U.S. Department of 

Transportation 

Federal Railroad 

Administration

A Pilot Examination of a Joint Railroad 

Management-Labor Approach to Root Cause 

Analysis of Accidents, Incidents, and Close Calls 

in a Diesel and Car Repair Shop Environment 

Office of Research 

and Development 

Washington, DC 20590 

DOT/FRA/ORD-06/24 Final Report 

November 2006 

This document is available to the 

U.S. public through the National 

Technical Information Service, 

Springfield, VA 22161. 
NOTICE 

This document is disseminated under the sponsorship of the 

Department of Transportation in the interest of information 

exchange. The United States Government assumes no liability for 

its contents or use thereof. 

NOTICE 

The United States Government does not endorse products or 

manufacturers. Trade or manufacturers’ names appear herein 

solely because they are considered essential to the objective of this 

report. 

 
iii

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 June 2003–November 2005 

4. TITLE AND SUBTITLE

A Pilot Examination of a Joint Railroad Management-Labor Approach to Root Cause Analysis 

of Accidents, Incidents, and Close Calls in a Diesel and Car Repair Shop Environment 

6. AUTHOR(S)

Alex Viale and Stephen Reinach 

5. FUNDING NUMBERS 

7. PERFORMING ORGANIZATION NAME(S) AND ADDRESS(ES)

Foster-Miller, Inc. 

350 Second Avenue 

Waltham, MA 02451-1196 

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DFRA.010350 

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U.S. Department of Transportation 

Federal Railroad Administration 

Office of Research and Development 

1120 Vermont Ave. NW MS-20 

Washington, DC 20590 

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 AGENCY REPORT NUMBER

DOT/FRA/ORD-06/24

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COTR: Dr. Thomas Raslear 

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This document is available to the public through the National Technical Information Service, 

Springfield, VA 22161, and at www.fra.dot.gov. 

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13. ABSTRACT

This report presents findings from a 1-year pilot study investigating the feasibility and practicality of a joint railroad managementlabor approach to root cause analysis (RCA) of accidents, incidents, and close calls in a diesel and car repair shop environment. 

The primary objective of the study was to evaluate the value and utility of a joint railroad management-labor RCA process. 

Participating labor and management representatives identified seven RCA opportunities during the study period; however, only 

one was investigated. Participants identified a number of barriers that made it difficult for the project to succeed in its current 

form. Key barriers included a lack of study leadership; poor interaction and communication between labor and management 

participants and between participants and the employees involved in the accidents, incidents, and close calls; challenges with 

employee participation; perceived minimal opportunity to conduct RCA; and complexity of the RCA tools and process. 

Suggestions for future implementation addressed these barriers. The report discusses additional lessons learned and 

recommendations for any future implementation of a joint labor-management RCA process. The joint management-labor RCA 

process and tools should experience greater success once these barriers are addressed. 

15. NUMBER OF PAGES

81 

14. SUBJECT TERMS

Root cause analysis, accident/incident investigation, human error, diesel shop, car repair shop, 

railroad safety 16. PRICE CODE

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iv

METRIC/ENGLISH CONVERSION FACTORS 

ENGLISH TO METRIC METRIC TO ENGLISH

LENGTH (APPROXIMATE) LENGTH (APPROXIMATE) 

1 inch (in) = 2.5 centimeters (cm) 1 millimeter (mm) = 0.04 inch (in) 

1 foot (ft) = 30 centimeters (cm) 1 centimeter (cm) = 0.4 inch (in) 

1 yard (yd) = 0.9 meter (m) 1 meter (m) = 3.3 feet (ft) 

1 mile (mi) = 1.6 kilometers (km) 1 meter (m) = 1.1 yards (yd) 

 1 kilometer (km) = 0.6 mile (mi)

AREA (APPROXIMATE) AREA (APPROXIMATE) 

1 square inch (sq in, in2) = 6.5 square centimeters (cm2) 1 square centimeter (cm2) = 0.16 square inch (sq in, in2) 

1 square foot (sq ft, ft2) = 0.09 square meter (m2) 1 square meter (m2) = 1.2 square yards (sq yd, yd2) 

1 square yard (sq yd, yd2) = 0.8 square meter (m2) 1 square kilometer (km2) = 0.4 square mile (sq mi, mi2) 

1 square mile (sq mi, mi2) = 2.6 square kilometers (km2) 10,000 square meters (m2) = 1 hectare (ha) = 2.5 acres 

1 acre = 0.4 hectare (he) = 4,000 square meters (m2) 

MASS - WEIGHT (APPROXIMATE) MASS - WEIGHT (APPROXIMATE) 

1 ounce (oz) = 28 grams (gm) 1 gram (gm) = 0.036 ounce (oz) 

1 pound (lb) = 0.45 kilogram (kg) 1 kilogram (kg) = 2.2 pounds (lb) 

1 short ton = 2,000 pounds 

(lb) 

= 0.9 tonne (t) 1 tonne (t) =

=

1,000 kilograms (kg) 

1.1 short tons

VOLUME (APPROXIMATE) VOLUME (APPROXIMATE) 

1 teaspoon (tsp) = 5 milliliters (ml) 1 milliliter (ml) = 0.03 fluid ounce (fl oz) 

1 tablespoon (tbsp) = 15 milliliters (ml) 1 liter (l) = 2.1 pints (pt) 

1 fluid ounce (fl oz) = 30 milliliters (ml) 1 liter (l) = 1.06 quarts (qt) 

1 cup (c) = 0.24 liter (l) 1 liter (l) = 0.26 gallon (gal) 

1 pint (pt) = 0.47 liter (l) 

 1 quart (qt) = 0.96 liter (l) 

1 gallon (gal) = 3.8 liters (l) 

1 cubic foot (cu ft, ft3) = 0.03 cubic meter (m3) 1 cubic meter (m3) = 36 cubic feet (cu ft, ft3) 

1 cubic yard (cu yd, yd3) = 0.76 cubic meter (m3) 1 cubic meter (m3) = 1.3 cubic yards (cu yd, yd3)

TEMPERATURE (EXACT) TEMPERATURE (EXACT) 

[(x-32)(5/9)] °F = y °C [(9/5) y + 32] °C = x °F

QUICK INCH - CENTIMETER LENGTH CONVERSION

0 1 2 34 5

Inches

Centimeters 01 3 2 6 11 4 5 7 13 8 9 10 12

QUICK FAHRENHEIT - CELSIUS TEMPERATURE CONVERSION

 -40° -22° -4° 14° 32° 50° 68° 86° 104° 122° 140° 158° 176° 194° 212°

 

°F

 °C -40° -30° -20° -10° 0° 10° 20° 30° 40° 50° 60° 70° 80° 90° 100°

For more exact and or other conversion factors, see NIST Miscellaneous Publication 286, Units of Weights and 

Measures. Price $2.50 SD Catalog No. C13 10286 Updated 6/17/98
v

Contents 

Illustrations .................................................................................................................................... vi 

Tables............................................................................................................................................. vi 

Preface........................................................................................................................................... vii 

Executive Summary........................................................................................................................ 1 

1. Introduction ................................................................................................................. 7 

1.1 Background ................................................................................................................. 7 

1.2 Objectives.................................................................................................................... 8 

1.3 Overall Approach ........................................................................................................ 8 

1.4 Scope ........................................................................................................................... 9 

1.5 Organization of the Report .......................................................................................... 9 

2. Methods..................................................................................................................... 11 

2.1 RCA........................................................................................................................... 11 

2.2 HFACS ...................................................................................................................... 12 

2.3 HFACS-RR ............................................................................................................... 14 

2.4 Development of RCA Tools...................................................................................... 17 

2.5 Stakeholder Meeting.................................................................................................. 21 

2.6 Study Participant Training......................................................................................... 21 

2.7 Data Collection Procedures ....................................................................................... 21 

3. Results ....................................................................................................................... 23 

3.1 Accidents, Incidents, and Close Calls ....................................................................... 23 

3.2 Barriers to Implementation and Suggestions for Future Implementation ................. 24 

4. Key Findings, Lessons Learned, and Recommendations for Future Research......... 29 

4.1 Key Findings ............................................................................................................. 29

4.2 Additional Lessons Learned...................................................................................... 30 

4.3 Recommendations for Future Implementation of a 

Joint Labor-Management RCA Process.................................................................... 31 

4.4 Conclusions ............................................................................................................... 32 

5. References ................................................................................................................. 33 

Appendix A. Data Collection Checklist....................................................................................... 35

Appendix B. Interview Questions................................................................................................ 37 

Appendix C. HFACS-RR Flowcharts.......................................................................................... 45 

Appendix D. HFACS-RR Worksheet.......................................................................................... 51 

Appendix E. Corrective Actions Guide ....................................................................................... 57 

Appendix F. Incident Report Form.............................................................................................. 67 

Appendix G. Post-Study Feedback Questions............................................................................. 71 

Abbreviations and Acronyms ....................................................................................................... 73 
vi

Illustrations 

Figure 1. Original HFACS Taxonomy ........................................................................................ 13 

Figure 2. HFACS-RR .................................................................................................................. 16 

Figure 3. HFACS-RR Flow of Influence..................................................................................... 17 

Figure 4. Pilot Study Flowchart................................................................................................... 19 

Tables 

Table 1. Original HFACS and New HFACS-RR Top-Level Categories .................................... 15 

Table 2. Results of HFACS-RR Analysis.................................................................................... 25 
vii

Preface 

This report presents the results of a 1-year pilot study aimed at outfitting railroad labor and 

management personnel with the training and materials necessary to enable them to conduct their 

own root cause analyses (RCA) of accidents, incidents, and close calls in a diesel and car repair 

shop setting. The goal of this exploratory research was to determine the feasibility of railroad 

labor and management jointly conducting their own RCA of accidents, incidents, and close calls 

using a set of data collection and analysis tools developed for this project. The study focused on 

determining the utility and value of the RCA approach and tools. 

This research was sponsored by the Federal Railroad Administration (FRA) Office of Research 

and Development Contract DTFR53-01-D-00029. The authors express thanks to Dr. Thomas 

Raslear, FRA Office of Research and Development Human Factors Program, for supporting this 

work. The authors also give special thanks to the representatives from the participating railroad 

and labor unions for their time and energy experimenting with a novel, joint approach to 

accident/incident investigation. Thanks, too, for their candid opinions regarding why this study 

was not successful in its current form and how to successfully implement any future joint labormanagement RCA initiatives. Lastly, the authors thank Ms. Judith Gertler and Ms. Susan 

McDonough for reviewing drafts of this manuscript and providing valuable feedback on its 

readability. 

1

Executive Summary 

Safety in the railroad industry has improved markedly over the last decade. According to recent 

Federal Railroad Administration (FRA) data, the total accident/incident rate in the railroad 

industry has fallen from 26.37 per million train miles (mtm) in 1996 to 17.39 in 2005.1 In 

addition, employee injuries (including fatal) have declined. FRA data indicate 9,199 railroad 

employees were injured while on duty and an additional 33 killed in 1996.2,3 By 2005, the 

number of employee-on-duty injuries had declined to 5,557, and fatalities totaled 25. Further 

analysis indicates, however, that while the total accident/incident rate and employee injuries have 

decreased, the number and rate of train accidents alone has increased over this time period. In 

1996, 2,443 train accidents (3.64 train accidents per mtm) occurred. In 2005, this number rose to 

3,152 (3.99 train accidents per mtm). 

One of the most effective means of reducing accidents/incidents and increasing safety is to 

understand the diverse set of contributing factors that allow an accident/incident to occur. This 

report describes the results of a 1-year (yr) pilot examination of a joint railroad managementlabor approach to root cause analysis (RCA) of accidents, incidents, and close calls in a railroad 

diesel and car repair shop environment. RCA is a systematic approach to accident, incident, and 

close call investigation that enables one or more individuals to identify individual, 

organizational, technological, and situational factors that contributed to each accident, incident, 

or close call. A guiding principle behind RCA is that a single event is not responsible for an 

accident, incident, or close call. Rather, multiple factors play a role in every accident, incident, 

and close call, and each factor is important to identify and understand as a means to mitigate 

future occurrences.

The research team chose the Human Factors Analysis and Classification System (HFACS) to 

provide the theoretical backbone to the RCA. HFACS has its basis in James Reason’s (1) 

generic error modeling system (GEMS) and (2) Swiss cheese model of accident causation 

(Reason, 1990). The Swiss cheese model depicts accidents as arising from holes in an 

organization’s defenses at various levels of the organization, beginning with the operator and 

working all the way up to organizational decisions and conditions. Active failures by the 

operator combine with latent conditions or factors upstream in the organization to lead to an 

accident (or incident or close call). Accidents (and incidents and close calls) occur, therefore, 

when all of the active and latent factors (i.e., holes) line up to allow accident energy 

(characterized as a straight line) to penetrate these various organizational levels. Accidents (and 

incidents and close calls) are prevented when an organization’s defenses and barriers prohibit the 

alignment of active and latent factors and conditions. 

