GOOD MORNING. I AM ROBERT SUMWALT. I AM HONORED TO HERE AS THE CHAIR OF THE NTSB. JOINING ME, MY COLLEAGUES ON THE BOARD, EARL WAINER AND VALAR DANZAR. WE MEET TO DISCUSS SIMILAR RAIL ACCIDENTS THAT HAPPENED WITHIN WEEKS OF EACH OTHER. THE TRAINS STRUCK BUMPING POSTS AT THE ENDS OF THEIR TRACTS AND CONTINUED INTO THE STATIONS. THE FIRST HAPPENED SEPTEMBER 29 2016 ON A NEW JERSEY TRANSIT COMMUTER RAILROAD AT HOBOKEN, NEW JERSEY. ONE PERSON DIED. THE PASSENGER STATION WAS BADLY DAMAGED. THE SECOND ACCIDENT, JANUARY 4, 2017 WAS A LONG ISLAND RAILROAD COLLISION IN BROOKLYN, NEW YORK INJURING 108 PEOPLE. ON BEHALF OF MY COLLEAGUES IN THE ENTIRE NTSB STAFF I WOULD LIKE TO OFFER OUR SINCEREST CONDOLENCES TO THE LOVED ONES OF THE PERSON WHO LOST THEIR LIFE IN THE HOBOKEN ACCIDENT IN THE HUNDREDS INJURED IN THESE TWO ACCIDENTS. WE HOPE YOU ARE ON YOUR WAY TO THE FULLEST RECOVERY POSSIBLE. TODAY WE WILL DISCUSS AS WE HAVE SO OFTEN IN THIS BOARD ROOM THE ROLE OF FATIGUE IN TWO MORE RAILROAD ACCIDENTS. AS WE WILL DISCUSS ONCE AGAIN, POSITIVE TRAIN CONTROL, PTC, WHICH CAN STOP A SPEEDING TRAIN AUTOMATICALLY. THE TRACK SEGMENTS WERE EXCLUDED FROM PTC REQUIREMENTS. WE WILL ALSO DISCUSS PLANS WHICH SHOULD IDENTIFY AND MITIGATE HAZARDS. BOTH RAILROADS HAD SUCH PLANS AND BOTH HAVE EXPERIENCED LESS SEVERE END OF TRACK COLLISIONS. TODAY THE NTSB WILL BRIEFLY PRESENT THE MOST PERTINENT FACTS AND ANALYSIS FOUND IN ITS SPECIAL INVESTIGATION. OUR PUBLIC DOCUMENT AVAILABLE AT NTSB.GOV CONTAINS MORE EXTENSIVE INFORMATION. STAFF HAVE PURSUED ALL AVENUES TO PROPOSE FINDINGS. PROBABLE CAUSES AND RECOMMENDATIONS TO THE BOARD. WE WILL QUESTION THE STAFF FOLLOWING THEIR PRESENTATIONS TO ENSURE THE REPORT AS WE ADOPTED TRULY PROVIDES THE BEST OPPORTUNITY TO ENHANCE SAFETY. AS YOU -- IF YOU WILL KINDLY ANNOUNCE THE STAFF.

I REQUEST THE FOLKS IN THE BOARD ROOM, IF YOU HAVE NOT DONE SO, PLEASE SILENCE YOUR MOBILE PHONES. THERE ARE TWO EXITS IN FRONT OF THE AUDITORIUM. ONE TO MY LEFT , ONE TO MY RIGHT. YOU MAY ALSO EXIT TO THE REAR OF THE AUDITORIUM. GO UP THE STAIRS AND EXIT THROUGH THE LARGE GLASS DOORS TO THE OUTSIDE. ONCE YOU HAVE EXITED TURN LEFT AND FOLLOW THE SIDEWALK TO THE END OF THE STREET. IN THE EVENT OF AN EMERGENCY WALK QUICKLY TO THE NEAREST EXIT. DO NOT DELAY. DO NOT RETURN TO THE BOARD ROOM UNTIL ADVISED TO. IF YOU HAVE ANY QUESTIONS DO NOT HESITATE TO CONTACT ANY NTSB PERSONNEL. JOINING US TODAY, TO MY IMMEDIATE RIGHT, ROBERT HALL, AND TO HIS RIGHT IS DAVE BUSCHER , TO HIS RIGHT IS TED TURPIN , IN CHARGE OF THE ATLANTIC TERMINAL ACCIDENT. HE'S ALSO THE PROJECT MANAGER FOR THE SPECIAL INVESTIGATION REPORT. TO HIS RIGHT, NICK WEBSTER. BEHIND HIM, RUBEN, -- AND DR. BOB BEATON. TO HIS LEFT, AND THE DIRECTOR OF RESEARCH. TO HIS LEFT, OUR GENERAL COUNSEL . TO HER LEFT, -- DIRECTLY BEHIND HIM, GLORIA WHO WILL BE HANDLING OUR VISUAL AND OUR TIMER. TO HER RIGHT, THE WRITER EDITOR. TO HER RIGHT IS MICHAEL HAMILTON WHO WILL BE HANDLING SAFETY RECOMMENDATIONS. TO HIS RIGHT, CASEY JOHNSON. WE WILL OPEN WITH DAVE BUSCHER.

GOOD MORNING CHAIRMAN AND MEMBERS. THE NTSB LAUNCHED INVESTIGATIVE TEAMS TO TWO SIMILAR ACCIDENTS WITHIN 13 WEEKS OF ONE ANOTHER. IN BOTH ACCIDENTS THE ENGINEERS FAILED TO STOP THEIR TRAINS BEFORE REACHING THE END OF A TERMINATING TRACK AT A STATION. THIS SPECIAL INVESTIGATION REPORT INCLUDES DISCUSSIONS OF BOTH ACCIDENTS. IT EXAMINES THE COMMON SAFETY ISSUES AND REVIEWS THE STEPS TAKEN IN RESPONSE TO THESE ACCIDENTS. I WILL BEGIN BY DISCUSSING THE NEW JERSEY TRANSIT ACCIDENT. ON SEPTEMBER 20 9, 2017 , 8:38 IN THE MORNING, NEW JERSEY TRANSIT TRAIN 1614 ENTERED HOBOKEN STATION, FAILED TO STOP, OVERRODE A BUMPING POST, AND CAME TO REST AFTER STRIKING A WALL OF THE HOBOKEN TERMINAL. AS A RESULT, ONE PERSON ON THE PLATFORM NEAR THE END OF THE TRACK WAS HIT BY FALLING DEBRIS AND DIED. 110 PEOPLE WERE INJURED. TOTAL DAMAGES TO THE TRAIN TRACK AND FACILITY, ESTIMATED AT 6 MILLION. THE NEW JERSEY TRANSIT TRAIN CREW CONSISTED OF AN ENGINEER CONDUCTOR AND BRAKEMAN. THEY WENT ON DUTY IN SPRING VALLEY, NEW YORK AND IMPARTED ON TIME AT 7:23 A.M. TRAIN 1614 MADE STOPS AT 16 PASSAGES, THE LAST STATION BEFORE HOBOKEN. AFTER DEPARTING, TRANSIT ESTIMATED THERE WERE 250-300 PASSENGERS ON THE TRAIN WHEN ARRIVING. ONE MINUTE BEFORE THE COLLISION , A RECORDER CAPTURED THE SOUND OF THE TRAIN HORN AND BELL WHILE THE TRAIN APPROACHED THE TERMINAL. THE TRAIN BILL CONTINUING -- CONTINUED UNTIL THE END OF THE RECORDING. THE EVENT RECORDER INDICATED 38 SECONDS BEFORE THE COLLISION THE THROTTLE INCREASED TO THE FOURTH POSITION. THE TRAIN SPRAYED -- BEATING REACHED A MAXIMUM OF 21 MILES PER HOUR. BEFORE THE COLLISION THE EVENT RECORDER INDICATED THE THROTTLE WENT FROM THE NUMBER FOUR POSITION DOWN TO IDLE. THE EMERGENCY BRAKE WAS APPLIED LESS THAN ONE SECOND BEFORE THE COLLISION WITH THE BUMPING POST WITH THE TRAIN STILL TRAVELING AT 21 MILES PER HOUR. THIS IS THE HEAD END CAP CAR, AFTER IT COLLIDED WITH THE WALL OF THE HOBOKEN TERMINAL. THE TRADE IMPACTED A SUPPORT COLUMN RESULTING IN PORTIONS OF THE ROOF OVER THE END STATION PLATFORM TO COLLAPSE ON AND INTO THE CAR. THE RED ARROW POINTS TO A LARGE STEEL SUPPORT BEAM THAT THEY'LL FROM THE ROOF STRUCTURE AS RESULT OF THE TRAIN IMPACT. THE STEEL BEAM WAS DRIVEN INTO THE INTERIOR OF THE LEAD CAR. THE YELLOW ARROW POINTS TO ADDITIONAL ROOFING MATERIALS INCLUDING CONCRETE THAT FELL INTO THE LEAD CAR. THESE ARE THE PARTIES OF THE INVESTIGATION. TED TURPIN WILL NOW PRESENT THE LONG ISLAND RAILROAD ATLANTIC TERMINAL ACCIDENT AND THE INTRODUCTION OF THE SPECIAL INVESTIGATION REPORT.

GOOD MORNING.

LONG ISLAND RAILROAD, PASSENGER TRAIN 2017 CONSISTING OF SIX CARS OVERRAN. IT CAME TO REST AT THE END OF THE TRACK. 108 PEOPLE WERE INJURED VERY DAMAGE WAS $5.3 MILLION. HERE IS A DIAGRAM OF THE TRACTS OF ATLANTIC TERMINAL. THE TRAIN ENTERED THE TERMINAL FROM THE RIGHT ON TRACK ONE. THE SIGNAL ON THE FAR RIGHT REQUIRE THE ENGINEER TO SLOW THE TRAIN TO RESTRICT ITS SPEED. THE TRAIN WAS GOING TO CROSS OVER TO MAIN TRACK 2. ADDITIONALLY THE OPERATING RULES REQUIRE THE ENGINEERS NOT EXCEED FIVE MILES PER HOUR. THEY NEXT SIGNAL REQUIRED ENGINEER TO CONTINUE AT RESTRICTED SPEED. ON THE DAY OF THE ACCIDENT THE TRAIN SLOWED TO 2.4 MILES PER HOUR ENTERING THE STATION TRACK WITH AN ACCELERATED 10 MILES PER HOUR, AND SLOW TO 8.5 MILES PER HOUR, AND GRADUALLY ACCELERATED TO 13 MILES PER HOUR WITH THE MASTER CONTROLLER IN THE MINIMUM POWER POSITION WHEN IT STRUCK THE BUMPING POST. WHEN STAFF COMPARED, THESE WERE THE PARTIES OF THE INVESTIGATION. THEY RECOGNIZE THEY HAD SEVERAL SIMILARITIES. BOTH ENGINEERS FAILED TO CONTROL THEIR TRAINS, SLEEP APNEA ISSUES, AND BOTH TRAINS OVERRAN THE TRACK, GRANTED AN EXEMPTION FROM POSITIVE TRAIN CONTROL ON THESE TERMINAL TRACTS. THE SPECIAL INVESTIGATION REPORT ADDRESSES THREE PRIMARY SAFETY ISSUES DEVELOPED FOR BOTH ACCIDENTS. IMPROVING MEASURES TO ENSURE ENGINEERS ARE FIT FOR DUTY, AND DEVELOPING AND IMPLEMENTING -- AND SLEEP APNEA.

