[Federal Register Volume 76, Number 196 (Tuesday, October 11, 2011)]
[Notices]
[Pages 62894-62897]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 2011-26283]
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DEPARTMENT OF TRANSPORTATION
Federal Railroad Administration
[Safety Advisory 2011-02]
Following Procedures When Going Between Rolling Equipment
AGENCY: Federal Railroad Administration (FRA), Department of
Transportation (DOT).
ACTION: Notice of Safety Advisory.
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SUMMARY: FRA is issuing Safety Advisory 2011-02 to remind railroads and
their employees of the importance of following procedures when going
[[Page 62895]]
between rolling equipment. This safety advisory contains various
recommendations to railroads to ensure that these issues are addressed
by appropriate railroad operating policies and procedures, and to
ensure that those policies and procedures are effectively implemented.
FOR FURTHER INFORMATION CONTACT: Ron Hynes, Director, Office of Safety
Assurance and Compliance, Office of Railroad Safety, FRA, 1200 New
Jersey Avenue, SE., Washington, DC 20590, telephone (202) 493-6404; or
Joseph St. Peter, Trial Attorney, Office of Chief Counsel, FRA, 1200
New Jersey Avenue, SE., Washington, DC 20590, telephone (202) 493-6047.
SUPPLEMENTARY INFORMATION: The overall safety of railroad operations
has improved in recent years. However, recent fatal events highlight
the need for the railroad industry to refocus its attention on
compliance with safety rules and procedures that apply to employees
who, in the course of their work, place themselves between rolling
equipment. The railroad industry has long recognized that employees
whose responsibilities necessitate physically placing themselves
between rolling equipment, as often occurs during switching operations,
must take adequate safety precautions and be alert and aware of their
surroundings at all times. Consequently, railroads developed rules and
procedures designed to ensure the safety of employees when between
rolling equipment.
In 1998, the industry recognized a troubling increase in the number
of employee fatalities occurring during switching operations, including
incidents of employees effectively being crushed between rolling
equipment. At FRA's request, a voluntary group comprised of industry
stakeholders was formed to examine and address that trend of increasing
deaths. The group included representatives from the Association of
American Railroads (AAR), the American Short Line and Regional Railroad
Association (ASLRRA), the Brotherhood of Locomotive Engineers and
Trainmen (BLET), the United Transportation Union (UTU), and FRA. The
group was later named the Switching Operations Fatality Analysis (SOFA)
Working Group. In October 1999, the Working Group issued a report
titled ``Findings and Recommendations of the SOFA Working Group.'' The
report can be found on FRA's Web site at http://www.fra.dot.gov/Pages/1781.shtml.\1\ The report contains five major findings with an
accompanying recommendation and discussion for each finding. The first
of these five recommendations is directly applicable to situations
where employees go between rolling equipment, or otherwise foul track
or equipment. That recommendation reads as follows:
\1\ More recently, in March 2011, the SOFA Working Group issued
a report titled ``Findings and Advisories of the SOFA Working
Group,'' available online at: http://www.fra.dot.gov/rrs/pages/fp_Findings%20and%20Advisories.shtml.
Any crew member intending to foul track or equipment must notify
the locomotive engineer before such action can take place. The
locomotive engineer must then apply locomotive or train brakes, have
the reverser centered, and then confirm this action with the
individual on the ground. Additionally, any crew member that intends
to adjust knuckles/drawbars, or apply or remove EOT device, must
insure that the cut of cars to be coupled into is separated by no
less than 50 feet. Also, the person on the ground must physically
inspect the cut of cars not attached to the locomotive to insure
that they are completely stopped and, if necessary, a sufficient
number of hand brakes must be applied to insure the cut of cars will
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not move.
Many railroads have procedures similar to those described in this
SOFA recommendation, and other railroads have adopted or modified their
procedures to be utilized when going between rolling equipment to
reflect this recommendation.
When the pre-SOFA, 9-year period (1992-2000) is compared with the
post-SOFA, 9-year period (2001-2009), the industry realized a 60-
percent reduction (15 vs. 6) in the number of employees killed when
working between rolling equipment. Unfortunately, this positive trend
has not continued. Within the last 10 weeks, the railroad industry has
experienced three employee fatalities that have occurred when employees
were between rolling equipment. In addition to these most recent
fatalities, over the last 2 years, two additional employee fatalities
have occurred when employees were between rolling equipment. This rise
in employee fatalities as a result of being crushed between rolling
equipment suggests a need to remind railroads and their employees of
the critical importance of maintaining and abiding by railroad rules
and procedures designed to ensure safety when going between rolling
equipment.
