
[Federal Register Volume 78, Number 86 (Friday, May 3, 2013)]
[Notices]
[Pages 26110-26112]
From the Federal Register Online via the Government Printing Office [www.gpo.gov]
[FR Doc No: 2013-10545]


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

DEPARTMENT OF TRANSPORTATION

Federal Railroad Administration

[Safety Advisory 2013-03]


Kicking Cars and Going Between Rolling Equipment During Flat 
Switching Operations

AGENCY: Federal Railroad Administration (FRA), Department of 
Transportation (DOT).

ACTION: Notice of Safety Advisory.

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

SUMMARY: A fatality occurred during a railroad switching operation that 
involved a railroad employee kicking cars and subsequently going 
between rolling equipment. In response, FRA is publishing this Safety 
Advisory 2013-03 to make recommendations to railroads regarding the 
adoption of car-handling procedures during flat switching operations at 
certain locations and to re-emphasize the importance of following 
procedures when going between rolling equipment due to the hazards 
involved. FRA previously made related recommendations to railroads and 
their employees regarding going between rolling equipment in Safety 
Advisory 2011-02.

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; 
Douglas H. Taylor, Staff Director, Operating Practices Division, Office 
of Safety Assurance and Compliance, FRA, 1200 New Jersey Avenue SE., 
Washington, DC 20590, telephone (202) 493-6255; 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, in July 2012, a fatal event 
occurred during a switching operation which involved a railroad 
employee going between rolling equipment after kicking \1\ two loaded 
tank cars up a 0.2-percent ascending grade. This 2012 incident 
illustrates the safety risks that are present when railroads allow the 
kicking of cars in flat switching operations at locations where the 
cars will likely roll back out toward the employees conducting such 
operations if the cars do not couple to secured standing equipment as

[[Page 26111]]

intended. This incident also highlights the need for the railroad 
industry to again focus its attention on compliance with safety rules 
and procedures that apply to employees who, in the course of their 
work, must place themselves between rolling equipment.
---------------------------------------------------------------------------

    \1\ As referenced in 49 CFR 218.99(a)(2), kicking cars refers to 
the common railroad switching practice of shoving or pushing rolling 
equipment and then uncoupling the equipment and allowing it to roll 
free.
---------------------------------------------------------------------------

    As background, FRA previously published a safety advisory regarding 
the importance of following procedures when going between rolling 
equipment. Safety Advisory 2011-02 \2\ was issued in response to a 
series of fatal switching accidents that also involved employees 
placing themselves between rolling equipment. As discussed in that 
safety advisory, FRA previously established a group of industry 
stakeholders to examine and address a past trend of increasing deaths 
occurring during railroad switching operations. The group included 
representatives from both industry and labor organizations, and was 
named the Switching Operations Fatality Analysis (SOFA) Working Group. 
In 1999, the SOFA Working Group issued a report that contained five 
major findings with an accompanying recommendation and discussion for 
each finding.\3\ 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:

    \2\ 76 FR 62894 (Oct. 11, 2011).
    \3\ See ``Findings and Recommendations of the SOFA Working 
Group''; available online at: http://www.fra.dot.gov/eLib/details/L03078. 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/eLib/details/L03071.

    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 
---------------------------------------------------------------------------
not move. [Emphasis added]

    Most 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 
respond to this recommendation. However, as discussed further below, in 
flat switching operations where cars are kicked into a coupling rather 
than shoved, it may be more difficult for railroad employees engaged in 
such operations to make the determination that cars not attached to the 
locomotive are stopped and secured in compliance with this SOFA 
recommendation. That difficulty in making the determination that cars 
are stopped and secured is heightened at locations where grade or other 
conditions can cause kicked cars to roll back out towards crews 
conducting switching operations, and correspondingly can lead to 
increased safety risks when employees then have to place themselves 
between rolling equipment.

Incident Summary

    As noted above, Safety Advisory 2011-02 discussed the circumstances 
surrounding five switching fatalities that occurred between 2009 and 
2011. The following is an overview of the circumstances surrounding the 
most recent fatal switching incident that occurred in July 2012. 
Information regarding this incident is based on FRA's preliminary 
investigatory findings. The probable cause of this incident has not yet 
been established. Accordingly, nothing in this safety advisory is 
intended to attribute a definitive cause to this incident, or place 
responsibility for the incident on the acts or omissions of any 
specific person or entity.
     On July 31, 2012, at approximately 2:30 a.m., a 
conventional three-person crew, consisting of an engineer, a footboard 
yardmaster, and a conductor/switchman (switchman) were conducting 
switching operations. The crew kicked--rather than shoved--two loaded 
tank cars southward into a yard track with the goal of coupling them to 
other cars that had been previously placed into the yard track and 
secured. The yard track had a 0.2-percent ascending grade (southward). 
The switchman had originally positioned himself to verify that the cars 
kicked into the track coupled to the standing equipment. However, after 
the footboard yardmaster was not able to uncouple the cars and kick 
them into the track, he shoved the cars toward the switchman's location 
so that the switchman could make the cut and kick the cars into the 
standing equipment. After the two tank cars were kicked into the yard 
track by the switchman, he noticed that the knuckle on the last car of 
the block of cars still attached to the crew's locomotive had fallen to 
the ground and needed to be reinserted. The switchman then informed the 
crew that the knuckle pin was missing. Following applicable railroad 
rules, prior to reinserting and adjusting the knuckle, the switchman 
first requested and received ``Red Zone'' protection. However, the two 
loaded tank cars that had previously been kicked into the yard track 
did not couple to the standing cars on that track as intended, and the 
uncoupled cars rolled back northward. As the switchman adjusted the 
knuckle, the two loaded tank cars struck him and the standing equipment 
attached to the locomotive. The conductor sustained fatal injuries.

