Safety Recommendation R-12-016
Details
Synopsis: On April 17, 2011, about 6:55 a.m. central daylight time, eastbound BNSF Railway (BNSF) coal train C-BTMCNMO-26, BNSF 9159 East, travelling about 23 mph, collided with the rear end of standing BNSF maintenance-of-way (MOW) equipment train U-BRGCRI-15, BNSF 9470 East, near Red Oak, Iowa. The accident occurred near milepost (MP) 448.3 on main track number two on the Creston Subdivision of the BNSF Nebraska Division. The collision resulted in the derailment of 2 locomotives and 12 cars. As a result of collision forces, the lead locomotive's modular crew cab was detached, partially crushed, and involved in a subsequent diesel fuel fire. Both crewmembers on the striking train were fatally injured. Damage was in excess of $8.7 million. The National Transportation Safety Board (NTSB) determined that the probable cause of the accident was the failure of the crew of the striking train to comply with the signal indication requiring them to operate in accordance with restricted speed requirements and stop short of the standing train because they had fallen asleep due to fatigue resulting from their irregular work schedules and their medical conditions. Contributing to the accident was the absence of a positive train control system that identifies the rear of a train and stops a following train if a safe braking profile is exceeded. Contributing to the severity of collision damage to the locomotive cab of the striking coal train was the absence of crashworthiness standards for modular locomotive crew cabs.
Recommendation: TO THE FEDERAL RAILROAD ADMINISTRATION: Require railroads to medically screen employees in safety-sensitive positions for sleep apnea and other sleep disorders.
Original recommendation transmittal letter: PDF
Overall Status: Open - Unacceptable Response
Mode: Railroad
Location: Red Oak, IA, USA
Is Reiterated: Yes
Is Hazmat: No
Is NPRM: No
Accident #: DCA11FR002
Accident Reports:
Report #: RAR-12-02
Accident Date: 4/17/2011
Issue Date: 5/10/2012
Date Closed:
Addressee(s) and Addressee Status: FRA (Open - Unacceptable Response)
Keyword(s):