GOOD MORNING. I WILL BE DISCUSSING UNDIAGNOSED , UNTREATED SEVERE DESTRUCTIVE SLEEP APNEA PRISON IN BOTH ENGINEERS INVOLVED IN THESE COLLISIONS. OBSTRUCTIVE SLEEP APNEA IS A CHRONIC DISEASE IN WHICH PATIENTS EXPERIENCE EPISODES OF AIRWAY OBSTRUCTION WHILE SLEEPING. THE PERSON STOPS BREATHING FOR A TIME , WHICH CAUSES OXYGEN LEVELS TO BUILD UP, AND CARBON DIOXIDE LEVELS TO RISE. WHEN THE BUILDUP GETS TOO HIGH THE BRAIN DETECTS IT AND THE PERSON WAKES TO PRE-. THE END RESULTS IS CHRONICALLY FRAGMENTED SLEEP, SLEEPINESS AND FATIGUE, WHICH WAY IT -- WHICH LEADS TO INCREASE ACCIDENT RISK. RISK FACTORS FOR OBSTRUCTIVE SLEEP APNEA INCLUDE MALE GENDER, OBESITY MUST SNORING, DAYTIME SLEEPINESS, HIGH BLOOD PRESSURE, AND LARGE AND HIP CIRCUMFERENCE. IT IS EASILY SCREENED FOR WITH A SIMPLE OFFICE QUESTIONNAIRE , AND NONINVASIVE MEASUREMENTS. WHEN INDIVIDUAL MEETS SCIENTIFICALLY VALIDATED REFERRAL CRITERIA, THEY SHOULD BE REFERRED FOR TESTING. IF THEY ARE DIAGNOSED WITH SLEEP APNEA THEY CAN BE TREATED WITH A NUMBER OF DIFFERENT OPTIONS. INDIVIDUALS WITH TREATED OBSTRUCTED SLEEP APNEA ARE AT REDUCED RISK OF FATIGUE AND ACCIDENTS COMPARED TO UNTREATED INDIVIDUALS. I AM GOING TO DISCUSS THE SCREENING PROGRAM. NEW JERSEY TRANSIT REQUIRES PERIODIC PHYSICAL EXAMINATIONS WHICH IS SUPPOSED TO INCLUDE DOCUMENTATION OF RISK FACTORS, INCLUDING ENGINEERS, CONDUCTORS, AND BRAKEMAN. THE ENGINEER RECEIVED ANNUAL EXAMINATIONS. THE ONLY FULLY COMPLETED SCREENING FOR HIM WAS FROM 2013 , AND FORMS FOR SUBSEQUENT EXAMS WERE INCOMPLETE OR NOT LOCATED AT ALL. IN 2013 HE MET CRITERIA FOR A REFERRAL FOR A SLEEP STUDY AND MET CRITERIA ON THREE SUBSEQUENT EXAMS BUT WAS NOT SENT FOR A SLEEP STUDY. THE NGA TX EVENT MET CRITERIA FOR REFERRAL BUT HAD NOT BEEN REFERRED FOR A SLEEP STUDY. A SLEEP STUDY IS USED TO DETERMINE IF AN AT RISK INDIVIDUAL HAS OBSTRUCTED SLEEP APNEA. THE SOFT TISSUES OF THE AIRWAY OBSTRUCT FLOW DURING SLEEP. THE IMAGE ON THE LEFT DEMONSTRATES NORMAL BREATHING. THE IMAGE ON THE RIGHT DEMONSTRATES AN EXAMPLE OF THE SOFT TISSUES IN THE THROAT OBSTRUCTING THE AIRWAY DURING SLEEP. THE EXTENT OF OBSTRUCTION IS MEASURED DURING SLEEP STUDIES BY INDIVIDUALS APNEA, OR A HI. THIS IS A MEASURE OF HOW MANY TIMES AN HOUR A SLEEPING PATIENT STOPS BREATHING , OR IS BREATHING IN ADEQUATELY FOR HIS BLOTTERS -- BODIES KNEES -- BODY'S NEEDS. AND A HI OF 30 TIMES IN OUR INDICATES SEVERE SLEEP APNEA. ABOUT TWO WEEKS AFTER THE ACCIDENT THE ENGINEER WAS REFERRED FOR A SLEEP STUDY. THE STUDY REVEALED AN AIH INDICATING SEVERE SLEEP APNEA. THE SLEEPING OXYGEN SATURATION ABOVE 95% IN AN AWAKE ADULT DROP TO 53% WHILE HE WAS SLEEPING AS RESULT OF FAILING TO ADEQUATELY BREATHE. THE ENGINEER WAS DIAGNOSED WITH SEVERE OBSTRUCTIVE SLEEP APNEA, PRESCRIBED CONTINUOUS POSITIVE AIRWAY PRESSURE TO TREAT THE CONDITION. I AM NOW GOING TO DISCUSS THE LONG ISLAND RAILROAD OBSTRUCT TO OSA SCREENING. AT THE TIME OF THE BROOKLYN NEW YORK ACCIDENT, OSA SCREENING WAS PLANNED BUT HAD NOT IMPLEMENTED. THE LIRR ENGINEER HAD NOT BEEN REFERRED FOR A SLEEP STUDY. SHORTLY AFTER THE ACCIDENT THEY LONG ISLAND ENGINEER WAS ALSO REFERRED FOR OSA TESTING. HE WAS ALSO DIAGNOSED WITH SEVERE OBSTRUCTIVE SLEEP APNEA AND WAS PRESCRIBED CPAP FOR TREATMENT. THE NTSB HAS INVESTIGATED MULTIPLE RAILROAD ACCIDENTS CAUSED BY FATIGUE FROM UNDIAGNOSED, UNTREATED OR INACCURATE -- IN ADEQUATELY TREATED SLEEP APNEA. IN RED OAK IOWA, AGAIN, IN THE BRONX, NEW YORK, IN 2013. THEN AGAIN IN 2014. ALL THESE ACCIDENTS HAD A COMMON SAFETY PROBLEM. INADEQUATE SCREENING THE DIAGNOSIS OR TREATMENT OF OBSTRUCTED SLEEP APNEA AND SAFETY SENSITIVE WORKERS THAT LED TO WORK OR IMPAIRMENT, AND DERAILMENT OR COLLISIONS INVOLVING TENS OF MILLIONS OF DOLLARS OF DAMAGE. SIGNIFICANT INJURIES AND LOSS OF LIFE. IN THIS REPORT WE HAVE TWO MORE EVENTS. IN HOBOKEN, NEW JERSEY AND IN THE LIRR ACCIDENTS. THEY ARE FURTHER EVIDENCE OF THE HAZARD THAT UNDIAGNOSED AND UNTREATED OBSTRUCTIVE SLEEP APNEA POSED TO PUBLIC TRANSPORTATION SAFETY. OVER THE LAST 16 YEARS THERE HAVE BEEN EIGHT SAFETY RECOMMENDATIONS REGARDING THE NEED TO AGGRESSIVELY SCREEN AND ENSURE SAFETY EMPLOYEES ROUTINELY RECEIVE ADEQUATE TREATMENT FOR OBSTRUCTIVE SLEEP APNEA. SINCE THE ACCIDENT, BOTH NEW JERSEY TRANSIT AND LONG ISLAND RAILROAD HAVE MADE SIGNIFICANT SAFETY ADVANCES WITH PROGRAMS FOR OBSTRUCTIVE SLEEP APNEA. IN MARCH, THEY REQUESTED DATA CONCERNING THE PREVALENCE OF MODERATE TO SEVERE SLEEP APNEA AND THE CONSEQUENCES TO TRANSPORTATION SAFETY. THIS MOVE TOWARDS IMPROVED SAFETY WAS SHORT-LIVED. IN AUGUST 2017, THEY WITHDREW AND INDICATED THEY WOULD NOT CONTINUE DEVELOPING REGULATIONS TO ADDRESS SLEEP DISORDERS. THE AGENCIES BELIEVE CURRENT SAFETY PROGRAMS AND RULEMAKING ADDRESSING FATIGUE RISK MANAGEMENT ARE THE APPROPRIATE AVENUES TO ADDRESS OSA. IS THIS REPORT DEMONSTRATES ACCIDENTS INVOLVING OBSTRUCTIVE SLEEP APNEA CONTINUED TO OCCUR AND DEMONSTRATE THE SIGNIFICANT HAZARD UNDIAGNOSED, UNTREATED OSA POSES TO RAIL SAFETY. IT WOULD LIGHTLY MITIGATE THESE HAZARDS. ON JANUARY 18, 2018, THE COMMUNICATED -- NTSB COMMUNICATED THAT THERE HAD BEEN KNOWN TO THE CAN PROGRESS ON ROW MAKING TO MITIGATE THESE HAZARDS. OSA POSES TO RAIL SAFETY AND INFORMED THE FRA THAT 1216 AND ARE 16 044 WATER OPEN -- WERE OPEN. STAFF HAS THESE RECOMMENDATIONS. THANK YOU. MR. PIYAM WILL NOW DISCUSS SAFETY CONTROL.

CONGRESS --TO IMPLEMENT A POSITIVE TRAIN CONTROL SYSTEM ON MOST MAINLINE TRACTS. IN ADDITION TO THE 4 PRIMARY REQUIREMENTS ON THIS SLIDE, RAILROADS MUST EQUIP LOCOMOTIVES SO THEY ARE INTEROPERABLE WITH OTHER RAILROADS, TO ALLOW UNINTERRUPTED TRAIN MOVEMENTS. IN OCTOBER 2008 THE REAL SAFETY IMPROVEMENT ACT MANDATED IT TO BE INSTALLED NO LATER THAN DECEMBER 31, 2015. IN OCTOBER, CONGRESS EXTENDED THE DEADLINE BY THREE YEARS UNTIL DECEMBER 2018. A RAILROAD MAY HAVE THIS DEADLINE EXTENDED BY TWO YEARS PROVIDED THE RAILROADS MEET CERTAIN CRITERIA ESTABLISHED BY THE FRA. WITHOUT AN EXTENSION THE CURRENT DEADLINE IS ONLY 10 MONTHS AWAY. LET'S REVIEW THE PROGRESS. THIS GRAPHIC PROVIDED BY THE FRA REPRESENTS THE PTC IMPLEMENTATION STATUS OF THE LONG ISLAND RAILROAD AND NEW JERSEY TRANSIT. AS SEEN IN THE GRAPHIC, THERE IS AN EXTENSIVE AMOUNT OF WORK REMAINING TO MEET THE DEADLINE. IN ADDITION TO THE POSSIBLE TWO-YEAR EXTENSION, REGULATIONS ALLOW RAILROADS EXEMPTIONS OR EXCLUSIONS FROM IMPLEMENTATION WITHIN YARDS AND TERMINAL STATIONS IF CERTAIN CRITERIA ARE MET. AT THIS TIME HOBOKEN AND ATLANTIC TERMINALS HAVE BEEN GRANTED EXEMPTIONS AND THEREFORE ARE NOT INSTALLING ON TERMINAL TRACTS. WITHOUT ANY SAFETY DEVICES, COLLISIONS WILL MOST LIKELY CONTINUE TO OCCUR AND MAY RESULT IN LOSS OF LIFE, CAUSE INJURIES AND PROPERTY DAMAGE. STAFF HAVE PROPOSED A RECOMMENDATION IN THIS AREA. THAT CONCLUDES MY PRESENTATION. MS. GREGORY WILL NOW ADDRESS SYSTEM SAFETY.

GOOD MORNING. I WILL REVIEW THE THESE ELEMENTS OF SYSTEM SAFETY. THE FEDERAL WROTE WORD ADMINISTRATION FIND SYSTEM SAFETY IS PROACTIVE PROCESSES AND PROCEDURES TO IDENTIFY AND MITIGATE OR ELIMINATE HAZARDS. HAZARDS SHOULD BE MINIMIZED TO THE HIGHEST LEVEL PRACTICAL. ORGANIZATION SHOULD DO THAT IF I -- IDENTIFY THAT INCLUDING SYSTEMS, PROGRAMS, PROJECTS, OPERATIONS AND FACILITIES. SAFETY MANAGEMENT SYSTEM IS A FULL BOARD PHILOSOPHY THAT OUTLINES HOW AN ORGANIZATION MANAGES THE D. IT IS THE BUSINESS APPROACH TO MANAGING SAFETY REQUIRING SYSTEMATIC ATTENTION TO THOSE THINGS THE ORGANIZATION BELIEVES IMPORTANT AND MANAGES AND VALUE SAFETY JUST AS THEY MANAGE AND VALUE OTHER VITAL BUSINESS ASPECTS. IT IS A FORMAL TOP-DOWN ORGANIZATION APPROACH TO MANAGING RISK. BUSINESS AND SAFETY STRATEGIES TO SUPPORT A POSITIVE SAFETY CULTURE. THERE ARE FOUR COMPONENTS. SAFETY MANAGEMENT POLICY. SAFETY RISK MANAGEMENT. SAFETY ASSURANCE. SAFETY PROMOTION. TODAY I WILL BE ADDRESSING SAFETY RISK MANAGEMENT. THE SYSTEM SAFETY PROGRAM PLAN IS A TOP-LEVEL GOVERNING DOCUMENT THAT ESTABLISHES THE ORGANIZATION SAFETY STRATEGIES AND PROVIDES THE MEANS FOR IMPLEMENTING THIS SYSTEM SAFETY THROUGHOUT THE OPERATIONAL SYSTEM. THE AMERICAN PUBLIC TRANSPORTATION ASSOCIATION PUBLISHED A VOLUNTEER STANDARD AS GUIDANCE TO HELP IN DEVELOPING SYSTEM SAFETY PROGRAM PLANS. THIS INCLUDES ELEMENTS FOR INCLUSION IN A SYSTEM SAFETY PROGRAM PLAN. AT THE TIME OF THESE ACCIDENTS IN NEW JERSEY TRANSIT AND THE LONG ISLAND RAILROAD HAD LONG-ESTABLISHED PLANS BASED ON THE APT STANDARD. RISK MANAGEMENT IS AT THE HEART OF THE PROGRAM PLAN AND IS ONE OF THE CORE COMPONENTS. RISK MANAGEMENT IS A FORMAL SYSTEM OF HAZARD IDENTIFICATION ANALYSIS AND MITIGATION. THIS INCORPORATES SYSTEMATIC METHODS WITH ANALYZING AND CONTROLLING HAZARDS. RISK MANAGEMENT AIDS IN REDUCING ERRORS AND IMPROVING TASK ACCOMPLISHMENTS THROUGH INCREASED EFFICIENCY. THE NEW JERSEY TRANSIT AND THE LONG ISLAND RAIL PREFERENCE THE MILITARY STANDARD AS THE TOOL FOR HAZARD ANALYSIS TO DETERMINE THE PROBABILITY AND CRITICALITY OF AN IDENTIFIED HAZARD. HE INTENDS TO APPLY THAT PROCESS TO ALL HAZARDS. BOTH RAILROADS HAVE A HISTORY OF COLLISIONS AT THE END OF THE TRACK THAT NEITHER HAD COMPLETED A FORMAL HAZARD ANALYSIS. BOTH RAILROADS RELIED ON CREW MEMBER COMPLIANCE TO AVOID THESE COLLISIONS. EITHER RAILROAD HAD A COMPLETED RESPECT TO FITNESS FOR DUTY. THE SYSTEM PLAN ON BOTH RAILROADS FAILED TO DISCUSS THE PROCESS FOR IDENTIFYING OR MANAGING THESE TWO HAZARDS. THE ACCIDENTS ARE EXAMPLES OF INEFFECTIVE HAZARD MANAGEMENT AND ARE PROPOSING SAFETY RECOMMENDATIONS IN THIS AREA. IN ANTICIPATION OF THE FEDERAL RULE REQUIREMENT IN NEW JERSEY TRANSIT AND THE LONG ISLAND RAILROAD ESTABLISHED SYSTEM SAFETY PLANS MANY YEARS AGO. BOTH HAVE A HISTORY OF COLLISIONS AT THE END OF THE TRACK. THE NEW JERSEY TRANSIT NOR THE LONG ISLAND RAILROAD IDENTIFIED COLLISIONS AT THE END OF THE TRACK AS A HAZARD. NEITHER IDENTIFIED ENGINEERED IMPAIRMENT CAUSED BY FATIGUE AS A HAZARD. THOSE RAILROADS WERE INEFFECTIVE IN IDENTIFYING HAZARDS. THE ACTIONS TAKEN BY THE FEDERAL RAILROAD ADMINISTRATION TO ADDRESS SYSTEM SAFETY RESULTED IN THE PROPOSAL OF A NEW REGULATION, 49, PORT TO 70. THE FRA ISSUED ITS FINAL RULE FOR THIS REGULATION IN 2016 , BUT SUBSEQUENTLY STAYED ITS EFFECTIVE DATE FIVE SEPARATE TIMES. THE LATEST OCCURRING NOVEMBER 30, 2017 DELAYS THE EFFECTIVE DATE UNTIL DECEMBER 4, 2018. THE FRA PUBLISHED THE ANALYSIS GUIDE. FOR CONDUCTING A HAZARD ANALYSIS USING COMPUTER RAILROADS. THEY CAN FORMALIZE THE PROCESS FOR HAZARD ANALYSIS AND ADDRESS HAZARDS SUCH AS TRAINS OVERRUNNING THE END OF A TRACK. AFTER 23 YEARS, WE ARE STILL WAITING FOR THE A-FRET TO PUBLISH A SYSTEM SAFETY RULE FOLLOWING THE INVESTIGATION INTO A 2016 ACCIDENT IN WHICH THEY STRUCK A BACKHOE IN PENNSYLVANIA. WE CONCLUDED BY DELAYING PROGRESSIVE SAFETY REGULATIONS, THE FRA HAS FAILED TO MAXIMIZE SAFETY STANDARDS AND THE TRAVELING PUBLIC. THE HOBOKEN AND ATLANTIC TERMINAL ACCIDENTS FURTHER ILLUSTRATE THE NEED FOR THE FRA TWO AND A SAFETY REGULATION THAT WOULD STANDARDIZE THE APPROACH TO SYSTEM SAFETY WITH THE ADDITION OF THE COLLISION HAZARD ANALYSIS GUIDES. THE RIVER ROAD COULD DEVELOP A PROCESS FOR IDENTIFICATION. STAFF HAS PROPOSED RECOMMENDATIONS TO ADDRESS THESE ISSUES. THIS CONCLUDES THE PRESENTATION . STAFF IS PREPARED TO ANSWER ANY QUESTIONS. THANK YOU.

