    Rail Safety: The Federal Railroad Administration Is Taking Steps
    to Better Target Its Oversight, but Assessment of Results Is
    Needed to Determine Impact (26-JAN-07, GAO-07-149).

    Since 1980, the train accident rate has improved significantly,
    but progress has leveled off over the past 10 years. Recent
    serious accidents--such as one in Graniteville, South Carolina,
    that led to 9 deaths and 292 injuries--elevated concerns. The
    Federal Railroad Administration (FRA) develops safety standards
    and inspects and enforces railroads' compliance with these
    standards. This report addresses how FRA (1) focuses its efforts
    on the highest priority risks related to train accidents in
    planning its oversight, (2) identifies safety problems on
    railroad systems in carrying out its oversight, and (3) assesses
    the impact of its oversight efforts on safety. To complete this
    work, GAO reviewed FRA regulations, planning and policy
    documents, and safety data. GAO also contacted FRA officials in
    headquarters and three regional offices and others.
    -------------------------Indexing Terms-------------------------
    REPORTNUM:   GAO-07-149
        ACCNO:   A65187
      TITLE:     Rail Safety: The Federal Railroad Administration Is
    Taking Steps to Better Target Its Oversight, but Assessment of
    Results Is Needed to Determine Impact
         DATE:   01/26/2007
      SUBJECT:   Accident prevention
    	     Accidents
    	     Agency evaluation
    	     Inspection
    	     Performance measures
    	     Policy evaluation
    	     Railroad accidents
    	     Railroad industry
    	     Railroad regulation
    	     Railroad safety
    	     Risk management
    	     Safety regulation
    	     Safety standards
    	     Strategic planning
    	     Transportation
    	     Government agency oversight
    	     Policies and procedures
    	     Program goals or objectives
    	     FRA National Rail Safety Action Plan

    ******************************************************************
    ** This file contains an ASCII representation of the text of a  **
    ** GAO Product.                                                 **
    **                                                              **
    ** No attempt has been made to display graphic images, although **
    ** figure captions are reproduced.  Tables are included, but    **
    ** may not resemble those in the printed version.               **
    **                                                              **
    ** Please see the PDF (Portable Document Format) file, when     **
    ** available, for a complete electronic file of the printed     **
    ** document's contents.                                         **
    **                                                              **
    ******************************************************************
    GAO-07-149

         * [1]Results in Brief
         * [2]Background
         * [3]FRA Has Made Progress in Targeting Its Oversight Efforts on

              * [4]National Rail Safety Action Plan Provides Strategy for Addre
              * [5]FRA Is Making a Number of Efforts to Reduce Accidents Caused
              * [6]FRA Is Pursuing Several Initiatives to Improve the Detection
              * [7]FRA Has Made Progress in Targeting Its Inspections on the Ba

         * [8]FRA Relies Primarily on Direct Inspections to Identify Safet

              * [9]FRA's Oversight Identifies a Range of Site-Specific and Broa
              * [10]Several Other Organizations Have Implemented Comprehensive A

         * [11]FRA Measures Its Progress in Achieving a Variety of Safety G

              * [12]FRA Has Established a Range of Safety Goals and Uses Coopera
              * [13]Performance Measures Support FRA's Oversight, but Informatio
              * [14]FRA Has Made Changes in Response to Evaluations but Has Not

         * [15]Conclusions
         * [16]Recommendations for Executive Action
         * [17]Agency Comments
         * [18]Appendix I: Scope and Methodology

              * [19]Other Aspects of Our Work

         * [20]Appendix II: FRA Addresses Safety Problems through Cooperati
         * [21]Appendix III: Oversight of Risk Management in the U.S. Commu
         * [22]Appendix IV: GAO Contact and Staff Acknowledgments

              * [23]GAO Contact
              * [24]Staff Acknowledgments

                   * [25]Order by Mail or Phone

    Report to Congressional Committees

    United States Government Accountability Office

    GAO

    January 2007

    RAIL SAFETY

    The Federal Railroad Administration Is Taking Steps to Better Target Its
    Oversight, but Assessment of Results Is Needed to Determine Impact

    GAO-07-149

    Contents

    Letter 1

    Results in Brief 3
    Background 6
    FRA Has Made Progress in Targeting Its Oversight Efforts on the Basis of
    Risk 15
    FRA Relies Primarily on Direct Inspections to Identify Safety Problems and
    Does Not Oversee Railroads' Management of Safety Risks 27
    FRA Measures Its Progress in Achieving a Variety of Safety Goals, but Has
    Limited Information on the Direct Results of Its Oversight 39
    Conclusions 50
    Recommendations for Executive Action 50
    Agency Comments 51
    Appendix I Scope and Methodology 52
    Other Aspects of Our Work 53
    Appendix II FRA Addresses Safety Problems through Cooperation and
    Enforcement 56
    Appendix III Oversight of Risk Management in the U.S. Commuter Railroad,
    U.S. Pipeline, and Canadian Railroad Industries 62
    Appendix IV GAO Contact and Staff Acknowledgments 65

    Tables

    Table 1: FRA's Inspection Disciplines 13
    Table 2: Key FRA Initiatives Aimed at Addressing Main Causes of Train
    Accidents 17
    Table 3: FRA's Safety Performance Measures 43
    Table 4: Description of FRA Enforcement Actions and Frequency of Use,
    January 2005 through July 2006 57
    Table 5: Risk Management Framework 62

    Figures

    Figure 1: Train Accident Rates, 1980 through 2005 2
    Figure 2: Train Miles Traveled, 1996 through 2005 7
    Figure 3: Train Injuries and Deaths, 1980 through 2005 8
    Figure 4: Primary Causes of Train Accidents, 2005 10
    Figure 5: Human Factor and Track Accident Rates, 1980 through 2005 11
    Figure 6: FRA Inspector Measuring Track Gauge 29
    Figure 7: FRA Inspector Inspecting Train Cars 30
    Figure 8: Inspections Conducted and Defects and Violations Cited, by
    Inspection Discipline, in 2005 32
    Figure 9: How FRA's Inspection and Enforcement Programs Contribute to Rail
    Safety 41
    Figure 10: FRA's Civil Penalties, 1996 through 2005, in 2005 Dollars 59

    Abbreviations

    APTA American Public Transportation Association

    FRA Federal Railroad Administration

    NTSB National Transportation Safety Board

    PHMSA Pipeline and Hazardous Materials Safety Administration

    This is a work of the U.S. government and is not subject to copyright
    protection in the United States. It may be reproduced and distributed in
    its entirety without further permission from GAO. However, because this
    work may contain copyrighted images or other material, permission from the
    copyright holder may be necessary if you wish to reproduce this material
    separately.

    United States Government Accountability Office

    Washington, DC 20548

    January 26, 2007

    The Honorable Patty Murray
    Chairman
    The Honorable Christopher Bond
    Ranking Minority Member
    Subcommittee on Transportation, Housing and Urban Development,
    and Related Agencies
    Committee on Appropriations
    United States Senate

    The Honorable John Olver
    Chairman
    The Honorable Joe Knollenberg
    Ranking Minority Member
    Subcommittee on Transportation, Housing and Urban
    Development, and Related Agencies
    Committee on Appropriations
    House of Representatives

    Since 1980, the overall safety record in the railroad industry, as
    measured by the rate of train accidents, has improved markedly. (See fig.
    1.) However, during the past decade, the rate of improvement has leveled
    off, and a number of serious accidents in 2004 and 2005 elevated concerns
    about railroad safety. For example, in January 2005, a train carrying
    hazardous materials collided with a standing train in Graniteville, South
    Carolina, resulting in 9 deaths and 292 injuries and requiring the
    evacuation of 5,400 people. In response to the leveling off of the train
    accident rate, this accident, and other serious train accidents, in May
    2005, the federal railroad safety regulator, the Federal Railroad
    Administration (FRA), announced a National Rail Safety Action Plan to
    improve its safety oversight. The plan outlines strategies for FRA to
    target the most frequent, highest-risk causes of accidents, focus federal
    oversight and inspection resources, and research the use of technologies
    in order to improve rail safety. Since 1980, the overall safety record in
    the railroad industry, as measured by the rate of train accidents, has
    improved markedly. (See fig. 1.) However, during the past decade, the rate
    of improvement has leveled off, and a number of serious accidents in 2004
    and 2005 elevated concerns about railroad safety. For example, in January
    2005, a train carrying hazardous materials collided with a standing train
    in Graniteville, South Carolina, resulting in 9 deaths and 292 injuries
    and requiring the evacuation of 5,400 people. In response to the leveling
    off of the train accident rate, this accident, and other serious train
    accidents, in May 2005, the federal railroad safety regulator, the Federal
    Railroad Administration (FRA), announced a National Rail Safety Action
    Plan to improve its safety oversight. The plan outlines strategies for FRA
    to target the most frequent, highest-risk causes of accidents, focus
    federal oversight and inspection resources, and research the use of
    technologies in order to improve rail safety.

    Figure 1: Train Accident Rates, 1980 through 2005

    Citing concerns over several serious accidents that occurred in 2005, the
    Senate Appropriations Committee directed that we assess FRA's oversight
    approach. Accordingly, this report concentrates on how FRA (1) focuses its
    efforts on the highest priority risks related to train accidents in
    planning its safety oversight, (2) identifies safety problems on railroad
    systems in carrying out its oversight, and (3) assesses the impact of its
    oversight efforts on safety.

    To determine how FRA focuses its efforts on the highest priority risks
    related to train accidents in planning its safety oversight, we reviewed
    the agency's National Rail Safety Action Plan, plans for developing new
    regulations, inspection planning documents, and other key planning
    documents related to targeting its oversight at these risks. We also
    discussed oversight planning efforts with FRA officials. To assess how FRA
    identifies safety problems on railroad systems in carrying out its
    oversight, we reviewed FRA's statutory authority; regulations; and
    policies, procedures, and guidance for conducting inspections and
    identifying safety issues. We reviewed data from FRA on its inspection
    activities for the period from 1996 through 2005. We also examined risk
    management principles and safety oversight approaches used by other modal
    administrations within the Department of Transportation and elsewhere that
    have similar safety missions in order to determine their possible
    application to FRA. To determine how FRA assesses the impact of its
    oversight efforts on safety, we examined FRA safety performance measures
    and evaluations of its oversight activities, determined how FRA uses this
    information in making decisions about its oversight, and reviewed our
    products on performance measurement and evaluation.

    As part of our work in each of these areas, we interviewed program and
    enforcement officials at FRA headquarters, as well as at three regional
    offices covering states with the highest train accident rates. We also
    discussed FRA's approach to safety oversight with representatives of
    railroads, unions, and state railroad safety organizations. Our work
    focused on FRA oversight efforts to reduce the rate of train accidents
    rather than those to reduce highway-rail crossing and trespassing
    accidents because (1) the Department of Transportation's Inspector General
    has recently assessed efforts to reduce highway-rail crossing accidents^1
    and (2) trespassing accidents primarily involve issues not related to
    railroad safety performance. We also focused on FRA's oversight of
    railroads rather than its oversight of nonrailroad companies (such as
    shippers of hazardous materials by rail) because the agency's oversight
    efforts focus primarily on railroads. In addition, according to FRA, most
    recent serious train accidents involving the release of hazardous
    materials have resulted from problems with railroad operations. As part of
    our review, we assessed internal controls and the reliability of FRA's
    data on its inspection activities and enforcement actions that were
    pertinent to these efforts. We determined that the data elements were
    sufficiently reliable for our purposes. We conducted our work from
    November 2005 through January 2007 in accordance with generally accepted
    government auditing standards. (See app. I for additional information on
    our scope and methodology.)

    Results in Brief

    In planning its safety oversight, FRA is focusing its efforts on the
    highest priority risks related to train accidents through various
    initiatives aimed at addressing the main causes of these accidents as well
    as through improvements in its inspection planning approach. The agency's
    overall strategy for targeting its oversight at the greatest risks is the
    National Rail Safety Action Plan. This plan provides a reasonable
    framework for guiding the agency's efforts to improve its oversight. It
    includes initiatives to address the two main causes of train
    accidents--human factors and defective track--and FRA has pursued some
    additional initiatives to address these causes since issuing the plan.^2
    These initiatives--which include new regulations, research on new
    technologies and approaches for improving safety, and new vehicles for
    inspecting track--have the potential to reduce the risks associated with
    these causes and thereby reduce the rate of train accidents. For example,
    FRA has recently issued proposed regulations that, if finalized, will
    enable the agency to take enforcement actions when railroad employees do
    not follow key railroad operating procedures for ensuring safety and,
    therefore, may help to reduce some common types of accidents caused by
    human factors. However, most of these initiatives have not yet been fully
    implemented, and, while some may start showing results in the next year or
    two, their overall impact on safety will probably not be apparent for a
    number of years. Furthermore, the ability of many of these efforts to
    improve safety will depend on voluntary actions by railroads, such as the
    adoption of a model FRA has developed to improve train crew scheduling
    practices in order to prevent worker fatigue. In addition, the National
    Rail Safety Action Plan announced a new approach for planning inspections
    that relies on greater use of accident and inspection data and other data.
    Under this approach, which FRA has been using for over a year, inspectors
    focus their efforts on locations that, according to data-driven models,
    are likely to have safety problems. This new planning approach allows FRA
    to use its inspectors more effectively and better target the greatest
    safety risks.

    ^1See U.S. Department of Transportation, Office of the Inspector General,
    Audit of Oversight of Highway-Rail Grade Crossing Accident Reporting,
    Investigations and Safety Regulations, MH-2006-016 (Washington, D.C., Nov.
    28, 2005); and Report on the Audit of the Highway-Rail Grade Crossing
    Safety Program, MH-2004-065 (Washington, D.C., June 16, 2004).

    In carrying out its safety oversight, FRA identifies safety problems on
    railroad systems mainly through routine inspections that determine whether
    operating practices, track, and equipment, such as signals and
    locomotives, are in compliance with safety standards. Through this
    approach, FRA inspectors identify a range of safety problems at various
    sites on railroads' systems. FRA also identifies some broad-scale problems
    that affect multiple sites, primarily through analyses of accident and
    inspection data, internal discussions, and some nonroutine inspections.
    However, the number of FRA and state inspectors is small relative to the
    size of the industry and FRA inspections are able to cover only about 0.2
    percent of railroads' operations each year.^3 Also, these inspections
    focus on compliance with minimum standards and are not designed to
    determine how well railroads are managing safety risks throughout their
    systems that could lead to accidents. The American Public Transportation
    Association (APTA), the Pipeline and Hazardous Materials Safety
    Administration (PHMSA), and Transport Canada have implemented approaches
    to oversee the management of safety risks by U.S. commuter railroads, U.S.
    pipelines, and Canadian railroads, respectively. Risk management can be
    described as a continuous process of managing--through the systematic
    identification, analysis, and control of risks associated with safety
    hazards (such as train collisions)--the likelihood of hazards' occurrence
    and their negative impact.^4 These oversight approaches complement, rather
    than replace, traditional compliance inspections and, therefore, provide
    additional assurance of safety. However, because we believe that FRA's
    initiatives to reduce train accident rates need time to mature and
    demonstrate their effects on safety, we are not recommending that FRA
    adopt an approach for overseeing railroads' management of safety risks.

    ^2Generally, human factors are behaviors that affect job performance, such
    as incorrectly setting switches. According to FRA, the term human factors
    refers broadly to the role of human participation in any system and to the
    ways in which human beings positively or negatively contribute towards
    system performance.

    FRA uses a broad range of goals and measures to assess the impact of its
    oversight efforts on safety. For example, it has developed new goals to
    target its inspection and enforcement efforts at reducing various types of
    railroad accidents and related measures to track its progress. These
    measures include the level of train accidents caused by human factors,
    track defects, and equipment defects, both nationwide and within each of
    its eight regions. These safety performance measures provide FRA with much
    information that it uses to make decisions about its oversight approach.
    However, its ability to make informed decisions is limited because it
    lacks measures of the direct results of its inspection and enforcement
    programs, such as measures of the extent to which these programs have
    resulted in the correction of identified safety problems or improvements
    in compliance. We have found that it is a useful practice for agencies to
    establish measures of programs' direct results to help show their
    contributions to the ultimate results the agencies seek to achieve.
    Furthermore, while FRA has made some changes in its oversight approach in
    response to external and internal evaluations, the agency has not
    evaluated the effectiveness of its enforcement program in achieving
    desired results. Evaluations can provide a broader range of information on
    program performance and how to improve it than performance measures alone.
    Both performance measures and evaluations can provide valuable information
    on program results that helps hold agencies accountable for the
    performance of their programs.

    ^3This figure is an FRA estimate, based on an estimation of the amount of
    activity, such as train movements, on each railroad in the United States.

    ^4Risk is the combination of the likelihood and the consequence of a
    specified hazard being realized.

