United States Government Accountability Office

GAO Report to Congressional Committees

RAIL SAFETY 

The Federal Railroad 

Administration Is 

Taking Steps to Better 

Target Its Oversight, 

but Assessment of 

Results Is Needed to 

Determine Impact 

January 2007 

 

GAO-07-149 
What GAO Found

United States Government Accountability Office

Why GAO Did This Study

Highlights

Accountability Integrity Reliability

January 2007

RAIL SAFETY

The Federal Railroad Administration Is 

Taking Steps to Better Target Its 

Oversight, but Assessment of Results Is 

Needed to Determine Impact 

Highlights of GAO-07-149, a report to 

congressional committees 

Since 1980, the train accident rate

has improved significantly, but 

progress has leveled off over the

past 10 years. Recent serious 

accidents—such as one in

Graniteville, South Carolina, that

led to 9 deaths and 292 injuries—

elevated concerns. The Federal

Railroad Administration (FRA) 

develops safety standards and 

inspects and enforces railroads’ 

compliance with these standards. 

This report addresses how FRA (1) 

focuses its efforts on the highest 

priority risks related to train 

accidents in planning its oversight,

(2) identifies safety problems on

railroad systems in carrying out its 

oversight, and (3) assesses the 

impact of its oversight efforts on 

safety. To complete this work, 

GAO reviewed FRA regulations, 

planning and policy documents, 

and safety data. GAO also 

contacted FRA officials in

headquarters and three regional

offices and others. 

What GAO Recommends

GAO is recommending that FRA 

develop measures of the direct 

results of its oversight and evaluate

the effectiveness of its enforcement

program. The Department of 

Transportation did not provide 

overall comments on these 

recommendations but did provide 

several technical comments, which 

were incorporated as appropriate. 

In planning its safety oversight, FRA is focusing its efforts on the highest 

priority risks related to train accidents through initiatives aimed at 

addressing their main causes—human behaviors and defective track—as 

well as through improvements in its inspection planning approach. In its 

May 2005 National Rail Safety Action Plan, the overall strategy for targeting

its oversight at the greatest risks, FRA provides a reasonable framework for 

guiding these efforts. Its initiatives to address the most common causes of 

accidents are promising, although the success of many of them will depend 

on voluntary actions by the railroads. In addition, the action plan outlined 

the agency’s development of a new inspection planning approach. Under 

this approach, inspectors focus their efforts on locations that data-driven 

models indicate are most likely to have safety problems. 

In carrying out its safety oversight, FRA identifies a range of specific and 

broad-scale safety problems on railroad systems mainly by determining 

whether operating practices, track, and equipment are in compliance with 

minimum safety standards. However, FRA is able to inspect only about 0.2 

percent of railroads’ operations each year and its inspections do not examine 

how railroads are managing safety risks throughout their systems that could 

lead to accidents. Such an approach, as a supplement to traditional 

compliance inspections, is used in the oversight of U.S. commuter railroads 

and pipelines and of Canadian railroads. While this type of approach can 

provide additional assurance of safety, GAO is not recommending that FRA 

adopt it because its various initiatives to reduce the train accident rate have 

not yet had time to demonstrate their effects on safety. 

 

FRA uses a broad range of goals and measures to assess the impact of its 

oversight. For example, it has developed (1) new goals to target its 

inspection and enforcement programs at reducing various types of railroad 

accidents and (2) related measures to monitor its progress. These measures

include the rate of train accidents caused by human behaviors, track defects, 

and equipment defects. However, FRA’s ability to make informed decisions 

about these programs is limited because it lacks measures of their direct 

results, such as the correction of identified safety problems. Furthermore, 

FRA has not evaluated the effectiveness of its enforcement program. 

Track Inspector Examining Rail to Assess Its Safety Compliance

www.gao.gov/cgi-bin/getrpt?GAO-07-149.

To view the full product, including the scope 

and methodology, click on the link above. 

For more information, contact Katherine 

Siggerud at (202) 512-2834 or 

siggerudk@gao.gov. 
Contents 

Letter 1

Results in Brief 3

Background 6

FRA Has Made Progress in Targeting Its Oversight Efforts on the 

Basis of Risk 15 

FRA Relies Primarily on Direct Inspections to Identify Safety 

Problems and Does Not Oversee Railroads’ Management of 

Safety Risks 27 

FRA Measures Its Progress in Achieving a Variety of Safety Goals, 

but Has Limited Information on the Direct Results of Its 

Oversight 39

Conclusions 50

Recommendations for Executive Action 50 

Agency Comments 51 

Appendix I Scope and Methodology 52 

Other Aspects of Our Work 53 

Appendix II FRA Addresses Safety Problems through 

Cooperation and Enforcement 56 

Appendix III Oversight of Risk Management in the U.S. 

Commuter Railroad, U.S. Pipeline, and Canadian 

Railroad Industries 62 

Appendix IV GAO Contact and Staff Acknowledgments 65 

Tables 

Table 1: FRA’s Inspection Disciplines 13 

Table 2: Key FRA Initiatives Aimed at Addressing Main Causes of 

Train Accidents 17 

Table 3: FRA’s Safety Performance Measures 43 

Table 4: Description of FRA Enforcement Actions and Frequency 

of Use, January 2005 through July 2006 57 

Table 5: Risk Management Framework 62 

Page i GAO-07-149 Railroad Safety Oversight
Figures 

Figure 1: Train Accident Rates, 1980 through 2005 2 

Figure 2: Train Miles Traveled, 1996 through 2005 7 

Figure 3: Train Injuries and Deaths, 1980 through 2005 8 

Figure 4: Primary Causes of Train Accidents, 2005 10 

Figure 5: Human Factor and Track Accident Rates, 1980 through 

2005 11

Figure 6: FRA Inspector Measuring Track Gauge 29 

Figure 7: FRA Inspector Inspecting Train Cars 30 

Figure 8: Inspections Conducted and Defects and Violations 

Cited, by Inspection Discipline, in 2005 32 

Figure 9: How FRA’s Inspection and Enforcement Programs 

Contribute to Rail Safety 41 

Figure 10: FRA’s Civil Penalties, 1996 through 2005, in 2005 Dollars 59 

Abbreviations 

APTA American Public Transportation Association 

FRA Federal Railroad Administration 

NTSB National Transportation Safety Board 

PHMSA Pipeline and Hazardous Materials Safety Administration 

This is a work of the U.S. government and is not subject to copyright protection in the 

United States. It may be reproduced and distributed in its entirety without further 

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other material, permission from the copyright holder may be necessary if you wish to 

reproduce this material separately. 

Page ii GAO-07-149 Railroad Safety Oversight
United States Government Accountability Office

Washington, DC 20548 

January 26, 2007 

The Honorable Patty Murray 

Chairman 

The Honorable Christopher Bond 

Ranking Minority Member 

Subcommittee on Transportation, 

 Housing and Urban Development, 

 and Related Agencies 

Committee on Appropriations 

United States Senate 

The Honorable Patty Murray 

Chairman 

The Honorable Christopher Bond 

Ranking Minority Member 

Subcommittee on Transportation, 

 Housing and Urban Development, 

 and Related Agencies 

Committee on Appropriations 

United States Senate 

The Honorable John Olver 

Chairman 

The Honorable Joe Knollenberg 

Ranking Minority Member 

Subcommittee on Transportation, 

 Housing and Urban Development,

 and Related Agencies 

Committee on Appropriations 

House of Representatives 

The Honorable John Olver 

Chairman 

The Honorable Joe Knollenberg 

Ranking Minority Member 

Subcommittee on Transportation, 

 Housing and Urban Development,

 and Related Agencies 

Committee on Appropriations 

House of Representatives 

Since 1980, the overall safety record in the railroad industry, as measured 

by the rate of train accidents, has improved markedly. (See fig. 1.) 

However, during the past decade, the rate of improvement has leveled off, 

and a number of serious accidents in 2004 and 2005 elevated concerns 

about railroad safety. For example, in January 2005, a train carrying 

hazardous materials collided with a standing train in Graniteville, South 

Carolina, resulting in 9 deaths and 292 injuries and requiring the 

evacuation of 5,400 people. In response to the leveling off of the train 

accident rate, this accident, and other serious train accidents, in May 2005, 

the federal railroad safety regulator, the Federal Railroad Administration

(FRA), announced a National Rail Safety Action Plan to improve its safety 

oversight. The plan outlines strategies for FRA to target the most frequent,

highest-risk causes of accidents, focus federal oversight and inspection 

resources, and research the use of technologies in order to improve rail 

safety. 

Since 1980, the overall safety record in the railroad industry, as measured 

by the rate of train accidents, has improved markedly. (See fig. 1.) 

However, during the past decade, the rate of improvement has leveled off, 

and a number of serious accidents in 2004 and 2005 elevated concerns 

about railroad safety. For example, in January 2005, a train carrying 

hazardous materials collided with a standing train in Graniteville, South 

Carolina, resulting in 9 deaths and 292 injuries and requiring the 

evacuation of 5,400 people. In response to the leveling off of the train 

accident rate, this accident, and other serious train accidents, in May 2005, 

the federal railroad safety regulator, the Federal Railroad Administration

(FRA), announced a National Rail Safety Action Plan to improve its safety 

oversight. The plan outlines strategies for FRA to target the most frequent,

highest-risk causes of accidents, focus federal oversight and inspection 

resources, and research the use of technologies in order to improve rail 

safety. 

Page 1 GAO-07-149 Railroad Safety Oversight
Figure 1: Train Accident Rates, 1980 through 2005 

0

2

4

6

8

10

12

199

1999

2000

2001

2002

2003

2004

2005

8

19

1990

1991

1992

1993

1994

1995

1996

1997

89

1988

1987

1986

1985

1984

1983

1982

1981

1980

Accident rate (per million train miles)

Source: FRA.

Year

Citing concerns over several serious accidents that occurred in 2005, the 

Senate Appropriations Committee directed that we assess FRA’s oversight 

approach. Accordingly, this report concentrates on how FRA (1) focuses 

its efforts on the highest priority risks related to train accidents in 

planning its safety oversight, (2) identifies safety problems on railroad 

systems in carrying out its oversight, and (3) assesses the impact of its 

oversight efforts on safety. 

To determine how FRA focuses its efforts on the highest priority risks 

related to train accidents in planning its safety oversight, we reviewed the

agency’s National Rail Safety Action Plan, plans for developing new 

regulations, inspection planning documents, and other key planning 

documents related to targeting its oversight at these risks. We also 

discussed oversight planning efforts with FRA officials. To assess how 

FRA identifies safety problems on railroad systems in carrying out its 

oversight, we reviewed FRA’s statutory authority; regulations; and 

policies, procedures, and guidance for conducting inspections and 

identifying safety issues. We reviewed data from FRA on its inspection 

activities for the period from 1996 through 2005. We also examined risk 

management principles and safety oversight approaches used by other 

modal administrations within the Department of Transportation and 

Page 2 GAO-07-149 Railroad Safety Oversight
elsewhere that have similar safety missions in order to determine their 

possible application to FRA. To determine how FRA assesses the impact 

of its oversight efforts on safety, we examined FRA safety performance 

measures and evaluations of its oversight activities, determined how FRA 

uses this information in making decisions about its oversight, and 

reviewed our products on performance measurement and evaluation. 

As part of our work in each of these areas, we interviewed program and 

enforcement officials at FRA headquarters, as well as at three regional 

offices covering states with the highest train accident rates. We also 

discussed FRA’s approach to safety oversight with representatives of 

railroads, unions, and state railroad safety organizations. Our work 

focused on FRA oversight efforts to reduce the rate of train accidents 

rather than those to reduce highway-rail crossing and trespassing 

accidents because (1) the Department of Transportation’s Inspector 

General has recently assessed efforts to reduce highway-rail crossing 

accidents1

 and (2) trespassing accidents primarily involve issues not 

related to railroad safety performance. We also focused on FRA’s 

oversight of railroads rather than its oversight of nonrailroad companies 

(such as shippers of hazardous materials by rail) because the agency’s 

oversight efforts focus primarily on railroads. In addition, according to 

FRA, most recent serious train accidents involving the release of 

hazardous materials have resulted from problems with railroad operations. 

As part of our review, we assessed internal controls and the reliability of 

FRA’s data on its inspection activities and enforcement actions that were 

pertinent to these efforts. We determined that the data elements were 

sufficiently reliable for our purposes. We conducted our work from 

November 2005 through January 2007 in accordance with generally 

accepted government auditing standards. (See app. I for additional 

information on our scope and methodology.) 

In planning its safety oversight, FRA is focusing its efforts on the highest 

priority risks related to train accidents through various initiatives aimed at

addressing the main causes of these accidents as well as through 

improvements in its inspection planning approach. The agency’s overall 

Results in Brief 

 1

See U.S. Department of Transportation, Office of the Inspector General, Audit of 

Oversight of Highway-Rail Grade Crossing Accident Reporting, Investigations and

Safety Regulations, MH-2006-016 (Washington, D.C., Nov. 28, 2005); and Report on the 

Audit of the Highway-Rail Grade Crossing Safety Program, MH-2004-065 (Washington, 

D.C., June 16, 2004). 

Page 3 GAO-07-149 Railroad Safety Oversight
strategy for targeting its oversight at the greatest risks is the National Rail

Safety Action Plan. This plan provides a reasonable framework for guiding

the agency’s efforts to improve its oversight. It includes initiatives to 

address the two main causes of train accidents—human factors and 

defective track—and FRA has pursued some additional initiatives to 

address these causes since issuing the plan.2

 These initiatives—which 

include new regulations, research on new technologies and approaches for 

improving safety, and new vehicles for inspecting track—have the 

potential to reduce the risks associated with these causes and thereby 

reduce the rate of train accidents. For example, FRA has recently issued 

proposed regulations that, if finalized, will enable the agency to take 

enforcement actions when railroad employees do not follow key railroad 

operating procedures for ensuring safety and, therefore, may help to 

reduce some common types of accidents caused by human factors. 

However, most of these initiatives have not yet been fully implemented, 

and, while some may start showing results in the next year or two, their 

overall impact on safety will probably not be apparent for a number of 

years. Furthermore, the ability of many of these efforts to improve safety 

will depend on voluntary actions by railroads, such as the adoption of a 

model FRA has developed to improve train crew scheduling practices in 

order to prevent worker fatigue. In addition, the National Rail Safety 

Action Plan announced a new approach for planning inspections that 

relies on greater use of accident and inspection data and other data. Under 

this approach, which FRA has been using for over a year, inspectors focus 

their efforts on locations that, according to data-driven models, are likely

to have safety problems. This new planning approach allows FRA to use 

its inspectors more effectively and better target the greatest safety risks. 

In carrying out its safety oversight, FRA identifies safety problems on 

railroad systems mainly through routine inspections that determine 

whether operating practices, track, and equipment, such as signals and 

locomotives, are in compliance with safety standards. Through this 

approach, FRA inspectors identify a range of safety problems at various 

sites on railroads’ systems. FRA also identifies some broad-scale problems 

that affect multiple sites, primarily through analyses of accident and 

inspection data, internal discussions, and some nonroutine inspections. 

However, the number of FRA and state inspectors is small relative to the 

 2

Generally, human factors are behaviors that affect job performance, such as incorrectly 

setting switches. According to FRA, the term human factors refers broadly to the role of

human participation in any system and to the ways in which human beings positively or 

negatively contribute towards system performance. 

Page 4 GAO-07-149 Railroad Safety Oversight
size of the industry and FRA inspections are able to cover only about 0.2 

percent of railroads’ operations each year.3

 Also, these inspections focus 

on compliance with minimum standards and are not designed to 

determine how well railroads are managing safety risks throughout their 

systems that could lead to accidents. The American Public Transportation 

Association (APTA), the Pipeline and Hazardous Materials Safety 

Administration (PHMSA), and Transport Canada have implemented 

approaches to oversee the management of safety risks by U.S. commuter 

railroads, U.S. pipelines, and Canadian railroads, respectively. Risk 

management can be described as a continuous process of managing—

through the systematic identification, analysis, and control of risks 

associated with safety hazards (such as train collisions)—the likelihood of 

hazards’ occurrence and their negative impact.4

 These oversight 

approaches complement, rather than replace, traditional compliance 

inspections and, therefore, provide additional assurance of safety. 

However, because we believe that FRA’s initiatives to reduce train 

accident rates need time to mature and demonstrate their effects on 

safety, we are not recommending that FRA adopt an approach for 

overseeing railroads’ management of safety risks. 