Safety Recommendation History
From: NTSB
To: FRA
Date: 2/17/2021
Response: The National Transportation Safety Board (NTSB) has reviewed the Federal Railroad Administration’s (FRA) December 22, 2020, notice of proposed rulemaking (NPRM), Fatigue Risk Management Programs for Certain Passenger and Freight Railroads. Federal Register (FR) Vol. 85, no. 246 (December 22, 2020): 83484. In this NPRM, the FRA stated that, pursuant to the Rail Safety Improvement Act (RSIA) of 2008, the FRA proposes to issue regulations requiring certain railroads to develop and implement a fatigue risk management program (FRMP) as one component of the railroads’ larger railroad safety risk reduction programs. Rail Safety Improvement Act of 2008, Public Law 110-432 (Oct. 16, 2008): 20156 Railroad Safety Risk Reduction Program. The NPRM describes an FRMP as a comprehensive, system-oriented approach in which a railroad determines its fatigue risk by identifying and analyzing applicable hazards and takes action to mitigate, if not eliminate, that fatigue risk. A railroad would implement its FRMP with a written FRMP plan that would be submitted to the FRA for review and approval. A railroad’s FRMP plan would become part of its existing safety risk reduction program plan, and the railroad would be required to implement its FRA-approved FRMP plan, annually conduct an internal assessment of its FRMP, and update its FRMP plan periodically. A railroad’s FRMP would also be subject to assessments by the FRA. The NTSB has identified fatigue as a probable cause or a contributing factor in investigations across all modes of transportation, and Reduce Fatigue Related Accidents is an issue on the NTSB’s 2019-2020 Most Wanted List of transportation safety improvements. Between 2000 and 2020, the NTSB conducted 11 major investigations of accidents involving railroads subject to FRA jurisdiction in which fatigue was identified as the probable or a contributing cause of the accident. Congress passed the RSIA in 2008, which mandated railroads to include fatigue management plans in their safety risk reduction programs. Fatigue continues to be a major safety issue in the railroad industry; however, many railroads have yet to develop or implement such a plan. The NTSB notes that since Congress passed the RSIA of 2008, the Federal Aviation Administration developed FRMP guidance. Federal Aviation Administration, Advisory Circular 120-103A Fatigue Risk Management Systems for Aviation Safety, May 6, 2013. In December 2011, the FRA, through its Rail Safety Advisory Committee, formed a Fatigue Management Plans Working Group to provide input regarding development of regulations for fatigue management plans. The group, which met several times in 2012-2013, was unable to reach consensus on how fatigue management plans should be implemented. The NTSB supports the RSIA of 2008 requirement for fatigue management plans and is encouraged that this NPRM proposes to require that railroads develop and implement FRMPs. As a result of the investigation of the April 17, 2011, collision of a BNSF railway coal train with a standing BNSF maintenance-of-way equipment train near Red Oak, Iowa, the NTSB issued Safety Recommendation R-12-17, which asked the FRA to establish an ongoing program to monitor, evaluate, report on, and continuously improve fatigue management systems implemented by operating railroads. Implementation of the requirements proposed in the NPRM would likely satisfy this recommendation. The NTSB notes that the NPRM effectively identifies the causes of fatigue and proposes mitigation strategies, and we believe that the information provided in the NPRM provides railroads a solid foundation to develop an effective FRMP. The NPRM states that “a railroad shall develop and implement mitigation strategies to reduce the risk of railroad accidents, incidents, injuries, and fatalities where fatigue of any of its safety-related employees is a contributing factor.” The NTSB is encouraged that the NPRM includes track, mechanical, and hazmat employees in its definition of safety-related employees. We recently completed an investigation of a track worker who was fatally injured when he stepped in front of an approaching train. That investigation identified the railroad’s allowance of overtime work schedules without properly considering and mitigating workers’ risk of fatigue as a contributing cause to this accident. NTSB (National Transportation Board), Long Island Rail Road Roadway Worker Fatality, Queens Village, New York, June 10, 2017, RAR-20/01 (Washington, DC: NTSB, 2020). While the NTSB is encouraged by this NPRM, it does have concerns about the ability of some railroads to effectively execute such a plan once it is implemented. These concerns and proposed actions to address these areas are as follows: 1. The lack of personnel proficient in fatigue science needed to effectively identify and analyze fatigue risks. The NPRM recognizes that fatigue is a complex and multifaceted condition. The NPRM provides strategies railroads can use to identify the risk of fatigue, such as evaluating operator scheduling including on-duty call practices, work and rest cycles, and changes in start times. The FRA further suggests the use of validated biomathematical models of fatigue to assist in this assessment. The NTSB has recommended the use of biomathematical models of fatigue in the following railroad reports: NTSB-RAR-20/01; NTSB, Collision of Two Union Pacific Railroad Freight Trains, Hoxie, Arkansas, August 17, 2014, RAR-16/03 (Washington, DC: NTSB, 2016); NTSB, Collision of BNSF Coal Train With the Rear End of Standing BNSF Maintenance-of-Way Equipment Train, Red Oak, Iowa, April 17, 2011, RAR-12/02 (Washington, DC: NTSB, 2012); NTSB, Chicago Transit Authority Train Collides with Bumping Post and Escalator at O’Hare Station, Chicago, Illinois, March 24, 2014, RAR-15-01 (Washington, DC: NTSB, 2015). For railroads that do not use fatigue models, however, a fatigue assessment would be made by company officials, who may not have the educational background, training, or experience needed to identify and evaluate fatigue risks or appropriate fatigue mitigation strategies. Therefore, the NTSB believes that to ensure that railroads accurately identify fatigue risks, the FRMP regulation should require that risk-based hazard analyses include personnel who have formal education or training in fatigue science and the evaluation of conditions, especially work schedules, that lead to human fatigue. 2. The need for comprehensive employee medical records required to evaluate medical conditions that can affect fatigue. In numerous accidents, the NTSB has identified medical conditions and medications that resulted in operator fatigue. See, for example: NTSB, Collision of Two Canadian National/Illinois Central Railway Trains Near Clarkston, Michigan, November 15, 2001, RAR-02/04 (Washington DC: NTSB, 2002); NTSB, Derailment of Metro-North Railroad Train 8808, Bronx, New York, December 1, 2013, RAB-14/12 (Washington, DC: NTSB, 2014). The NTSB supports the FRA’s position that fatigue analyses consider general health and medical conditions that can affect the fatigue levels of safety-related railroad employees. However, the NTSB notes that FRA regulations only require safety-sensitive employees to be medically evaluated for hearing and vision. Title 49 Code of Federal Regulations (CFR) 240.121 Criteria for Vision and Hearing Acuity Data. The NTSB is aware that many railroads collect additional employee medical information beyond these basic federal requirements, but that is not necessarily the case for all railroads who are subject to this FRMP regulation. Since 2002, the NTSB has been recommending that the FRA expand the required medical screening to include sleep disorders. There are two recommendations on this subject currently classified “Open—Unacceptable Response.” Safety Recommendation R-12-16 “Require railroads to medically screen employees in safety-sensitive positions for sleep apnea and other sle

From: NTSB
To: FRA
Date: 9/16/2019
Response: We note that, on March 10, 2016, you and the FMCSA issued an advance notice of proposed rulemaking (ANPRM) on obstructive sleep apnea and received more than 700 comments from individuals, medical professionals, labor groups, and industry stakeholders, including from us and from three members of Congress (the Honorable Anna Eshoo, the Honorable Sam Farr, and the Honorable Michael M. Honda). You told us that, after reviewing the comments and considering your current safety programs and planned rulemaking addressing fatigue risk management, you withdrew the ANPRM on August 4, 2017, believing that the appropriate safety programs are already in place, and that planned rulemaking regarding fatigue risk management is a more appropriate way to address our concerns. We are disappointed that you have withdrawn the ANPRM, as we do not believe that your current safety programs and planned rulemaking sufficiently address fatigue risk management. As we previously concluded in our September 5, 2018, correspondence, you have not taken any effective action to address the hazards posed by inadequately diagnosed and treated sleep disorders in the rail industry. Accordingly, Safety Recommendation R 12 16 remains classified OPEN--UNACCEPTABLE RESPONSE.

