Safety Advisory 2010-03
Notice Of Safety Advisory; Staying Alert And Situational Awareness.
FRA is issuing Safety Advisory 2010-03 to remind railroads and their employees of the importance of situational awareness and the need to stay alert whenever the job that is being performed changes, particularly in main track territory. This safety advisory contains various recommendations to railroads to ensure that these issues are addressed by appropriate policies and procedures.
Table of Contents Back to Top
FOR FURTHER INFORMATION CONTACT: Back to Top
Ronald Hynes, Director, Office of Safety Compliance and Assurance, 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) 493-6052.
SUPPLEMENTARY INFORMATION: Back to Top
The overall safety of railroad operations has improved in recent years. However, a series of events over the past 24 months highlight the need to review current railroad procedures and practices. This safety advisory emphasizes the need for railroads to review and update their current procedures relating to situational awareness, alertness when working on or near main tracks, and job briefings whenever there is a change in situation.
Recent Incidents Back to Top
The following is a discussion of the circumstances surrounding a recent fatal incident, and is based only on FRA's preliminary investigation. The accident is still under investigation by FRA and local authorities. The causes and contributing factors, if any, have not yet been established. Therefore, nothing in this safety advisory is intended to attribute a cause to the incident or place responsibility for the incident on the acts or omissions of any person or entity.
The fatal incident occurred on September 1, 2010, at approximately 6:50 a.m., in Coon Rapids, Minnesota, on the BNSF Railway's (BNSF) Twin Cities Division, Staples Subdivision, in double-main track territory. The incident occurred when a westbound BNSF track geometry train stopped on Main Track #1 just west of Egrett Boulevard, a public highway-rail grade crossing equipped with flashers and gates, to allow a BNSF roadmaster (track supervisor) to disembark from the geometry car. The roadmaster stepped off the rear (east) end of the geometry car on the field side of Main Track #1 and onto the highway-rail grade crossing. As the geometry train resumed movement west, the roadmaster walked perpendicularly across the crossing, toward a BNSF vehicle parked on the opposite side of the crossing that was waiting to pick him up. As he did so, he stepped into the path of an oncoming passenger train traveling east on adjacent Main Track #2 at 79 mph, and was struck and killed. The roadmaster was a 53-year-old employee with 31 years of railroad service.
FRA is investigating a number of potential factors that may have been involved in this fatal event. FRA is determining whether any of these factors, or any other factors it may discover, worked to drastically change the roadmaster's job situation when he alighted from the geometry car, or provided a false sense of security regarding the conditions at the crossing. Some of these factors include:
(1) The potential distraction caused by the paperwork the roadmaster was holding.
(2) The location of the involved crossing in a “quiet zone.” Consequently, the striking passenger train was not required to sound its horn at the grade crossing where the incident occurred.
(3) Whether the locomotive engineer of the passenger train was aware that he or she was passing maintenance-of-way equipment. 
(4) The view afforded the roadmaster of adjacent Main Track #2, to the west, as the geometry train departed in that direction.
(5) The location of the BNSF vehicle the roadmaster was walking toward.
(6) The affect of the active warnings displayed by the warning devices at Egrett Boulevard.
Subsequent to the incident discussed above, BNSF conducted an incident briefing with all of their employees, specifically reminding the employees that fouling track during work, or incidental fouling for crossing over a track, can never be taken as a routine matter. Additionally, the briefing addressed several existing BNSF operating rules mandating that employees be alert and attentive to their duties, be alert to potential train movements, and take proper precautions when fouling tracks, including incidental fouling when walking across tracks when protection has not been provided. FRA fully supports these rules and applauds BNSF for taking the initiative to remind all of its employees of the dangers inherent when fouling tracks. FRA believes the foremost obligation of each employee, with regard to his or her own personal safety, is individual awareness and accountability.
FRA notes that there have been other recent incidents in which railroad employees have been killed and injured after potentially becoming distracted or unaware of changing job situations. For instance:
(1) In 2008, an incident occurred when a two-person train crew, after reaching their destination, was instructed to secure their freight train at a location beyond their normal crew change point. The location was on double-main track on a bridge near a parking lot where a relief crew could reach the train. The conductor left the cab of the locomotive to tie hand brakes in order to secure the train, but appears to have done so without performing a job briefing with the engineer and without taking his hand-held radio. He crossed in front of the locomotive and walked across the bridge between the two tracks. An eastward train, approaching at 26 mph, observed the conductor in the foul, sounded its whistle, turned the locomotive's headlights to bright, and tried to stop. However, the eastward train struck and killed the conductor.
(2) In 2008, a track gang and a contractor were working together and walking track along the right-of-way on the Northeast Corridor. Periodically, the gang would request and receive “foul time” to do closer inspections. Sometime before the incident, the foul time was cancelled and acknowledged. Shortly thereafter, an Amtrak train passed into the area and struck three of the track workers and killed the contractor.
(3) In 2009, a four-person yard switching crew was pulling cars up a switching lead to make a shoving movement into a yard track while a road train was approaching in the same direction on the main track adjacent to the switching lead. The conductor riding the second locomotive of the yard switcher exited the cab and got off the train on the “live” side next to the main track, actually fouling the main track. He was subsequently struck and killed by the train operating on the main track.
The employees in the above-listed incidents were all familiar with operating and safety rules, yet in each case, the employees' situational awareness seems to have been degraded. FRA believes that employee alertness to changing job situations could have been heightened in these situations by the act of engaging in additional job briefings. As the railroad industry is well aware, a job briefing should take place at the beginning of a task and anytime the task changes. Railroad operating rules and certain Federal railroad safety regulations require that these job briefings take place. The job briefing can act, particularly when there is more than one person involved with the task, as a “time out,” so to speak, for the affected employees to reinforce the need to exercise vigilance and awareness in the performance of their tasks.
FRA also wishes to reiterate concerns previously expressed to the railroad industry in a letter dated January 26, 2010. In the present era of “instant communications and technology and information ‘overload,’ ” railroad employees need to maintain complete situational awareness and avoid distractions. Railroad employees should keep cell phones and other distracting devices turned off and focus their full attention on the task at hand. As the above examples indicate, even slight lapses in situational awareness can lead to tragedy.
Recommended Action: In light of the above discussion, and in an effort to maintain the safety of railroad employees on the Nation's rail system, FRA recommends that railroads:
(1) Develop processes that promote safety mentoring of fellow workers regardless of their titles or positions.
(2) Develop procedures that address the need for dialogue between coworkers when exiting equipment near tracks or moving equipment.
(3) Review their current process regarding job briefings and determine best practices that encourage constant communication about the activities at hand.
(4) Assess their current rules addressing personal safety and employee behavior when on or near tracks, with particular emphasis on main tracks.
(5) Review current rules pertaining to activities that could cause employees to become distracted, including rules pertaining to the use of electronic devices, with the view of strengthening and expanding them to include all employees when they are on or near tracks.
(6) Review current rules pertaining to sounding the locomotive horn, with the view of requiring the horn to be sounded when approaching and passing standing trains, especially at or near grade crossings, regardless of whether such crossings are located in quiet zones.
FRA encourages railroad industry members to take action consistent with the preceding recommendations and to take other actions to help ensure the safety of the Nation's railroad employees. FRA may modify this Safety Advisory 2010-03, issue 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 12, 2010.
Associate Administrator for Railroad Safety/Chief Safety Officer.
[FR Doc. 2010-26089 Filed 10-15-10; 8:45 am]
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