    To improve FRA's ability to determine the extent to which its inspection
    and enforcement programs are contributing to rail safety and whether
    changes in these programs are needed, we are recommending that FRA develop
    and implement measures of the direct results of its inspection and
    enforcement programs and evaluate its enforcement program. We provided a
    draft of this report to the Department of Transportation for its review
    and comment. The department did not offer overall comments on the draft
    report or its recommendations. It did offer several technical comments,
    which we incorporated where appropriate.

    Background

    Railroads are an important component of the transportation system,
    transporting about 42 percent of the nation's freight (as measured by
    weight). For passenger movement, railroads play a much smaller role than
    do highway and air travel; however, communities are looking to different
    forms of public transit for relief, particularly as highways become
    increasingly congested. Demand continues to grow for both freight and
    passenger transportation on railroads. In 2005, railroads traversed 790
    million train miles,^5 an increase of 18 percent since 1996. (See fig. 2.)
    Moreover, the Department of Transportation estimates that between 1998 and
    2020, the amount of freight transported by rail (as measured by weight)
    will increase by about 50 percent. Commuter and intercity passenger
    railroads have also grown--providing over 522 million passenger trips in
    2005, compared with 385 million in 1995. According to the Federal Transit
    Administration, as of 2006, seven more commuter rail systems throughout
    the country were being planned or designed.

    ^5A train mile is the movement of a train a distance of 1 mile.

    Figure 2: Train Miles Traveled, 1996 through 2005

    The railroad industry is primarily composed of 7 large freight railroads
    (called Class I railroads); about 560 smaller freight railroads (called
    Class II and III railroads); and 118 passenger, commuter, tourist,
    excursion, and other railroads.^6 Within the industry, Class I freight
    railroads predominate, representing about 93 percent of railroad freight
    revenue and 69 percent of the total U.S. rail mileage. Class II and Class
    III railroads include a number of regional and short line railroads that
    provide freight transportation. Class II regional railroads typically
    operate 400 to 650 miles of track in a region spanning two to four states,
    whereas Class III short lines typically perform point-to-point service
    over short distances.

    On average, about 446 people have been injured and 14 people have been
    killed each year over the past decade, from 1996 through 2005, exclusive
    of highway-railroad grade crossing and trespassing accidents. Despite
    overall improvements since 1980, gains have tapered off. Since 1992, the
    accident rate has remained at about or sometimes more than four accidents
    per million train miles. (See fig. 1.) In recent years, a number of
    serious accidents raised concerns about the level of safety in the
    railroad industry. Train accidents resulted in 1,884 injuries and 15
    deaths in 2002, and 733 injuries and 33 deaths in 2005. (See fig. 3.) FRA
    officials attributed the large rise in number of injuries and deaths in
    2002, and subsequently in 2005, to one or two major accidents, as opposed
    to a series of accidents. For example, in 2002, a derailment in Minot,
    North Dakota, led to the release of approximately 200,000 gallons of
    anhydrous ammonia, 1,442 injuries and 1 death. In 2005, a train collision
    in Graniteville, South Carolina, resulted in the evacuation of 5,400
    people, 292 injuries and 9 deaths.

    ^6For 2005, the Surface Transportation Board has defined Class I railroads
    as railroads earning adjusted annual operating revenues of $319.3 million
    or more. Class II railroads are those earning between $25.5 million and
    $319.3 million, and Class III railroads are those earning less than $25.5
    million.

    Figure 3: Train Injuries and Deaths, 1980 through 2005

    Note: Injuries were far more common than deaths during the period of 1980
    through 2005; deaths ranged from 4 to 67 per year. Figures do not include
    highway-railroad crossing and trespassing incidents.

    Although Class I railroads have a lower rate of accidents than Class II
    and III railroads, because of their size, they account for most train
    accidents; in 2005, Class I railroads were involved in 76 percent of train
    accidents.^7 Moreover, Class I railroads were involved in 53 percent of
    injuries and 58 percent of deaths during that year.

    According to FRA data, the majority of train accidents are attributable to
    either human factors or track defects. (See fig. 4.) For 2005, FRA data
    show that human factors and track defects were the primary causes of 72
    percent of all train accidents. Those accidents caused by human factors
    often result from actions such as improperly positioning switches, shoving
    cars without properly checking for safe conditions, leaving cars in a
    position that obstructs track, and failing to secure a sufficient number
    of handbrakes. Those accidents caused by defective track often result from
    defective or ineffective crossties; broken or worn switch points; and
    broken, fissured or fractured rail components.

    ^7FRA defines a train accident as any collision, derailment, fire,
    explosion, act of God, or other event involving operation of railroad
    on-track equipment (standing or moving) that results in reportable damages
    greater than the current reporting threshold to railroad on-track
    equipment, signals, track, track structures, and roadbed. The threshold
    for 2006 was $7,700.

    Figure 4: Primary Causes of Train Accidents, 2005

    ^aInteraction of lateral and vertical forces refers to a specific type of
    accident that occurs when a lateral, or sideways, force exceeds a vertical
    force, or gravity, by 50 percent or more. Lateral force may be caused by
    travel through curves and alignment imperfections in the track.

    ^bThe miscellaneous category of accident causes contains a number of
    subcategories, none of which exceeds 1.5 percent.

    As have overall accident rates, improvements in human factor and track
    accident rates have leveled off over the past decade, achieving their
    lowest rates in 1996 and 1995, respectively. (See fig. 5.) According to
    FRA, the increase in the human factor accident rate in 2004 can be
    attributed to increases in accidents caused by employees not following
    railroad operating rules. (These rules specify various operating
    procedures, such as the proper positioning of track switches, to ensure
    safe operations.) However, according to FRA, these types of human factor
    accidents decreased by 21 percent from the first half of 2005 to the first
    half of 2006. Officials attribute this decrease largely to actions the
    agency has taken to focus railroads' attention on this problem,^8
    including issuing a safety
    and equipment, such as wheel safety requirements and formulas that
    determine maximum allowable speeds on curved track. However, some
    regulations are not prescriptive and allow railroads greater flexibility
    in determining how to comply. For example, if a railroad chooses to
    implement a processor-based train control system or product,^10 it must
    develop and receive FRA's approval for a railroad safety program plan. The
    plan should include a description of risk assessment procedures and the
    safety assessment process, and railroads have flexibility to adjust their
    programs to accommodate the specific system or product change. In
    addition, some regulations require railroads to develop and implement
    safety programs, such as accident and incident reporting programs and
    roadway worker protection programs.

    ^8In addition, according to FRA, train accident rates for 2006 will
    probably appear slightly more favorable than those for 2005 because of a
    single, large increase in the dollar level reporting threshold for the
    year 2006. Specifically, starting in 2006, railroads are required to
    report accidents resulting in railroad property damage exceeding $7,700,
    up from the previous threshold of $6,700.

    In 1996, FRA adopted a more participatory approach to rulemaking through
    the creation of the Railroad Safety Advisory Committee. This committee is
    designed to include all segments of the rail community in developing
    solutions to safety regulatory issues. Currently, the committee consists
    of 39 member organizations, including representatives from railroads,
    railroad associations, labor, states, and agencies with railroad
    regulatory responsibility in Canada and Mexico.

    FRA conducts inspections to determine railroads' compliance with its
    regulations. Typically, inspectors conduct inspections at specific sites
    of railroad operations. For example, inspectors examine track, equipment,
    devices, employee actions, or procedures and may review records maintained
    by the railroad in order to determine the railroad's compliance with FRA
    regulations. Inspectors generally specialize in one of five areas, called
    inspection disciplines: (1) operating practices, (2) track, (3) hazardous
    materials, (4) signal and train control, and (5) motive power and
    equipment. (See table 1.) FRA's policy is to cite defects for most
    instances of noncompliance and to encourage the railroad to comply
    voluntarily.

    ^10A processor-based train control system or product is one that is
    dependent for its proper functioning on a digital processor, such as an
    onboard signal or switch control.

    Table 1: FRA's Inspection Disciplines

                                Examples of what inspections cover (not all
    Inspection Discipline    inclusive)
    Operating practices      Railroad operations related to human factors,
                                including employee compliance with railroad
                                operating rules, railroads' monitoring of this
                                compliance, drug and alcohol testing of
                                employees, employees' hours of service, radio
                                communications, locomotive engineer
                                qualification, and accident and incident
                                reporting.
    Track and structures^a   Condition of track and structures, including
                                track components and geometry, railroad track
                                inspections, and programs to maintain continuous
                                welded rail track and protect roadway workers.
    Hazardous materials      Rail transportation of hazardous materials,
                                including the integrity, markings, maintenance,
                                and placement of tank cars; the training of train
                                crews; security; and emergency preparedness.
    Signal and train control Signal switching systems, locomotive signal
                                devices, locks and brake application, including
                                related recordkeeping, testing, modifications,
                                and repairs.
    Motive power and         Design and operation of railroad rolling
    equipment                equipment, including railroad freight and
                                passenger car safety, locomotive safety and
                                maintenance, safety devices, brake system safety,
                                and emergency preparedness procedures.

    Source: GAO analysis of FRA information.

    Notes: FRA has recently established a new inspection discipline,
    industrial hygiene, which covers the protection of railroad employees on
    the job, including enforcement of FRA standards for occupational safety
    and health. The discipline is also responsible for the operation of FRA's
    internal occupational safety and health program for ensuring FRA employee
    safety and health. The resources devoted to this inspection discipline are
    relatively small--FRA plans to have a total of 5 industrial hygienist
    inspectors. In comparison, the other inspection disciplines each have
    between 50 and 90 inspectors, approximately.

    aIn addition to its manual inspections, FRA has an automated track
    inspection program that uses data produced by vehicles that precisely
    measure track geometry.

    When railroads do not comply voluntarily or identified defects are
    serious, FRA may cite violations and assess civil penalties*either against
    railroads or individuals*or take other enforcement actions to promote
    compliance with its regulations. FRA developed the concept of focused
    enforcement in the mid-1990s to ensure that inspectors know which
    violations pose the greatest hazards and make enforcement decisions
    accordingly. The purpose of this approach is to concentrate FRA's
    enforcement efforts on the areas with the greatest potential safety
    benefits. FRA's enforcement policy, as stated in its regulations,
    specifies that before recommending penalties, inspectors should consider
    the seriousness of the condition or act, the potential safety hazards, and
    the current level of compliance of the individual or railroad, among other
    things. FRA is authorized to negotiate civil penalties with railroads and
    exercises this authority. For example, it settles claims annually with
    each Class I railroad. FRA uses civil penalties as its primary enforcement
    tool. However, it also has other available enforcement tools. These
    include compliance agreements and compliance orders, special notices for
    repair, emergency orders, criminal penalties, disqualification orders and
    injunctions. (See app. II for further discussion.)

    FRA conducts additional oversight of Class I railroads through the
    Railroad System Oversight program, established in October 2005, which
    addresses safety issues not subject to regulation, such as aspects of
    worker fatigue, as well as safety compliance issues. Under this program,
    the agency assigns an FRA manager for each Class I railroad to cooperate
    with it on identifying and resolving safety issues. These managers act as
    liaisons with the railroads and labor officials, analyze accident and
    inspection data for their assigned railroad, and support FRA's inspection
    and enforcement efforts. Finally, under this program, FRA has begun annual
    meetings with the leadership of each Class I railroad to discuss its
    safety performance.

    The Railroad System Oversight program replaced FRA's Safety Assurance and
    Compliance Program, which had emphasized using teams--consisting of FRA
    inspectors and other FRA officials, railroad officials, and union
    representatives--to identify and resolve safety issues, as a complement to
    FRA's regular inspection activity. The agency envisioned this program as a
    comprehensive approach to safety through which these representatives would
    work together to identify and correct the root causes of problems across
    an entire railroad. According to FRA, the program had a number of
    accomplishments, such as improving collaboration among management, labor
    and FRA, and encouraging railroads' voluntary cooperation in taking
    corrective action on safety issues not covered under FRA's safety
    regulations. However, FRA ended this program in response to concerns that
    it had lost its effectiveness, inhibited enforcement actions, and shifted
    regional resources away from conducting site-specific inspections, the
    mainstay of FRA's safety program.

    In addition to these activities, FRA conducts other types of safety
    oversight aimed at reducing train accidents, such as monitoring of
    railroad safety data, accident investigations and reviews and
    investigations of complaints, and education efforts aimed at small
    railroads.^11 Furthermore, FRA funds research and development that
    supports its safety oversight, by, for example, assisting in the
    development of new regulations and the revision of existing regulations.

    FRA is a small agency, especially in relation to the industry it
    regulates. As of July 2006, FRA had 657 full-time and part-time safety
    staff, including about 400 inspectors in the field (in its regional,
    district, and local offices). In addition, 30 state oversight agencies
    participate in a partnership program with FRA to conduct safety oversight
    activities at railroads' operating sites. Currently, about 160 state
    inspectors work with FRA to conduct inspections and other investigative
    and surveillance activities as needed. In contrast, the railroad industry
    has about 235,000 employees,^12 219,000 miles of track in operation,
    158,000 signals and switches, and over 1.6 million locomotives and cars.

    ^11For example, FRA conducts twice yearly training seminars for short line
    railroads on how to comply with its regulations and operate safely.

    FRA Has Made Progress in Targeting Its Oversight Efforts on the Basis of Risk

    In planning its safety oversight, FRA focuses its efforts on the highest
    priority risks related to train accidents through a number of initiatives
    aimed at addressing the main causes of these accidents as well as through
    improvements in its inspection planning approach. The agency's overall
    strategy for targeting its oversight at the greatest risks--the National
    Rail Safety Action Plan--provides a reasonable framework for guiding the
    agency's efforts. FRA's various initiatives to address the two main causes
    of train accidents--human factors and defective track--are promising.
    However, most of these initiatives are not yet fully implemented and their
    overall impact on safety will probably not be apparent for a number of
    years. FRA has also recently implemented new approaches for planning its
    inspection activity--based on analyses of accident, inspection, and other
    data--that allow it to better target the greatest safety risks and more
    effectively use its inspectors.

    National Rail Safety Action Plan Provides Strategy for Addressing Highest
    Priority Risks, but Impact of Safety Initiatives Is Not Yet Clear

    FRA's May 2005 National Rail Safety Action Plan provides an overarching
    framework for the agency's efforts to target its oversight at the highest
    priority risks. The agency developed the plan in response to a leveling
    off of the train accident rate in recent years and the occurrence of
    serious train accidents in 2004 and early 2005. The plan outlines a number
    of initiatives aimed at reducing the main types of train accidents, those
    caused by human factors and track defects.^13 These efforts include some
    innovative approaches for the railroad industry, such as a pilot project
    for reporting close calls, that are designed to prevent accidents by
    addressing safety problems that may cause them.^14 Other efforts include
    new regulations, several research endeavors, and new track inspection
    vehicles. We have not reviewed these individual initiatives in depth, but
    believe that the plan provides a reasonable strategy for guiding and
    prioritizing FRA's efforts to reduce the rates of accidents attributable
    to human factors and track defects.

    ^12This number does not include contractor employees hired by the
    railroads.

    ^13The National Rail Safety Action Plan also includes initiatives to
    improve hazardous materials safety and emergency response capability. Most
    of the serious accidents involving the release of hazardous material that
    have occurred in the last several years have been caused by human factors
    or track defects.

    Some of the efforts outlined in the action plan are underway, and some are
    planned for the near future. FRA issued a progress report to the Secretary
    of Transportation on the action plan in June 2006 and intends to continue
    to report on the plan's implementation. Since issuing the plan, the agency
    has pursued additional initiatives to target risks posed by human factors
    and track defects, including issuing new track regulations in response to
    a congressional mandate and encouraging a new braking technology. (See
    table 2.) The combined initiatives hold promise for reducing the risks
    associated with human factors and track defects. However, these efforts
    are in varying stages of development or implementation and their overall
    impact on safety will probably not be apparent for a number of years. Some
    individual initiatives, such as the close call reporting project, may
    start showing results in the next year or two.

    ^14According to FRA, a close call is an opportunity to improve safety
    practices in a situation or incident that has a potential for more serious
    consequences. It represents a situation in which an ongoing sequence of
    events was stopped from developing further, preventing the occurrence of
    potentially serious safety-related consequences.

