety-sensitive employees or that, when an employee reports a diagnosed sleep disorder, your policies and procedures ensure the condition is appropriately treated and the employee is fit for duty. We are concerned that neither VRE nor KRSV has such policies and procedures in place, and we ask that, if you do, you describe them. Pending our review of these policies and procedures, Safety Recommendation R-16-45 is classified OPEN--UNACCEPTABLE RESPONSE.

From: Virginia Railway Express
To: NTSB
Date: 4/20/2017
Response: -From Doug Allen, Chief Executive Officer, Virginia Railway Express: On behalf of the Virginia Railway Express (VRE), I am pleased to respond to your letter dated January 23, 2017, detailing the actions VRE has taken, or intends to take, to implement Safety Recommendation R-16-045. As background, VRE is a commuter rail service linking Washington, D.C. and Northern Virginia. VRE currently operates thirty-two (32) daily revenue trains carrying an average of approximately 19,000 weekday trips on two (2) lines. Since VRE began operations in 1992, VRE has contracted with third parties to provide commuter rail train operations. Currently, Keolis Rail Services Virginia, LLC (KRSV} provides these services for VRE. Upon receipt of your letter, VRE and KRSV together reviewed our medical rules, standards and protocols for safety sensitive employees as requested . In response to your specific inquiries, I asked KRSV to summarize their approach to the fatigue mitigation issues that you have identified, as well as those requirements outlined in FRA Safety Advisories 2004-04 and 2016-03. I have enclosed their response for your review. VRE staff and KRSV management continue to collaborate to ensure this very important safety issue is at the forefront of our overall fatigue mitigation program. We will continue to work with the NTSB, FRA and others within the rail industry to implement best practices and recommendations. We very much appreciate your leadership on this issue. Please contact me if I can be of any assistance to you. FROM JOHN KERINS, GENERAL MANAGER, KEOLIS, DATED APRIL 11, 2017. THIS LETTER IS FROM KEOLIS, NOT VIRGINIA RAILWAY EXPRESS: This letter is in response to your request for Keolis Rail Services Virginia to identify actions taken or being planned in regard to employee fatigue mitigation, and in particular those actions recommended by FRA Safety Advisories 2004-04 and 2016-03. FRA regulates certain aspects of the medical fitness ofrailroad employees. These current regulatory requirements include hearing and vision, ( 49 CFR Part 240), alcohol/drugs ( 49 CFR Part 219), and hours of service (49 CFR Part 228). For each of these regulatory requirements, KRSV has comprehensive policies and procedures in place to maintain compliance. In addition to compliance with these medical fitness requirements, KRSV maintains policies, procedures and training for other employee fitness for duty aspects, including the mitigation of employee fatigue. In regards to employee fatigue within VRE Commuter Service, KRSV workers enjoy the benefit of regular work schedules, five day per week operations with weekends off, and with no assignments going on duty before 4:00 am. KRSV and the Agency have worked together to avo id creating "Type 2" work assignments for operating crews, which require mandatory fatigue mitigation analysis and actions. (Those KRSV assignments requiring an employee to work past 8:01 pm were deemed and recognized by the FRA as Type 1 assignments and have an acceptable level of risk for fatigue that does not violate the defined fatigue threshold that create a Type 2 assignment.) To further augment the favorable working conditions of the VRE service, KRSV has implemented policies, procedures, and training to insure the fitness of safety sensitive employees in regard to fatigue, and the medical management of sleep disorders. The following are voluntary actions taken by KRSV in close coordination with VRE. Fatigue Education and Prevention: • All employees briefed on, and given a copy of both FRA Safety Advisories (2004-04 & 2016-03) • FRA "Railroaders Guide to Healthy Sleep" web-site https://www.railroadersleep.org was provided to each employee during briefing and is posted on safety bulletin boards • Employees were shown the videos on FRA website for fatigue mitigation during safety briefings • All employees receive annual Fatigue Mitigation Training using the USDOT Transportation Safety Institute's on-line training program, Fatigue and Sleep Apnea Awareness for Transit Employees • Train and Engine service employees are provided with private hotel rooms for mid-day rest periods • KRSV attendance policy is being revised to accommodate sleep disorder treatment absences without penalty • KRSV Mentoring Program has put transportation managers on the engines and trains on a much more frequent basis to observe employee behavior and identify potential fatigue issues. • KRSV has worked closely with the Agency to put in place rules for the effective use of interior and exterior mounted cameras on the locomotives and cab control cars. These actions are intended to enable our employees to recognize and be aware of the hazards of fatigue on and off duty; to know when to seek medical help for sleep related issues; to remove any penalty associated with absence for the diagnosis or treatment of sleep disorders; and to allow for the monitoring of operating employees while performing activities on-board trains. KRSV has willfully enacted the aforementioned activities in the name of railroad safety, and in the spirit of cooperation with the FRA Safety Advisories on the subject of fatigue mitigation. We believe that our efforts are more than sufficient given the nature of the VRE service and work schedules.

From: NTSB
To: Tri-County Metro Transit District of Oregon
Date: 1/24/2017
Response: On December 19, 2016, we adopted our 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 to the Federal Railroad Administration (FRA); and issued five new recommendations, including two to the FRA, one to UP, one to the Class I Railroads, and the following recommendation to BNSF Railway, Canadian National Railway, Canadian Pacific Railway, CSX Transportation, Kansas City Southern Railway, Norfolk Southern Railway Company, Intercity Railroads, and Commuter Railroads, including Alaska Railroad Corporation.