The following is an overview of the circumstances surrounding these
recent fatal incidents. Information regarding the three most recent
incidents is based on FRA's preliminary investigation findings as the
probable causes and or contributing factors of these incidents have not
yet been established. Accordingly, nothing in this safety advisory is
intended to attribute a definitive cause to these incidents, or place
responsibility for the incidents on the acts or omissions of any person
or entity.
Recent Incidents
The most recent incident occurred on September 8, 2011. At
approximately 5:15 a.m., a single helper locomotive had coupled to the
rear of a standing 125-car train with the intent of assisting the
train's movement up an ascending grade. At some point, the movement
stopped and the conductor of the single helper locomotive detrained and
separated his locomotive from the train he and his engineer had
assisted. After the separation, the conductor of the single helper
locomotive reattached the end of train device to the last car of the
assisted train, and announced to the crew of that train that he had
finished his tasks. He then began to walk back to his locomotive.
Shortly thereafter, the slack on the assisted train adjusted and the
conductor was crushed between the rear car of the assisted train and
his locomotive. The deceased was 59 years old with 5 years of railroad
experience.
On August 15, 2011, at approximately 1:30 p.m., a three-
person remote control locomotive (RCL) crew consisting of a foreman, a
helper, and a trainee entered a track in a bowl yard from the east and
coupled onto a cut of cars. The foreman and the trainee boarded the
locomotive to provide point protection and the helper, using his remote
control transmitter, began stretching the cars eastward to identify
gaps created by uncoupled blocks of cars. As the gaps were revealed,
the helper repeatedly entered the space between the blocks of cars and
made adjustments to knuckles and/or drawbars. Using his remote control
transmitter, he then shoved the cars attached to the locomotive
westward to couple the cars before continuing the process. The last
time the helper went into a gap to adjust the knuckles and/or drawbars,
the cars attached to the locomotive moved west and crushed the helper
between the cars being coupled. The deceased was 52 years old and had
approximately 17 years of railroad experience.
On July 25, 2011, at approximately 12:30 a.m., a two-
person RCL operation had shoved into a classification track and coupled
to the westernmost car on the track. The RCL conductor on the crew was
creating gaps in the cuts of cars (by pulling west) to adjust couplers
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and/or align drawbars with the intent of coupling the entire track of
28 cars and pulling it from the classification track. The conductor's
helper was riding on the locomotive to provide point protection. The
grade on the track was descending from east to west. During one such
operation, when the conductor opened a gap, the cars standing to the
east of him rolled westward into the cars attached to the locomotive,
crushing the conductor. The deceased was 33 years old and had
approximately 3[frac12] years of railroad experience.
On July 13, 2010, at approximately 1:30 a.m., a switching
crew was performing a conventional flat, switching operation on a lead
track. After separating a cut of cars, the conductor entered the space
between the cars attached to his locomotive and those that he had just
cut away from in order to make an adjustment to a coupler. He was
crushed between the cars still attached to his locomotive and the cut
of cars the crew had just cut away from. The deceased was 35 years old
and had approximately 6 years of railroad experience.
On May 10, 2009, at approximately 6:40 p.m., a remote
control locomotive operator (RCO) was working in a bowl track, coupling
railroad cars together for placement on a departure track. The RCO
created gaps in the cuts of cars to adjust couplers and/or align
drawbars, and then coupled the cars attached to the locomotive to the
cars left standing. The RCO also replaced a knuckle on one of the cars
he intended to couple. The RCO went in between the cars to adjust the
knuckle he had just installed, and was crushed between equipment when
the drawbars bypassed. The deceased employee was 33 years old and had
approximately 8 years of railroad experience. The National
Transportation Safety Board (NTSB) investigated this incident and cited
the deceased employee's loss of situational awareness when he stepped
between moving equipment in violation of the railroad's safety rules as
a probable cause of the incident.
FRA understands that multiple factors typically contribute to fatal
events. Three of the five cases outlined above involved remote control
locomotive operations, and in all three cases, the fatally injured
employee was in control of the movement at the time of the incident.