FRA uses a broad range of goals and measures to assess the impact of its 

oversight efforts on safety. For example, it has developed new goals to 

target its inspection and enforcement efforts at reducing various types of 

railroad accidents and related measures to track its progress. These 

measures include the level of train accidents caused by human factors, 

track defects, and equipment defects, both nationwide and within each of

its eight regions. These safety performance measures provide FRA with 

much information that it uses to make decisions about its oversight 

approach. However, its ability to make informed decisions is limited 

because it lacks measures of the direct results of its inspection and 

enforcement programs, such as measures of the extent to which these 

programs have resulted in the correction of identified safety problems or 

improvements in compliance. We have found that it is a useful practice for 

agencies to establish measures of programs’ direct results to help show 

their contributions to the ultimate results the agencies seek to achieve. 

Furthermore, while FRA has made some changes in its oversight approach 

 3

This figure is an FRA estimate, based on an estimation of the amount of activity, such as 

train movements, on each railroad in the United States. 

4

Risk is the combination of the likelihood and the consequence of a specified hazard being

realized. 

Page 5 GAO-07-149 Railroad Safety Oversight
in response to external and internal evaluations, the agency has not 

evaluated the effectiveness of its enforcement program in achieving 

desired results. Evaluations can provide a broader range of information on 

program performance and how to improve it than performance measures 

alone. Both performance measures and evaluations can provide valuable

information on program results that helps hold agencies accountable for

the performance of their programs. 

To improve FRA’s ability to determine the extent to which its inspection 

and enforcement programs are contributing to rail safety and whether 

changes in these programs are needed, we are recommending that FRA 

develop and implement measures of the direct results of its inspection and 

enforcement programs and evaluate its enforcement program. We 

provided a draft of this report to the Department of Transportation for its 

review and comment. The department did not offer overall comments on 

the draft report or its recommendations. It did offer several technical 

comments, which we incorporated where appropriate. 

Railroads are an important component of the transportation system, 

transporting about 42 percent of the nation’s freight (as measured by 

weight). For passenger movement, railroads play a much smaller role than

do highway and air travel; however, communities are looking to different 

forms of public transit for relief, particularly as highways become 

increasingly congested. Demand continues to grow for both freight and

passenger transportation on railroads. In 2005, railroads traversed 790 

million train miles,5

 an increase of 18 percent since 1996. (See fig. 2.) 

Moreover, the Department of Transportation estimates that between 1998 

and 2020, the amount of freight transported by rail (as measured by 

weight) will increase by about 50 percent. Commuter and intercity 

passenger railroads have also grown—providing over 522 million 

passenger trips in 2005, compared with 385 million in 1995. According to

the Federal Transit Administration, as of 2006, seven more commuter rail 

systems throughout the country were being planned or designed. 

Background 

 5

A train mile is the movement of a train a distance of 1 mile. 

Page 6 GAO-07-149 Railroad Safety Oversight
Figure 2: Train Miles Traveled, 1996 through 2005 

0

100

200

300

400

500

600

700

800

900

1996 1997 1998 1999 2000 2001 2002 2003 2004 2005

Train miles (millions)

Source: FRA.

Year

The railroad industry is primarily composed of 7 large freight railroads 

(called Class I railroads); about 560 smaller freight railroads (called Class 

II and III railroads); and 118 passenger, commuter, tourist, excursion, and

other railroads.6

 Within the industry, Class I freight railroads predominate, 

representing about 93 percent of railroad freight revenue and 69 percent of

the total U.S. rail mileage. Class II and Class III railroads include a number

of regional and short line railroads that provide freight transportation. 

Class II regional railroads typically operate 400 to 650 miles of track in a

region spanning two to four states, whereas Class III short lines typically

perform point-to-point service over short distances. 

On average, about 446 people have been injured and 14 people have been 

killed each year over the past decade, from 1996 through 2005, exclusive 

of highway-railroad grade crossing and trespassing accidents. Despite 

overall improvements since 1980, gains have tapered off. Since 1992, the 

accident rate has remained at about or sometimes more than four 

 6

For 2005, the Surface Transportation Board has defined Class I railroads as railroads 

earning adjusted annual operating revenues of $319.3 million or more. Class II railroads are 

those earning between $25.5 million and $319.3 million, and Class III railroads are those 

earning less than $25.5 million. 

Page 7 GAO-07-149 Railroad Safety Oversight
accidents per million train miles. (See fig. 1.) In recent years, a number of 

serious accidents raised concerns about the level of safety in the railroad 

industry. Train accidents resulted in 1,884 injuries and 15 deaths in 2002,

and 733 injuries and 33 deaths in 2005. (See fig. 3.) FRA officials attributed

the large rise in number of injuries and deaths in 2002, and subsequently in 

2005, to one or two major accidents, as opposed to a series of accidents. 

For example, in 2002, a derailment in Minot, North Dakota, led to the 

release of approximately 200,000 gallons of anhydrous ammonia, 1,442 

injuries and 1 death. In 2005, a train collision in Graniteville, South 

Carolina, resulted in the evacuation of 5,400 people, 292 injuries and 9 

deaths. 

Figure 3: Train Injuries and Deaths, 1980 through 2005 

0

500

1,000

1,500

2,000

199

1999

2000

2001

2002

2003

2004

2005

8

19

1990

1991

1992

1993

1994

1995

1996

1997

89

1988

1987

1986

1985

1984

1983

1982

1981

1980

Deaths and injuries

Source: FRA.

Year

Note: Injuries were far more common than deaths during the period of 1980 through 2005; deaths

ranged from 4 to 67 per year. Figures do not include highway-railroad crossing and trespassing 

incidents. 

Although Class I railroads have a lower rate of accidents than Class II and 

III railroads, because of their size, they account for most train accidents; in

Page 8 GAO-07-149 Railroad Safety Oversight
2005, Class I railroads were involved in 76 percent of train accidents.7

Moreover, Class I railroads were involved in 53 percent of injuries and 58 

percent of deaths during that year. 

According to FRA data, the majority of train accidents are attributable to 

either human factors or track defects. (See fig. 4.) For 2005, FRA data 

show that human factors and track defects were the primary causes of 72

percent of all train accidents. Those accidents caused by human factors 

often result from actions such as improperly positioning switches, shoving 

cars without properly checking for safe conditions, leaving cars in a 

position that obstructs track, and failing to secure a sufficient number of 

handbrakes. Those accidents caused by defective track often result from 

defective or ineffective crossties; broken or worn switch points; and 

broken, fissured or fractured rail components. 

 7

FRA defines a train accident as any collision, derailment, fire, explosion, act of God, or 

other event involving operation of railroad on-track equipment (standing or moving) that 

results in reportable damages greater than the current reporting threshold to railroad ontrack equipment, signals, track, track structures, and roadbed. The threshold for 2006 was

$7,700. 

Page 9 GAO-07-149 Railroad Safety Oversight
Figure 4: Primary Causes of Train Accidents, 2005 

Source: GAO analysis of FRA data.

11%

12%

33%

39%

Human factors

Track 

Miscellaneousb

Equipment 

3%

Interaction of lateral

and vertical forcesa

2%

Signal 

a

Interaction of lateral and vertical forces refers to a specific type of accident that occurs when a 

lateral, or sideways, force exceeds a vertical force, or gravity, by 50 percent or more. Lateral force 

may be caused by travel through curves and alignment imperfections in the track. 

b

The miscellaneous category of accident causes contains a number of subcategories, none of which 

exceeds 1.5 percent. 

As have overall accident rates, improvements in human factor and track 

accident rates have leveled off over the past decade, achieving their lowest 

rates in 1996 and 1995, respectively. (See fig. 5.) According to FRA, the 

increase in the human factor accident rate in 2004 can be attributed to 

increases in accidents caused by employees not following railroad 

operating rules. (These rules specify various operating procedures, such as 

the proper positioning of track switches, to ensure safe operations.) 

However, according to FRA, these types of human factor accidents 

decreased by 21 percent from the first half of 2005 to the first half of 2006. 

Officials attribute this decrease largely to actions the agency has taken to 

focus railroads’ attention on this problem,8

 including issuing a safety 

 8

In addition, according to FRA, train accident rates for 2006 will probably appear slightly 

more favorable than those for 2005 because of a single, large increase in the dollar level 

reporting threshold for the year 2006. Specifically, starting in 2006, railroads are required to

report accidents resulting in railroad property damage exceeding $7,700, up from the

previous threshold of $6,700. 

Page 10 GAO-07-149 Railroad Safety Oversight
Page 11 GAO-07-149 Railroad Safety Oversight 

advisory and an emergency order in 2005 to address the problem of 

employees leaving hand-operated main track switches in nonsignaled 

territory in the wrong position, the cause of an increasing number of 

accidents, including the Graniteville accident.9

Figure 5: Human Factor and Track Accident Rates, 1980 through 2005 

While the individual railroads have primary responsibility for their safe 

operation, FRA conducts various activities to oversee safety. FRA 

develops and enforces regulations for the industry that include 

requirements related to safety. For example, these regulations include 

requirements governing track, signal and train control systems, grade 

crossing warning device systems, mechanical equipment—such as 

locomotives and tank cars—and railroad operating practices. FRA also 

enforces hazardous materials regulations issued by PHMSA as they relate 

to the safe transportation of such materials by rail. Many of FRA’s 

regulations have detailed, prescriptive minimum requirements for track 

 9

Nonsignaled territory refers to sections of track where no signal or other system is in 

service that indicates that a main track switch may be in other than its normal position. 

0

1

2

3

4

5

199

1999

2000

2001

2002

2003

2004

2005

8

19

1990

1991

1992

1993

1994

1995

1996

1997

89

1988

1987

1986

1985

1984

1983

1982

1981

1980

Accident rate (per million train miles)

Source: FRA.

Year

Track

Human factor
and equipment, such as wheel safety requirements and formulas that 

determine maximum allowable speeds on curved track. However, some 

regulations are not prescriptive and allow railroads greater flexibility in 

determining how to comply. For example, if a railroad chooses to 

implement a processor-based train control system or product,10 it must 

develop and receive FRA’s approval for a railroad safety program plan. 

The plan should include a description of risk assessment procedures and 

the safety assessment process, and railroads have flexibility to adjust their 

programs to accommodate the specific system or product change. In 

addition, some regulations require railroads to develop and implement 

safety programs, such as accident and incident reporting programs and 

roadway worker protection programs. 

In 1996, FRA adopted a more participatory approach to rulemaking 

through the creation of the Railroad Safety Advisory Committee. This 

committee is designed to include all segments of the rail community in 

developing solutions to safety regulatory issues. Currently, the committee 

consists of 39 member organizations, including representatives from 

railroads, railroad associations, labor, states, and agencies with railroad 

regulatory responsibility in Canada and Mexico. 

FRA conducts inspections to determine railroads’ compliance with its 

regulations. Typically, inspectors conduct inspections at specific sites of 

railroad operations. For example, inspectors examine track, equipment, 

devices, employee actions, or procedures and may review records 

maintained by the railroad in order to determine the railroad’s compliance 

with FRA regulations. Inspectors generally specialize in one of five areas, 

called inspection disciplines: (1) operating practices, (2) track, (3) 

hazardous materials, (4) signal and train control, and (5) motive power 

and equipment. (See table 1.) FRA’s policy is to cite defects for most 

instances of noncompliance and to encourage the railroad to comply 

voluntarily. 

 10A processor-based train control system or product is one that is dependent for its proper

functioning on a digital processor, such as an onboard signal or switch control. 

Page 12 GAO-07-149 Railroad Safety Oversight
Table 1: FRA’s Inspection Disciplines 

Inspection Discipline Examples of what inspections cover (not all inclusive) 

Operating practices Railroad operations related to human factors, including employee compliance with railroad

operating rules, railroads’ monitoring of this compliance, drug and alcohol testing of employees, 

employees’ hours of service, radio communications, locomotive engineer qualification, and accident 

and incident reporting. 

Track and structuresaCondition of track and structures, including track components and geometry, railroad track 

inspections, and programs to maintain continuous welded rail track and protect roadway workers. 

Hazardous materials Rail transportation of hazardous materials, including the integrity, markings, maintenance, and 

placement of tank cars; the training of train crews; security; and emergency preparedness. 

Signal and train control Signal switching systems, locomotive signal devices, locks and brake application, including related 

recordkeeping, testing, modifications, and repairs. 

Motive power and equipment Design and operation of railroad rolling equipment, including railroad freight and passenger car 

safety, locomotive safety and maintenance, safety devices, brake system safety, and emergency 

preparedness procedures. 

Source: GAO analysis of FRA information. 

Notes: FRA has recently established a new inspection discipline, industrial hygiene, which covers the

protection of railroad employees on the job, including enforcement of FRA standards for occupational 

safety and health. The discipline is also responsible for the operation of FRA’s internal occupational 

safety and health program for ensuring FRA employee safety and health. The resources devoted to 

this inspection discipline are relatively small—FRA plans to have a total of 5 industrial hygienist 

inspectors. In comparison, the other inspection disciplines each have between 50 and 90 inspectors,

approximately. 

a

In addition to its manual inspections, FRA has an automated track inspection program that uses data 

produced by vehicles that precisely measure track geometry. 

When railroads do not comply voluntarily or identified defects are serious, 

FRA may cite violations and assess civil penaltieseither against railroads 

or individualsor take other enforcement actions to promote compliance 

with its regulations. FRA developed the concept of focused enforcement in 

the mid-1990s to ensure that inspectors know which violations pose the 

greatest hazards and make enforcement decisions accordingly. The 

purpose of this approach is to concentrate FRA’s enforcement efforts on 

the areas with the greatest potential safety benefits. FRA’s enforcement 

policy, as stated in its regulations, specifies that before recommending 

penalties, inspectors should consider the seriousness of the condition or 

act, the potential safety hazards, and the current level of compliance of the 

individual or railroad, among other things. FRA is authorized to negotiate 

civil penalties with railroads and exercises this authority. For example, it 

settles claims annually with each Class I railroad. FRA uses civil penalties 

as its primary enforcement tool. However, it also has other available 

enforcement tools. These include compliance agreements and compliance 

orders, special notices for repair, emergency orders, criminal penalties, 

disqualification orders and injunctions. (See app. II for further discussion.) 

Page 13 GAO-07-149 Railroad Safety Oversight
FRA conducts additional oversight of Class I railroads through the 

Railroad System Oversight program, established in October 2005, which 

addresses safety issues not subject to regulation, such as aspects of 

worker fatigue, as well as safety compliance issues. Under this program, 

the agency assigns an FRA manager for each Class I railroad to cooperate 

with it on identifying and resolving safety issues. These managers act as 

liaisons with the railroads and labor officials, analyze accident and 

inspection data for their assigned railroad, and support FRA’s inspection 

and enforcement efforts. Finally, under this program, FRA has begun 

annual meetings with the leadership of each Class I railroad to discuss its 

safety performance. 

The Railroad System Oversight program replaced FRA’s Safety Assurance 

and Compliance Program, which had emphasized using teams—consisting

of FRA inspectors and other FRA officials, railroad officials, and union 

representatives—to identify and resolve safety issues, as a complement to 

FRA’s regular inspection activity. The agency envisioned this program as a 

comprehensive approach to safety through which these representatives 

would work together to identify and correct the root causes of problems 

across an entire railroad. According to FRA, the program had a number of 

accomplishments, such as improving collaboration among management, 

labor and FRA, and encouraging railroads’ voluntary cooperation in taking

corrective action on safety issues not covered under FRA’s safety 

regulations. However, FRA ended this program in response to concerns 

that it had lost its effectiveness, inhibited enforcement actions, and shifted 

regional resources away from conducting site-specific inspections, the 

mainstay of FRA’s safety program. 

In addition to these activities, FRA conducts other types of safety 

oversight aimed at reducing train accidents, such as monitoring of railroad 

safety data, accident investigations and reviews and investigations of 

complaints, and education efforts aimed at small railroads.11 Furthermore, 

FRA funds research and development that supports its safety oversight, 

by, for example, assisting in the development of new regulations and the 

revision of existing regulations. 

FRA is a small agency, especially in relation to the industry it regulates. As

of July 2006, FRA had 657 full-time and part-time safety staff, including 

 11For example, FRA conducts twice yearly training seminars for short line railroads on how

to comply with its regulations and operate safely. 

Page 14 GAO-07-149 Railroad Safety Oversight
about 400 inspectors in the field (in its regional, district, and local offices). 

In addition, 30 state oversight agencies participate in a partnership 

program with FRA to conduct safety oversight activities at railroads’ 

operating sites. Currently, about 160 state inspectors work with FRA to 

conduct inspections and other investigative and surveillance activities as 

needed. In contrast, the railroad industry has about 235,000 employees,12

219,000 miles of track in operation, 158,000 signals and switches, and over 

1.6 million locomotives and cars. 