HFACS has a logical structure and is a scientifically valid approach to human error. 

Furthermore, HFACS, as a classification system, is diagnostic, reliable, and comprehensive, 

 

1

 SOURCE: FRA Office of Safety data retrieved from 

http://safetydata.fra.dot.gov/OfficeofSafety/Query/Default.asp?page=statsSas.asp June 9, 2006. 

2

 Ibid. 

3

 SOURCE: FRA Office of Safety data retrieved from 

http://safetydata.fra.dot.gov/OfficeofSafety/Query/Default.asp?page=castab.asp June 9, 2006. 
2

according to its authors. This is critical since the taxonomy must accommodate a wide range of 

railroad operational situations and circumstances that can lead to accidents, incidents, and close 

calls. Wiegmann and Shappell initially developed HFACS for the aviation domain (2003). As a 

result, the research team made some minor changes to HFACS to optimize its relevancy to the 

railroad industry. The modified HFACS taxonomy has the label HFACS-RR (railroad). 

The primary objective of this research was to gain an understanding of the potential for railroads 

and labor to jointly conduct human factors-based RCA investigations of accidents, incidents, and 

close calls to uncover contributing factors at various levels of the railroad system. The focus of 

the project was on participant feedback on (1) implementation of the RCA method and tools and 

(2) the utility of the approach for the railroad industry in general. 

The specific objectives of this research project were to: 

• Assist the railroad industry in identifying contributing factors to accidents, incidents, and 

close calls beyond the employee. 

• Obtain industry and labor feedback on the value and utility of the RCA methods and 

tools. 

• Examine the usefulness of a modified version of HFACS in the railroad industry to 

support accident, incident, and close call investigations. 

Implementing a joint management-labor RCA process required a location where labor and 

management were co-located. The diesel and car repair shop operating environment was a 

candidate study environment because management and labor are co-located, and this 

environment hosts a variety of skilled craft workers, providing access to a variety of job types 

and numerous and varied work experiences throughout each day. 

The researchers invited representatives from several railroads and labor unions, as well as FRA, 

to participate in a stakeholder meeting in April 2004. Researchers shared and discussed project 

goals and methods at this informational meeting. One railroad and four labor unions 

subsequently agreed to participate in the pilot study. Each labor union identified one local 

member to participate in the study, while the railroad identified several candidates to support the 

project. 

Researchers developed a set of paper-based tools based on HFACS-RR to guide management 

and labor investigators through the data collection and analysis process. Foster-Miller conducted 

a 2-day (d) training session at the host railroad with management and labor representatives in 

November 2004. The training served to educate and familiarize participants (some of whom had 

not attended the stakeholder meeting) on the principles of RCA, the HFACS-RR taxonomy of 

human error, and the specific RCA tools and methodology for data collection and analysis. 

Candidate occurrences for RCA included all accidents, incidents, and close calls that took place 

in the diesel and car repair shop environment regardless of whether the event met FRA reporting 

criteria. The accident, incident, or close call had to occur in the diesel or car repair shop 

environment and involve a member of a participating union. Events where the Federal 

Employer’s Liability Act (FELA) might be involved were not candidates for study. 

The original methodology required one management and one labor representative to jointly 

conduct each RCA. The labor representative that participated in a particular RCA depended on 

who was involved in the accident, incident, or close call. For example, if a carman was involved 
3

in an accident, then a carman representative participated. If a sheet metal worker was involved, 

then a sheet metal worker representative participated. During the initial training, labor and 

management agreed to allow labor representatives to conduct each RCA on their own while 

management representatives would be available to assist as needed. 

The initial data collection period lasted 6 months (mo), from November 10, 2004, to May 10, 

2005. Because participants were able to conduct only one RCA in this time period, the data 

collection period was extended an additional 6 mo, to the end of November 2005. In the end, 

participants identified a total of 7 RCA opportunities during the 1-yr study period, but 

investigated only 1 incident using the RCA tools and method. One labor and one management 

representative jointly performed the single RCA. They identified five contributing factors 

associated with three of the five HFACS-RR levels. 

Midway through the study, it became clear a number of barriers were preventing successful 

implementation of the RCA process and tools. To identify these barriers, researchers conducted 

telephone interviews with participating management and labor representatives to obtain their 

feedback. The debriefing survey, a set of questions originally designed to obtain feedback at the 

end of the study on the utility and value of the RCA tools and process, helped tap into study 

barriers and solicit suggestions for future implementation. 

Key themes among barriers identified include the following: 

• Lack of leadership. Participants felt that labor and management lacked strong leadership 

to ensure the study’s success. 

• Poor interaction and communications. Participants noted that it was awkward to 

interview a co-worker as part of the RCA process. Participants also noted inadequate 

communication from some study participants to other diesel and car repair shop 

employees about the study, as well as from management to labor participants about the 

existence of accidents, incidents, or close calls. 

• Challenges associated with participation. Participants observed several barriers related 

to their own participation and that of employees involved in an accident, incident, or 

close call. Participants identified a lack of participant availability for one RCA and 

difficulty coordinating multiple participant and employee schedules to conduct RCAs. In 

addition, concern over management retribution was a factor for one labor representative 

participant who chose not to support the project after the training. The same concern was 

noted as a possible factor for why those involved in an accident, incident, or close call 

chose not to cooperate. Some felt that FELA may have contributed to low cooperation by 

employees involved in accidents, incidents, or close calls. 

• Perceived minimal opportunity to conduct RCA. Some perceived few opportunities to 

investigate accidents, incidents, or close calls due to the relatively safe diesel and car 

repair shop work environment. 

• Complex RCA tools and process. At least one participant felt that the RCA tools and 

method may be too complicated and the training insufficient, and that these may have 

hindered participation. 
4

Based on study participant feedback and pilot study experience, the researchers make the 

following recommendations to increase the likelihood of success of any future attempt at 

implementing a joint management-labor RCA process: 

• Expand study to all yard crafts. Any future study should be opened up to include the 

entire yard environment, including train and engine employees. This strategy will 

increase the number and types of opportunities to conduct RCA. This will require initial 

stakeholder buy-in from additional labor unions, such as the United Transportation Union 

and Brotherhood of Locomotive Engineers and Trainmen. 

• Draw on the railroad’s safety committee(s) to provide study participants, and use the 

safety committee venue to discuss, raise awareness of, and select RCAs to pursue. 

Incorporate the study as a task for the participating railroad’s safety committee(s) to take 

on. Safety committee members could serve as representative labor and management 

participants, and accidents, incidents, and close calls that are brought to the attention of 

the safety committee could serve as possible candidates for RCA. 

• Communicate information about the study to, and solicit cooperation from, all railroad 

employees. The participating railroad should increase communication to all yard 

employees about the study. The participating railroad might consider posting a general 

notice to all employees to: inform them about the project; ask employees to notify 

participating labor or management representatives about any accident, incident, or close 

call they were involved in; ask employees to cooperate in any RCA process; and 

encourage employees to cooperate and make it clear that their participation is sanctioned 

by both labor and management. Participating labor unions may also consider posting a 

similar notice to their members. Enhancing the process of communicating the existence 

of accidents, incidents, and close calls to study participants will help ensure that few 

opportunities are missed due to omissions or delays. 

• Train participating labor and management representatives to better recognize RCA 

opportunities. The combination of expanding the study to all crafts and increasing the 

ability of participants to recognize RCA opportunities will improve the overall likelihood 

of successfully completing a number of RCAs. 

• Identify one labor representative and one management representative to be study 

champions. Select one labor representative and one management representative as the 

overall study co-chairs whose jobs are to act as a conduit of information and serve as 

study administrators. These two chairs could have specific roles, such as identifying 

RCA opportunities, assigning participants to conduct the RCA, communicating 

information to their relative constituents (labor and management), and performing 

general problem solving. These chairs could also act as liaisons among the participating 

railroad, labor organizations, and researchers, in case assistance is needed or questions 

arise. 

• Indemnify participating labor and management involved in RCA (both participants and 

involved employees) so that neither labor nor management can use information collected 

in the RCA against the other party. Indemnification should reduce concerns over 

retribution and FELA. This, in turn, should increase the number of those who participate 

as labor and management participants and employees who have been involved in an 
5

accident, incident, or close call. Indemnification may require some type of written 

agreement. 

A number of obstacles impeded implementing the joint approach to RCA in the pilot study. 

These obstacles, however, do not necessarily indicate a complete failure of the process. Instead, 

the obstacles and pilot study experience highlight the challenges that must be addressed before 

future attempts are made at implementing a joint railroad management-labor approach to RCA of 

accidents, incidents, and close calls. 

7

1. Introduction 

This report describes the results of a 1-yr pilot examination of a joint railroad management-labor 

approach to RCA of accidents, incidents, and close calls in a railroad diesel and car repair shop 

environment. Accidents and incidents include collisions, derailments, employee-on-duty 

injuries, and other incidents that result in some type of harm to railroad property, infrastructure, 

or personnel. Close calls are events that narrowly avoid resulting in an accident or incident. 

Close calls share similar contributing factors with events that result in some type of harm; the 

primary difference is that some type of defense, or barrier, helped to avoid a negative outcome. 

RCA is a methodical approach to accident, incident, and close call investigation that enables one 

or more individuals to systematically identify individual, organizational, technological, and 

situational factors that contributed to an accident, incident, or close call. A guiding principle 

behind RCA is that accidents, incidents, and close calls are not caused by one event. Rather, 

multiple factors play a role in every accident, incident, and close call, and each is important in 

mitigating future occurrences. 

The primary goal of this pilot effort focused on obtaining feedback on the utility and value of 

this approach for the railroad industry. 

1.1 Background 

Safety in the railroad industry has improved markedly over the last decade. The total 

accident/incident rate in the railroad industry has fallen from 26.37 per mtm in 1996 to 17.39 in 

2005.4 In addition, employee injuries (including fatal) have declined. According to FRA data,5,6

in 1996, 9,199 railroad employees were injured while on duty and an additional 33 killed. By 

2005, the number of employee-on-duty injuries declined to 5,557, and fatalities totaled 25. 

Additional analysis shows, however, that while the total accident/incident rate, as well as 

employee injuries, has decreased, the number and rate of strictly train accidents has increased 

over this time period. In 1996, 2,443 train accidents (3.64 train accidents per mtm) occurred, and 

in 2005, this number rose to 3,152 (3.99 train accidents per mtm). 

Furthermore, accidents/incidents are costly. For example, job-related injuries cost American 

railroads over $1 billion annually (Transportation Research Board, 1994). American railroads do 

not operate under workman’s compensation statutes. When a railroad employee is injured, 

depending on the circumstances, he or she may submit an injury claim to the railroad, which, in 

turn, chooses either to pay the injured employee or to litigate the case. Though only a small 

number of claims reach the courtroom, the litigation costs to the railroads are high, and the legal 

process often delays settlements to injured employees. 

 

4

 SOURCE: FRA Office of Safety data retrieved from 

http://safetydata.fra.dot.gov/OfficeofSafety/Query/Default.asp?page=statsSas.asp June 9, 2006. 

5

 Ibid. 

6

 SOURCE: FRA Office of Safety data retrieved from 

http://safetydata.fra.dot.gov/OfficeofSafety/Query/Default.asp?page=castab.asp June 9, 2006. 
8

To reduce the number and severity of accidents/incidents and thereby increase railroad safety 

and reduce costs associated with accidents/incidents, it is imperative to understand the diverse set 

of circumstances and characteristics (i.e., the contributing factors) that allow accidents/incidents 

to occur. One of the most effective means of understanding the circumstances and 

characteristics of accidents/incidents is through the appropriate design and use of RCA. 

This report describes the results of a 1-yr pilot examination of a joint management-labor 

approach to RCA of accidents, incidents, and close calls in a railroad diesel and car repair shop 

environment. 

1.2 Objectives 

The primary objective of this research was to gain an understanding of the potential for railroads 

and labor to jointly conduct human factors-based RCA investigations of accidents, incidents, and 

close calls to uncover contributing factors at various levels of the railroad system. Neither the 

volume of cases investigated nor the raw data were of primary interest in this project. Rather, 

the focus of the project was on participant feedback on implementing the RCA methods and 

tools, as well as the utility of the approach for the railroad industry in general. Ideally, human 

factors RCA would eventually become a standard and acceptable practice in the railroad 

industry. 

The specific objectives of this research project were to: 

• Assist the railroad industry in identifying contributing factors to accidents, incidents, and 

close calls beyond the employee. 

• Obtain industry and labor feedback on the value and utility of the RCA methods and 

tools. 

