[Federal Register Volume 76, Number 233 (Monday, December 5, 2011)]
[Notices]
[Pages 75945-75948]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 2011-31058]


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DEPARTMENT OF TRANSPORTATION

Federal Railroad Administration


Safety Advisory 2011-03

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

ACTION: Notice of Safety Advisory; Bridge Walkway Hazards.

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SUMMARY: FRA is issuing Safety Advisory 2011-03 to remind each railroad 
bridge worker, railroad, and contractor or subcontractor to a railroad 
of the dangers posed by walking on unsecured sections of walkway and 
platform gratings, especially without fall protection. This safety 
advisory contains various recommendations to the employers of bridge 
workers to ensure that this issue is addressed by appropriate policies, 
procedures, and 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 (202) 493-6404; 
Carlo Patrick, Staff Director, Rail and Infrastructure Integrity 
Division, Office of Railroad Safety, FRA, 1200 New Jersey Avenue SE., 
Washington, DC 20590, telephone (202) 493-6399; or Alan H. Nagler, 
Senior Trial Attorney, Office of Chief Counsel, FRA, 1200 New Jersey 
Avenue SE., Washington, DC 20590, telephone (202) 493-6049.

SUPPLEMENTARY INFORMATION: In 1992, FRA established safety standards 
for the protection of those who work on railroad bridges at Title 49 
Code of Federal Regulations (CFR) part 214, subpart B. The regulations 
require railroads and railroad contractors to provide, and employees to 
use, fall protection and personal protective equipment, including head, 
foot, eye, and face equipment for employees as they work on railroad 
bridges. The regulation also contains standards related to scaffolding. 
The purpose of FRA's bridge worker safety standards regulation is to 
prevent accidents and casualties to employees involved in certain 
railroad inspection, maintenance, and construction activities.
    The purpose of this safety advisory is to focus attention on the 
unsafe

[[Page 75946]]

practices preliminarily found to be potential contributing causes in 
two incidents occurring this year that resulted in two workers falling 
from railroad bridges, one sustaining a fatal injury. In 2008, another 
worker fell under similar circumstances. In each of these three 
incidents, the fallen bridge worker was not using a personal fall 
arrest system and fell when stepping on an unsecured walkway or 
platform grating. The responsible railroads, contractors, and 
subcontractors had also not erected a safety net system. Furthermore, 
in each instance, the unsecured grating is known or presumed to have 
flipped or tipped as it was found to have fallen along with the worker. 
By focusing attention on these accidents, FRA intends to raise 
awareness and hopefully prevent a continuing pattern of accidents 
involving similar circumstances.

Results of Preliminary Investigations

    The following discussion of the circumstances surrounding the three 
incidents noted above is based on FRA's preliminary investigations. FRA 
did not conduct full investigations of the August 25, 2008, and May 20, 
2011, incidents, and does not plan to produce final findings or reports 
for either of these two incidents. In addition, the September 19, 2011, 
fatal incident described in this safety advisory is still under 
investigation by FRA. Because their causes and contributing factors, if 
any, have not been formally established, nothing in this safety 
advisory should be construed as placing blame or responsibility for any 
of these accidents on the acts or omissions of any person or entity.

Vermillion, Ohio: August 25, 2008

    At 5:55 p.m., a Norfolk Southern Railway (NS) bridge worker fell 
from a Vermillion River railroad bridge, struck a concrete bridge pier, 
and then fell into the river. The worker fell nearly 35 feet. 
Fortunately, NS had hired a contractor to search for and retrieve 
sunken bridge ties and the contractor's employees saw the NS worker 
fall. The worker was reportedly in great pain and struggling to keep 
his head above water when a diver for the contractor, who was already 
in the water, rescued the worker. As a result of this accident, the 
worker suffered a dislocated right shoulder.
    The bridge is a 3-span, deck plate girder bridge with an open deck, 
and upon which there are two tracks. As part of a bridge tie 
replacement project, workers were installing bridge tie spacing timbers 
on the newly installed bridge ties on Track 1. Track 1 was occupied by 
on-track equipment. The worker had worked alongside an assistant 
foreman (i.e., the roadway worker-in-charge of the working limits) for 
most of the work period in order to learn how to permit train movements 
past the stop boards on adjacent Track 2. As the stop boards were in 
effect until 5 p.m., the worker took the stop boards down soon 
thereafter and an alternative form of Roadway Worker Protection was 
established.
    After the worker took the stop boards down, he began walking on 
sections of a walkway grating located on the bridge between the two 
tracks so that he could drill holes in the timber tie spacers. The 
grating on that walkway was mainly in 20-foot-long sections. The 
walkway sections were not secured to the bridge ties as the usual 
practice was to secure the metal walkway grating at the end of the work 
day.
    One section of grating was only approximately 8 feet long. This 
shorter section of walkway was supported in the middle with a 14-foot 
long ``outrigger'' tie. The worker stepped on one end of the 8-foot 
section of walkway, which was overlapping a 19-foot section of walkway 
on the opposite end. There was no tie support underneath the end that 
the worker stepped on. As a result, the employee's body weight caused 
the 8-foot section of walkway to pivot downward on the 14-foot long 
``outrigger'' tie. This action allowed the grating to drop between the 
tracks and the worker to fall into the river.