From: NTSB
To: FRA
Date: 9/5/2018
Response: We note that you collaborated with the Federal Motor Carrier Safety Administration (FMCSA), issuing an advanced notice of proposed rulemaking (ANPRM) in March 2016 that addressed obstructive sleep apnea (OSA). However, in August 2017, you withdrew the ANPRM, stating that you “believe railroads will consider OSA when addressing medical conditions that affect alertness under a railroad’s fatigue risk management plan as part of an RRP or SSP.” Because the rulemaking to address system safety programs has been placed on hold, though, and no railroad has a reviewed or approved program, you do not know if any railroads have included OSA in their plans. Ultimately, you have not taken any effective action to address the hazards posed by inadequately diagnosed and treated OSA in the rail industry. Accordingly, Safety Recommendation R-12-16 remains classified OPEN--UNACCEPTABLE RESPONSE.

From: FRA
To: NTSB
Date: 6/28/2018
Response: -From Ronald L. Batory, Administrator: On March 30, 2017, FRA notified the NTSB that in response to Safety Recommendation R-12-16, FRA, with the assistance of the Department of Transportation's Volpe Center, fatigue researchers, and medical professionals, had developed the Railroaders' Guide to Healthy Sleep website (www.railroadersleep.org). On January 18, 2018, the NTSB replied that while it believed creating the website was a positive step, it fell short of achieving the recommendation; accordingly, the NTSB classified Safety Recommendation R-12-16 as "Open-Unacceptable Response." On March 10, 2016, FRA and the Federal Motor Carrier Safety Administration (FMCSA) issued an Advance Notice of Proposed Rulemaking (ANPRM) on obstructive sleep apnea and received more than 700 comments from individuals, medical professionals, labor groups, and industry stakeholders. Comments on the ANPRM were also provided by the NTSB and three members of Congress (the Honorable Anna Eshoo, the Honorable Sam Farr, and the Honorable Michael M. Honda). After reviewing the comments and considering FRA's current safety programs and planned rulemaking addressing fatigue risk management, FRA and FMCSA withdrew the ANPRM on August 4, 2017. FRA believes its safety programs already in place and planned rulemaking addressing fatigue risk management are more appropriate measures for addressing the NTSB's concern. Therefore, FRA respectfully requests that the NTSB close Safety Recommendation R-12-16.

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

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

From: NTSB
To: FRA
Date: 1/18/2018
Response: We note that, along with the Volpe Center, fatigue researchers, and medical professionals, you developed a guide for railroaders on healthy sleep. Although this is a positive step, it does not require railroads to ensure that employees in safety-sensitive positions are medically screened for sleep apnea and other sleep disorders, as recommended. Additionally, we are aware that you withdrew your August 3, 2016, advance notice of proposed rulemaking (ANPRM) on sleep apnea in August 2017. We remain concerned about sleep apnea and other sleep-related disorders because we continue to find they are causal factors in our accident investigations. Pending your requiring railroads to medically screen employees in safety-sensitive positions for sleep apnea and other sleep disorders, Safety Recommendation R 12-16 remains classified as OPEN--UNACCEPTABLE RESPONSE.

From: FRA
To: NTSB
Date: 3/30/2017
Response: -From Patrick T. Warren, Executive Director performing the duties of the Administrator: Thank you for your January 24, 2017, letter to the Federal Railroad Administration (FRA) regarding the National Transportation Safety Board's (NTSB) Safety Recommendations R-16-043 and R-16-044, as well as the reiterations of Safety Recommendations R-13-21 and R-12-16. FRA understands NTSB issued these recommendations as a result of its investigation of an August 17, 2014, accident, in which two Union Pacific Railroad (UP) freight trains collided at the UP Hoxie subdivision in Hoxie, AR. The enclosure responds to Safety Recommendations R-16-043 and R-16-044, and explains FRA's position on these recommendations as well as Safety Recommendations R-13-21 and R-12-16. FRA is actively working to achieve the intent of these recommendations and offer the attached description of action to inform you of our progress. As discussed in the response to R-16-044, section 103 ofRSIA requires that certain railroads develop a railroad safety risk reduction program. 49 U.S.C. 20156. Section 103(d)(2) of the RSIA requires a railroad to include a fatigue management plan in its safety risk reduction program that meets the requirements of subsection (f). 49 U.S.C. 20156(d)(2). As part of the development of FMPs, railroads will be required to provide opportunities for the identification, diagnosis, and treatment of any medical condition that may affect alertness or fatigue, including sleep disorders. Additionally, railroads will be required to provide employee education and training on the physiological and human factors that affect fatigue. FRA is currently developing a regulation, consistent with input from an RSAC working group, responsive to the RSIA' s FMP requirements. FRA, with the Volpe Center, fatigue researchers, and medical professionals, developed the Railroaders' Guide to Healthy Sleep (RGHS) website at www.railroadersleep.org, as an educational resource. One section of the website includes an anonymous self-screening tool for sleep disorders. Railroaders using this site who are deemed to be at risk for a sleep disorder are provided with links to medical professionals and sleep centers in their area that can assist in the diagnosis and treatment of any sleep disorders, including OSA. Since June 2012, the website has been regularly promoted to and user-tested on its target audience of railroaders and railroader support networks. The RGHS implementation team has attended multiple national and regional labor meetings each year and various academic conferences. Railroads are increasingly using the site in their internal trainings and safety briefings. The website was relaunched in February 2016 with updated content, enhanced site features, and mobile optimization. The RGHS implementation team is collaborating with FRA's Office of Public Affairs to increase the site's visibility in the industry, and drive more traffic to the website.