• Examine the usefulness of a modified version of HFACS in the railroad industry to 

support accident, incident, and close call investigations. 

1.3 Overall Approach 

To implement a joint management-labor RCA process, researchers first identified a location 

where labor and management were co-located, since the project involved both. Researchers 

identified the diesel and car repair shop operating environment as a candidate study environment 

because management and labor are co-located and this environment hosts a variety of skilled 

craft workers, providing access to a variety of job types and numerous and varied work 

experiences throughout each day. 

Researchers invited representatives from several railroads and labor unions, as well as FRA, to 

participate in a stakeholder meeting in April 2004. Discussions of the project goals and methods 

were a part of this informational meeting. One railroad and four labor unions subsequently 

agreed to participate in the pilot study. Each labor union identified one local member to 

participate in the study, while the railroad identified several candidates to support the project. 

A set of paper-based tools, based on HFACS-RR, guided management and labor investigators 

through the data collection and analysis process. A 2-d training session, conducted at the host 

railroad with management and labor representatives in November 2004, introduced the study 

participants to the RCA methods and tools. The training served to educate and familiarize 
9

participants, some of whom had not attended the stakeholder meeting, on the principles of RCA, 

HFACS-RR taxonomy of human error, and specific RCA tools and methodology for data 

collection and analysis. 

The initial data collection period lasted 6 mo, from November 10, 2004, to May 10, 2005. Due 

to the lack of RCA conducted in the first 6 mo, researchers extended the data collection period an 

additional 6 mo, to the end of November 2005. Researchers developed a debriefing 

questionnaire for use at the conclusion of the study to elicit, from study participants, the merits of 

the joint RCA process and tools, as well as possible next steps. 

1.4 Scope 

Candidate RCA opportunities included all accidents, incidents, and close calls that occurred in 

the diesel and car repair shop environment, regardless of whether the event met FRA reporting 

criteria. The accident, incident, or close call had to occur in the diesel or car repair shop 

environment and involve a member of a participating union. Researchers excluded events where 

FELA might be involved. Otherwise, study participants chose which events to investigate using 

the RCA process and tools. 

1.5 Organization of the Report 

This report has several sections. Section 2 discusses the methods used in the pilot study. 

Section 3 contains the results. Section 4 presents key findings and lessons learned from the pilot, 

and it also includes some recommendations for future research. Section 5 contains a list of 

references used in the conduct of this study. The report includes a number of appendices. The 

first six appendices contain the RCA data collection and analysis tools (job aids) developed for 

use in the pilot study. Specifically, Appendix A presents a copy of the data collection checklist. 

Appendix B presents the interview questions: one each for operators, frontline supervisors, and 

senior level managers. Appendix C presents the five HFACS-RR flowcharts (one for each of the 

five HFACS-RR levels) that were aids to data collection and analysis. Appendix D presents an 

HFACS-RR analysis worksheet that was designed to aid participants. Appendix E presents a set 

of corrective actions mapped to specific HFACS-RR categories. Appendix F presents an 

incident report form. Appendix G presents a set of post-study questions that were designed to 

obtain participant feedback regarding the RCA process and tools. A list of abbreviations and 

acronyms used in the report follows the last appendix. 

11

2. Methods 

This section presents the methods used in the study. First, Section 2.1 provides a description of 

RCA—the overall philosophy behind the study. Next, Section 2.2 describes HFACS, an 

accepted taxonomy of human error. Section 2.3 describes a slightly modified version of HFACS 

(HFACS-RR); HFACS-RR provides the backbone and structure to the data collection and 

analysis. Section 2.4 then describes a number of RCA tools developed for this project for 

collecting and analyzing accident, incident, and close call data. Researchers hosted an initial 

stakeholder meeting to share the study’s objectives and methods; Section 2.5 contains details of 

the stakeholder meeting. Section 2.6 describes a 2-d training period provided to participants. 

Finally, Section 2.7 details the data collection procedures for the accidents, incidents, and close 

calls investigated. 

2.1 RCA 

RCA is a method of accident, incident, and close call investigation (data collection) and analysis 

that enables investigators or researchers to identify individual, organizational, technological, and 

situational factors that contributed to an accident, incident, or close call. RCA is a qualitative 

approach to understanding accidents, incidents, and close calls that complements quantitative 

analysis of large descriptive accident, incident, and close call databases. A guiding principle 

behind RCA is that a single event does not solely cause accidents, incidents, and close calls. 

Rather, multiple factors play a role in every accident, incident, or close call. RCA is a process 

used to methodically and objectively shed light on these contributing factors; many of which are 

otherwise difficult to find or are not readily identifiable in larger accident, incident, and close 

call databases. 

RCA examines active and latent factors. Active factors are those decisions, conditions, or other 

aspects that are closest in time and physical space to the accident, incident, or close call. 

Traditionally, active factors are most often cited as the cause of an accident, incident, or close 

call (for example, an operator’s errant press of the wrong button on a remote control device). On 

the other hand, latent factors (decisions or conditions) often exist for years and may never be 

identified as a safety issue unless they are subject to examination. An example might be a poor 

interface design for a piece of equipment or an unsafe operating practice. 

The basis of RCA is the tenet that the immediate act that precedes an accident, incident, or close 

call is simply the last step in a series of events that led to the occurrence. RCA focuses on 

unwinding the tape to explore all of the systemic factors that led to the accident, incident, or 

close call. To do this, one examines individual, organizational, technological, and situational 

factors. Each of these factors can be, and often is, at least partly responsible for providing a 

situation conducive to the accident, incident, or close call’s occurrence. RCA yields complex 

and rich information regarding the likely contributors to an accident, incident, or close call, 

possibly leading to a more complete understanding of organizational safety. 

An important element of RCA is its nonpunitive nature. An operator often bears the blame for 

an accident, incident, or close call because the operator is associated most recently in time and 

most closely in space with the last event that goes wrong. This punitive approach to accident, 

incident, and close call investigation, referred to as the bad apple theory by Dekker (2002), seeks 
12

to fix the problem by blaming the employee. Taken to its extreme, management removes the 

employee from service or fires him/her. Thus, the problem appears to be fixed. Given that this 

approach does not remedy any real systemic problems, however, other employees are likely to 

repeat the same unsafe act for which their coworker received discipline. 

Human error is much more complex. In fact, as Petersen (2003, p. 28) notes in a discussion of 

human error, “Human errors at lower levels of the organization are symptoms of things that are 

wrong in the organization at higher levels.” Furthermore, James Reason, a leading expert in the 

field of human error theory, notes, 

...human error is a consequence not a cause. Errors...are shaped and provoked 

by upstream workplace and organizational factors. Identifying an error is merely 

the beginning of the search for causes, not the end. The error, just as much as the 

disaster that may follow it, is something that requires an explanation. Only by 

understanding the context that provoked the error can we hope to limit its 

recurrence (Reason, 1997, p. 126). 

Since errors “are shaped and provoked by upstream workplace and organizational factors,” a 

basic tenet of RCA is that it seeks to identify a broad range of factors that may have contributed 

to an accident, incident, or close call, from an individual operator’s action or inaction to a seniorlevel executive decision that may have occurred several years before the event. 

2.2 HFACS 

To support the RCA, researchers necessarily identified an appropriate human error taxonomy to 

provide the framework for data collection and analysis. One particularly successful human error 

classification system is HFACS (Wiegmann and Shappell, 2003). HFACS has its basis in 

Reason’s (1) GEMS and (2) Swiss cheese model of accident causation (Reason, 1990). The 

Swiss cheese model depicts accidents as arising from holes in an organization’s defenses at 

various levels of the organization, beginning with the operator and working all the way up to 

organizational decisions and conditions. Active failures by the operator combine with latent 

conditions or factors upstream in the organization to lead to an accident (or incident or close 

call). Accidents (and incidents and close calls) occur, therefore, when all of the active and latent 

factors (i.e., holes) line up to allow accident energy (depicted as a straight line) to penetrate these 

various organizational levels. An organization’s defenses and barriers can, however, prohibit the 

alignment of active and latent factors and conditions thereby preventing accidents (and incidents 

and close calls). 

Wiegmann and Shappell (2003) originally developed HFACS as a classification system to help 

analyze U.S. naval aviation mishaps. HFACS was subsequently broadened to include 

commercial and general aviation domains as well. HFACS models error at four different levels, 

beginning with the operator and moving upward in the organization. The four levels mirror 

Reason’s Swiss cheese model of error. The four levels of HFACS are unsafe acts (Reason’s 

active failures—the operator activity that occurs closest in time and space to an accident, 

incident, and close calls), preconditions for unsafe acts, unsafe supervision, and organizational 

influences. These latter three levels relate to Reason’s latent factors or conditions, and they often 

exist for years before they contribute to an accident, incident, and close call. For each level, 

Wiegmann and Shappell (2003) identified a number of second-level categories. Some secondlevel categories divide further into third-level categories. A total of 19 unique categories of 
13

contributing factors exist. Figure 1 provides an overview of HFACS and conveys the structure 

of HFACS and the unique categories of contributing factors. HFACS applies Reason’s Swiss 

cheese model of human error to an accident, incident, and close call classification system and 

provides a theory-driven structure to accident, incident, and close call investigation (i.e., RCA) 

findings. For a discussion of each unique category’s definitions, see Wiegmann and Shappell 

(2003). 

Figure 1. Original HFACS Taxonomy (Wiegmann and Shappell, 2003) 
14

The use of a theoretically-driven RCA approach ensures that the accident, incident, and close call 

contributing factors identified during an investigation go beyond what happened to why an error 

occurred. Furthermore, such an approach allows for identifying the relationship between 

contributing factors more readily (for example, some types of errors may be linked to other types 

of contributing factors). Classifying errors based on their underlying theoretical nature enables 

identifying global trends across error forms, which on the surface may appear totally different. 

Consequently, and perhaps most importantly, one can identify corrective actions more readily to 

prevent errors and accidents, incidents, and close calls from recurring, since the data collected 

during the investigation highlight the underlying systemic problems that contributed to the events 

in the first place. 

Historically, HFACS provided the means primarily to analyze data available from existing 

accident, incident, and close call investigations. However, HFACS was also a methodology that 

could guide accident, incident, and close call investigations and support collection of human 

factors-related information. Some Federal agencies, such as the U.S. Coast Guard and the U.S. 

Department of Defense, are now experimenting, using HFACS to support accident, incident, and 

close call investigations, as well as analysis (Wiegmann and Shappell, 2003; A. Carvalhais, 

personal communication, October 11, 2005). 

Researchers selected HFACS to provide the theoretical backbone to RCA, given its logical 

structure and scientifically valid approach to human error. Furthermore, HFACS, as a 

classification system, is diagnostic, reliable, and comprehensive (Wiegmann and Shappell, 

2003). This is critical since the taxonomy must accommodate a wide range of railroad 

operational situations and circumstances that can lead to accidents, incidents, and close calls. 

The initial use of HFACS was in the aviation domain. As a result, researchers made some minor 

changes to HFACS to optimize its relevancy to the railroad industry. The following section 

discusses these changes. 

2.3 HFACS-RR 

To ensure the best fit between HFACS and the railroad industry and to increase its acceptance 

within the railroad industry, researchers made several minor changes to HFACS. The overall 

tree structure of HFACS remained. The modified HFACS taxonomy has the label HFACS-RR. 

An advantage of the original HFACS is that it uses generic terms and descriptors that are 

applicable to a range of industries and activities. Although others have made minor alterations to 

HFACS to suit their particular application, for example, to address air traffic control (HFACSATC; Scarborough and Pounds, 2001) and military activities (Canadian Armed Forces or CFHFACS; see Wiegmann and Shappell, 2003), most of the original HFACS taxonomy remains in 

HFACS-RR to preserve the original structure, thus facilitating future comparisons between data 

collected in this study and HFACS-based accident, incident, and close call analyses in other 

industries. 

To begin, researchers softened the names of the top HFACS level to become more neutral. For 

example, unsafe acts of operators is now operator acts. Table 1 presents the original and 

modified terms. 
15

Table 1. Original HFACS and New HFACS-RR Top-Level Categories 

Original HFACS Top-Level 

Category 

Modified HFACS-RR Top-Level 

Category

Unsafe acts of operators Operator acts 

Preconditions for unsafe acts Preconditions for operator acts 

Unsafe supervision Supervisory factors 

Organizational influences Organizational factors 

Researchers also added a new fifth level named outside factors to the HFACS-RR taxonomy. 

Outside factors include the regulatory environment and the economic/political/social/legal7

environment in which railroads operate. Outside factors cover those influences outside the 

railroad or organization that affect how the organization operates and its decisions. 

