2011-8232. Safety Advisory 2011-01

AGENCY:

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

ACTION:

Notice of Safety Advisory; equipment fouling adjacent tracks.

SUMMARY:

FRA is issuing Safety Advisory 2011-01 to remind each railroad and railroad employees of the importance of compliance with Federal regulations and railroad operating rules regarding rolling equipment being left in a location that is clear of any adjacent tracks. This safety advisory contains various recommendations to railroads to ensure that this issue is addressed by appropriate policies and procedures, and receives employee compliance.

FOR FURTHER INFORMATION CONTACT:

Ron Hynes, Director, Office of Safety Assurance and Compliance, Office of Railroad Safety, FRA, 1200 New Jersey Avenue, SE., Washington, DC 20590, telephone [phone]; or Joseph St. Peter, Trial Attorney, Office of Chief Counsel, FRA, 1200 New Jersey Avenue, SE., Washington, DC 20590, telephone [phone].

SUPPLEMENTARY INFORMATION:

The overall safety of railroad operations in the area of equipment securement and protection has improved in recent years. However, two recent fatal incidents highlight the need to review and adhere to existing Federal regulations and railroad operating rules pertaining to rolling equipment being left in a location that is clear of any adjacent tracks.

On May 18, 2005, the Railroad Safety Advisory Committee (RSAC) authorized the RSAC Operating Rules Working Group to address eight human factors (HF) train accident report cause codes that were attributed to nearly half (47 percent) of all HF-caused train accidents nationwide. On February 13, 2008, FRA published a final rule addressing those HF causes, which was codified at Title 49 Code of Federal Regulations (CFR) Part 218, Subpart F (Subpart F). Two of those eight HF cause codes, H301 and H302, were designated for rolling equipment left out to foul. From 2005 to 2010, HF-caused train accidents, attributed to these two cause codes, were reduced by 66 percent. Unfortunately, despite that overall improvement, the rail industry experienced two recent railroad employee fatalities that appear to have been related to equipment being left in a location where it fouled an adjacent track.

Recent Incidents

The following is a discussion of the circumstances surrounding two recent fatal incidents, and is based only on FRA's preliminary investigations. The incidents are still under investigation by FRA. The causes and contributing factors, if any, have not yet been established. Therefore, nothing in this safety advisory is intended to attribute a cause to the incidents or place responsibility for the incidents on the acts or omissions of any person or entity.

Two railroad employees, while each riding the side of rolling equipment to protect a shoving movement, were fatally injured (in separate incidents) when the equipment they were riding struck other equipment that was left out to foul. A common factor in both accidents was that the equipment was left in a location where it fouled an adjacent track by the very employees who were involved in the incidents.

The first incident occurred on September 2, 2010, in Bridgeport, New Jersey, when a conventional two-person switching crew was shoving rolling equipment into an industrial facility. The locomotive engineer was in the locomotive control compartment and the conductor was positioned on the leading end of a tank car directing the shoving move. The conductor had one foot on the end platform and the other on the side ladder tread as he began to pass a tank car that he had spotted at that location the previous day. Unfortunately, the car had been left in the foul of the adjacent track and the cars struck each other; the conductor sustained fatal injuries.

The second incident occurred on February 8, 2011, in Kankakee, Illinois. A conventional switching crew that consisted of a conductor, engineer, and a conductor-in-training was switching cars on a switching lead track and using various other yard tracks. The crew had left a car on one of the yard tracks in a location where it was in the foul of an adjacent track. Shortly thereafter, the conductor and conductor-in-training boarded opposite sides of the leading end of a gondola car and began a shoving movement. Subsequently, the side of the gondola on which the conductor was riding struck the car that was previously left in the foul of the adjacent track. The conductor was crushed between the two cars and sustained fatal injuries.

Although the preponderance of incidents involving equipment that is left in the foul of an adjacent track fortunately only result in railroad property damage, the potential for injury or death in such instances is always present. By issuing this safety advisory, FRA is reminding all stakeholders of the importance of situational awareness and compliance with all applicable operating and safety rules, particularly those related to leaving rolling equipment in a location that is clear of adjacent tracks.

FRA Action: Despite the significant reduction in train accidents caused by equipment being left in the foul of an adjacent track, a review of FRA's inspection data relative to 49 CFR 218.101 indicates a disturbing trend. From calendar year (CY) 2009 to CY 2010, violations of 49 CFR 218.101 recommended for prosecution by FRA inspectors increased 124 percent. Based on the results of inspection data for the first 2 months of 2011, if trends continue, violations recommended for prosecution in 2011 versus 2010 would increase by an additional 81 percent. Whether the increase in violations is due to greater vigilance by FRA or is due to an actual increase in the number of instances where equipment is being left in such locations, FRA intends to ensure that railroads take necessary steps to prevent and reduce the potential trend indicated by the statistics noted above.

Over the next several months, FRA intends to increase its inspection activity to focus on compliance with railroad operating rules that address all of the requirements contained in Subpart F. Particular emphasis will be placed on the requirements contained in 49 CFR 218.101. FRA will also focus its inspection efforts on railroad operational testing activity, particularly as it relates to Subpart F. FRA strongly encourages railroad industry members to reemphasize the importance of leaving equipment in the clear as frequently as possible, and to take such other actions as may help ensure safety on the Nation's railroads.

Recommended Railroad Action: In light of the recent accidents discussed above, and in an effort to maintain the safety of railroad employees on the Nation's rail system, FRA recommends that railroads:

(1) Review with employees the circumstances of the two most recent fatal incidents;

(2) Reinstruct supervisors and employees on the operating and safety rules applicable to leaving rolling equipment in a location that is clear of adjacent tracks. Particular emphasis should be placed on the procedures that enable employees to identify clearance points and the means to identify locations where clearance points will not permit a person to safely ride on the side of a car;

(3) Increase operational testing on those operating and safety rules that pertain to leaving rolling equipment in a location that is clear of adjacent tracks; and

(4) Review current job briefing procedures among coworkers and determine if the procedures are sufficient to encourage more effective communication regarding switching activities, specifically as the procedures relate to the positioning of rolling equipment so that the equipment is in a location that is clear of adjacent tracks.

FRA encourages railroad industry members to take action that is consistent with the preceding recommendations and to take other actions to help ensure the safety of the Nation's railroad employees. FRA may modify this Safety Advisory 2011-01, issue additional safety advisories, or take other appropriate action necessary to ensure the highest level of safety on the Nation's railroads, including pursing other corrective measures under its rail safety authority.

Issued in Washington, DC, on April 1, 2011.

Jo Strang,

Associate Administrator for Railroad Safety/Chief Safety Officer.