Findings and Recommendations 

of the SOFA Working Group 

October 1999

F R A 

 U T U

A A R

B L E 

A S L R R A

S O F A

Switching Operations Fatality Analysis

DOT-VNTSC-FRA-00-08

DOT/FRA/ORD-00/04

This report may also be

found on the FRA website at

http://www.fra.dot.gov
NOTICE

The SOFA Working Group was supported by the Federal Railroad Administration’s, Office of

Research and Development and Office of Safety. The final recommendations and findings

printed in this report are consensus recommendations and findings established by the SOFA

Working Group. The Federal Railroad Administration report number DOT/FRA/ORD-00/04,

referenced on the cover of this document, is published for the convenience of those wishing to

obtain copies and for general information purposes. This report also may be found on the FRA

web site at http://www.fra.dot.gov.
iii 

Acknowledgements 

The SOFA Working Group wishes to acknowledge the following people as instrumental in 

beginning this effort to systematically investigate employee fatalities in railroad switching 

operations and develop data-based recommendations to enhance safety: George A. Gavalla, 

Associate Administrator for Safety, Federal Railroad Administration (FRA); Charles E. 

Dettmann, Executive Vice President, Association of American Railroads (AAR); William E. 

Loftus, President, American Short Line and Regional Railroad Association (ASLRRA); Charles 

L. Little, International President, United Transportation Union (UTU); and Clarence V. Monin 

International President, Brotherhood of Locomotive Engineers (BLE). 

The SOFA Working Group also wishes to acknowledge the ongoing support of Frank Turner, 

President of ASLRRA; Ed Hamberger, President of AAR; and Edward Dubroski, International 

President of BLE. 

The SOFA Working Group would like to thank Dr. E. Donald Sussman, Chief and Dr. Jordan 

Multer for their instructive comments on this report. Both are from the Operations Performance 

and Safety Analysis Division of the John A.Volpe National Transportation System Center, 

Cambridge, MA. The SOFA Working Group would also like to thank Sian Steward and Arthur 

H. Rubin for their editorial assistance; and Claire L. Orth of FRA’s Office of Research and 

Development for providing continual financial support. 
iv 
v 

Table of Contents

Section Page

SOFA Executive Summary ......................................................................................................... xi 

1. Introduction........................................................................................................................... 1-1 

1.1 Background of SOFA................................................................................................ 1-1 

1.2 Description of the SOFA Data.................................................................................. 1-2 

1.3 Perspectives on Human Error ................................................................................... 1-3 

 1.4 Using the SOFA Matrix to Examine the Chain of Events ....................................... 1-6 

1.5 Summary of Report Content..................................................................................... 1-7 

2. SOFA Tasks........................................................................................................................... 2-1

2.1 Method of Producing Database.................................................................................. 2-1 

2.2 Description of Data in SOFA Matrix......................................................................... 2-1 

 2.2.1 Conceptually Grouping SOFA Variables................................................. 2-2 

 2.2.2 Coding Types for Variables of SOFA Matrix.......................................... 2-3 

 2.2.3 Possible Contributing Factors (PCFs)...................................................... 2-3 

2.3 Selectively Coding FEs before SOFA Period, 1975 through 1991............................ 2-4 

2.4 Adjustment for Exposure ........................................................................................... 2-5 

2.5 Analyzing SOFA Matrix............................................................................................ 2-5 

 2.5.1 Introductory Comments ........................................................................... 2-5 

 2.5.2 SOFA Matrix Information Was Missing or Incomplete .......................... 2-6 

2.5.3 SOFA Matrix Information Was Complete, but Exposure Data 

 was Unavailable ....................................................................................... 2-7 

 2.5.4 Classifying FEs by Train movement, Equipment Struck by, etc. .......... 2-14 

 2.6 Discussion ................................................................................................................ 2-15 

3. Human Factors Tasks.......................................................................................................... 3-1 

 3.1 Human Factors Tasks................................................................................................. 3-1 

 3.2 Category Definition Task........................................................................................... 3-1 

 3.2.1 Method ..................................................................................................... 3-1 

 3.2.2 Results...................................................................................................... 3-1 

 3.3 Rating Task ................................................................................................................ 3-3 

 3.3.1 Method ..................................................................................................... 3-3 

 3.3.2 Results...................................................................................................... 3-3 

 3.3.3 Conclusions.............................................................................................. 3-7 

 3.4 Sorting Task.............................................................................................................. 3-7 

 3.4.1 Method ..................................................................................................... 3-7 

 3.4.2 Results...................................................................................................... 3-8 

 3.4.3 Conclusions............................................................................................ 3-11 
vi 

Table of Contents (cont.) 

Section Page

 3.5 Paired Comparison Task.......................................................................................... 3-11 

 3.5.1 Method ................................................................................................... 3-11 

 3.5.2 Results.................................................................................................... 3-11 

 3.5.3 Conclusions............................................................................................ 3-13 

 3.6 General Discussion .................................................................................................. 3-13 

4. Recommendations ................................................................................................................ 4-1 

 4.1 Recommendations to Improve Safety........................................................................ 4-1 

 4.1.1 Major Finding 1 ....................................................................................... 4-2 

 4.1.2 Description of FEs for Major Finding 1................................................... 4-2 

 4.1.3 Recommendation 1 .................................................................................. 4-3 

 4.1.4 Discussion................................................................................................ 4-4 

 4.1.5 Major Finding 2 ....................................................................................... 4-5 

 4.1.6 Description of FEs for Major Finding 2................................................... 4-5 

 4.1.7 Recommendation 2 .................................................................................. 4-6 

 4.1.8 Discussion................................................................................................ 4-6 

 4.1.9 Major Finding 3 ....................................................................................... 4-8 

 4.1.10 Description of FEs for Major Finding 3................................................... 4-8 

 4.1.11 Recommendation 3 .................................................................................. 4-9 

 4.1.12 Discussion................................................................................................ 4-9 

 4.1.13 Major Finding 4 ..................................................................................... 4-10 

 4.1.14 Description of FEs for Major Finding 4................................................. 4-10 

 4.1.15 Recommendation 4 ................................................................................ 4-12 

 4.1.16 Discussion.............................................................................................. 4-12 

 4.1.17 Major Finding 5 ..................................................................................... 4-13 

 4.1.18 Description of FEs for Major Finding 5................................................. 4-13 

 4.1.19 Recommendation 5 ................................................................................ 4-15 

 4.1.20 Discussion.............................................................................................. 4-15 

 4.2 Additional Suggested Actions.................................................................................. 4-16 

 4.2.1 Safety Training Concerning the Implications of Unexpected Train 

 Movement .............................................................................................. 4-16 