Other changes to the original HFACS taxonomy (and contained in the new HFACS-RR 

taxonomy) include the following: 

• Replaced the term violations with the term contraventions throughout the HFACS-RR 

taxonomy to avoid stigma and biases associated with violations. Violations in the 

railroad industry are often associated strictly with (operating, safety) rules. 

Contraventions are more general short-cutting and rule-bending, and they may not 

necessarily be tied to violating a specific rule. 

• Added a new subcategory under operator acts/contraventions called acts of sabotage. 

Acts of sabotage are related to the investigation only when the act is in response to a 

problematic organizational factor that is identified. 

• Added fourth subcategory under the organizational factors category called organizational 

contraventions. This subcategory addresses upper level management and executive 

contraventions and short-cutting of existing organizational (i.e., internal) procedures or 

processes. This subcategory further addresses externally imposed municipal, State 

regulations, and Federal regulations. This category parallels supervisory contraventions 

and contraventions of the operators themselves. 

Figure 2 presents the new HFACS-RR taxonomy with these modifications incorporated. The 

new HFACS-RR taxonomy contains a total of 23 unique categories of accident, incident, and 

close call contributing factors. Several of the 23 unique categories can be further classified (see 

Wiegmann and Shappell, 2003), if sufficient information exists to support the subcategorization: 

• Skill-based errors can be subcategorized into attention failures, memory failures, and 

technique errors. 

• Decision errors can be subcategorized into procedural errors, poor choices, and problemsolving errors. 

• Resource management can be subcategorized into human resources, equipment and 

facility resources, and monetary/budget resources. 

 

7

 The legal environment includes other-than-regulatory laws that affect railroad operations. 
16

Figure 2. HFACS-RR 
17

• Organizational climate can be subcategorized into organizational structure, organizational 

policies, and organizational culture. 

• Organizational process can be subcategorized into organizational operations, 

organizational practices and procedures,8

 and organizational oversight. 

Figure 3 reconfigures the five HFACS-RR levels according to their flow of influence. Influence 

flows from the outer levels toward the inner levels. That is, outside factors can influence all 

other HFACS-RR levels (organizational factors, supervisory factors, preconditions, and operator 

acts); organizational factors can influence supervisory factors, preconditions, and operator acts; 

supervisory factors can influence preconditions and operator acts; and preconditions can 

influence operator acts. This diagram pictorially shows how a number of contexts—

preconditions, supervisory factors, organizational factors, and outside factors—can influence 

operator acts. 

Figure 3. HFACS-RR Flow of Influence 

Researchers used the RCA philosophy combined with the HFACS-RR structure to develop 

paper-based tools to guide management and labor investigators through the data collection and 

analysis process. The following section describes each of these tools. 

2.4 Development of RCA Tools 

Researchers developed a number of paper-based tools based on the HFACS-RR taxonomy and 

Reason’s Swiss cheese model of human error. They designed tools to systematically guide 

 

8

 Wiegmann and Shappell (2003) originally discuss procedures under the organizational influences/organizational 

process subcategory. The authors changed procedures to practices and procedures in the HFACS-RR taxonomy 

since many of the activities undertaken in a railroad switching yard environment involve practices (more broad 

methods of operation), rather than procedures, which are more specifically prescribed methods. 
18

management and labor users through the RCA process, primarily focusing on data collection and 

analysis. Descriptions of each individual tool appear below. 

2.4.1 RCA Primer 

The RCA primer provides study participants with a theoretical background and overview of the 

pilot study. The primer briefly discusses the objectives of the study, RCA methodology, 

HFACS-RR taxonomy of human error, study methodology, and paper-based tools. 

2.4.2 RCA Pilot Study Flowchart 

The flowchart illustrated in Figure 4 conveys the overall process of conducting an RCA and 

served as a job aid to study participants. It presents the general flow of activities that were to 

take place when an accident, incident, or close call occurred during the pilot study. 

2.4.3 HFACS-RR Diagram 

The HFACS-RR diagram provides an overview of the human error taxonomy and aids 

investigators in systematically focusing on the five distinct error contribution categories: (1) 

operator acts (often referred to as active factors since they are the conditions, decisions, or other 

aspects that are closest in time and physical space to the accident, incident, or close call), (2) 

preconditions for these operator acts, (3) supervisory factors, (4) organizational factors, and (5) 

outside factors. Figure 2 presents the HFACS-RR taxonomy. 

2.4.4 HFACS-RR Flow of Influence Diagram 

Figure 3, which conveys the flow of influence among the five HFACS-RR levels, is part of the 

HFACS-RR worksheet described in Section 2.4.8. It serves as a job aid to support the theoretical 

understanding of how contributing factors at different levels of the organization influence each 

other. 

2.4.5 Data Collection Checklist 

This checklist (see Appendix A) contains a list of employee and railroad records and information 

that investigators may want to consider or otherwise examine as part of an RCA. It is a broadbased list designed to address a variety of possible accidents, incidents, or close calls. The list, 

however, is not exhaustive. The types of data of interest will depend on the circumstances of the 

particular accident, incident, or close call investigated. Investigators may pick and choose items 

from this checklist to help identify, prioritize, and eventually examine relevant information as 

part of the RCA. 

2.4.6 Interview Questions 

A series of three questionnaires (Appendix B) contain interview questions investigators may 

consider asking as part of the RCA. Much like the data collection checklist, each set of 

questions is broad-based to address a variety of possible accidents, incidents, or close calls. No 

set of questions is exhaustive. Rather, the questions serve to help investigators begin to consider 

factors at each of the five different HFACS-RR levels that may have contributed to the accident, 
19

incident, or close call. The types of questions of interest will depend on the circumstances of the 

accident, incident, or close call being investigated. As with the data collection checklist, 

investigators can pick and choose questions from these questionnaires to guide interviews with 

employees, supervisors, and management. Investigators may also find that they have many other 

questions once they know the specifics of the accident, incident, or close call they are 

investigating. Researchers developed separate questionnaires for operators, frontline 

supervisors, and upper management. 

Figure 4. Pilot Study Flowchart 
20

2.4.7 HFACS-RR Flowcharts 

Researchers designed five flowcharts (see Appendix C) to help investigators look for and 

consider particular factors in each of the five HFACS-RR levels, as they relate to the accident, 

incident, or close call under investigation. The five flowcharts serve to guide both initial 

collection of information and analysis of the information. Use of these flowcharts enables 

investigators to think through potential contributing factors at each level of the organizational 

system during the data collection phase and the actual analysis. The flowcharts are helpful in 

ensuring that active and latent failures are at least considered, if not identified, as contributing to 

a particular accident, incident, or close call. 

2.4.8 HFACS-RR Worksheet 

The HFACS-RR worksheet (see Appendix D) helps investigators be as thorough as possible in 

the investigation and analysis. This worksheet requires the investigator to affirm whether or not 

each category contributed to the accident, incident, or close call. The worksheet first prompts an 

investigator to record all operator acts that have been identified as contributing to the accident, 

incident, or close call, and to include a brief explanation. Next, the worksheet prompts the 

investigator to consider preconditions for operator acts and determine whether factors at that 

level influenced the operator acts. The investigator then considers supervisory factors, 

organizational factors, and finally outside factors. For each level, the investigator must note 

whether or not any factors contributed to the accident, incident, or close call. Finally, for each 

contributing factor, he/she then must identify the corresponding HFACS-RR category. 

2.4.9 Corrective Actions Guide 

Five corrective action charts (see Appendix E) help to identify which, of 11, potential corrective 

actions may be used to mitigate contributing factors that are identified. One corrective action 

chart exists for each of the five HFACS-RR levels, and corrective actions map to specific 

HFACS-RR categories. The corrective action charts, which mirror the HFACS-RR flowcharts, 

and the mapping of corrective actions to HFACS-RR categories facilitate the identification of 

one or more appropriate corrective actions for each contributing factor that is identified. 

2.4.10 Accident, Incident, and Close Call Report Form 

The accident, incident, and close call report form (see Appendix F) is a top-level, two-page form 

that calls for basic descriptive information about the accident, incident, or close call that was 

investigated; this provides a matrix where the investigators can record their HFACS-RR analysis 

of the accident, incident, or close call. Investigators complete this form at the conclusion of each 

RCA investigation. 

2.4.11 Post-Study Feedback Questionnaire 

The researchers developed a set of post-study feedback questions (see Appendix G) to elicit 

feedback on the usefulness and value of the RCA methods and paper-based tools to support joint 

labor-management accident, incident, and close call investigations in the railroad industry. 
21

2.5 Stakeholder Meeting 

Researchers invited FRA, five railroads, and six labor unions that represent diesel and car repair 

shop employees to participate in an initial stakeholder meeting in April 2004. The purpose of 

this meeting was to share the study’s objectives and methods with potential participants. 

Researchers explained the benefits of participation, which included a more thorough 

understanding of factors that contribute to diesel and car repair shop accidents, incidents, and 

close calls; and an improved ability to identify these factors, improved safety, and potentially 

improved labor-management relations. Participants discussed challenges and concerns of 

conducting this type of study in an operational setting, and the researchers encouraged attendees 

to express their ideas for how to successfully implement this project. Ultimately, one railroad 

and four labor unions agreed to participate in the pilot study. 

2.6 Study Participant Training 

The authors conducted a 2-d training session at the host railroad with management and labor 

representatives in November 2004. The training served to educate and familiarize participants—

some of whom had not attended the stakeholder meeting—on the principles of RCA, the 

HFACS-RR taxonomy of human error, and the specific RCA tools and methodology for data 

collection and analysis. The training also included the opportunity to review public National 

Transportation Safety Board (NTSB) investigations as examples and practice mapping NTSBidentified contributing factors to HFACS-RR categories using the flowcharts and other RCA 

tools. 

2.7 Data Collection Procedures 

Candidates for RCA included all accidents, incidents, and close calls that occurred in the diesel 

and car repair shop environment. These include both FRA-reportable and non-reportable 

accidents and injuries. The accident, incident, or close call had to occur in the diesel or car shop 

environment and must have involved a member of a participating union. Occurrences where 

FELA might be involved were not candidates for study. 

A particular union’s participation in the RCA was dependent on which employee was involved in 

the occurrence. If an accident, incident, or close call involved an electrical worker, for example, 

then a labor representative from that craft worked with one local management representative to 

investigate the occurrence. If an occurrence involved a member of another union (for example, a 

sheet metal worker), then the labor representative for that craft participated in the investigation 

alongside railroad management. 

Participating labor and management also agreed that if the railroad would routinely conduct an 

investigative hearing following the particular accident, incident, or close call, this hearing would 

be waived unless criminal activity was involved. If criminal activity were a factor, then railroads 

and labor could elect a traditional approach to investigating. The goal of bypassing the routine 

investigation was to facilitate an open rapport between the railroad and employees involved in 

the accident, incident, or close call under investigation. 

Researchers encouraged participants to limit the duration of each investigation to 8-12 hours (h) 

per investigator. This was considered a reasonable amount of time to spend on each RCA given 

that study participants still needed to tend to their regular job responsibilities. Once labor and 
22

management made a decision to investigate an accident, incident, or close call, the study 

participants-turned-investigators used the RCA tools to guide data collection and analysis. 

The original methodology required one management representative and one labor representative 

to jointly conduct each RCA. The representative that participated in a particular RCA depended 

on who was involved in the accident, incident, or close call. If a carman was involved in an 

accident, then the carman representative participated. If a sheet metal worker was involved, then 

the sheet metal worker representative participated, and so on. During the initial training, 

however, both labor and management agreed in empowering labor to conduct each RCA while 

management representatives would be available to assist as needed. 

Researchers planned to conduct a feedback meeting at the end of the data collection period. The 

purpose of this meeting was to discuss the advantages and disadvantages of the RCA 

process/tools used in the pilot study, parts of the process/tools that were liked and disliked, and 

suggested changes to facilitate employing this approach in the railroad industry on a larger scale. 

To prepare for this meeting, researchers asked participants to record personal observations of the 

process and tools throughout the pilot study. This end-of-study debriefing meeting never 

occurred due to a number of barriers that were encountered during data collection. The next 

section discusses the results of the study along with these barriers. 
23

3. Results 

This section presents the results of the RCA study. Participants identified a total of seven RCA 

opportunities. One RCA was performed among these seven opportunities. Section 3.1 presents 

the seven opportunities that study participants identified. More specifically, Section 3.1.1 

presents a brief description of the six RCA opportunities that were not investigated, while 

Section 3.1.2 presents the details and the results of the single RCA. 

A number of barriers prevented more successful implementation of the RCA process, including 

failure to identify additional RCA opportunities. Section 3.2 describes a number of participantidentified barriers to more successful RCA implementation and presents their suggestions for 

future implementation. The section concludes with some additional participant observations on 

the utility and application of the RCA tools and method to the railroad industry. 