THANK YOU TO THE ENTIRE STAFF ARE THOSE PRESENTATIONS. I WILL NOW TORN -- TURN TO THE BOARD MEMBER QUESTIONS.

THANK YOU. THANK YOU MR. HALL AND YOUR COLLEAGUES FOR THIS S IR AND YOUR HARD WORK. THANK YOU FOR YOUR PRESENTATION ON PTC. WE HAVE DISCUSSED PTC QUITE A LOT IN THE LAST FEW YEARS, EVEN ON OUR LAST TWO YEARS COMPLETED INVESTIGATIONS LIKE PHILADELPHIA , CHESTER, OTHER PLACES. I HAVE BEEN A STRONG SUPPORTER OF THE NTSB PTC RECOMMENDATIONS . I ALSO THINK WE SHOULD NOT FORGET ABOUT THE OTHER TECHNOLOGIES THAT CAN BE AN ADDITIONAL LAYER OF SAFETY IN CERTAIN ACCIDENTS. IN THIS CASE I WOULD LIKE TO ASK YOU ABOUT BOTH PTC AND THESE OTHER TECHNOLOGIES AND DEVICES. IN BOTH OF THESE ACCIDENTS WE SOLVE THE ENGINEERS BROUGHT THE TRAIN DOWN TO THE REQUIRED SPEED AT THE LAST SIGNAL, BUT AFTER PASSING THAT SIGNAL THEY WERE ABLE TO BRING THE SPEED BACK UP AGAIN. COULD YOU BRIEFLY EXPLAIN HOW THAT IS POSSIBLE?

I WILL FOCUS ON THE ATLANTIC TERMINAL. I AM MORE FAMILIAR WITH THAT ONE. THE TRADITIONAL SYSTEM THAT WAS THERE ALLOWED THE SIGNAL TO PROCEED PAST THE INTERLOCKING AT RESTRICTED SPEED. THERE WAS NO SPEED COAT WHICH IS A CODE TO THE TRAIN WHICH RESTRICTS IT TO 50 MILES PER HOUR. HAD THE TRAIN EXCEEDED 50 MILES PER HOUR IT WOULD HAVE RECEIVED A PENALTY. ON TOP OF THE RESTRICTED SPEED THE RAILROADS HAD AN ADDITIONAL REQUIREMENT TO OPERATE TRAINS INTO THE TERMINAL. THE FIVE MILES PER HOUR WAS ONLY ENFORCED BY THE OPERATOR. THERE WAS NO SIGNAL SIGNAL -- SIGNAL ENFORCING THAT. ABOVE THAT THE SIGNAL SYSTEM WOULD HAVE PENALIZE THEM. THE GAP BETWEEN THE OPERATOR AND THE SIGNAL SYSTEM IS WHERE THE TRAIN WAS ALLOWED TO ACCELERATE INTO THE END OF THE TRACK.

THANK YOU. CLEARLY YOU ARE EXPERIENCED IN SIGNALS. CAN YOU EXPLAIN THE TERMINAL LOCATION LIKE IN HOBOKEN?

THE MAIN ITEM, THAT PTC USES, A LOT OF THESE SYSTEMS ARE GOING TO USE GPS. THERE ARE A LOT OF TRACTS, SHORT TRACK CIRCUITS. LOW SPEEDS THAT TRAINS OPERATE ON. TO MAIN TRAIN -- MAINTAIN IN THESE LOCATIONS, ESPECIALLY WHEN THEY ARE UNDERGROUND, YOU RESULT TO WHEEL ROTATIONS. THE LONGER YOU GO WITHOUT GPS, THE MORE AIR YOU INTRODUCE INTO YOUR TRAIN LOCATION. ON TOP OF THAT THERE IS THE SHORT TRACK CIRCUITS AND THE SLOW SPEED THE TRAIN OPERATES ON. THROUGHOUT THE RAILROADS, THEY MUST THE ABLE TO OPERATE TRAINS AT LOW SPEED, TO ACCOMMODATE FOR TRAINS THAT BREAK DOWN, TO UNCOUPLE TRAINS. THERE IS A MARGIN WHERE YOU HAVE TO ALLOW TRAINS TO OPERATE AT SLOW SPEED WITHOUT STOPPING THEM BECAUSE YOU WANT THEM TO PROCEED. THERE IS THAT OPERATING VARIANCE THAT IS RECOVERING -- REQUIRED SOMETIMES.

IN THIS REPORT WE ARE NOT RECOMMENDING PTC BUT RECOMMENDING THE FRA REQUIRE REVERENCED IMPLEMENT TECHNOLOGY TO STOP A TRAIN BEFORE REACHING THE END OF THE TRACTS. COULD YOU TELL ME WHAT KIND OF TECHNOLOGY EXISTS THAT WOULD DO THAT?

THAT IS THE BIG HURDLE THEY ARE TRYING TO FIGURE OUT. FRA REALIZED THIS OPEN CHANCE FOR AN OPEN ACCIDENT REGARDING THIS AREA. PTC WAS DESIGNED FOR MAINLINE HIGH-SPEED TRAIN SEPARATION. THEY HAVE BEEN WORKING WITH UNIVERSITIES TO SEE ABOUT A SYSTEM THAT CAN WORK AT TERMINALS AND THEY HAVE DONE SOME TESTS, AND THEY HAVE MORE SCHEDULES. WE HAD A MEETING WITH THEM AND THEY TOLD US BELT RESULTS THEY GOT FROM THEIR FIRST TEST. THEY ARE STILL WORKING ON TESTS BEFORE THEY COME OUT WITH SOMETHING THAT MIGHT HELP.

THERE ARE TECHNOLOGIES IN DEVELOPMENT.

YES. THEY HAVE DONE SOME PRELIMINARY TESTS. THEY HAD FAVORABLE RESULTS WITH THOSE TESTS.

I DO UNDERSTAND AS A STRONG PROPONENT AS I AM, I UNDERSTAND IT -- WHAT ABOUT INDUCTIVE TRAIN STOPS UTILIZED IN SOME LOCATIONS ? AT LEAST ONE THAT I KNOW INSURERS ENGINEERS ARE ENGAGED WITH THE FACT THAT THEIR TRAIN IS ENTERING A TERMINAL. COULD THAT BE A TYPE OF TECHNOLOGY USED EITHER AT THE METRO-NORTH RAILROAD OR THE ALLY ARE?

INDUCTIVE TRAIN STOPS HAVE BEEN AROUND SINCE THE 1940'S. IT IS ALL TECHNOLOGY -- OLD TECHNOLOGY. BUT THE DESIGN HAS BEEN AROUND FOR A LONG TIME. THE ONLY DOWNSIDE OF THIS TECHNOLOGY, IT IS REACTIVE. IT WAITS FOR THE ENGINEER TO VIOLATE THE SIGNAL BEFORE IT APPLIES THE BRAKES. IN SOME INSTANCES IF THE TRAIN COMES IN TO FAST -- TOO FAST, THERE MAY NOT BE ENOUGH SPACE TO STOP THE TRAIN BEFORE HE IS PENALIZED.

IS IT POSSIBLE FOR A RAILROAD TO PLACE TEMPORARY STOP TRANSPONDERS JUST OUTSIDE THE TERMINAL STATION TO ENFORCE ADDITIONAL STOPS AND ENSURE THAT A TRAIN DOES NOT RUN INTO A STOPPING POST?

THERE IS. SOME OF THE METHODS BEING USED TO PROTECT WORKERS OUT THERE, TEMPORARY TRANSPONDERS. THE MAIN HURDLE IS PRECISE TRAIN LOCATION. TO KNOW WHERE TO STOP, TO KNOW HOW FAR TO GO IS THE CHALLENGE. THE LONGER THE TRAIN GOES WITHOUT A GPS OR PRECISE LOCATION OF THE MORE AIR YOU INTRODUCE INTO THE LOCATION. IT IS HARDER TO LOCATE HOW TO STOP THE TRAIN.

MY TIME IS UP. THANK YOU, CHAIRMAN.

THIS WILL BE A QUESTION FOR EITHER MR. BOOKER OR MR. TURPIN. HOW MANY TRAIN TERMINALS HAVE THIS CONFIGURATION WITH MULTIPLE TRACTS GOING IN?

WHEN WE INITIALLY SENT OUT REQUESTS, THEY HAD 35 TERMINALS WITH MULTIPLE TRACTS THROUGHOUT THE UNITED STATES. SINCE THEN THEY HAVE UPDATED THAT AND GAVE US MORE DETAILS. THERE ARE 42. OF THOSE SOME ARE WITHIN A YARD AND THEY DO NOT HANDLE REVENUE PASSENGERS. WE ASKED THEM TO COME BACK WITH A DETAIL OF EXACTLY HOW MANY THERE ARE A WE HAVE YET TO HEAR FROM THEM. WE SAY AT LEAST 35 THROUGHOUT THE UNITED STATES. BASICALLY THERE ARE 35 THAT WE KNOW OF.

ALL OF THESE HAVE BEEN GIVEN EXEMPTIONS. DOES THAT EXTEND TO OTHER TECHNOLOGIES WHICH MIGHT SUPERSEDE IN THIS TERMINAL ARRIVAL?

IN TRYING TO IMPLEMENT COME IT DOES NOT EXCLUDE ANY OTHER METHOD OR DEVISE.

IS IT TRUE TO SAY THAT THE REQUIREMENTS THAT THEY HAD TO MEET FROM A DESIGN POINT OF VIEW WERE INADEQUATE IN TERMS OF NOT REQUIRING THE KIND OF PROTECTION IN THE TERMINAL AREA?

I AM NOT SURE I WOULD CATEGORIZE IT AS INADEQUATE. THE INITIAL THRUST WAS MAIN TRACK OPERATIONS AND COLLISIONS . AS IT GREW THEY GOT TO THIS POINT WHERE THEY LOOKED AT TERMINALS AND SAID THIS SYSTEM CAN'T GET THROUGH THESE COMPLEX TRACTS DOWN TO THE END OF A STATION TRACK. I THINK THEY FOUND THAT OUT AFTER THE FACT WHEN THEY WERE LOOKING AT PTC. THEY WILL HAVE TO CREATE AN EXCLUSION FOR THOSE COMPLEX TERMINALS. DID THAT ANSWER YOUR QUESTION?

I WAS LOOKING AT IT FROM A DESIGN POINT OF VIEW. THE REQUIREMENTS THAT COULD TELL YOU WHAT IT HAS TO PERFORM. IT JUST SEEMS THAT WE ARE MISSING AN AREA WHERE WE NEED PROTECTION BUT WE DON'T HAVE IT IN THE REQUIREMENTS.

CORRECT. THAT IS WHAT WE ARE TRYING TO POINT OUT HERE. WE RECOGNIZE IT IS COMPLEX. MAYBE TOO COMPLEX. WE ARE THE INDUSTRY TO JOIN FORCES AND FIGURE OUT A METHOD TO PREVENT TRAINS FROM REACHING THE END OF THE TRACK.

WHO WAS INVOLVED IN THAT? IT SOUNDS LIKE A CONSORTIUM OF SOME SORT.