 4.2.2 Train Crew Resource Management........................................................ 4-16 

4.2.3 Follow-on SOFA Analysis: Review of Incidents Involving Severe 

Injury...................................................................................................... 4-16 

5. Recommendations for Incident Investigation ................................................................... 5-1

5.1.1 Establish and Maintain Database of Objective FE Data .......................... 5-1 

 5.1.2 Recommendation for Providing Computer Support to the Data Collection 

Process ..................................................................................................... 5-1 

5.1.3 Recommendation for Continued Review and Monitoring of Fatal 

Accident Data........................................................................................... 5-2 
vii 

Table of Contents (cont.) 

Section Page

5.1.4 Modification of FRA’s Data Collection Process to Include a Team 

Concept .................................................................................................... 5-2 

5.1.5 Fatal Incident Investigation Protocol ....................................................... 5-2 

REFERENCES.......................................................................................................................... R-1 

Appendices

A: Origin of SOFA Working Group ................................................................................... A-1 

B: SOFA Working Group Membership and Affiliation .......................................................B-1 

C: Definitions of Possible Contributing Factors (PCFs): and Activity, Event, and 

 Location Codes ................................................................................................................C-1 

D: Frequency of Possible Contributing Factors (PCFs) and Pairs of PCFs......................... D-1 

E: Working Version of SOFA Matrix (Full SOFA Matrix appears in Appendix II) ...........E-1 

F: Recommendation Summary by FE ..................................................................................F-1 

G: Data Format for Recommendations for Incident Investigation....................................... G-1 

Note: Appendix II, with supporting data, to be issued by December 1999. 
viii 

List of Figures 

Figure Page

1-1. Fatalities of Employees (FEs) engaged in switching operations, January 1, 1992 

to July 1, 1998.................................................................................................................. 1-2 

1-2. Fatalities of Employees (FEs) engaged in switching operations, January 1, 1975 

to July 1, 1998.................................................................................................................. 1-3 

1-3. Taxonomy of unsafe acts (from Reason, 1997) ............................................................... 1-5 

1-4. Employee location before fatal event............................................................................... 1-6 

2-1. 1983 to 1992, Pre-SOFA Period; 1992 to July 1, 1998 SOFA period............................. 2-4 

2-2. Distribution of time-on-duty before fatal event ............................................................... 2-6 

2-3. Distribution of crew size involved in 76 employee fatalities........................................... 2-7 

2-4. Employee fatalities by state not normalized by exposure ................................................ 2-8 

2-5. Distribution of FEs by month......................................................................................... 2-11 

2-6. Distribution of FEs by day of week ............................................................................... 2-12 

2-7. Distribution of FEs by time of day, January 1, 1975 to July 1, 1998............................. 2-13 

2-8. Distribution of employee fatalities by work shift .......................................................... 2-13 

2-9. Decomposition of Employee Fatalities: train movement, location, 

hit by own equipment or not, and direction of movement ............................................. 2-15 

3-1. The summary ratings of eight SOFA Members of the number of fatalities (FEs) 

for whom each contributing cause category was rated as extremely, very or 

moderately important ....................................................................................................... 3-4 

3-2. MDS Scale illustrating the dimension: People vs. Equipment ...................................... 3-12 

3-3. MDS Scale illustrating the dimension: Individual vs. Group ........................................ 3-12 

3-4. MDS Scale illustrating the dimension: Movement vs. Static ........................................ 3-13 
ix 

List of Tables 

Table Page

1-1. FE Formation as Chain of Events .................................................................................... 1-7 

2-1. SOFA Categories for Grouping Variables ....................................................................... 2-2 

2-2. Employee fatalities and fatalitity rate by million yard switching miles, 1975 to 1997.. 2-10 

2-3. Employment and Service Hours for Class I Railroads................................................... 2-11 

3-1. Railroad Switching Operations Cause Categories ........................................................... 3-2 

3-2. FEs having 4 or more categories rated as important. A one (1) in the column 

 indicates a rating of 3 or lower — moderately important ................................................ 3-5 

3-3. FEs having 3 cause categories rated as important. A one (1) in the column 

indicates a rating of 3 or lower — moderately important ................................................ 3-5 

3-4. FEs having 2 cause categories rated as important. A one (1) in the column indicates 

 a rating of 3 or lower — moderately important ............................................................... 3-6 

3-5. Factors Contributing to Switching Fatalities Grouped by Primary Causal Factor 

as Identified by SOFA Group .......................................................................................... 3-9 

4-1. FEs for Adjusting Knuckles, Drawbars, or Installing EOT Device................................. 4-2 

4-2. FEs Struck by Other Than Own Equipment .................................................................... 4-5 

4-3. FEs for Job Safety Briefings ............................................................................................ 4-8 

4-4. FEs for Improper Communication ................................................................................. 4-10 

4-5. FEs for Experience and Training ................................................................................... 4-13 
x 
xi 

SOFA Executive Summary 

Introduction 

On February 1998, a Switching Operations Fatalities Analysis (SOFA) Working Group, with 

representatives from the Federal Railroad Administration (FRA), Association of American 

Railroads, United Transportation Union, Brotherhood of Locomotive Engineers, American Short 

Line and Regional Railroad Association, was formed at the request of the FRA to review recent 

fatal incidents and develop recommendations for reducing fatalities in switching operations. 

Initial efforts of this Working Group have been sponsored by the Office of Safety at the FRA and 

supported by human factors expertise from the FRA Office of Research and Development, and 

the John A. Volpe National Transportation Systems Center. Working Group membership and 

affiliations are given in Appendix B. 