3.1 Accidents, Incidents, and Close Calls 

Study participants identified 7 RCA opportunities during the 1-yr study period. Opportunities 

consisted of six employee injuries and one close call. Participants conducted a single RCA for 

one of the injuries. Section 3.1.1 describes the six opportunities that were not investigated. 

Section 3.1.2 presents the single event that was investigated using RCA. 

3.1.1 Accidents, Incidents, and Close Calls Not Investigated 

Participants identified 6 RCA opportunities that they did not investigate during the 1-yr study 

period. Brief descriptions of each of the six opportunities include the following: 

1. An employee was replacing a brake shoe when the truck moved. This was a close call, 

but no injuries occurred. This event occurred just before the start of the study, so 

participants used this case as their first RCA. In the RCA interview the employee was 

unable to recall details or information pertaining to the occurrence. 

2. An employee injured his back replacing brake shoes. The employee was using a pry bar 

to free the brake rigging from the wheel when he slipped and complained of back pain. 

The employee refused medical treatment, and no railroad incident report was filed. It 

was not clear whether or not this individual was actually injured at work. Due to the lack 

of clarity regarding the injury, labor participants did not pursue this incident. The 

incident subsequently became a reportable work-related injury when the individual took 

time off for the injury. 

3. A carman was injured while crossing on-track equipment. The employee relates that he 

crossed over on a walkway of a covered hopper; he swung around to the side ladder and 

stepped down to the ground. As he did so, he said he lost his balance putting his foot on 

an obstruction in the walkway, probably a brake shoe, which caused him to twist around 

to the left, hitting his head on the side of the car. The labor representative who was going 

to participate was out of town and thus not immediately available. In addition, a 

temporary fall-out between management and labor occurred around the same time. 
24

4. A carman pinched his finger using a hand tool. A railroad management representative 

attempted to conduct an RCA alone several months later, but the injured employee 

became uncomfortable so the RCA was terminated. 

5. A carman struck his head on a grab iron while dismounting a car. 

6. A diesel shop machinist ground off part of his right index finger proximal to distal 

phalanx and lacerated a tendon. The machinist was holding a washer in his hand against 

the side of the pedestal grinding wheel. While exerting force with his hand to push the 

washer against the wheel, his work kicked off the grinder.

3.1.2 Slip/Trip/Fall RCA 

The one incident that was investigated jointly by one management and one labor representative 

involved a slip/trip/fall injury to a carman described in the following paragraph. 

The employee was walking from a vehicle across the 42/43 switch, carrying an 

end-of-train (EOT) device toward a main on track 39. The employee was 

carrying the 25-pound (lb) EOT device on his right shoulder. He stepped with his 

left foot over the south end of the rail switch at heel of point. The employee 

stated he was not aware that the ground was lower than the ties, and his left foot 

went about 4 inches (in) down farther than he anticipated. He caught himself and 

touched the south rail with the toe of his right foot. The employee felt the south 

main track in his left side lower back. He continued work after the incident and 

reportedly felt fine. He later reported the incident to the company around 2 p.m. 

after he felt pain at rest while eating lunch. He declined medical attention. 

The investigation took the labor and management representatives approximately 2 h to complete. 

Labor and management jointly identified five contributing factors associated with three of the 

five HFACS-RR levels. Table 2 summarizes the HFACS-RR analysis. 

Following the RCA, the participating labor and management representatives recorded their 

feedback regarding the RCA tools and approach. They found the HFACS-RR flow of influence 

diagram helpful in explaining the purpose of the study to the injured employee. Feedback 

suggests that the HFACS-RR flowcharts were also helpful. The participating labor and 

management representatives read the flowchart questions aloud to the employee or otherwise 

reviewed them as the interview proceeded. They noted that the flowcharts were valuable in 

assuring that everything was covered. 

3.2 Barriers to Implementation and Suggestions for Future Implementation 

By the end of the first 6 mo of the study period, it was apparent that significant barriers existed to 

successful implementation of the RCA process and tools, even on a pilot basis. To learn more, 

researchers contacted participating labor and management representatives via telephone to obtain 

their feedback and opinions to better understand barriers to implementation and solicit 

suggestions for how to improve the process and chances of success in the future. The 

researchers used several questions from the end-of-study debriefing survey to help identify study 

barriers and suggestions for future implementation. 
25

Table 2. Results of HFACS-RR Analysis

General HFACS-RR Category Occurrence Specific HFACS-RR Category 

Operator Acts Slip, trip, fall. Lack of attention to 

condition of footing in switch. 

Skill-based error/attention failure 

Preconditions Carrying EOT device (25 lb) on 

shoulder creates additional balance 

issue if footing is not 100 percent. 

Ballast between ties lower than ties. 

Not looking ahead despite clear view 

understanding footing/ [loss of] 

situational awareness. 

Environmental factors/technological 

environment 

Environmental factors/physical 

environment 

Condition of operators/adverse 

mental state 

Supervisory Factors None. 

Organizational Factors Employee spent the first part of the 

shift retrieving EOT devices in yard 

before he could work outbound 

trains. Employee says he was not 

hurried. 

Resource 

management/equipment/facility 

resources 

Outside Factors None. 

3.2.1 Barriers to Implementation 

This section presents labor and management-identified barriers related to participation in the 

study. A majority of the barriers relate to the RCA process. Identified barriers included the 

following: 

• Awkwardness interviewing a co-worker. Participants noted that it was awkward 

approaching and interviewing a co-worker involved in an accident, incident, or close call. 

• Minimal opportunity to investigate accidents, incidents, or close calls. The diesel and car 

repair shop environment is one of the safer railroad work environments. Consequently, 

few opportunities (accidents, incidents, or close calls) existed to conduct RCA. 

• Lack of a study champion. Several participants noted that, although labor and 

management officials supported the study at higher levels of their respective 

organizations, no single champion was onsite to ensure that RCAs were conducted and 

that the study succeeded. In one example, participants initiated the RCA process, but one 

of the participants was subsequently pulled in other directions and did not return to 

followup. Consequently, participants did not perform the RCA. Separately, some 

participants observed that a change in upper management (not the management 

participant) part-way through the study appeared to change the tone of the organizational 

culture and may have led to a shifting of the railroad’s priorities. 

• Lack of study participant (i.e., labor representative) availability. The absence of one 

study participant who was going to conduct a particular RCA resulted in a delay in 

implementation and eventually a lost opportunity to conduct the RCA. 
26

• Need for coordination of multiple schedules. The need to coordinate multiple schedules 

made it difficult to bring specific study participants and the involved employee together 

to conduct RCAs. 

• Inadequate communication. Two separate communication issues existed. First, a lack of 

communication existed about the study in general to diesel and car repair shop employees 

not participating in the project, regarding their roles of notifying study participants of any 

accidents, incidents, or close calls. For example, some employees who were involved in, 

or knew of any incidents, were not aware of the study, and they therefore did not know to 

contact a study participant. Second, inadequate communication also existed between 

participating management and labor. Some labor participants did not hear about 

particular accidents, incidents, or close calls, or they heard about an event only through 

the grape vine. 

• Concern over management retribution. Several participants noted that fear of retribution 

or embarrassment may have caused involved employees to not want to participate and 

share information. Separately, one study participant explained that he was never 

interested in the project because he felt that retribution for participating would occur. 

Consequently, this participant did not involve himself in the study subsequent to the 

November 2004 training. 

• FELA. FELA may have impacted the willingness of labor representatives and employees 

involved in an accident, incident, or close call to participate. 

• Overly complex RCA tools and method. Some participants noted that a reluctance or 

hesitation may have existed to participate by some because the RCA tools and method 

may have been too complicated, or some study participants may have lacked a full 

understanding of the principles of RCA and human factors. At least one participant also 

suggested that the one-time skills training session at the beginning of the study may not 

have been adequate to fully prepare participants. 

• Unclear nature of one particular accident, incident, or close call. In one case, 

participants were unclear at the time of the event whether or not the incident occurred on 

the job. The injured employee refused medical treatment, and, as a result, study 

participants did not pursue the incident. Subsequently, management treated the injury as 

a reportable work injury. Although the nature of the injury is not specifically related to 

the RCA process or tools, it did create a barrier to carrying out RCA in this particular 

instance. 

3.2.2 Suggestions for Future Implementation 

Labor and management offered a number of suggestions to make future RCA implementation 

successful. All suggestions are process-oriented improvements. 

• The study needs a champion. Some study participants suggested that railroad 

management take a more active role in leading the project and make it clear that 

management encourages participation by labor representatives and involved employees. 

Another suggestion was for union officers to demonstrate a clear leadership role because 

otherwise analysis of one employee’s actions by another union employee may not be 
27

feasible. Participants felt that participating management and labor representatives must 

take the study and process seriously. 

• Whoever is first available among labor representatives should investigate. Because the 

railroad is small and the work environment is common, most people know one another 

across craft lines; consequently, craft distinction is not a significant issue. Therefore, no 

need exists to match the labor representative with the craft of the individual involved in 

the accident, incident, or close call. This will avoid problems due to delays in identifying 

the right people to conduct a particular accident, incident, or close call RCA 

investigation. 

• Identify safety committee members who can participate in the study as labor 

representatives since safety committee members are clearly interested in determining 

causes of accidents, incidents, and close calls and finding solutions. This is in contrast to 

the pilot study, where participating labor union officers chose a member of their 

organization to participate as a labor representative in the study. 

• Use accident, incident, and close call data posted on bulletin boards each week as 

candidate opportunities to conduct RCA. Safety data posted on bulletin boards have 

recently become a source of regular communication from management to employees 

about yard safety each week. This information could be a starting point for identifying 

candidate cases for RCA.

• Use previously investigated accidents, incidents, and close calls as a source of candidate 

RCA opportunities. Include one of the participating labor representatives during an 

official investigation of an accident, incident, or close call, or enable labor representatives 

to conduct the RCA immediately after railroad management collects their own data for 

their own accident/incident investigation. If labor representatives are not available, then 

brief them immediately after the investigation or as soon as possible. 

• Improve communication about the accident, incident, or close call to participating labor 

representatives. 

• Gain the trust of those employees involved in the accident, incident, or close call, and 

ensure that information provided by these employees will not be used against them. 

Participants suggested that this may require more than a verbal agreement. 

3.2.3 Observations on the Utility and Application of the RCA Tools and Method to 

the Railroad Industry 

Lastly, several participants offered observations on the RCA tools and process that did not 

clearly fall into the categories of barriers or suggestions for future implementation. These 

observations related to the utility and application of the RCA methodology to the railroad 

industry. Participant observations included the following: 

• One participant felt that the RCA tools and method focus too much on blaming 

individuals rather than on identifying contributing causes. This participant explained 

that the host railroad’s current process of accident, incident, and close call analysis does 

not delve into sources of operator error (e.g., technique error) as much as identifying 

contributing causes (e.g., training issue). According to this participant, the current 
28

railroad approach identifies significant human factor causes, and more complicated or 

systemic human factor issues are handled as retraining or process adjustments with 

minimum reference to a particular individual, thus getting away from fixing too much 

blame. This participant also felt that the railroad’s current approach helps to reach 

consensus in the field so that leadership can move away from blaming someone and 

implement improvements and prevention strategies as quickly as possible. 

• This process may be better suited to other, more complex operating environments where 

a higher degree of human input exists. Examples include dispatching and signal work, 

where the process could be used to identify sources of error in these environments. 

• The value of the RCA process is in proportion to the value of the severity of the accident, 

incident, or close call. As one participant observes, 

At an abstract level, experienced accident investigators know that the 

difference between a bumped head getting off a car and a fall, and a much 

more serious injury can be infinitely small in time or space. The ‘accident 

pyramid’ is an accepted concept. But application of the RCA for smaller 

accidents, incidents, or close calls does not seem to yield the insights per 

hour invested that a quick but thorough interview can yield. 
29

4. Key Findings, Lessons Learned, and Recommendations for Future 

Research 

Section 4 is organized into three sections. Section 4.1 presents key findings from the study, 

including participant-identified barriers and suggested improvements for future implementation. 

Next, Section 4.2 discusses some additional lessons learned. These include barriers to the 

current study and suggestions for future implementation beyond those identified by labor and 

management participants. Finally, Section 4.3 discusses recommendations for future 

implementation. Recommendations are based on what has been learned in this study in order to 

increase the likelihood of success in the future. 

4.1 Key Findings 

Participating labor and management representatives helped identify a number of barriers that 

made it difficult for the project to succeed in its current form. Participant-identified barriers 

focused on the study’s process for identifying candidate RCA opportunities and collecting data. 

Many of these process issues were related to the interaction between participants or between 

participants and involved employees. A positive consequence of participants’ abilities to 

identify specific barriers is that they were also able to identify specific suggestions for 

overcoming these barriers in future implementations of the RCA process. 