    In the incident discussed above, the switchman did not physically 
inspect the cut of cars to verify that they were stopped and secured 
prior to going between them and the cars still attached to the 
locomotive. Further, because the tank cars were kicked toward the 
standing equipment rather than shoved into a coupling, and, thus, not 
stretched as is standard railroad operating practice to ensure that a 
coupling is made, it may have been more difficult for the switchman to 
ascertain whether the cars had coupled. These factors became 
particularly significant because the switching operation occurred on a 
track with a 0.2-percent grade, and because the sloshing action that 
typically occurs in loaded tank cars can cause the cars to roll in the 
opposite direction after they have stopped. Environmental factors such 
as the time of day (light) and noise interference from a refrigerated 
car standing approximately 50 feet away from the incident location on 
an adjacent track may have also interfered with the employee's ability 
to see and hear the two approaching free rolling tank cars. In 
addition, during flat switching operations when cars are kicked into a 
coupling, and, thus, have to roll free for a certain distance, 
employees are often physically located farther from the location where 
a coupling is to be made than if the cars are shoved into a coupling, 
dependent on the number of cars to be cut off and distance that the 
cars have to travel into a track. The farther an employee is from the 
location of an intended coupling, the more difficult it may be to make 
a proper determination that cars are stopped and secured.

    As a result, in such situations, it is imperative that railroad 
employees adhere to--and the railroads require--verification that the 
cars the employees go between are completely stopped, and, if 
necessary, secured with handbrakes. Depending on a track's grade and 
the type of equipment being switched, kicking cars rather than shoving 
them into a coupling increases

[[Page 26112]]

safety risks because if the kicked cars fail to couple, there is a 
likelihood that the equipment may roll backward toward employees who 
have to place themselves between rolling equipment in the course of 
conducting switching operations. Thus, one of FRA's recommendations 
below is that railroads adopt procedures to prohibit crews from kicking 
cars in flat switching operations at locations where the physical 
characteristics make it likely that such cars will roll back out toward 
the crew if a proper coupling is not made.
    The discussion contained in this safety advisory is not intended to 
place blame on or assign responsibility to individuals or railroads, 
but rather to emphasize the fact that a culture of safety and rules 
compliance is everyone's responsibility. FRA encourages railroad 
management to adopt and adhere to policies that promote the safest 
course of action in conducting switching operations, particularly by 
taking into account unique characteristics that exist at different 
locations when adopting those policies. Further, a culture of 
performing each task safely and as instructed in training in accordance 
with applicable railroad operating rules must be reinforced not only by 
management, but by railroad employees as well. Railroad management must 
positively reinforce, via job briefings and other appropriate means, 
safe job performance in accordance with established rules and 
procedures. Support from railroad management and positive peer pressure 
from fellow railroad 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 Action: In light of the above discussion, and 
in an effort to maintain a heightened sense of vigilance among 
railroads and their employees who conduct switching operations, FRA 
recommends that railroads:
    (1) Review with their employees the circumstances of the fatal 
incident described in this Safety Advisory 2013-03.
    (2) Evaluate locations where flat switching operations are 
conducted and identify those where the physical characteristics and the 
types of cars being switched heighten the possibility that cars will 
roll out toward the employees conducting such operations. After 
identifying such locations, FRA recommends that railroads adopt 
procedures requiring that cars be shoved into couplings rather than 
kicked during such operations in an effort to lessen the potential 
safety risks, particularly when employees have to go between equipment.
    (3) Review with their employees, including management employees, 
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. FRA recommends that 
railroads place emphasis on the portion of SOFA Safety Recommendation 
1 discussing the need to ensure that equipment not attached to 
the locomotive is stopped, and is secured with handbrakes when 
necessary, before employees go between rolling equipment. Inherent in 
complying with SOFA Safety Recommendation 1 is recognition of 
the physical characteristics of the track on which switching operations 
are being conducted and the rolling characteristics of the type of 
equipment being switched, particularly as related to the handling of 
loaded tank cars.
    (4) Re-emphasize the recommendations contained in previous Safety 
Advisory 2011-02 with all of their employees, including railroad 
management.
    FRA encourages railroad industry members to take actions that are 
consistent with the preceding recommendations, and to take other 
complementary actions to help ensure the safety of the Nation's 
railroad employees. FRA may modify this Safety Advisory 2013-03, 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 April 29, 2013.
Joseph C. Szabo,
Administrator.
[FR Doc. 2013-10545 Filed 5-2-13; 8:45 am]
BILLING CODE 4910-06-P