The Working Group developed a codified database of standardized information, referred to as the 

“SOFA Matrix” from the wide range of information in the 76 FRA fatal accident case files 

between January 1992 and July of 1998. In addition the group reviewed very limited data 

obtained from FRA files concerning FEs (employee fatalities) from 1975 to 1991 and 

participated in a series of systematic exercises designed to tap the extensive expertise acquired by 

the Working Group during their review and analysis of the FEs. This database and the expertise 

capturing exercises were then used to generate trends or patterns in the data for a more 

comprehensive understanding of the fatalities they were investigating, and became the foundation 

for the analysis and recommendations in the report provided here. The small number of FEs and 

diversity of their circumstances precluded formal statistical analysis. However, based on the 

objective evidence of likely contributing factors a number of findings and a series of 

recommendations were developed. These recommendations include actions to improve both the 

safety of railroad switching operations and the quality of data collected on fatalities in switching 

operations. 

General Findings 

1. The occurrence of fatalities in switching yards has not decreased over the period under 

investigation. They remain a serious problem today. 

2. Fatalities are not often the result of a single precipitating cause. Almost always they are the 

result of multiple possible contributing factors (PCFs). For six of the FEs studied four or 

more PCFs were identified. For an additional 26 FEs, three PCFs were judged to be 

contributors. 

3. Although data were reviewed concerning time of day, day of the week, geographic location, 

number of crew members on duty at the time, seniority and years experience in particular 

jobs, and several other variables of this kind, none of them could be interpreted reliably 

because there were not sufficient exposure data. Better exposure data are needed to 

understand the frequency of occurrence of these conditions in the absence of a fatality. Such 

data would correct the fatality data for the possibility that the differences observed just 

reflected differences in activity levels, and not real differences in the occurrence of fatalities 

under equivalent conditions. There is a critical need to develop more detailed data about 

general levels of activity in switching yards as a function of basic criteria that can be used to 
xii 

normalize the fatality data so that it might be examined more realistically to diagnose 

critical issues leading to FEs. 

4. Despite the voluminous amount of detail available and the quality of each technical 

summary, there were still information gaps in the fatality reports that had originally been 

collected by the FRA. The existing FE files could be greatly improved by including a much 

broader range of information that can support the interpretation of the possible contributing 

factors associated with FEs. 

The Working group generated two sets of specific recommendations based on their work. First, 

based on the objective data they reviewed, they made a series of recommendations designed to 

improve the safety of switching operations. Second, they developed recommendations for the 

improvement of FE reporting methodologies used by the FRA and by the industry. 

 

Findings and Recommendations for Safety of Switching Operations 

Major Finding 1

Eleven of the seventy-six FEs occurred while the employee was adjusting knuckles, adjusting 

drawbars, or installing an end-of-train device. 

Recommendation 1 

Any crew member intending to foul track or equipment must notify the locomotive 

engineer before such action can take place. The locomotive engineer must then apply 

locomotive or train brakes, have the reverser centered, and then confirm this action with 

the individual on the ground. Additionally, any crew member that intends to adjust 

knuckles/drawbars, or apply or remove EOT device, must insure that the cut of cars to be 

coupled into is separated by no less than 50 feet. Also, the person on the ground must 

physically inspect the cut of cars not attached to the locomotive to insure that they are 

completely stopped and, if necessary, a sufficient number of hand brakes must be applied 

to insure the cut of cars will not move. 

Discussion 1

This recommendation emphasizes the importance of securing the equipment. A thorough 

understanding by all crew members that the area between cars is a hazardous location, whether 

equipment is moving or standing, is imperative. 

Major Finding 2 

Twenty of seventy-six FEs were struck by equipment other than their own. Of those twenty FEs, 

nine occurred in yard or industry tracks. 
xiii 

Recommendation 2

When two or more train crews are simultaneously performing work in the same yard or 

industry tracks, extra precautions must be taken: 

SAME TRACK 

• Two or more crews are prohibited from switching into the same track at the 

same time, without establishing direct communication with all crew members 

involved. 

ADJACENT TRACK 

• Protection must be afforded when there is the possibility of movement on 

adjacent track(s). Each crew will arrange positive protection for (an) adjacent 

track(s) through positive communication with yardmaster and/or other crew 

members. 

Discussion 2

FE-06-94 and FE-31-94 both involved standing equipment left by another crew. In both cases, it 

can be argued that there was no possibility of either piece of equipment being moved. However, 

the fact that both pieces of equipment contributed to the fatalities and in both cases the respective 

crews had no knowledge that the equipment had been moved into the work area and that the 

physical layout expected by each fatality had changed contributed to the incident. Compliance 

with and an understanding of this recommendation would have prevented the other seven 

fatalities. 

Major Finding 3 

A lack of, or inadequate job safety briefings contributed to at least eight FEs. 

Recommendation 3 

At the beginning of each tour of duty, all crew members will meet and discuss all safety 

matters and work to be accomplished. Additional briefings will be held any time work 

changes are made and when necessary to protect their safety during their performance of 

service. 

Discussion 3 

Safe switching operations require teamwork and accountability among all crew members. Each 

crew member takes responsibility for their own and their fellow crew member’s safety. Team 

work begins with a detailed, effective job briefing, but includes continued updates to all crew 

members describing the current state of each move as it is executed. 
xiv 

Major Finding 4

Ten of the 76 fatalities occurred because of a combination of radio/hand communication, or 

initial and/or ongoing movement of equipment without specific distances given. 

Recommendation 4

When using radio communication, locomotive engineers must not begin any shove move 

without a specified distance from the person controlling the move. Strict compliance with 

“distance to go” communication must be maintained. 

When controlling train or engine movements, all crew members must communicate by 

hand signals or radio signals. A combination of hand and radio signals is prohibited. All 

crew members must confirm when the mode of communication changes. 

Discussion 4

The SOFA group believes that the key to radio use when backing, shoving or pushing a train or 

cut of cars is the communication between the locomotive engineer and the train crew. The crew 

must develop the discipline to remain stopped until specific car counts are given by the ground 

person, rather than to begin moving and then expect to receive the count. If this is done, fatalities 

related to improper radio communication can be substantially reduced. Additionally, mixing 

radio and hand signals causes confusion, reduces the chance that other members of the crew 

would hear of a change in the switching operations, thereby greatly increasing 

misunderstandings, and, has directly led to fatalities studied by the SOFA Group. 