Key themes among barriers identified include the following: 

• Lack of leadership. Participants felt that labor and management lacked strong leadership 

to ensure the study’s success. 

• Poor interaction and communications. Participants noted that it was awkward to 

interview a co-worker as part of the RCA process. Participants also noted inadequate 

communication from some study participants to other diesel and car repair shop 

employees about the study, as well as from management to labor participants about the 

existence of accidents, incidents, or close calls. 

• Challenges associated with participation. Participants observed several barriers related 

to their own participation and that of employees involved in an accident, incident, or 

close call. Participants identified a lack of participant availability for one RCA and 

difficulty coordinating multiple participant and employee schedules to conduct RCAs. In 

addition, concern over management retribution was a factor for one participating labor 

representative who chose not to support the project after the training. The same concern 

was noted as a possible factor for why those involved in an accident, incident, or close 

call chose not to cooperate. Some felt that FELA may have contributed to low 

cooperation by employees involved in accidents, incidents, or close calls. 

• Perceived minimal opportunity to conduct RCA. Some perceived few opportunities to 

investigate accidents, incidents, or close calls due to the relatively safe diesel and car 

repair shop work environment. 

• Complex RCA tools and process. At least one participant felt that the RCA tools and 

method may be too complicated and the training insufficient, which may have hindered 

participation. 
30

Participant suggestions for future RCA implementation specifically addressed barriers that were 

identified. Key themes among these suggestions include the following: 

• A need for effective leadership and communication exists. Participants suggested the 

study needs champions, and suggestions included both labor and management leadership. 

Other related suggestions include improving communications about the incidence of 

accidents, incidents, and close calls to participating labor representatives; gaining the 

trust of those employees involved in the accident, incident, or close call; and ensuring 

that information provided by these employees will not be used against them. 

• Improve the process for identifying who participates in the study. Participants suggested 

several improvements to the selection process, including selecting labor participants from 

within the safety committee and allowing whoever is first available among labor 

representatives to conduct the RCA; the process used in the pilot study was to match the 

craft of the labor representative to the craft of the involved employee (e.g., if a carman 

were injured, then the carmen labor representative was responsible for conducting the 

RCA). 

• Increase awareness of opportunities to conduct RCA. Participants identified several 

ways to increase awareness of opportunities to conduct RCA, including using accident, 

incident, and close call data posted on bulletin boards each week as opportunities to 

conduct RCA and using officially investigated accidents/incidents as a source of RCA 

opportunities. 

4.2 Additional Lessons Learned 

Additional lessons learned included: 

• Researchers not being co-located with the study limited their effectiveness to provide 

oversight to the RCA process. The distance between the researchers’ location and the 

study site precluded close oversight of the study, possibly influencing participation by 

study participants and those employees involved in an accident, incident, or close call. A 

local researcher’s presence could have assisted some RCA by facilitating interviews or 

making employees more comfortable and, in general, could have served as a more 

effective study champion. Researchers’ offers to make telephone calls or sit in meetings 

were generally ineffective. 

• Empowering labor to be solely responsible for identifying RCA opportunities and 

conducting RCA was not effective. At the start of the study, rail management empowered 

participants to be solely responsible for identifying the accidents, incidents, or close calls 

and conducting the RCA. However, a variety of barriers prevented this from being an 

effective strategy. In fact, labor and management jointly performed the single RCA that 

occurred. Because management is in the best position to first learn about accidents, 

incidents, or close calls, and because they are in the best position to influence people and 

make critical decisions about resources used in the study, researchers recommend that 

future attempts to implement RCA employ management and labor jointly from the start. 
31

4.3 Recommendations for Future Implementation of a Joint Labor-Management 

RCA Process 

Based on study participant feedback and pilot study experience, researchers make the following 

recommendations to increase the likelihood of success of any future attempt at implementing a 

joint management-labor RCA process: 

• Expand study to all yard crafts. Any future study should include the entire yard 

environment, including train and engine employees. This strategy will increase the 

number and types of opportunities to conduct RCA. This will require initial stakeholder 

buy-in from additional labor unions, such as the United Transportation Union and 

Brotherhood of Locomotive Engineers and Trainmen. 

• Draw on the railroad’s safety committee(s) to provide study participants, and use the 

safety committee venue to discuss, raise awareness of, and select RCAs to pursue. 

Incorporate the study as a task for the participating railroad’s safety committee(s) to take 

on. Safety committee members could serve as representative labor and management 

participants; accidents, incidents, and close calls that are brought to the attention of the 

safety committee could serve as possible candidates for RCA. 

• Communicate information about the study to, and solicit cooperation from, all railroad 

employees. The participating railroad should increase communication to all yard 

employees about the study. The participating railroad might consider posting a general 

notice to all employees to inform them about the project; ask employees to notify 

participating labor or management representatives about any accident, incident, or close 

call they were involved in; ask employees to cooperate in any RCA process; and 

encourage employees to cooperate and make it clear that their participation is sanctioned 

by both labor and management. Participating labor unions may also consider posting a 

similar notice to their members. Enhancing the process of communicating the existence 

of accidents, incidents, and close calls to study participants will help ensure that few 

opportunities are missed due to omissions or delays. 

• Train participating labor and management representatives to better recognize RCA 

opportunities. The combination of expanding the study to all crafts and increasing the 

ability of participants to recognize RCA opportunities will improve the overall likelihood 

of successfully completing a number of RCAs. 

• Identify one labor and one management representative to be study champions. Select one 

labor representative and one management representative as the overall study co-chairs 

whose jobs are to act as a conduit of information and serve as study administrators. 

These two chairs could have specific roles, such as identifying RCA opportunities, 

assigning participants to conduct the RCA, communicating information to their relative 

constituents (labor and management), and performing general problem solving. These 

chairs could also act as liaisons among the participating railroad, labor organizations, and 

researchers, in case assistance is needed or questions arise. 

• Indemnify participating labor and management involved in RCA (both participants and 

involved employees) so that neither labor nor management can use information collected 

in the RCA against the other party. Indemnification should reduce concerns over 

retribution and FELA, thereby increasing the number of those who participate as labor 
32

and management participants and employees who have been involved in an accident, 

incident, or close call. Indemnification may require some type of written agreement. 

4.4 Conclusions 

The goal of this pilot study was to evaluate the feasibility of railroad labor and management 

jointly conducting their own RCA of accidents, incidents, and close calls using a set of data 

collection and analysis tools that were developed for this project. The focus of the study was on 

determining the utility and value of the joint approach to RCA, including the RCA process and 

tools. Clearly a number of obstacles impeded successful implementation of the RCA 

methodology. These obstacles, however, do not necessarily indicate a failure of the process, but 

rather, highlight challenges that must be addressed before future attempts are made to implement 

a joint railroad management-labor approach to RCA of accidents, incidents, and close calls. 

There was limited evaluation of the RCA tools due to the lack of opportunity to apply them. The 

limited feedback on the utility and value of the RCA tool was both positive and negative. While 

some participants suggested that the tools may have been complex, at least one participant noted 

that the tools were helpful in explaining the purpose of the study to an individual interviewed in 

an incident and in ensuring complete application of the RCA methodology. The one complete 

RCA demonstrated further utility in the tools. Labor and management participants were able to 

identify 5 contributing factors associated with 3 of the 5 HFACS-RR levels, while requiring only 

2 h to complete the investigation. Although a number of barriers to successful implementation of 

RCA existed in this pilot study, there are indications that this methodology could be successful 

once these barriers are removed.
33

5. References 

Dekker, S. (2002). The field guide to human error investigations. Aldershot: Ashgate 

Publishing Ltd. 

Federal Railroad Administration. (2003). FRA guide for preparing accident/incident reports. 

DOT/FRA/RRS-22. FRA Office of Safety. Washington, DC: Author. 

Federal Railroad Administration Office of Safety data retrieved from

http://safetydata.fra.dot.gov/OfficeofSafety/Query/Default.asp?page=castab.asp June 9, 2006. 

Federal Railroad Administration Office of Safety data retrieved from 

http://safetydata.fra.dot.gov/OfficeofSafety/Query/Default.asp?page=statsSas.asp June 9, 

2006. 

Federal Railroad Administration Office of Safety data retrieved from 

http://safetydata.fra.dot.gov/OfficeofSafety/Query/Default.asp?page=castally1.asp June 27, 

2006. 

Peterson, D. (2003). Human error: A closer look at safety’s next frontier. Professional Safety, 

48 (12), 25-32. 

Reason, J. (1990). Human Error. New York: Cambridge University Press. 

Reason, J. (1997). Managing the risks of organizational accidents. Aldershot: Ashgate 

Publishing Ltd. 

Scarborough, A. & Pounds, J. (2001). Retrospective human factors analysis of ATC operational 

errors. Paper presented at the 11th International Symposium on Aviation Psychology, 

Columbus, OH. 

Transportation Research Board. (1994). Compensating injured railroad workers under the 

Federal Employers' Liability Act, Special Report 241. Washington, DC: National Academy 

Press. 

Wiegmann, D. & Shappell, S. (2003). A human error approach to aviation accident analysis: 

The human factors analysis and classification system. Aldershot: Ashgate Publishing Ltd. 

35

Appendix A. 

Data Collection Checklist 

The data collection checklist contains a list of employee and railroad information that 

investigators may want to consider or otherwise examine as part of RCA. It is a broad-based list 

designed to address a variety of possible accidents, incidents, and close calls, but it is not 

exhaustive. Investigators can pick and choose items from this checklist to help identify, 

prioritize, and eventually examine relevant information as part of the RCA. 

Researchers attempted to categorize each checklist item into one of the five different HFACS 

categories, but often an item could be categorized into two or more HFACS categories 

depending on the information collected. For example, work schedule and rest information could 

be related to a precondition (personal readiness, say, if an employee did not get enough sleep the 

night before because he was out late with friends) or a supervisory factor (if, for example, work 

scheduling is the issue). Consequently, the following checklist items are simply listed based on 

whether the information pertains to (1) the employee or (2) the carrier and the accident, incident, 

or close call. 

• Employee information 

o Time employee(s) went on-duty before accident, incident, or close call. 

o Number of hours on duty at time of accident, incident, or close call. 

o Hours of service/work schedule records for previous 30 days for employees 

involved in accident, incident, or close call. For each of the last 30 days, collect 

information on: 

 Date and time on-duty 

 Date and time off-duty 

o Qualification dates for employee(s) involved in accident, incident, or close call. 

o Dates and performance data related to employee training and his/her most recent 

rules test. 

o Number of efficiency tests performed in last 12 months, and of these how many 

were related to the circumstances involved in the accident, incident, or close call. 

How many of the tests over the last 12 months did the employee pass and fail? 

 Date and outcome of most recent efficiency test? Related to the accident, 

incident, and close call? 

o Information on any prior infractions, discipline, and commendations. 

• Carrier and accident, incident, and close call information 

o All relevant operating and safety rules that were in effect at the time of the 

accident, incident, or close call. 

o Copies of any Special Instructions, General Notices, General Orders, General 

Bulletins, Superintendent Instructions, and/or Division special orders and 

instructions that supersede or augment timetable and rulebook authority, that were 
36

in effect at the time of the accident, incident, or close call and that were relevant 

to the accident, incident, or close call in any way. 

o Copy of any work orders used at time of accident, incident, or close call. 

o Overview of the training program(s) received by employee(s) involved in the 

accident, incident, or close call. 

o Copy of employee statements and initial carrier report. 

o Copy of photographs of accident, incident, or close call. 

o PPE worn and condition of PPE. 

o Work equipment inspection and maintenance logs and record books. 

o Rolling equipment (cars, locomotives, and other rail vehicle) inspection and 

maintenance logs and record books. 

o Work equipment operating instruction manuals/guides. 

o Rolling equipment operating instruction manuals/guides. 

o Maintenance/inspection procedure checklists, guides, aids, manuals, and 

directions. 
37

Appendix B. 

Interview Questions 

Researchers developed three questionnaires to aid investigators in probing accidents, incidents, 

and close calls. Each questionnaire focuses on a different level of the organization; within each 

questionnaire, researchers organized questions by HFACS-RR level. The first interview 

questionnaire addresses issues related to the operating employees. The second questionnaire 

addresses front-line supervisors. The third questionnaire focuses on senior-level managers 

within the organization. Much like the data collection checklist, each questionnaire is broadbased and addresses a variety of possible accidents, incidents, and close calls, but it is not 

exhaustive. Rather, questionnaires should help investigators to begin to consider factors at each 

of the five different HFACS-RR levels that may have contributed to the accident, incident, or 

close call. Questionnaires begin on the following page. 
38

Operator Interview Questionnaire

Starter questions

1. Imagine yourself back at the incident. Think about where you were, what you saw, what 

you heard, what you smelled, what you felt. Please tell us about what happened, starting 

at the beginning. Try to be as specific as possible regarding times and locations and 

landmarks when describing the events for us. We would like to hear all of the details, 

regardless of how important you think they are. Start whenever you are ready and take as 

much time as you would like. 