In planning its safety oversight, FRA focuses its efforts on the highest 

priority risks related to train accidents through a number of initiatives 

aimed at addressing the main causes of these accidents as well as through

improvements in its inspection planning approach. The agency’s overall 

strategy for targeting its oversight at the greatest risks—the National Rail 

Safety Action Plan—provides a reasonable framework for guiding the 

agency’s efforts. FRA’s various initiatives to address the two main causes 

of train accidents—human factors and defective track—are promising. 

However, most of these initiatives are not yet fully implemented and their 

overall impact on safety will probably not be apparent for a number of 

years. FRA has also recently implemented new approaches for planning its 

inspection activity—based on analyses of accident, inspection, and other 

data—that allow it to better target the greatest safety risks and more 

effectively use its inspectors. 

FRA Has Made 

Progress in Targeting 

Its Oversight Efforts 

on the Basis of Risk 

National Rail Safety Action 

Plan Provides Strategy for 

Addressing Highest 

Priority Risks, but Impact 

of Safety Initiatives Is Not 

Yet Clear 

FRA’s May 2005 National Rail Safety Action Plan provides an overarching 

framework for the agency’s efforts to target its oversight at the highest 

priority risks. The agency developed the plan in response to a leveling off 

of the train accident rate in recent years and the occurrence of serious 

train accidents in 2004 and early 2005. The plan outlines a number of 

initiatives aimed at reducing the main types of train accidents, those 

caused by human factors and track defects.13 These efforts include some 

innovative approaches for the railroad industry, such as a pilot project for 

reporting close calls, that are designed to prevent accidents by addressing

 12This number does not include contractor employees hired by the railroads.

13The National Rail Safety Action Plan also includes initiatives to improve hazardous

materials safety and emergency response capability. Most of the serious accidents 

involving the release of hazardous material that have occurred in the last several years 

have been caused by human factors or track defects. 

Page 15 GAO-07-149 Railroad Safety Oversight
safety problems that may cause them.

14 Other efforts include new 

regulations, several research endeavors, and new track inspection 

vehicles. We have not reviewed these individual initiatives in depth, but 

believe that the plan provides a reasonable strategy for guiding and 

prioritizing FRA’s efforts to reduce the rates of accidents attributable to 

human factors and track defects. 

Some of the efforts outlined in the action plan are underway, and some are 

planned for the near future. FRA issued a progress report to the Secretary

of Transportation on the action plan in June 2006 and intends to continue 

to report on the plan’s implementation. Since issuing the plan, the agency

has pursued additional initiatives to target risks posed by human factors 

and track defects, including issuing new track regulations in response to a 

congressional mandate and encouraging a new braking technology. (See

table 2.) The combined initiatives hold promise for reducing the risks 

associated with human factors and track defects. However, these efforts 

are in varying stages of development or implementation and their overall 

impact on safety will probably not be apparent for a number of years. 

Some individual initiatives, such as the close call reporting project, may 

start showing results in the next year or two. 

 14According to FRA, a close call is an opportunity to improve safety practices in a situation

or incident that has a potential for more serious consequences. It represents a situation in

which an ongoing sequence of events was stopped from developing further, preventing the 

occurrence of potentially serious safety-related consequences. 

Page 16 GAO-07-149 Railroad Safety Oversight
Table 2: Key FRA Initiatives Aimed at Addressing Main Causes of Train Accidents 

Cause of train

accidents Initiative FRA action and time frame 

Human factors Rail Safety Action Plan initiatives 

Regulations on employee compliance with railroad 

operating rules

Issued proposed regulation in October 2006. Plans to 

issue final regulation by the end of 2007. 

Pilot project to establish voluntary reporting system to 

learn from close call incidents 

Plans to initiate this 5-year project in January 2007 at one 

Class I railroad site. FRA is seeking the participation of 

other railroads. 

Research on worker fatigue to develop a model that 

could be used to improve crew scheduling 

Discussed results of the research with key stakeholders 

and released a report on the results in November 2006. 

Other initiatives 

Pilot project to establish voluntary risk management 

programs at railroad worksites

Is considering establishing a pilot project in fiscal year 

2008. 

Encouraging new braking technology that can prevent 

or reduce human error 

Released a study on new brake system technology in

August 2006 and plans to issue proposed regulations in

May 2007 to facilitate its use.

Track defects Rail Safety Action Plan initiatives 

New track inspection vehicles Plans to deploy two new vehicles in early 2007. 

Research and development on new inspection 

technologies 

Demonstrated a prototype system in October 2005. 

Enhanced the system in 2006 and is planning further 

enhancements in 2007. 

Other initiatives 

Additional regulations on continuous welded rail track Issued a final rule on rail joint inspection in October 2006. 

Plans to develop additional regulations for improving 

management of this type of track, but has not yet 

developed time frames for this effort. 

Source: GAO analysis of FRA data. 

The National Rail Safety Action Plan also outlines the agency’s

development of a new approach for planning its inspections, based on 

greater use of its accident and inspection data. Since issuing the plan, FRA 

has made other efforts to improve its approach for planning its 

inspections.15 Starting in fiscal year 2006, FRA’s new inspection planning 

approach has allowed the agency to better target its inspections on the 

 15Other key agency plans that focus efforts on the highest priority risks related to train 

accidents include the department’s rulemaking agenda, strategic plan and annual 

performance plan, and FRA’s performance budget. The rail safety goals and measures

contained in the performance plan and performance budget are discussed later in this

report. 

Page 17 GAO-07-149 Railroad Safety Oversight
basis of risk and to better coordinate inspection planning among its 

headquarters and regional offices. 

FRA Is Making a Number 

of Efforts to Reduce 

Accidents Caused by 

Human Factors 

Human factor accidents result from unsafe acts of individuals, such as 

employee errors, and can occur for a number of reasons, such as 

employee fatigue or inadequate supervision, training, or staffing.16 FRA has 

recently issued proposed regulations aimed at reducing the most common 

causes of such human factor train accidents: improper positioning of track 

switches or derails,17 shoving rail cars without properly monitoring for safe 

conditions or controlling the movement, and leaving rail cars in a position 

that obstructs adjacent track. Procedures for employees to follow to avoid

these types of accidents are contained in railroads’ operating rules.18

Currently, FRA regulations contain general requirements that railroads 

train employees on their operating rules and periodically test their 

compliance with these rules, but do not specifically require that employees 

follow the rules that can prevent these types of accidents.19 As a result, 

according to FRA officials, the agency has had a limited ability to cite 

noncompliance and take enforcement actions in this area. The proposed 

regulations mirror established railroad operating rules that require 

employees to follow procedures, such as procedures related to the 

positioning of track switches, that if followed, could prevent these types of

accidents. In addition, they include further requirements for railroads to 

train employees on these rules and monitor their compliance with these 

rules. According to FRA, these new requirements and its ability to enforce

them will make railroad employees more accountable for following 

 16Management decisions at the organizational level, such as decisions regarding the 

allocation of resources or crew scheduling, can have consequences in the workplace that

can contribute to human factor accidents.

17Derails are devices used to prevent the obstruction of track by unauthorized movements

of trains or unattended rolling stock.

18Most Class I railroads use one of two sets of standard rules: the Northeast Operating 

Rules Advisory Committee rulebook and the General Code of Operating Rules. Railroads 

must file their operating rules with FRA. 

19In a few cases, FRA’s regulations do require some practices, such as securing a sufficient 

number of handbrakes, that are in railroad operating rules. Also, the Switching Operations

Fatality Analysis working group—made up of representatives of FRA, unions, railroads, 

and the Department of Transportation’s Volpe National Transportation Systems Center—

studies fatalities that occur to workers engaged in switching operations and recommends 

ways that such events can be prevented. 

Page 18 GAO-07-149 Railroad Safety Oversight
operating rules and railroad management more accountable for ensuring 

that employees do so. 

FRA is also sponsoring a 5-year Confidential Close Call Reporting System 

pilot project, through which employees of participating railroads can 

provide confidential information on close calls. A neutral party, the 

Bureau of Transportation Statistics, will maintain the close call data and a 

team of representatives from the participating railroad, labor 

organizations, FRA, and the bureau will review these data to identify 

safety problems. Railroads will be expected to correct identified problems 

in order to prevent accidents. The purpose of this project is to determine 

the effectiveness of such a voluntary reporting system for the railroad 

industry. FRA has developed plans to monitor and evaluate the 

performance of the project over time; these plans include short-term and 

long-term performance measures. The agency anticipates that it will have 

early indications of how the program is affecting safety in the next year or 

two. To date, one Class I railroad has committed to participate in this 

project, at one yard on its system, and, according to FRA, two others have

expressed strong interest. Such systems have contributed to significant 

reductions in accidents in some other industries, such as aviation. 

FRA and the National Transportation Safety Board (NTSB) have identified

employee fatigue as a significant factor in many train accidents. Railroad 

employees often work long hours and have unpredictable and fluctuating 

work schedules. Under current law, these employees could potentially 

work a maximum of 11 hours and 59 minutes, followed by 8 hours off 

duty, and then another 11 hours and 59 minutes on duty, continually.20 In 

addition, time spent waiting for transportation at the end of a tour of duty 

and being transported to a release point, called limbo time, does not count 

as either duty or off-duty time and can be significant. FRA has sponsored a 

study to develop a fatigue model that could be used to improve train crew 

scheduling practices, has discussed the draft results with railroads and 

labor organizations, and released the final report on the study in 

November 2006. The agency is also taking some other actions to 

encourage railroads to improve their management of employee fatigue, 

such as providing funding for a new program, in use at a Class I railroad, 

that tracks and analyzes crew scheduling to remedy practices that could 

contribute to fatigue. 

 20The law also specifies that train employees are required to have 10 consecutive hours off

duty following 12 continuous hours on duty.

Page 19 GAO-07-149 Railroad Safety Oversight
Through a recent investigation of a 2004 train accident in which three 

people died, NTSB found that the engineer and conductor were likely 

asleep at the controls and recommended that FRA require railroads to use 

scientifically based principles when assigning work schedules for train 

crew members and to limit crew member limbo time.21 In recent testimony, 

the FRA Administrator noted that, several times in the 1990s, the 

Department of Transportation proposed legislation to repeal or reform the 

hours-of-service law or to require railroads to develop fatigue management 

plans, but that these bills encountered opposition and were not passed. 

However, since that time, FRA has not submitted such legislation. The 

agency has not yet responded to NTSB’s recommendations, but has told us 

that it intends to tell the board, as it has in the past, that the agency lacks 

jurisdiction to issue regulations addressing hours of service.22

While we were conducting our work, FRA was considering establishing a 

pilot project that would use risk management to help reduce human factor

accidents at selected railroad worksites. Risk management can be 

described as a systematic approach for identifying, analyzing, and 

controlling risks.23 The agency envisioned that, under such a project, each 

worksite would collect and analyze data on precursors to human factor 

accidents—such as close call incidents, employee errors, or organizational 

characteristics—to better identify and correct individual and

organizational factors that contribute to such accidents and therefore 

reduce the risks of such accidents occurring. The agency proposed that 

funding for this project be included in its fiscal year 2008 budget request 

and this proposal was approved by the department. In January 2007, as we 

were finalizing our report, FRA told us that it had decided to expand the 

scope of this project to include efforts to use risk management to reduce 

all types of accidents, not only human factor accidents. 

 21NTSB, Collision of Union Pacific Railroad Train MHOTU-23 With BNSF Railway 

Company Train MEAP-TUL-126-D With Subsequent Derailment and Hazardous

Materials Release, Macdona, Texas, June 28, 2004, Railroad Accident Report NTSB/RAR06/03 (Washington, D.C., 2006). 

22According to FRA, it is the only safety regulatory agency in the Department of 

Transportation that lacks regulatory authority over worker duty hours. 

23Risk is the combination of the likelihood and the consequence of a specified hazard (or 

threat) being realized. We have developed a framework for risk management based on

industry best practices. See app. III for a discussion of this framework as well as 

comprehensive risk management approaches in use by several other transportation

agencies for overseeing the U.S. commuter railroad, U.S. pipeline, and Canadian railroad 

industries.

Page 20 GAO-07-149 Railroad Safety Oversight
FRA has examined possible approaches to use for this project. According

to agency officials, one possible approach is represented by a new 

program that a Class I railroad has implemented at two locations on its 

system. In this program—which has received funding from FRA—a 

committee of employees documents employee behaviors that could lead to

unsafe conditions, without recording names, and provides feedback to the 

responsible employees to help them eliminate these behaviors. FRA has 

also considered the approach used by the Occupational Safety and Health

Administration’s Voluntary Protection Program. This program recognizes 

individual worksites with exemplary safety records and practices, 

including the identification, analysis, prevention, and control of workplace 

hazards that could lead to employee injuries and illnesses.24

As envisioned by FRA officials, this project will focus on establishing risk 

management programs at three separate railroad worksites and will 

include close monitoring and evaluation of these programs to determine 

their impact in reducing accidents over a 5-year period. If the pilot is 

successful, FRA anticipates establishing a voluntary risk management 

program for the railroad industry, which would encourage railroads to 

implement this type of approach on a systemwide basis in order to reduce 

human factor accidents, as well as other types of accidents. 

Finally, FRA has recently issued a study on a new braking technology, 

electronically controlled pneumatic brakes, which improves train-handling 

and decreases stopping distances by 40 to 60 percent. These brakes use an 

electronic line to uniformly command brake applications and releases 

throughout the train. FRA has decided that it will develop new regulations 

to facilitate the use of this technology over the next decade. According to 

FRA officials, improving railroads’ braking systems can have a significant 

safety benefit by improving the ability of locomotive engineers to control 

 24In reviewing the Voluntary Protection Program of the Occupational Safety and Health 

Administration, along with several other voluntary compliance programs, we found that 

benefits reported by participating worksites included reduced injury and illness rates, an 

improved safety culture, and improved employee-management relations. See GAO,

Workplace Safety and Health: OSHA’s Voluntary Compliance Strategies Show Promising 

Results, but Should Be Fully Evaluated before They Are Expanded, GAO-04-378 

(Washington, D.C.: Mar. 19, 2004). 

Page 21 GAO-07-149 Railroad Safety Oversight
their trains and, therefore, avoid or reduce the severity of some types of 

human factor-caused accidents.25

The above initiatives use a variety of approaches, some quite innovative,

for addressing the causes of human factor accidents. These initiatives, 

which are in varying stages of development or implementation, have the 

potential to eventually reduce these types of accidents. However, while 

some may start showing results in the next year or two, their overall 

impact will likely not be apparent for a number of years. Furthermore, all 

of these initiatives, except for the proposed regulations on operating rules, 

depend on voluntary actions by railroads, and, in some cases, labor as 

well, for their success. For example, the impact of FRA’s effort to develop 

a model to address the problem of worker fatigue depends on the extent to 

which railroads eventually use this model to improve train crew

scheduling practices. FRA has worked with railroads and labor on some of 

these initiatives, but it is too early to predict their outcomes. 

FRA Is Pursuing Several 

Initiatives to Improve the 

Detection and 

Management of Track 

Defects 

Railroads operate trains on about 219,000 miles of track across the United 

States. This track consists of traditional jointed rail as well as newer rails 

that are smooth bands of welded steel, called continuous welded rail. 

Derailments can occur when rails are uneven or too wide apart or when 

rails or joint bars are cracked or broken. FRA inspects track conditions 

through manual inspections conducted on-foot or in on-track equipment, 

and with automated track inspection vehicles that precisely measure track 

and can identify problems that are difficult to detect through other types 

of inspections. The agency operates one automated track inspection 

vehicle that it uses in inspecting track and plans to add two more for this 

purpose in early 2007.26 According to FRA, these additional vehicles will 

allow the agency to triple the miles of track that it is able to inspect per 

year, to nearly 100,000 miles.27

 25FRA has also recently issued standards for processor-based positive train control

systems. These systems are an advanced train control technology that can prevent train 

collisions through automatic brake applications. They also can provide enhanced 

protection for maintenance-of-way workers. 

26FRA also has two additional automated track inspection vehicles that are primarily used 

for research activities but occasionally are used for inspections. 

27However, FRA may inspect some sections of track more than once a year. 

Page 22 GAO-07-149 Railroad Safety Oversight
FRA is also developing an automated inspection system for improving the 

detection of cracks in joint bars. Such cracks can lead to a derailmentcausing break but can be difficult to detect through simple visual 

inspections. Specifically, FRA has designed and is refining a highresolution video inspection system that can be used in on-track inspection

equipment and will improve detection of these defects.28 According to 

FRA, the technology is ready for use, was demonstrated and refined in the 

field in 2006, and will undergo further enhancements in 2007. The agency 

expects that railroads will make use of the technology and is reviewing 

how to use it in its own inspections. According to FRA, one Class I 

railroad is starting to make use of this technology and others have shown 

strong interest in it. 

