Washington – In final reports on five accidents that resulted in six fatalities, The National Transportation Safety Board faulted Metro North for poor track maintenance and lax inspections, inadequate training and questionable screening and scheduling of train engineers.

The NTSB said a Metro-North derailment in the Bronx on Dec. 1, 2013, that killed four people occurred when the engineer fell asleep and failed to comply with a 30-mile-per-hour speed limit on a dangerous stretch of track. The engineer fell asleep because of undiagnosed “sleep apnea exacerbated by a recent circadian rhythm shift required by his work schedule,” the NTSB said.

Federal investigators said Metro-North’s lack of a sleep disturbance policy and an automatic brake control system that would have slowed the train also contributed to the accident, which also caused more than $9 million in damages.

“Contributing to the severity of the accident was the loss of the window glazing that resulted in the fatal ejection of four passengers from the train,” the NTSB said.

Metro North said it has made a number of safety changes since the accidents, though Connecticut lawmakers and Gov. Dannel Malloy say they want to see more.

“This report confirms the concerns that I raised with Metro-North leadership regarding their business practices well over a year and half ago,” Malloy said. ” Since then, much has been accomplished, but it will take an ongoing commitment to ensuring a safety culture in the organization as well as investing in the essential safety, maintenance and training resources at Metro-North.”

Sen. Richard Blumenthal, D-Conn., a chief critic of Metro-North and the Federal Railroad Administration for failing to implement dozens of congressional mandates adn NTSB recommendations, was harsher in his reaction.

“This represents a real call to action,” Blumenthal said. “It documents in new depth and detail a rail safety culture in disarray.”

The first in a rash of Metro-North accidents was a crash between two commuter trains outside Bridgeport on May 17, 2013.

The NTSB said the crash injured 65 people and caused $18.5 million in damages.

The NTSB determined the cause of that crash and derailment was an undetected pair of broken joint bars that hold the rails together and the lack of a track maintenance program that prioritizes needed repairs based on inspection reports. It also blamed a regulation that exempts high-density commuter railroads from a requirement that each main track be inspected by vehicle or on foot at least once every two weeks.

Connecticut owns the tracks used by Metro-North in the state, but under an agreement with the state, the commuter rail company is responsible for inspection and maintenance of the tracks.

The NTSB also completed its investigation of two accidents that each resulted in the death of a railroad employee.

The first accident, which occurred near the West Haven station on May 28, 2013, killed foreman Robert Luden, who was working on the track. The accident was blamed on a student rail traffic controller’s decision to remove a signal protection that would have stopped the oncoming train. The NTSB also blamed Metro-North’s failure to require a backup signal system.

The second railroad-worker fatality occurred in Manhattan on March 10, and the NTSB determined the probable cause was incomplete and inaccurate job briefings of railroad workers.

The NTSB also found fault with Metro-North in a derailment of a CSX freight train in the Bronx.

Metro-North has instituted a number of reforms in the last years, including a backup signal system and an automatic brake control system.

“Metro-North today is a different railroad from the one that existed 18 months ago,” said Metro-North President Joseph Giulietti. “Every decision and change that has been made since I became president last February has been made to advance safety. Our goal is to build a culture of safety where each employee is responsible for the safety of every customer and every other employee, and no one is afraid to bring up safety concerns. I am confident that our dedicated and committed employees will not let up on this full-bore effort.”

Connecticut’s lawmakers have pressed Metro-North to adopt additional safety measures and are backing legislation in Congress that would require them of all rail companies.

“This report confirms what we already know: The Federal Railroad Administration and Metro-North’s operations and safety practices need to change,” said Rep. Rosa DeLauro, D-3rd District. “They have made progress in these areas, but Connecticut commuters deserve to have confidence in their rail system.”

Rep. Jim Himes, D-4th District, said “I will push for the NTSB recommendations to be put in place as quickly and as efficiently as possible, where that has not already been done, and will continue to urge Congress to pass the Rail Safety Enforcement Act.”

Railroad reform bills did not move forward in this Congress. Blumenthal said he would also re-introduce his legislation next year.

Here are verbatim summaries of the findings contained in the NTSB’s report:

Bridgeport May 17, 2013: (Metro-North train derailment) The NTSB determined that the probable cause of the derailment was an undetected broken pair of compromise joint bars on the north rail of Track 4 on the Metro-North Railroad New Haven subdivision at milepost 53.25 resulting from: (1) the lack of a comprehensive track maintenance program that prioritized the inspection findings to schedule proper corrective maintenance; (2) the regulatory exemption for high-density commuter railroads from the requirement to traverse the tracks they inspect; and (3) Metro-North’s decisions to defer scheduled track maintenance.

West Haven, May 28, 2013: (Employee fatality) The National Transportation Safety Board determines that the probable cause of this accident was the student rail traffic controller’s removal (while working without direct supervision) of signal blocking protection for the track segment occupied by the track foreman and the failure of Metro-North to use any redundant feature to prevent this single point failure. Contributing to the accident was the failure to require redundant signal protection, as recommended by Safety Recommendation R-08-6.

Bronx, N.Y. Oct. 24, 2013 : (CSX train derailment) The National Transportation Safety Board determines that the probable cause of the accident was excessive track gage due to a combination of fouled ballast, deteriorated concrete ties, and profile deviations resulting from Metro-North’s decision to defer scheduled track maintenance.

Bronx, N.Y. Dec. 1,2013 (Metro-North train derailment, four fatalities) The National Transportation Safety Board determines that the probable cause of the accident was the engineer’s noncompliance with the 30-mph speed restriction because he had fallen asleep due to undiagnosed severe obstructive sleep apnea exacerbated by a recent circadian rhythm shift required by his work schedule. Contributing to the accident was the absence of a Metro-North Railroad policy or a Federal Railroad Administration regulation requiring medical screening for sleep disorders. Also contributing to the accident was the absence of a positive train control system that would have automatically applied the brakes to enforce the speed restriction. Contributing to the severity of the accident was the loss of the window glazing that resulted in the fatal ejection of four passengers from the train.

Manhattan, N.Y. March 10 2014 :(Employee fatality) The National Transportation Safety Board determines that the probable cause of the accident was the miscommunication of the limits of on-track protection resulting from incomplete and inaccurate roadway worker job briefings. Contributing to the accident was use of a reference point for on-track protection (the AB Split) that was poorly understood by some of the workers on the track.

Ana has written about politics and policy in Washington, D.C.. for Gannett, Thompson Reuters and UPI. She was a special correspondent for the Miami Herald, and a regular contributor to The New York TImes, Advertising Age and several other publications. She has also worked in broadcast journalism, for CNN and several local NPR stations. She is a graduate of the University of Maryland School of Journalism.

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