    Table 2: Key FRA Initiatives Aimed at Addressing Main Causes of Train
    Accidents

    Cause of train
    accidents      Initiative              FRA action and time frame
    Human factors  Rail Safety Action Plan
                      initiatives
                      Regulations on employee Issued proposed regulation in
                      compliance with         October 2006. Plans to issue final
                      railroad operating      regulation by the end of 2007.
                      rules
                      Pilot project to        Plans to initiate this 5-year
                      establish voluntary     project in January 2007 at one
                      reporting system to     Class I railroad site. FRA is
                      learn from close call   seeking the participation of other
                      incidents               railroads.
                      Research on worker      Discussed results of the research
                      fatigue to develop a    with key stakeholders and released
                      model that could be     a report on the results in November
                      used to improve crew    2006.
                      scheduling
                      Other initiatives
                      Pilot project to        Is considering establishing a pilot
                      establish voluntary     project in fiscal year 2008.
                      risk management
                      programs at railroad
                      worksites
                      Encouraging new braking Released a study on new brake
                      technology that can     system technology in August 2006
                      prevent or reduce human and plans to issue proposed
                      error                   regulations in May 2007 to
                                              facilitate its use.
    Track defects  Rail Safety Action Plan
                      initiatives
                      New track inspection    Plans to deploy two new vehicles in
                      vehicles                early 2007.
                      Research and            Demonstrated a prototype system in
                      development on new      October 2005. Enhanced the system
                      inspection technologies in 2006 and is planning further
                                              enhancements in 2007.
                      Other initiatives
                      Additional regulations  Issued a final rule on rail joint
                      on continuous welded    inspection in October 2006. Plans
                      rail track              to develop additional regulations
                                              for improving management of this
                                              type of track, but has not yet
                                              developed time frames for this
                                              effort.

    Source: GAO analysis of FRA data.

    The National Rail Safety Action Plan also outlines the agency's
    development of a new approach for planning its inspections, based on
    greater use of its accident and inspection data. Since issuing the plan,
    FRA has made other efforts to improve its approach for planning its
    inspections.^15 Starting in fiscal year 2006, FRA's new inspection
    planning approach has allowed the agency to better target its inspections
    on the basis of risk and to better coordinate inspection planning among
    its headquarters and regional offices.

    ^15Other key agency plans that focus efforts on the highest priority risks
    related to train accidents include the department's rulemaking agenda,
    strategic plan and annual performance plan, and FRA's performance budget.
    The rail safety goals and measures contained in the performance plan and
    performance budget are discussed later in this report.

    FRA Is Making a Number of Efforts to Reduce Accidents Caused by Human Factors

    Human factor accidents result from unsafe acts of individuals, such as
    employee errors, and can occur for a number of reasons, such as employee
    fatigue or inadequate supervision, training, or staffing.^16 FRA has
    recently issued proposed regulations aimed at reducing the most common
    causes of such human factor train accidents: improper positioning of track
    switches or derails,^17 shoving rail cars without properly monitoring for
    safe conditions or controlling the movement, and leaving rail cars in a
    position that obstructs adjacent track. Procedures for employees to follow
    to avoid these types of accidents are contained in railroads' operating
    rules.^18 Currently, FRA regulations contain general requirements that
    railroads train employees on their operating rules and periodically test
    their compliance with these rules, but do not specifically require that
    employees follow the rules that can prevent these types of accidents.^19
    As a result, according to FRA officials, the agency has had a limited
    ability to cite noncompliance and take enforcement actions in this area.
    The proposed regulations mirror established railroad operating rules that
    require employees to follow procedures, such as procedures related to the
    positioning of track switches, that if followed, could prevent these types
    of accidents. In addition, they include further requirements for railroads
    to train employees on these rules and monitor their compliance with these
    rules. According to FRA, these new requirements and its ability to enforce
    them will make railroad employees more accountable for following operating
    rules and railroad management more accountable for ensuring that employees
    do so.

    ^16Management decisions at the organizational level, such as decisions
    regarding the allocation of resources or crew scheduling, can have
    consequences in the workplace that can contribute to human factor
    accidents.

    ^17Derails are devices used to prevent the obstruction of track by
    unauthorized movements of trains or unattended rolling stock.

    ^18Most Class I railroads use one of two sets of standard rules: the
    Northeast Operating Rules Advisory Committee rulebook and the General Code
    of Operating Rules. Railroads must file their operating rules with FRA.

    ^19In a few cases, FRA's regulations do require some practices, such as
    securing a sufficient number of handbrakes, that are in railroad operating
    rules. Also, the Switching Operations Fatality Analysis working
    group--made up of representatives of FRA, unions, railroads, and the
    Department of Transportation's Volpe National Transportation Systems
    Center--studies fatalities that occur to workers engaged in switching
    operations and recommends ways that such events can be prevented.

    FRA is also sponsoring a 5-year Confidential Close Call Reporting System
    pilot project, through which employees of participating railroads can
    provide confidential information on close calls. A neutral party, the
    Bureau of Transportation Statistics, will maintain the close call data and
    a team of representatives from the participating railroad, labor
    organizations, FRA, and the bureau will review these data to identify
    safety problems. Railroads will be expected to correct identified problems
    in order to prevent accidents. The purpose of this project is to determine
    the effectiveness of such a voluntary reporting system for the railroad
    industry. FRA has developed plans to monitor and evaluate the performance
    of the project over time; these plans include short-term and long-term
    performance measures. The agency anticipates that it will have early
    indications of how the program is affecting safety in the next year or
    two. To date, one Class I railroad has committed to participate in this
    project, at one yard on its system, and, according to FRA, two others have
    expressed strong interest. Such systems have contributed to significant
    reductions in accidents in some other industries, such as aviation.

    FRA and the National Transportation Safety Board (NTSB) have identified
    employee fatigue as a significant factor in many train accidents. Railroad
    employees often work long hours and have unpredictable and fluctuating
    work schedules. Under current law, these employees could potentially work
    a maximum of 11 hours and 59 minutes, followed by 8 hours off duty, and
    then another 11 hours and 59 minutes on duty, continually.^20 In addition,
    time spent waiting for transportation at the end of a tour of duty and
    being transported to a release point, called limbo time, does not count as
    either duty or off-duty time and can be significant. FRA has sponsored a
    study to develop a fatigue model that could be used to improve train crew
    scheduling practices, has discussed the draft results with railroads and
    labor organizations, and released the final report on the study in
    November 2006. The agency is also taking some other actions to encourage
    railroads to improve their management of employee fatigue, such as
    providing funding for a new program, in use at a Class I railroad, that
    tracks and analyzes crew scheduling to remedy practices that could
    contribute to fatigue.

    ^20The law also specifies that train employees are required to have 10
    consecutive hours off duty following 12 continuous hours on duty.

    Through a recent investigation of a 2004 train accident in which three
    people died, NTSB found that the engineer and conductor were likely asleep
    at the controls and recommended that FRA require railroads to use
    scientifically based principles when assigning work schedules for train
    crew members and to limit crew member limbo time.^21 In recent testimony,
    the FRA Administrator noted that, several times in the 1990s, the
    Department of Transportation proposed legislation to repeal or reform the
    hours-of-service law or to require railroads to develop fatigue management
    plans, but that these bills encountered opposition and were not passed.
    However, since that time, FRA has not submitted such legislation. The
    agency has not yet responded to NTSB's recommendations, but has told us
    that it intends to tell the board, as it has in the past, that the agency
    lacks jurisdiction to issue regulations addressing hours of service.^22

    While we were conducting our work, FRA was considering establishing a
    pilot project that would use risk management to help reduce human factor
    accidents at selected railroad worksites. Risk management can be described
    as a systematic approach for identifying, analyzing, and controlling
    risks.^23 The agency envisioned that, under such a project, each worksite
    would collect and analyze data on precursors to human factor
    accidents--such as close call incidents, employee errors, or
    organizational characteristics--to better identify and correct individual
    and organizational factors that contribute to such accidents and therefore
    reduce the risks of such accidents occurring. The agency proposed that
    funding for this project be included in its fiscal year 2008 budget
    request and this proposal was approved by the department. In January 2007,
    as we were finalizing our report, FRA told us that it had decided to
    expand the scope of this project to include efforts to use risk management
    to reduce all types of accidents, not only human factor accidents.

    ^21NTSB, Collision of Union Pacific Railroad Train MHOTU-23 With BNSF
    Railway Company Train MEAP-TUL-126-D With Subsequent Derailment and
    Hazardous Materials Release, Macdona, Texas, June 28, 2004, Railroad
    Accident Report NTSB/RAR-06/03 (Washington, D.C., 2006).

    ^22According to FRA, it is the only safety regulatory agency in the
    Department of Transportation that lacks regulatory authority over worker
    duty hours.

    ^23Risk is the combination of the likelihood and the consequence of a
    specified hazard (or threat) being realized. We have developed a framework
    for risk management based on industry best practices. See app. III for a
    discussion of this framework as well as comprehensive risk management
    approaches in use by several other transportation agencies for overseeing
    the U.S. commuter railroad, U.S. pipeline, and Canadian railroad
    industries.

    FRA has examined possible approaches to use for this project. According to
    agency officials, one possible approach is represented by a new program
    that a Class I railroad has implemented at two locations on its system. In
    this program--which has received funding from FRA--a committee of
    employees documents employee behaviors that could lead to unsafe
    conditions, without recording names, and provides feedback to the
    responsible employees to help them eliminate these behaviors. FRA has also
    considered the approach used by the Occupational Safety and Health
    Administration's Voluntary Protection Program. This program recognizes
    individual worksites with exemplary safety records and practices,
    including the identification, analysis, prevention, and control of
    workplace hazards that could lead to employee injuries and illnesses.^24

    As envisioned by FRA officials, this project will focus on establishing
    risk management programs at three separate railroad worksites and will
    include close monitoring and evaluation of these programs to determine
    their impact in reducing accidents over a 5-year period. If the pilot is
    successful, FRA anticipates establishing a voluntary risk management
    program for the railroad industry, which would encourage railroads to
    implement this type of approach on a systemwide basis in order to reduce
    human factor accidents, as well as other types of accidents.

    Finally, FRA has recently issued a study on a new braking technology,
    electronically controlled pneumatic brakes, which improves train-handling
    and decreases stopping distances by 40 to 60 percent. These brakes use an
    electronic line to uniformly command brake applications and releases
    throughout the train. FRA has decided that it will develop new regulations
    to facilitate the use of this technology over the next decade. According
    to FRA officials, improving railroads' braking systems can have a
    significant safety benefit by improving the ability of locomotive
    engineers to control their trains and, therefore, avoid or reduce the
    severity of some types of human factor-caused accidents.^25

    24In reviewing the Voluntary Protection Program of the Occupational Safety
    and Health Administration, along with several other voluntary compliance
    programs, we found that benefits reported by participating worksites
    included reduced injury and illness rates, an improved safety culture, and
    improved employee-management relations. See GAO, Workplace Safety and
    Health: OSHA's Voluntary Compliance Strategies Show Promising Results, but
    Should Be Fully Evaluated before They Are Expanded, [26]GAO-04-378
    (Washington, D.C.: Mar. 19, 2004).

    The above initiatives use a variety of approaches, some quite innovative,
    for addressing the causes of human factor accidents. These initiatives,
    which are in varying stages of development or implementation, have the
    potential to eventually reduce these types of accidents. However, while
    some may start showing results in the next year or two, their overall
    impact will likely not be apparent for a number of years. Furthermore, all
    of these initiatives, except for the proposed regulations on operating
    rules, depend on voluntary actions by railroads, and, in some cases, labor
    as well, for their success. For example, the impact of FRA's effort to
    develop a model to address the problem of worker fatigue depends on the
    extent to which railroads eventually use this model to improve train crew
    scheduling practices. FRA has worked with railroads and labor on some of
    these initiatives, but it is too early to predict their outcomes.

    FRA Is Pursuing Several Initiatives to Improve the Detection and Management of
    Track Defects

    Railroads operate trains on about 219,000 miles of track across the United
    States. This track consists of traditional jointed rail as well as newer
    rails that are smooth bands of welded steel, called continuous welded
    rail. Derailments can occur when rails are uneven or too wide apart or
    when rails or joint bars are cracked or broken. FRA inspects track
    conditions through manual inspections conducted on-foot or in on-track
    equipment, and with automated track inspection vehicles that precisely
    measure track and can identify problems that are difficult to detect
    through other types of inspections. The agency operates one automated
    track inspection vehicle that it uses in inspecting track and plans to add
    two more for this purpose in early 2007.^26 According to FRA, these
    additional vehicles will allow the agency to triple the miles of track
    that it is able to inspect per year, to nearly 100,000 miles.^27

    25FRA has also recently issued standards for processor-based positive
    train control systems. These systems are an advanced train control
    technology that can prevent train collisions through automatic brake
    applications. They also can provide enhanced protection for
    maintenance-of-way workers.

    ^26FRA also has two additional automated track inspection vehicles that
    are primarily used for research activities but occasionally are used for
    inspections.

    ^27However, FRA may inspect some sections of track more than once a year.

    FRA is also developing an automated inspection system for improving the
    detection of cracks in joint bars. Such cracks can lead to a
    derailment-causing break but can be difficult to detect through simple
    visual inspections. Specifically, FRA has designed and is refining a
    high-resolution video inspection system that can be used in on-track
    inspection equipment and will improve detection of these defects.^28
    According to FRA, the technology is ready for use, was demonstrated and
    refined in the field in 2006, and will undergo further enhancements in
    2007. The agency expects that railroads will make use of the technology
    and is reviewing how to use it in its own inspections. According to FRA,
    one Class I railroad is starting to make use of this technology and others
    have shown strong interest in it.

    Finally, in response to a congressional mandate and NTSB recommendations,
    FRA has recently finalized regulations that require track owners to
    conduct detailed and periodic inspections of rail joints in continuous
    welded rail track. Although FRA issued regulations in 1998 requiring
    railroads to develop and implement procedures for the inspection and
    maintenance of continuous welded rail track, a number of train accidents
    occurred since that time in which the failure of a rail joint on this type
    of track was a factor.^29 FRA officials told us that the railroads'
    overall management of the condition of continuous welded rail track is a
    major concern for the agency because about 20 accidents involving problems
    with this type of track occur per year and these accidents are usually
    serious. FRA has estimated that continuous welded rail track represents
    between 99,000 and 120,000 miles of the 219,000 miles of track in
    operation in the United States. The agency is working with the Railroad
    Safety Advisory Committee to develop additional regulations to improve
    railroads' management of this type of track.

    These initiatives have the potential to reduce accidents caused by track
    defects. FRA's deployment of two new track inspection vehicles in early
    2007 will enable the agency to significantly expand its ability to monitor
    the condition of the nation's track. The agency's development of an
    automated inspection system has the potential to help prevent derailments,
    provided that railroads make use of this technology. Finally, FRA's
    issuance of new regulations related to continuous welded rail track and
    development of further regulations in this area should eventually improve
    railroads' management of this type of track, although time frames for the
    development of new regulations are not yet clear.

    ^28FRA also has a number of other ongoing efforts to improve track
    inspection capabilities. For example, since 2002 it has sponsored a Rail
    Integrity Task Force--composed of experts in the railroad industry, FRA,
    and the Department of Transportation's Volpe National Transportation
    Systems Center--to identify best practices for rail inspection,
    maintenance, and replacement.

    ^29In continuous welded rail track, rails are welded together to form one
    continuous rail that may be several miles long. There may be joints in
    this rail for several reasons, including the need for insulated joints
    that electrically separate track segments for signaling purposes and the
    need to replace a section of defective rail.

    FRA Has Made Progress in Targeting Its Inspections on the Basis of Risk

    Like other modal safety administrations within the Department of
    Transportation, FRA has few resources for overseeing railroads compared
    with the scope of its responsibility. According to agency officials, it
    inspects 0.2 percent of railroad operations per year. FRA has developed a
    new approach--the National Inspection Plan--for using available data to
    target its inspections at the greatest safety risks. The agency began
    using the new approach for three of its inspection disciplines (operating
    practices, track, and motive power and equipment) in October 2005 and
    expanded it to the remaining two disciplines (hazardous materials and
    signal and train control) by March 2006. The purpose of the plan is to
    optimize FRA's ability to reduce the rates of various types of train
    accidents as well as releases of hazardous materials. The plan provides
    guidance to each regional office on how its inspectors, who each
    specialize in one of the five inspection disciplines, should divide up
    their work by railroad.

    Developing the plan involves two steps. In the first step, FRA
    headquarters produces an initial plan for each of the agency's eight
    regions. This plan specifies, by inspection discipline, numeric goals for
    the level of inspection activity to allocate to each railroad, by state.
    These numeric goals are derived from models--based on trend analyses of
    accident, inspection, and other data--that predict, by inspection
    discipline, locations where train accidents and incidents are likely to
    occur within each region and provide the optimal allocation of inspection
    resources to prevent accidents.^30 FRA has developed separate models for
    each inspection discipline based on how well individual data elements,
    such as historical information on inspection results, tend to predict
    accidents. According to FRA officials, they expect to refine this new
    planning process to reflect lessons learned during the first year of its
    implementation.

    ^30We did not evaluate these models or the data on which they are based.
    FRA defines train incidents as events involving the movement of railroad
    equipment that results in a casualty but does not cause damage above the
    reporting threshold established for train accidents, which was $7,700 in
    2006.