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

From: NTSB
To: FRA
Date: 1/24/2017
Response: From the Railroad Accident Report "Collision of Two Union Pacific Railroad Freight Trains, Hoxie, Arkansas August 17, 2014" published on January 24, 2017, Report Number: RAR-16-03. Adopted December 19, 2016, PB2017-100970: 2.5 Southbound Train Locomotive Engineer’s Medical Issues The southbound engineer’s postaccident urine toxicology testing identified 94 ng/ml diphenhydramine and citalopram/escitalopram in his urine, but no blood was available for testing. Although diphenhydramine is considered sedating, there is no accepted method for relating postmortem urine drug results for diphenhydramine to cognitive function impairment at the time of the fatal injury.19 Therefore, it cannot be determined if the engineer was impaired by this sedating antihistamine or its hangover effects at the time of the accident. Urine testing did not differentiate between citalopram and escitalopram, antidepressants commonly marketed with the names Celexa and Lexapro. Both are psychoactive medications and carry warnings about the risk of cognitive impairment in the mental and/or physical ability required for the performance of potentially hazardous tasks (such as, driving, operating heavy machinery). However, personal medical records revealed the southbound engineer had been using escitalopram for many years without reported performance problems. According to his personal medical records, between 2006 and 2014, the southbound engineer repeatedly reported feeling tired to his primary care physician. In 2010, the primary care physician considered the diagnosis of obstructive sleep apnea and obtained a polysomnography, also known as a sleep study, which was performed in a sleep laboratory. The results included an apnea-hypopnea index (AHI) of 19.3 episodes/hour, oxygen saturation ranging from 93-87 percent, and 29 periodic limb movements recorded with an index of 5.3 per hour.20 All of these measurements are considered abnormal. The sleep specialist diagnosed moderate sleep apnea and the possibility of restless leg syndrome.21 The southbound engineer returned to the sleep center for a trial of treatment with continuous positive airway pressure (CPAP). Following that trial, the sleep specialist recommended the “CPAP be placed at 7 cm/H2O. (No apneas, no snoring, no periodic limb movements).” The NTSB medical officer reviewed records from the sleep laboratory and sleep specialist, as well as the primary care physician, and interviewed the primary care physician. However, no follow-up visits or evidence of treatment initiation, maintenance, or review with the sleep specialist or the primary care physician were discovered. No evidence was found that the southbound engineer ever obtained or used a CPAP machine to treat his sleep disorder. The night before the accident, the southbound engineer’s work schedule required him to sleep away from home. He had checked out of his accommodation and did not have a CPAP device in his possession at the time of the accident. There is also no evidence that he obtained any other treatment for his sleep apnea, such as surgery or a customized mouthpiece. The NTSB concludes the southbound engineer was fatigued and likely asleep due to his diagnosed but inadequately treated moderate sleep apnea and operating the train in the early morning hours when he was predisposed to sleep. In September 2013, the southbound engineer was noted to be 6 feet, 3 inches tall and weigh 250 pounds. According to the body mass calculator from the National Institutes of Health, National Heart, Lung, and Blood Institute, his body mass index was 31.2 kg/mg2, which is considered obese.22 Although his body mass index was in the obese category, which increased the risk for sleep apnea, the southbound engineer’s weight was not known to directly cause it. The NTSB has investigated a number of previous railroad accidents where undiagnosed or inadequately treated sleep apnea or other sleep disorders in safety-sensitive employees caused or contributed to the accident. A head-on collision of two Canadian National/Illinois Central Railway trains occurred in Clarkston, Michigan, in 2001 that the NTSB determined was due to “…crewmembers’ fatigue, which was primarily due to the engineer’s untreated and the conductor’s insufficiently treated obstructive sleep apnea.” (NTSB 2002) As a result, the NTSB issued the following safety recommendation to the FRA: R-02-24 Develop a standard medical examination form that includes questions regarding sleep problems and require that the form be used, pursuant to [Title] 49 Code of Federal Regulations Part 240, to determine the medical fitness of locomotive engineers; the form should also be available for use to determine the medical fitness of other employees in safety-sensitive positions. In 2006, partly in response to this recommendation, the FRA created a Medical Standards Working Group as part of the Railroad Safety Advisory Committee (RSAC). Although the FRA has mentioned the RSAC and its Medical Standards Working Group in responses to NTSB recommendations on a number of occasions, it was disbanded after 5 years for being unable to reach consensus.23 On March 10, 2016, the FRA and the Federal Motor Carrier Safety Administration jointly published an advance notice of proposed rulemaking in the Federal Register (FR) regarding obstructive sleep apnea. (FR 2016, 12642) However, the notice primarily poses questions and asks for public comments on the topic. It does not provide information regarding any proposed rules. Currently, no public action has been taken by the FRA to develop guidelines or require screening, diagnosis, or treatment of sleep disorders among railroad employees. Following the investigation of a head-on collision between two UP freight trains in Goodwell, Oklahoma, in June 2012, the NTSB determined the probable cause of the accident was, in part, due to the conductor’s lack of engagement and the engineer’s inability to see and interpret signals due to a chronic illness and deteriorating eyesight. (NTSB 2013) As a result of this, the NTSB reclassified Safety Recommendation R-02-24 to the FRA as Closed?Unacceptable Action and superseded it with the following safety recommendation: R-13-21 Develop medical certification regulations for employees in safety-sensitive positions that include, at a minimum, (1) a complete medical history that includes specific screening for sleep disorders, a review of current medications, and a thorough physical examination, (2) standardization of testing protocols across the industry, and (3) centralized oversight of certification decisions for employees who fail initial testing; and consider requiring that medical examinations be performed by those with specific training and certification in evaluating medication use and health issues related to occupational safety on railroads. The FRA reported it had already created a new RSAC working group, the Fatigue Management Working Group, to develop standards for a railroad’s fatigue management plan.24 The NTSB did not view this reply as responsive to this recommendation and has, therefore, classified Safety Recommendation R-13-21 Open—Unacceptable Response. Like the previous medical working group, the fatigue working group has been operating for years without any publicly available output regarding medical conditions and fatigue. In the investigation of the April 27, 2011, rear-end collision in Red Oak, Iowa, discussed earlier in this report, the NTSB determined the collision occurred due to “the failure of the crew of the striking train to comply with the signal indication requiring them to operate in accordance with restricted speed requirements and stop short of the standing train because they had fallen asleep due to fatigue resulting from their irregular work schedules and their medical conditions.” Among other ailments, the medical conditions included probable sleep apnea, restless leg syndrome, and chronic inso

