[Federal Register Volume 65, Number 213 (Thursday, November 2, 2000)]
[Notices]
[Pages 65895-65897]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 00-28150]


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DEPARTMENT OF TRANSPORTATION

Federal Railroad Administration


Notice of Safety Advisory 2000-03

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

ACTION: Notice of safety advisory.

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SUMMARY: FRA is issuing Safety Advisory 2000-03 addressing safety 
practices to reduce the risk of serious injury or death both to 
railroad employees engaged in switching operations and to the general 
public.

FOR FURTHER INFORMATION CONTACT: Douglas H. Taylor, Staff Director, 
Operating Practices Division, Office of Safety Assurance and 
Compliance, FRA, 1120 Vermont Avenue, N.W., RRS-11, Mail Stop 25, 
Washington, D.C. 20590 (telephone 202-493-6255) or David H. Kasminoff, 
Trial Attorney, Office of Chief Counsel, 1120 Vermont Avenue, N.W., 
RCC-12, Mail Stop 10, Washington, D.C. 20590 (telephone 202-493-6043).

SUPPLEMENTARY INFORMATION: FRA has determined that the safety of 
railroad employees and the general public compels the issuance of this 
safety advisory. A review of FRA's accident/incident data demonstrates 
that overall the safety of rail transportation has continued to 
improve; however, so far this year, ten railroad employees have lost 
their lives while engaged in switching operations. This figure already 
exceeds the total number of switching-related deaths in 1999, and has 
caused FRA serious concern about the safety of certain aspects of rail 
operations. Specifically, these deaths have raised questions about the 
safety practices employed by crewmembers assigned to perform switching 
operations. These deaths occurred on both large and small railroads and 
included employees with levels of experience that ranged from as little 
as two years to over 30 years.
    The most recent incident occurred on September 9, 2000. FRA 
believes that each of the ten fatalities could probably have been 
prevented if all employees on each railroad had strictly followed the 
five recommendations of FRA's Switching Operations Fatality Analysis 
(SOFA) Working Group and the applicable Federal and railroad company 
operating and safety rules to which they relate.\1\ The ten employee 
fatalities, which occurred between January 2 and September 9, 2000, on 
seven separate railroads, are summarized in Appendix A to this safety 
advisory.
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    \1\ Each of the five SOFA Working Group recommendations is 
described in the ``Findings and Recommended Actions of the SOFA 
Working Group'' section of this advisory.
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Findings and Recommended Actions of the SOFA Working Group

    During February of 1998, the SOFA Working Group was formed at the 
request of FRA to review recent fatal incidents that occurred during 
railroad switching operations and to develop recommendations for 
preventing such fatalities. The Working Group was comprised of 
representatives from FRA, the Association of American Railroads, the 
United Transportation Union, the Brotherhood of Locomotive Engineers, 
and The American Short Line and Regional Railroad Association. The 
Working Group developed a codified database of standardized 
information, referred to as the ``SOFA Matrix,'' from the wide range of 
information on the 76 fatal switching incidents that occurred between 
January 1992 and July 1998. In addition, the Working Group reviewed 
very limited data obtained from FRA files concerning employee 
fatalities from 1975 to 1991 and participated in a series of systematic 
exercises designed to tap the extensive expertise acquired by the 
Working Group during its review and analysis of these employee 
fatalities.
    For statistical purposes, the total number of employee fatalities 
studied by the Working Group was too small and the circumstances were 
too varied to permit formal statistical analysis. Notwithstanding these 
limitations, based on the objective evidence of likely contributing 
factors, a number of findings and recommendations were developed. The 
Working Group's recommendations include actions to improve both the 
safety of railroad switching operations and the quality of data 
collected on fatalities in switching operations. That database and the 
expertise-capturing exercises were then used to identify trends or 
patterns in the data for a more comprehensive understanding of the 
fatalities the Working Group was investigating, and became the 
foundation for the analysis and recommendations in the report, entitled 
``Switching Operations Fatality Analysis,'' which the Working Group 
issued in October 1999.
    The five critical SOFA Working Group recommendations (``five SOFA 
lifesavers'') are set forth below:
     Recommendation 1. Notification to the locomotive engineer 
before fouling track or equipment. ``Any crew member intending to foul 
track or equipment must notify the locomotive engineer before such 
action can take place. The

[[Page 65896]]

