Wednesday, February 07, 2018

NTSB says fatigue caused LIRR, NJ Transit accidents

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NJ Transit Pascack Valley Line train #1614 after crashing into the New Jersey Transit Hoboken Terminal Sept. 29, 2016. NJ Transit Pascack Valley Line train #1614 after crashing into the New Jersey Transit Hoboken Terminal Sept. 29, 2016. Chris O'Neil/NTSB

The National Transportation Safety Board (NTSB) determined that two commuter railroad terminal accidents in the New York area were caused by engineer fatigue resulting from undiagnosed severe obstructive sleep apnea.

The NTSB found the two accidents had "almost identical" probable causes and safety issues. The board also determined that these safety issues were not unique to these two properties, but exist throughout the country at many intercity passenger and commuter passenger train terminals.

The Sept. 29, 2016, accident on the New Jersey Transit railroad at Hoboken, N.J., killed one person, injured 110 and resulted in major damage to the station. The Jan. 4, 2017, accident on the Long Island Rail Road at the Atlantic Terminal in Brooklyn, N.Y., injured 108 people. Both accidents involved trains that struck end-of-track bumping posts and crashed into stations.

"The traveling public deserves alert operators," said NTSB Chairman Robert L. Sumwalt. "That is not too much to ask."

In August 2017, the Federal Railroad Administration (FRA) and Federal Motor Carrier Safety Administration withdrew a proposed rule that would have regulated actions addressing sleep apnea for workers in safety sensitive positions. FRA cited current safety programs and its own rulemaking addressing fatigue risk management as appropriate avenues to address the issue of sleep apnea monitoring.

At the time of the withdrawal, NTSB issued a statement expressing disappointment with the decision, stating, "Obstructive sleep apnea has been in the probable cause of 10 highway and rail accidents investigated by the NTSB in the past 17 years ... Medical fitness and fatigue, two of the NTSB's 10 Most Wanted List of Transportation Safety Improvements for 2017 – 2018, are tied to obstructive sleep apnea."

Following the incidents, Metropolitan Transportation Authority (MTA) said in January 2017 that it would expand its sleep apnea monitoring to include workers at LIRR, as well as other properties. NJ Transit outlined a series of safety initiatives it had instituted since the 2016 incident that included fatigue monitoring and replacing all stub end tracks at Hoboken Terminal with sliding friction bumper blocks.

The issue of positive train control (PTC) arose during the NTSB hearings, as well. NTSB explained that when operating a train into a terminating track, the engineer's actions, or lack thereof, solely determine whether the train stops before the end of the track.

"According to the FRA, there are currently no mechanisms installed in the U.S. that will automatically stop a train at the end of the track if the engineer is incapacitated, inattentive or disengaged. Some railroads have overspeed capabilities, including New Jersey Transit and the LIRR. However, as shown in these two accidents, once the engineer slowed the train to the prescribed speed, the system did not stop the trains before they reached the end of the track," NTSB said.

In addition to recommending safety-sensitive personnel be screened for obstructive sleep apnea, NTSB recommended the use of technology, such as PTC, in terminal stations and improving the effectiveness of system safety program plans to improve terminal operations. The NTSB made two recommendations to NJ Transit, and the MTA and two to the FRA.

"Today's new recommendations, if acted upon, have the potential to eliminate end-of-track collisions,'' Sumwalt said. "That translates to protection for passengers on trains, and for people standing on terminal platforms."