The fact that RCLs were in use in three incidents does not appear to
have any bearing on the events. In the 2010 conventional switching
incident there appears to have been no radio transmissions made
announcing that the employee on the ground was going between cuts of
cars. In the most recent event, it appears there may not have been
sufficient distance between the rolling equipment the employee went
between.
Each of the above described events, however, demonstrate one
consistency--the employees involved either did not have enough room or
time to avoid the moving equipment, or were unaware that any equipment
they were working with was in motion. These incidents suggest that
existing railroad rules governing going between rolling equipment may
not have been fully complied with, and also potentially indicate a loss
of situational awareness by the employees involved, as well as
inadequate management oversight of safety rules compliance by
employees.\2\
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\2\ FRA published Safety Advisory 2010-03 (75 Fed. Reg. 63893
(Oct. 18, 2010)), titled ``Staying Alert and Situational
Awareness,'' in response to railroad incidents where employees were
killed. In addition to the recommendations made in this Safety
Advisory 2011-02, FRA encourages railroads to review those
recommendations previously made in Safety Advisory 2010-03 as well.
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Railroad operating employees work in an environment which is, by
nature, often absent direct management oversight. As the above examples
indicate, even slight lapses in rules compliance and situational
awareness can lead to tragedy. Without a strong sense of personal
responsibility for one's own safety, employees can become complacent
and a danger to themselves or other crewmembers. A culture of
performing each task safely and as instructed in training must be
reinforced not only by management, but by senior, more experienced
employees as well. Good workplace habits should be passed along, while
questionable work practices should be identified and re-evaluated as
newer employees are brought into the railroad workforce. At the same
time, railroad management must positively reinforce the need for
employees to perform their tasks safely and in accordance with
established rules and procedures, and as operations change, management
must review existing rules and procedures to ensure that the relevant
safety risks of the operating environment are addressed, and that
employees are appropriately trained. Moreover, railroad management must
eliminate the pressures that it places on employees to expedite train
and yard movements as such pressures can negatively impact an
employee's ability and desire to perform their assigned task safely.
The discussion contained in this safety advisory is not intended to
place blame on or assign responsibility to individuals or railroads,
but to emphasize the fact that a robust culture of operating and safety
rules compliance is everyone's job. Too often, it is not until after an
incident has occurred that railroad management, labor, and regulators
fully realize that dangerous work habits were formed and those routine
behaviors have not been properly addressed. Support from railroad
management and peer pressure from fellow employees encouraging
individuals to perform each task in a safe manner via the proper
procedures will help railroad employees maintain responsibility for
their own safety.
Recommended Railroad and Railroad Employee Action: In light of the
above discussion, and in an effort to maintain a heightened sense of
safety vigilance among railroad employees who place themselves between
pieces of rolling equipment, FRA recommends that railroads:
(1) Review current operating and safety rules that specifically
address both remote control locomotive and conventional switching
operations that require employees to go between rolling equipment, and
determine whether those rules provide adequate protection to employees,
or need to be updated or revised.
(2) Develop, implement, and monitor sound communication protocols
that require employees on multi-person switch crews to notify their
fellow crewmembers when the need arises to enter between two pieces of
rolling equipment--regardless of whether the employee is the primary
RCO or working on a conventional crew.
(3) Review the SOFA Safety Recommendation 1, Adjusting
Knuckles, Adjusting Drawbars, and installing End of Train Devices,
reproduced above, and communicate its procedures implementing that
recommendation to employees working in yards or other locations where
the possibility of entering between rolling equipment exists.
(4) Convey to employees that their own personal safety is their
responsibility and that railroad management supports and encourages
those employees that make safety their number one priority, regardless
of their immediate assignment.
(5) Convey to employees that they should encourage fellow employees
to perform their tasks safely and in compliance with established
railroad rules and procedures.
FRA encourages railroad industry members to take action that is
consistent with the preceding recommendations, and to take other
complimentary actions to help ensure the safety of the Nation's
railroad employees. FRA may modify this Safety Advisory 2011-02, issue
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additional safety advisories, or take other appropriate actions
necessary to ensure the highest level of safety on the Nation's
railroads, including pursuing other corrective measures under its rail
safety authority.
Issued in Washington, DC, on October 5, 2011.
Joseph C. Szabo,
Administrator.
[FR Doc. 2011-26283 Filed 10-7-11; 8:45 am]
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