
[Federal Register: October 18, 2010 (Volume 75, Number 200)]
[Notices]               
[Page 63893-63895]
From the Federal Register Online via GPO Access [wais.access.gpo.gov]
[DOCID:fr18oc10-125]                         

-----------------------------------------------------------------------

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.

-----------------------------------------------------------------------

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\
---------------------------------------------------------------------------

    \1\ BNSF has an operating rule that requires the horn to be 
sounded when approaching engineering department employees and their 
related 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

[[Page 63895]]

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]
BILLING CODE 4910-06-P