HE WOULD BE THE RESULT OF THE RECOMMENDATION WE MAKE. THEY WILL REACH OUT AND ASK ABOUT IT. I BACKTRACK ABOUT WHAT WAS SAID EARLIER. 30 YEARS AGO WE SAID WE NEED PTC. THERE WAS NOT ANYTHING OFF THE SHELF YOU COULD GET. SINCE THEN THEY HAVE DEVELOPED AND STANDARDIZED. NOW WE ARE DOING THE SAME THING WITH THE END OF THE TRACK AND A COMPLEX TERMINAL. HERE IS THE GOAL. STOP THE TRAIN BEFORE THE END OF THE TRACK. DON'T RELY ON ENGINEERS TO STOP THE TRAINS. WE HAVE HAD TOO MANY FAILURES. WE ARE JUST STARTING. FRA, WE NEED YOU TO FIGURE OUT A WAY TO STOP TRAINS.

EXPERIENCES SHOWN THAT FOR HIGHER RELIABILITY THERE ARE MULTIPLE LEVELS OF INTERVENTION, SAFETY REQUIRED. GOING BACK TO THE MODEL FOR SWISS CHEESE, YOU HAVE TO GET THE HOLES TO LINE UP. ONE OF THOSE LAYERS IS I PRESUME THE OPERATING RULES. IS THERE AN OPERATING RULE THAT SAYS YOU DON'T HIT A BUMPING POST?

I DON'T KNOW THAT I READ ONE THAT SAID DO NOT HIT THE END OF THE TRACK. THERE IS A SPOT ON THE PLATFORM. THAT IS AN INTERESTING THING. THEY ARE NOT SUPPOSED TO HIT THE END OF THE TRACK. THEY ENTERED THE LONG ISLAND RAIL WITH FIVE MILES PER HOUR AT THE TIME.

IT IS INTERESTING TO SPECULATE ON THE SAFETY ANALYSIS. THEY ASSUME THAT THE RULES HAVE BEEN BROKEN, AND TO SAY WHAT ELSE IT TURNS OUT TO HAVE SIGNIFICANT SAFETY ISSUE.

THAT IS THE DIRECTION WE WOULD LIKE TO HAVE GONE. WHAT WE BELIEVE, THEY FELT THE COMPLIANCE WITH THE RULE WAS THE MITIGATING FACTOR.

IN TERMS OF AVIATION SAFETY, THE FAA HAS A RULE THAT SAYS IF YOU HAVE AN ACCIDENT, YOU VIOLATED A RULE. THAT IS KIND OF CIRCULAR. I GUESS IN THIS CASE WE NEED TO ASSUME RULES GET BROKEN, AND THEN TO SEE WHAT SAFETY INTERVENTION HAS POPPED UP IN THAT CASE.

I WOULD AGREE.

BASICALLY WE ARE ASSUMING COMPLETELY THE ENGINEERS -- THE ENGINEER ALERTNESS IS GOING TO STOP THE TRAIN.

THAT IS WHAT WAS RELIED ON IN THESE ACCIDENTS, YES. TOTALLY RELIED ON THE BEHAVIOR OF ONE ENGINEER.

THAT TRANSITIONS INTO DR. WEBSTER'S FITNESS FOR DUTY. IF THERE IS A FITNESS FOR DUTY ISSUE, THERE IS NO INTERVENTION. I THINK I WILL YIELD THE REMAINING 10 SECONDS OF MY TIME.

THANK YOU VERY MUCH. APPRECIATE THAT 10 SECONDS. DR. WEBSTER, YOU MENTIONED IN MARCH OF 2016 THE FEDERAL RAILROAD ADMINISTRATION PUBLISH AN ADVANCED PROPOSED RULEMAKING FOR OBSTRUCTIVE SLEEP APNEA SCREENING. THEN THEY WITHDREW THAT RULE MAKING IN AUGUST 2017. I AM MYSTIFIED AS TO WHY THEY WITHDREW THAT. IN THE ADVANCED NOTICE THEY ACKNOWLEDGED UNDIAGNOSED OR INADEQUATELY TREATED MODERATE TO SEVERE OSA CAN CAUSE UNINTENDED SLEEP EPISODES AND DEFICITS IN ATTENTION, AND MEMORY WITH US REDUCING THE ABILITY TO SAFELY RESPOND TO HAZARDS WHEN PERFORMING SAFETY SENSITIVE DUTIES, THUS OSA IS A CRITICAL SAFETY ISSUE THAT CAN AFFECT OPERATIONS IN ALL MODES OF TRANSPORTATION. THEN THEY WENT THROUGH AND THEY ACKNOWLEDGE MANY OF THE ACCIDENTS THAT YOU POINTED OUT. WHY DID THE FRA WITH DRAW THIS RULEMAKING EFFORT?

THAT IS AN INTERESTING QUESTION. I REALLY DON'T HAVE AN ANSWER AS TO THE REASON THEY WITHDREW IT. IN THEIR STATEMENT THEY SAID THEY WERE GOING TO CONTINUE TO USE THE CURRENT IN THEIR FATIGUE MANAGEMENT PROGRAM. LOOKING AT THE MULTIPLE PILE OF BROKEN SHEET-METAL, AND BROKEN ENGINES, AND BROKEN PEOPLE, IT DOESN'T SEEM TO HAVE BEEN EFFECTIVE. SO, THEY HAVE A PLAN, THEY HAVE A REASON. BUT IT DOESN'T SEEM TO WORK.

BASED ON THE HISTORY, THE HISTORY IS NOT REAL GOOD. WHATEVER PROBLEMS THEY RELIED ON IS RESULTING IN ACCIDENTS. THE NEW JERSEY TRANSIT ACCIDENT RESULTED IN $6 MILLION IN PROPERTY DAMAGE PLUS THE LOSS OF LIVES IN THE LOSS OF ONE LIFE, PLUS MANY INJURIES AND THE ATLANTIC TERMINAL ACCIDENT RESULTED IN A LOT OF DAMAGE AS WELL. IT IS IN THE MILLIONS OF DOLLARS. THE GOVERNMENT, WHEN THEY DO RULEMAKING, THEY ARE CONCERNED ABOUT COST-BENEFIT ANALYSIS THAT WHAT WOULD THE COST BE, HOW INTRUSIVE IS THIS ON INDUSTRY TO PERFORM SUCH SCREENING? IS IT EXPENSIVE?

SCREENING IS RELATIVELY SIMPLE. THERE IS NOTHING SPECIAL TO SCREEN THESE INDIVIDUALS TO SHOW THEY ARE AT RISK. WHEN YOU GET FURTHER DOWN THE ROAD AND FIND SOMEBODY WHO IS AT RISK THERE IS A COST ASSOCIATED WITH THE SPECIFIC TESTING AND TREATMENT. BUT THE TREATMENT IMPROVES QUALITY OF LIFE. FOR THESE ENGINEERS. NOT ONLY ARE THEY FIT FOR DUTY, IT IMPROVES THEIR ALERTNESS ON DUTY AND OFF DUTY. IT IMPROVES THEIR OVERALL WELL-BEING. IT HAS BEEN DEMONSTRATED TO DECREASE THE CHANCES OF HEART DISEASE AND OTHER COMORBIDITIES ASSOCIATED WITH SLEEP APNEA. I DON'T UNDERSTAND AS A PHYSICIAN WHY YOU CAN'T SCREEN AND TREAT THESE PEOPLE.

THANK YOU. I DID FIND THE FIGURE FOR THE ACCIDENT. $5.3 MILLION IN PROPERTY DAMAGE. $11 MILLION IN JUST PROPERTY DAMAGE. DR. WEBSTER, ANOTHER DOT AGENCY WOULD BE A FEDERAL AVIATION ADMINISTRATION. WHAT MEASURES HAS THE FAA PUT IN PLACE FOR PILOTS WITH RESPECT TO OSA SCREENING?

THE FAA ACTUALLY DOES THEIR OWN. THEY HAVE MEDICAL EXAMINERS THAT DO EXAMS FOR THE FAA, UNLIKE THE FRA WHERE THE COMPANY DOES THE EXAMS. BUT, THE FAA, AS PART OF THE PHYSICAL EXAM HAS AREAS FOR SCREENING PEOPLE FOR OBSTRUCTIVE SLEEP APNEA AND THEY HAVE SPECIFIC RULES FOR SOMEBODY DIAGNOSED WITH OBSTRUCTIVE SLEEP APNEA THAT THEY RECEIVE TREATMENT. IN FACT, FAA REQUIRES PILOTS TO USE A RECORDING CPAP DEVISE AND DEMONSTRATE 75 SLEEP PERIODS AN AVERAGE SIX HOURS OF NIGHT OF SLEEP. THIS ADDRESSES OUR SECOND PROPOSED RECOMMENDATION. NOT ONLY DO WE WANT PEOPLE SCREENED BUT WE WANT THEM TREATED. THE FAA ADDRESSES BOTH ISSUES.

FOR THE FAA, IS THAT JUST COMMERCIAL PILOTS?

THOSE ARE FOR THE PILOTS SUBJECTED TO PERIODIC PHYSICAL EXAMINATIONS. COMMERCIAL PILOTS THAT FLY ANY OF OUR PASSENGERS AROUND, AS WELL AS PRIVATE PILOTS.

IT DOESN'T REALLY MAKE SENSE TO ME THAT ONE DOT AGENCY WOULD BE THE FEDERAL AGENCY -- FEDERAL AVIATION ADMINISTRATION, TAKING A REASONABLE APPROACH, WHERE ANOTHER DOT AGENCY, THE FRA, THE FEDERAL MOTOR CARRIER ASSOCIATION, PART OF THAT ADVANCED RULEMAKING, I AM NOT SURE WHY THERE IS A DIFFERENCE. I'M NOT SURE ANYBODY HERE CAN SAY IT. I AM EXTREMELY DISTURBED THAT THE FRA HAS WITHDRAWN THIS SLEEP APNEA PROPOSAL. IT IS UNACCEPTABLE TO ME. I DON'T KNOW HOW MANY BOARD MEMBERS I HAVE SAT THROUGH EITHER ON HIGHWAY OR RAIL THAT HAVE INVOLVED OSA. IT CAN BE SCREENED AND TREATED. I JUST TOOK THE 17 SECONDS THAT YOU GAVE ME AND I HAVE OVERBLOWN THAT.

THANK YOU. IN THE REPORT, ONCE NEW JERSEY TRANSIT IMPLEMENTS PTC THE CURRENT SYSTEM ULTIMATELY -- LIMIT THE TRAINS BUT NOT STOP THE TRAINS FROM REACHING THE END OF THE TRACK. RESTRICTED SPEED IS 20 MILES PER HOUR. IS THAT CORRECT?

NEW JERSEY, I BELIEVE. BUT IT IS NOT. IT IS PREPARED TO STOP. THE ABSOLUTE MAXIMUM IS 20. LIKE SOME DEFINED AS 15 MILES PER HOUR.

THEY USE A DIFFERENT ABSOLUTE.

I UNDERSTAND WHEN YOU LOWER THE RESTRICTED SPEED IT MEANS IT WOULD OCCUR IN MANY LOCATIONS AND NOT JUST THIS ONE LOCATION. COULD A RAILROAD COMPANY REDUCE THE RESTRICTED SPEEDS FROM 20-15 MILES PER HOUR WORK?

BY RULE, ABSOLUTELY. IT IS A WRITTEN RULE. IT IS NOT LIMITED BY THE SIGNAL SYSTEM. THAT IS A DIFFERENT ISSUE. IT IS LIMITED BY THE RULES.

THIS WOULD POTENTIALLY MITIGATE BECAUSE IT WOULD FLOW DOWN THE SPEED BY FIVE MILES PER HOUR. WHAT ARE THE TRADE-OFFS OF HAVING THIS, REDUCING THE SPEED COMMANDS SYSTEMWIDE?

THOSE ARE TWO DIFFERENT ISSUES. BUT YOUR OPERATING RULE RESTRICTIVE SPEED IS EVERYWHERE ON THE PROPERTY. IT WILL HAVE TO FOLLOW THAT ABSOLUTE. IN THE SIGNAL SYSTEM IF YOU CHANGE THE CODE YOU'RE GOING TO HAVE TO DO APPLY EVERYWHERE. THAT CODE IS GOING TO BE AT ALL LOCATIONS WHERE YOU GET THAT RESTRICTING SIGNAL. IF THE SIGNAL IS GREEN YOU DO NOT GET THAT.

GOT IT. IT WOULD BE ENFORCED. POTENTIALLY AT 15 INCIDENT 20.

CORRECT. THEY ARE OFTEN IN A DELAY. YOU WILL BE ENGINEERED TO HAVE THE ABILITY TO RESPOND. THERE IS USUALLY A LITTLE BIT OF A DELAY BEFORE THEY HAVE TO DO SOMETHING ABOUT IT. IF THEY DON'T IT WILL BE A PENALTY APPLICATION AND COME TO A STOP. IT IS SIMPLY WHEN IT STARTED. IF IT IS CLOSE TO THE END OF THE TRACK IT WILL STILL HIT THE BUMPING POSED. -- POST.

I AM JUST TRYING TO THINK OF OTHER POTENTIAL SOLUTIONS.

LET ME. NEW JERSEY TRANSIT IS IN THE PROCESS OF TRYING TO COME UP WITH A COMBINATION. THEY HAVE LOWERED THEIR TRACK SPEED AND THEIR CODE SPEED TO 10. THEY ARE IN THE PROCESS OF INSTALLING EXTENSIVE BUMPING SYSTEMS. NOW YOU HAVE A MATCH. THERE IS ONE PROBLEM. BUMPING POSED SYSTEMS ARE NOT DESIGNED TO PREVENT TRAINS UNDER POWER. EVEN WITH THAT 10 MILE PER HOUR LIMIT OF A SIGNAL THERE IS NOTHING TO STOP THAT ENGINEER FROM MAKING SURE HE IS UNDER THAT LIMIT AND STILL BEING IN POWER WITH THE TRAIN. IT IS BETTER THAN WHAT IS THERE BUT IT IS NOT AT THAT POINT. STOP THE TRAIN BEFORE ENDING THE TRACK. WHICH IS WHAT WE ARE GOING FOR.