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 to adjust 
knuckles/drawbars, or apply or remove EOT device, must 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 that the cut of cars will not move.''
     Recommendation 2. Extra precautions when two or more train 
crews are working on the same track. ``When two or more train crews are 
simultaneously performing work in the same yard or industry tracks, 
extra precautions must be taken:
     Same Track. Two or more crews are prohibited from 
switching into the same track at the same time, without establishing 
direct communication with all crew members involved.
     Adjacent Track. Protection must be afforded when there is 
the possibility of movement on adjacent track(s). Each crew will 
arrange positive protection for (an) adjacent track(s) through positive 
communication with yardmaster and/or other crew members.''
     Recommendation 3. Safety briefing. ``At the beginning of 
each tour of duty, all crew members will meet and discuss all safety 
matters and work to be accomplished. Additional briefings will be held 
any time work changes are made and when necessary to protect their 
safety during their performance of service.''
     Recommendation 4. Proper communications. ``When using 
radio communication, locomotive engineers must not begin any shove move 
without a specified distance from the person controlling the move. 
Strict compliance with `distance to go' communication must be 
maintained. When controlling train or engine movements, all crew 
members must communicate by hand signals or radio signals. A 
combination of hand and radio signals is prohibited. All crew members 
must confirm when the mode of communication changes.''
     Recommendation 5. Paying proper attention to new crew 
members. ``Crew members with less than one year of service must have 
special attention paid to safety awareness, service qualifications, on-
the-job training, physical plant familiarity, and overall ability to 
perform service safely and efficiently. Programs such as peer review, 
mentoring, and supervisory observation must be utilized to insure 
employees are able to perform service in a safe manner.''
    The recommendations from the SOFA Working Group and the 
circumstances surrounding the ten unfortunate deaths that have occurred 
this year during switching operations were discussed at length at the 
September 14, 2000, meeting of FRA's Railroad Safety Advisory Committee 
(RSAC \2\) in Washington, D.C. As a result, FRA and RSAC 
representatives jointly wrote a Declaration expressing the firm 
commitment of the railroad community to address this issue. Consensus 
was achieved, and a Declaration was approved by the RSAC members 
present at the meeting. Subsequent to the RSAC meeting, the wording in 
the Declaration was slightly modified, and concurred with and signed by 
the appropriate 32 RSAC members. Those signatories were:
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    \2\ The RSAC is compried of representativs of the varoius 
interest groups of the railroad industry, including management and 
labor, and representatives of the National Transportation Safety 
Board. The RSAC provies a forum for FRA to receive advice on 
railroad safety issues.
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     Ross Capon, Executive Director, National Association of 
Railroad Passengers
     Daniel Davis, Director--Railroad Department, International 
Brotherhood of Electrical Workers
     Charles E. Dettmann, Executive Vice President, Association 
of American Railroads
     Edward Dubroski, International President, Brotherhood of 
Locomotive Engineers
     Diane Elliott, Executive Director, American Association of 
Private Railroad Car Owners
     Allan C. Fisher, Director of Operating Rules, Consolidated 
Rail Corporation
     Dewey Garland, International Representative, Sheet Metal 
Workers International Association
     George Gavalla, Associate Administrator for Safety, 
Federal Railroad Administration
     Carl Ice, Senior Vice President Operations, The Burlington 
Northern and Santa Fe Railway Company
     Rick A. Inclima, Director of Education and Safety, 
Brotherhood of Maintenance of Way Employes
     Thomas F. Jacobi, Senior Assistant Vice President Safety & 
Operating Practices, Union Pacific Railroad Company
     Richard A. Johnson, General President, Brotherhood of 
Railway Carmen Division--Transportation Communications Union
     Leroy Jones, Vice President and National Legislative 
Representative, Brotherhood of Locomotive Engineers
     Tom Leopold, General Director Rules & Safety, The Kansas 
City Southern Ry. Co.
     Jerry Martin, Director, Rail Division, Texas Railroad 
Commission, (Representing the State Rail Safety Program Managers)
     Chris Martinez, Legislative Representative--New Mexico, 
Brotherhood of Maintenance of Way Employees, (Representing the Labor 
Council for Latin American Advancement)
     Jack T. McBain, Senior Vice President Operations, Canadian 
National Railway
     Francis G. McKenna, President, Tourist Railway Association 
Inc.
     Dennis Mogan, Director, Safety and Rules, Metra (Chicago)
     Jolene M. Molitoris, Administrator, Federal Railroad 
Administration
     Chuck R. Mundy, Vice President, American Train Dispatchers 
Department/Brotherhood of Locomotive Engineers
     Carmen Patriarca, NRC Safety Committee Chairman, National 
Railroad Construction & Maintenance Association
     Pat Pender, Vice President Field Operations, Canadian 
Pacific Railway
     W. Dan Pickett, President, Brotherhood of Railroad 
Signalmen
     Franklin Pursley, Vice President, Safety and Service 
Design, CSX Transportation
     John M. Samuels, Senior Vice President, Operations 
Planning and Support, Norfolk Southern Corporation
     James A. Stem, Alternate National Legislative Director, 
United Transportation Union
     Greg Stengem, Vice President of Safety, Training & 
Operations, The Burlington Northern and Santa Fe Railway Company,
     William J. Thompson, Chairman and State Legislative 
Director, Ohio, United Transportation Union
     Frank K. Turner, President, American Short Line & Regional 
Railroad Association
     Kathryn D. Waters, Manager and Chief Operating Officer, 
Mass Transit Administration of Maryland--MARC Train Service
     Paul Worley, Assistant Director for Engineering & Safety 
American Association of State Highway & Transportation Officials
    The modified Declaration is set forth in Appendix B to this safety 
advisory.