Finally, in response to a congressional mandate and NTSB 

recommendations, FRA has recently finalized regulations that require 

track owners to conduct detailed and periodic inspections of rail joints in 

continuous welded rail track. Although FRA issued regulations in 1998 

requiring railroads to develop and implement procedures for the 

inspection and maintenance of continuous welded rail track, a number of 

train accidents occurred since that time in which the failure of a rail joint 

on this type of track was a factor.29 FRA officials told us that the railroads’ 

overall management of the condition of continuous welded rail track is a 

major concern for the agency because about 20 accidents involving 

problems with this type of track occur per year and these accidents are 

usually serious. FRA has estimated that continuous welded rail track 

represents between 99,000 and 120,000 miles of the 219,000 miles of track 

in operation in the United States. The agency is working with the Railroad 

Safety Advisory Committee to develop additional regulations to improve 

railroads’ management of this type of track. 

These initiatives have the potential to reduce accidents caused by track 

defects. FRA’s deployment of two new track inspection vehicles in early

 28FRA also has a number of other ongoing efforts to improve track inspection capabilities. 

For example, since 2002 it has sponsored a Rail Integrity Task Force—composed of

experts in the railroad industry, FRA, and the Department of Transportation’s Volpe 

National Transportation Systems Center—to identify best practices for rail inspection,

maintenance, and replacement.

29In continuous welded rail track, rails are welded together to form one continuous rail that

may be several miles long. There may be joints in this rail for several reasons, including the

need for insulated joints that electrically separate track segments for signaling purposes 

and the need to replace a section of defective rail. 

Page 23 GAO-07-149 Railroad Safety Oversight
2007 will enable the agency to significantly expand its ability to monitor 

the condition of the nation’s track. The agency’s development of an 

automated inspection system has the potential to help prevent 

derailments, provided that railroads make use of this technology. Finally, 

FRA’s issuance of new regulations related to continuous welded rail track 

and development of further regulations in this area should eventually

improve railroads’ management of this type of track, although time frames 

for the development of new regulations are not yet clear. 

FRA Has Made Progress in 

Targeting Its Inspections 

on the Basis of Risk 

Like other modal safety administrations within the Department of 

Transportation, FRA has few resources for overseeing railroads compared 

with the scope of its responsibility. According to agency officials, it 

inspects 0.2 percent of railroad operations per year. FRA has developed a 

new approach—the National Inspection Plan—for using available data to 

target its inspections at the greatest safety risks. The agency began using

the new approach for three of its inspection disciplines (operating 

practices, track, and motive power and equipment) in October 2005 and 

expanded it to the remaining two disciplines (hazardous materials and 

signal and train control) by March 2006. The purpose of the plan is to 

optimize FRA’s ability to reduce the rates of various types of train 

accidents as well as releases of hazardous materials. The plan provides 

guidance to each regional office on how its inspectors, who each 

specialize in one of the five inspection disciplines, should divide up their 

work by railroad. 

Developing the plan involves two steps. In the first step, FRA headquarters 

produces an initial plan for each of the agency’s eight regions. This plan 

specifies, by inspection discipline, numeric goals for the level of 

inspection activity to allocate to each railroad, by state. These numeric 

goals are derived from models—based on trend analyses of accident, 

inspection, and other data—that predict, by inspection discipline, 

locations where train accidents and incidents are likely to occur within 

each region and provide the optimal allocation of inspection resources to 

prevent accidents.30 FRA has developed separate models for each 

inspection discipline based on how well individual data elements, such as 

historical information on inspection results, tend to predict accidents. 

 30We did not evaluate these models or the data on which they are based. FRA defines train 

incidents as events involving the movement of railroad equipment that results in a casualty 

but does not cause damage above the reporting threshold established for train accidents,

which was $7,700 in 2006. 

Page 24 GAO-07-149 Railroad Safety Oversight
According to FRA officials, they expect to refine this new planning 

process to reflect lessons learned during the first year of its 

implementation. 

In the second step, the regional administrators are allowed to adjust the 

goals for their region on the basis of local knowledge and emerging issues, 

such as recent accidents. However, according to FRA officials, there were 

only a few such adjustments for fiscal year 2006. Throughout the year, 

FRA monitors how the regions are meeting their goals. Starting in fiscal 

year 2007, regional administrators will have a second opportunity to adjust

their inspection plans at midyear to respond to safety issues that emerged

during the first 6 months of the year.

Previously, FRA had a less structured, less consistent, and less data-driven 

approach for planning inspections. According to agency officials, each

region prepared its own inspection plan, based on judgments about 

appropriate priorities and analysis of available data. However, the use of 

data was not consistent from region to region. Inspectors had greater 

discretion about where to inspect and based decisions about priorities on 

their knowledge of their inspection territories. 

The National Inspection Plan covers federal inspectors, but not state 

inspectors. Other than funding training and computer equipment, FRA 

does not provide funding for state inspection activities.31 Therefore, each

state makes its own decisions about how to use its inspectors. FRA 

officials told us that the agency has not included states in the National 

Inspection Plan because it does not have authority to tell the states what 

inspections to conduct. The 30 states that participate in FRA’s state 

program have varying numbers of inspectors and most conduct 

inspections in some, but not all, of FRA’s five inspection disciplines. 

According to FRA, its regional offices coordinate with the states in their 

region to avoid duplication of effort. The regional administrators may 

make adjustments to their National Inspection Plan goals based on the 

work of state inspectors within their region. 

The National Inspection Plan also does not establish priorities across 

regions and inspection disciplines, but rather, for given staffing levels for 

each discipline within each region, assigns inspection levels to railroads 

 31FRA provides training for state inspectors and certifies them as qualified to perform

inspections and cite violations. 

Page 25 GAO-07-149 Railroad Safety Oversight
and states. However, FRA eventually plans to use its results to help decide 

how to optimally allocate additional inspectors, as vacancies occur or new 

positions are funded. According to headquarters officials, the National 

Inspection Plan model played a role in a decision to allocate additional 

inspection staff to the operating practices discipline in the regions.32

However, officials told us that they will need more time to determine how 

well the plan is working before using it to reallocate resources among the 

regional offices. 

The fiscal year 2006 plan resulted in various reallocations of inspection 

activity within FRA’s regional offices. These reallocations have allowed 

FRA to better target its inspections on the basis of risk. For example, in 

the track area, in some cases regions are focusing more attention on 

certain railroads that have higher accident rates and worse track 

conditions than others. Conversely, in the area of operating practices, 

some regional offices have decreased their focus on certain railroads that

have shown good or improving performance in this area compared with 

other railroads. 

In fiscal year 2006, in addition to implementing the National Inspection 

Plan, the agency implemented a new coordinated approach for planning 

nonroutine inspection activity, by inspection discipline. Examples of these 

types of inspections include in-depth inspections by a regional office of a 

railroad’s compliance with track standards; interregional inspections of 

compliance with certain regulations, such as those related to bridge safety, 

of a Class I railroad that operates in multiple regions; and headquarters-led 

inspections of Class I railroads’ drug and alcohol testing programs. Some 

of these planned inspections are based on analyses of data on accidents by 

railroad, accident causes, and inspection results in order to define, beyond

the National Inspection Plan goals, what railroad locations and specific 

regulatory requirements warrant increased attention by inspectors. Others, 

such as inspections of some required railroad safety programs, are 

performed periodically. According to FRA officials, the regional offices 

and headquarters previously planned such inspections separately and 

made less use of data in their planning. Under this new planning approach, 

 32Overall, the motive power and equipment discipline currently has the highest number of 

inspectors (86), followed by the operating practices discipline (76), the track and 

structures discipline (73), the signal and train control discipline (61), and the hazardous

materials discipline (55). However, to help reduce human factor accidents, which account 

for the highest percentage of train accidents, inspectors in the motive power and 

equipment discipline conduct some inspections of operating practices. 

Page 26 GAO-07-149 Railroad Safety Oversight
FRA headquarters and regional offices coordinate in developing plans for 

inspections they will conduct, by inspection discipline. These plans are 

compiled into an agencywide plan, and then FRA tracks the completion of 

these inspections. 

FRA’s new approaches for planning its inspection activity allow it to better 

target the greatest safety risks and coordinate inspection planning among 

its eight regional offices and headquarters offices. Therefore, they allow 

FRA to make more effective use of its inspectors. However, it is not yet 

clear whether these new planning approaches will lead to a prioritization 

of inspection levels across regions and inspection disciplines or improved 

safety. 

In carrying out its safety oversight, FRA identifies safety problems on 

railroad systems mainly through routine inspections to determine whether 

operations, track, and equipment, such as signals and locomotives, are in 

compliance with safety standards. Through this approach, FRA inspectors 

identify a range of safety problems at various sites on railroads’ systems, 

through citing defects and violations. FRA also identifies some broad-scale 

compliance problems that affect multiple sites, mainly through analyses of

accident and inspection data, internal discussions, and some nonroutine 

inspections. 

FRA’s inspections focus on compliance with minimum standards within 

five separate inspection disciplines and do not attempt to determine how 

well railroads are managing safety risks on their systems. APTA, PHMSA, 

and Transport Canada have implemented approaches to oversee the 

management of safety risks by U.S. commuter railroads, U.S. pipelines, 

and Canadian railroads, respectively. These oversight approaches 

complement, rather than replace, traditional compliance inspections and 

therefore provide additional assurance of safety. However, we are not 

recommending that FRA adopt such an oversight approach, since the 

agency is currently pursuing various initiatives to reduce train accident 

rates. In our view, these initiatives need time to mature to demonstrate 

their effects and, subsequently, an informed assessment would need to be

made about whether additional actions are warranted. 

FRA Relies Primarily 

on Direct Inspections 

to Identify Safety 

Problems and Does 

Not Oversee 

Railroads’ 

Management of Safety 

Risks 

Page 27 GAO-07-149 Railroad Safety Oversight
Overseeing the safety of the railroad industry is a huge task. FRA’s 400 

inspectors, along with about 160 state inspectors, oversee 686 railroads, 

with about 235,000 employees, 219,000 miles of track, 24,000 locomotives, 

1.6 million cars, 158,000 signals and switches, and 240,000 highway-rail 

grade crossings.33 As noted previously, according to FRA officials, the 

agency’s inspectors are able to directly observe only about 0.2 percent of

the railroad industry’s operations per year. FRA carries out this oversight 

responsibility primarily through inspections of railroads’ compliance with 

its safety standards at various locations on railroads’ systems and through 

cooperation and enforcement aimed at resolving identified problems. 

During inspections, which are generally conducted separately within the 

five inspection disciplines, inspectors examine railroads’ compliance with

a broad range of federal standards. Inspectors discuss identified 

compliance problems (called defects) with railroads to achieve voluntary

compliance, and cite violations—recommending that the agency take

enforcement action against a railroad—when they determine that the 

problems are serious or when a railroad does not voluntarily comply. (See 

app. II for a description of FRA’s use of cooperation and enforcement to 

resolve safety problems and improve safety.) In addition, FRA’s Railroad 

System Oversight managers work with Class I railroads and labor to 

identify and resolve some safety problems that are not directly related to

compliance with the agency’s regulations. For example, one manager 

worked with a railroad and labor organization to improve the railroad’s 

program for communicating with roadway workers to ensure that they are

aware of and implement key safety procedures. 

FRA’s Oversight Identifies 

a Range of Site-Specific 

and Broad-Scale Problems 

on Railroad Systems 

FRA primarily monitors railroads’ compliance through routine inspections

by individual inspectors at specific sites on railroads’ systems.34 As 

discussed previously, FRA inspects locations likely to have safety 

problems, which it identifies using accident and previous inspection data

as well as other information. Inspectors typically cover a range of 

standards within their discipline during these inspections. This inspection 

approach focuses on direct observations of specific components of the 

train, related equipment, and railroad property—including the track and 

signal systems—as well as operating practices to determine whether they 

meet FRA’s standards. (See figs. 6 and 7.) Inspectors also examine 

 33These figures do not include railroad contractor employees or track that is not in use. 

34Inspectors also sometimes travel along part of a railroad’s system in conducting 

inspections. According to FRA, from 2002 to 2005, inspectors traveled between two 

locations in 17 percent of the routine inspections of railroads. 

Page 28 GAO-07-149 Railroad Safety Oversight
railroads’ inspection and maintenance records. The railroads have their 

own inspectors who are responsible for ensuring that railroad equipment, 

track, and operations meet federal rail safety standards. For example, FRA 

requires that railroads inspect brake systems, signal systems, passenger 

equipment, track conditions, and train crews’ adherence to operating 

rules, among other things. According to FRA officials, the agency’s 

inspectors often review the railroads’ records of inspection to determine 

whether the records accurately represent the types of problems FRA 

inspectors are finding during their own inspection activities. 

Figure 6: FRA Inspector Measuring Track Gauge

Source: FRA.

Page 29 GAO-07-149 Railroad Safety Oversight
Figure 7: FRA Inspector Inspecting Train Cars 

Source: FRA.

FRA also conducts more in-depth inspection efforts that generally focus 

on railroads’ compliance in a particular area, such as their inspections of 

employees’ adherence to operating rules. These efforts often involve a 

team conducting separate inspections at multiple sites, generally within 

one of FRA’s eight regions.35 FRA focuses these in-depth inspection efforts 

on emerging issues, identified through previous routine inspections or 

analyses of accident data. FRA also periodically conducts in-depth 

inspections of some systemwide programs that the railroad is required to

implement, such as employee drug and alcohol testing programs and 

accident and incident reporting programs. In some cases, FRA may 

conduct a systemwide in-depth set of inspections on a railroad to 

 35However, in some cases, FRA conducts nationwide inspections of railroads’ compliance 

with specific requirements. For example, in mid-2006, it began a set of nationwide 

inspections of various railroads’ compliance with requirements for notifying train crews of

the types of hazardous materials being transported on their trains, after identifying 

noncompliance in this area as a problem. 

Page 30 GAO-07-149 Railroad Safety Oversight
determine its overall compliance within a single inspection discipline or in

several disciplines. For example, in early 2006, in response to a Class I 

railroad’s high accident rates, FRA conducted an in-depth set of 

inspections of the railroad’s compliance with operating practices, track, 

signal and train control, motive power and equipment, and hazardous 

materials regulations across its system. However, according to an FRA 

headquarters official, the agency does not frequently perform systemwide 

or multidisciplinary inspections. 

In 2005, federal and state inspectors conducted a total of about 63,000 

inspections.36 According to FRA, routine inspections constituted about 75 

percent of the inspections of railroads and in-depth inspections accounted 

for about 11 percent. The remainder of these inspections (14 percent) 

consisted of other types of activities, such as investigations of accidents 

and complaints. Inspectors in the track discipline performed the most 

inspections, followed by those in the motive power and equipment, 

operating practices, hazardous materials, and signal and train control 

disciplines.37 This approach to oversight enables FRA inspectors and 

managers to identify a wide range of safety problems. Inspectors identify 

specific compliance problems—conditions that do not meet FRA’s 

standards—at sites they visit by citing defects. Inspectors cite violations 

for those defects that they believe warrant enforcement action. They 

consider a number of factors in making this decision, including the 

railroad’s history of compliance at that location and the seriousness of the 

noncompliance (such as whether it is likely to cause accidents, injuries, or 

releases of hazardous materials). Inspectors in some disciplines cite more 

defects and violations than others. (See fig. 8.) Overall, FRA and state 

inspectors cited about 293,000 defects and about 9,500 violations during 

the 63,000 inspections conducted in 2005. 

 36This number includes inspections of railroads as well as of nonrailroads (companies that

ship hazardous materials by rail, tank car manufacturers, and tank car repairers). In 2005, 

inspections of nonrailroads represented 7 percent of all inspections. 

37To help reduce accidents caused by human factors, which are the leading cause of train 

accidents, FRA’s motive power and equipment inspectors conduct some inspections to

look for operating practices problems that can lead to these types of accidents. 

Page 31 GAO-07-149 Railroad Safety Oversight
Figure 8: Inspections Conducted and Defects and Violations Cited, by Inspection 

Discipline, in 2005 

0

20

40

60

80

100

120

140

Track and

structures

Signal and

train control

Operating

practices Motive power

and equipment

Hazardous materials

Number (in thousands)

Source: GAO analysis of FRA data.

FRA disciplines

Inspections conducted

Defects cited

Violations cited

9.6

15.5

1.5

15.6

132.1

3.6

15.6 16.0

1.6 5.0

23.9

1.1

17.5

105.1

1.6

Note: These figures include inspections carried out by both federal and state inspectors. Inspectors 

are instructed to cite defects for most instances of noncompliance found, but have discretion in 

determining which instances to cite as violations warranting enforcement action. 