THANK YOU. THAT WAS A VERY USEFUL. IT SEEMS THAT IN THE INTERVIEWS WITH INVESTIGATORS, NEW JERSEY TRANSIT, THEY DID NOT SEE A POTENTIAL FOR A COLLISION IN THEIR HAZARD ANALYSIS BECAUSE THEY WERE NOT MAJOR ISSUES FACING THE RAILROADS THAT WE KNOW BOTH HAD OTHER LESS CATASTROPHIC INCIDENTS. SO COULD YOU EXPLAIN, HOW, WHY DID THE RAILROADS OVERLOOK THESE PRIOR INDICATIONS?

WHEN STAFF INTERVIEWED BOTH RAILROADS, AT LONG ISLAND RAILROAD WE WERE VERBALLY TOLD THEY HAD DOWN A FORMAL ANALYSIS ON THAT ANALYSIS ON THAT RISK, BUT NO DOCUMENTATION COULD BE REDUCED. -- PRODUCED. NEW JERSEY TRANSIT SAID THEY RELIED ON COMPLIANCE ON THE PART OF THE LOCOMOTIVE ENGINEER. THE EVOLVING SYSTEM SAFETY THROUGHOUT COMMUTER RAIL AND TRANSIT PROPERTIES, THE FIRST WAS ON NEW PROPERTIES AND NEW STARTS, AND THEY HAVE DONE A GOOD JOB OF INCORPORATING SYSTEM SAFETY INTO NEW PROJECT DESIGN AND DEVELOPED PLANS AND THAT SORT. WE DO NEED TO IMPROVE IN THE INDUSTRY AS FAR AS OPERATIONAL RISK, AND THAT IS WHAT WE ARE ADDRESSING IN THIS REPORT.

THANK YOU. MR. TURPIN, I APPRECIATE YOUR REPORT OF SOME OF THE POST ACCIDENT ACTIONS NEW JERSEY TRANSIT HAS TAKEN. ARE THERE OTHER ACTIONS BY NEW JERSEY TRANSIT AND LIRR? YOU HAVE MENTIONED THERE ARE SOME GAPS. THE YOU THINK THEY ARE SUFFICIENT TO PREVENT THIS TYPE OF ACCIDENT FROM HAPPENING AGAIN?

I WOULD NOT BE ABLE TO SAY THAT. NO, NEW JERSEY TRANSIT MADE THOSE MOVES AS WELL AS RIGHT AFTER HOBOKEN, THEY PUT TWO PEOPLE IN THE CAP, WHICH WE CANNOT SUPPORT WITH DATA, BUT IT WAS OBVIOUSLY A MOVE ON THEIR PART TO HAVE TWO PEOPLE IN THE CAB AS THEY APPROACH THE END OF THE TRACK. SADLY, LONG ISLAND RAIL ROAD WAS INCREMENTING IT THE DAY OF THE ACCIDENT. THEY NOW OPERATE WITH TWO PEOPLE IN THE CAB. WE CANNOT JUSTIFY THAT WITH ANY DATA. WE HAVE ACCIDENTS WITH TWO PEOPLE IN THE CAB ALL THE TIME. YOU MAY HAVE NOTICED THE RECOMMENDATION FOR THIS DOES NOT GO TO THE RAILROADS BECAUSE BOTH RAILROADS ARE NOW SCREENING AND TREATING, HOPEFULLY TREATING THEIR EMPLOYEES. THERE WERE A FEW MINOR ADJUSTMENTS IN THE FATIGUE AREA. I KNOW SPECIFICALLY WITH LONG ISLAND RAIL ROAD, WE WERE CONCERNED IN THE DETAIL OF THAT, IF YOU REMEMBER THE LOCOMOTIVE ENGINEER, HE WOULD DECENT ANALYSIS SLEEP PATTERNS ON THE WEEKENDS. HE WORKED NIGHTS, AND ON THE WEEKENDS HE WOULD GO TO DAYTIME. HE WAS ALSO SPLITTING HAS SLEEP TIME. HE FELT GOOD. HE GOT EIGHT HOURS SLEEP. IT WASN'T REALLY ADEQUATE. IT WAS NOT PROPER. WE ADDRESSED SOME OF THOSE THINGS INTERNALLY. THERE HAS BEEN MOVEMENT, AND THAT IS WHY THERE IS LIMITED RECOMMENDATION. WE FOCUS ON PEOPLE THAT HAVE NOT MADE CHANGES SO FAR.

THANK YOU VERY MUCH.

THANK YOU. MEMBER WEENER.

I AM NOT SURE WHO TO AIM THE QUESTION. THE REPORT SAYS THAT ACCORDING TO THE FRA, THERE ARE CURRENTLY NO MECHANISMS INSTALLED IN ANY TERMINALS IN THE U.S. THAT AUTOMATICALLY STOP A TRAIN. NOW, REAL SYSTEMS ARE IN USE PRETTY MUCH ALL OVER THE WORLD. WHAT DO SOME OF THE OTHER COUNTRIES OR OTHER SYSTEMS DO?

WE RESEARCHED SOME OF THOSE ACCIDENTS AND OTHER COUNTRIES AND FOCUSED KIND OF ON THE SPANISH SYSTEM THAT HAD VERY SIMILAR ACCIDENTS TO OURS. THEY ARE KIND OF IN THE SAME PLACE WE ARE. THEY DON'T HAVE AN ENFORCEMENT SYSTEM TO STOP THE TRAINS FROM HITTING. THEY HAVE THE EUROPEAN RAIL TRAIN MANAGEMENT SYSTEM, JUST ALMOST THE EQUIVALENT OF PTC, BUT THEY DO NOT IN FORCE ATTRACT COMPLIANCE -- ENFORCE END OF TRACK COMPLIANCE.

IN OTHER WORDS, THIS PROBLEM HAS NOT BEEN SOLVED BY SOMEBODY ELSE.

NOT YET. WE HEARD FROM ONE OF THE VENDORS THAT THEY HAD A SYSTEM THAT COULD HELP, BUT WE DID NOT HAVE TIME TO RESEARCH IT FAR ENOUGH TO SEE IF IT WAS IN PLACE ANYWHERE CURRENTLY. THERE MIGHT BE SOME SOLUTIONS COMING UP, BUT NONE THAT WE KNOW THAT ARE IN SERVICE RIGHT NOW.

OK. THANK YOU. HAVE WE INVESTIGATED, ON BOTH ACCIDENTS, AT THIS TERMINAL BEFORE?

AT HOBOKEN TERMINAL, WE HAD INVESTIGATED A BUMPING POST ACCIDENT. I BELIEVE IT WAS IN 2012, ACTUALLY MOTHER'S DAY OF 2012. IT WAS A DIFFERENT RAILROAD, SAME TERMINAL. I DID RESEARCH THROUGH OUR DATABASE OF RAIL ACCIDENTS. THE NTSB ON THE FRA REGULATED SIDE HAS ONLY INVESTIGATED THREE BUMPING POSTS, THAT PASSED ACCIDENT, AND THESE TWO WE'RE DISCUSSING TODAY. WE HAVE INVESTIGATED NUMEROUS BUMPING POST ACCIDENTS ON THE TRANSIT SIDE.

WAS THERE EVIDENCE OF OTHER BUMPING INCIDENTS AT HOBOKEN?

YES, EXAMINING THE BUMPING POST ON THE OTHER TRACK, THERE WAS ON SCENE EVIDENCE OF OTHER STRIKES ON THE POSTS. THEY WERE OBVIOUSLY MINIMAL STRIKES. THEY DID NOT HAVE SIGNIFICANT DAMAGE. OBVIOUSLY, THE EQUIPMENT WAS TOUCHING THE POSTS.

A GOOD RISK MANAGEMENT ACTIVITY LOOKS AT FREQUENCY AS WELL AS THE EXTENT OF THE HAZARD. WE HAVE DATA THAT INDICATES SOME DEGREE OF FREQUENCY HERE. HOW DOES THAT HELP US, OR HELP WHEN WE DO A SAFETY ANALYSIS, RISK ANALYSIS?

WE WOULD HOPE THAT THEY WOULD. A GOOD ESTIMATE PROGRAM, SYSTEM SAFETY PROGRAM PLAN WOULD REQUIRE A HAZARD ANALYSIS TO BE DONE FOR THAT, PARTICULARLY IN LIGHT OF THESE TWO ACCIDENTS AS WELL AS THE PAST ACCIDENT, AND THEN THE VISUAL EVIDENCE OF PREVIOUS ACCIDENTS. EACH RAILROAD HAD ALSO REPORTED OVER THE PAST SEVEN TO 10 YEARS BEFORE THESE ACCIDENTS, I THINK LONG ISLAND RAIL ROAD HAD REPORTED 15 REPORTABLE ACCIDENTS IN A 10 YEAR PERIOD. NEW JERSEY TRANSIT HAD REPORTED SEVEN ACCIDENTS IN A SHORTER PERIOD OF TIEM, I DON'T HAVE THAT ON TOP OF MY HEAD. 10 YEARS. THANK YOU. IF YOU DO THE RISK MATRIX, I THINK YOU WOULD COME UP WITH A ONE B OR TWO B, CONSIDERING THE PROBABILITY, AND WE KNOW THE PROBABILITY IS POSITIVE, SO IT WILL MUST LIKELY HAPPEN AGAIN. AS FAR AS THE CRITICALLIITY, THERE IS ALWAYS THE POSSIBLY OF MULTIPLE INJURIES OR ACCIDENTS.

SAFETY MANAGEMENT SYSTEMS WERE BEING INCREMENTED AT BOTH RAILROADS?

BOTH RAILROADS HAVE A SYSTEM SAFETY PROGRAM IN PLAN.

WHAT IS THE DIFFERENCE BETWEEN A SYSTEM SAFETY PROGRAM PLAN, AND AN SMS?

IT IS A NUANCE. THE SMS TAKES THE FOUR PILLARS THAT WERE ON ONE OF MY SLIDES, WHICH INCLUDE RISK MANAGEMENT, WHEREAS THE SYSTEM SAFETY PROGRAM PLANS IS A HIGH-LEVEL DOCUMENT THAT WOULD LOGICALLY INCORPORATE BY REFERENCE MANY OTHER PROCESSES AND PROCEDURES OF AN ORGANIZATION TO DEMONSTRATE HOW THEY INCREMENTED THEIR SAFETY PLANS. IT IS JUST THEIR PLAN DOCUMENT, WHEREAS I CONSIDER SMS MORE OF A PHILOSOPHY OF HOW AN ORGANIZATION EMBRACES SAFETY AS A QUART VALUE -- CORE VALUE AND EXECUTES IT SAFETY PROGRAM THROUGHOUT, AS IT WOULD ANY OTHER OR BUSINESS -- CORE B USINESS PROCESS. FOR EXAMPLE, YOU WOULD VALUE SAFETY AT THE SAME LEVEL AS YOU DO YOUR FINANCIAL BUSINESS SHEETS. THAT IS WHAT SMS DOES. THE PLAN IS JUST THE PLAN ON HOW YOU DO IT.

WHEN WE TALK ABOUT IMPLEMENTING SAFETY MANAGEMENT SYSTEMS, WE TALK ABOUT IT BEING A JOURNEY AS OPPOSED TO A DESTINATION, SOMETHING YOU ARE REALLY NEVER FINISHED WITH. HOW DYNAMIC WAS SMS OR THE SSPP IN TERMS OF BEING REVIEWED, RENEWED, LOOKED AT?

NEW JERSEY TRANSIT IS IN THE PROCESS OF GOING THROUGH SOME ORGANIZATIONAL CHANGES. TWO OR THREE YEARS AGO NOW, THEY SET UP -- THEY HIRED A CHIEF SAFETY OFFICER AND PULLED ALL OF THEIR SYSTEM SAFETY INTO ONE OFFICE. BEFORE THAT IT HAD BEEN SPREAD OUT AMONGST THE AGENCY. THEY HAD A RAIL SAFETY OFFICE, AND I BELIEVE IT IS ADDRESSED AS IT CAME FROM THE REALM DEPARTMENT -- RAIL DEPARTMENT RATHER THAN BEING A TOTAL PLAN FOR THE ENTIRE AGENCY. LONG ISLAND RAIL ROAD WAS A LITTLE BIT MORE ADVANCED WITH THEIR SYSTEM SAFETY PROGRAM PLAN. IT HAD BEEN REVIEWED AND REVISED AS THEY STATED IT WOULD BE. NEW JERSEY TRANSIT IS IN THE PROCESS OF DOING THAT NOW, COMPLETING THAT REVIEW. THEY WERE A LITTLE TARDY WITH THAT. I INTERVIEWED THAT TO THE CHANGE IN THEIR ORGANIZATIONAL STRUCTURE.

THANK YOU. I HAVE USED MY 15 SECONDS.

THANK YOU. MS. GREGORY, THANK YOU FOR YOUR DISCUSSIONS ON SYSTEM SAFETY. I DON'T KNOW IF MAYBE WE HAVE A HIDDEN SLIDE THAT WOULD SHOW THE RISK MATRIX. IS THERE BY CHANCE A SLIDE OF THAT? IF NOT, THAT IS OK. I WILL YOU TO TRANSLATE, I THINK YOU SAID TOWO A OR TWOB, WHAT DOES THAT TRANSLATE TO?

WE DON'T HAVE A HIDDEN SLIDE. IT IS A QUITE BUSY SLIDE IF YOU PUT IT UP ON THE SCREEN. WHEN USING THE MILITARY STANDARDS, YOU WOULD FIRST CALCULATE THE PROBABILITY. IT WOULD EITHER BE AT THE TOP OF THE SCALE, IT IS HAPPENING, AND YOU GO DOWN THE SCALE TO PROBABLE, REMOTE, AND EXTREMELY REMOTE. ON THE HORIZONTAL AXIS, YOU WOULD HAVE THE CATASTROPHIC, CRITICAL, MINIMAL, OR --

NEGLIGIBLE.