Major Finding 5

Eleven of the 76 FEs were shown to have experience of one year or less and/or deficiencies in 

training. One additional FE had less than 1.5 years and is included below. Of these 12 FEs, all 

but one occurred in yard or industry tracks. 

Recommendation 5 

Crew members with less than one year of service must have special attention paid to safety 

awareness, service qualifications, on-the-job training, physical plant familiarity, and 

overall ability to perform service safely and efficiently. Programs such as peer review, 

mentoring, and supervisory observation must be utilized to insure employees are able to 

perform service in a safe manner. 

Discussion 5

While class room training time has increased, in general, the SOFA group has focused on 

experience and on-the-job training. We have found that limited training and experience continues 

to factor into many switching operation fatalities. Additional on-the-job training and experience, 

while working with more experienced peers, may help reduce fatalities among crew members 

with limited service. 
xv 

Additional Suggested Actions 

The recommendations above address those issues for which the Working Group felt they could 

respond with confidence based on their expertise and the objective data. In this section we 

consider other actions that the Working Group recommends taking, based on their expertise to 

continue to improve the safety of switching operations. 

Safety Training Concerning the Implications of Unexpected Train Movement 

Finding: Compelling evidence suggests many fatalities resulted from unexpected train 

movement, particularly at very low speeds. 

Action: The railroad industry should consider their existing switching operations training 

programs to assure that no opportunities are being overlooked to heighten safety awareness and 

to focus it on the serious implications of unexpected train movement, and on the importance of 

continual mutual awareness of the location and activities of all crew members. 

Rationale: Such FEs are preventable if the crew members have proper understanding of all 

planned movements, take care to be sure that no individuals are exposed to potential hazards at 

the time movements are initiated and to assure that detached equipment has been properly 

protected, i.e., locomotive reverser centered or hand brakes applied, to prevent unplanned 

movement. Safety awareness training can encourage a strong focus on these issues. 

Train Crew Resource Management 

Finding: The Working Group has also concluded that an important contributing factor to many of 

the FEs reviewed was incomplete or inadequate communication among crew members. 

Sometimes this was a failure of, or improper use of communications equipment, but more often it 

was a failure or reluctance of the crew member to elevate the importance of communications 

impacting on safety to the level needed to assure successful, safe operations. 

Action: The industry (labor, management, FRA) should consider programs that address 

improving crew coordination and communication such as Crew Resource Management (CRM) 

which has been used effectively in the aviation industry. 

Rationale: The goal of these training procedures in all industries is to promote safe operations 

through improved crew member proficiency, situational awareness, effective communication and 

teamwork, and by providing strategies for appropriately challenging and questioning authority 

where safety could be jeopardized. Training in the importance of and procedures for effective 

intra-crew communication has the potential to make a major contribution to the safety of 

switching operations. 

Follow-on SOFA Analysis : Review of Incidents Involving Severe Injury

Finding: The SOFA Working Group has been an effective task force for accomplishing goals 

that span the interests of labor, management and the FRA in switching operations. Although the 

review of switching fatalities has been very useful, the body of data is relatively small. Incidents 

in which serious injury has resulted, such as loss of a limb or requiring that the employee be 

placed on extended disability are likely to be very similar in kind to FEs. They are likely to 
xvi 

reflect the same safety implications in the sense that the only difference is in the degree of 

severity of the injury. 

Action: The SOFA Working Group or its successor should extend the scope of its investigations 

by undertaking the review of available FEs where severe injuries have resulted. 

Rationale: The data collection procedures for examining railroad injuries has recently been 

improved so that more complete and useful data for understanding the safety implications are 

available. In 1998 there were more than 8,000 non-fatal railroad incidents, not including grade 

crossing incidents. While we do not know the number of these that would be classified as serious 

and the number that involved switching operations, it is likely to be a significant proportion of 

this total and therefore would substantially augment the statistical reliability of the aggregate 

database and the ability to make objective recommendations based on it. 

Recommendations for Incident Investigation 

Establish and Maintain Database of Objective FE Data

Finding: FRA’s existing FE files could be greatly improved by including a much broader range 

of information that can support the interpretation of the possible contributing factors associated 

with FEs. 

Recommendation: When investigating FEs, the FRA should establish a comprehensive historical 

database summarizing the objective data and interpretation of FEs occurring in switching 

operations that will be updated regularly to accumulate reliable and consistent information about 

the occurrence of switching operations fatalities. 

The Working Group, taking advantage of the insights resulting from its extensive analysis of 

existing data, is providing its recommendations for ensuring that specific data are collected by 

the FRA during its investigation of FEs. 

Discussion: The generated database will provide more reliable clues to the factors contributing to 

switching operations FEs and support the justification of safety improvements in terms of the 

number of lives potentially saved. Additionally, the newly generated database will substantially 

reduce the time and cost of subsequent analyses and recommendations. 

Recommendation for Providing Computer Support to the Data Collection Process

Finding: Current data collection procedures involve use of printed forms, notes, diagrams and 

photographs that do not provide a thorough or uniform data collection to perform accurate 

statistical analyses. 

Recommendation: The FRA should consider creating software to facilitate data entry at the 

source and at the time the investigation is taking place. This software could operate on portable 

laptop computers already available to investigators or on off-the-shelf personal data units (PDUs) 

that are especially suited to the data collection application. The SOFA Working Group offers its 

assistance in a project to revise the data collection protocol and to develop software to support 

the fatality investigation and data codification process. 
xvii 

Discussion: The efficiency, accuracy, and thoroughness of the existing data collection in each 

investigation would be improved. Computer support could reduce the time and cost associated 

with the complete data collection and consistent codification process. 

Recommendation for Continued Review and Monitoring of Fatal Accident Data

Finding: The SOFA Working Group has accumulated the most knowledge of the potential causes 

of switching operation FEs in the industry. 

Recommendation: The SOFA Working Group, or its successor, should undertake a periodic 

review of the FE switching operations data as it accumulates to seek new lessons learned, to 

review the integrity of the data, to monitor its usefulness and recommend improvements to the 

data being collected where appropriate. 