    In the second step, the regional administrators are allowed to adjust the
    goals for their region on the basis of local knowledge and emerging
    issues, such as recent accidents. However, according to FRA officials,
    there were only a few such adjustments for fiscal year 2006. Throughout
    the year, FRA monitors how the regions are meeting their goals. Starting
    in fiscal year 2007, regional administrators will have a second
    opportunity to adjust their inspection plans at midyear to respond to
    safety issues that emerged during the first 6 months of the year.

    Previously, FRA had a less structured, less consistent, and less
    data-driven approach for planning inspections. According to agency
    officials, each region prepared its own inspection plan, based on
    judgments about appropriate priorities and analysis of available data.
    However, the use of data was not consistent from region to region.
    Inspectors had greater discretion about where to inspect and based
    decisions about priorities on their knowledge of their inspection
    territories.

    The National Inspection Plan covers federal inspectors, but not state
    inspectors. Other than funding training and computer equipment, FRA does
    not provide funding for state inspection activities.^31 Therefore, each
    state makes its own decisions about how to use its inspectors. FRA
    officials told us that the agency has not included states in the National
    Inspection Plan because it does not have authority to tell the states what
    inspections to conduct. The 30 states that participate in FRA's state
    program have varying numbers of inspectors and most conduct inspections in
    some, but not all, of FRA's five inspection disciplines. According to FRA,
    its regional offices coordinate with the states in their region to avoid
    duplication of effort. The regional administrators may make adjustments to
    their National Inspection Plan goals based on the work of state inspectors
    within their region.

    The National Inspection Plan also does not establish priorities across
    regions and inspection disciplines, but rather, for given staffing levels
    for each discipline within each region, assigns inspection levels to
    railroads and states. However, FRA eventually plans to use its results to
    help decide how to optimally allocate additional inspectors, as vacancies
    occur or new positions are funded. According to headquarters officials,
    the National Inspection Plan model played a role in a decision to allocate
    additional inspection staff to the operating practices discipline in the
    regions.^32 However, officials told us that they will need more time to
    determine how well the plan is working before using it to reallocate
    resources among the regional offices.

    ^31FRA provides training for state inspectors and certifies them as
    qualified to perform inspections and cite violations.

    The fiscal year 2006 plan resulted in various reallocations of inspection
    activity within FRA's regional offices. These reallocations have allowed
    FRA to better target its inspections on the basis of risk. For example, in
    the track area, in some cases regions are focusing more attention on
    certain railroads that have higher accident rates and worse track
    conditions than others. Conversely, in the area of operating practices,
    some regional offices have decreased their focus on certain railroads that
    have shown good or improving performance in this area compared with other
    railroads.

    In fiscal year 2006, in addition to implementing the National Inspection
    Plan, the agency implemented a new coordinated approach for planning
    nonroutine inspection activity, by inspection discipline. Examples of
    these types of inspections include in-depth inspections by a regional
    office of a railroad's compliance with track standards; interregional
    inspections of compliance with certain regulations, such as those related
    to bridge safety, of a Class I railroad that operates in multiple regions;
    and headquarters-led inspections of Class I railroads' drug and alcohol
    testing programs. Some of these planned inspections are based on analyses
    of data on accidents by railroad, accident causes, and inspection results
    in order to define, beyond the National Inspection Plan goals, what
    railroad locations and specific regulatory requirements warrant increased
    attention by inspectors. Others, such as inspections of some required
    railroad safety programs, are performed periodically. According to FRA
    officials, the regional offices and headquarters previously planned such
    inspections separately and made less use of data in their planning. Under
    this new planning approach, FRA headquarters and regional offices
    coordinate in developing plans for inspections they will conduct, by
    inspection discipline. These plans are compiled into an agencywide plan,
    and then FRA tracks the completion of these inspections.

    ^32Overall, the motive power and equipment discipline currently has the
    highest number of inspectors (86), followed by the operating practices
    discipline (76), the track and structures discipline (73), the signal and
    train control discipline (61), and the hazardous materials discipline
    (55). However, to help reduce human factor accidents, which account for
    the highest percentage of train accidents, inspectors in the motive power
    and equipment discipline conduct some inspections of operating practices.

    FRA's new approaches for planning its inspection activity allow it to
    better target the greatest safety risks and coordinate inspection planning
    among its eight regional offices and headquarters offices. Therefore, they
    allow FRA to make more effective use of its inspectors. However, it is not
    yet clear whether these new planning approaches will lead to a
    prioritization of inspection levels across regions and inspection
    disciplines or improved safety.

    FRA Relies Primarily on Direct Inspections to Identify Safety Problems and Does
    Not Oversee Railroads' Management of Safety Risks

    In carrying out its safety oversight, FRA identifies safety problems on
    railroad systems mainly through routine inspections to determine whether
    operations, track, and equipment, such as signals and locomotives, are in
    compliance with safety standards. Through this approach, FRA inspectors
    identify a range of safety problems at various sites on railroads'
    systems, through citing defects and violations. FRA also identifies some
    broad-scale compliance problems that affect multiple sites, mainly through
    analyses of accident and inspection data, internal discussions, and some
    nonroutine inspections.

    FRA's inspections focus on compliance with minimum standards within five
    separate inspection disciplines and do not attempt to determine how well
    railroads are managing safety risks on their systems. APTA, PHMSA, and
    Transport Canada have implemented approaches to oversee the management of
    safety risks by U.S. commuter railroads, U.S. pipelines, and Canadian
    railroads, respectively. These oversight approaches complement, rather
    than replace, traditional compliance inspections and therefore provide
    additional assurance of safety. However, we are not recommending that FRA
    adopt such an oversight approach, since the agency is currently pursuing
    various initiatives to reduce train accident rates. In our view, these
    initiatives need time to mature to demonstrate their effects and,
    subsequently, an informed assessment would need to be made about whether
    additional actions are warranted.

    FRA's Oversight Identifies a Range of Site-Specific and Broad-Scale Problems on
    Railroad Systems

    Overseeing the safety of the railroad industry is a huge task. FRA's 400
    inspectors, along with about 160 state inspectors, oversee 686 railroads,
    with about 235,000 employees, 219,000 miles of track, 24,000 locomotives,
    1.6 million cars, 158,000 signals and switches, and 240,000 highway-rail
    grade crossings.^33 As noted previously, according to FRA officials, the
    agency's inspectors are able to directly observe only about 0.2 percent of
    the railroad industry's operations per year. FRA carries out this
    oversight responsibility primarily through inspections of railroads'
    compliance with its safety standards at various locations on railroads'
    systems and through cooperation and enforcement aimed at resolving
    identified problems. During inspections, which are generally conducted
    separately within the five inspection disciplines, inspectors examine
    railroads' compliance with a broad range of federal standards. Inspectors
    discuss identified compliance problems (called defects) with railroads to
    achieve voluntary compliance, and cite violations--recommending that the
    agency take enforcement action against a railroad--when they determine
    that the problems are serious or when a railroad does not voluntarily
    comply. (See app. II for a description of FRA's use of cooperation and
    enforcement to resolve safety problems and improve safety.) In addition,
    FRA's Railroad System Oversight managers work with Class I railroads and
    labor to identify and resolve some safety problems that are not directly
    related to compliance with the agency's regulations. For example, one
    manager worked with a railroad and labor organization to improve the
    railroad's program for communicating with roadway workers to ensure that
    they are aware of and implement key safety procedures.

    FRA primarily monitors railroads' compliance through routine inspections
    by individual inspectors at specific sites on railroads' systems.^34 As
    discussed previously, FRA inspects locations likely to have safety
    problems, which it identifies using accident and previous inspection data
    as well as other information. Inspectors typically cover a range of
    standards within their discipline during these inspections. This
    inspection approach focuses on direct observations of specific components
    of the train, related equipment, and railroad property--including the
    track and signal systems--as well as operating practices to determine
    whether they meet FRA's standards. (See figs. 6 and 7.) Inspectors also
    examine railroads' inspection and maintenance records. The railroads have
    their own inspectors who are responsible for ensuring that railroad
    equipment, track, and operations meet federal rail safety standards. For
    example, FRA requires that railroads inspect brake systems, signal
    systems, passenger equipment, track conditions, and train crews' adherence
    to operating rules, among other things. According to FRA officials, the
    agency's inspectors often review the railroads' records of inspection to
    determine whether the records accurately represent the types of problems
    FRA inspectors are finding during their own inspection activities.

    ^33These figures do not include railroad contractor employees or track
    that is not in use.

    ^34Inspectors also sometimes travel along part of a railroad's system in
    conducting inspections. According to FRA, from 2002 to 2005, inspectors
    traveled between two locations in 17 percent of the routine inspections of
    railroads.

    Figure 6: FRA Inspector Measuring Track Gauge

    Figure 7: FRA Inspector Inspecting Train Cars

    FRA also conducts more in-depth inspection efforts that generally focus on
    railroads' compliance in a particular area, such as their inspections of
    employees' adherence to operating rules. These efforts often involve a
    team conducting separate inspections at multiple sites, generally within
    one of FRA's eight regions.^35 FRA focuses these in-depth inspection
    efforts on emerging issues, identified through previous routine
    inspections or analyses of accident data. FRA also periodically conducts
    in-depth inspections of some systemwide programs that the railroad is
    required to implement, such as employee drug and alcohol testing programs
    and accident and incident reporting programs. In some cases, FRA may
    conduct a systemwide in-depth set of inspections on a railroad to
    determine its overall compliance within a single inspection discipline or
    in several disciplines. For example, in early 2006, in response to a Class
    I railroad's high accident rates, FRA conducted an in-depth set of
    inspections of the railroad's compliance with operating practices, track,
    signal and train control, motive power and equipment, and hazardous
    materials regulations across its system. However, according to an FRA
    headquarters official, the agency does not frequently perform systemwide
    or multidisciplinary inspections.

    ^35However, in some cases, FRA conducts nationwide inspections of
    railroads' compliance with specific requirements. For example, in
    mid-2006, it began a set of nationwide inspections of various railroads'
    compliance with requirements for notifying train crews of the types of
    hazardous materials being transported on their trains, after identifying
    noncompliance in this area as a problem.

    In 2005, federal and state inspectors conducted a total of about 63,000
    inspections.^36 According to FRA, routine inspections constituted about 75
    percent of the inspections of railroads and in-depth inspections accounted
    for about 11 percent. The remainder of these inspections (14 percent)
    consisted of other types of activities, such as investigations of
    accidents and complaints. Inspectors in the track discipline performed the
    most inspections, followed by those in the motive power and equipment,
    operating practices, hazardous materials, and signal and train control
    disciplines.^37 This approach to oversight enables FRA inspectors and
    managers to identify a wide range of safety problems. Inspectors identify
    specific compliance problems--conditions that do not meet FRA's
    standards--at sites they visit by citing defects. Inspectors cite
    violations for those defects that they believe warrant enforcement action.
    They consider a number of factors in making this decision, including the
    railroad's history of compliance at that location and the seriousness of
    the noncompliance (such as whether it is likely to cause accidents,
    injuries, or releases of hazardous materials). Inspectors in some
    disciplines cite more defects and violations than others. (See fig. 8.)
    Overall, FRA and state inspectors cited about 293,000 defects and about
    9,500 violations during the 63,000 inspections conducted in 2005.

    ^36This number includes inspections of railroads as well as of
    nonrailroads (companies that ship hazardous materials by rail, tank car
    manufacturers, and tank car repairers). In 2005, inspections of
    nonrailroads represented 7 percent of all inspections.

    ^37To help reduce accidents caused by human factors, which are the leading
    cause of train accidents, FRA's motive power and equipment inspectors
    conduct some inspections to look for operating practices problems that can
    lead to these types of accidents.

    Figure 8: Inspections Conducted and Defects and Violations Cited, by
    Inspection Discipline, in 2005

    Note: These figures include inspections carried out by both federal and
    state inspectors. Inspectors are instructed to cite defects for most
    instances of noncompliance found, but have discretion in determining which
    instances to cite as violations warranting enforcement action.

    The motive power and equipment discipline cites almost half of all defects
    and over a third of all violations. FRA officials told us that the
    standards in this inspection discipline are the most prescriptive, making
    defects and violations easier to find. However, these types of defects
    cause a much smaller proportion of accidents than human factors and track
    defects.^38 (See fig. 4.) The most frequently cited violations include
    those for noncompliance with standards regarding locomotives and freight
    cars, track conditions, recordkeeping on the inspection and repair of
    equipment and track, and the condition of hazardous materials tank cars.

    ^38FRA officials have explained that operating practices inspectors have
    had a limited ability to cite defects and violations because of the way
    regulations in this area are written. For example, as noted previously,
    the regulations contain general requirements about railroads' programs for
    inspecting employees' adherence to operating rules and do not specifically
    require that employees follow these rules. The agency expects that its
    proposed regulations on operating rules will improve its ability to
    enforce in this area, because the requirements will be more stringent than
    existing regulations.

    While individual defects and violations are generally for compliance
    problems identified at specific locations on railroads' systems, FRA also
    identifies broad-scale compliance problems, by inspection discipline, that
    affect multiple locations on a railroads' system. It does so mainly
    through analyses of accident data and data on defects and violations found
    during inspections, communications among managers at headquarters and in
    its eight regional offices on the results of analyses and inspections, and
    further inspections to obtain more information about identified problems.
    Agency officials told us that they hold frequent internal discussions
    about emerging issues to determine where problems are occurring and plan
    actions that the agency should take to address them. The agency's Railroad
    System Oversight managers support this effort by analyzing systemwide
    accident and inspection data, by inspection discipline, for the Class I
    railroads to identify trends and emerging issues. FRA may plan and conduct
    in-depth inspections to determine the scope of such issues. For example,
    if the rate of human factor accidents has increased at various locations
    on a railroad's system, FRA may conduct inspections of operating practices
    at these locations.

    Examples of broad-scale problems FRA has identified at railroads include
    weak implementation within a particular state of a program for monitoring
    employees' adherence to operating rules, poor inspections by a railroad of
    its track in a particular region, systemic problems in reporting accidents
    and incidents, and defective equipment across a railroad's system. In some
    cases, FRA inspectors identify some higher-level management issues, such
    as a lack of supervision or inadequate training of railroad personnel,
    which could have led to the compliance problems. According to FRA
    officials, they discuss broad-scale compliance problems with railroad
    officials to try to get these problems resolved. For example, after an
    in-depth inspection, inspectors meet with railroad managers to discuss
    overall problems found and, according to headquarters officials, usually
    provide a written summary of those problems. Efforts to cooperate with the
    railroad to resolve broad-scale problems may be combined with enforcement
    actions, usually civil penalties, for specific violations identified at
    individual sites. According to FRA officials, the agency always conducts
    follow-up on serious problems it has identified to ensure that they are
    resolved.^39

    While FRA does track and maintain data on various types of train accidents
    and incidents as well as defects and violations cited by inspectors and
    enforcement actions taken, the agency does not centrally track the
    broad-scale compliance problems it has identified.^40 These problems are
    described in some agency documents, such as inspectors' summary reports on
    findings of in-depth inspection efforts; various reports prepared by the
    Railroad System Oversight managers on the Class I railroads;^41 and the
    agency's overall plan, by region and inspection discipline, for its
    nonroutine inspection activity. As explained in the next section, this
    lack of centralized tracking can impede the ability of the agency to
    measure the effectiveness of its efforts to resolve identified broad-scale
    problems.

    FRA's five Railroad System Oversight managers also identify some broad
    safety problems at Class I railroads that are not related to compliance.
    They identify these problems mainly through contacts with labor and
    railroad officials and FRA regional officials and try to address them
    through cooperation with the railroad. For example, these managers have
    worked with railroads in addressing labor's concerns about practices for
    transporting train crews at the end of their shifts that may worsen
    fatigue and programs for training employees on the railroads' operating
    rules. In some cases, these problems were first identified under the
    Safety Assurance and Compliance Program.

    ^39App. II contains a description of FRA's efforts to resolve such
    problems through discussions with railroad officials as well as
    enforcement actions. According to FRA officials, the agency uses
    compliance agreements, which require railroads to take significant actions
    to improve their ability to comply, when broad-scale compliance problems
    are egregious and have not been resolved through other methods. FRA has
    issued eight such agreements since 2000. These agreements have mainly
    focused on compliance problems in the operating practices and track
    disciplines.

    ^40According to FRA officials, its ability to track broad-scale compliance
    problems is limited because its existing databases related to safety are
    not integrated. The agency has an effort underway to better integrate its
    existing data. The next section contains a description of this effort.

    ^41The Railroad System Oversight managers track the status of
    nonregulatory problems, as well as some regulatory problems, that they are
    working on and, in response to our request, created papers for us
    describing systemwide and regional issues for each of the Class I
    railroads. In addition, these managers produce quarterly and annual
    reports showing safety trends--based mainly on accident data--for each of
    the Class I railroads.

