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NTSB: Sleep apnea is probable cause of Hoboken crash

“The traveling public deserves alert operators. That’s not too much to ask,” said National Transportation Safety Board Chairman Robert Sumwalt.

The NTSB reported on Tuesday that’s not what the traveling public got on Sept. 29, 2016 when an NJ Transit commuter train slammed into the Hoboken Train Station. The crash killed a woman in the terminal and injured 110 passengers.

The NTSB determined the probable cause of the accident was engineer Thomas Gallagher’s failure to stop the train due to undiagnosed obstructive sleep apnea. It faulted NJ Transit for failing to properly screen for it. Gallagher’s last recorded physical was in 2013, before the accident, and investigators found he was at higher risk for sleep apnea.

“The engineer had gained about 90 pounds since 2013, which creates an increase in your BMI,” said NTSB medical officer Dr. Nicholas  Webster. “It provides evidence he should have been referred for additional testing,”

The board acknowledged that since the accident, NJ Transit’s implemented a screening program that diagnosed 44 out of 57 engineers with sleep apnea, and requires them to be medically certified for duty. It criticized the Federal Railroad Administration, or FRA, for backtracking on national regulations last September.

“I’m extremely disturbed that the FRA has withdrawn this sleep apnea screening program, this proposal. It’s unacceptable to me,” said Sumwalt.

Besides recommending a robust sleep apnea screening program, the board urged all passenger railroads to develop and implement safety management systems, noting NJ Transit had failed to adequately gauge end-of-track accident hazards, and finally, to mandate that all passenger railroads, including NJ Transit, install Positive Train Control, or PTC, at terminal tracks. But the NTSB also reported that the industry needs new technology to help stop the train inside the terminal where PTC may not be completely effective.

“It’s complex for PTC, maybe too complex, so we’re asking the industry and the FRA to join forces and figure out a method to prevent trains from reaching the end of the track … Don’t rely on engineers to stop the train. It’s got too many open failures,” said NTSB investigator, Ted Turpin.

Transportation advocates welcomed the NTSB report’s timing, saying Gov. Murphy just signed an executive order demanding a complete audit of NJ Transit.

“What they can do is roll the finding of this report into that audit and make it part of the bigger reform process,” said Director for New Jersey Policy for the Tri-State Transportation Campaign Janna Chernetz.

NJ Transit’s long lacked adequate funding, an argument underscored by Sen. Bob Menendez, who said the board’s report shows “NJ Transit has become the poster child for what can go wrong when you bleed a transit agency dry of critical resources and fail to prioritize infrastructure investment.”

NJ Transit’s response? “… [We] cooperated fully with the NTSB’s investigation and are pleased that the NTSB acknowledged our aggressive sleep apnea screening protocol …” adding it’s reduced the speed limit into Hoboken and Atlantic City Terminals, outfitted locomotives and cab cars with inward and outward-facing cameras, and is installing friction bumper blocks designed to absorb impact at Hoboken.

Congressman Josh Gottheimer’s proposed a bill that would codify transportation safety requirements.

“You have a new administration that comes in and changes the rules suddenly decides whether someone who suffers from sleep apnea should be flagged or not flagged. So our legislation addresses that, so that from one administration to the next, we don’t suddenly weaken the safety rules,” said Gottheimer.

The NTSB’s recommendations are not mandatory, but Congress and regulatory agencies generally follow its advice about 75 percent of the time.