Discussion: Their review of the data will (1) provide the best checks that the data being requested 

are useful, (2) put them in a position to recommend improvements to data collection and (3) put 

them in a position to recommend potential safety improvements to reduce the incidence of death 

and injury. 

Modification of FRA’s Data Collection Process to Include a Team Concept

Finding: No one has all the expertise required to undertake a comprehensive review and revision 

of FE investigation procedures. 

Recommendation: The Working Group believes it is important that FRA’s investigation process 

be consistent, and that a team concept be implemented to insure complete data collection. 

Rationale: The SOFA Working Group recognizes that some inspectors collect and produce 

reports better than others, while other inspectors are more versed in analyzing the FE data. A 

team (to include all affected disciplines) concept in data collection and analysis will insure a 

more consistent FE investigation.
1-1 

1. INTRODUCTION 

1.1 Background of SOFA 

In February 1998, a Switching Operations Fatalities Analysis (SOFA) Working Group, with 

representatives from the Federal Railroad Administration (FRA), labor and management, was 

formed at the request of the FRA to review recent employee fatalities (FEs) and develop 

recommendations for reducing fatalities in switching operations. The charge to the Working 

Group was contained in a letter (see Appendix A) from George Gavalla, Associate Administrator 

for Safety of the FRA to the following four organizations: Association of American Railroads 

(AAR), American Short Line and Regional Railroad Association (ASLRRA), Brotherhood of 

Locomotive Engineers (BLE), and the United Transportation Union (UTU). It proposed that the 

group, “Conduct a detailed fact-finding review and analysis of these incidents to determine 

whether trends or patterns can be found, identify best practices, and, if possible, formulate 

recommendations for the entire industry based on its findings.” 

This small group of senior railroad experts in switching operations met almost monthly for the 

past 20 months, and reviewed the individual case histories of FEs that occurred in switching 

operations since 1992. Initial efforts of this Working Group have been sponsored by the Office of 

Safety and supported by the Office of Research and Development at the FRA. Working Group 

membership and affiliation are given in Appendix B. 

The group began its work by reviewing the FEs summaries available from the FRA. However, 

they soon realized that to better understand the underlying causal factors of these fatalities, they 

would need to look in more detail at the entire FE files, including photographs of the site and 

statements of eyewitnesses. From experience, the SOFA Working Group recognized they could 

not objectively evaluate the underlying causal factors common across these fatalities by 

reviewing individual case files. 

Consequently, it was determined that a database of selected information in the case files was 

needed for aggregating data and conducting expert analysis. After several months of dedicated 

effort pouring over dozens of case files, and with considerable give-and-take from the different 

parties represented, the SOFA Working Group generated a codified database of standardized 

information, referred to as the “SOFA Matrix.” This codified database was then used to help 

generate trends or patterns in the data for a more comprehensive understanding of the fatalities 

they were investigating, and became the foundation for the analysis and recommendations in this 

report. These recommendations include short- and long-term actions to improve the safety of 

railroad switching operations and the quality of data collected on fatalities in switching 

operations. 

While the FE reports generally tried to establish a single probable cause of each switching FE, it 

appeared, to the SOFA Working Group, that fatalities more often resulted from the coming 

together of a complex set of factors. Had any one of these factors not been present, the fatality 

would have been less likely to occur. 

Shortly after beginning their evaluation process, the SOFA Working Group accepted Human 

Factors support offered from the Office of Research and Development at the FRA, which then 

requested additional Human Factors support from the Volpe Center. The Human Factors team 

brought additional perspectives to the SOFA Working Group while supporting their premise that 

most FEs have multiple contributing factors. They also helped the SOFA Working Group to 
1-2 

refine the SOFA Matrix, and suggested methods to analyze the database to help answer some of 

the many questions that arose. 

In the course of these lengthy investigations, the Working Group became a highly experienced 

team in understanding the variety of circumstances that can lead to FEs in switching operations. 

Periodically, the Human Factors Team would lead one of the meetings, devoting specific 

attention to such things as elaborating and systematizing the possible contributing factors to 

fatalities, and establishing the relative importance of these possible contributing factors for each 

of the FEs they had studied. Results of these meetings form the basis for this report. 

1.2 Description of the SOFA Data 

In March 1999, the Working Group completed a comprehensive database of objective and 

interpretive data associated with the 76 railroad operations switching fatalities that occurred from 

January 1, 1992 to July 1, 1998 as shown in Figure 1-1. The database contains nearly two 

hundred attributes for each of the 76 switching-related, employee fatalities herein referred to as 

FEs. Previously, no single database of comprehensive information related to railroad switching 

fatalities was available for electronic analysis. After codifying the database, it then became

possible to analyze these FEs, look for common factors and trends, and make appropriate, 

preventive recommendations. 

Figure 1-1. Fatalities of Employees (FEs) engaged in switching operations, 

January 1, 1992 to July 1, 1998. 

Additionally, the Working Group supplemented the data in the SOFA Matrix with seventeen 

mores years of switching FEs which were coded back to 1975 for just eight descriptive attributes. 

These attributes are listed in section 2.3. This time-series is shown in Figure 1-2. Finally, the 

Working Group identified important measures of adjusting the data for exposure, such as FEs per 

million switching miles, to provide a more valid interpretation of any apparent trends in the data. 

14

15

12

11

7

11

6

0

2

4

6

8

10

12

14

16

1992 1993 1994 1995 1996 1997 1998

year

FEs 1998 is to July 1
1-3 

Figure1-2. Fatalities of Employees (FEs) engaged in switching operations, 

January 1, 1975 to July 1, 1998. 

1.3 Perspectives on Human Error 

The goal of the SOFA Working Group has been to better understand how switching FEs occur 

and to make recommendations for safer working conditions, improved training, and other 

important policy changes to minimize both injuries and deaths in switching operations. Injuries 

and fatalities can be caused by a number of factors, including poor design, equipment failure, 

inadequate maintenance, or human error. 

