[Federal Register Volume 76, Number 196 (Tuesday, October 11, 2011)]
[Pages 62894-62897]
[FR Doc No: 2011-26283]



Federal Railroad Administration

[Safety Advisory 2011-02]

Following Procedures When Going Between Rolling Equipment

AGENCY: Federal Railroad Administration (FRA), Department of 
Transportation (DOT).

ACTION: Notice of Safety Advisory.


SUMMARY: FRA is issuing Safety Advisory 2011-02 to remind railroads and 
their employees of the importance of following procedures when going

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between rolling equipment. This safety advisory contains various 
recommendations to railroads to ensure that these issues are addressed 
by appropriate railroad operating policies and procedures, and to 
ensure that those policies and procedures are effectively implemented.

Jersey Avenue, SE., Washington, DC 20590, telephone (202) 493-6404; or 
Joseph St. Peter, Trial Attorney, Office of Chief Counsel, FRA, 1200 
New Jersey Avenue, SE., Washington, DC 20590, telephone (202) 493-6047.

SUPPLEMENTARY INFORMATION: The overall safety of railroad operations 
has improved in recent years. However, recent fatal events highlight 
the need for the railroad industry to refocus its attention on 
compliance with safety rules and procedures that apply to employees 
who, in the course of their work, place themselves between rolling 
equipment. The railroad industry has long recognized that employees 
whose responsibilities necessitate physically placing themselves 
between rolling equipment, as often occurs during switching operations, 
must take adequate safety precautions and be alert and aware of their 
surroundings at all times. Consequently, railroads developed rules and 
procedures designed to ensure the safety of employees when between 
rolling equipment.
    In 1998, the industry recognized a troubling increase in the number 
of employee fatalities occurring during switching operations, including 
incidents of employees effectively being crushed between rolling 
equipment. At FRA's request, a voluntary group comprised of industry 
stakeholders was formed to examine and address that trend of increasing 
deaths. The group included representatives from the Association of 
Association (ASLRRA), the Brotherhood of Locomotive Engineers and 
Trainmen (BLET), the United Transportation Union (UTU), and FRA. The 
group was later named the Switching Operations Fatality Analysis (SOFA) 
Working Group. In October 1999, the Working Group issued a report 
titled ``Findings and Recommendations of the SOFA Working Group.'' The 
report can be found on FRA's Web site at http://www.fra.dot.gov/Pages/1781.shtml.\1\ The report contains five major findings with an 
accompanying recommendation and discussion for each finding. The first 
of these five recommendations is directly applicable to situations 
where employees go between rolling equipment, or otherwise foul track 
or equipment. That recommendation reads as follows:

    \1\ More recently, in March 2011, the SOFA Working Group issued 
a report titled ``Findings and Advisories of the SOFA Working 
Group,'' available online at: http://www.fra.dot.gov/rrs/pages/fp_Findings%20and%20Advisories.shtml.

    Any crew member intending to foul track or equipment must notify 
the locomotive engineer before such action can take place. The 
locomotive engineer must then apply locomotive or train brakes, have 
the reverser centered, and then confirm this action with the 
individual on the ground. Additionally, any crew member that intends 
insure that the cut of cars to be coupled into is separated by no 
less than 50 feet. Also, the person on the ground must physically 
inspect the cut of cars not attached to the locomotive to insure 
that they are completely stopped and, if necessary, a sufficient 
number of hand brakes must be applied to insure the cut of cars will 
not move.

    Many railroads have procedures similar to those described in this 
SOFA recommendation, and other railroads have adopted or modified their 
procedures to be utilized when going between rolling equipment to 
reflect this recommendation.
    When the pre-SOFA, 9-year period (1992-2000) is compared with the 
post-SOFA, 9-year period (2001-2009), the industry realized a 60-
percent reduction (15 vs. 6) in the number of employees killed when 
working between rolling equipment. Unfortunately, this positive trend 
has not continued. Within the last 10 weeks, the railroad industry has 
experienced three employee fatalities that have occurred when employees 
were between rolling equipment. In addition to these most recent 
fatalities, over the last 2 years, two additional employee fatalities 
have occurred when employees were between rolling equipment. This rise 
in employee fatalities as a result of being crushed between rolling 
equipment suggests a need to remind railroads and their employees of 
the critical importance of maintaining and abiding by railroad rules 
and procedures designed to ensure safety when going between rolling 
    The following is an overview of the circumstances surrounding these 
recent fatal incidents. Information regarding the three most recent 
incidents is based on FRA's preliminary investigation findings as the 
probable causes and or contributing factors of these incidents have not 
yet been established. Accordingly, nothing in this safety advisory is 
intended to attribute a definitive cause to these incidents, or place 
responsibility for the incidents on the acts or omissions of any person 
or entity.

