[Federal Register Volume 75, Number 200 (Monday, October 18, 2010)]
[Notices]
[Pages 63893-63895]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 2010-26089]
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DEPARTMENT OF TRANSPORTATION
Federal Railroad Administration
Safety Advisory 2010-03
AGENCY: Federal Railroad Administration (FRA), Department of
Transportation (DOT).
ACTION: Notice of Safety Advisory; staying alert and situational
awareness.
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SUMMARY: 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.
FOR FURTHER INFORMATION CONTACT: 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: 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
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
[[Page 63894]]
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.\1\
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\1\ BNSF has an operating rule that requires the horn to be
sounded when approaching engineering department employees and their
related equipment.
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(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
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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.
Jo Strang,
Associate Administrator for Railroad Safety/Chief Safety Officer.
[FR Doc. 2010-26089 Filed 10-15-10; 8:45 am]
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