There is a strong tendency throughout industry to attribute FEs to human error, especially in 

railroad switching operations where the work is very directly dependent on the actions of 

individuals. This is only natural, since for FEs to occur, somehow the individual(s) involved had 

to be caught in a dangerous situation. However, even when it is appropriate to cite human error, 

the error may be the result of conditions beyond the control of the individual. For example, the 

individual may be trying to compensate for equipment or operating procedures. 

Conversely, not all human error leads to an incident. Sometimes it only results in noticeable 

reduced efficiency or waste. Sometime it happens in a way or at a time where it has no impact at 

all. 

Incidents are not usually the result of a single failure. In some cases they result from the 

accumulated effects of several contributing factors. This can be seen in the sequence of events in 

the following two FEs: 

34

30

48

35

28

33

18

24

15

12

10

13

10 9 9

7

10

14 15

12 11

7

11

6

0

10

20

30

40

50

60

1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998

year

FEs

1998 is to July 1
1-4 

• The first FE occurred when the brakes were not securely applied and the space 

between the freight cars was inadequate. When the freight cars suddenly rolled toward 

the locomotive, the worker was pinned between the coupler knuckles. 

• The second FE occurred when a cut of cars rolled slowly out from another track while 

a foreman on the adjacent track was riding the point and using a radio to direct a 

shove move. The foreman, with ten months experience, was crushed when struck by 

the rolling cars. 

It is easy to think of incidents in terms of the immediate cause. The crew member fell into the 

path of a moving train or caught clothing on moving equipment and was dragged along the 

roadbed. However, in order to benefit from incident analysis, one must look beyond the 

immediate cause to understand the conditions that led up to it. Often the critical event occurs at a 

prior time or at a distance from the observable result. The terms unsafe acts, latent conditions

and organizational factors address attributes of an incident that may be further removed from the 

immediate cause (Reason, 1990, 1997). 

An unsafe act may have been the responsibility of the victim, or it may have been performed by 

another crew member who put the injured party in jeopardy. For example, was the injured 

brakeman standing near, or “fouling,” the track while the on-track equipment was moving? Or 

did the locomotive engineer fail to wait for confirmation of a radio transmission before initiating 

a shoving movement? 

Latent conditions are the circumstances that contribute to the incident. They are circumstances 

that are likely to be present for a long time before they have a negative impact. They are 

sometimes referred to as “incidents waiting to happen.” They can arise from careless operations, 

bad equipment design, lack of equipment, unworkable operating practices, maintenance failures, 

and inadequate training. 

Organizational factors are policies and/or practices that lead to the latent conditions. Was 

roadbed maintenance assigned a low priority? Was there a history of inadequate training of the 

crews? Were job briefings conducted regularly and taken seriously? 

Figure 1-3 shows some examples of the ways in which unsafe acts can involve human 

information processing. In the figure, unsafe acts are partitioned into intended and unintended

actions. Then it breaks down each type into further categories. Unintended actions can be slips or 

lapses. Slips are typically unintentional failures of attention. A yardman intending to uncouple 

two cars, but walking right by them without doing it would be an example. Lapses are cases 

where the failure is derived from mis-remembering a rule or procedure. An example might 

involve forgetting to throw a critical switch setting up a move. Mistakes are cases where the 

actions taken were intended, but it was not a good thing to do. Examples include applications of 

the wrong rule, or one not appropriate to the current conditions, or an inappropriate shortcut to a 

procedure. 
1-5 

Unsafe 

 acts

Unintended 

 action

Intended 

 action

slip

lapse

mistake

violation

Attentional failures 

 intrusion 

 omission 

 reversal 

 misordering 

 mistiming

Memory failures 

 omitting planned items 

 place-losing 

 forgetting intentions

Rule-based mistakes 

 misapplication of good rule 

 application of bad rule 

Knowledge-based mistakes 

 many variable forms

Routine violations 

Exceptional violations 

Acts of sabotage

Basic error 

 types

Figure 1-3. Taxonomy of unsafe acts (From Reason, 1997. Reprinted with the permission 

of Cambridge University Press.) 

With respect to violations, it is good to remember that no well-motivated worker intentionally 

causes an incident unless it is an act of sabotage or terrorism. No such incidents were identified 

in the cases investigated by the SOFA working group. 

The goal of this report is to make recommendations that, when implemented, will reduce the 

incidence of fatalities and any related injuries in switching operations. Accordingly, the 

recommendations focus on actions that can be taken by the FRA, and the railroad industry, to 

improve the safety of switching operations. The Working Group identified five approaches to 

improving safety that can impact the occurrence of unsafe acts, or latent conditions, that 

contribute to incidents. 

• Improved design of equipment used in yards, rolling stock, worksite and 

layout. 

• Improved training or communication procedures, such as job briefings. 

• Revised or re-emphasized rules and procedures. 

• Improved track or equipment maintenance. 

• Modifications to management policy and workplace culture. 
1-6 

1.4 Using the SOFA Matrix to Examine the Chain of Events 

The SOFA Matrix contains a wealth of information – some 200 variables -- about each FE. To 

discern which factors contributed to each FE, the Working Group looked at the chain of events 

leading up to the FE. The actual trauma-causing event may have been a derailment, collision, or 

sudden and unexpected movement of equipment, but other contributing or latent conditions 

surrounding the event sequence may have been involved as well. 

Using the information contained in the SOFA Matrix, the event chains for FEs start with the 

general location of the FE, either on the ground or equipment. Forty-nine FEs (64%) were 

classified as starting on the ground; 27 FEs (36%) were on railroad equipment as shown in 

Figure 1-4. From there, the sequence describes a more specific location of the FE, then to the 

physical act the FE was engaged in, the trauma-producing event itself, and the FE crew’s next 

anticipated move. Possible Contributing Factors (PCFs discussed below), and personnel-related 

information may be provided. Weather, ground conditions, and lighting serve as possible latent 

conditions. 

Figure 1-4. Employee location before fatal event. 