Recent Incidents

     The most recent incident occurred on September 8, 2011. At 
approximately 5:15 a.m., a single helper locomotive had coupled to the 
rear of a standing 125-car train with the intent of assisting the 
train's movement up an ascending grade. At some point, the movement 
stopped and the conductor of the single helper locomotive detrained and 
separated his locomotive from the train he and his engineer had 
assisted. After the separation, the conductor of the single helper 
locomotive reattached the end of train device to the last car of the 
assisted train, and announced to the crew of that train that he had 
finished his tasks. He then began to walk back to his locomotive. 
Shortly thereafter, the slack on the assisted train adjusted and the 
conductor was crushed between the rear car of the assisted train and 
his locomotive. The deceased was 59 years old with 5 years of railroad 
     On August 15, 2011, at approximately 1:30 p.m., a three-
person remote control locomotive (RCL) crew consisting of a foreman, a 
helper, and a trainee entered a track in a bowl yard from the east and 
coupled onto a cut of cars. The foreman and the trainee boarded the 
locomotive to provide point protection and the helper, using his remote 
control transmitter, began stretching the cars eastward to identify 
gaps created by uncoupled blocks of cars. As the gaps were revealed, 
the helper repeatedly entered the space between the blocks of cars and 
made adjustments to knuckles and/or drawbars. Using his remote control 
transmitter, he then shoved the cars attached to the locomotive 
westward to couple the cars before continuing the process. The last 
time the helper went into a gap to adjust the knuckles and/or drawbars, 
the cars attached to the locomotive moved west and crushed the helper 
between the cars being coupled. The deceased was 52 years old and had 
approximately 17 years of railroad experience.
     On July 25, 2011, at approximately 12:30 a.m., a two-
person RCL operation had shoved into a classification track and coupled 
to the westernmost car on the track. The RCL conductor on the crew was 
creating gaps in the cuts of cars (by pulling west) to adjust couplers

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and/or align drawbars with the intent of coupling the entire track of 
28 cars and pulling it from the classification track. The conductor's 
helper was riding on the locomotive to provide point protection. The 
grade on the track was descending from east to west. During one such 
operation, when the conductor opened a gap, the cars standing to the 
east of him rolled westward into the cars attached to the locomotive, 
crushing the conductor. The deceased was 33 years old and had 
approximately 3[frac12] years of railroad experience.
     On July 13, 2010, at approximately 1:30 a.m., a switching 
crew was performing a conventional flat, switching operation on a lead 
track. After separating a cut of cars, the conductor entered the space 
between the cars attached to his locomotive and those that he had just 
cut away from in order to make an adjustment to a coupler. He was 
crushed between the cars still attached to his locomotive and the cut 
of cars the crew had just cut away from. The deceased was 35 years old 
and had approximately 6 years of railroad experience.
     On May 10, 2009, at approximately 6:40 p.m., a remote 
control locomotive operator (RCO) was working in a bowl track, coupling 
railroad cars together for placement on a departure track. The RCO 
created gaps in the cuts of cars to adjust couplers and/or align 
drawbars, and then coupled the cars attached to the locomotive to the 
cars left standing. The RCO also replaced a knuckle on one of the cars 
he intended to couple. The RCO went in between the cars to adjust the 
knuckle he had just installed, and was crushed between equipment when 
the drawbars bypassed. The deceased employee was 33 years old and had 
approximately 8 years of railroad experience. The National 
Transportation Safety Board (NTSB) investigated this incident and cited 
the deceased employee's loss of situational awareness when he stepped 
between moving equipment in violation of the railroad's safety rules as 
a probable cause of the incident.
    FRA understands that multiple factors typically contribute to fatal 
events. Three of the five cases outlined above involved remote control 
locomotive operations, and in all three cases, the fatally injured 
employee was in control of the movement at the time of the incident. 
The fact that RCLs were in use in three incidents does not appear to 
have any bearing on the events. In the 2010 conventional switching 
incident there appears to have been no radio transmissions made 
announcing that the employee on the ground was going between cuts of 
cars. In the most recent event, it appears there may not have been 
sufficient distance between the rolling equipment the employee went 
    Each of the above described events, however, demonstrate one 
consistency--the employees involved either did not have enough room or 
time to avoid the moving equipment, or were unaware that any equipment 
they were working with was in motion. These incidents suggest that 
existing railroad rules governing going between rolling equipment may 
not have been fully complied with, and also potentially indicate a loss 
of situational awareness by the employees involved, as well as 
inadequate management oversight of safety rules compliance by 