From: NTSB
To: FRA
Date: 5/31/2016
Response: The National Transportation Safety Board (NTSB) has reviewed the Federal Motor Carrier Safety Administration (FMCSA)-Federal Railroad Administration (FRA) advance notice of proposed rulemaking (ANPRM) and request for public comments, “Evaluation of Safety Sensitive Personnel for Moderate-to-Severe Obstructive Sleep Apnea,” published in the Federal Register, vol. 81, no. 47 (12642), March 10, 2016. The notice requests data and information regarding screening, diagnosis, and treatment for obstructive sleep apnea (OSA) among surface transportation vehicle operators. The NTSB has found inadequately diagnosed and treated sleep disorders among operators involved in accidents in both the highway and rail modes since 2000. In the past 16 years, OSA has been included in the probable cause of eight highway and rail accidents investigated by the NTSB.1 We have made two safety recommendations to the FMCSA and three safety recommendations to the FRA on this topic.2 We are pleased that the ANPRM addresses the important issue of OSA among operators performing safety-critical tasks. Although we agree that “OSA is a critical safety issue that can affect operations in all modes of travel in the transportation industry,” we maintain that further rulemaking is necessary to adequately address the need to screen, diagnose, and treat OSA among transportation operators in safety-sensitive positions. Footnotes: 1 (a) Motorcoach Run-Off-the-Road and Collision With Vertical Highway Signpost, Interstate 95 Southbound, New York City, New York, March 21, 2011, NTSB/HAR-12/01 (Washington, DC: NTSB, 2012). (b) Truck-Tractor Semitrailer Rear-End Collision Into Passenger Vehicles on Interstate 44 Near Miami, Oklahoma, June 26, 2009, NTSB/HAR-10/02 (Washington, DC: NTSB, 2010). (c) Work Zone Collision Between a Tractor-Semitrailer and a Tennessee Highway Patrol Vehicle, Jackson, Tennessee, July 26, 2000, NTSB/HAR-02/01 (Washington, DC: NTSB, 2002). (d) Collision of Union Pacific Railroad Freight Train With BNSF Railway Freight Train Near Chaffee, Missouri, May 25, 2013, NTSB/RAR-14/02 (Washington, DC: NTSB, 2014). (e) Collision of BNSF Coal Train With the Rear End of Standing BNSF Maintenance-of-Way Equipment Train, Red Oak, Iowa, April 17, 2011, NTSB/RAR-12/02 (Washington, DC: NTSB, 2012). (f) Collision Between Two Massachusetts Bay Transportation Authority Green Line Trains, Newton, Massachusetts, May 28, 2008, NTSB/RAR-09/02 (Washington, DC: NTSB, 2009). (g) Collision of Two Canadian National/Illinois Central Railway Trains Near Clarkston, Michigan, November 15, 2001, NTSB/RAR-02/04 (Washington, DC: NTSB, 2002). (h) Maryland Transit Administration Light Rail Vehicle Accidents at the Baltimore-Washington International Airport Transit Station Near Baltimore, Maryland, February 13 and August 15, 2000, NTSB/SIR-01/02 (Washington, DC: NTSB, 2001). 2 See Safety Recommendations H-09-15 and -16 from the Jackson, Tennessee, investigation; and Safety Recommendations R-13-21 (from Head-On Collision of Two Union Pacific Railroad Freight Trains Near Goodwell, Oklahoma, June 24, 2012, NTSB/RAR-13/02 [Washington, DC: NTSB, 2013]), R-12-16 from the Red Oak, Iowa, investigation, and R-02-24 from the Clarkston, Michigan, investigation.