    Several Other Organizations Have Implemented Comprehensive Approaches for
    Overseeing the Management of Safety Risks in Transportation Industries

    FRA officials have noted that their approach of directly inspecting safety
    conditions and targeting locations that are most likely to have compliance
    problems provides a safety net and holds railroad management accountable.
    However, because the number of FRA and state inspectors is small relative
    to the size of railroad operations, FRA inspections can cover only a very
    small proportion of railroad operations (0.2 percent). Also, FRA targets
    inspections at locations on railroads' systems where accidents have
    occurred, among other factors, rather than overseeing whether railroads
    systematically identify and address safety risks that could lead to
    accidents.

    Rail transportation poses a variety of potential safety hazards, including
    collision or derailment; injury to workers, passengers, or nearby
    residents; and damage to property or the environment. Risk management is a
    systematic approach for dealing with the risks posed by such safety
    hazards and has been used in the private and public sectors for decades.
    It can be described as a continuous process of managing--through the
    systematic identification, analysis, and control of risks associated with
    hazards (or threats)--the likelihood of their occurrence and their
    negative impact.^42 A framework for risk management based on industry best
    practices and other criteria that we have developed divides risk
    management into five major phases: (1) setting strategic goals and
    objectives, and determining constraints; (2) assessing risks; (3)
    evaluating alternatives for addressing these risks; (4) selecting the
    appropriate alternatives; and (5) implementing the alternatives and
    monitoring the progress made and results achieved.^43 Risk management can
    help to improve systemwide safety by systematically identifying and
    assessing risks associated with various safety hazards and prioritizing
    them so that resources may be allocated to address the highest risks
    first. It also can help in ensuring that the most appropriate alternatives
    to prevent or mitigate the effects of hazards are designed and
    implemented.

    ^42Risk is the combination of the likelihood and the consequence of a
    specified hazard being realized. In risk management, the term "threat" is
    sometimes used in place of hazard.

    ^43GAO, Risk Management: Further Refinements Needed to Assess Risks and
    Prioritize Protective Measures at Ports and Other Critical Infrastructure,
    [27]GAO-06-91 (Washington, D.C.: Dec. 15, 2005); Homeland Security:
    Summary of Challenges Faced in Targeting Oceangoing Cargo Containers for
    Inspection, [28]GAO-04-557T (Washington, D.C.: Mar. 31, 2004); and Rail
    Security: Some Actions Taken to Enhance Passenger and Freight Rail
    Security, but Significant Challenges Remain, [29]GAO-04-598T (Washington,
    D.C.: Mar. 23, 2004).

    Other transportation oversight organizations have developed and
    implemented approaches for overseeing industries' overall management of
    safety risks. In particular, during the last 10 years, APTA, PHMSA, and
    Transport Canada have developed and implemented such oversight approaches
    for U.S. commuter railroads, U.S. pipelines, and Canadian railroads,
    respectively. These approaches complement, rather than replace,
    traditional compliance inspections. APTA established a U.S. commuter
    railroad oversight program in 1996, in partnership with FRA and the
    commuter rail industry, that supplements FRA's inspections of these
    railroads.^44 Under this program, APTA provides guidelines to these
    railroads on managing the safety of their systems--including safety
    risks--and audits their plans for and implementation of this management
    approach. Beginning in 2000, PHMSA issued a series of requirements for
    pipeline operators to develop "integrity management" programs to manage
    risk in areas--such as those that are densely populated--where leaks or
    ruptures could have the greatest impact on public safety.^45 The agency's
    integrity management regulations supplement its minimum safety
    regulations, and it inspects operators' compliance with both types of
    standards. In Canada, the department responsible for overseeing railroad
    safety, Transport Canada, in 2001 began requiring that railroads establish
    safety management systems that include risk management.^46 Transport
    Canada assesses these systems as well as railroads' compliance with its
    traditional safety standards.^47 (For further information on GAO's risk
    management framework and these oversight approaches, see app. III.)

    ^44APTA is a nonprofit organization representing the transit industry,
    including U.S. commuter rail systems. APTA offered to develop this program
    after FRA directed passenger railroads to develop system safety plans for
    addressing hazards associated with passengers occupying the lead units of
    a train. The APTA program is more extensive and is intended to cover all
    aspects of system safety. FRA issued this directive in 1996, in an
    emergency order, after two passenger train accidents caused 14 deaths.

    ^45PHMSA administers the national regulatory program to ensure the safe
    transportation of hazardous liquids and natural gas by pipeline. PHMSA and
    FRA are similar in several respects. For example, both oversee large
    industries with relatively few inspectors. Both also oversee industries
    that have relatively few deaths, injuries, and accidents (as compared to
    transportation as a whole), making additional safety gains more difficult.

    ^46Transport Canada oversees the safety and security of Canada's rail,
    marine, highway, and aviation operations.

    These oversight approaches are intended to provide additional assurance of
    safety beyond that provided by inspections of compliance with minimum
    safety standards. They supplement uniform, minimum standards by
    encouraging or requiring companies to identify and address their unique
    safety risks. APTA, PHMSA, and Transport Canada have emphasized that risk
    management provides a higher standard of performance than traditional
    safety regulation based on compliance alone. According to APTA officials,
    their approach helps companies to prioritize their actions for addressing
    risk and therefore optimize safety within constraints of their resources.
    According to PHMSA officials, pipeline companies' compliance with the
    agency's traditional regulations ensures minimum safety performance, but
    its integrity management approach has improved the ability of these
    companies to systematically address the full range of safety threats to
    their pipelines. According to Transport Canada officials, by encouraging
    systemwide improvements in companies' safety performance in order to
    address systemic causes of specific problems, its new approach helps the
    agency to leverage its resources. Transport Canada has emphasized that
    risk management ensures that risks are being adequately addressed and
    should point railroads to areas where they could undertake initiatives
    beyond their current practices that could improve their overall safety
    performance. Transport Canada officials also told us that a primary
    objective of their new approach is for railroads to assume more
    responsibility for the safety of their operations. Similarly, APTA
    officials told us that their oversight approach is proactive because it
    encourages companies to identify and address potential hazards before
    accidents occur.

    We have reviewed PHMSA's gas transmission pipeline integrity management
    oversight approach and have recently concluded that it enhances public
    safety.^48 We also found that representatives from the pipeline industry,
    safety advocacy groups, and state agencies generally agree that this
    approach improves public safety. Operators told us that the primary
    benefit of the program is the comprehensive knowledge they acquire about
    the condition of their pipelines. APTA and Transport Canada officials have
    told us that their oversight approaches have not been formally evaluated
    to determine their effectiveness. However, according to FRA officials,
    APTA's system safety oversight approach has strengthened safety program
    management in the commuter rail sector. Finally, Transport Canada is
    expanding its safety management system approach to its oversight of civil
    aviation.

    ^47In addition, the European Commission has funded an effort to develop
    proposed guidelines for a safety management system for rail companies of
    its member nations. These proposed guidelines recommend that European
    railways incorporate some basic risk management elements--including safety
    performance targets, risk assessment and control, and an internal audit
    process--in their safety management systems. See E.M. El Koursi, L. Tordai
    and J. Rodriguez. European Commission Fifth Framework Programme, SAMNET
    Thematic Network, SAMNET Synthesis Report, Safety Management and
    Interoperability (SAMNET, February 2006).

    While FRA does not oversee railroads' overall approach for managing safety
    risks on their systems, it has taken some steps in a limited number of
    areas to oversee and encourage risk management in the railroad industry.
    For example, the agency has several regulations in place that require
    railroads to use a risk-based approach for managing safety in specific
    areas: the operation of high-speed passenger trains, the fire safety of
    new passenger cars and locomotives, and the adoption of new
    processor-based signal and train control technologies. In addition, PHMSA,
    in consultation with FRA and the Transportation Security Administration,
    has recently proposed a regulation that could lead to greater FRA
    oversight of railroads' management of hazardous materials risks.^49 FRA
    has also issued guidance for passenger railroads on assessing collision
    hazards and risks and developing strategies for addressing them.^50 In
    addition, FRA is currently working with APTA and some commuter railroads
    to improve these railroads' abilities to conduct collision hazard
    analyses. Finally, as discussed earlier, FRA is considering establishing a
    pilot project to examine how a risk management approach could be used in
    the railroad industry, on a voluntary basis, to reduce human factor
    accidents as well as other types of accidents.

    ^48GAO, Natural Gas Pipeline Safety: Integrity Management Benefits Public
    Safety, but Consistency of Performance Measures Should Be Improved,
    [30]GAO-06-946 (Washington, D.C.: Sept. 8, 2006).

    ^49As noted previously, FRA enforces PHMSA's hazardous material
    regulations as they relate to the transportation of such materials by
    rail. Specifically, under this proposed regulation, which was issued in
    December 2006, railroads would be required to compile annual data on
    certain shipments of hazardous materials that are particularly hazardous,
    use the data to analyze safety and security risks along the rail
    transportation routes where those materials are transported, assess
    alternative routing options, and base routing decisions on those
    assessments.

    ^50FRA has also worked with Amtrak, which does not participate in APTA's
    program, to assist it in developing a system safety plan that is
    consistent with APTA's guidelines.

    Although FRA is taking some steps to encourage increased use of risk
    management in the railroad industry, oversight of railroads' overall
    approach for managing safety risks on their systems, in addition to FRA's
    existing discipline-specific compliance-based oversight, has the potential
    to provide additional assurance of safety. Such an approach could help to
    ensure that railroads systematically identify and address the full range
    of risks on their systems and could also encourage railroads to take on
    more responsibility for safety. According to agency officials, FRA is
    concerned that railroads too often wait for inspectors to show up before
    addressing problem areas, while FRA would prefer that they find and fix
    problems on their own. However, developing and implementing such a new
    oversight approach would be a major undertaking for the agency and would
    also require the support and participation of the railroad industry.

    While we believe that adopting a comprehensive approach for overseeing
    railroads' management of safety risks, similar to the approaches discussed
    in this section, can lead to improved safety, we are not making a
    recommendation aimed at encouraging FRA to adopt such an oversight
    approach. As discussed in the previous section, FRA is pursuing several
    initiatives aimed at reducing train accident rates. In our view, these
    initiatives need time to mature to demonstrate their effects and, at the
    appropriate time, the department may wish to conduct an informed
    assessment to determine whether additional actions are warranted.

    FRA Measures Its Progress in Achieving a Variety of Safety Goals, but Has
    Limited Information on the Direct Results of Its Oversight

    FRA has a broad range of goals and measures that it uses to provide
    direction to and track the performance of its safety oversight activities.
    However, its ability to make informed decisions about its inspection and
    enforcement programs is limited because it lacks measures of the
    intermediate outcomes, or direct results, of these programs that would
    show how they are contributing toward the end outcomes, or ultimate safety
    improvements, that the agency seeks to achieve. Furthermore, while FRA has
    made some changes in its oversight approach in response to external and
    internal evaluations, it has not evaluated the effectiveness of its
    enforcement approach. Evaluations can provide a broader range of
    information on program performance and how to improve it than performance
    measures alone. Both performance measures and evaluations can provide
    valuable information on program results that helps hold agencies
    accountable for their programs' performance.

    FRA Has Established a Range of Safety Goals and Uses Cooperation and Enforcement
    to Achieve These Goals

    To its credit, FRA has adopted a range of useful safety performance
    goals.^51 These safety goals are useful because they help the agency
    target its oversight efforts to help achieve the department's goals of
    reducing (1) the rate of rail-related accidents and incidents and (2) the
    number of serious hazardous materials releases. For fiscal year 2007, FRA
    established six new agencywide safety goals that are aligned with its five
    inspection disciplines and its grade crossing efforts. These goals are to
    reduce the rates of (1) accidents caused by human factors; (2) accidents
    caused by track defects; (3) accidents caused by equipment failure; (4)
    accidents attributable to other causes, including signal defects; (5)
    hazardous materials releases; and (6) grade-crossing incidents. These
    departmental and agency goals represent the key end outcomes, or ultimate
    results, FRA seeks to achieve through its oversight efforts. The agency
    has also recently established regional office goals that are generally
    aligned with the new agencywide goals. These regional office goals help
    FRA to link the oversight activities of its eight regional offices with
    its overall goals.

    FRA officials told us that their inspection and enforcement programs
    contribute to meeting these safety goals, or end outcomes, by resulting in
    the correction of safety problems and compliance.^52 These desired direct
    results can be called the intermediate outcomes of the inspection and
    enforcement programs, although FRA has not identified them as such. FRA
    officials told us that they use a combination of cooperation with
    railroads and enforcement actions to achieve the correction of safety
    problems and compliance. The linkages between such program outputs and
    desired intermediate and end outcomes can be demonstrated in a "logic
    model" that helps to show how program activities contribute to the
    ultimate results the agency seeks to achieve.^53 (See fig. 9.)

    ^51We have reported that agencies should create a set of performance goals
    that address important and various aspects of program performance. See,
    for example, GAO, Results-Oriented Government: GPRA Has Established a
    Solid Foundation for Achieving Greater Results, [31]GAO-04-38 (Washington,
    D.C.: Mar. 10, 2004); Managing for Results: Strengthening Regulatory
    Agencies' Performance Management Practices, [32]GAO/GGD-00-10 (Washington,
    D.C.: Oct. 28, 1999); and Agency Performance Plans: Examples of Practices
    That Can Improve Usefulness to Decisionmakers, [33]GAO/GGD/AIMD-99-69
    (Washington, D.C.: Feb. 26, 1999).

    ^52A number of other agency efforts--including the Railroad Safety
    Oversight program, the development of new safety standards, rail-related
    research and development, and initiatives to improve highway-rail grade
    crossing safety--also contribute toward these end outcomes.

    Figure 9: How FRA's Inspection and Enforcement Programs Contribute to Rail
    Safety

    Note: The program outputs and intermediate outcomes identified in this
    figure are examples of the outputs and intended direct results of FRA's
    inspection and enforcement and resulted from discussions with FRA
    officials. FRA has not identified these as outputs or intermediate
    outcomes. In addition to the agency's inspection and enforcement efforts,
    its Railroad System Oversight managers work cooperatively with the Class I
    railroads to achieve safety improvements not related to compliance.

    FRA uses cooperation with railroads and enforcement actions in various
    ways to resolve safety problems and achieve compliance. As explained
    previously, problems identified in inspections can be site-specific
    compliance problems or broader problems affecting multiple sites.
    Inspectors try to resolve site-specific compliance problems found during
    routine inspections by discussing defects with railroad officials in order
    to achieve voluntary compliance. The agency's policy of focused
    enforcement requires that inspectors cite violations and recommend
    enforcement actions, most frequently civil penalties, for those compliance
    problems that pose the greatest safety hazards. Enforcement actions can
    require railroads to correct identified compliance problems as well as
    deter future noncompliance. After in-depth inspection efforts at multiple
    sites, inspectors meet with railroad managers to discuss overall findings
    of safety problems that need to be corrected to achieve compliance. FRA
    sometimes encourages or requires railroads to make broad-scale
    improvements, such as in the training of railroads' track inspectors,
    which could help a railroad to comply with the agency's standards. (See
    app. II for more information on how FRA uses cooperation and enforcement
    to improve safety.)

    ^53We have suggested that regulatory programs develop logic models to
    develop a better understanding of how their programs deliver results, in
    order to select appropriate performance goals and measures. See
    [34]GAO-04-38 and [35]GAO/GGD-00-10 .

    Performance Measures Support FRA's Oversight, but Information on Direct Results
    Is Limited

    Consistent with the Government Performance and Results Act of 1993, which
    calls on federal agencies to develop performance measures to help
    determine the extent to which intended outcomes are achieved, FRA has
    developed a range of performance measures that it uses to track the
    progress of--and provide direction to--its safety oversight programs.^54
    (See table 3.) A number of these measures provide useful information about
    the extent to which various desired end outcomes, or ultimate results, are
    being achieved. In particular, FRA has developed a number of measures,
    based on agency and regional goals, that capture important components of
    its progress in achieving the department's overall safety goals. Since
    these new measures are linked to inspection and enforcement activities of
    its inspection disciplines and regional offices, they can provide some
    useful information on progress in achieving the desired end outcomes. For
    example, the agency expects that inspection and enforcement efforts in the
    operating practices discipline will reduce accidents caused by human
    factors, and it tracks the extent to which these accidents are reduced,
    both at the national and the regional level.

    ^54This act is the centerpiece of a statutory framework that Congress put
    in place during the 1990s to help resolve the long-standing management
    problems that have undermined the federal government's efficiency and
    effectiveness and to provide greater accountability for results. See
    [36]GAO-04-38 .