The motive power and equipment discipline cites almost half of all defects 

and over a third of all violations. FRA officials told us that the standards in 

this inspection discipline are the most prescriptive, making defects and 

violations easier to find. However, these types of defects cause a much 

smaller proportion of accidents than human factors and track defects.38

 38FRA officials have explained that operating practices inspectors have had a limited ability 

to cite defects and violations because of the way regulations in this area are written. For 

example, as noted previously, the regulations contain general requirements about railroads’ 

programs for inspecting employees’ adherence to operating rules and do not specifically 

require that employees follow these rules. The agency expects that its proposed regulations 

on operating rules will improve its ability to enforce in this area, because the requirements 

will be more stringent than existing regulations. 

Page 32 GAO-07-149 Railroad Safety Oversight
(See fig. 4.) The most frequently cited violations include those for 

noncompliance with standards regarding locomotives and freight cars, 

track conditions, recordkeeping on the inspection and repair of equipment

and track, and the condition of hazardous materials tank cars.

While individual defects and violations are generally for compliance 

problems identified at specific locations on railroads’ systems, FRA also 

identifies broad-scale compliance problems, by inspection discipline, that

affect multiple locations on a railroads’ system. It does so mainly through 

analyses of accident data and data on defects and violations found during 

inspections, communications among managers at headquarters and in its 

eight regional offices on the results of analyses and inspections, and 

further inspections to obtain more information about identified problems. 

Agency officials told us that they hold frequent internal discussions about 

emerging issues to determine where problems are occurring and plan 

actions that the agency should take to address them. The agency’s 

Railroad System Oversight managers support this effort by analyzing 

systemwide accident and inspection data, by inspection discipline, for the 

Class I railroads to identify trends and emerging issues. FRA may plan and 

conduct in-depth inspections to determine the scope of such issues. For 

example, if the rate of human factor accidents has increased at various 

locations on a railroad’s system, FRA may conduct inspections of 

operating practices at these locations. 

Examples of broad-scale problems FRA has identified at railroads include 

weak implementation within a particular state of a program for monitoring

employees’ adherence to operating rules, poor inspections by a railroad of 

its track in a particular region, systemic problems in reporting accidents 

and incidents, and defective equipment across a railroad’s system. In some 

cases, FRA inspectors identify some higher-level management issues, such 

as a lack of supervision or inadequate training of railroad personnel, which 

could have led to the compliance problems. According to FRA officials, 

they discuss broad-scale compliance problems with railroad officials to try 

to get these problems resolved. For example, after an in-depth inspection,

inspectors meet with railroad managers to discuss overall problems found 

and, according to headquarters officials, usually provide a written 

summary of those problems. Efforts to cooperate with the railroad to 

resolve broad-scale problems may be combined with enforcement actions, 

usually civil penalties, for specific violations identified at individual sites.

Page 33 GAO-07-149 Railroad Safety Oversight
According to FRA officials, the agency always conducts follow-up on 

serious problems it has identified to ensure that they are resolved.39

While FRA does track and maintain data on various types of train 

accidents and incidents as well as defects and violations cited by 

inspectors and enforcement actions taken, the agency does not centrally

track the broad-scale compliance problems it has identified.40 These 

problems are described in some agency documents, such as inspectors’ 

summary reports on findings of in-depth inspection efforts; various reports 

prepared by the Railroad System Oversight managers on the Class I 

railroads;41 and the agency’s overall plan, by region and inspection 

discipline, for its nonroutine inspection activity. As explained in the next 

section, this lack of centralized tracking can impede the ability of the 

agency to measure the effectiveness of its efforts to resolve identified 

broad-scale problems. 

FRA’s five Railroad System Oversight managers also identify some broad 

safety problems at Class I railroads that are not related to compliance. 

They identify these problems mainly through contacts with labor and 

railroad officials and FRA regional officials and try to address them 

through cooperation with the railroad. For example, these managers have

worked with railroads in addressing labor’s concerns about practices for 

transporting train crews at the end of their shifts that may worsen fatigue 

and programs for training employees on the railroads’ operating rules. In 

some cases, these problems were first identified under the Safety 

Assurance and Compliance Program. 

 39App. II contains a description of FRA’s efforts to resolve such problems through

discussions with railroad officials as well as enforcement actions. According to FRA

officials, the agency uses compliance agreements, which require railroads to take

significant actions to improve their ability to comply, when broad-scale compliance 

problems are egregious and have not been resolved through other methods. FRA has issued 

eight such agreements since 2000. These agreements have mainly focused on compliance 

problems in the operating practices and track disciplines. 

40According to FRA officials, its ability to track broad-scale compliance problems is limited 

because its existing databases related to safety are not integrated. The agency has an effort

underway to better integrate its existing data. The next section contains a description of

this effort. 

41The Railroad System Oversight managers track the status of nonregulatory problems, as 

well as some regulatory problems, that they are working on and, in response to our request,

created papers for us describing systemwide and regional issues for each of the Class I 

railroads. In addition, these managers produce quarterly and annual reports showing safety 

trends—based mainly on accident data—for each of the Class I railroads. 

Page 34 GAO-07-149 Railroad Safety Oversight
FRA officials have noted that their approach of directly inspecting safety

conditions and targeting locations that are most likely to have compliance 

problems provides a safety net and holds railroad management 

accountable. However, because the number of FRA and state inspectors is 

small relative to the size of railroad operations, FRA inspections can cover 

only a very small proportion of railroad operations (0.2 percent). Also, 

FRA targets inspections at locations on railroads’ systems where accidents 

have occurred, among other factors, rather than overseeing whether 

railroads systematically identify and address safety risks that could lead to 

accidents. 

Several Other 

Organizations Have 

Implemented 

Comprehensive 

Approaches for Overseeing 

the Management of Safety 

Risks in Transportation 

Industries 

Rail transportation poses a variety of potential safety hazards, including 

collision or derailment; injury to workers, passengers, or nearby residents; 

and damage to property or the environment. Risk management is a 

systematic approach for dealing with the risks posed by such safety 

hazards and has been used in the private and public sectors for decades. It 

can be described as a continuous process of managing—through the 

systematic identification, analysis, and control of risks associated with 

hazards (or threats)—the likelihood of their occurrence and their negative 

impact.42 A framework for risk management based on industry best 

practices and other criteria that we have developed divides risk 

management into five major phases: (1) setting strategic goals and 

objectives, and determining constraints; (2) assessing risks; (3) evaluating

alternatives for addressing these risks; (4) selecting the appropriate 

alternatives; and (5) implementing the alternatives and monitoring the 

progress made and results achieved.43 Risk management can help to 

improve systemwide safety by systematically identifying and assessing 

risks associated with various safety hazards and prioritizing them so that 

resources may be allocated to address the highest risks first. It also can 

help in ensuring that the most appropriate alternatives to prevent or 

mitigate the effects of hazards are designed and implemented. 

 42Risk is the combination of the likelihood and the consequence of a specified hazard being

realized. In risk management, the term “threat” is sometimes used in place of hazard. 

43GAO, Risk Management: Further Refinements Needed to Assess Risks and Prioritize 

Protective Measures at Ports and Other Critical Infrastructure, GAO-06-91 (Washington,

D.C.: Dec. 15, 2005); Homeland Security: Summary of Challenges Faced in Targeting 

Oceangoing Cargo Containers for Inspection, GAO-04-557T (Washington, D.C.: Mar. 31, 

2004); and Rail Security: Some Actions Taken to Enhance Passenger and Freight Rail

Security, but Significant Challenges Remain, GAO-04-598T (Washington, D.C.: Mar. 23, 

2004). 

Page 35 GAO-07-149 Railroad Safety Oversight
Other transportation oversight organizations have developed and 

implemented approaches for overseeing industries’ overall management of 

safety risks. In particular, during the last 10 years, APTA, PHMSA, and 

Transport Canada have developed and implemented such oversight 

approaches for U.S. commuter railroads, U.S. pipelines, and Canadian 

railroads, respectively. These approaches complement, rather than 

replace, traditional compliance inspections. APTA established a U.S. 

commuter railroad oversight program in 1996, in partnership with FRA and 

the commuter rail industry, that supplements FRA’s inspections of these 

railroads.44 Under this program, APTA provides guidelines to these 

railroads on managing the safety of their systems—including safety risks—

and audits their plans for and implementation of this management 

approach. Beginning in 2000, PHMSA issued a series of requirements for 

pipeline operators to develop “integrity management” programs to manage 

risk in areas—such as those that are densely populated—where leaks or 

ruptures could have the greatest impact on public safety.45 The agency’s 

integrity management regulations supplement its minimum safety 

regulations, and it inspects operators’ compliance with both types of 

standards. In Canada, the department responsible for overseeing railroad

safety, Transport Canada, in 2001 began requiring that railroads establish 

safety management systems that include risk management.46 Transport 

Canada assesses these systems as well as railroads’ compliance with its 

 44APTA is a nonprofit organization representing the transit industry, including U.S.

commuter rail systems. APTA offered to develop this program after FRA directed 

passenger railroads to develop system safety plans for addressing hazards associated with 

passengers occupying the lead units of a train. The APTA program is more extensive and is

intended to cover all aspects of system safety. FRA issued this directive in 1996, in an 

emergency order, after two passenger train accidents caused 14 deaths. 

45PHMSA administers the national regulatory program to ensure the safe transportation of

hazardous liquids and natural gas by pipeline. PHMSA and FRA are similar in several 

respects. For example, both oversee large industries with relatively few inspectors. Both 

also oversee industries that have relatively few deaths, injuries, and accidents (as 

compared to transportation as a whole), making additional safety gains more difficult. 

46Transport Canada oversees the safety and security of Canada’s rail, marine, highway, and 

aviation operations. 

Page 36 GAO-07-149 Railroad Safety Oversight
traditional safety standards.47 (For further information on GAO’s risk 

management framework and these oversight approaches, see app. III.) 

These oversight approaches are intended to provide additional assurance

of safety beyond that provided by inspections of compliance with 

minimum safety standards. They supplement uniform, minimum standards 

by encouraging or requiring companies to identify and address their 

unique safety risks. APTA, PHMSA, and Transport Canada have 

emphasized that risk management provides a higher standard of 

performance than traditional safety regulation based on compliance alone. 

According to APTA officials, their approach helps companies to prioritize 

their actions for addressing risk and therefore optimize safety within 

constraints of their resources. According to PHMSA officials, pipeline 

companies’ compliance with the agency’s traditional regulations ensures 

minimum safety performance, but its integrity management approach has

improved the ability of these companies to systematically address the full 

range of safety threats to their pipelines. According to Transport Canada 

officials, by encouraging systemwide improvements in companies’ safety

performance in order to address systemic causes of specific problems, its 

new approach helps the agency to leverage its resources. Transport 

Canada has emphasized that risk management ensures that risks are being 

adequately addressed and should point railroads to areas where they could 

undertake initiatives beyond their current practices that could improve 

their overall safety performance. Transport Canada officials also told us 

that a primary objective of their new approach is for railroads to assume 

more responsibility for the safety of their operations. Similarly, APTA 

officials told us that their oversight approach is proactive because it 

encourages companies to identify and address potential hazards before 

accidents occur. 

We have reviewed PHMSA’s gas transmission pipeline integrity 

management oversight approach and have recently concluded that it 

 47In addition, the European Commission has funded an effort to develop proposed 

guidelines for a safety management system for rail companies of its member nations. These

proposed guidelines recommend that European railways incorporate some basic risk

management elements—including safety performance targets, risk assessment and control, 

and an internal audit process—in their safety management systems. See E.M. El Koursi, L.

Tordai and J. Rodriguez. European Commission Fifth Framework Programme, SAMNET 

Thematic Network, SAMNET Synthesis Report, Safety Management and Interoperability 

(SAMNET, February 2006). 

Page 37 GAO-07-149 Railroad Safety Oversight
enhances public safety.48 We also found that representatives from the 

pipeline industry, safety advocacy groups, and state agencies generally

agree that this approach improves public safety. Operators told us that the 

primary benefit of the program is the comprehensive knowledge they 

acquire about the condition of their pipelines. APTA and Transport Canada 

officials have told us that their oversight approaches have not been 

formally evaluated to determine their effectiveness. However, according to

FRA officials, APTA’s system safety oversight approach has strengthened 

safety program management in the commuter rail sector. Finally, 

Transport Canada is expanding its safety management system approach to

its oversight of civil aviation. 

While FRA does not oversee railroads’ overall approach for managing 

safety risks on their systems, it has taken some steps in a limited number 

of areas to oversee and encourage risk management in the railroad 

industry. For example, the agency has several regulations in place that 

require railroads to use a risk-based approach for managing safety in 

specific areas: the operation of high-speed passenger trains, the fire safety 

of new passenger cars and locomotives, and the adoption of new 

processor-based signal and train control technologies. In addition, 

PHMSA, in consultation with FRA and the Transportation Security 

Administration, has recently proposed a regulation that could lead to 

greater FRA oversight of railroads’ management of hazardous materials 

risks.49 FRA has also issued guidance for passenger railroads on assessing 

collision hazards and risks and developing strategies for addressing them.50

In addition, FRA is currently working with APTA and some commuter 

railroads to improve these railroads’ abilities to conduct collision hazard 

analyses. Finally, as discussed earlier, FRA is considering establishing a 

pilot project to examine how a risk management approach could be used

 48GAO, Natural Gas Pipeline Safety: Integrity Management Benefits Public Safety, but 

Consistency of Performance Measures Should Be Improved, GAO-06-946 (Washington, 

D.C.: Sept. 8, 2006). 

49As noted previously, FRA enforces PHMSA’s hazardous material regulations as they relate 

to the transportation of such materials by rail. Specifically, under this proposed regulation, 

which was issued in December 2006, railroads would be required to compile annual data on

certain shipments of hazardous materials that are particularly hazardous, use the data to

analyze safety and security risks along the rail transportation routes where those materials 

are transported, assess alternative routing options, and base routing decisions on those 

assessments.

50FRA has also worked with Amtrak, which does not participate in APTA’s program, to

assist it in developing a system safety plan that is consistent with APTA’s guidelines. 

Page 38 GAO-07-149 Railroad Safety Oversight
in the railroad industry, on a voluntary basis, to reduce human factor 

accidents as well as other types of accidents. 

Although FRA is taking some steps to encourage increased use of risk 

management in the railroad industry, oversight of railroads’ overall 

approach for managing safety risks on their systems, in addition to FRA’s 

existing discipline-specific compliance-based oversight, has the potential

to provide additional assurance of safety. Such an approach could help to

ensure that railroads systematically identify and address the full range of 

risks on their systems and could also encourage railroads to take on more 

responsibility for safety. According to agency officials, FRA is concerned 

that railroads too often wait for inspectors to show up before addressing 

problem areas, while FRA would prefer that they find and fix problems on

their own. However, developing and implementing such a new oversight 

approach would be a major undertaking for the agency and would also 

require the support and participation of the railroad industry. 

While we believe that adopting a comprehensive approach for overseeing

railroads’ management of safety risks, similar to the approaches discussed 

in this section, can lead to improved safety, we are not making a 

recommendation aimed at encouraging FRA to adopt such an oversight 

approach. As discussed in the previous section, FRA is pursuing several 

initiatives aimed at reducing train accident rates. In our view, these 

initiatives need time to mature to demonstrate their effects and, at the 

appropriate time, the department may wish to conduct an informed 

assessment to determine whether additional actions are warranted. 

FRA has a broad range of goals and measures that it uses to provide 

direction to and track the performance of its safety oversight activities. 

However, its ability to make informed decisions about its inspection and 

enforcement programs is limited because it lacks measures of the 

intermediate outcomes, or direct results, of these programs that would 

show how they are contributing toward the end outcomes, or ultimate 

safety improvements, that the agency seeks to achieve. Furthermore, while

FRA has made some changes in its oversight approach in response to 

external and internal evaluations, it has not evaluated the effectiveness of 

its enforcement approach. Evaluations can provide a broader range of 

information on program performance and how to improve it than 

performance measures alone. Both performance measures and evaluations 

can provide valuable information on program results that helps hold 

agencies accountable for their programs’ performance. 

FRA Measures Its 

Progress in Achieving 

a Variety of Safety 

Goals, but Has 

Limited Information 

on the Direct Results 

of Its Oversight 

Page 39 GAO-07-149 Railroad Safety Oversight
To its credit, FRA has adopted a range of useful safety performance 

goals.51 These safety goals are useful because they help the agency target 

its oversight efforts to help achieve the department’s goals of reducing (1) 

the rate of rail-related accidents and incidents and (2) the number of 

serious hazardous materials releases. For fiscal year 2007, FRA established 

six new agencywide safety goals that are aligned with its five inspection 

disciplines and its grade crossing efforts. These goals are to reduce the 

rates of (1) accidents caused by human factors; (2) accidents caused by 

track defects; (3) accidents caused by equipment failure; (4) accidents 

attributable to other causes, including signal defects; (5) hazardous 

materials releases; and (6) grade-crossing incidents. These departmental 

and agency goals represent the key end outcomes, or ultimate results, FRA 

seeks to achieve through its oversight efforts. The agency has also recently 

established regional office goals that are generally aligned with the new 

agencywide goals. These regional office goals help FRA to link the 

oversight activities of its eight regional offices with its overall goals. 