Minooka, Illinois: May 20, 2011

    An accident occurred in Minooka, Illinois, at approximately 7:30 
a.m. when a bridge worker stepped on a section of unsecured platform 
grating and fell approximately 11 feet to a cross-brace. The worker 
landed on his back, and, at the time of the accident, appeared to have 
bruises on his back and shoulders. A subcontractor, hired by the 
general contractor, employed the worker primarily to torque bolts on a 
railroad bridge owned by Canadian National Railway (CN). On May 25, 
2011, the worker died. Although the coroner did not determine that the 
injuries sustained in the fall from the bridge were the primary cause 
of death, the coroner found that the blunt trauma due to the fall may 
have been a significant condition contributing to death but not related 
to the underlying cause of death.
    On May 16, 2011, 5 days prior to the accident, the worker had 
raised safety concerns with the safety manager for the general 
contractor regarding that the grating on the platform was not properly 
installed. The safety manager agreed with the worker that the grating 
was not installed properly and consulted the subcontractor responsible 
for installing grating for platforms on this job. A coworker of the 
involved worker noticed that there were up to 6-inch gaps between 
several of the pieces of grating and that nothing was fastening the 
individual pieces to the structure on this platform located 103 feet 
above the water at the top of a vertical lift bridge counterweight 
tower. The safety manager reported back to the involved worker that it 
would be difficult to properly install the grating with all of the 
heavy tools and machinery on the platform and that the weight of all 
the tools and machinery was holding the grating in place. The safety 
manager believed that workers did not need fall protection or 
restraints because the platform had a 42-inch-high hand railing 
surrounding the perimeter. The coworker of the involved worker noticed 
that between May 16 and May 19, the tool boxes and heavy equipment on 
the platform were gradually removed so the machinists could use the 
tools and equipment at other locations. Although the two workers had 
previously used fall protection on a different platform while working 
on this same bridge, the coworker did not consider using fall 
protection because of the presence of the hand rails on this platform.
    The accident occurred approximately 15 minutes after a job briefing 
covering trip and fall hazards at the work site. The two workers 
climbed the stairs that led to the platform. Approximately 5 minutes 
after reaching the platform, the coworker heard a loud crash and turned 
around to see that the involved worker was no longer on the platform. 
The coworker noticed a piece of grating missing that was approximately 
4 feet square. The coworker could see the worker lying on his back on 
an approximately 10-inch-wide horizontal I-beam that was located 11 
feet below the platform. The coworker was able to help the involved 
worker get up a ladder to the platform before contacting the employee-
in-charge for further assistance.

 Havre de Grace, Maryland: September 19, 2011

    A fatal accident occurred at approximately 1:50 p.m. when a CSX 
Transportation, Inc.'s (CSX) bridge worker fell approximately 75 feet 
from the Susquehanna River Bridge in Havre de Grace, Maryland. The 
deceased worker was a 58-year-old man with approximately 38 years of 
railroad service. The deceased worker was a

[[Page 75947]]

member of a six-person bridge worker team that was engaged in the 
replacement of bridge ties on the structure. The equipment at the work 
site included an on-track tie handler and a hi-rail boom truck.
    Although there were no witnesses to the actual fall, FRA's 
preliminary investigation suggests that the deceased stepped on the 
unsupported end of an unsecured, 85-inch-long section (i.e., 7 feet 1 
inch) of steel walkway grating. The missing walkway grating location 
was measured at 75 inches long and was outside the rails. Aside from 
the 85-inch-long section of grating found on the ground near the 
deceased, all the grating observed in the area of the extended work 
site were found to be in sections that were 20 feet long. Additionally, 
each section of grating in the area of the extended work site was 
unsecured. At the accident site, the walkway railing was not in place.
    The hi-rail boom truck was occupying the track next to the missing 
walkway grating. This truck was equipped with a horizontal life line 
for connecting a harness. The preliminary investigation suggests that 
the truck's horizontal life line may not have been long enough so that 
a worker could be provided with fall protection while walking along the 
entire side of the truck. A safety net system was not used. The 
deceased was wearing a harness. Preliminary findings also suggest that 
the deceased worker was not distracted by any personal electronic 
devices.