    Table 3: FRA's Safety Performance Measures

    Type of measure            Description
    End outcomes
    Departmental safety goals  Rate of rail-related accidents and incidents^a
                                  and number of serious hazardous materials
                                  releases
    Agency safety goals        Rates of train accidents caused by human
                                  factors, track defects, equipment defects, or
                                  other (signal and miscellaneous) causes; rate
                                  of nonaccident rail-related hazardous materials
                                  releases; and rate of highway-rail grade
                                  crossing incidents
    Regional office safety     By region, numbers of train accidents caused by
    goals                      human factors, track, equipment, and other
                                  causes and numbers of highway-rail grade
                                  crossing incidents
    Class I railroad safety    Trends in rates of accidents of various types
    performance trends         for each Class I railroad
    Program outputs and
    management
    Agency efficiency goal     Ratio of safety budget expenditures on
                                  safety-related activities, such as inspections,
                                  versus administrative activities
    Management of inspection      o Various measures used in targeting
    and enforcement activities    inspections and determining enforcement
                                     actions, including trends in various types
                                     of accidents and employee injuries and cited
                                     defects and violations, by inspection
                                     discipline, region, state, and railroad
                                     o Inspections conducted and costs by region
                                     and inspection discipline
                                     o Extent to which regions are meeting
                                     planned targets for inspections
                                     o Timeliness of reports received from
                                     railroads on actions taken to remedy
                                     violations^b
                                     o Measures related to enforcement, including
                                     civil penalties assessed and collected and
                                     processing times

    Source: GAO analysis of FRA information.

    aIncludes train accidents as well as grade-crossing, trespassing, and
    other accidents.

    bFor those violations requiring corrective action, railroads are required,
    within 30 days after the end of the month in which the violation occurred,
    to notify FRA of the actions they have taken.

    The agency has adjusted its oversight approach in response to trends in
    end outcome measures. For example, it developed the National Rail Safety
    Action Plan in response to a flat trend in the overall train accident rate
    and an increasing rate of accidents caused by human factors. In addition,
    FRA has developed measures to track the performance of Class I railroads,
    and it reviews these measures quarterly to assist in making decisions
    about oversight of these railroads.

    FRA also uses various measures of program outputs, such as numbers of
    inspections and enforcement actions, as well as some other types of
    measures to manage its oversight efforts. While the agency does not track
    its cooperative efforts to achieve compliance, it does track inspection
    and enforcement activities. In fiscal year 2007, the agency will start
    using an efficiency measure to track its progress in using its resources
    on safety-related activities, such as inspections, rather than on
    administrative activities. FRA headquarters and inspection staff use data
    on defects and violations cited in inspections, together with data on
    accidents and incidents, in planning inspection activities and making
    enforcement decisions. Finally, FRA tracks whether railroads report on
    actions taken to correct violations within the required time.

    While FRA has developed a range of measures of end outcomes and program
    outputs, it lacks measures of the desired intermediate outcomes, or direct
    results, of its inspection and enforcement efforts--that is, the
    correction of identified safety problems and compliance. We have found
    that it is a useful practice for agencies to establish measures of
    intermediate outcomes to help show programs' contributions to desired end
    outcomes.^55 According to FRA officials, inspectors review reports on
    corrective actions provided by railroads and may ask a railroad to
    resubmit a report if they believe that it does not adequately address the
    violation.^56 FRA officials also told us that inspectors always follow up
    on serious problems identified--both site-specific and broader scale
    problems--to ensure that they are corrected, and may cite additional
    violations if they find continuing problems.^57 However, the agency does
    not measure the extent to which identified safety problems have been
    corrected. Without such a measure, FRA cannot determine the extent to
    which its inspection and enforcement efforts are achieving the desired
    direct results.

    Measuring whether safety problems have been corrected is particularly
    important when serious compliance problems are broad-scale, affecting
    multiple sites, whether the problems are local, regional, or systemwide.
    These problems are sometimes identified in reports of in-depth
    inspections. For example, one set of track inspections of a Class I
    railroad at various sites within a region in early 2006 led to overall
    findings that these locations had deteriorating track conditions, that no
    repair work was scheduled, and that the railroad's track inspections were
    not adequate.^58 According to FRA officials, headquarters managers and
    managers of the agency's eight regional offices frequently discuss serious
    safety problems, indicated by the results of field inspections and data
    analyses, to determine the scope of the problems and decide on actions the
    agency should take to ensure that railroads resolve them. However, while
    FRA tracks a variety of safety related data, it does not centrally track
    these broad-scale compliance problems or their status and therefore lacks
    overall information on the effectiveness of its efforts to ensure that
    they are resolved.^59

    55See [37]GAO/GGD/AIMD-99-69 and [38]GAO/GGD-00-10 .

    ^56For violations determined by the inspector to require corrective
    action, railroads are required to provide FRA with a report within 30 days
    of the end of that month on the corrective actions they have taken. These
    reports also include the type of action taken, such as repair or
    replacement of equipment and disciplinary action or training of employees.
    FRA tracks whether these reports are received on time as well as the types
    of actions taken.

    ^57FRA's inspection reports contain a field for recording the receipt of
    railroads' reports on corrective actions but do not contain a field for
    recording whether inspectors have determined, in following up on
    violations, that the corrective actions are adequate. Furthermore, some
    regional staff told us that inspectors do not consistently record
    follow-up inspections as such.

    FRA also lacks overall measures of railroads' compliance. FRA officials
    told us that, while defect rates (the ratio of defects found per units
    inspected) measure noncompliance found by inspectors, they cannot be used
    to produce statistically valid measures of railroads' overall level of
    compliance because inspections are focused on problem areas and FRA is not
    able to conduct enough inspections of railroads to ensure that it is
    getting a good measure of compliance.^60 Officials have emphasized that
    the agency relies on inspectors' day-to-day oversight of and interaction
    with railroads to track compliance. Also, as noted previously, FRA
    officials, both at the headquarters and regional levels, analyze defect
    data in each inspection discipline to identify emerging issues and plan
    inspection activity. Finally, officials noted that the agency is planning
    to use its automated track inspection vehicles to survey most of the
    national track system and to monitor improvements in the condition of
    track over time.

    ^58In contrast, defects and violations tend to be much more specific. In
    this case, inspectors also found numerous defects concerning specific
    instances of track not meeting federal standards and two violations
    concerning defects that had gone for more than 30 days without corrective
    action.

    ^59In fiscal year 2006, FRA compiled information for the first time on all
    in-depth inspection activity by its headquarters and regional offices into
    one report and began producing quarterly updates on the status of these
    inspections. These updates contain some information on findings of
    broad-scale problems, in narrative form, but do not provide overall
    assessments of progress being made by each railroad as a whole in
    addressing these problems.

    ^60However, FRA does include in its quarterly review of Class I railroads'
    performance trends certain operating practices and track defect rates that
    it has found to be related to accident rates.

    We recognize that developing measures of intermediate outcomes would be
    difficult and that it is challenging for regulatory agencies to develop
    such measures.^61 Nevertheless, some other regulatory agencies in the
    Department of Transportation have developed such measures. For example,
    the Federal Motor Carrier Safety Administration measures the percentage of
    truck companies that improve their performance in a follow-up inspection
    and PHMSA measures the extent of improvement in pipeline operators'
    integrity management programs, as indicated by successive inspections of
    operators' programs. FRA officials have told us that the fact that the
    agency has not integrated its existing safety-related databases has
    impeded its ability to develop measures of intermediate outcomes. The
    agency has an initiative underway to better integrate these databases,
    including its database on accidents and incidents and its inspection and
    enforcement databases, in order to better manage its information
    resources.^62

    Performance measures should provide agency managers with information that
    helps them make decisions that improve program performance, including
    decisions to adjust policies and priorities. As noted, FRA has used its
    existing performance measures to make decisions about its oversight
    approach in a variety of ways. However, not having measures of the
    intermediate outcomes of its inspection and enforcement approaches limits
    FRA's ability to make informed decisions about these approaches and adjust
    them to improve performance. Intermediate outcome measures can provide
    more timely information on program performance than end outcome measures,
    because it may take longer for program efforts to affect end outcomes.

    Measures of program results can also help hold agencies accountable for
    the performance of their programs. Congress needs information on program
    results to support its oversight of agencies and their budgets. FRA's new
    discipline-specific and region-specific outcome measures do help ensure
    accountability for results. However, without measures of intermediate
    outcomes, the extent to which FRA's inspection and enforcement programs
    are achieving direct results and contributing to desired end outcomes is
    not clear. FRA officials have noted that they cannot attribute any drops
    in accident rates solely to FRA's efforts because other factors, such as
    railroads' investments in their systems, also play an important role.

    ^61We have reported on such challenges and how agencies have overcome
    them. See, in particular, [39]GAO-04-38 ; [40]GAO/GGD-00-10 ; Managing for
    Results: Measuring Program Results That Are Under Limited Federal Control,
    [41]GAO/GGD-99-16 (Washington, D.C.: Dec. 11, 1998); and Managing for
    Results: Regulatory Agencies Identified Significant Barriers to Focusing
    on Results, [42]GAO/GGD-97-83 (Washington, D.C.: June 24, 1997).

    ^62FRA has tasked a contractor with developing a plan for a data
    warehousing strategy for the agency that will integrate its data from
    various sources. According to agency officials, this initiative will allow
    FRA to better monitor its performance, through, for example, providing
    scorecards and graphical tools to depict performance.

    FRA can also use measures of intermediate outcomes to increase railroads'
    accountability for correcting safety problems. In spring 2006, the agency
    instituted annual meetings with the heads of the Class I railroads to
    discuss their overall safety performance, using trends in various accident
    rates. These meetings are a good step forward for the agency because they
    represent an opportunity for FRA to put pressure on top railroad
    executives to adequately address major problems the agency has identified.
    However, without measures of the extent to which individual railroads have
    addressed such problems, FRA cannot take full advantage of this
    opportunity. In addition, without central tracking of these problems and
    their status, FRA's ability to identify continuing or recurring problems
    as well as interrelated problems and make appropriate enforcement
    decisions may be impaired, especially since much of this work is performed
    in eight separate FRA regional offices and in five separate inspection
    disciplines.^63 According to FRA, annual meetings with the major railroads
    to negotiate civil penalties focus on individual violations but also
    address systemic issues that have been identified through analysis of
    individual violations. However, regional officials told us that these
    meetings do not generally deal with systemic issues. Readily available
    information on the status of broader problems would help put a railroad's
    individual violations into perspective and could help ensure that FRA
    negotiates appropriate final amounts with railroads.

    FRA Has Made Changes in Response to Evaluations but Has Not Evaluated Its
    Enforcement Approach

    Besides requiring performance measurement, the Government Performance and
    Results Act of 1993 calls for agencies to evaluate the effectiveness of
    their programs in achieving intended outcomes. We have found that, since
    it can be challenging for regulatory agencies to measure the direct
    results of their programs, program evaluations are particularly helpful in
    determining these results.^64 Program evaluations are objective,
    systematic studies that answer questions about program performance and
    results. By examining a broader range of information than is feasible to
    monitor on an ongoing basis through performance measures, evaluation
    studies can explore the benefits of a program as well as ways to improve
    program performance. They can also be used to develop or improve agencies'
    measures of program performance and help ensure agencies' accountability
    for program results.^65

    63A major concern with the previous Safety Assurance and Compliance
    Program, which ended in 2005, was that systemwide safety problems handled
    under this program took too long to resolve.

    FRA's safety oversight activities have recently undergone several external
    evaluations by the department's Inspector General, as well as an internal
    review, and FRA has made some changes as a result. For example, on the
    basis of several reviews since 1998, the department's Inspector General in
    2004 recommended that FRA develop a plan to make meaningful use of
    available data to focus its inspection and enforcement activity.^66 FRA
    developed its National Inspection Plan in response. Also, in 2004, FRA
    established a committee to conduct an internal review of its Safety
    Assurance and Compliance Program. This committee solicited the views of
    various FRA managers on the strengths and weaknesses of the program. Based
    on its findings, FRA terminated this program and replaced it with its
    Railroad System Oversight program.

    In addition, the Office of Management and Budget assessed FRA's overall
    safety program in 2003.^67 Although the office found this overall program
    to be moderately effective, it also found that FRA had not arranged for
    independent evaluations of its design and effectiveness. In response, FRA
    arranged for a review of its Railroad Safety Board process and has stated
    that it will continue to have regular independent reviews of various
    aspects of its safety program.^68 The agency is planning to have an
    independent evaluation of its Railroad System Oversight program conducted
    in the third quarter of fiscal year 2007. FRA also made some other
    improvements in response to recommendations of the Office of Management
    and Budget assessment, including developing its new efficiency measure and
    procuring new vehicles for conducting track inspections.

    ^64Such evaluations can also help determine the extent to which a program
    is having an impact on these outcomes versus other variables that affect
    outcomes. See [43]GAO-04-38 .

    ^65See GAO, Program Evaluation: An Evaluation Culture and Collaborative
    Partnerships Help Build Agency Capacity, [44]GAO-03-454 (Washington, D.C.:
    May 2, 2003); and Program Evaluation: Studies Helped Agencies Measure or
    Explain Program Performance, [45]GAO/GGD-00-204 (Washington, D.C.: Sept.
    29, 2000).

    ^66U.S. Department of Transportation-Office of the Inspector General,
    Review of Allegations that FRA Deputy Administrator Attempted to Relax
    Safety Enforcement Against Union Pacific (Washington, D.C., Dec. 10,
    2004); and Audit of Oversight of Highway-Rail Grade Crossing Accident
    Reporting, Investigations, and Safety Regulations, MH-2006-016
    (Washington, D.C., Nov. 28, 2005).

    ^67The Office of Management and Budget performed this assessment using its
    Program Assessment Rating Tool. This tool examines factors that affect and
    reflect program performance, including program purpose and design,
    performance measurement and evaluations, and aspects of program
    management.

    Although FRA has modified various aspects of its safety oversight in
    response to evaluations, it has not evaluated the extent to which its
    enforcement is achieving desired results. In addition to providing
    information on program performance and how it could be improved, an
    evaluation of FRA's enforcement approach could help to identify data
    needed to develop useful performance measures. For example, the Federal
    Motor Carrier Safety Administration examined the rate of violations by
    trucking companies before and after implementing a policy of assessing
    maximum penalties for such violations and, based on initial analyses, has
    improved its data system to be better able to analyze this trend.

    Under FRA's focused enforcement policy, developed in the mid-1990s,
    inspectors cite a small percentage of identified defects (about 3 percent
    in 2005) as violations that they recommend for enforcement action,
    generally civil penalties. While this policy relies, to a great extent, on
    cooperation with railroads to achieve compliance and is intended to focus
    FRA's enforcement efforts on those instances of noncompliance that pose
    the greatest safety hazards, it is not clear whether the number of civil
    penalties issued, or their amounts, are having the desired effect of
    improving compliance. FRA officials have told us that they have not
    evaluated the effectiveness of civil penalties in ensuring compliance,
    noting that this would be difficult because penalty payments usually occur
    after the agency's yearly settlement process. However, without an
    evaluation of its enforcement program, FRA is missing an opportunity to
    obtain valuable information on the performance of this program and on any
    need for adjustments to improve this performance.

    ^68The Railroad Safety Board approves or denies requests for waivers or
    special approval submitted by railroads and other parties subject to FRA
    regulations.

    Conclusions

    The various initiatives that FRA has begun in the past year and a half to
    better target its oversight--by addressing the main causes of train
    accidents and better focusing inspections on problem areas--hold promise
    for bringing down the train accident rate, reducing injuries, and saving
    lives. Some initiatives, such as reporting of close call incidents,
    encourage the railroad industry to address safety problems before they
    result in accidents. However, the success of many of these initiatives
    will depend on voluntary actions by the railroads and their overall safety
    impact will likely not be apparent for a number of years. While FRA is
    pursuing these initiatives, it has not changed its approach for conducting
    inspections, which relies primarily on direct observations of operations,
    equipment, and track. An additional approach that has provided additional
    assurance of safety in the U.S. commuter railroad, U.S. pipeline, and
    Canadian railroad industries is oversight of companies' overall management
    of safety risks. Although we believe that a similar approach could help
    improve rail safety, we are not recommending that FRA adopt such an
    approach because its current initiatives to bring down the train accident
    rate need time to demonstrate their effects.

    Without measures of the direct results of its inspection and enforcement
    programs, FRA cannot demonstrate how these programs are contributing to
    rail safety and lacks key information that could help it improve
    performance. This information could also help FRA hold railroads
    accountable for addressing safety problems it identifies. While these
    measures are not always easy to develop, at least one other modal
    administration within the department has done so at our recommendation.
    Coupled with better measures of FRA's direct results is the need to assess
    the effectiveness of its enforcement program, especially its use of civil
    penalties, to understand the degree to which they contribute to improved
    safety outcomes and to determine whether it should adjust its approach to
    improve performance.