As an example (FE-29-94): a 57-year-old worker, with 38-years experience, is on the ground 

(general location) on a flat-yard track (specific location), standing (activity), when struck by his 

own equipment being shoved at 6 mph. The employee’s crew next anticipated move was to 

“couple.” The SOFA Working Group felt that intra-crew communication and failure to comply 

with shoving requirements were PCFs. The event occurred during daylight hours on a Tuesday 

with a temperature of 55 degrees Fahrenheit and cloudy atmospheric conditions. The threeperson crew was using both hand and radio communication. Evaluating this FE as a chain of 

sequential events and latent conditions, as shown in Table 1-1, provides a better understanding of 

the PCFs involved and allows for more specific recommendations to be developed. 

Em ployee Fatalities

1992 - 1998 49 FEs -- 64% -- were on

ground before event

27 FEs -- 36% -- were on

equipm ent before event
1-7 

Table 1-1. FE Formation as Chain of Events. 

General location ! Specific Location ! Physical act !Anticipated next move

On ground flat yard track standing to “couple” 

Possible Contributing factors Latent Conditions 

Intra-crew communication 3-person crew 

Failure to comply w/speed both hand and radio signals used 

 55 degrees F 

1.5 Summary of Report Content 

The remainder of this report is broken into four additional sections. In section 2 we describe the 

SOFA database, how it was produced and present some summary data that represent findings of 

the Working Group. In section 3 we describe some additional data collection and analyses that 

were designed to gain a broader perspective on the knowledge that has been gained by the SOFA 

Working Group as a result of critical review and analysis of the FE files. In section 4 we present 

the Working Group’s recommendations to the FRA, and to the railroad industry. The report 

concludes with recommendations for incident investigation in section 5. The Appendix contains 

the following sections: 

• A: Origin of SOFA Working Group 

• B: SOFA Working Group Membership and Affiliation 

• C: Definitions of Possible Contributing Factors (PCFs): and Activity, Event, and 

Locations Codes 

• D: Frequency of possible Contributing Factors (PCFs) and Pairs of PCFs 

• E: Working Version of SOFA Matrix (Full SOFA Matrix appears in Appendix II *) 

• F: Recommendation Summary by FE 

• G: Data Format for Recommendations for Incident Investigation 

* Note: Appendix II, with supporting data, to be issued by December 1999.
2. SOFA TASKS 

2.1 Method of Producing Database 

The SOFA Working Group began its work by reviewing the FE summaries available 

from the FRA. However, the Working Group soon realized that to better understand the 

underlying causal factors of these fatalities, they would need to look in more detail at the 

entire FE files and develop a codified database of information derived from the files. It 

also became clear that they would need to use their expert judgment to reach conclusions 

about how the Possible Contributing Factors (PCFs) for each FE were identified and 

coded into the database. 

First, the Working Group solicited suggestions from each of the following groups: 

Association of American Railroads (AAR), American Short Line and Regional Railroad 

Association (ASLRRA), Brotherhood of Locomotive Engineers (BLE), Federal Railroad 

Administration (FRA), and the United Transportation Union (UTU). These groups 

established a list of categories to be used for coding the database. As the group gained 

increasing experience analyzing individual FEs, and as they began to better understand 

the specific circumstances surrounding each of the FEs, they gradually refined the 

structure of the database to its present form. 

Before any PCFs were assigned to an individual FE, the entire case file for that FE was 

thoroughly reviewed and extensively discussed by the SOFA members present at that 

meeting. They reviewed all related summary documentation of the FE, including the FRA 

summary report, on-site interviews, diagrams and drawings, pictures, autopsy reports, 

and any other information available. A detailed diagram of the scene was then 

reconstructed. This visual representation of the FE served as a focal point for discussing 

and assigning the PCFs to that FE. Ensuing discussions often lasted several hours or 

more. When questions about the FE arose that could not be answered at that meeting, but 

which the information was known to be available, one of the SOFA members was 

assigned the task of finding the answer and reporting back to the group at the next 

meeting. Only after these extensive discussions and follow-up discussions would the 

group decide which PCFs to assign to that FE for coding into the database. Furthermore, 

all members had to agree that the identified factor was indeed a PCF to the FE before it 

was coded into the SOFA Matrix. 

 The Working Group represented a wide range of perspectives and interests. Much 

confidential discussion preceded many of the decisions about how to code individual 

entries in the database. The process of creating and codifying the SOFA database 

required approximately eighteen months of regular monthly meetings. The resulting 

database and findings are described below. 

2.2 Description of Data in SOFA Matrix 

By March 1999, the Working Group completed a comprehensive database of objective 

and interpretive data associated with railroad operations switching fatalities covering the 

period from January 1, 1992 to July 1, 1998, totaling 76 FEs. For the six full years of the 

SOFA period, FEs averaged 11.3 per year with a range of 7 to 15 FEs a year. 
 2-2 

The SOFA Matrix has provision to code some 200 attributes or variables for each FE. 

Conceptually, it is a matrix with 76 rows representing the FEs and some 200 columns 

representing the attributes for each of those fatalities. However, not all variables of the matrix 

apply to each FE. Additionally, some variables were missing because the information was not 

available. The reasons why this information was not available varied, but were usually because of 

the time lapse between occurrence and coding, the need for additional investigation, or lack of 

record keeping. The pattern of missing information across FEs was inconsistent, which makes 

some analyses impossible or inconclusive. 

Although a total of 76 cases, with up to 200 attributes for each case, were included in the 

database, the small number of cases, combined with the limited number of potential variables, 

made it insufficient to establish statistical significance in any of the findings. Even after the 

addition of 95 FEs, with eight attributes coded for each and covering a pre-SOFA period from 

1983-1991, statistical significance could still not be established. When the matrix was partitioned 

into meaningful categories, the number of cases contributing to a particular inference was just too 

small. There were too few occurrences per year; and too many different causal mechanisms that 

could have played a role. For example, there were six FEs in which derailment was the traumaproducing event. Yet the last derailment event in the SOFA period occurred in September 1994. 

However, that does not mean that the SOFA findings should be taken lightly. When multiple FEs 

can be marshaled to show that a particular contributing factor was involved repeatedly, and a 

fatality resulted from each of them, it is hard to argue that safety would not be improved by 

reducing or eliminating the likelihood of that contributing factor. In fact, when it can be asserted 

that a policy, procedure, or training change could eliminate the potential occurrence of even one 

death, then that change is certainly a meaningful candidate for evaluation. 

