The National Transportation Safety Board (NTSB) issued a special investigation report on common organizational factors in five New York Metro North Railroad accidents between May 2013 and March 2014. Taken together, the accidents killed six people and injured 126.

The report examines several common safety management problems present in all the accidents. Last month the NTSB released accident briefs identifying the probable causes of these accidents.

"Metro-North and the Metropolitan Transportation Authority have much work yet to do," said NTSB Acting Chairman Christopher A. Hart. "The FRA has much work to do as well. Railroad safety across the country depends on the FRA turning decisively to the task."

NTSB investigations revealed Metro-North safety programs that were in place were not effectively used to manage the safety of its operations and employees. Furthermore, Metro-North did not effectively investigate accidents and incidents to identify and fix safety deficiencies. In addition, known deficiencies were not corrected.

The report examined not only the safety gaps at Metro-North and MTA, but also problems with Federal Railroad Administration (FRA) regulations, inspection and oversight that allowed the safety gaps to exist. Had previous NTSB recommendations been implemented by the FRA, many of the safety issues encountered in these accidents could have been prevented, the report noted.

Examination of the FRA's national inspection program revealed that its system for prioritizing enforcement efforts was ineffective and that current methodology may not be effective in identifying systemic safety issues. This resulted in a lower FRA presence at Metro-North while track conditions were deteriorating, which increased the risk of a catastrophic accident.

The NTSB issued recommendations to the FRA, Metro-North and the MTA, as well as several other entities. The recommendations address Metro-North safety policy and safety programs, safety protocols, rules on screening for obstructive sleep apnea and other sleep disorders, and track inspection plans.

To view an abstract of the special report, click here.