From: FRA
To: NTSB
Date: 3/23/2016
Response: -From Sarah E. Feinberg, Administrator: FRA is addressing railroad employees' medical fitness for duty issues sequentially based on NTSB accident investigations of railroad accidents. For example, on March 10, 2016, FRA, with the Federal Motor Carriers Safety Administration (FMCSA), published an Advance Notice of Proposed Rulemaking (ANPRM) regarding obstructive sleep apnea. In this ANPRM, FRA and FMC SA request data and information concerning the prevalence of moderate-to-severe obstructive sleep apnea (OSA) among individuals occupying safety sensitive positions in highway and rail transportation and on its potential consequences for the safety of rail and highway transportation. FMC SA and FRA (collectively "the Agencies") also request information on potential costs and benefits from regulatory actions that address the safety risks associated with motor carrier and rail transportation workers in safety sensitive positions who have OSA. Once FRA has fully considered how to address obstructive sleep apnea, FRA will next consider strategies to address other medical conditions that are also contributing causes to accidents.

From: NTSB
To: FRA
Date: 12/8/2014
Response: R-12-016 was reiterated in the report Collision of Union Pacific Railroad Freight Train with BNSF Railway Freight Train near Chaffee, Missouri on May 25, 2013. RAR-14-02, adopted November 17, 2014, notation 8507A, published December 8, 2014. Conclusion 9: Had the medical screening described in Safety Recommendation R-12-16 been in place, or had the fatigue management components required by the Rail Safety Improvement Act of 2008 been in place, the Union Pacific Railroad engineer likely would have been identified as at high risk for sleep disorders, which may have led to appropriate medical intervention. As a result of this accident investigation, the National Transportation Safety Board reiterates and reclassifies from “Open—Acceptable Response” to “Open—Unacceptable Response” the following safety recommendation : R-12-016. In the FRA’s July 31, 2012, response to Safety Recommendation R-12-16, the FRA administrator wrote, “Currently, FRA, in conjunction with a working group of members from the Railroad Safety Advisory Committee, is developing a fatigue management regulation that will be responsive to the requirements set forth in the RSIA.” However, the time limit set by Congress for the Department of Transportation to create and issue this regulation passed on October 16, 2012. As noted previously, the Railroad Safety Advisory Committee medical working group continues to meet, but there has been no public output regarding fatigue management and no proposed changes to existing regulations since it was created. The NTSB concludes that had the medical screening described in Safety Recommendation R-12-16 been in place, or had the fatigue management components required by the RSIA of 2008 been in place, the UP engineer likely would have been identified as at high risk for sleep disorders, which may have led to appropriate medical intervention. Therefore, the NTSB reiterates Safety Recommendation R-12-16 and reclassifies it as OPEN--UNACCEPTABLE RESPONSE.

From: NTSB
To: FRA
Date: 12/8/2014
Response: R-12-016 was reiterated in the report Collision of Union Pacific Railroad Freight Train with BNSF Railway Freight Train near Chaffee, Missouri on May 25, 2013. RAR-14-02, adopted November 17, 2014, notation 8507A, published December 8, 2014.