    Recommendations for Executive Action

    To enhance FRA's ability to determine the extent to which its inspection
    and enforcement programs are contributing to rail safety and whether
    changes in these programs are needed, we recommend that the Secretary of
    Transportation direct the Administrator of FRA to take the following two
    actions:

               o develop and implement measures of the direct results of its
               inspection and enforcement programs; and

               o evaluate the agency's enforcement program to provide further
               information on its results, the need for additional data to
               measure and assess these results, and the need for any changes in
               this program to improve performance.

    			  Agency Comments

               We provided a draft of this report to the Department of
               Transportation for its review and comment. The department did not
               offer overall comments on the draft report or its recommendations.
               It did offer several technical comments, which we incorporated
               where appropriate.

               We are sending copies of this report to congressional committees
               and subcommittees with responsibility for transportation safety
               issues; the Secretary of Transportation; the Administrator,
               Federal Railroad Administration; and the Director, Office of
               Management and Budget. We will also make copies available to
               others upon request. This report will be available at no charge on
               the GAO Web site at http://www.gao.gov .

               If you have any questions about this report, please contact me at
               (202) 512-2834 or siggerudk@gao.gov . Contact points for our
               Offices of Congressional Relations and Public Affairs may be found
               on the last page of this report. Staff who made key contributions
               to this report are listed in appendix IV.

               Katherine A. Siggerud
    			  Director, Physical Infrastructure Issues

    			  Appendix I: Scope and Methodology

               To determine how the Federal Railroad Administration (FRA) focuses
               its efforts on the highest priority risks related to train
               accidents in planning its safety oversight, we reviewed FRA's
               National Rail Safety Action Plan, plans for developing new
               regulations, documents related to its initiatives for reducing
               human factor and track-caused accidents, and inspection planning
               documents. We also discussed the agency's inspection planning
               approach and key initiatives with headquarters and regional
               officials responsible for these areas. In addition, we obtained
               information on FRA's initiatives through attending congressional
               hearings on FRA's oversight and meetings of the Railroad Safety
               Advisory Committee.

               To determine how FRA identifies safety problems on railroad
               systems in carrying out its oversight, we determined how FRA uses
               its inspections, the Railroad System Oversight program, and other
               oversight activities to oversee safety and identify problems. In
               order to do this, we reviewed FRA's regulations, policies,
               procedures, and guidance for conducting inspections and
               identifying safety problems as well as reports on inspection
               results. We also reviewed the agency's statutory authority under
               the Federal Railroad Safety Act and reviewed Railroad Safety
               Oversight program documents. We discussed FRA's oversight
               activities with FRA headquarters managers and inspection
               discipline specialists and Railroad Safety Oversight managers to
               gain a greater understanding of how FRA identifies safety problems
               on railroad systems. We also contacted three (Chicago, Forth
               Worth, and Atlanta) of the eight FRA regional offices reporting
               the highest numbers of accidents in their jurisdictions during
               2005. We discussed this topic with administrators and track and
               human factor discipline specialists from each of these regional
               offices. We conducted these interviews on-site at the offices
               located in Fort Worth, Texas, and Chicago, Illinois. We also
               discussed this topic with officials from the three state
               regulatory associations employing the greatest number of railroad
               safety inspectors in order to discuss how state inspectors
               coordinate their activities with FRA inspectors. (See the end of
               this appendix for a list of organizations that we contacted.) We
               also examined our published work on risk management and safety
               oversight approaches used by other modal administrations within
               the Department of Transportation as well as some other
               organizations responsible for overseeing rail safety.

               We reviewed FRA data on its inspection activities for the period
               from 1996 through 2005. To assess the reliability of the
               inspection data, we (1) performed electronic testing of required
               data elements, (2) reviewed existing information about the data
               and the system that produced them, and (3) interviewed agency
               officials knowledgeable about the data. We discussed our
               preliminary results with FRA to ensure that we were capturing the
               correct information and consulted with these officials to resolve
               questions on the data collection process. We determined that the
               data were sufficiently reliable for the purposes of this report.

               To determine how FRA assesses the impact of its oversight efforts
               in improving safety, we examined the methods FRA uses to assess
               the results of its oversight programs and FRA's use of this
               information to make decisions about its oversight strategy. As
               part of this effort, we reviewed FRA documents on its safety
               performance measures and evaluations of its oversight and
               enforcement activities. We also discussed this issue with managers
               at headquarters and in the regional offices responsible for
               developing and using performance information. In addition, we
               reviewed our recommendations on performance measurement, the use
               of performance information, and program evaluation and determined
               the extent to which FRA's practices are consistent with these
               recommendations.

               We focused our work on FRA's oversight activities aimed at
               reducing train accidents-such as train collisions and
               derailments-rather than those aimed at reducing highway-rail
               crossing and trespassing accidents. FRA's oversight of
               highway-rail grade crossing safety has been the subject of two
               recent Department of Transportation Inspector General audits. In
               addition, both these types of accidents and trespassing accidents
               involve issues not related to railroad safety performance, such as
               driver awareness of grade crossing safety and individuals'
               willingness to abide by railroads' warning signs on their
               property. We also focused on FRA's oversight of railroads rather
               than its oversight of non-railroad companies (such as shippers of
               hazardous materials by rail) because the agency `s oversight
               efforts focus primarily on railroads. In addition, according to
               FRA, most recent serious train accidents involving the release of
               hazardous materials have resulted from problems with railroad
               operations.

    			  Other Aspects of Our Work

               We also examined how FRA uses enforcement and other methods for
               ensuring that safety problems on railroad systems are resolved. In
               order to do this, we reviewed FRA's policies, procedures, and
               guidance for conducting enforcement; major enforcement actions
               such as compliance agreements; Railroad Safety Oversight program
               documents; and other agency documents. We also discussed FRA's
               approaches to resolving safety problems, through enforcement and
               other means, with officials from FRA headquarters, Railroad System
               Oversight managers, and administrators and inspection discipline
               specialists in three regional offices. Regarding FRA's enforcement
               approach, we reviewed how FRA employs enforcement to improve
               safety on railroads' systems. However, we could not determine the
               extent to which railroads address systemic safety problems as a
               result of enforcement because FRA does not track the broad-scale
               safety problems it identifies or the extent to which these
               problems are resolved. We focused on FRA's use of enforcement as
               part of its overall oversight strategy and did not examine the
               agency's individual enforcement actions.

               We also obtained FRA data on civil penalties from FRA's
               enforcement database, which includes data on assessed and
               collected amounts from 1996 through 2005. We assessed the
               reliability of the enforcement data by the same means that we
               employed to assess the reliability of FRA's inspection data. We
               determined that the enforcement data used in this report were
               sufficiently reliable for the purposes of this report.

               Finally, we met with or contacted the following organizations or
               persons in order to obtain a fuller understanding of railroad
               safety issues and obtain their perspectives on FRA's oversight
               approach.

               Other federal agencies:

               National Transportation Safety Board

               Freight railroads (Class I):

               BNSF Railway Company CSX Transportation, Inc. Norfolk Southern
               Railway Company Union Pacific Railroad Company

               Passenger railroads:

               National Railroad Passenger Corporation, or Amtrak Northeast
               Illinois Regional Commuter Rail Corporation, or Metra New Jersey
               Transit Rail Operations

               Regional and short line railroad management companies:

               Cedar American Rail Holdings, Inc. RailAmerica

               Industry associations:

               American Chemistry Council Association of American Railroads
               American Public Transportation Association American Short Line and
               Regional Railroad Association

               Labor unions:

               AFL-CIO Brotherhood of Maintenance of Way Employees Brotherhood of
               Locomotive Engineers and Trainmen United Transportation Union

               State oversight organizations:

               Association of State Rail Safety Managers California Public
               Utilities Commission Ohio Public Utilities Commission Texas
               Department of Transportation

               Canadian oversight organization:

               Transport Canada

               Academic expert:

               Dr. Ian Savage, Department of Economics, Northwestern University

               FRA uses cooperation with railroads and enforcement actions in
               various ways to resolve identified safety problems and achieve
               compliance. When inspectors find problems during inspections,
               FRA's policy is to cite defects for most instances of
               noncompliance and to encourage the railroad to comply voluntarily.
               For example, issues may be addressed on site with railroad
               officials during inspections. According to FRA officials,
               railroads often correct identified problems immediately and if so,
               these problems would not require additional action. When railroads
               do not comply voluntarily or the identified defects are serious,
               FRA may cite violations and recommend civil penalties or take
               other enforcement actions--either against railroads or
               individuals--to promote compliance with safety regulations.^1
               According to FRA officials, inspectors follow up on violations or
               high numbers of defects within 60 days to ensure that they are
               corrected.^2

               FRA most commonly uses civil penalties against companies as its
               enforcement tool for site-specific violations.^3 From January 2005
               through July 2006, FRA assessed about 8,600 violations for civil
               penalties. FRA has other enforcement tools. These include
               compliance agreements and compliance orders, civil penalties
               against individuals, special notices for repair, emergency orders,
               criminal penalties, disqualification orders, and injunctions. (See
               table 4.) FRA uses these tools much less frequently than it does
               civil penalties. For example, FRA issued 288 special notices for
               repair, 118 warning letters and fewer than a dozen of all other
               enforcement actions during this period.^4

    ^1While we reviewed how FRA employs enforcement to improve safety on
    railroads' systems, we could not determine the extent to which railroads
    address systemic safety problems as a result of enforcement. This is
    because FRA does not track the broad-scale safety problems it identifies
    or the extent to which these problems are resolved. We focused on FRA's
    use of enforcement as part of its overall oversight strategy and did not
    examine the agency's individual enforcement actions.

    ^2Often, an inspector will conduct follow-up re-inspections during other
    routine inspections. However, an inspector may make a special visit to
    conduct follow-up if warranted.

    ^3FRA's Statement of Enforcement Policy specifies that before citing
    violations and recommending penalties, inspectors consider the seriousness
    of the condition or act, the potential safety hazard posed by the
    condition or act, and the current level of compliance of the offending
    person (e.g., a railroad or individual), among other things.

    ^4FRA could not supply data covering a longer period on the frequency of
    use of all of its enforcement actions without substantial effort.

    Table 4: Description of FRA Enforcement Actions and Frequency of Use,
    January 2005 through July 2006

                                  Number of
    Enforcement action        times used  Description
    Civil penalty against a        8,606  Imposes a monetary penalty on a
    railroad or other entity              railroad or other entity, such as a
    except for an individual              company that ships hazardous
                                             materials by rail, that violates a
                                             rail safety or hazardous materials
                                             statute, regulation, or order. Each
                                             day that the violation continues is
                                             a separate violation.
    Special notice for repair        288  Orders a locomotive, freight car, or
                                             passenger car out of service and may
                                             require a reduction of the maximum
                                             operating speed over defective track
                                             segments.
    Warning letter to an             118  Informs an individual that FRA
    individual                            believes that the individual has
                                             committed a rail safety or hazardous
                                             materials violation and that any
                                             future violation by the individual
                                             will result in enforcement action.
    Civil penalty against an           6  Imposes a monetary penalty on any
    individual                            individual who willfully violates or
                                             willfully causes the violation of a
                                             rail safety statute, regulation, or
                                             order.
    Compliance agreement               2  States a railroad's agreement to
                                             take a specified action to promote
                                             compliance. The railroad agrees that
                                             if, in FRA's judgment, the required
                                             action is not performed, the
                                             railroad will not contest FRA's
                                             sanction-typically a compliance
                                             order. See below.
    Criminal penalty                   1  Imposes (1) either a monetary
                                             penalty or imprisonment for up to 2
                                             years, or both, on an individual for
                                             knowingly and willfully violating
                                             certain reporting, recordkeeping, or
                                             other regulations or (2) a monetary
                                             penalty or imprisonment for up to 5
                                             years, or both, for knowingly
                                             violating the hazardous materials
                                             statute or an implementing
                                             regulation or order.
    Disqualification order             1  Prohibits an individual from
                                             performing safety-sensitive
                                             functions in the rail industry for a
                                             specified period if the individual's
                                             violation of a rail safety statute
                                             or regulation demonstrates unfitness
                                             to perform such functions.
    Emergency order                    1  Orders corrective action where an
                                             unsafe condition or practice causes
                                             an emergency situation involving a
                                             hazard of death or personal injury.
    Compliance order                   0  Directs compliance following
                                             repeated failure to comply with rail
                                             safety or hazardous material statute
                                             or regulation.
    Injunction                         0  Restrains a violation of, or
                                             enforces, a rail safety or hazardous
                                             materials regulation or order.

    Source: FRA.

    FRA inspectors cite many defects, but cite comparatively few of these
    defects as violations warranting enforcement action. Since 1996, FRA
    inspectors have cited an average of about 4 violations for every 100
    defects cited annually. According to FRA officials, inspectors cite
    relatively few defects as violations warranting enforcement action because
    FRA's focused enforcement policy guides inspectors to cite violations only
    for problems that pose safety risks. In addition, inspectors have
    discretion in citing a defect or a violation for a given instance of
    noncompliance--FRA directs inspectors to first seek and obtain the
    railroads' voluntary compliance with the rail safety regulations.

    According to FRA officials, inspectors usually choose to provide the
    railroad with information about defects they found during their
    inspection, discuss these instances of noncompliance, and attempt to
    obtain the railroad's commitment to improve compliance. If the railroad's
    response is inadequate or the inspector finds that the problem warranting
    the defect is serious, the inspector may exercise the agency's enforcement
    discretion by citing a violation, recommending that FRA take enforcement
    action, generally a civil penalty. The agency makes an initial penalty
    assessment against the railroad based on the type of violation that
    occurred.^5 FRA meets with the major railroads in an annual settlement
    meeting to negotiate a final amount for all civil penalties cited in the
    past year. This amount is based on the railroad's compliance history and
    efforts to correct the problem, among other factors.^6 The total value of
    civil penalties assessed and collected each year was higher from 2001
    through 2005 than from 1996 to 2000. (See fig. 10.) According to FRA
    officials, the higher civil penalty assessments after 2000 reflect the
    agency's efforts to focus its inspection activity on areas that present
    the greatest risk. FRA officials also told us that when the agency
    initiated the Safety Assurance and Compliance Program--which emphasized a
    partnership approach with railroads to improve safety--in 1995, inspectors
    initially cited fewer violations. They noted that in 2001 FRA's management
    pushed for inspectors to be more aggressive in citing violations. Since
    2001, the amounts collected have been about 63 percent of the amounts
    initially assessed. Consistent with the purpose of the federal railroad
    safety laws and with federal court decisions interpreting the purpose of
    such laws, the agency's goals are to promote safety and to gain compliance
    rather than to maximize amounts collected. For example, FRA may agree to a
    reduced penalty amount if the railroad immediately remedies the safety
    problem or implements a new program to prevent a problem from recurring.^7
    This is consistent with federal law. In other cases, FRA will agree to a
    reduced penalty amount if its documentation on the violation is not
    substantial enough.

    ^5In December 2006, FRA published in the Federal Register proposed
    amendments to its schedules of civil penalties for each type of violation
    to ensure that penalty amounts more fully reflect the risk associated with
    a railroad's violation of the rail safety regulations.

    ^6Given the volume of civil penalty cases, FRA usually negotiates civil
    penalties with smaller railroads and shippers through the mail and
    telephone conferences. FRA is authorized to negotiate civil penalties with
    railroads and exercises this authority by annually settling civil penalty
    amounts with each railroad. The criteria for compromising with railroads
    on civil penalty amounts are set in statute. In determining the amount of
    a compromise, the Secretary shall consider (1) the nature, circumstances,
    extent, and gravity of the violation; (2) with respect to the violator,
    the degree of culpability, any history of violations, the ability to pay,
    and any effect on the ability to continue to do business; and (3) other
    matters that justice requires.

    Figure 10: FRA's Civil Penalties, 1996 through 2005, in 2005 Dollars

    Notes: Individual penalties resulting from violations are consolidated
    into one or more case(s) for each railroad and are negotiated annually
    with FRA and the railroad during settlement conferences.

    Each year's amounts are for cases initiated in that year. Some penalties
    may be initially assessed in one year, with the final assessment in
    another year. FRA, in commenting on a draft of our report, provided 2006
    civil penalty figures. However, we did not use this information because
    there was not enough time to assess its reliability before the report was
    issued.

    Penalties against individuals are not included. From 1996 through 2005,
    FRA issued an average of 1 civil penalty per year against individuals.

    ^7The Federal Motor Carrier Safety Administration follows a similar
    policy. See GAO, Large Truck Safety: Federal Enforcement Efforts Have Been
    Stronger Since 2000, but Oversight of State Grants Needs Improvement,
    [48]GAO-06-156 (Washington, D.C.: Dec. 15, 2005).

