NTSB: Failure to screen NJ Transit engineer for sleeping disorder caused Hoboken crash

WASHINGTON — The chairman of the National Transportation Safety Board took the Trump administration to task Tuesday for killing a proposed rule that would have required train engineers and truck drivers to be screened for a sleeping disorder.

That condition, obstructive sleep apnea, was found to be a factor in a fatal September 2016 NJ Transit crash at Hoboken Terminal, as well as a January 2017 Long Island Rail Road crash in Brooklyn.

The NTSB also recommended that a form of positive train control be installed in rail terminals such as Hoboken's and Atlantic Terminal in Brooklyn. However, experts testified that the collision-avoidance system was designed to work primarily on high-speed main tracks, not in terminal areas.

While federal regulators continue to work toward technology that could be installed at roughly 35 rail terminals nationwide, train operators are the last line of defense to prevent collisions such as the ones in Hoboken and Brooklyn. And the NTSB said screening them for sleep apnea is a key part of ensuring their fitness for duty.

Experts testified that the NTSB had investigated five other train crashes since 2001 in which sleep apnea was a cause.

Both NJ Transit and the Federal Railroad Administration said they would review the NTSB's recommendations.

Chairman Robert Sumwalt said he was "mystified" why the Federal Railroad Administration and the Federal Motor Carrier Safety Administration withdrew the proposed requirement in August.

"I’m extremely disturbed that FRA has withdrawn the sleep apnea screening proposal," Sumwalt said. "It’s unacceptable."

Editorial: Sleep apnea and the fatal Hoboken crash

Initial coverage: High speed into chaos: Seeking answers after deadly NJ Transit train wreck

Medical check: NJ Transit didn't screen engineer for sleep apnea before Hoboken crash, records show

Complete coverage: Stories and videos from the Hoboken train crash

The NTSB on Tuesday presented its findings and recommendations on the Hoboken crash, bringing the board's 15-month investigation to a close. One person was killed and more than 100 others were injured in the Sept. 29, 2016, crash.

The board determined that the crash was caused by engineer Thomas Gallagher's failure to stop the train before it collided with an end-of-track barrier. It determined he was incapacitated by undiagnosed severe obstructive sleep apnea, a sleeping disorder that causes fatigue.

The board found that NJ Transit failed to account for both the risk of the collision with the track barrier and Gallagher's medical condition.

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NTSB medical expert Nicholas Webster testified that Gallagher had annual physical examinations, and that one in 2013 indicated that he exhibited risk factors for sleep apnea, but he was not referred for further evaluation.

Webster said sleep apnea screening forms were either missing or incomplete for three subsequent physical exams of Gallagher.

"There were multiple opportunities to screen him," Webster testified.

In the intervening years, Webster noted, Gallagher gained 90 pounds, further increasing his risk for sleep apnea. He was diagnosed and treated for the disorder only after the crash.

Webster further testified that the Hoboken train's conductor and brakeman exhibited risk factors for obstructive sleep apnea, but could not say whether they had the disorder, because NJ Transit's physicians never referred them for additional testing.

"We felt like their program, overall, was not effective," Sumwalt said of NJ Transit's approach to sleep apnea screening before the Hoboken crash.

Nancy Snyder, an NJ Transit spokeswoman, said the agency has developed an "aggressive" protocol that pulls employees who screen positive from active work and reinstates them only when they receive medical certification.

While NJ Transit and LIRR both have improved their processes for screening and testing safety-critical employees for sleep apnea, the Trump administration in August reversed an Obama administration proposal to make the testing mandatory.

As for concerns about cost, Webster said it's simple to screen employees to show whether they're at risk, and that treatment improves their quality of life and job performance.

"The traveling public deserves alert operators," Sumwalt said. "That’s not too much to ask."

NTSB experts also said both railroads had failed to identify recurring hazards in their system safety plans.

"Both railroads have a history of collisions at the end of the track," testified Georgetta Gregory, an NTSB rail investigator. "Neither identified it as a hazard."

Investigators in Hoboken had discovered evidence of numerous times when trains struck the barriers at the end of the track, but none as severe as the 2016 crash.

NJ Transit had received an exemption from federal regulators from installing positive train control at Hoboken Terminal. Snyder said NJ Transit is now developing a solution for terminal tracks that would effectively do what positive train control does.

Railroads, including NJ Transit and LIRR, are required by Congress to install the system by the end of this year. It is designed to prevent trains from taking curves too fast, or running past a stop signal or through an improperly aligned track switch.

Federal officials believe that the system could have prevented fatal crashes in recent years on Amtrak in Philadelphia and Metro-North in the Bronx, and, in recent months, deadly Amtrak derailments in Washington State and South Carolina.

But NTSB experts said that system, which relies heavily on GPS, cannot be counted on to slow or stop a train as it approaches the end of track in a terminal, and something else will be needed.

"We’re putting down the first brick in the wall," said Ted Turpin, an NTSB rail investigator.