2. Who else was nearby or involved? Where were they located? What were they doing? 

3. Describe the workday leading up to the incident. Did you have any rest breaks the day of 

the incident? 

Operator Acts

1. Was your task during the time of the incident routine to you? Did you have prior 

experience with this task? 

2. Is there more than one way you could have completed the task? What are they? 

3. Were there any distractions at the time of the incident? 

4. Were there any explicit operating and safety rules that governed your activity leading up 

to the incident? What were they? How helpful are they? Did you take any short-cuts? 

Is this common? 

5. What PPE were you wearing? Who provides your PPE—you or the railroad? 

Preconditions

1. Prior to the incident when did you last work? 

2. What was your work schedule during the previous 3 d? What were your other activities 

during this 3-d period? 

3. When did you go to sleep each of the previous 3 nights? When did you wake up? Did 

you feel well rested? 

4. Is your work schedule regular or irregular? 

5. Is your work schedule predictable (i.e., known ahead of time) or are you on-call? 

6. Were you working an unusual schedule the day the incident occurred? 

7. How many consecutive days, including the day of the incident, had you worked? 

8. Approximately how many days in the last month did you work? 

9. When are your days off? When was your last vacation and how many days was it? 
39

10. How was your workload on the day of the incident? Were there any time pressures or 

incentives to work faster? 

11. What was the condition of the equipment when you began your shift? Did you have any 

problems with any of the equipment? Did you or other employees ever complain about 

the condition of the equipment to supervisors? 

12. What was the condition of the PPE? Was the PPE adequate? 

13. Describe the operating environment the day of the incident—what was the weather like, 

temperature, noise, visibility, etc. 

14. What was the mood of the other employees before the incident? 

15. Did you hold a job briefing at the beginning of the shift? What did it address? Do you 

hold a job briefing every day? 

16. More generally, how would you describe the communication among employees the day 

of the incident? What about communication specifically among your own team, as well 

as between you and the supervisor on duty at the time of the incident? 

17. In the past year: 

a. Have you had major changes in your health (good or bad)? 

b. Have there been major changes in your financial situation (good or bad)? 

c. Have there been major changes in your personal life (e.g., separation, divorce, 

birth, death, changes in the health of immediate family/close friends)? 

Supervisory Factors

1. What was your training like? Please be as specific as you can. Was it sufficient? Who 

trained you? How much work experience did they have? 

2. Do you feel you were adequately prepared to do your job at the end of your training? If 

not, why not? 

3. Does any of your work involve coordination with other employees (i.e., do you work as 

part of a team)? If so, did you receive any training in crew resource management or any 

other type of communication and coordination among team members? 

4. Has this sort of incident or problem happened before to anyone that you are aware of? 

Was it reported? Was something done to correct it? 

5. How would you describe your supervision? 

6. Have you ever been encouraged by a supervisor to cut corners or bend rules? 

a. Have you heard of others being encouraged to cut corners or bend rules? 

b. If rule bending occurs, is your supervisor aware of it? 

7. Are you aware of your supervisor ever cutting corners, or disregarding a rule, procedure, 

or policy, to get something done on time, or for any other reason? 
40

Organizational Factors

1. Do you feel that staffing in the shop is adequate? 

2. Has workload level recently increased in the shop? To what do you attribute this? 

3. How is safety communicated to you? 

4. How would you describe the safety culture at your railroad? 

5. How do you report safety-related problems or recommendations? Are your comments 

received well? Is there a way for you to bring up safety-related issues without fear of 

retribution, such as through a safety hotline? Do you find this effective? 

6. Are there any barriers to you communicating with the people above you who influence 

your job? 

7. What contact is there between top management and yourself or other employees? 

8. How would you describe labor/management relations in the shop and at the railroad more 

generally? 
41

Frontline Supervisor Questionnaire

Operator Acts

1. What should the operator(s) have done? Typically what would have happened? 

2. What operating/safety/other rules, notices, special instructions, etc., govern the operator’s 

activities just prior to the incident? 

3. Did the operator violate a practice, rule or procedure? Which ones? Could you describe? 

4. Is there more than one way the operator could have completed the task? What are they? 

 

Preconditions

1. What was the condition of the equipment used to do the job? Describe how this 

equipment is maintained. Are there any problems with any of the equipment or parts 

known to you or others? 

2. What PPE should the operator have been wearing at the time of the incident? What was 

the condition of the PPE at the time of the incident? 

3. (If working in a team) Had the operators worked together before? 

4. (If working in a team) Did the operators get along personally? 

5. How did the operator get along with other operators working at the time? 

6. Did anyone ever complain about working with this operator? 

Supervisory Factors

1. Are supervisors (foremen, assistant supervisor, and superintendent) required to be current 

on all operating rules and procedures? 

2. Have you ever been trained to use the equipment used in the incident? How many 

supervisors are qualified or otherwise familiar with the equipment in use at the time of 

the incident? 

3. Please describe the training for the operator involved in the incident. Who trains the 

operators? What is the instructor’s prior background and experience? What is the 

classroom portion of training like? What is on-the-job training (OJT) like? Is there any 

structure to OJT? How does the railroad determine when an individual is qualified? Are 

any formal checklists or other aids used? 

4. Do you provide crew resource management or any type of communications training to 

operators who work in teams? What does it entail? 

5. How do you track operator performance? 

6. What is the performance record of the operator(s) involved in the incident? Has the 

operator been involved in any previous incidents? 
42

7. Who investigates incidents, and what is involved (i.e., what is the process)? What does 

the investigation result in? 

8. How many similar incidents have happened at this location? What has been done to 

correct the situation? 

Organizational Factors

1. How does the railroad communicate safety information to operators (e.g., newsletters, 

videos)? 

2. How would you describe the safety culture at this shop? 

3. How much overtime is there at this shop? How does overtime work? 

4. How would you describe labor/management relations at this shop? 

5. How would you describe communication between you and your management? 

6. Have you ever received pressure or encouragement from your supervisor or superior to 

bend rules or cut corners? 

7. Has there been a large increase or decrease in staffing or workload recently? Can you 

describe it? To what do you attribute this increase or decrease? 

Outside Factors

1. How much communication do you have with the FRA? What is the nature of this 

communication? How often are FRA inspectors onsite? What types of things do they 

look at/for? 
43

Middle and Upper Management Questionnaire 

Organizational Factors

1. In the past several years, has the railroad undergone a significant expansion or reduction 

of its operations? To what do you attribute this? Was this increase/decrease in staff or 

workload anticipated? 

2. How would you describe labor-management relations? 

3. What contact is there between your railroad’s headquarters and your location? 

4. Do you have a corporate safety office? What are its activities? Who does it report to? 

5. How does your railroad communicate safety information to its employees (e.g., 

newsletters, videos)? 

6. How are incidents investigated? Is there incident reporting and investigation? How and 

to whom are incidents reported? 

7. Describe the railroad’s safety program and management methods. 

8. How does the company examine safety trends (good and bad) in the diesel and car repair 

shops? 

9. Are you aware of similar incidents in other parts of your system? 

Outside Factors

1. How much interaction does your railroad have with the FRA? How would you describe 

the relationship between your railroad and the FRA? 

2. Are there any regulations or other outside influences such as the economy that you feel 

contributed, perhaps indirectly, to the incident? Please describe. 

45

Appendix C. 

HFACS-RR Flowcharts 

Figures C-1 through C-5 depict five flowcharts designed to help investigators look for and 

consider particular factors in each of the five HFACS-RR levels as they relate to the accident, 

incident, or close call under investigation. These flowcharts enable investigators to think 

through potential contributing factors at each level of the organizational system during the data 

collection phase and the actual analysis. The flowcharts are helpful in ensuring that active and 

latent failures are at least considered, if not identified, as contributing to a particular accident, 

incident, or close call. 
46

Figure C-1. Operator Acts Flowchart
47

Figure C-2. Preconditions for Operator Acts Flowchart 
48

Figure C-3. Supervisory Factors Flowchart 
49

Figure C-4. Organizational Factors Flowchart 
50

Figure C-5. Outside Factors Flowchart 
51

Appendix D. 

HFACS-RR Worksheet 

The HFACS-RR worksheet helps investigators to be as thorough as possible in the investigation 

and analysis. The worksheet allows space for the investigator to note whether or not each unique 

HFACS-RR category contributed to the accident, incident, or close call. The worksheet also 

prompts investigators to list all contributing factors and map each contributing factor to the 

appropriate HFACS-RR category. 
52

HFACS-RR Worksheet 

Introduction: This worksheet has been prepared to aid you in exploring the deeper contributing factors 

related to the operator acts that have been identified. Using the operator acts as a starting point, this 

worksheet will help you consider each HFACS-RR category, and note whether or not each HFACS-RR 

category influenced or otherwise played a role in contributing to the incident. Although rare, it is possible 

that some operator acts do not have any higher level contributing factors associated with them. The 

majority of operator acts, though, will have several higher-level contributing factors. 

To recap, the HFACS-RR is a model of human error that looks at incidents at five different, hierarchical 

categories. These five categories are operator acts, preconditions for the operator acts, supervisory 

factors, organizational factors, and lastly factors outside the organization (see Figure D-1). You will 

notice the flow of influence such that the outer boxes influence the inner boxes. For example, supervisory 

factors influence preconditions for operator acts and operator acts. As a second example, outside factors 

may influence all other categories, starting with organizational factors. 

Figure D-1. HFACS-RR Flow of Influence 

Instructions: Begin by recording all operator acts (the center of the diagram) that you have identified as 

contributing to the incident, and a brief explanation. For example, if a train crew passes an absolute stop 

signal, the operator act category might be attentional failure (a type of HFACS-RR operator act). Use the 

information you have collected to assign the most specific category of operator act that is possible. For 

example, if it is known that the train crew was responding to a call from a cell phone, then attentional 

failure might be identified as the HFACS-RR operator act. If the crew did not see the signal due to glare 

from the sun, on the other hand, this might be categorized as a perceptual error. You may choose to 

select a broader HFACS-RR category without further specification if you lack sufficient information to 

support your analysis. For example, if you are not sure the error was due to a memory failure or 

attentional failure, you might simply categorize the operator act as a skill-based error. 
53

Next, review the HFACS-RR preconditions for operator acts (the next outer square), and think about 

whether any of the operator acts you have identified were influenced by any HFACS-RR preconditions. 

After you are done, consider supervisory factors, and whether any supervisory factors affected any 

preconditions or operator acts. Next, consider organizational factors, and whether any organizational 

factors affected or influenced any supervisory factors, preconditions or operator acts. Lastly, consider 

outside factors and whether any of these may have played a role in influencing any organizational factors, 

supervisory factors, preconditions or operator acts. 

Please be sure to complete the entire worksheet. 

Operator Acts

Operator acts involve actions or inactions by those closest in time and space to the incident—a train 

crewmember or shop employee, for example. These actions most recently contributed to the incident’s 

occurrence, but they are only one of several factors that contributed to the incident. In fact, for each 

incident, there may be multiple operator acts that are identified. 

Please list below all operator acts that you have identified as contributing to the incident. Use the 

HFACS-RR flow charts to assist you in categorizing each operator act. 

HFACS-RR operator act 1: 

HFACS-RR operator act 2: 

HFACS-RR operator act 3: 

HFACS-RR operator act 4: 

Preconditions for Operator Acts

Preconditions for operator acts are those work-related, contextual, environmental and personal factors that 

exist prior to the incident but that indirectly contribute to an incident's occurrence, often by setting up a 

situation in which one or more operator acts occur. Preconditions are organized into three major 

categories: Environmental factors, personnel factors and the condition of operators. 

Please confirm whether or not one or more preconditions contributed to any of the operator acts listed 

above. Note that more than one precondition can influence each operator act. For each precondition you 

have identified, please provide a brief explanation. 

Environmental factors: 

Physical environment: Yes No 

Technological environment: Yes No 

Personnel factors: 

Crew resource management: Yes No 

Personal readiness: Yes No 

Operator Condition 

Adverse mental state: Yes No 

Adverse physiological state: Yes No 

Physical/mental limitation: Yes No 
54

Explanation(s): 

 

Supervisory Factors 

Supervisory factors consist of failures or deficiencies by front line supervisors (e.g., shift supervisors, 

gang leaders) and first and second-level railroad officers (e.g., managers, foremen) in ensuring that 

operators have a safe working environment, are properly trained and equipped, and operations and 

facilities are adequately staffed. Supervisory factors are manifested in several ways: inadequate 

supervision, planned but inappropriate actions, failure to correct problems, and supervisory 

contraventions. 