Safety Issues

Fall Protection

    Generally, when bridge workers work 12 feet or more above the 
ground or water surface, FRA regulations require that a personal fall 
arrest system or safety net system be provided and used. 49 CFR 
214.103. Fall protection is a system used to arrest the fall of a 
person from a working level. It consists of an anchorage, connectors, 
body harness, lanyard, deceleration device, lifeline, or a combination 
of these. 49 CFR 214.7 (defining ``personal fall arrest system''). 
Although there are some exceptions to the requirement that fall 
protection be used, FRA's preliminary investigations indicate that none 
of the exceptions applied to any of the incidents described in this 
safety advisory.
    As stated previously, FRA's bridge worker safety standards are 
premised on the broad requirements that railroads and railroad 
contractors provide fall protection for employees as they work on 
railroad bridges--and that the employees, when warranted, must use the 
fall protection provided. In the investigation of each incident, it was 
preliminarily found that the railroad, contractor, or subcontractor had 
provided the personal fall arrest system but that the bridge worker did 
not use the personal fall arrest system at the time of the incident. 
Because the failure to use a personal fall arrest system appears to 
have played a role in each of these incidents, FRA believes it is 
necessary to stress the importance of bridge workers using the personal 
fall arrest system provided to them.
    However, the agency in no way suggests that these incidents 
resulted only from each worker's failure to use a personal fall arrest 
system. The preliminary investigations suggest that there were a number 
of potential causes or contributing factors. For instance, supervisors 
were apprised of the unsecured grating but did not necessarily assess 
the dangers posed or take reasonable steps to mitigate the potential 
threat to worker safety. The preliminary investigations suggest that 
supervisors and employers could have taken additional steps to protect 
bridge workers by putting up safety net systems, securing the grating, 
ensuring that the fall protection provided would be adequate under 
actual working conditions, and emphasizing specific actions during the 
job safety briefings where the use of the provided personal fall arrest 
system would be required by law.

Grating

    Typical steel bridge walkway grating is supplied in 20-foot 
lengths, with the standard widths of 24, 30, or 36 inches. The grating 
weighs about 9 pounds per square foot. Where long bridge ties are used 
as outriggers to support the grating, spacing of these outrigger ties 
normally range from 4 feet 8 inches to 5 feet 4 inches, center to 
center. Walkway grating sections are normally fastened to the ties or 
bridge structure, but during some maintenance activities, the 
fastenings are removed to permit access to other parts of the bridge 
structure. When a full, 20-foot section of grating is placed on the 
outrigger ties, even when one end is not fully supported and the 
grating has not been fastened down, there is sufficient weight behind 
the last supporting tie to more than counterbalance the weight of one 
person that steps on the portion of grating that extends beyond the 
last support.
    In comparison, a hazard is created when shorter sections of grating 
are placed in such a manner that there may not be sufficient weight to 
counterbalance a person stepping on a cantilevered portion of grating 
that is not fastened to the bridge structure. If this occurs, the end 
of the grating where a person steps will tilt downward while the 
opposite end rises, causing both the person and the grating to fall to 
the surface below. This appears to be what occurred in all three of the 
incidents described in this safety advisory.
    All three of the incidents occurred when bridge work was in 
progress and the workers involved knew, or should have known, that the 
grating was not secure. In the case of the subcontractor's employee in 
Minooka, Illinois, the preliminary investigation suggested that the 
employee had brought concerns about the unsecured grating to the 
attention of the general contractor's safety manager prior to the 
accident. In the other two incidents, information available to FRA 
suggests that the workers should have been aware that the grating was 
not secured because it was common practice to keep the grating 
unsecured until the end of each day or until all the bridge tie 
replacement was completed for a specific work area. Although each 
incident contains additional particular facts that suggest other 
potential contributing causes were factors in the incidents, the 
preliminary investigations suggest that the injured workers either 
decided to risk not using a personal fall arrest system or lost sight 
of the risk in their focus to complete the work. Given that bridge 
workers are exposed to serious injury or death from a fall, employers 
should take extra precautions to keep walkway and platform gratings 
fastened, especially shorter sections of gratings, whenever possible.
    Recommended Railroad Action: In light of the foregoing concerns and 
in an effort to maintain safety on the Nation's railroad bridges, FRA 
recommends that each railroad, and contractor or subcontractor to a 
railroad, that employs bridge workers to work on railroad bridges that 
have walkways or platforms with sections of grating:
    (1) Ensure that the grating be kept fastened, unless immediate work 
requires unfastening. Once the immediate work is complete, ensure that 
the fastening is reapplied.
    (2) Ensure that when grating is left unfastened, particularly when 
sections of grating are shorter than 20 feet, the unfastened grating is 
identified by marking or signage.
    (3) Ensure that workers on railroad bridges can safely walk around 
obstacles, such as on-track equipment.
    (4) Employ daily safety briefings with all bridge workers of any 
craft who may be exposed to the hazard of unsecured grating, and 
specifically identify the location and nature of the unfastened 
grating. Such daily safety briefings

[[Page 75948]]

should address what fall protection is being provided and remind bridge 
workers of the likely specific circumstances when a personal fall 
arrest system is required or advised.
    Failure of industry members to take action consistent with the 
preceding recommendations or to take other actions to ensure bridge 
worker safety may result in FRA pursuing other corrective measures 
under its rail safety authority. FRA may modify this Safety Advisory 
2011-03, issue additional safety advisories, or take other appropriate 
action necessary to ensure the highest level of safety on the Nation's 
railroad bridges.

    Issued in Washington, DC, on November 29, 2011.
Jo Strang,
Associate Administrator for Railroad Safety/Chief Safety Officer.
[FR Doc. 2011-31058 Filed 12-2-11; 8:45 am]
BILLING CODE 4910-06-P