It wasn’t supposed to happen again. After that devastating winter three years ago, after Governor Cuomo called for a task force, after an investigation and dozens of recommendations, we weren’t supposed to be sitting here wondering why so many horses are breaking down at Aqueduct, again.

But we are. In the 20 days since Aqueduct’s winter meet began, 11 horses have died.  And people are rightly, vocally, repeatedly asking, “Why?”

Determining why one horse breaks down can seem fairly straightforward; finding out why many horses, suddenly, are dying, less so. But as a result of the 2012 Task Force, NYRA has an Equine Safety Review Board that is supposed to do just that.

The review board was among the recommendations in the report submitted by the New York Task Force on Racehorse Health and Safety in September 2012.  Comprising Dr. Scott Palmer, Dr. Mary Scollay, former jockey Jerry Bailey, and attorney and Thoroughbred Horsemen’s Association president Alan Foreman, the Task Force produced a 209-page document containing far-reaching suggestions for reforming the practices at the New York Racing Association, among them a call for a “NYRA Mortality Review Board” to be established to review all racing and training fatalities.

“This review board should be chaired by the NYRA executive who is responsible for overseeing all aspects of the racing operation and should include the chief examining vet and reps from the NYTHA [New York Thoroughbred Horsemen’s Association] and the Jockeys’ Guild,” read the suggestion.

In February 2013, NYRA announced that such a board would be formed, calling it the Equine Safety Review Board (a pleasanter take than “Mortality Review Board,” to be sure).

“The mission of the Equine Safety Review Board is to create an educational process that emphasizes the safety of horses and jockeys,” said Anthony Bonomo at the time. Bonomo chairs the Equine Safety Committee of NYRA’s board of directors.

Named to the original board were NYRA steward Braulio Baeza, Jr., appointed chair of the committee; Dr. Anthony Verderosa, NYRA’s chief examining veterinarian; Glen Kozak, NYRA’s vice president of facilities and racing surfaces; Kenneth V. Handal, NYRA’s acting general counsel and chief ethics officer; the Task Force’s Palmer; Dr. Brian Caserto, a pathologist at the Cornell University College of Veterinary Medicine; Dr. W. Theodore Hill, Jockey Club Steward; and representatives of the New York Thoroughbred Horsemen’s Association (NYTHA) and the New York State Gaming Commission.

NYRA’s February 2013 release also noted that when NYRA hired an equine veterinary medical director, also a recommendation of the Task Force, that person would sit on the board.  Last January, Palmer was appointed to that role, though he was hired by the Gaming Commission, not by NYRA, and it is the Gaming Commission to which he reports.

The September 2012 Task Force report recommended that, in the event of a fatal racing or training breakdown, the trainer or assistant trainer and the horse’s attending veterinarian  attend the meeting, and the board review all factors “believed to have possibly contributed to the fatal injury, using a standardized procedure and determine whether opportunities for intervention were missed to reduce future injures.”

The Task Force also recommended that a report of review board proceedings be made part of the record of the Gaming Commission’s investigation into the incident. (The Task Force report referred to the New York State Racing and Wagering Board, but that body was dissolved early in 2013 and replaced by the Gaming Commission).

Two and a half years after the Task Force recommendation and two years after its creation, the Equine Safety Review Board still exists, though in a different form than envisioned and originally constituted.

When a horse dies during racing—though not during training—the body is sent to Cornell University, where Dr. Caserto performs a necropsy. The results are sent to Dr. Palmer, after which the board meets to review Caserto’s findings.

According to Martin Panza, NYRA’s senior vice president of racing operations, in attendance at review board meetings are, in person or by phone, the trainer of the horse in question; NYRA safety steward Hugh Gallagher; Caserto; Verderosa; and Kozak.

The Task Force recommended that the committee by chaired by the “NYRA executive who is responsible for overseeing all aspects of the racing operation,” but Panza neither sits on the committee nor attends the meetings. He has, though, changed the make-up of the committee since joining NYRA in October of 2013, because, he said, the board is an educational and information-gathering body.

“This is a NYRA panel,” he said. “We’re just looking into what happened to see if there was anything that happened that would make us or the trainer want to do something differently.”

To that end, he directed that stewards no longer be present at review board meetings.

“It’s not an official inquiry,” Panza emphasized. “If the stewards are in here, it can be seen as our trying to put blame on somebody, and that’s not what it’s about. I basically asked to them out of [of the meeting] because when you put a steward in there, it’s no longer just informational; it becomes official. It wasn’t fair to the horsemen.”

Panza also said that while trainers are invited to request that a NYTHA representative be present, few do because NYTHA president Rick Violette can be seen as “a competing trainer.”

Nor does a representative of the Jockeys Guild attend. Though former jockey Richard Migliore, a NYRA race analyst who oversees the organization’s apprentice jockey program, attended the meetings for a time, he no longer does.

Other NYRA employees have at times attended the meeting without being official members of the board, but over the last six months, their participation has ceased.

“I’ve tried to make it so that the people that are there are relevant,” explained Panza.

“We go through the results of what they found on the autopsy, what the training patterns were, what the [past performances] look like,” he said. “Could anything have been done? Was there—I’m not going to say negligence, but why did this happen?”

He also pointed out that if the stewards are concerned about an individual breakdown, they can access the necropsy records and call a hearing.

“And if we found some negligence, we might take it to the stewards,” he added.

Panza estimated that the board will meet “about a month or two” after a horse breaks down, given the time for the necropsy to be done and the report to get to Dr. Palmer.  Though the Task Force recommended that review board proceedings become part of an official Gaming Commission record, no individual reports are generated from these meetings.  The Equine Safety Review Board is a NYRA entity, but Panza said that the Gaming Commission’s Dr. Palmer would be the one to create any reports that might come from the meetings.

Palmer didn’t respond to multiple interview requests.

Last month, concerns had already been raised about breakdowns at Aqueduct, and while Panza declined to talk about specific incidents, he said that the board was on the lookout for patterns—of a certain type of injury, for instance—that might warrant further investigation.

He also said that offering advice to trainers would be inappropriate.

“None of us are trainers,” he pointed out. “I don’t feel comfortable, in that setting, for us to tell a trainer how to train horses because none of us, including the vets, has a trainer’s license.”

Can the Equine Safety Review Board play a significant role in addressing the recent surge in fatalities at Aqueduct? Perhaps not, given the time frame offered by Panza, as it will be February or March before the discussions are held about the horses that have recently died. But as NYRA grapples with a breakdown rate that wasn’t supposed to happen again, the board’s responsibility is to identify both the factors that contributed to the horses’ deaths and missed opportunities for intervention, a responsibility that Panza acknowledged.

“[The board] is to review why those horses perished, and what we can learn from it,” he stated.

Said Bonomo in 2013, “We will use the information gleaned through this process to promote additional equine safety measures intended to prevent fatal injuries in the future.”

That future is not, unfortunately, now.