Safety Recommendation R-14-064
Synopsis: During the time period between May 2013 and March 2014, the National Transportation Safety Board (NTSB) launched investigative teams to five significant accidents on the Metro-North Railroad (Metro-North): (1) the May 17, 2013, derailment and subsequent collision in Bridgeport, Connecticut; (2) the May 28, 2013, employee fatality in West Haven, Connecticut; (3) the July 18, 2013, CSX derailment on Metro-North tracks in The Bronx, New York; (4) the December 1, 2013, derailment in The Bronx, New York; and (5) the March 10, 2014, employee fatality in Manhattan, New York. In combination, these accidents resulted in 6 fatalities, 126 injuries and more than $28 million in damages. The continued safe operation of Metro-North is vital to New York City and the tri-state area of New York, New Jersey, and Connecticut. As the NTSB investigations progressed, it became apparent that several organizational factors issues were involved in the accidents. The November 2013 NTSB investigative hearing on the Bridgeport and West Haven accidents (the NTSB hearing) explored the role of Metro-North and the Federal Railroad Administration (FRA) organizational factors in these accidents. The NTSB was not alone in observing that organizational factors were relevant to the series of Metro-North accidents. Subsequent actions by the FRA, which conducted a focused audit, and the Metropolitan Transportation Authority (MTA), which formed a Blue Ribbon Panel (BRP) to review safety and created an MTA Board Safety Committee to monitor safety, have reinforced the need to examine both the role of Metro-North and FRA organizational factors in relation to these five accidents. This special investigation report discusses all five of the recent Metro-North accidents investigated by the NTSB, examines some of the common elements of these accidents, and addresses the steps that Metro-North, the MTA, and the FRA have taken as a result of these investigations. The report also highlights lessons learned and provides recommendations to Metro-North, MTA, and several other entities to improve railroad safety on Metro-North and elsewhere.
Recommendation: TO METRO-NORTH RAILROAD: Develop and implement protocols to routinely screen and fully evaluate your safety-sensitive employees for sleep disorders and ensure that such disorders are adequately addressed if diagnosed.
Original recommendation transmittal letter: PDF
Overall Status: Closed - Acceptable Action
Mode: Railroad
Location: United States
Is Reiterated: No
Is Hazmat: No
Accident #: DCA14SS005
Accident Reports:
Report #: SIR-14-04
Accident Date: 4/2/2014
Issue Date: 11/24/2014
Date Closed: 11/8/2019
Addressee(s) and Addressee Status: Metro North Railroad (Closed - Acceptable Action)

Safety Recommendation History
From: NTSB
To: Metro North Railroad
Date: 11/8/2019
Response: We note that you have developed and implemented a program to identify and treat sleep disorders in your employees in safety-sensitive positions. We further note that all MTA railroad locomotive engineers, as well as MTA New York City Transit train and bus operators, are now routinely screened for sleep disorders, and you are in the process of extending this program to employees in other safety-sensitive positions, as well. You refer employees for diagnostic sleep studies when their screening results indicate that they are at risk for OSA, and employees who are diagnosed with sleep disorders are not disciplined, but are removed from safety-sensitive work until their medical issue is corrected. We believe that OSA is a critical medical issue, and we applaud your efforts to ensure your employees are screened and treated for it and other sleep disorders. Accordingly, Safety Recommendations R-14-62, -64, and -65 are classified CLOSED--ACCEPTABLE ACTION.

From: Metro North Railroad
Date: 5/10/2018
Response: -From Joseph J. Lhota, Chairman: As you are aware, the MTA has developed a very aggressive program to identify sleep disorders that screens, tests, and treats employees as necessary. A pilot program that screened all of MNR' s locomotive engineers was the basis for the "steady state" program now in place. To support this effort and ensure consistency in the screening program, a nationally-recognized sleep specialist was consulted and provided a Continuing Medical Education workshop for our physicians and occupational health services staff, focusing on sleep disorders with an in-depth segment focused on Obstructive Sleep Apnea (OSA). This workshop is available on video for any of our staff that wishes to refresh or for new staff to ensure consistency. All locomotive engineers at the MTA Railroads as well as train and bus operators at MTA New York City Transit are now screened routinely for sleep disorders. In addition, the MTA is in the process of extending the program to other safety sensitive positions and also will be educating all of its employees about the importance of adequate sleep as part of a broader wellness initiative. Those employees whose screening results indicate that they are at risk for Obstructive Sleep Apnea (OSA) are referred for a diagnostic sleep study. Employees who are diagnosed with OSA are required to demonstrate adherence to prescribed therapy. We are pleased to report that our program has screened all of the locomotive engineers at MNR and the LIRR (with the exception of a very small number of engineers who are in a non-work status). Because of our successful revision to our protocols and implementation of a robust sleep disorder, screening, testing and treatment program, we request that, recommendations (R-14-062, R-14-064 and R-14-065) be classified as "Closed-Acceptable Action."

From: NTSB
To: Metro North Railroad
Date: 3/17/2016
Response: We note that you (1) awarded a contract to Persante Health Care for a pilot OSA testing and treatment program, (2) set up the testing process as a wellness program, and (3), so long as an identified employee cooperates with the steps outlined in the program, he or she will be allowed to continue working. We further note that you have gained full union cooperation as you work to develop a robust program to routinely screen and evaluate safety sensitive employees for sleep disorders. We understand that you intend to continue to develop and evaluate the pilot program so that best practices can be applied to the permanent program. Pending confirmation that the permanent program has been fully implemented, Safety Recommendation R-14-64 is classified OPEN—ACCEPTABLE RESPONSE.

From: Metro North Railroad
Date: 6/15/2015
Response: -From Joe Giulietti, President: Metro-North has awarded a contract to Persante Health Care for an Obstructive Sleep Apnea testing and treatment pilot program. Metro-North has set up the testing process as a “wellness program,” and as long as the employees cooperate with the steps as outlined in the program, they will remain working. This was an important aspect of the pilot and has enabled us to achieve full cooperation with the labor organization (ACRE). This is an important first step as we work to develop a robust program that will routinely screen and evaluate safety sensitive employees for sleep disorders. We will continue to develop and evaluate the various aspects of this pilot program so that we can apply best practices to fully address this recommendation. We thank the NTSB for its consideration of this submission and we will continue to update you on our progress. If there is any additional information you need, we will be happy to provide it.