FRA Has Established a 

Range of Safety Goals and 

Uses Cooperation and 

Enforcement to Achieve 

These Goals 

FRA officials told us that their inspection and enforcement programs 

contribute to meeting these safety goals, or end outcomes, by resulting in

the correction of safety problems and compliance.52 These desired direct 

results can be called the intermediate outcomes of the inspection and 

enforcement programs, although FRA has not identified them as such. 

FRA officials told us that they use a combination of cooperation with 

railroads and enforcement actions to achieve the correction of safety 

problems and compliance. The linkages between such program outputs 

and desired intermediate and end outcomes can be demonstrated in a 

 51We have reported that agencies should create a set of performance goals that address

important and various aspects of program performance. See, for example, GAO, ResultsOriented Government: GPRA Has Established a Solid Foundation for Achieving Greater 

Results, GAO-04-38 (Washington, D.C.: Mar. 10, 2004); Managing for Results: 

Strengthening Regulatory Agencies’ Performance Management Practices, GAO/GGD-00-10 

(Washington, D.C.: Oct. 28, 1999); and Agency Performance Plans: Examples of Practices 

That Can Improve Usefulness to Decisionmakers, GAO/GGD/AIMD-99-69 (Washington,

D.C.: Feb. 26, 1999). 

52A number of other agency efforts—including the Railroad Safety Oversight program, the

development of new safety standards, rail-related research and development, and 

initiatives to improve highway-rail grade crossing safety—also contribute toward these end

outcomes. 

Page 40 GAO-07-149 Railroad Safety Oversight
“logic model” that helps to show how program activities contribute to the 

ultimate results the agency seeks to achieve.

53 (See fig. 9.) 

Figure 9: How FRA’s Inspection and Enforcement Programs Contribute to Rail Safety 

Program outputs

Enforcement actions for

violations found 

Cooperation with railroads, 

such as discussions to 

remedy safety problems

Intermediate outcomes

Correct safety problems

Achieve compliance

End outcomes

Reduce railroad

accidents and incidents

Reduce releases of

hazardous materials

Source: GAO analysis of FRA information.

Note: The program outputs and intermediate outcomes identified in this figure are examples of the 

outputs and intended direct results of FRA’s inspection and enforcement and resulted from 

discussions with FRA officials. FRA has not identified these as outputs or intermediate outcomes. In

addition to the agency’s inspection and enforcement efforts, its Railroad System Oversight managers 

work cooperatively with the Class I railroads to achieve safety improvements not related to 

compliance. 

FRA uses cooperation with railroads and enforcement actions in various 

ways to resolve safety problems and achieve compliance. As explained 

previously, problems identified in inspections can be site-specific 

compliance problems or broader problems affecting multiple sites. 

Inspectors try to resolve site-specific compliance problems found during 

routine inspections by discussing defects with railroad officials in order to 

achieve voluntary compliance. The agency’s policy of focused

enforcement requires that inspectors cite violations and recommend 

enforcement actions, most frequently civil penalties, for those compliance 

problems that pose the greatest safety hazards. Enforcement actions can 

require railroads to correct identified compliance problems as well as 

deter future noncompliance. After in-depth inspection efforts at multiple 

sites, inspectors meet with railroad managers to discuss overall findings of 

safety problems that need to be corrected to achieve compliance. FRA 

sometimes encourages or requires railroads to make broad-scale 

improvements, such as in the training of railroads’ track inspectors, which 

 53We have suggested that regulatory programs develop logic models to develop a better

understanding of how their programs deliver results, in order to select appropriate 

performance goals and measures. See GAO-04-38 and GAO/GGD-00-10. 

Page 41 GAO-07-149 Railroad Safety Oversight
could help a railroad to comply with the agency’s standards. (See app. II 

for more information on how FRA uses cooperation and enforcement to 

improve safety.) 

Performance Measures 

Support FRA’s Oversight, 

but Information on Direct 

Results Is Limited 

Consistent with the Government Performance and Results Act of 1993, 

which calls on federal agencies to develop performance measures to help 

determine the extent to which intended outcomes are achieved, FRA has 

developed a range of performance measures that it uses to track the 

progress of—and provide direction to—its safety oversight programs.54

(See table 3.) A number of these measures provide useful information 

about the extent to which various desired end outcomes, or ultimate 

results, are being achieved. In particular, FRA has developed a number of 

measures, based on agency and regional goals, that capture important 

components of its progress in achieving the department’s overall safety 

goals. Since these new measures are linked to inspection and enforcement 

activities of its inspection disciplines and regional offices, they can 

provide some useful information on progress in achieving the desired end 

outcomes. For example, the agency expects that inspection and 

enforcement efforts in the operating practices discipline will reduce 

accidents caused by human factors, and it tracks the extent to which these 

accidents are reduced, both at the national and the regional level. 

 54This act is the centerpiece of a statutory framework that Congress put in place during the 

1990s to help resolve the long-standing management problems that have undermined the

federal government’s efficiency and effectiveness and to provide greater accountability for 

results. See GAO-04-38. 

Page 42 GAO-07-149 Railroad Safety Oversight
Table 3: FRA’s Safety Performance Measures 

Type of measure Description 

End outcomes

Departmental safety goals Rate of rail-related accidents and incidentsa and number of serious hazardous materials 

releases 

Agency safety goals Rates of train accidents caused by human factors, track defects, equipment defects, or 

other (signal and miscellaneous) causes; rate of nonaccident rail-related hazardous 

materials releases; and rate of highway-rail grade crossing incidents 

Regional office safety goals By region, numbers of train accidents caused by human factors, track, equipment, and 

other causes and numbers of highway-rail grade crossing incidents 

Class I railroad safety performance trends Trends in rates of accidents of various types for each Class I railroad 

Program outputs and management 

Agency efficiency goal Ratio of safety budget expenditures on safety-related activities, such as inspections, 

versus administrative activities

Management of inspection and enforcement 

activities 

• Various measures used in targeting inspections and determining enforcement 

actions, including trends in various types of accidents and employee injuries and 

cited defects and violations, by inspection discipline, region, state, and railroad 

• Inspections conducted and costs by region and inspection discipline 

• Extent to which regions are meeting planned targets for inspections 

• Timeliness of reports received from railroads on actions taken to remedy violationsb

• Measures related to enforcement, including civil penalties assessed and collected 

and processing times 

Source: GAO analysis of FRA information.

a

Includes train accidents as well as grade-crossing, trespassing, and other accidents.

b

For those violations requiring corrective action, railroads are required, within 30 days after the end of

the month in which the violation occurred, to notify FRA of the actions they have taken. 

The agency has adjusted its oversight approach in response to trends in 

end outcome measures. For example, it developed the National Rail Safety

Action Plan in response to a flat trend in the overall train accident rate and 

an increasing rate of accidents caused by human factors. In addition, FRA 

has developed measures to track the performance of Class I railroads, and 

it reviews these measures quarterly to assist in making decisions about 

oversight of these railroads. 

FRA also uses various measures of program outputs, such as numbers of 

inspections and enforcement actions, as well as some other types of 

measures to manage its oversight efforts. While the agency does not track 

its cooperative efforts to achieve compliance, it does track inspection and 

enforcement activities. In fiscal year 2007, the agency will start using an 

efficiency measure to track its progress in using its resources on safetyrelated activities, such as inspections, rather than on administrative 

activities. FRA headquarters and inspection staff use data on defects and 

Page 43 GAO-07-149 Railroad Safety Oversight
violations cited in inspections, together with data on accidents and 

incidents, in planning inspection activities and making enforcement 

decisions. Finally, FRA tracks whether railroads report on actions taken to

correct violations within the required time. 

While FRA has developed a range of measures of end outcomes and 

program outputs, it lacks measures of the desired intermediate outcomes, 

or direct results, of its inspection and enforcement efforts—that is, the 

correction of identified safety problems and compliance. We have found

that it is a useful practice for agencies to establish measures of 

intermediate outcomes to help show programs’ contributions to desired 

end outcomes.55 According to FRA officials, inspectors review reports on 

corrective actions provided by railroads and may ask a railroad to 

resubmit a report if they believe that it does not adequately address the 

violation.56 FRA officials also told us that inspectors always follow up on 

serious problems identified—both site-specific and broader scale 

problems—to ensure that they are corrected, and may cite additional 

violations if they find continuing problems.57 However, the agency does not

measure the extent to which identified safety problems have been 

corrected. Without such a measure, FRA cannot determine the extent to

which its inspection and enforcement efforts are achieving the desired 

direct results. 

Measuring whether safety problems have been corrected is particularly 

important when serious compliance problems are broad-scale, affecting 

multiple sites, whether the problems are local, regional, or systemwide. 

These problems are sometimes identified in reports of in-depth 

inspections. For example, one set of track inspections of a Class I railroad 

at various sites within a region in early 2006 led to overall findings that 

 55See GAO/GGD/AIMD-99-69 and GAO/GGD-00-10. 

56For violations determined by the inspector to require corrective action, railroads are

required to provide FRA with a report within 30 days of the end of that month on the 

corrective actions they have taken. These reports also include the type of action taken, 

such as repair or replacement of equipment and disciplinary action or training of

employees. FRA tracks whether these reports are received on time as well as the types of

actions taken. 

57FRA’s inspection reports contain a field for recording the receipt of railroads’ reports on

corrective actions but do not contain a field for recording whether inspectors have 

determined, in following up on violations, that the corrective actions are adequate. 

Furthermore, some regional staff told us that inspectors do not consistently record followup inspections as such. 

Page 44 GAO-07-149 Railroad Safety Oversight
these locations had deteriorating track conditions, that no repair work was 

scheduled, and that the railroad’s track inspections were not adequate.58

According to FRA officials, headquarters managers and managers of the 

agency’s eight regional offices frequently discuss serious safety problems, 

indicated by the results of field inspections and data analyses, to 

determine the scope of the problems and decide on actions the agency

should take to ensure that railroads resolve them. However, while FRA 

tracks a variety of safety related data, it does not centrally track these 

broad-scale compliance problems or their status and therefore lacks 

overall information on the effectiveness of its efforts to ensure that they

are resolved.

59

FRA also lacks overall measures of railroads’ compliance. FRA officials 

told us that, while defect rates (the ratio of defects found per units 

inspected) measure noncompliance found by inspectors, they cannot be 

used to produce statistically valid measures of railroads’ overall level of 

compliance because inspections are focused on problem areas and FRA is 

not able to conduct enough inspections of railroads to ensure that it is 

getting a good measure of compliance.60 Officials have emphasized that the 

agency relies on inspectors’ day-to-day oversight of and interaction with 

railroads to track compliance. Also, as noted previously, FRA officials, 

both at the headquarters and regional levels, analyze defect data in each 

inspection discipline to identify emerging issues and plan inspection 

activity. Finally, officials noted that the agency is planning to use its 

automated track inspection vehicles to survey most of the national track 

system and to monitor improvements in the condition of track over time. 

 58In contrast, defects and violations tend to be much more specific. In this case, inspectors 

also found numerous defects concerning specific instances of track not meeting federal 

standards and two violations concerning defects that had gone for more than 30 days 

without corrective action. 

59In fiscal year 2006, FRA compiled information for the first time on all in-depth inspection 

activity by its headquarters and regional offices into one report and began producing 

quarterly updates on the status of these inspections. These updates contain some 

information on findings of broad-scale problems, in narrative form, but do not provide

overall assessments of progress being made by each railroad as a whole in addressing these 

problems. 

60However, FRA does include in its quarterly review of Class I railroads’ performance 

trends certain operating practices and track defect rates that it has found to be related to 

accident rates. 

Page 45 GAO-07-149 Railroad Safety Oversight
We recognize that developing measures of intermediate outcomes would 

be difficult and that it is challenging for regulatory agencies to develop

such measures.61 Nevertheless, some other regulatory agencies in the 

Department of Transportation have developed such measures. For 

example, the Federal Motor Carrier Safety Administration measures the 

percentage of truck companies that improve their performance in a followup inspection and PHMSA measures the extent of improvement in pipeline 

operators’ integrity management programs, as indicated by successive 

inspections of operators’ programs. FRA officials have told us that the fact 

that the agency has not integrated its existing safety-related databases has

impeded its ability to develop measures of intermediate outcomes. The 

agency has an initiative underway to better integrate these databases, 

including its database on accidents and incidents and its inspection and

enforcement databases, in order to better manage its information 

resources.62

Performance measures should provide agency managers with information 

that helps them make decisions that improve program performance, 

including decisions to adjust policies and priorities. As noted, FRA has 

used its existing performance measures to make decisions about its 

oversight approach in a variety of ways. However, not having measures of 

the intermediate outcomes of its inspection and enforcement approaches 

limits FRA’s ability to make informed decisions about these approaches 

and adjust them to improve performance. Intermediate outcome measures

can provide more timely information on program performance than end 

outcome measures, because it may take longer for program efforts to 

affect end outcomes. 

Measures of program results can also help hold agencies accountable for

the performance of their programs. Congress needs information on 

program results to support its oversight of agencies and their budgets. 

FRA’s new discipline-specific and region-specific outcome measures do 

 61We have reported on such challenges and how agencies have overcome them. See, in 

particular, GAO-04-38; GAO/GGD-00-10; Managing for Results: Measuring Program

Results That Are Under Limited Federal Control, GAO/GGD-99-16 (Washington, D.C.: Dec. 

11, 1998); and Managing for Results: Regulatory Agencies Identified Significant Barriers

to Focusing on Results, GAO/GGD-97-83 (Washington, D.C.: June 24, 1997).

62FRA has tasked a contractor with developing a plan for a data warehousing strategy for 

the agency that will integrate its data from various sources. According to agency officials, 

this initiative will allow FRA to better monitor its performance, through, for example, 

providing scorecards and graphical tools to depict performance. 

Page 46 GAO-07-149 Railroad Safety Oversight
help ensure accountability for results. However, without measures of 

intermediate outcomes, the extent to which FRA’s inspection and 

enforcement programs are achieving direct results and contributing to 

desired end outcomes is not clear. FRA officials have noted that they 

cannot attribute any drops in accident rates solely to FRA’s efforts 

because other factors, such as railroads’ investments in their systems, also 

play an important role. 

FRA can also use measures of intermediate outcomes to increase 

railroads’ accountability for correcting safety problems. In spring 2006, the 

agency instituted annual meetings with the heads of the Class I railroads to 

discuss their overall safety performance, using trends in various accident

rates. These meetings are a good step forward for the agency because they 

represent an opportunity for FRA to put pressure on top railroad 

executives to adequately address major problems the agency has 

identified. However, without measures of the extent to which individual 

railroads have addressed such problems, FRA cannot take full advantage 

of this opportunity. In addition, without central tracking of these problems 

and their status, FRA’s ability to identify continuing or recurring problems 

as well as interrelated problems and make appropriate enforcement 

decisions may be impaired, especially since much of this work is 

performed in eight separate FRA regional offices and in five separate 

inspection disciplines.63 According to FRA, annual meetings with the major 

railroads to negotiate civil penalties focus on individual violations but also 

address systemic issues that have been identified through analysis of 

individual violations. However, regional officials told us that these 

meetings do not generally deal with systemic issues. Readily available 

information on the status of broader problems would help put a railroad’s

individual violations into perspective and could help ensure that FRA 

negotiates appropriate final amounts with railroads. 

FRA Has Made Changes in 

Response to Evaluations 

but Has Not Evaluated Its 

Enforcement Approach 

Besides requiring performance measurement, the Government 

Performance and Results Act of 1993 calls for agencies to evaluate the 

effectiveness of their programs in achieving intended outcomes. We have

found that, since it can be challenging for regulatory agencies to measure 

the direct results of their programs, program evaluations are particularly 

 63A major concern with the previous Safety Assurance and Compliance Program, which

ended in 2005, was that systemwide safety problems handled under this program took too

long to resolve.

Page 47 GAO-07-149 Railroad Safety Oversight
helpful in determining these results.64 Program evaluations are objective, 

systematic studies that answer questions about program performance and 

results. By examining a broader range of information than is feasible to 

monitor on an ongoing basis through performance measures, evaluation 

studies can explore the benefits of a program as well as ways to improve 

program performance. They can also be used to develop or improve 

agencies’ measures of program performance and help ensure agencies’ 

accountability for program results.65

FRA’s safety oversight activities have recently undergone several external 

evaluations by the department’s Inspector General, as well as an internal 

review, and FRA has made some changes as a result. For example, on the

basis of several reviews since 1998, the department’s Inspector General in 

2004 recommended that FRA develop a plan to make meaningful use of 

available data to focus its inspection and enforcement activity.66 FRA 

developed its National Inspection Plan in response. Also, in 2004, FRA 

established a committee to conduct an internal review of its Safety 

Assurance and Compliance Program. This committee solicited the views of 

various FRA managers on the strengths and weaknesses of the program. 