    \2\ FRA published Safety Advisory 2010-03 (75 Fed. Reg. 63893 
(Oct. 18, 2010)), titled ``Staying Alert and Situational 
Awareness,'' in response to railroad incidents where employees were 
killed. In addition to the recommendations made in this Safety 
Advisory 2011-02, FRA encourages railroads to review those 
recommendations previously made in Safety Advisory 2010-03 as well.

    Railroad operating employees work in an environment which is, by 
nature, often absent direct management oversight. As the above examples 
indicate, even slight lapses in rules compliance and situational 
awareness can lead to tragedy. Without a strong sense of personal 
responsibility for one's own safety, employees can become complacent 
and a danger to themselves or other crewmembers. A culture of 
performing each task safely and as instructed in training must be 
reinforced not only by management, but by senior, more experienced 
employees as well. Good workplace habits should be passed along, while 
questionable work practices should be identified and re-evaluated as 
newer employees are brought into the railroad workforce. At the same 
time, railroad management must positively reinforce the need for 
employees to perform their tasks safely and in accordance with 
established rules and procedures, and as operations change, management 
must review existing rules and procedures to ensure that the relevant 
safety risks of the operating environment are addressed, and that 
employees are appropriately trained. Moreover, railroad management must 
eliminate the pressures that it places on employees to expedite train 
and yard movements as such pressures can negatively impact an 
employee's ability and desire to perform their assigned task safely.
    The discussion contained in this safety advisory is not intended to 
place blame on or assign responsibility to individuals or railroads, 
but to emphasize the fact that a robust culture of operating and safety 
rules compliance is everyone's job. Too often, it is not until after an 
incident has occurred that railroad management, labor, and regulators 
fully realize that dangerous work habits were formed and those routine 
behaviors have not been properly addressed. Support from railroad 
management and peer pressure from fellow employees encouraging 
individuals to perform each task in a safe manner via the proper 
procedures will help railroad employees maintain responsibility for 
their own safety.
    Recommended Railroad and Railroad Employee Action: In light of the 
above discussion, and in an effort to maintain a heightened sense of 
safety vigilance among railroad employees who place themselves between 
pieces of rolling equipment, FRA recommends that railroads:
    (1) Review current operating and safety rules that specifically 
address both remote control locomotive and conventional switching 
operations that require employees to go between rolling equipment, and 
determine whether those rules provide adequate protection to employees, 
or need to be updated or revised.
    (2) Develop, implement, and monitor sound communication protocols 
that require employees on multi-person switch crews to notify their 
fellow crewmembers when the need arises to enter between two pieces of 
rolling equipment--regardless of whether the employee is the primary 
RCO or working on a conventional crew.
    (3) Review the SOFA Safety Recommendation  1, Adjusting 
Knuckles, Adjusting Drawbars, and installing End of Train Devices, 
reproduced above, and communicate its procedures implementing that 
recommendation to employees working in yards or other locations where 
the possibility of entering between rolling equipment exists.
    (4) Convey to employees that their own personal safety is their 
responsibility and that railroad management supports and encourages 
those employees that make safety their number one priority, regardless 
of their immediate assignment.
    (5) Convey to employees that they should encourage fellow employees 
to perform their tasks safely and in compliance with established 
railroad rules and procedures.
    FRA encourages railroad industry members to take action that is 
consistent with the preceding recommendations, and to take other 
complimentary actions to help ensure the safety of the Nation's 
railroad employees. FRA may modify this Safety Advisory 2011-02, issue

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additional safety advisories, or take other appropriate actions 
necessary to ensure the highest level of safety on the Nation's 
railroads, including pursuing other corrective measures under its rail 
safety authority.

    Issued in Washington, DC, on October 5, 2011.
Joseph C. Szabo,
[FR Doc. 2011-26283 Filed 10-7-11; 8:45 am]