Recommended Actions

    FRA believes that each employee is personally accountable for his 
or her actions on the job. Based upon FRA's review of the circumstances

[[Page 65897]]

surrounding the above-referenced employee deaths, the five SOFA Working 
Group recommendations, and the RSAC Declaration, FRA further believes 
that railroads can reduce the likelihood of suffering the loss of 
additional employee lives during switching operations if they and their 
employees elect to follow the recommendations of the Working Group and 
commit to the principles of the RSAC Declaration.
    Based on the information obtained from FRA's ongoing initiatives 
concerning safety during switching operations, investigations of 
railroad accidents and incidents, and information gathered pursuant to 
the Declaration and other partnership initiatives with rail labor and 
management, FRA may modify Safety Advisory 2000-03, issue additional 
safety advisories, or take other appropriate necessary action to ensure 
the highest level of safety on the Nation's railroads.

Appendix A--Calendar Year 2000 Switching Operations Fatalities

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                                         Years of
          Employee job title             railroad           Date of death          Circumstances surrounding the
                                         service                                               death
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Conductor............................           21  January 2....................  Struck by a box car fouling
                                                                                    the track while riding the
                                                                                    lead car of a shoving
                                                                                    movement into an industry
                                                                                    track.
Conductor............................           23  March 9......................  Coupled (crushed) between two
                                                                                    rail cars while switching in
                                                                                    a classification yard.
Foreman..............................           32  April 21.....................  Stepped into the path of a
                                                                                    rail car that had been
                                                                                    released into the track for
                                                                                    classification from the
                                                                                    gravity hump.
Brakeman.............................            2  May 22.......................  Crushed between the side of a
                                                                                    hopper car and a coal
                                                                                    unloader while riding the
                                                                                    leading end of a shoving
                                                                                    move into a customer's
                                                                                    siding.
Switchman............................            2  May 31.......................  Crushed between the
                                                                                    locomotive he was riding and
                                                                                    a standing cut of box cars.
Conductor............................           19  July 7.......................  Stepped between moving cars
                                                                                    and was struck and run over
                                                                                    by the equipment.
Conductor............................           30  July 24......................  Struck by own locomotive
                                                                                    after lining a switch on the
                                                                                    opposite side of the track
                                                                                    from the engineer.
Brakeman.............................           27  July 28......................  Pinned between the car he was
                                                                                    riding and the loading dock
                                                                                    at a customer's siding
                                                                                    during a shoving move.
Brakeman.............................            4  August 11....................  Struck by another train
                                                                                    crew's consist while
                                                                                    switching at an intermodal
                                                                                    facility.
Switch Foreman.......................           27  September 9..................  Stepped into the path of and
                                                                                    struck by own equipment.
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Appendix B--The Railroad Safety Advisory Committee Declaration

    Together, the railroad community will initiate an on-going 
focused safety campaign to prevent fatalities and injuries from 
occurring during switching operations. This initiative underscores 
our collective commitment to zero injuries and accidents in the 
workplace. This safety campaign will include the following steps:
     Switching operations industry wide will immediately be 
assessed as a team effort by labor, management and FRA through 
increased monitoring and audits to determine safety risks;
     Supervisors and employees will increase their efforts 
to communicate the importance of safety and urge everyone to 
redouble their focus on safe practices;
     The Switching Operations Fatality (SOFA) Analysis 
report and the ``Five SOFA Lifesavers'' will be used as the basis to 
create a plan to address safety risks; and
     Managers will communicate with employees and their 
families to educate them on potential dangers and to seek their 
support in eliminating fatalities and injuries in the workplace.
    We will work together to further strengthen a rail safety 
culture that protects the lives and well being of every railroad 
employee. As an industry, we are dedicated to achieving this safety 
goal.

    Issued in Washington, D.C. on October 27, 2000.
Jolene M. Molitoris,
Administrator, Federal Railroad Administration.

[FR Doc. 00-28150 Filed 11-01-00; 8:45 am]
BILLING CODE 4910-06-P