NEGLIGIBLE. THANK YOU FOR THAT. YOU WOULD TAKE THOSE TWO ACCIDENTS AND DETERMINE THE PROBABILITY, WHICH IN THIS CASE, AS I SAID THIS HAS HAPPENED BEFORE, IT IS PROBABLE. THEN YOU WOULD DETERMINE THE CRITICALITY. IN THIS CASE, WE HAVE A CRITICALITY, I DON'T THINK I WOULD RATE IT AS AN A. GENERALLY, IF THEY DO HAVE THAT CAB SIGNALS, THEY BRING IT DOWN THE TRAIN. I DON'T THINK IT WOULD BE CATASTROPHIC, HOWEVER I DO THINK IT WOULD BE CRITICAL. MY COLLEAGUES JUST PASSED ME A CHEAT SHEET.

GREAT. THAT IS ON PAGE 58 OF THE DRAFT REPORT. YOU ARE GOING OUT OF THE DRAFT, TABLE TWO.

I DID FAIRLY WELL OFF OF MEMORY. YOU WOULD TAKE THIS, ONCE YOU HAVE DONE THAT, AND THERE ARE -- IF YOU HAVE ON AE, A, B, C OR TWO A, THAT IS CONSIDERED A HIGH RISK. A ONE B OR TWO B NEEDS TO BE MITIGATED WITH SOMETHING MORE THAN JUST COMPLIANCE ON THE PART OF THE LOCOMOTIVE ENGINEER TO STOP FROM HITTING THE BUMPING POST.

I THINK YOU SAID THIS HAZARD OF STRIKING A BUMPING POST WOULD BE, WHAT DID YOU SAY? WHAT WOULD BE THE RATING OF THAT?

EITHER ONE B OR TWO B. BOTH OF THOSE FALL IN, THE ONE A IS FREQUENT WITH A HIGH RISK. TWO B IS PROBABLE WITH A CRITICAL OR HIGH RISK. THOSE BOTH NEED TO BE ADDRESSED WITH A FORMAL MITIGATION. THE FORMAL ANALYSIS WOULD REQUIRE THAT MITIGATION.

YES. WHEN I LOOK AT THAT, ANYTHING DEEMED TO BE AT THAT LEVEL IS CONSIDERED, AS YOU POINTED OUT, UNACCEPTABLE RISK.

YES, SIR.

THE SUGGESTED ACTION IS TO ELIMINATE THE HAZARD BY CONTROLLING THAT RISK, AND WE HAVE ALREADY TALKED ABOUT A FEW MEASURES THAT COULD HELP CONTROL THAT MEASURE. -- THAT RISK. ONE MIGHT BE ADDING A SECOND CREWMEMBER WHILE YOU ARE APPROACHING A TERMINAL STATION, TERMINAL TRACK. ANOTHER WOULD BE SOME SORT OF TECHNOLOGY. THE FACT IS THAT RISK AS IT IS IS UNACCEPTABLE. I ALWAYS HATE TO TALK ABOUT THE AVIATION BUSINESS BECAUSE THERE ARE THINGS THEY DON'T DO RIGHT, BUT WHEN IT COMES TO SAFETY, THEY HAVE CERTAINLY DONE SOME THINGS RIGHT OVER THE LAST FEW YEARS. WE DON'T JUST LOOK AND SAY THIS ACCIDENT DID NOT HAPPEN ON MY PROPERTY, THEREFORE I AM NOT CONCERNED ABOUT IT. THERE WAS AN ACCIDENT IN AVIATION, THE WORLD'S LARGEST AVIATION DISASTER HAPPENED IN THE CANARY ISLANDS. IT WAS A RUNWAY INCURSION. WE DON'T JUST SAY THAT HAPPENED AT SOME ISLAND, SO WE'RE NOT GOING TO WORRY ABOUT IT HERE IN THE UNITED STATES. IT IS VERY MUCH OF A CONCERN TO EVERYBODY IN THE AVIATION WORLD. LIKEWISE, MR. PAYAN, YOU AND I WENT TO ARGENTINA A YEAR OR TWO YEARS AGO, AND WE KNOW THERE WAS AN ACCIDENT WHERE A TRAIN HIT A BUMPING POST AND KILLED 51 PEOPLE RIGHT IN DOWNTOWN ONE IS HARRY'S -- BEUNUENOS AIRES. IT VERY MUCH CAN HAPPEN HERE, AND IT HAS HAPPENED HERE. THEREFORE, OPERATORS NEED TO LOOK AT THE GLOBAL SITUATION AND DETERMINE JUST BECAUSE IT HASN'T HAPPENED HERE DOESN'T MEAN IT WILL NOT HAPPEN. BOTH NEW JERSEY TRANSIT AND LONG ISLAND RAILROAD HAD HAD BUMPING POST EVENTS. LET'S GO BACK TO SLEEP APNEA. AS I UNDERSTAND IT, DR. WEBSTER, ALL THREE OF THE CREW MEMBERS ON THE NEW JERSEY TRANSIT TRAIN, THEY ARE OPERATING IN WHAT WE CALLED SAFETY SENSITIVE POSITIONS, THE ENGINEER, THE CONDUCTOR, AND THEN THE ASSISTANT CONDUCTOR. ALL THREE OF THOSE WOULD BE CONSIDERED SAFETY SENSITIVE. WHAT DID WE FIND? HOW WOULD THEY HAVE TESTED IF THEY HAD BEEN SCREENED PRIOR TO THE ACCIDENT?

WHEN WE LOOKED THROUGH THE RECORDS, LOOKING THROUGH THE ENGINEERS RECORDS, AS I MENTIONED, THE ENGINEER SINCE 2013 HAD HAD MULTIPLE OPPORTUNITIES TO FULLY SCREEN HIM, BUT EACH YEAR THERE WAS EVIDENCE THAT HE HAD NOT BEEN FULLY SCREENED, OR THAT IT HAD NOT BEEN DOCUMENTED THAT HE WAS FULLY SCREENED AND WAS NEVER REFERRED. FURTHERMORE, I BELIEVE IT IS THE CONDUCTOR AND BRIGHT MAN -- B RAKEMAN ALSO MET CRITERIA FOR REFERRAL BUT WERE NOT REFERRED FOR FURTHER SCREENING. SINCE THIS ACCIDENT, THOUGH, THE FOLKS AT NEW JERSEY TRANSIT HAVE IMPLEMENT THE PROGRAMS TO ENSURE THAT THE PAPERWORK IS FULLY COMPLETED SO THAT IT IS MANAGED PROPERLY AND THAT PEOPLE WHO MEET A CERTAIN CRITERIA ARE APPROPRIATELY REFERRED TO A DEFINITIVE TESTING, AND IF NEEDED, TREATMENT. THEY HAVE MADE A LOT OF SIGNIFICANT IMPROVEMENTS SINCE THE ACCIDENT. I THINK THEY HAVE LEARNED FROM WHAT THEY FOUND.

THANK YOU. AS I RECALL, AND YOU ARE RIGHT, IT WAS THE ENGINEER, THE CONDUCTOR, AND THE BRAKEMAN, ALL THREE OF THOSE POSTACCIDENT WERE FOUND TO HAVE SEVERE SLEEP APNEA.

NO, SIR. I MUST HAVE BEEN UNCLEAR ON THAT. WE KNOW THE ENGINEER HAD SEVERE SLEEP APNEA. THE LAST TIME I CHECKED, THE SCREENING OF THE TWO OTHER INDIVIDUALS HAVE NOT BEEN ACCOMPLISHED, BUT PLANS TO ACCOMPLISH IT WHEN THEY RETURN FOR WORK. I CANNOT SAY. THEY DEFINITELY HAD THE RISK FACTORS FOR SLEEP APNEA, BUT WE CANNOT SAY. THEY WERE NOT SCREENED.

I GUESS I WAS REFERRING TO THEIR BODY MASS INDEX, WHICH WOULD PUT THEM IN A HIGH RISK CATEGORY.

DEFINITELY.

THANK YOU VERY MUCH. MEMBER DINH-ZARR.

THANK YOU, CHAIRMAN. I APPRECIATE YOU BRINGING UP THE CONFLICT OF HOW THIS AFFECTS THE WHOLE INDUSTRY. AS I THINK ONE OF THE STAFF MENTIONED, IT HAS BEEN MORE THAN 20 YEARS SINCE THE FRA ISSUED EMERGENCY ORDER 20. THAT WAS INTRODUCING THE CONCEPT OF SYSTEM SAFETY WE ARE TALKING ABOUT HERE, YET HERE WE ARE AGAIN TODAY. THAT IS VERY TROUBLING AND TRAGIC, ESPECIALLY FOR THE PEOPLE WHO WERE AFFECTED. I HAVE A FEW CLARIFICATION QUESTIONS TO ASK. MR. PAYAN, YOU WERE SPEAKING EARLIER ABOUT PTC, AND YOU MENTIONED THERE ARE LIMITATIONS TO GPS TO THE POSITION OF A LOCATION. IS THERE POSSIBLE TO SOME RADIO SIGNAL REPEATER TO SEND MORE PRECISE LOCATIONS TO A PTC SYSTEM TO OVERCOME THAT LIMITATION?

YES, THERE IS WAYS TO REFRESH THE GPS SIGNAL, AND THEY DO THE REAL ROTATION -- WHEEL ROTATION DISCOUNTERS SO THEY CAN TRACK THE TRAIN A BIT. THAT IS JUST PART OF THE PROBLEM. THERE ARE JUST THE SHORT TRACK CIRCUITS AND ALL THE COMPETITION DIFFERENT ROUTES THE TRAINS CAN TAKE INTO THE STATION, WHICH, CASE THINGS.

IS THAT ONE OF THE SOLUTIONS THAT IS BEING LOOKED AT TO TRY TO SOLVE SOME OF THE ISSUES, SOME OF THE CHALLENGES THAT COME WITH THAT?

THEY WERE LOOKING AT SOMETHING OUTSIDE OF GPS FROM WHAT FRA DESCRIBED? OR OUTSIDE OF PTC, ANOTHER SYSTEM THAT WOULD HANDLE COMPENSATED INTERLOCHEN'S IN AND OUT OF TERMINAL STATIONS. -- COMPLICATED INTERLOCKINGS IN AND OUT OF TERMINAL STATIONS.

WHEN I WAS TALKING ABOUT RESTRICTION FROM 20 TO 15 MILES PER HOUR, I SUPPOSE MY THOUGHT WAS THAT RESTRICTING THE SPEED WOULD MITIGATE A POTENTIAL AND A TERMINAL -- END OF TERMINAL ACCIDENT BECAUSE IF THERE IS AN INATTENTIVE ENGINEER OR ENGINEER WHO HAS FALLEN ASLEEP, THEY WOULD ONLY BE GOING 15 MILES PER HOUR INSTEAD OF 20. OF COURSE, THAT WOULD BE BETTER IF IT WERE ENFORCED RATHER THAN JUST A RULE. MR. TURPIN, NEW JERSEY TRANSIT WAS PART OF THE CLOSE CALL REPORTING EYELET PROJECT -- PI LOT PROJECT. THEY ARE STILL GETTING REPORTING DATA. DO YOU BELIEVE AN EXAMINATION OF THIS KIND OF DATA COULD HELP US KNOW ABOUT INCIDENTS WHERE ENGINEERS SELF-REPORT HAVING MICRO SLEEPS OR BEING DISTRACTED OR HAVING SITUATIONAL AWARENESS WHEN ENTERING THE STATION?

THE CLOSE CALL REPORTING SYSTEM IS A VERY POSITIVE , A LOT OF POSITIVE FEEDBACK. THE BENEFIT AND THE WAY THAT IT ENCOURAGES EMPLOYEES TO REPORT INCIDENTS IS THE CONFIDENTIALITY. THE DATA IS USUALLY USED IN HOUSE AND USED BY MANAGEMENT TO ADDRESS SAFETY ISSUES THAT COME UP AS PART OF THE ANALYSIS FROM THE REPORTS THAT COME IN. I DON'T THINK THERE HAS EVER BEEN A DECISION TO SHARE THAT OUTSIDE THE PARTICULAR RAILROAD, AND THAT ALL GOES BACK TO ENCOURAGING EMPLOYEES TO REPORT THE INCIDENTS. THAT IS KIND OF HOWARD NOT IS UP TO THE AVIATION MODEL.

AS YOU SAID, IS CONFIDENTIAL, WHICH WE HOPE WOULD ENCOURAGE MORE ACCURATE REPORTING. WITH THIS TYPE OF REPORTING SYSTEM ON OTHER RAILROADS HELPED GET THE NEEDED DATA TO SEE HOW BIG OF A PROBLEM THIS IS THROUGHOUT THE INDUSTRY? AND IS THIS BEING DONE?

YES, I THINK THE NTSB HAS ENCOURAGED THE OTHER RAILROADS TO ADOPT THIS SYSTEM, C3RS. IT IS BEING SLOWLY ACCEPTED. IT IS NOT INDUSTRYWIDE YET.

THANK YOU, MR. BUCHER. WE WILL KEEP URGING PEOPLE TO DO THAT. THANK YOU. I YIELD THE REMAINDER OF MY TIME.

THANK YOU. MEMBER WEENER.

I BELIEVE IT WAS MR. TURPIN AND MENTIONED -- WHO MENTIONED ONE OF THE LINES WAS GOING TO ADD A CREW MEMBER IN THE TERMINAL APPROACH. ARE THERE ANY DOWNSIDES TO ADDING A CREW MEMBER? IF TWO ARE BETTER THAN ONE, MAYBE THREE ARE BETTER THAN TWO .

