1. Lapses in the New Jersey Transit engineer’s alertness prior to the accident resulted from his undiagnosed and untreated severe obstructive sleep apnea.
2. The failure of the New Jersey Transit obstructive sleep apnea screening program to adequately screen the engineer and refer him for definitive diagnostic testing and subsequent treatment contributed to the accident.
3. The failure of New Jersey Transit to follow internal guidance and refer at-risk safety-sensitive personnel including the engineer and other at-risk crew members for obstructive sleep apnea screening is evidence of a systemic failure of a critical safety system to ensure these personnel were fit for duty.
4. It was likely that fatigue from a variety of factors⸺including a rotating schedule, insufficient nightly sleep, poor sleep habits, and impaired sleep quality undiagnosed and untreated severe obstructive sleep apnea⸺resulted in the Long Island Rail Road engineer falling asleep during entry into the terminal, causing the collision.
5. The failure of the Federal Railroad Administration to adequately address the issue of employee fatigue due to obstructive sleep apnea and other sleep disorders, most recently evidenced by the August 2017 withdrawal of the advance notice of proposed rulemaking, jeopardizes public safety.
6. These accidents demonstrate the need for effective screening programs to reduce the risk of safety-sensitive employees with untreated obstructive sleep apnea operating trains.
7. Since the Federal Railroad Administration did not implement Safety Recommendation R-12-16 or comply with the legislated time limit in the Rail Safety Improvement Act to require railroads to develop and implement fatigue management plans, New Jersey Transit and Long Island Rail Road were not required to have a screening and treatment program for obstructive sleep apnea.
8. The New Jersey Transit obstructive sleep apnea screening and treatment program should reduce the risk safety-sensitive employees with undetected and untreated obstructive sleep apnea pose to rail safety.
9. The Metropolitan Transportation Authority obstructive sleep apnea screening and treatment program should reduce the risk safety-sensitive employees with undetected and untreated obstructive sleep apnea pose to rail safety.
10. As evidenced by these two accidents, relying solely on an engineer’s ability to stop his or her train before reaching the end of these tracks does not provide the level of safety necessary to protect the public.
11. Bumping posts, of the type used in Hoboken and Atlantic Terminals, do not by themselves provide adequate protection at the end of a track.
12. Both the New Jersey Transit and the Long Island Rail Road system safety program plans were ineffective in identifying operational hazards associated with operating trains into terminal tracks.
13. The use of operating rules and procedures to mitigate end-of-track collisions was an inadequate method for preventing these accidents because it failed to eliminate the possibility of a single point failure.
14. New Jersey Transit and Long Island Rail Road did not consider that the previous end-of-track collisions represented an increased risk of future accidents.
15. If both New Jersey Transit and the Long Island Rail Road system safety program plans had identified obstructive sleep apnea screening as a risk-reduction action when evaluating employees for fitness for duty, it would have been unlikely that these employees would have been operating trains with undiagnosed and untreated obstructive sleep apnea.
16. If the Federal Railroad Administration, at a minimum, instructed railroads to use the Collision Hazard Analysis Guide: Commuter and Intercity Passenger Rail Service when identifying and mitigating hazards, commuter and intercity railroad safety would be improved.