Based on its findings, FRA terminated this program and replaced it with its 

Railroad System Oversight program. 

In addition, the Office of Management and Budget assessed FRA’s overall 

safety program in 2003.

67 Although the office found this overall program to 

be moderately effective, it also found that FRA had not arranged for 

independent evaluations of its design and effectiveness. In response, FRA 

 64Such evaluations can also help determine the extent to which a program is having an

impact on these outcomes versus other variables that affect outcomes. See GAO-04-38. 

65See GAO, Program Evaluation: An Evaluation Culture and Collaborative Partnerships

Help Build Agency Capacity, GAO-03-454 (Washington, D.C.: May 2, 2003); and Program

Evaluation: Studies Helped Agencies Measure or Explain Program Performance, 

GAO/GGD-00-204 (Washington, D.C.: Sept. 29, 2000). 

66U.S. Department of Transportation–Office of the Inspector General, Review of Allegations 

that FRA Deputy Administrator Attempted to Relax Safety Enforcement Against Union

Pacific (Washington, D.C., Dec. 10, 2004); and Audit of Oversight of Highway-Rail Grade 

Crossing Accident Reporting, Investigations, and Safety Regulations, MH-2006-016 

(Washington, D.C., Nov. 28, 2005). 

67The Office of Management and Budget performed this assessment using its Program 

Assessment Rating Tool. This tool examines factors that affect and reflect program

performance, including program purpose and design, performance measurement and 

evaluations, and aspects of program management. 

Page 48 GAO-07-149 Railroad Safety Oversight
arranged for a review of its Railroad Safety Board process and has stated 

that it will continue to have regular independent reviews of various 

aspects of its safety program.68 The agency is planning to have an 

independent evaluation of its Railroad System Oversight program 

conducted in the third quarter of fiscal year 2007. FRA also made some 

other improvements in response to recommendations of the Office of 

Management and Budget assessment, including developing its new 

efficiency measure and procuring new vehicles for conducting track 

inspections. 

Although FRA has modified various aspects of its safety oversight in 

response to evaluations, it has not evaluated the extent to which its 

enforcement is achieving desired results. In addition to providing 

information on program performance and how it could be improved, an 

evaluation of FRA’s enforcement approach could help to identify data 

needed to develop useful performance measures. For example, the Federal 

Motor Carrier Safety Administration examined the rate of violations by 

trucking companies before and after implementing a policy of assessing 

maximum penalties for such violations and, based on initial analyses, has 

improved its data system to be better able to analyze this trend. 

Under FRA’s focused enforcement policy, developed in the mid-1990s, 

inspectors cite a small percentage of identified defects (about 3 percent in

2005) as violations that they recommend for enforcement action, generally

civil penalties. While this policy relies, to a great extent, on cooperation 

with railroads to achieve compliance and is intended to focus FRA’s 

enforcement efforts on those instances of noncompliance that pose the 

greatest safety hazards, it is not clear whether the number of civil 

penalties issued, or their amounts, are having the desired effect of 

improving compliance. FRA officials have told us that they have not 

evaluated the effectiveness of civil penalties in ensuring compliance, 

noting that this would be difficult because penalty payments usually occur 

after the agency’s yearly settlement process. However, without an 

evaluation of its enforcement program, FRA is missing an opportunity to 

obtain valuable information on the performance of this program and on 

any need for adjustments to improve this performance. 

 68The Railroad Safety Board approves or denies requests for waivers or special approval

submitted by railroads and other parties subject to FRA regulations. 

Page 49 GAO-07-149 Railroad Safety Oversight
The various initiatives that FRA has begun in the past year and a half to

better target its oversight—by addressing the main causes of train 

accidents and better focusing inspections on problem areas—hold 

promise for bringing down the train accident rate, reducing injuries, and 

saving lives. Some initiatives, such as reporting of close call incidents, 

encourage the railroad industry to address safety problems before they 

result in accidents. However, the success of many of these initiatives will 

depend on voluntary actions by the railroads and their overall safety 

impact will likely not be apparent for a number of years. While FRA is 

pursuing these initiatives, it has not changed its approach for conducting 

inspections, which relies primarily on direct observations of operations, 

equipment, and track. An additional approach that has provided additional 

assurance of safety in the U.S. commuter railroad, U.S. pipeline, and 

Canadian railroad industries is oversight of companies’ overall 

management of safety risks. Although we believe that a similar approach 

could help improve rail safety, we are not recommending that FRA adopt 

such an approach because its current initiatives to bring down the train 

accident rate need time to demonstrate their effects. 

Without measures of the direct results of its inspection and enforcement 

programs, FRA cannot demonstrate how these programs are contributing 

to rail safety and lacks key information that could help it improve 

performance. This information could also help FRA hold railroads 

accountable for addressing safety problems it identifies. While these 

measures are not always easy to develop, at least one other modal 

administration within the department has done so at our recommendation. 

Coupled with better measures of FRA’s direct results is the need to assess

the effectiveness of its enforcement program, especially its use of civil 

penalties, to understand the degree to which they contribute to improved 

safety outcomes and to determine whether it should adjust its approach to

improve performance. 

To enhance FRA’s ability to determine the extent to which its inspection 

and enforcement programs are contributing to rail safety and whether 

changes in these programs are needed, we recommend that the Secretary 

of Transportation direct the Administrator of FRA to take the following 

two actions: 

Conclusions 

Recommendations for 

Executive Action 

• develop and implement measures of the direct results of its inspection and 

enforcement programs; and 

Page 50 GAO-07-149 Railroad Safety Oversight
• evaluate the agency’s enforcement program to provide further information 

on its results, the need for additional data to measure and assess these 

results, and the need for any changes in this program to improve 

performance. 

We provided a draft of this report to the Department of Transportation for 

its review and comment. The department did not offer overall comments 

on the draft report or its recommendations. It did offer several technical 

comments, which we incorporated where appropriate. 

We are sending copies of this report to congressional committees and 

subcommittees with responsibility for transportation safety issues; the 

Secretary of Transportation; the Administrator, Federal Railroad 

Administration; and the Director, Office of Management and Budget. We 

will also make copies available to others upon request. This report will be 

available at no charge on the GAO Web site at http://www.gao.gov. 

If you have any questions about this report, please contact me at (202) 512-

2834 or siggerudk@gao.gov. Contact points for our Offices of 

Congressional Relations and Public Affairs may be found on the last page 

of this report. Staff who made key contributions to this report are listed in

appendix IV.

Katherine A. Siggerud 

Director, Physical Infrastructure Issues 

Agency Comments 

Page 51 GAO-07-149 Railroad Safety Oversight
Appendix I: Scope and Methodology Appendix I: Scope and Methodology 

To determine how the Federal Railroad Administration (FRA) focuses its 

efforts on the highest priority risks related to train accidents in planning 

its safety oversight, we reviewed FRA’s National Rail Safety Action Plan, 

plans for developing new regulations, documents related to its initiatives 

for reducing human factor and track-caused accidents, and inspection 

planning documents. We also discussed the agency’s inspection planning 

approach and key initiatives with headquarters and regional officials 

responsible for these areas. In addition, we obtained information on FRA’s 

initiatives through attending congressional hearings on FRA’s oversight 

and meetings of the Railroad Safety Advisory Committee. 

To determine how FRA identifies safety problems on railroad systems in 

carrying out its oversight, we determined how FRA uses its inspections, 

the Railroad System Oversight program, and other oversight activities to 

oversee safety and identify problems. In order to do this, we reviewed 

FRA’s regulations, policies, procedures, and guidance for conducting 

inspections and identifying safety problems as well as reports on 

inspection results. We also reviewed the agency’s statutory authority 

under the Federal Railroad Safety Act and reviewed Railroad Safety 

Oversight program documents. We discussed FRA’s oversight activities 

with FRA headquarters managers and inspection discipline specialists and 

Railroad Safety Oversight managers to gain a greater understanding of 

how FRA identifies safety problems on railroad systems. We also 

contacted three (Chicago, Forth Worth, and Atlanta) of the eight FRA 

regional offices reporting the highest numbers of accidents in their 

jurisdictions during 2005. We discussed this topic with administrators and 

track and human factor discipline specialists from each of these regional

offices. We conducted these interviews on-site at the offices located in

Fort Worth, Texas, and Chicago, Illinois. We also discussed this topic with 

officials from the three state regulatory associations employing the 

greatest number of railroad safety inspectors in order to discuss how state 

inspectors coordinate their activities with FRA inspectors. (See the end of

this appendix for a list of organizations that we contacted.) We also 

examined our published work on risk management and safety oversight 

approaches used by other modal administrations within the Department of 

Transportation as well as some other organizations responsible for 

overseeing rail safety. 

We reviewed FRA data on its inspection activities for the period from 1996 

through 2005. To assess the reliability of the inspection data, we (1) 

performed electronic testing of required data elements, (2) reviewed 

existing information about the data and the system that produced them, 

and (3) interviewed agency officials knowledgeable about the data. We 

Page 52 GAO-07-149 Railroad Safety Oversight
Appendix I: Scope and Methodology 

discussed our preliminary results with FRA to ensure that we were 

capturing the correct information and consulted with these officials to 

resolve questions on the data collection process. We determined that the

data were sufficiently reliable for the purposes of this report. 

To determine how FRA assesses the impact of its oversight efforts in 

improving safety, we examined the methods FRA uses to assess the results 

of its oversight programs and FRA’s use of this information to make 

decisions about its oversight strategy. As part of this effort, we reviewed 

FRA documents on its safety performance measures and evaluations of its 

oversight and enforcement activities. We also discussed this issue with 

managers at headquarters and in the regional offices responsible for 

developing and using performance information. In addition, we reviewed 

our recommendations on performance measurement, the use of 

performance information, and program evaluation and determined the 

extent to which FRA’s practices are consistent with these 

recommendations. 

We focused our work on FRA’s oversight activities aimed at reducing train 

accidents–such as train collisions and derailments–rather than those 

aimed at reducing highway-rail crossing and trespassing accidents. FRA’s 

oversight of highway-rail grade crossing safety has been the subject of two 

recent Department of Transportation Inspector General audits. In addition,

both these types of accidents and trespassing accidents involve issues not 

related to railroad safety performance, such as driver awareness of grade 

crossing safety and individuals’ willingness to abide by railroads’ warning 

signs on their property. We also focused on FRA’s oversight of railroads

rather than its oversight of non-railroad companies (such as shippers of 

hazardous materials by rail) because the agency ‘s oversight efforts focus 

primarily on railroads. In addition, according to FRA, most recent serious 

train accidents involving the release of hazardous materials have resulted 

from problems with railroad operations. 

We also examined how FRA uses enforcement and other methods for 

ensuring that safety problems on railroad systems are resolved. In order to

do this, we reviewed FRA’s policies, procedures, and guidance for 

conducting enforcement; major enforcement actions such as compliance 

agreements; Railroad Safety Oversight program documents; and other 

agency documents. We also discussed FRA’s approaches to resolving 

safety problems, through enforcement and other means, with officials 

from FRA headquarters, Railroad System Oversight managers, and 

administrators and inspection discipline specialists in three regional 

Other Aspects of Our 

Work

Page 53 GAO-07-149 Railroad Safety Oversight
Appendix I: Scope and Methodology 

offices. Regarding FRA’s enforcement approach, we reviewed how FRA 

employs enforcement to improve safety on railroads’ systems. However, 

we could not determine the extent to which railroads address systemic 

safety problems as a result of enforcement because FRA does not track 

the broad-scale safety problems it identifies or the extent to which these 

problems are resolved. We focused on FRA’s use of enforcement as part of 

its overall oversight strategy and did not examine the agency’s individual 

enforcement actions. 

We also obtained FRA data on civil penalties from FRA’s enforcement 

database, which includes data on assessed and collected amounts from 

1996 through 2005. We assessed the reliability of the enforcement data by

the same means that we employed to assess the reliability of FRA’s 

inspection data. We determined that the enforcement data used in this 

report were sufficiently reliable for the purposes of this report. 

Finally, we met with or contacted the following organizations or persons 

in order to obtain a fuller understanding of railroad safety issues and 

obtain their perspectives on FRA’s oversight approach. 

Other federal agencies: 

National Transportation Safety Board 

Freight railroads (Class I): 

BNSF Railway Company 

CSX Transportation, Inc. 

Norfolk Southern Railway Company 

Union Pacific Railroad Company 

Passenger railroads: 

National Railroad Passenger Corporation, or Amtrak 

Northeast Illinois Regional Commuter Rail Corporation, or Metra 

New Jersey Transit Rail Operations 

Regional and short line railroad management companies: 

Cedar American Rail Holdings, Inc. 

RailAmerica 

Page 54 GAO-07-149 Railroad Safety Oversight
Appendix I: Scope and Methodology 

Industry associations: 

American Chemistry Council 

Association of American Railroads 

American Public Transportation Association 

American Short Line and Regional Railroad Association 

Labor unions: 

AFL-CIO 

Brotherhood of Maintenance of Way Employees 

Brotherhood of Locomotive Engineers and Trainmen 

United Transportation Union 

State oversight organizations: 

Association of State Rail Safety Managers 

California Public Utilities Commission 

Ohio Public Utilities Commission 

Texas Department of Transportation 

Canadian oversight organization: 

Transport Canada 

Academic expert:

Dr. Ian Savage, Department of Economics, Northwestern University 

Page 55 GAO-07-149 Railroad Safety Oversight
Appendix II: FRA Addresses Safety Problems Appendix II: FRA Addresses Safety Problems through Cooperation and Enforcement 

through Cooperation and Enforcement 

FRA uses cooperation with railroads and enforcement actions in various 

ways to resolve identified safety problems and achieve compliance. When

inspectors find problems during inspections, FRA’s policy is to cite defects 

for most instances of noncompliance and to encourage the railroad to 

comply voluntarily. For example, issues may be addressed on site with 

railroad officials during inspections. According to FRA officials, railroads

often correct identified problems immediately and if so, these problems 

would not require additional action. When railroads do not comply 

voluntarily or the identified defects are serious, FRA may cite violations 

and recommend civil penalties or take other enforcement actions—either 

against railroads or individuals—to promote compliance with safety 

regulations.1

 According to FRA officials, inspectors follow up on violations

or high numbers of defects within 60 days to ensure that they are 

corrected.2

FRA most commonly uses civil penalties against companies as its 

enforcement tool for site-specific violations.3

 From January 2005 through 

July 2006, FRA assessed about 8,600 violations for civil penalties. FRA has 

other enforcement tools. These include compliance agreements and 

compliance orders, civil penalties against individuals, special notices for 

repair, emergency orders, criminal penalties, disqualification orders, and 

injunctions. (See table 4.) FRA uses these tools much less frequently than

it does civil penalties. For example, FRA issued 288 special notices for 

repair, 118 warning letters and fewer than a dozen of all other enforcement 

actions during this period.

4

 1

While we reviewed how FRA employs enforcement to improve safety on railroads’ 

systems, we could not determine the extent to which railroads address systemic safety 

problems as a result of enforcement. This is because FRA does not track the broad-scale 

safety problems it identifies or the extent to which these problems are resolved. We 

focused on FRA’s use of enforcement as part of its overall oversight strategy and did not 

examine the agency’s individual enforcement actions. 

2

Often, an inspector will conduct follow-up re-inspections during other routine inspections. 

However, an inspector may make a special visit to conduct follow-up if warranted. 

3

FRA’s Statement of Enforcement Policy specifies that before citing violations and 

recommending penalties, inspectors consider the seriousness of the condition or act, the

potential safety hazard posed by the condition or act, and the current level of compliance 

of the offending person (e.g., a railroad or individual), among other things.

4

FRA could not supply data covering a longer period on the frequency of use of all of its

enforcement actions without substantial effort. 

Page 56 GAO-07-149 Railroad Safety Oversight
Appendix II: FRA Addresses Safety Problems

through Cooperation and Enforcement 

Table 4: Description of FRA Enforcement Actions and Frequency of Use, January 2005 through July 2006 

Enforcement action

Number of 

times used Description

Civil penalty against a 

railroad or other entity 

except for an individual 

8,606 Imposes a monetary penalty on a railroad or other entity, such as a company that 

ships hazardous materials by rail, that violates a rail safety or hazardous materials 

statute, regulation, or order. Each day that the violation continues is a separate 

violation. 