ACTUALLY, BOTH RAILROADS NOW HAVE TWO PEOPLE IN THE CAB. HOBOKEN DID IT RIGHT AWAY. FRA HAS SENT OUT A SAFETY ADVISORY, AND LONG ISLAND RAIL ROAD WAS GOING TO COMPLY WITH THE SAFETY ADVISOR. THERE WAS ACTUALLY NEGATIVE TO THAT. LONG ISLAND RAIL ROAD EXPRESSED THEY FELT IT WAS MORE IMPORTANT TO HAVE A KIND OF STERILE COCKPIT, AND IT IS BETTER MAINTAIN WITH ONLY ONE PERSON FOCUSING ON THEIR DUTIES. THERE CAN BE DISTRACTIONS WITH ANOTHER PERSON IN THE CAB. THAT HAS NOT BEEN OUR OBJECTION. WE DON'T KNOW WHAT ROLE THAT PLACE. WE ARE BACK TO SQUARE ONE AGAIN. THERE IS NOT DATA. THERE IS NO DATA. WE KNOW ANECDOTALLY THAT WE HAVE BASICALLY JUST AS MANY ACCIDENTS WITH TWO PEOPLE AS WE DO WITH ONE PERSON. WE DON'T HAVE RAW NUMBERS. WE ONLY GO ON LAUNCHES IN OUR DATA.

WHAT WOULD BE THE DUTIES OR THE PROCEDURES THAT THE SECOND CREW MEMBER WOULD HAVE TO ACCOMPLISH?

WHEN YOU ARE STRICTLY TALKING RULES AND RULES COMPLIANCE, THEN THE SECOND CREW MEMBER IS TO BE OBSERVANT, AND IF THE ENGINEER FAILS TO RESPOND PROPERLY TO ANY WAYSIDE SIGNAL OR CONDITION, THEN THEY ARE TO INTERCEDE, EITHER TO REMIND THE ENGINEER IF THERE IS TIME, OR TO TAKE ACTION AND STOP THE TRAIN.

WE HAVE LEARNED IN OTHER MODES, WITHOUT GOING INTO WHICH MODE, THAT IT IS IMPORTANT TO HAVE TWO PEOPLE OPERATING AS A TEAM AS OPPOSED TO ONE PERSON WITH A HOT SPEAR.

CORRECT.

SO A LARGE PART OF THE SAFETY THAT HAS BEEN ACHIEVED IN THE AVIATION MODE IS DUE TO COCKPITS DESIGNED TO BE OPERATED BY TWO CREW MEMBERS AS OPPOSED TO COCKPITS DESIGNED TO BE OPERATED BY A PILOT AND A SPARE. LET'S TALK ABOUT SLEEP APNEA OR MORE IMPORTANT, FITNESS FOR DUTY. THAT IS A FATIGUE ISSUE, AND FATIGUE CAN BECAUSE BY SLEEP APNEA OR ANY OTHER NUMBER OF THINGS IN THE ENVIRONMENT OR THAT A PERSON IS DEALING WITH. THE WAY THE INDUSTRY HAS APPROACHED IT IS PRESCRIPTIVE. IN A PRESCRIPTIVE WAY, YOU HAVE HOURS OF SERVICE. IN TERMS OF PRODUCTIVE, INSTEAD OF PRESCRIPTIVE, AS THE I NDUSTRY USED TECHNIQUES AND TOOLS SUCH AS FATIGUE MANAGEMENT SYSTEMS?

MEMBER WEENER, THE INDUSTRY IS WELL AWARE OF TOOLS SUCH AS THE FATIGUE AVOIDANCE SCHEDULING TOOL, OR FAST TOOL, OR A COMPARABLE ONE, FADE, AND HAS LAMENTED THAT IN SOME OF THEIR SCHEDULE ACTIVITIES. WORKERS ARE ON THE SO-CALLED EXTRA BOARD. THE FAST ANALYSIS WOULD BE A CRITERIA IN HELPING THE SCHEDULER OR DETAILER ESTABLISH WHO IS ON THAT CALL LIST.

I GUESS THE QUESTION IS HOW WELL RECEIVED, HOW WELL USED IS THE FATIGUE RISK MANAGEMENT SYSTEMS?

I THINK IT IS -- EXCUSE ME. IT IS OUR OBSERVATION THAT THIS GENERAL CLASS OF TOOL, BY A MATHEMATICAL MODELS OF -- BIOMAT HEMATICAL MODELS OF FATIGUE ARE ACCEPTED. THE APPLICATIONS HAVE BEEN RECEIVED. THE PRODUCTS TO ALLOW IMPLEMENTATION ARE AVAILABLE TO RAILROADS, AND SO WE ARE NOT SEEING SOMEONE RESISTING IT BECAUSE THEY CANNOT GET ACCESS TO IT OR UNDERSTAND IT.

INTERESTINGLY, A MONTH AGO I WENT TO THE DETROIT AUTO SHOW AND WAS WOWED WITH WHERE SOME OF THE MANUFACTURERS THINK THEY ARE IN TERMS OF AUTONOMOUS AUTOMOBILES, BUT THEY ARE HEAVILY DEPENDENT ON SOMETHING TO DETECT WHETHER OR NOT THE OPERATOR IS PAYING ATTENTION. IN FACT, IF YOU LOOK ON THE INTERNET, YOU CAN FIND I TRACTORS, HEAD NODDERS, SOME OF THE AUTOMOBILES HAD DETECTION SYSTEMS FOR WHEN YOU HAD BOTH HANDS OR ONE HAND ON THE WHEEL AND SO FORTH. ARE ANY OF THESE THINGS, SYSTEMS, APPROACHES, TECHNOLOGIES THAT COULD BE ADAPTED TO--

THE SHORT ANSWER IS YES. THERE ARE A VARIETY OF APPROACHES THAT RANGE FROM LOOKING AT VARIOUS PHYSIOLOGICAL STATES EITHER THROUGH THE BIOCHEMISTRY OF THE INDIVIDUAL TO THE PSYCHOLOGICAL STATE OF THE PERSON THROUGH EYTEE SCANS, EYE POSITIONS. SO IN PRINCIPLE, THERE IS AN ASSORTMENT OF THINGS THAT CAN BE USED. THE MODELS HAVE APPEALED BECAUSE OF THEIR CALCULATION. THEY ARE BASED ON DATA FOR POPULATION, AND IF YOU KNOW AN INDIVIDUAL'S PARAMETERS, THE DAYS THEY HAD BEEN SCHEDULED, THEN YOU CAN COME UP WITH THE CALCULATION. BUT THERE ARE OTHER APPROACHES AND MORE ADVANCED TECHNOLOGIES THAT ARE CENTERED ON AN INDIVIDUAL AS OPPOSED TO NORMATIVE DATA THAT WOULD IN PRINCIPLE PROVIDE MORE ACCURATE, RELIABLE APPROACHES. AND WE CAN USE SOME OF THE SIMPLER TECHNOLOGIES THAT HAVE BEEN AROUND FOR A WHILE SUCH AS BEHAVIORAL-BASED TECHNIQUES SUCH AS ALERTERS. IF I WERE CAR AND OPERATOR TO PROVIDE AN INPUT TO A MONITORING SYSTEM SUCH AS AN ALERTER DOES ON A TRAIN, THEN I HAVE A DIRECT BEHAVIORAL MEASURE OR INDICATION THAT THE OPERATOR IS ALERT AND ENGAGED IN A TASK. WE HAVE SEEN SHORTCOMINGS IN ALL THESE APPROACHES. SO FAR WE DO NOT HAVE A PERFECT SOLUTION, BUT I THINK THE SHORT ANSWER IS YES, THERE IS A VARIETY OF TECHNOLOGIES THAT HAVE POTENTIAL TO HELP US CONTROL THE FATIGUE.

THANK YOU.

THANK YOU. JUST GOT A FEW QUESTIONS. SO, DR. WEBSTER, NEW JERSEY TRANSIT HAD THEIR OWN PHYSICIANS TO PERFORM THEIR PHYSICALS. IS THAT CORRECT, FOR THEIR SAFETY SYSTEM EMPLOYEES?

IN MOST CASES THEY HAD A PHYSICIAN THAT WAS EITHER CONTRACTED OR WAS PART OF THE COMEDY.

OK, AND AS PART OF THE PHYSICAL, THAT PHYSICAL FOR LIKE THE ENGINEER, THAT PHYSICIAN WAS SUPPOSED TO COMPLETE AN OSA SCREENING FORM?

YES, SIR. IT WAS A FORM THAT REQUIRED THE PHYSICIAN, AS I READ THE FORM, TO DO MEASUREMENTS, WEIGHT, HEIGHTS, CALCULATED BODY MASS INDEX, AND DO A CIRCUMFERENCE, AND ALSO ASK A NUMBER OF QUESTIONS OF THE INDIVIDUAL ABOUT HOW SLEEPY THAT INDIVIDUAL WAS, TAKING ALL THAT INTO CONSIDERATION, AND THEN FOLLOWING GUIDELINES FOR RECOMMENDED REFERRAL.

WHEN THE ENGINEER OF THIS NEW JERSEY TRANSIT TRAIN THAT WAS INVOLVED IN THE HOBOKEN ACCIDENT, WHAT DID HIS MOST RECENT -- WHAT DID HIS MOST RECENT MEDICAL FORM ASSOCIATED WITH THAT -- WHAT DID THAT INDICATE?