From: NTSB
To: FRA
Date: 11/19/2014
Response: Reiterated in the Special Investigation Report "Organizational Factors in Metro-North Railroad Accidents" NTSB/SIR-14/04, Notation 8605, adopted November 19, 2014. Among other issues, the medical findings included probable sleep apnea, restless leg syndrome, and chronic insomnia. The NTSB made two medical recommendations as a result of that investigation: that the BNSF Railway medically screen employees in safety-sensitive positions for sleep apnea and other sleep disorders (R-12-26), and that the FRA require railroads to medically screen employees in safety-sensitive positions for sleep apnea and other sleep disorders (R-12-16). The response to R-12-26 from BNSF Railroad included the following paragraph: Previous attempts by BNSF to require additional medical information about certain safety related medical conditions, specifically including attempts to obtain medical information on sleep apnea, met with stiff resistance from our labor organizations who alleged that these attempts to obtain medical information were in violation of various federal and state laws. Indeed, 10 unions filed charges with the Equal Employment Opportunity Commission alleging that the BNSF requirement violated the federal Americans with Disabilities Act. Those charges remain pending. Simply stated, until there are some federal standards on medical qualification for such conditions as sleep apnea, other sleep disorders or, medical conditions that affect an employee's ability to work safely, it will be difficult to obtain and use such information without facing a variety of legal challenges. BNSF believes such information may be lawfully used to improve safety without violating employee rights and is an active participant in FRA’s Medical Standards Railroad Safety Advisory Council (RSAC) where this issue has been discussed. Essentially, BNSF told the NTSB that without related regulation, it is unable to comply with this recommendation. Safety Recommendation R-12-26 was therefore reclassified Open?Unacceptable Response. As discussed above, the NTSB is concerned the FRA is not making progress promulgating regulations requiring screening for OSA and other sleep disorders. Moreover, the NTSB is equally concerned some railroads may believe they are unable to adequately address the issue without FRA regulation. Further, the NTSB believes sleep disorders are part of a larger issue that the FRA is not addressing: medical fitness for duty. The NTSB recognizes the challenges organizations face with screening employees for sleep disorders or other medical conditions despite the fact that such screening, evaluation, and treatment will reduce the risk of catastrophic accidents and potentially improve the health and well-being of employees. The NTSB concludes that without evaluating safety-sensitive employees for sleep disorders or other medical conditions, increased risk to railroad employees, passengers, and the general public will remain, and the FRA has not adequately addressed the issue. Therefore, the NTSB recommends to the Association of American Railroads, the American Public Transportation Association, the American Short Line and Regional Railroad Association, the Brotherhood of Locomotive Engineers, and the International Association of Sheet Metal, Air, Rail and Transportation Workers collaborate to develop a model national labor agreement that supports effective programs for addressing sleep disorders and other medical conditions among safety-sensitive train operating personnel. In response to R-12-16, the FRA Administrator wrote to the NTSB citing the Rail Safety Improvement Act of 2008 (RSIA), which requires that certain railroads develop a Risk Reduction Program (RRP).61 Section 103(d)(2) of the RSIA (49 U.S.C. 20156) requires a railroad to include a Fatigue Management Plan in its RRP that meets the requirements of Subsection (f). 49 U.S.C. 20156(d)(2). As part of the development of Fatigue Management Plans, railroads will be required to provide opportunities for the identification, diagnosis, and treatment of any medical condition that may affect alertness or fatigue, including sleep disorders. The FRA Administrator went on to say, “Currently, FRA, in conjunction with a working group of members from the RSAC, is developing a fatigue management regulation that will be responsive to the requirements set forth in the RSIA.” The recommendation to the FRA was classified Open?Acceptable Response by the NTSB in October 2012. However, the RSIA specified a deadline of October 16, 2012, for this action and no action has yet been taken, nearly 2 years after the committed deadline. As a result, on November 17, 2014, NTSB reclassified Recommendation R-12-16 Open?Unacceptable Response. The NTSB concludes that had the FRA implemented NTSB recommendations R-02-24 and R-12-16, or complied with the legislated time limit in the RSIA to require fatigue management plans by railroads, Metro-North would have been required to appropriately screen, evaluate, and treat the engineer for obstructive sleep apnea prior to the December 1, 2013, derailment in The Bronx, and thus could have prevented the accident. Therefore, the NTSB reiterates R-12-16 and R-13-21.

From: NTSB
To: FRA
Date: 11/17/2014
Response: -From the NTSB report Collision of Union Pacific Railroad Freight Train with BNSF Railway Freight Train near Chaffee, Missouri, May 25, 2013, NTSB/RAR-14/02, Notation 8507A, adopted November 17, 2014: An August 23, 2012, letter to the NTSB from the BNSF Vice President for Training and Operations Support included the following paragraph in response to Safety Recommendation R-12-26: Previous attempts by BNSF to require additional medical information about certain safety related medical conditions, specifically including attempts to obtain medical information on sleep apnea, met with stiff resistance from our labor organizations who alleged that these attempts to obtain medical information were in violation of various federal and state laws. Indeed, 10 unions filed charges with the Equal Employment Opportunity Commission alleging that the BNSF requirement violated the federal Americans with Disabilities Act. Those charges remain pending. Simply stated, until there are some federal standards on medical qualification for such conditions as sleep apnea, other sleep disorders or, medical conditions that affect an employee's ability to work safely, it will be difficult to obtain and use such information without facing a variety of legal challenges. BNSF believes such information may be lawfully used to improve safety without violating employee rights and is an active participant in FRA's Medical Standards Railroad Safety Advisory Council where this issue has been discussed. Thus, at least one Class I railroad has been unable to accomplish appropriate evaluation for sleep disorders in the absence of regulation. In October 2008 Congress enacted the Rail Safety Improvement Act of 2008 (RSIA) (Pub. L. No. 110-432, div. A) following a head-on collision between a passenger train and a freight train in Chatsworth, California (NTSB 2010). Section 103(a) of the RSIA directed the Secretary of Transportation to require that most passenger and freight railroads develop fatigue management plans and to adopt regulations requiring creation of these plans no later than 4 years after enactment of the Act. These fatigue management plans were to include methods to manage and reduce fatigue experienced by railroad employees in safety-related positions and to reduce the likelihood of accidents, incidents, injuries, and fatalities caused by fatigue. In addition, fatigue management plan requirements specified in the RSIA include “opportunities for identification, diagnosis, and treatment of any medical condition that may affect alertness or fatigue, including sleep disorders” (49 United States Code § 20156(f)(3)). 31 In the FRA’s July 31, 2012, response to Safety Recommendation R-12-16, the FRA administrator wrote, “Currently, FRA, in conjunction with a working group of members from the Railroad Safety Advisory Committee, is developing a fatigue management regulation that will be responsive to the requirements set forth in the RSIA.” However, the time limit set by Congress for the Department of Transportation to create and issue this regulation passed on October 16, 2012. As noted previously, the Railroad Safety Advisory Committee medical working group continues to meet, but there has been no public output regarding fatigue management and no proposed changes to existing regulations since it was created. The NTSB concludes that had the medical screening described in Safety Recommendation R-12-16 been in place, or had the fatigue management components required by the RSIA of 2008 been in place, the UP engineer likely would have been identified as at high risk for sleep disorders, which may have led to appropriate medical intervention. Therefore, the NTSB reiterates Safety Recommendation R-12-16 and reclassifies it as OPEN--UNACCEPTABLE RESPONSE.