    FRA seeks to resolve broad-scale compliance problems it has identified by
    first discussing them with railroad officials and elevating them, as
    necessary, to obtain an appropriate response. After in-depth inspection
    efforts at multiple sites, inspectors meet with railroad managers
    responsible for those sites to discuss overall findings or problems. For
    very serious or systemic problems, FRA may ask railroads to submit
    corrective action plans and may review these plans for adequacy. FRA
    sometimes discusses broad problems with railroad headquarters officials to
    try to obtain corrective actions. For example, one regional administrator
    told us that his region arranged a multiregion meeting with the senior
    management of a Class I railroad to discuss systemic problems with the
    railroad's equipment. FRA asked the railroad to submit a corrective action
    plan to address the equipment problems. According to FRA officials, the
    railroad has been meeting the milestones in the corrective action plan and
    has been making progress in addressing its equipment problems. Also, FRA's
    Railroad System Oversight managers, who act as liaisons with the Class I
    railroads, help to maintain frequent communication with these railroads
    about major problems that have been identified and associated corrective
    actions. These efforts to cooperate with railroads to resolve problems may
    be combined with civil penalties for violations found at specific
    locations. According to FRA officials, when in-depth inspections result in
    findings of serious problems, inspectors always follow up to determine
    whether these problems are adequately resolved. However, FRA has no
    central repository for data on the status of these broader problems its
    inspectors have identified at railroads.

    FRA officials told us that they hold frequent internal discussions among
    headquarters and regional management about these broad-scale compliance
    problems that have been identified--whether local, regional, or
    systemwide--and actions that the agency should take to attempt to resolve
    them. According to FRA officials, the agency sometimes uses compliance
    agreements, which require railroads to take significant actions beyond
    those specifically required by regulations to improve their ability to
    comply, when broad-scale compliance problems are egregious and have not
    been resolved through other methods. Compliance agreements allow FRA to
    apply more leverage in trying to obtain compliance because FRA uses the
    agreements as an alternative to the railroad involved undergoing an FRA
    proceeding for a compliance order. For example, under recent compliance
    agreements, railroads have agreed to reinstruct managers on how to test
    employees' adherence to operating rules and to develop and implement track
    maintenance plans to eliminate systemic track defects. FRA monitors
    railroads' performance under these agreements. In some instances, FRA has
    also used compliance orders to address significant railroad compliance
    problems. However, these enforcement tools are seldom used. FRA has
    entered into 13 compliance agreements altogether and one compliance order
    since 1996, or an average of about 1 per year. In comparison, since 1996,
    FRA has assessed in the neighborhood of almost 40,000 violations for civil
    penalties.

    This approach to resolving broad-scale safety problems has had some
    success. For example, the three railroads that have entered into
    compliance agreements in the past 2 years have generally made progress in
    improving compliance, according to the results of FRA's follow-up.^8 In
    addition, FRA officials have cited a number of other successes, including
    improved compliance by several railroads with signal inspection and
    testing requirements,^9 and another railroad's implementation of an
    electronic system to record locomotive defects and repairs following FRA's
    finding that inadequate recordkeeping had resulted in the operation of
    locomotives with multiple defects. FRA's Railroad System Oversight
    managers have also worked with railroads to make some systemic safety
    improvements not related to compliance. For example, these managers have
    encouraged railroads to make improvements related to roadway worker
    communication, signal maintenance, and mentoring of new employees.

    ^8FRA's compliance agreements with three different divisions of one Class
    I railroad have resulted in improved compliance. FRA had to extend the
    compliance agreement with the third division because noncompliance
    continued but has since terminated the compliance agreement because of
    improved safety performance. While FRA does not have overall measures of
    compliance, it sometimes, in summary reports on follow-up inspections at a
    railroad, records trends in certain types of defects found.

    ^9FRA has noted instances of significant noncompliance with signal
    inspection and testing requirements on the part of two major commuter
    railroads and at least one Class I railroad.

    Appendix III: Oversight of Risk Management in the U.S. Commuter Railroad,
    U.S. Pipeline, and Canadian Railroad Industries

    Risk management is a systematic process for assessing risks and taking
    appropriate steps to deal with them. It is founded on several inspection
    disciplines, including financial economics, decision science,
    organizational theory, and strategic management. The National Academy of
    Sciences, a presidential commission, private organizations, and others
    have addressed the subject and have recognized its applicability in both
    the private and the public sectors. We have developed a framework for risk
    management based on industry best practices.^1 This framework divides risk
    management into five major phases. (See table 5.)

    Table 5: Risk Management Framework

    Phase                       Description
    Strategic goals,            Establish an organization's strategic goals
    objectives, and constraints and the steps needed to attain those results,
                                   including performance measures to assess
                                   progress. Constraints that affect outcomes can
                                   also be identified during this phase.
    Risk assessment             Assess the threats to and vulnerabilities of
                                   assets so that countermeasures may be
                                   instituted to prevent or mitigate risks. Risks
                                   can be assessed by various methods, depending
                                   on the specific application and knowledge
                                   available.
    Alternatives evaluation     Evaluate risk reduction methods by considering
                                   the countermeasures and the costs and benefits
                                   associated with each. Countermeasures can be
                                   considered and prioritized according to a
                                   number of factors, such as the degree of risk
                                   reduction they afford and the cost and
                                   difficulty to implement them.
    Management selection        Choose among alternative actions. Management's
                                   active participation is important at this
                                   phase because risk assessment tools contain
                                   various assumptions about preferences that may
                                   require value judgments and review at the
                                   management level.
    Implementation and          Move from planning to implementing the
    monitoring                  selected countermeasures. Following
                                   implementation, monitoring is essential to
                                   help ensure that the entire risk management
                                   process remains current and relevant.

    Source: GAO.

    During the last 10 years, the American Public Transportation Association
    (APTA), Pipeline and Hazardous Materials Safety Administration (PHMSA),
    and Transport Canada have developed and implemented new approaches for
    overseeing safety in the U.S. commuter railroad, U.S. pipeline, and
    Canadian railroad industries, respectively. These approaches promote the
    use of risk management and incorporate various elements of risk management
    noted above. They also complement traditional compliance inspections.

    ^1To develop the framework, we reviewed risk management literature, our
    reports and testimonies on this topic, and other government guidance. In
    addition, we consulted with experts on risk management, risk modeling, and
    terrorism. We reviewed numerous frameworks from industry, government and
    academic sources. We field-tested the framework, and it was reviewed by
    academic experts in risk management. See [49]GAO-06-91 .

    In 1996, following two serious commuter rail accidents, APTA, with FRA
    support, started a program to help its 16-member commuter railroad
    properties develop and implement plans for managing the safety of their
    systems. APTA had previously developed a similar program for the rapid
    transit industry. Risk management is a key aspect of these plans, which
    must include, among other things, goals and objectives, the identification
    of hazards, an assessment of their associated risks, the analysis and
    implementation of actions to reduce these risks, and internal assessments
    of the effectiveness of safety management. Commuter railroads are given
    the latitude to develop individual plans that conform to APTA's guidelines
    but that are based on their unique circumstances. APTA audits its member
    railroads' system safety management plans on a 3-year cycle. During the
    first year, APTA conducts an initial assessment of the plan; during the
    second year, APTA evaluates how well the railroad implements its plan; and
    during the third year, APTA follows up with the railroad to see what
    actions it has taken in response to APTA's audit findings.

    In 2000, to better focus on safety risks that are unique to individual
    pipelines, PHMSA, then operating as the Office of Pipeline Safety, issued
    the first in a series of integrity management regulations that now apply
    to more than 1,000 hazardous liquid and gas transmission pipelines
    operating in densely populated and environmentally sensitive areas. Under
    this approach, operators are required to develop programs to
    systematically assess and mitigate safety threats, such as corrosion, to
    pipelines located in such high-risk areas. For example, these programs
    must integrate all available information about pipeline integrity and the
    consequences of a leak or rupture, repair identified defects within
    defined time limits based on their severity, and evaluate the need for
    additional preventive and mitigating actions. In addition, operators are
    required to report program performance measures to PHMSA semi-annually.
    PHMSA inspects these written programs as well as their implementation in
    periodic comprehensive inspections.

    During the 1990s, a series of derailments raised concerns over the level
    of safety in the Canadian rail industry. In 2001, following a review of
    its oversight approach, Transport Canada determined that a more
    comprehensive safety management assessment was necessary to minimize
    safety risks, and adopted new safety management regulations under Canada's
    Railway Safety Act. The new regulations require that Canadian railway
    companies develop their own safety management systems, subject to
    Transport Canada's review. These systems must include, among other things,
    annual safety performance targets; the identification of safety issues
    through a variety of methods (such as analyses of safety data and input
    from employees); an assessment of the risks associated with these issues
    to determine their significance; the development, approval, and
    implementation of strategies for controlling these risks; and systems for
    monitoring these strategies and other management-approved corrective
    actions. Transport Canada audits the railroads' documentation and
    implementation of their safety management systems. The level of such
    monitoring varies depending on the safety performance of the railroad.

    Appendix IV: GAO Contact and Staff Acknowledgments

    GAO Contact

    Katherine Siggerud (202) 512-2834 or siggerudk@gao.gov

    Staff Acknowledgments

    In addition to the contact named above, James Ratzenberger, Assistant
    Director; Ashley Alley; Marianne Anderson; Timothy Bober; Elizabeth
    Eisenstadt; Judy Guilliams-Tapia; Brandon Haller; Bonnie Pignatiello Leer;
    Masha P. Pastuhov-Purdie; and Minette Richardson made key contributions to
    this report.

    (542077)

    GAO's Mission

    The Government Accountability Office, the audit, evaluation and
    investigative arm of Congress, exists to support Congress in meeting its
    constitutional responsibilities and to help improve the performance and
    accountability of the federal government for the American people. GAO
    examines the use of public funds; evaluates federal programs and policies;
    and provides analyses, recommendations, and other assistance to help
    Congress make informed oversight, policy, and funding decisions. GAO's
    commitment to good government is reflected in its core values of
    accountability, integrity, and reliability.

    Obtaining Copies of GAO Reports and Testimony

    The fastest and easiest way to obtain copies of GAO documents at no cost
    is through GAO's Web site ( www.gao.gov ). Each weekday, GAO posts
    newly released reports, testimony, and correspondence on its Web site. To
    have GAO e-mail you a list of newly posted products every afternoon, go to
    www.gao.gov and select "Subscribe to Updates."

    Order by Mail or Phone

    The first copy of each printed report is free. Additional copies are $2
    each. A check or money order should be made out to the Superintendent of
    Documents. GAO also accepts VISA and Mastercard. Orders for 100 or more
    copies mailed to a single address are discounted 25 percent. Orders should
    be sent to:

    U.S. Government Accountability Office 441 G Street NW, Room LM Washington,
    D.C. 20548

    To order by Phone: Voice: (202) 512-6000 TDD: (202) 512-2537 Fax: (202)
    512-6061

    To Report Fraud, Waste, and Abuse in Federal Programs

    Contact:

    Web site: www.gao.gov/fraudnet/fraudnet.htm E-mail:
    fraudnet@gao.gov Automated answering system: (800) 424-5454 or (202)
    512-7470

    Congressional Relations

    Gloria Jarmon, Managing Director, JarmonG@gao.gov (202) 512-4400 U.S.
    Government Accountability Office, 441 G Street NW, Room 7125 Washington,
    D.C. 20548

    Public Affairs

    Paul Anderson, Managing Director, AndersonP1@gao.gov (202) 512-4800
    U.S. Government Accountability Office, 441 G Street NW, Room 7149
    Washington, D.C. 20548

    www.gao.gov/cgi-bin/getrpt?GAO-07-149 .

    To view the full product, including the scope
    and methodology, click on the link above.

    For more information, contact Katherine Siggerud at (202) 512-2834 or
    siggerudk@gao.gov.

    Highlights of [57]GAO-07-149 , a report to congressional committees

    January 2007

    RAIL SAFETY

    The Federal Railroad Administration Is Taking Steps to Better Target Its
    Oversight, but Assessment of Results Is Needed to Determine Impact

    Since 1980, the train accident rate has improved significantly, but
    progress has leveled off over the past 10 years. Recent serious
    accidents--such as one in Graniteville, South Carolina, that led to 9
    deaths and 292 injuries--elevated concerns. The Federal Railroad
    Administration (FRA) develops safety standards and inspects and enforces
    railroads' compliance with these standards.

    This report addresses how FRA (1) focuses its efforts on the highest
    priority risks related to train accidents in planning its oversight, (2)
    identifies safety problems on railroad systems in carrying out its
    oversight, and (3) assesses the impact of its oversight efforts on safety.
    To complete this work, GAO reviewed FRA regulations, planning and policy
    documents, and safety data. GAO also contacted FRA officials in
    headquarters and three regional offices and others.

    [58]What GAO Recommends

    GAO is recommending that FRA develop measures of the direct results of its
    oversight and evaluate the effectiveness of its enforcement program. The
    Department of Transportation did not provide overall comments on these
    recommendations but did provide several technical comments, which were
    incorporated as appropriate.

    In planning its safetyoversight, FRA is focusing its efforts on the
    highest priority risks related to train accidents through initiatives
    aimed at addressing their main causes--human behaviors and defective
    track--as well as through improvements in its inspection planning
    approach. In its May 2005 National Rail Safety Action Plan, the overall
    strategy for targeting its oversight at the greatest risks, FRA provides a
    reasonable framework for guiding these efforts. Its initiatives to address
    the most common causes of accidents are promising, although the success of
    many of them will depend on voluntary actions by the railroads. In
    addition, the action plan outlined the agency's development of a new
    inspection planning approach. Under this approach, inspectors focus their
    efforts on locations that data-driven models indicate are most likely to
    have safety problems.

    In carrying out its safety oversight, FRA identifies a range of specific
    and broad-scale safety problems on railroad systems mainly by determining
    whether operating practices, track, and equipment are in compliance with
    minimum safety standards. However, FRA is able to inspect only about 0.2
    percent of railroads' operations each year and its inspections do not
    examine how railroads are managing safety risks throughout their systems
    that could lead to accidents. Such an approach, as a supplement to
    traditional compliance inspections, is used in the oversight of U.S.
    commuter railroads and pipelines and of Canadian railroads. While this
    type of approach can provide additional assurance of safety, GAO is not
    recommending that FRA adopt it because its various initiatives to reduce
    the train accident rate have not yet had time to demonstrate their effects
    on safety.

    FRA uses a broad range of goals and measures to assess the impact of its
    oversight. For example, it has developed (1) new goals to target its
    inspection and enforcement programs at reducing various types of railroad
    accidents and (2) related measures to monitor its progress. These measures
    include the rate of train accidents caused by human behaviors, track
    defects, and equipment defects. However, FRA's ability to make informed
    decisions about these programs is limited because it lacks measures of
    their direct results, such as the correction of identified safety
    problems. Furthermore, FRA has not evaluated the effectiveness of its
    enforcement program.

    Track Inspector Examining Rail to Assess Its Safety Compliance

    References

    Visible links
      26. http://www.gao.gov/cgi-bin/getrpt?GAO-04-378
      27. http://www.gao.gov/cgi-bin/getrpt?GAO-06-91
      28. http://www.gao.gov/cgi-bin/getrpt?GAO-04-557T
      29. http://www.gao.gov/cgi-bin/getrpt?GAO-04-598T
      30. http://www.gao.gov/cgi-bin/getrpt?GAO-06-946
      31. http://www.gao.gov/cgi-bin/getrpt?GAO-04-38
      32. http://www.gao.gov/cgi-bin/getrpt?GAO/GGD-00-10
      33. http://www.gao.gov/cgi-bin/getrpt?GAO/GGD/AIMD-99-69
      34. http://www.gao.gov/cgi-bin/getrpt?GAO-04-38
      35. http://www.gao.gov/cgi-bin/getrpt?GAO/GGD-00-10
      36. http://www.gao.gov/cgi-bin/getrpt?GAO-04-38
      37. http://www.gao.gov/cgi-bin/getrpt?GAO/GGD/AIMD-99-69
      38. http://www.gao.gov/cgi-bin/getrpt?GAO/GGD-00-10
      39. http://www.gao.gov/cgi-bin/getrpt?GAO-04-38
      40. http://www.gao.gov/cgi-bin/getrpt?GAO/GGD-00-10
      41. http://www.gao.gov/cgi-bin/getrpt?GAO/GGD-99-16
      42. http://www.gao.gov/cgi-bin/getrpt?GAO/GGD-97-83
      43. http://www.gao.gov/cgi-bin/getrpt?GAO-04-38
      44. http://www.gao.gov/cgi-bin/getrpt?GAO-03-454
      45. http://www.gao.gov/cgi-bin/getrpt?GAO/GGD-00-204
      48. http://www.gao.gov/cgi-bin/getrpt?GAO-06-156
      49. http://www.gao.gov/cgi-bin/getrpt?GAO-06-91
      57. http://www.gao.gov/cgi-bin/getrpt?GAO-07-149
    *** End of document. ***