Special notice for repair 288 Orders a locomotive, freight car, or passenger car out of service and may require a 

reduction of the maximum operating speed over defective track segments. 

Warning letter to an 

individual 

118 Informs an individual that FRA believes that the individual has committed a rail safety 

or hazardous materials violation and that any future violation by the individual will 

result in enforcement action. 

Civil penalty against an 

individual 

6 Imposes a monetary penalty on any individual who willfully violates or willfully causes 

the violation of a rail safety statute, regulation, or order. 

Compliance agreement 2 States a railroad’s agreement to take a specified action to promote compliance. The 

railroad agrees that if, in FRA’s judgment, the required action is not performed, the 

railroad will not contest FRA’s sanction–typically a compliance order. See below. 

Criminal penalty 1 Imposes (1) either a monetary penalty or imprisonment for up to 2 years, or both, on 

an individual for knowingly and willfully violating certain reporting, recordkeeping, or 

other regulations or (2) a monetary penalty or imprisonment for up to 5 years, or both, 

for knowingly violating the hazardous materials statute or an implementing regulation 

or order. 

Disqualification order 1 Prohibits an individual from performing safety-sensitive functions in the rail industry for 

a specified period if the individual’s violation of a rail safety statute or regulation 

demonstrates unfitness to perform such functions. 

Emergency order 1 Orders corrective action where an unsafe condition or practice causes an emergency 

situation involving a hazard of death or personal injury. 

Compliance order 0 Directs compliance following repeated failure to comply with rail safety or hazardous 

material statute or regulation. 

Injunction 0 Restrains a violation of, or enforces, a rail safety or hazardous materials regulation or 

order. 

Source: FRA. 

FRA inspectors cite many defects, but cite comparatively few of these 

defects as violations warranting enforcement action. Since 1996, FRA 

inspectors have cited an average of about 4 violations for every 100 defects 

cited annually. According to FRA officials, inspectors cite relatively few 

defects as violations warranting enforcement action because FRA’s 

focused enforcement policy guides inspectors to cite violations only for 

problems that pose safety risks. In addition, inspectors have discretion in 

citing a defect or a violation for a given instance of noncompliance—FRA 

directs inspectors to first seek and obtain the railroads’ voluntary 

compliance with the rail safety regulations. 

Page 57 GAO-07-149 Railroad Safety Oversight
Appendix II: FRA Addresses Safety Problems

through Cooperation and Enforcement 

According to FRA officials, inspectors usually choose to provide the 

railroad with information about defects they found during their inspection, 

discuss these instances of noncompliance, and attempt to obtain the 

railroad’s commitment to improve compliance. If the railroad’s response is 

inadequate or the inspector finds that the problem warranting the defect is 

serious, the inspector may exercise the agency’s enforcement discretion 

by citing a violation, recommending that FRA take enforcement action, 

generally a civil penalty. The agency makes an initial penalty assessment 

against the railroad based on the type of violation that occurred.5

 FRA 

meets with the major railroads in an annual settlement meeting to 

negotiate a final amount for all civil penalties cited in the past year. This 

amount is based on the railroad’s compliance history and efforts to correct 

the problem, among other factors.6

 The total value of civil penalties 

assessed and collected each year was higher from 2001 through 2005 than

from 1996 to 2000. (See fig. 10.) According to FRA officials, the higher civil 

penalty assessments after 2000 reflect the agency’s efforts to focus its 

inspection activity on areas that present the greatest risk. FRA officials 

also told us that when the agency initiated the Safety Assurance and 

Compliance Program—which emphasized a partnership approach with 

railroads to improve safety—in 1995, inspectors initially cited fewer 

violations. They noted that in 2001 FRA’s management pushed for 

inspectors to be more aggressive in citing violations. Since 2001, the 

amounts collected have been about 63 percent of the amounts initially 

assessed. Consistent with the purpose of the federal railroad safety laws 

and with federal court decisions interpreting the purpose of such laws, the 

agency’s goals are to promote safety and to gain compliance rather than to

maximize amounts collected. For example, FRA may agree to a reduced 

penalty amount if the railroad immediately remedies the safety problem or 

 5

In December 2006, FRA published in the Federal Register proposed amendments to its

schedules of civil penalties for each type of violation to ensure that penalty amounts more 

fully reflect the risk associated with a railroad’s violation of the rail safety regulations. 

6

Given the volume of civil penalty cases, FRA usually negotiates civil penalties with smaller 

railroads and shippers through the mail and telephone conferences. FRA is authorized to 

negotiate civil penalties with railroads and exercises this authority by annually settling civil 

penalty amounts with each railroad. The criteria for compromising with railroads on civil 

penalty amounts are set in statute. In determining the amount of a compromise, the 

Secretary shall consider (1) the nature, circumstances, extent, and gravity of the violation; 

(2) with respect to the violator, the degree of culpability, any history of violations, the

ability to pay, and any effect on the ability to continue to do business; and (3) other matters 

that justice requires. 

Page 58 GAO-07-149 Railroad Safety Oversight
Appendix II: FRA Addresses Safety Problems

through Cooperation and Enforcement 

implements a new program to prevent a problem from recurring.7 This is 

consistent with federal law. In other cases, FRA will agree to a reduced 

penalty amount if its documentation on the violation is not substantial 

enough. 

Figure 10: FRA’s Civil Penalties, 1996 through 2005, in 2005 Dollars 

0

2

4

6

8

10

12

14

16

18

20

1996 1997 1998 1999 2000 2001 2002 2003 2004 2005

Dollars (in millions)

Source: GAO analysis of FRA data.

Year

Civil penalties assessed

Civil penalties collected

Notes: Individual penalties resulting from violations are consolidated into one or more case(s) for 

each railroad and are negotiated annually with FRA and the railroad during settlement conferences. 

Each year’s amounts are for cases initiated in that year. Some penalties may be initially assessed in 

one year, with the final assessment in another year. FRA, in commenting on a draft of our report, 

provided 2006 civil penalty figures. However, we did not use this information because there was not 

enough time to assess its reliability before the report was issued. 

Penalties against individuals are not included. From 1996 through 2005, FRA issued an average of 1 

civil penalty per year against individuals. 

 7

The Federal Motor Carrier Safety Administration follows a similar policy. See GAO, Large 

Truck Safety: Federal Enforcement Efforts Have Been Stronger Since 2000, but Oversight 

of State Grants Needs Improvement, GAO-06-156 (Washington, D.C.: Dec. 15, 2005).

Page 59 GAO-07-149 Railroad Safety Oversight
Appendix II: FRA Addresses Safety Problems

through Cooperation and Enforcement 

FRA seeks to resolve broad-scale compliance problems it has identified by 

first discussing them with railroad officials and elevating them, as 

necessary, to obtain an appropriate response. After in-depth inspection 

efforts at multiple sites, inspectors meet with railroad managers 

responsible for those sites to discuss overall findings or problems. For 

very serious or systemic problems, FRA may ask railroads to submit 

corrective action plans and may review these plans for adequacy. FRA 

sometimes discusses broad problems with railroad headquarters officials 

to try to obtain corrective actions. For example, one regional

administrator told us that his region arranged a multiregion meeting with 

the senior management of a Class I railroad to discuss systemic problems 

with the railroad’s equipment. FRA asked the railroad to submit a 

corrective action plan to address the equipment problems. According to 

FRA officials, the railroad has been meeting the milestones in the 

corrective action plan and has been making progress in addressing its 

equipment problems. Also, FRA’s Railroad System Oversight managers, 

who act as liaisons with the Class I railroads, help to maintain frequent 

communication with these railroads about major problems that have been

identified and associated corrective actions. These efforts to cooperate 

with railroads to resolve problems may be combined with civil penalties 

for violations found at specific locations. According to FRA officials, when 

in-depth inspections result in findings of serious problems, inspectors 

always follow up to determine whether these problems are adequately 

resolved. However, FRA has no central repository for data on the status of 

these broader problems its inspectors have identified at railroads. 

FRA officials told us that they hold frequent internal discussions among 

headquarters and regional management about these broad-scale 

compliance problems that have been identified—whether local, regional, 

or systemwide—and actions that the agency should take to attempt to 

resolve them. According to FRA officials, the agency sometimes uses 

compliance agreements, which require railroads to take significant actions 

beyond those specifically required by regulations to improve their ability 

to comply, when broad-scale compliance problems are egregious and have

not been resolved through other methods. Compliance agreements allow 

FRA to apply more leverage in trying to obtain compliance because FRA 

uses the agreements as an alternative to the railroad involved undergoing

an FRA proceeding for a compliance order. For example, under recent 

compliance agreements, railroads have agreed to reinstruct managers on 

how to test employees’ adherence to operating rules and to develop and 

implement track maintenance plans to eliminate systemic track defects. 

FRA monitors railroads’ performance under these agreements. In some 

instances, FRA has also used compliance orders to address significant 

Page 60 GAO-07-149 Railroad Safety Oversight
Appendix II: FRA Addresses Safety Problems

through Cooperation and Enforcement 

railroad compliance problems. However, these enforcement tools are 

seldom used. FRA has entered into 13 compliance agreements altogether 

and one compliance order since 1996, or an average of about 1 per year. In 

comparison, since 1996, FRA has assessed in the neighborhood of almost 

40,000 violations for civil penalties. 

This approach to resolving broad-scale safety problems has had some 

success. For example, the three railroads that have entered into 

compliance agreements in the past 2 years have generally made progress 

in improving compliance, according to the results of FRA’s follow-up.8

 In 

addition, FRA officials have cited a number of other successes, including 

improved compliance by several railroads with signal inspection and 

testing requirements,9

 and another railroad’s implementation of an 

electronic system to record locomotive defects and repairs following 

FRA’s finding that inadequate recordkeeping had resulted in the operation

of locomotives with multiple defects. FRA’s Railroad System Oversight 

managers have also worked with railroads to make some systemic safety 

improvements not related to compliance. For example, these managers 

have encouraged railroads to make improvements related to roadway 

worker communication, signal maintenance, and mentoring of new 

employees. 

 8

FRA’s compliance agreements with three different divisions of one Class I railroad have

resulted in improved compliance. FRA had to extend the compliance agreement with the

third division because noncompliance continued but has since terminated the compliance

agreement because of improved safety performance. While FRA does not have overall 

measures of compliance, it sometimes, in summary reports on follow-up inspections at a 

railroad, records trends in certain types of defects found. 

9

FRA has noted instances of significant noncompliance with signal inspection and testing 

requirements on the part of two major commuter railroads and at least one Class I railroad.

Page 61 GAO-07-149 Railroad Safety Oversight
Appendix III: Oversight of Risk Management 

in the U.S. Commuter Railroad, U.S. Pipeline, Appendix III: Oversight of Risk Management and Canadian Railroad Industries 

in the U.S. Commuter Railroad, U.S. Pipeline, 

and Canadian Railroad Industries 

Risk management is a systematic process for assessing risks and taking

appropriate steps to deal with them. It is founded on several inspection 

disciplines, including financial economics, decision science, organizational 

theory, and strategic management. The National Academy of Sciences, a 

presidential commission, private organizations, and others have addressed 

the subject and have recognized its applicability in both the private and 

the public sectors. We have developed a framework for risk management 

based on industry best practices.1

 This framework divides risk 

management into five major phases. (See table 5.) 

Table 5: Risk Management Framework 

Phase Description

Strategic goals, objectives, and 

constraints 

Establish an organization’s strategic goals and the steps needed to attain those results, 

including performance measures to assess progress. Constraints that affect outcomes 

can also be identified during this phase. 

Risk assessment Assess the threats to and vulnerabilities of assets so that countermeasures may be 

instituted to prevent or mitigate risks. Risks can be assessed by various methods, 

depending on the specific application and knowledge available. 

Alternatives evaluation Evaluate risk reduction methods by considering the countermeasures and the costs and 

benefits associated with each. Countermeasures can be considered and prioritized

according to a number of factors, such as the degree of risk reduction they afford and 

the cost and difficulty to implement them. 

Management selection Choose among alternative actions. Management’s active participation is important at this 

phase because risk assessment tools contain various assumptions about preferences 

that may require value judgments and review at the management level. 

Implementation and monitoring Move from planning to implementing the selected countermeasures. Following 

implementation, monitoring is essential to help ensure that the entire risk management 

process remains current and relevant. 

Source: GAO.

During the last 10 years, the American Public Transportation Association 

(APTA), Pipeline and Hazardous Materials Safety Administration 

(PHMSA), and Transport Canada have developed and implemented new 

approaches for overseeing safety in the U.S. commuter railroad, U.S. 

pipeline, and Canadian railroad industries, respectively. These approaches

promote the use of risk management and incorporate various elements of 

 1

To develop the framework, we reviewed risk management literature, our reports and 

testimonies on this topic, and other government guidance. In addition, we consulted with

experts on risk management, risk modeling, and terrorism. We reviewed numerous

frameworks from industry, government and academic sources. We field-tested the

framework, and it was reviewed by academic experts in risk management. See GAO-06-91. 

Page 62 GAO-07-149 Railroad Safety Oversight
Appendix III: Oversight of Risk Management 

in the U.S. Commuter Railroad, U.S. Pipeline, 

and Canadian Railroad Industries 

risk management noted above. They also complement traditional 

compliance inspections. 

In 1996, following two serious commuter rail accidents, APTA, with FRA 

support, started a program to help its 16-member commuter railroad 

properties develop and implement plans for managing the safety of their 

systems. APTA had previously developed a similar program for the rapid 

transit industry. Risk management is a key aspect of these plans, which 

must include, among other things, goals and objectives, the identification

of hazards, an assessment of their associated risks, the analysis and 

implementation of actions to reduce these risks, and internal assessments 

of the effectiveness of safety management. Commuter railroads are given

the latitude to develop individual plans that conform to APTA’s guidelines 

but that are based on their unique circumstances. APTA audits its member 

railroads’ system safety management plans on a 3-year cycle. During the 

first year, APTA conducts an initial assessment of the plan; during the 

second year, APTA evaluates how well the railroad implements its plan; 

and during the third year, APTA follows up with the railroad to see what 

actions it has taken in response to APTA’s audit findings. 

In 2000, to better focus on safety risks that are unique to individual 

pipelines, PHMSA, then operating as the Office of Pipeline Safety, issued 

the first in a series of integrity management regulations that now apply to

more than 1,000 hazardous liquid and gas transmission pipelines operating 

in densely populated and environmentally sensitive areas. Under this 

approach, operators are required to develop programs to systematically 

assess and mitigate safety threats, such as corrosion, to pipelines located

in such high-risk areas. For example, these programs must integrate all 

available information about pipeline integrity and the consequences of a 

leak or rupture, repair identified defects within defined time limits based 

on their severity, and evaluate the need for additional preventive and 

mitigating actions. In addition, operators are required to report program 

performance measures to PHMSA semi-annually. PHMSA inspects these 

written programs as well as their implementation in periodic 

comprehensive inspections. 

During the 1990s, a series of derailments raised concerns over the level of

safety in the Canadian rail industry. In 2001, following a review of its 

oversight approach, Transport Canada determined that a more 

comprehensive safety management assessment was necessary to minimize

safety risks, and adopted new safety management regulations under 

Canada’s Railway Safety Act. The new regulations require that Canadian 

railway companies develop their own safety management systems, subject 

Page 63 GAO-07-149 Railroad Safety Oversight
Appendix III: Oversight of Risk Management 

in the U.S. Commuter Railroad, U.S. Pipeline, 

and Canadian Railroad Industries 

to Transport Canada’s review. These systems must include, among other 

things, annual safety performance targets; the identification of safety 

issues through a variety of methods (such as analyses of safety data and 

input from employees); an assessment of the risks associated with these 

issues to determine their significance; the development, approval, and 

implementation of strategies for controlling these risks; and systems for 

monitoring these strategies and other management-approved corrective 

actions. Transport Canada audits the railroads’ documentation and 

implementation of their safety management systems. The level of such 

monitoring varies depending on the safety performance of the railroad. 

Page 64 GAO-07-149 Railroad Safety Oversight
Appendix IV: 

A

GAO Contact and Staff 

cknowledgments 

Page 65 GAO-07-149

Appendix IV: GAO Contact and Staff 

Acknowledgments 

Katherine Siggerud (202) 512-2834 or siggerudk@gao.gov

In addition to the contact named above, James Ratzenberger, Assistant 

Director; Ashley Alley; Marianne Anderson; Timothy Bober; Elizabeth 

Eisenstadt; Judy Guilliams-Tapia; Brandon Haller; Bonnie Pignatiello Leer; 

Masha P. Pastuhov-Purdie; and Minette Richardson made key 

contributions to this report. 

GAO Contact 

Staff 

Acknowledgments 

(542077) Railroad Safety Oversight
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