Please confirm whether or not one or more supervisory factors contributed to any of the preconditions or 

operator acts that you have identified. Note that more than one supervisory factor could have contributed 

to any precondition or operator act. For each supervisory factor that you have identified, please provide a 

brief explanation. 

Inadequate supervision: Yes No 

Planned inappropriate operations: Yes No 

Failed to correct problem: Yes No 

Supervisory contraventions: Yes No 

Explanation(s): 

 

______________________________________________________________________________

Organizational Factors

Organizational factors are senior management and executive level-decisions, practices, policies, and 

procedures that guide the operation and general governance of an organization. Organizational influences 

include an organization's 1) management of capital resources, 2) climate, and its 3) processes. 

Please confirm whether or not one or more organizational factors contributed to any of the supervisory 

factors, preconditions or operator acts that you have identified. For each organizational factor that you 

have identified, please provide a brief explanation. 

Resource management 

Human resources: Yes No 

Equipment and facility resources: Yes No 

Monetary/budget resources: Yes No 
55

Organizational Climate 

Poor organizational structure: Yes No 

Poor organizational policies: Yes No 

Poor organizational culture: Yes No 

Organizational Process 

Organizational operations: Yes No 

Organizational practices and procedures: Yes No 

Organizational oversight: Yes No 

Organizational Contraventions: Yes No 

Explanation(s): 

 

Outside Factors

Outside factors are the conditions and influences that provide the context in which an organization 

operates, and consequently affect its operations, but that are beyond the organization’s direct control. 

These factors include the regulatory/legislative environment and the political/social/economic 

atmosphere. 

Please confirm whether or not one or more outside factors contributed to any of the organizational factors, 

supervisory factors, preconditions, or operator acts that you have identified. For each outside factor that 

you have identified, please provide a brief explanation. 

Regulatory oversight: Yes No 

Economical/Political/Social environment : Yes No 

Explanation(s): 

 

57

Appendix E. 

Corrective Actions Guide 

Appendix E presents 5 corrective action guides and a set of definitions of 11 generic corrective 

actions. Corrective actions map to specific HFACS-RR categories. Researchers formatted the 

guides similar to the HFACS-RR flowcharts to increase their usability. Figure E-1 presents 

corrective actions relevant to operator acts. Figure E-2 presents corrective actions relevant to 

preconditions for operator acts. Figure E-3 presents corrective actions relevant to supervisory 

factors. Figure E-4 presents corrective actions relevant to organizational factors. Figure E-5 

presents corrective actions relevant to outside factors. Lastly, Table E-1 presents definitions and 

examples of the 11 generic corrective actions. 
58

Figure E-1. Operator Acts Corrective Action Guide 
59

Figure E-2. Preconditions for Operator Acts Corrective Action Guide 
60

Figure E-3. Supervisory Factors Corrective Action Guide 
61

Figure E-4. Organizational Factors Corrective Action Guide 
62

Figure E-5. Outside Factors Corrective Action Guide 
63

Table E-1. Corrective Action Definitions and Examples

Corrective Action9 Definition Corrective 

Action 

(E)ngineering (A)dministrative (P)PE (G)overnment action 

Example

1. Improve training This action includes introducing new 

training or improving existing (new hire, new procedure, refresher) training. Corrective actions can address training content/materials and methods, and can include classroom, OJT, and simulation-based approaches, among others. 

A • Introduce refresher trai

infrequently used proc

• Improve existing traini

• Increase frequency of r

• Introduce job preview 

training 

• Implement crew resour

training 

2. Improve job tasks and 

responsibilities 

Improvements to job tasks and responsibilities include both complete overhaul of job tasks/responsibilities and changes to one task/responsibility. Improvements can be to existing tasks or the introduction of new tasks/responsibilities. 

E, A • Reduce job responsibil

3. Improve workspace Improvements to the workspace focus 

on the physical layout of the area or facility in which a particular job is carried out. This space can include a diesel or car repair shop, for example, or an entire yard or even a stretch of main track on which a train-and-engine crew makes runs. Improvements can be partial, where one or more 

E • Rearrange work station

flow 

• Add warning signs in y

presence of remote conoperations 

• Conduct an ergonomic 

eliminate or otherwise hazards 

9 While some corrective actions will involve unilateral implementation by the railroad, many will require cooperation and partnerships with labor unio

governmental body responsible for railroad safety in the affected area(s). 
64

Corrective Action9 Definition Corrective 

Action 

(E)ngineering (A)dministrative (P)PE (G)overnment action 

Example

components of the physical space are modified, or whole, where the physical space is completely overhauled. 

• Re-locate a supervisor 

closer to employees foresponsible 

4. Improve practices, procedures, 

rule books, manuals, written instructions and materials, and other written (i.e., nontechnological) job aids 

Improvements to practices, procedures, etc., cover all methods and materials that govern or aid employees in carrying out their work safely. Improvements can include the introduction of a new practice or procedure, or the modification of an existing one. 

A • Re-write a rule to incre

clarity 

• Create a new work pro

• Implement rest breaks 

• Introduce calisthenics 

employees in physicall

• Improve job briefing p

• Develop a new checkli

• Create 24-hr hotline to 

• Create a new procedur

updates to the rule boo

• Implement more frequ

facility inspections 

• Make proficiency testin

focus on safe behaviorviolations 

5. Improve policies This category includes those nonoperational strategies that dictate and 

govern all other aspects of work. These include policies regarding employee hiring, promotion, accident investigations, and hearings. 

A • Improve accountability 

• Introduce a new hire sc

6. Improve tools and equipment Improvements to tools and equipment 

can include acquisition of new tools/equipment and modifications to existing tools/equipment. This 

E • Introduce a guard to a 

exposed moving parts 

• Conduct a human facto
65

Corrective Action9 Definition Corrective 

Action 

(E)ngineering (A)dministrative (P)PE (G)overnment action 

Example

category also includes new or improved instructions, and assessments of tools and equipment to determine their adequacy. 

tool/equipment interfac

• Re-design a tool to avo

activation of a control 

• Add well-designed (i.e

communicated) warninequipment 

• Improve instructions 

7. Personal protective equipment 

(PPE) 

This category includes introducing, modifying, or making more accessible PPE, such as eyewear, ear protection, vests, clothing (e.g., rain gear), and boots. 

P • Introduce mandatory e

• Add eyeglass dispense

to increase PPE access

8. Develop a business case for 

safety 

This corrective action involves written and oral communications to superiors to convince superiors of the need and merit for additional resources. 

A • Produce cost/benefit an

preventive spending/im$250,000 spent now wlater) 

9. Re-allocate monetary 

resources 

This corrective action covers the redirection of financial assets to a safetyrelated program to explicitly address one of the safety deficiencies identified in the investigation. 

A • Increase spending on y

10. Political action This action involves official, 

organizational communications with, voting, and legal contributions to, political representatives, such as congressmen and senators, as well as local municipalities, in order to affect a change to a Federal, State, local, or other governmental regulation, or order. This action also includes 

G • Write letter to, or visit 

representative 
66

Corrective Action9 Definition Corrective 

Action 

(E)ngineering (A)dministrative (P)PE (G)overnment action 

Example

obtaining grants or other financial support from FRA and others outside the railroad to defray costs of implementing corrective actions. 

11. Improve regulations This corrective action involves 

working with FRA to improve safety and explicitly address one of the safety deficiencies identified in the investigation. The target deficiency must be governed by, or potentially governed by, a Federal, State, or other regulation. 

G • Work with FRA to cha
67

Appendix F. 

Incident Report Form 

Appendix F contains a copy of the incident report form used in this study. Researchers asked 

study participants to complete the two-page form after each RCA investigation and return it to 

the research team. 
68

Railroad Incident Report Form 

Instructions: Please complete the following information after completing your investigation to help us understand 

the circumstances under which the incident occurred and the context for your application of the root cause analysis 

methodology. 

Railroad: 

Investigators 

 Railroad representative: 

 Labor representative: 

Date of incident (mm/dd/yyyy): / / 

Time of day of incident (include a.m. or p.m.): 

Where did the incident occur (shop/facility name/location, etc.): 

Weather at the time of the incident: 

Temperature at the time of the incident: 

Date(s) incident was investigated: 

Approximate number of hours, per investigator, it took to complete the investigation: 

 for railroad representative for labor representative 

Describe the incident (the task being performed, equipment involved, personnel involved, the sequence of events 

leading up to the incident, the hazard(s) and/or unexpected event, the nature of the incident, the severity of the 

incident, etc.). Use a second page if necessary: 

 

 
69

HFACS-RR Analysis 

Instructions: Based on your use of the HFACS-RR flow charts and worksheets, please record your findings here, 

beginning with unsafe acts. For each general HFACS-RR category, include a brief description of the activity, event, 

or occurrence in the middle column, and record the specific HFACS-RR category in the far right column. 

General HFACS-RR 

Category 

Occurrence Specific HFACS-RR Category 

Operator Acts 

E.g., Æ Employee forgot a step in a maintenance procedure Memory failure 

 

Preconditions 

Supervisory Factors 

Organizational Factors 

Outside Factors 

71

Appendix G. 

Post-Study Feedback Questions 

Post-study feedback questions elicit feedback at the conclusion of the study on the usefulness of 

the RCA methods and paper-based tools, as well as the overall value of the RCA process. Due to 

various barriers encountered in this study, participants did not gain sufficient experience to 

provide complete answers to many of these questions. A subset of these questions, however, 

guided telephone interviews with labor and management part way through the study to obtain 

their feedback on barriers and suggestions to successful implementation in the future. 

The questions are organized around two primary themes—the RCA process and the RCA tools.

RCA process questions 

1. Did Foster-Miller provide sufficient training in the use and application of the RCA 

process and tools? 

2. Did you find the RCA process easy to use? 

3. Did you find the RCA process easy to incorporate into your own investigation approach? 

How did you incorporate the RCA process into your own investigation approach? 

4. What did you think of the labor-management collaborative process for investigating 

incidents? 

5. Did the RCA process provide new insights regarding contributing factors that you may 

not have otherwise identified using your traditional investigation approach? 

6. How easy was it to examine operating rules, supervisory procedures and overall railroad 

policies (i.e., the supervisory and organizational factors)? 

7. During the investigation and analysis, was it difficult to completely avoid culpability 

(blaming someone) for the incident? If so, why? 

8. How would you describe the interview process with those involved in the incident? Were 

interviewees cooperative? If so, to what do you attribute this? If not, why not? Did the 

RCA tools/process provide you with enough guidance on what questions to ask during 

the interviews? 

9. Was it clear when to conclude your investigation? What rules of thumb or guidance did 

you use to help you conclude your investigation? 

10. Were you able to complete the investigation in the 8-12 hour time period estimated for 

each incident investigation and analysis? How long did it take you to complete each 

investigation and analysis? Is this a reasonable amount of time to expect? If not, how 

much time is reasonable for each investigation and analysis? 

11. Do you feel that you or your railroad would benefit from incorporating this approach into 

the railroad’s existing investigation process? 

12. What are some barriers to incorporating this approach? 
72

13. What would you do differently if you were to formally incorporate this process into your 

railroad’s existing accident investigation process? If you were designing the RCA 

process for the entire railroad industry to use, what changes would you make? 

RCA tool questions 

1. Did you find the tools we gave you helpful or burdensome in investigating incidents and 

identifying contributing factors? Which tools were helpful and which were burdensome? 

2. Did the HFACS-RR flow charts help you to identify contributing factors, or did it make 

the investigation more cumbersome? 

3. Was it easy to classify contributing factors using the HFACS-RR categories? 

4. Was the tool that mapped the HFACS-RR categories to corrective action categories 

helpful? Were the corrective action categories explicit enough or too broad to be of use? 

Were you able to identify some specific corrective actions based on the corrective action 

categories? Would more explicit corrective action suggestions have been more helpful? 

5. Were you able to identify any operator acts that contributed to an incident? 

6. Were you able to identify any preconditions that contributed to an incident? 

7. Were you able to identify any supervisory factors that contributed to an incident? 

8. Were you able to identify any organizational factors that contributed to an incident? 

9. Were you able to identify any outside factors that contributed to an incident? 
73

Abbreviations and Acronyms 

d day(s) 

EOT device end-of-train device 

FELA Federal Employers’ Liability Act 

FRA Federal Railroad Administration 

GEMS generic error modeling system 

h hour(s) 

HFACS Human Factors Analysis and Classification System 

in inch(es) 

lb pound(s) 

mo month(s) 

mtm million train miles 

NTSB National Transportation Safety Board 

OJT on-the-job training 

RCA root cause analysis 

yr year(s)