From: NTSB
To: FRA
Date: 11/17/2014
Response: -From the NTSB report Collision of Union Pacific Railroad Freight Train with BNSF Railway Freight Train near Chaffee, Missouri, May 25, 2013, NTSB/RAR-14/02, Notation 8507A, adopted November 17, 2014: Reiterates R-12-16

From: NTSB
To: FRA
Date: 11/7/2014
Response: From “Collision of Union Pacific Railroad Freight Train with BNSF Railway Freight Train Near Chaffee, Missouri, May 25, 2013 (NTSB Report NTSB/RAR-14/02): In the FRA’s July 31, 2012, response to Safety Recommendation R-12-16, the FRA administrator wrote, “Currently, FRA, in conjunction with a working group of members from the Railroad Safety Advisory Committee, is developing a fatigue management regulation that will be responsive to the requirements set forth in the RSIA.” However, the time limit set by Congress for the Department of Transportation to create and issue this regulation passed on October 16, 2012. As noted previously, the Railroad Safety Advisory Committee medical working group continues to meet, but there has been no public output regarding fatigue management and no proposed changes to existing regulations since it was created. The NTSB concludes that had the medical screening described in Safety Recommendation R-12-16 been in place, or had the fatigue management components required by the RSIA of 2008 been in place, the UP engineer likely would have been identified as at high risk for sleep disorders, which may have led to appropriate medical intervention. Therefore, the NTSB reiterates Safety Recommendation R-12-16 and reclassifies it as “Open--Unacceptable Response.”

From: NTSB
To: FRA
Date: 10/16/2012
Response: The NTSB is aware that the Rail Safety Improvement Act of 2008 (RSIA) requires (1) certain railroads to develop a Risk Reduction Program (RRP) and (2) all railroads to include in their RRPs fatigue management plans that meet the requirements of Subsection (f), 49 United States Code section 20156(d)(2). Further, as part of the development of Fatigue Management Plans, railroads will be required to provide opportunities for the identification, diagnosis, and treatment of any medical condition that may affect alertness or fatigue, including sleep disorders. Railroads will also be required to provide employee education and training on the physiological and human factors that affect fatigue. The FRA is currently collaborating with a working group from the RSAC to develop a fatigue management regulation that will be responsive to the requirements set forth in the RSIA; accordingly, Safety Recommendation R-12-16 is classified OPEN—ACCEPTABLE RESPONSE pending completion of the recommended action.

From: FRA
To: NTSB
Date: 7/31/2012
Response: -From Joseph C. Szabo, Administrator: Thank you for your May 10, 2012, letter to the Federal Railroad Administration (FRA) concerning National Transportation Safety Board (NTSB) Safety Recommendations R-12-16 through -22, R-02-24 through -26, and R-10-01 and -02. These recommendations were issued as a result the April17, 2011, rear-end collision of eastbound BNSF Railway (BNSF) coal train C-BTMCNM0-26, BNSF 9159 East, into standing BNSF maintenance-of-way equipment train U-BRGCRI-15, BNSF 9470 East, near Red Oak, Iowa. FRA has enclosed its responses to the above-mentioned recommendations. The FRA respectfully requests that NTSB classify Safety Recommendations R -12-16 through -20 and -22 as "Open-Acceptable Response." Additionally, we request that NTSB classify Safety Recommendations R-12-21 as "Closed-Reconsidered," and R-02-24 as "Closed-Acceptable Alternative Action." Lastly, FRA requests Safety Recommendations R-02-25 and -26, and R-10-01 and -02, remain "Open-Acceptable Response." I appreciate your interest in this important transportation matter. We look forward to working with you. The Rail Safety Improvement Act of 2008 (RSIA) (Public Law 110–432, Division A, 122 Stat. 4848-4906, enacted Oct. 16, 2008) requires, under Section 103, that certain railroads develop a Risk Reduction Program (RRP). 49 U.S.C. § 20156. Section 103(d)(2) of the RSIA requires a railroad to include a Fatigue Management Plan in its RRP that meets the requirements of Subsection (f). 49 U.S.C. § 20156(d)(2). As part of the development of Fatigue Management Plans, railroads will be required to provide opportunities for the identification, diagnosis, and treatment of any medical condition that may affect alertness or fatigue, including sleep disorders. Additionally, railroads will be required to provide employee education and training on the physiological and human factors that affect fatigue. Currently, FRA, in conjunction with a working group of members from the Railroad Safety Advisory Committee (RSAC), is developing a fatigue management regulation that will be responsive to the requirements set forth in the RSIA.