THE MOST RECENT FORM, WE ACTUALLY HAD TO CONTACT THE MEDICAL PERSON, AND THEY LOOKED FOR THE FORM AND FINALLY SENT AND EMAIL TO US SAYING THE FORM COULD NOT BE LOCATED. MR. SUMWALT: OK, SO THAT FORM FOR THE MOST RECENT PHYSICAL FOR THE ENGINEER COULD NOT BE LOCATED. AND WERE THERE OTHER FORMS DATING BACK PRIOR TO HIS MORE RECENT PHYSICAL? DR. WEBSTER: HE HAD ANNUAL EXAMINATIONS, AND THE ONLY COMPLETED FORM WAS 2013. SINCE THAT TIME, THE POST ACCIDENT TESTING DEMONSTRATED THAT THE ENGINEER HAD GAINED ABOUT 90 POUNDS SINCE 2013, WHICH CREATES AN INCREASE IN YOUR BMI, WHICH WITH AN ELEVATED BMI COMBINED WITH NECK CIRCUMFERENCE, PROVIDES EVIDENCE THAT HE SHOULD POSSIBLY HAVE BEEN REFERRED FOR ADDITIONAL TESTING. MR. SUMWALT: THANK YOU. ARE YOU AWARE OF ANY ACCIDENTS THAT NEW JERSEY TRANSIT HAS TAKEN SINCE THIS ACCIDENT IF A SAFETY-SENT TO THE EMPLOYEE WERE TO BE TESTED, SCREENED, AND TESTED POSITIVELY FOR OSA, HOW THEY ARE HANDLING THAT? DR. WEBSTER: I WROTE THIS DOWN, BUT THEY HAVE IMPROVED OR MODIFIED THEIR SCREENING TO MAKE SURE THAT PEOPLE WHO SCREAM POSITIVE ARE REFERRED FOR SLEEP STUDY AND THOSE PEOPLE WHO ARE POSITIVE FOR SLEEP ARE APPROPRIATELY TREATED. MR. SUMWALT: AND THEY ARE ALSO REMOVED FROM SERVICE UNTIL THEY ARE UNDER A SUCCESSFUL TREATMENT PROGRAM? DR. WEBSTER: YES, SIR. MR. SUMWALT: I KNOW THAT IS NOT A POPULAR DECISION FOR LABOR, BUT IF YOU ARE INTERESTED IN SAFETY, IT IS THE RIGHT DECISION , AND I WANT TO APPLAUD THAT DECISION. I KNOW IT IS NOT POPULAR, BUT IT IS THE RIGHT THING TO DO, AND I KNOW IT TOOK A LOT OF GUTS, BUT THANK YOU VERY MUCH. SO DO ANY OTHER BOARD MEMBERS HAVE ANY QUESTIONS? OK, WITH THAT, WE WILL TAKE A BREAK. HE WILL COME BACK AT 11: -- WE WILL COME BACK AT 11:20. WE ARE IN RECESS. MR. SUMWALT: IF EVERYONE WOULD KINDLY TAKE THEIR SEATS, WE WILL BEGIN SHORTLY. MR. SUMWALT: OK, WE ARE BACK. AND, MR. JONES, IF YOU WOULD READ THE PROBABLE CAUSE STATEMENT FOR BOTH ACCIDENTS. RICHARD MR. JONES: FOR THE HOBOKEN ACCIDENT, THE NATIONAL TRANSPORTATION SAFETY BOARD DETERMINED THAT THE PROBABLE CAUSE OF THE HOBOKEN ACCIDENT WAS THE FAILURE OF NEW JERSEY TRANSIT'S TRAIN'S ENGINEER TO STOP THE TRAIN AFTER ENTERING THE HOBOKEN TERMINAL RESULTING FROM FATIGUE DUE TO HIS UNDIAGNOSED OBSTRUCTIVE SLEEP APNEA. ADDING TO THE ACCIDENT WAS NEW JERSEY TRANSIT'S NOT FOLLOWING GUIDANCE REFERRING SENSITIVE PERSONNEL FOR THE TESTING AND TREATMENT. FURTHER CONTRIBUTING TO THE ACCIDENT WAS THE FEDERAL RAILROAD ADMINISTRATION'S FAILURE TO REQUIRE RAILROADS TO MEDICALLY SCREENED EMPLOYEES IN SAFETY SENSITIVE POSITIONS FOR OF STRUCT OF SLEEP DISORDERS. ALSO CONTRIBUTED TO THE ACCIDENT WAS A LACK OF EITHER A DEVICE OR SAFETY SYSTEM THAT COULD HAVE INTERVENED TO STOP THE TRAIN BEFORE THE COLLISION. FOR THE ATLANTIC TERMINAL ACCIDENT, STAFF PROPOSES THE FOLLOWING PROBABLE CAUSE -- THE NATIONAL TRANSPORTATION SAFETY BOARD DETERMINED THE PROBABLE CAUSE OF THE BROOKLYN-NEW YORK ACCIDENT WAS THAT THE ENGINEER OF LONG ISLAND RAILROAD TRAIN 2817 FELL ASLEEP DUE TO HIS CHRONIC FATIGUE. INTERPRETING TO HIS CHRONIC FATIGUE WAS THE ENGINEER'S HYUNDAIS NOSED SEVERE OBSTRUCTIVE SLEEP APNEA AND LONG ISLAND RAILROAD'S FAILURE TO INTRODUCE SCREENINGS FOR SAFETY SENSITIVE PERSONNEL AND REFER AT-RISK SAFETY SENSITIVE PERSONNEL FOR DEFINITIVE OBSTRUCTIVE SLEEP APNEA TESTING AND TREATMENT FOR THE ACCIDENT. FURTHER CONVERTING TO THE ACCIDENT WAS THE ADMINISTRATION'S FAILURE TO REQUIRE RAILROADS TO MEDICALLY SCREENED EMPLOYEES IN SAFETY-SENSITIVE POSITIONS FOR SLEEP APNEA AND OTHER SLEEP DISORDERS. ALSO CONTRIBUTING TO THE ACCIDENT WAS A LACK OF EITHER A DEVICE OR A SAFETY SYSTEM THAT COULD HAVE INTERVENED TO STOP THE TRAIN BEFORE THE COLLISION. MR. SUMWALT: THANK YOU, MR. JONES. ARE THERE ANY AMENDMENTS TO EITHER OF THE PROBABLE CAUSE STATEMENTS? SEEING NONE, DO I HAVE A MOTION TO ADOPT THE PROBABLE CAUSE? DR. DINH-ZARR: SECOND. MR. SUMWALT: IT HAS BEEN MOVED AND SECONDED. ANY DISCUSSION? SEEING NONE, ALL IN FAVOR OF ADOPTING EACH OF THE PROBABLE CAUSE STATEMENT AS READ PLEASE SIGNIFY WITH A HAND AND SAY AYE. OPPOSED? THERE ARE NONE. THE MOTION TO ADOPT THE STATEMENTS PASSED FOR A 3-0 VOTE. MR. JONES, IF YOU WILL READ THE PROPOSED FINDINGS OF THE REPORT OF THE ENTIRE SPECIAL INVESTIGATION REPORT. MR. JONES: THANK YOU. AS RESULT OF THE INVESTIGATIONS, STAFF PROPOSES 16 FINDINGS. FINDING 1 -- LAPSES IN THE NEW JERSEY TRANSIT ENGINEER'S ALERTNESS PRIOR TO THE ACCIDENT RESULTED FROM HIS UNDIAGNOSED AND UNTREATED SEVERE OBSTRUCTIVE SLEEP APNEA. FINDING TWO -- THE FAILURE OF THE NEW JERSEY TRANSIT OBSTRUCTIVE SLEEP APNEA SCREENING PROGRAM TO ADEQUATELY SCREENED THE ENGINEER AND REFER HIM FOR DEFINITIVE DIAGNOSTIC TESTING AND SUBSEQUENT TREATMENT CONTRIBUTED TO THE ACCIDENT. FINALLY 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 AS EVIDENCE OF A SYSTEMIC FAILURE OF A CRITICAL SAFETY SYSTEM TO ENSURE THESE PERSONNEL WERE FIT FOR DUTY. FIGHTING FOUR -- IT IS LIKELY THAT FATIGUE FROM A VARIETY OF SCHEDULES, AS IN POOR SLEEP HABITS, AND UNTREATED SEVERE OBSTRUCTIVE SLEEP APNEA RESULTED IN THE LONG ISLAND RAILROAD ENGINEER FALLING ASLEEP DURING ENTRY INTO THE TERMINAL CAUSING THE COLLISION. FINDING 5 -- THE FAILURE OF THE FEDERAL RAILROAD ADMINISTRATION ADEQUATELY ADDRESS THE ISSUE OF EMPLOYEE FATIGUE DUE TO OBSTRUCTIVE SLEEP APNEA AND OTHER SLEEP DISORDERS, MOST RECENTLY EVIDENCED BY THE AUGUST 2017 -- OF THE ADVANCED NOTICE POST RULEMAKING JEOPARDIZES PUBLIC SAFETY. FINDING 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. FINDING 7 -- SINCE THE FEDERAL RAILROAD ADMINISTRATION DID NOT INFLUENCE SAFETY RECOMMENDATIONS R-12-16 OR COMPLIED WITH THE LEGISLATIVE TIME IN THE REAL SAFETY IMPROVEMENT ACT TO REQUIRE WHERE ROADS TO DEVELOP AN INTIMATE TO TAKE MANAGEMENT PLANS, NEW JERSEY TRANSIT AND LONG ISLAND RAILROAD WERE NOT REQUIRED TO HAVE A SCREENING AND TREATMENT PROGRAM FOR OBSTRUCTIVE SLEEP APNEA. FINDING 8 -- THE NEW JERSEY TRANSIT OBJECTIVE SLEEP APNEA SCREENING AND TREATMENT PROGRAM TO REDUCE THE RISK OF SAFETY SAFETY OF THE EMPLOYEES WITH UNDETECTED AND UNTREATED STRUCTURE SLEEP APNEA POSE TO RAIL SAFETY. FINDING 9 -- THE METROPOLITAN TRANSPORTATION AUTHORITY OBSTRUCTIVE SLEEP APNEA SCREENING AND TREATMENT PROGRAMS SHOULD REDUCE THE RISK OF SAFETY SENSITIVE EMPLOYEES WITH UNDETECTED AND UNTREATED OBSTRUCTIVE SLEEP APNEA OPPOSED TO RAIL SAFETY. FINDING 10 -- AS EVIDENCED I THESE TWO ACCIDENTS, RELIANCE SOLELY ON ENGINEER'S ABILITY TO STOP HIS OR HER TRAIN BEFORE REACHING THE END OF THE TRACKS THIS NOT PROVIDE THE LEVEL OF SAFETY NECESSARY TO PROTECT THE PUBLIC. FINDING 11 -- BUMP AND POST OR THE TYPE USED IN THE HOBOKEN TERMINAL DO NOT APPLY ITSELF PROVIDE ADEQUATE PROTECTION AT THE END OF A TRACK. FINDING 12 -- BOTH THE NEW JERSEY TRANSIT AND THE LONG ISLAND RAILROAD SYSTEM SAFETY PROGRAM PLANS WERE INEFFECTIVE IN IDENTIFYING OPERATIONAL HAZARDS ASSOCIATED WITH OPERATING TRAINS IN TERMINAL TRACKS. FIGHTING 13 -- THE USE OF OPERATING RULES AND PROCEDURES TO MITIGATE AND OF TRACK -- WITH AN INADEQUATE METHOD TO PREVENT THESE ACTIONS BECAUSE IT FAILED TO ELIMINATE THE POSSIBILITY OF A SINGLE POINT FAILURE. FINDING 14 -- NEW JERSEY TRANSIT AND LONG ISLAND RAILROAD NOT CONSIDER AT THE PREVIOUS END OF TRACK COLLISIONS REPRESENTED AN INCREASED RISK OF FUTURE ACCIDENTS. FINDING 15 -- BOTH NEW JERSEY TRANSIT TO THE LONG ISLAND RAILROAD SYSTEM SAFETY PROGRAM PLANS TO IDENTIFY OBSTRUCTIVE SLEEP APNEA SCREENINGS AS A RISK REDUCTION ACTION WHEN EVALUATING EMPLOYEES FOR FITNESS OF DUTY AND WOULD HAVE BEEN UNLIKELY THAT THESE EMPLOYEES HAVE BEEN OPERATING TRAINS WITH UNDIAGNOSED AND UNTREATED EXTRACTIVE SLEEP APNEA. AND LASTLY, FINDING OVER 16 -- THE FEDERAL RAILROAD ADMINISTRATION AT A MINIMUM INSTRUCTED REFERENCE TO USE A GUIDE, COMMUTER AND INTERCITY PASSENGER RAIL SERVICE, WHEN IDENTIFYING AND BEGINNING HAZARDS TO MEETETER SAFETY WOULD BE IMPROVED. MR. SUMWALT:

DO I HAVE A MOTION TO DOT THE FINDINGS AS PRESENTED? ANY DISCUSSION? ALL IN FAVOR OF ADOPTING THE FINDINGS AS PROPOSED SIGNIFY WITH A HAND AND SAY AYE. OPPOSED, THERE ARE NONE. IT PASSES 3-0 VOTE. MR. JONES, IF YOU WILL PLEASE READ THE PROPOSED RECOMMENDATIONS.

AS RESULT OF THESE INVESTIGATIONS STAFF PROPOSES FOR NEW RECOMMENDATIONS. TWO RECOMMENDATIONS, RECOMMENDATION ONE, REQUIRE INTERCITY RAILROADS TO IMPLEMENT TECHNOLOGY TO STOP A TRAIN BEFORE REACHING THE END OF THE TRACK. RECOMMENDATION 2. INCLUDE THE COLLISION HAZARD GUIDE FOR COMMUTER AND INNER SADIST -- INTERCITY REGULATION, PART OF A COMPLIANCE MANUAL TO ASSIST REGULATION PART 270. TWO RECOMMENDATIONS IN THE NEW JERSEY TRANSIT, RECOMMENDATION 3. REVIEW AND REVISE THE SYSTEMS, SAFETY PROGRAM TO ENSURE THAT THEY DOCUMENT PREVIOUS INCIDENTS AND USE THEM WHEN IDENTIFYING AND ASSESSING OPERATIONAL HAZARDS. RECOMMENDATION 4. ENSURE THE OPERATOR IMPAIRMENT DUE TO MEDICAL CONDITIONS AND TOOTING OBSTRUCTIVE SLEEP APNEA IS PART OF THE HAZARD -- INCLUDING OBSTRUCTIVE SLEEP APNEA IS PART OF THE HAZARD RECOMMENDATIONS. REQUIRE RAILROADS TO MEDICALLY SCREENED EMPLOYEES AND SAFETY SENSITIVE POSITIONS FOR SLEEP APNEA AND OTHER SLEEP DISORDERS. RECOMMENDATIONS, DEVELOP A STANDARD THAT MEDICAL EMPLOYEES AND SAFETY SENSITIVE POSITIONS MAY -- MUST MEET TO BE CONSIDERED FIT FOR DUTY.

ANY PROPOSED AMENDMENTS? WHAT'S NO. SEEING NONE, TO HAVE RECOMMENDATION? ANY DISCUSSION? SEEING NONE. THERE ARE NONE. VOTE TO PASS THE RECOMMENDATIONS AS PROPOSED. PASSED BY 3-0 VOTE. DOES ANYONE HAVE ANY ADDITIONAL ISSUES PRIOR TO OUR MOVING ON TO ADOPTION OF THE REPORT? IS THERE A MOTION TO ADOPT THE SPECIAL INVESTIGATION REPORT AS PRESENTED, WHICH INCLUDES THE ACCIDENT BRIEFS FOR EACH OF THE TWO ACCIDENTS? IS THERE A MOTION FOR THAT? IT HAS BEEN MOVED AND SECONDED. A DISCUSSION, SEEING NONE, ALL IN FAVOR OF PROVING THE SPECIAL INVESTIGATION REPORT, WHICH INCLUDES THE TWO ACCIDENT BRIEFS, PLEASE SIGNAL WITH A HAND. OPPOSED, THERE ARE NONE. THE SPECIAL INVESTIGATION REPORT HAS BEEN ADOPTED 3-0. DO ANY MEMBERS WISH TO FILE A CONCURRING OR DISSENTING STATEMENT? NONE. ANY FURTHER DISCUSSION? IN CLOSING, I WOULD LIKE TO RECOGNIZE THE HARD WORK FROM THE NTSB STAFF INVESTIGATING THESE ACCIDENTS AND DRAFTING THE SPECIAL INVESTIGATION REPORT. I WANT TO INVITE AND THANK OUR INVESTIGATORS IN CHARGE FOR WHICH WOULD BE JIM SOUTHWORTH. HE IS IN KC, SOUTH CAROLINA ON A RAIL ACCIDENT. I WOULD LIKE TO THANK YOU FOR FILLING IN FOR HIM. I WOULD LIKE TO THANK YOU FOR LEADING THE EFFORT, LEADING THE SPECIAL INVESTIGATION SUPPORT TEAM. THANK YOU FOR SPENDING SEVERAL DAYS ON SCENE AT HOBOKEN AND BEING OUR BOARD MEMBER ON SCENE. AND MY COLLEAGUES, FOR PREPARING FOR THIS BOARD MEETING, GOOD QUESTIONS. THANK YOU VERY MUCH. I BELIEVE TODAY'S RECOMMENDATION S HAVE THE POTENTIAL TO AND END OF TRACK COLLISIONS, THAT TRANSLATES TO PROTECTIONS PEOPLE STANDING ON PLATFORMS. THE RECOMMENDATIONS ON SLEEP APNEA SCREENING AND TREATMENT, THEY SPEAK FOR THEMSELVES. THE BROADER ISSUE OF REDUCING FATIGUE RELATED ACCIDENTS AND DEMANDING PHYSICAL FITNESS ARE ON THE NTSB'S MOST WANTED LIST OF TRANSPORTATION SAFETY IMPROVEMENTS. THESE ACCIDENTS REMIND US WHY WE HAVE THIS MOST WANTED LIST. THE TRAVELING PUBLIC DESERVES ALERT OPERATORS. THAT IS NOT TOO MUCH TO ASK. WE ASK OUR RECOMMENDATIONS BE IMPLEMENTED. WE STAND ADJOURNED.