The SOFA Working Group experience, grounded in the objective data they have so carefully 

analyzed and interpreted, remains the best source of findings and recommendations available. 

2.2.1 Conceptually Grouping SOFA Variables

The variables of the SOFA Matrix can be conceptually partitioned into groups. Grouping is 

helpful in selecting variables to understand the backward event chain and latent conditions 

involved in FE formation. Table 2-1 lists thirteen groups that were defined and each of the some 

200 variables can be thought of as belonging to just one group. The groups, with some examples 

of variables contained, were: 

Table 2-1. SOFA Categories for Grouping Variables. 

 Group Name Example

1. Background Information report number, date, and railroad 

2. Weather/Visibility temperature, wind speed, and visibility 

3. FE Personal Data date of birth, length of service, and time in 

occupation 

4. Work/Rest/Fatigue time work began 
 2-3 

Table 2-1. SOFA Categories for Grouping Variables. (cont.)

5. Personal Issues result of drug/alcohol testing 

6. Personal Protective Equipment What clothing/footwear/personal equipment 

was involved? 

7. FEs Crew Information Engine crew composition, number of crew 

members on ground 

8. Data on Other Involved Crews If any: Was another crew involved? 

9. FE Activity at Time of Incident FE physical act, FE event, FE location 

10. Site Information Track type, if yard, hump or flat yard? 

11. Communications Issues Type of signaling in use, were employees on 

the lookout for signals? 

12. Emergency Response Issues Were railroad emergency response 

procedures followed? 

13. Possible Contributing Factors (PCFs) Characteristics of worksheet, equipment 

failure 

The full list of variable definitions and complete SOFA Matrix appears in the Appendix, Vol. II. 

2.2.2 Coding Types for Variables of SOFA Matrix 

Three types of coding were used by the Working Group to represent information in the SOFA 

Matrix. First, numeric values were coded for variables like age, years of service, and those 

representing time since the last safety and rules examination as well as time, date, temperature, 

and equipment speed. Geographic location was spelled out. 

Second, discrete values, usually Yes or No, were used for interrogatives like “Were hand signals 

being used?” Many of these variables are blank because either the information did not apply to 

an FE; or, for reasons mentioned above, the information was not available. A few discrete values 

have multiple levels. Examples are visibility (cloudy, rain, fog, etc.), and ground footing 

condition (wet, frozen, snow, etc.). 

A third type of coding, Cause Codes, pre-defined information for insertion in FRA-required, 

railroad incident forms. These Cause Codes were taken verbatim from the FRA Guide for 

Preparing Accident/Incident Reports (1997) and were used for Possible Contributing Factors 

(PCFs). The SOFA Group also created nine new cause codes specific to switching FEs. To note 

unusual circumstances, short verbal explanations and narrative comments about events, event 

sequencing, and latent conditions were occasionally used. 

2.2.3 Possible Contributing Factors (PCFs)

For each FE case, the Working Group discussed whether to assign one or more Cause Codes to 

an FE. The cause codes assigned to each case represent the consensus of the group. The Working 

Group created nine new Cause Codes to capture specifics thought important in switching-related 

FEs. Examples of new codes are ones representing fouling track, intra-crew communication, 

close clearance, not providing adequate space between equipment, and insufficient training. 

Seventy-one percent of the time, multiple Cause Codes were assigned to an FE. However, there 

was no implied ranking or importance by the order which these codes were assigned. In fact, to 
 2-4 

avoid the implication that one cause code was more important than another, the Working Group 

replaced the term Cause Code with the term Possible Contributing Factors, or “PCFs”. Thinking 

in terms of PCFs was an important step in gaining consensus. A full list of PCFs, both new and 

existing and the frequency of use, appears in the Appendix C. 

2.3 Selectively Coding FEs before SOFA Period, 1975 through 1991 

The Working Group identified additional information resources to help interpret the information 

in the SOFA Matrix. These resources include additional years of consistently defined switching 

FEs coded back to 1975 for eight selected variables. The eight variables were ones that did not 

require discussion by the SOFA Working Group, (railroad, city, state, date, day-of-week, timeof-day, age, and length-of-service). Thus, for a question such as, “How has the number and 

monthly distribution of switching FEs changed over time?” it is possible to consider seventeen 

more years of data and 345 additional FEs. The extended time-series add support to some issues 

addressed in the six-and-one-half year period of the SOFA Matrix. 

The SOFA Working Group established, by examining this historical data, that the 1983 to 1991 

period was most like that of the January 1, 1992 to July 1, 1998 SOFA period. This can be seen 

in Figure 2-1 and is discussed further below. The pre-1983 period had higher yearly FE counts as 

shown in Figure 1-2. Forty-eight FEs occurred in 1977, the largest number of FEs for which data 

exists. Other years, 1975 to 1982, the count ranged from 35 FEs in 1976 to a low of 18 in 1981. It 

should be recognized that this data cannot be interpreted without adjustment for exposure. 

Figure 2-1. 1983 to 1992, Pre-SOFA Period; 1992 to July 1, 1998 SOFA Period. 

15

12

10

13

10

9 9

7

10

14

15

12

11

7

11

6

0

2

4

6

8

10

12

14

16

1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998

year

FEs 
 2-5 

2.4 Adjustment for Exposure 

To make a realistic interpretation of the patterns in the data, appropriate measures of fatality 

exposure are needed. Fatality exposure is basically defined as measures of railroad activity such 

as distances moved, number of workers, and number of operations like switching. An increase in 

FEs from one period to another could simply reflect the fact that there were more people working 

in the yards in one period than in the other. Similarly, a decrease in the number of FEs from one 

period to the next could reflect a reduced number of total switching personnel employed during 

the second period. Consequently before we can state that safety in switching operations is 

improving because the total number of fatalities are down, we must be certain that the rate of 

fatalities are also decreasing. The rate can be determined by dividing the number of fatalities in a 

given period by the total number of switchmen employed during the same period. We refer to 

this normalization as correcting for exposure. One needs to be sure that what looks like 

meaningful variations are not simply the result of some baseline variation in activity level. The 

fatality measures should consistently represent the exposed risk to those railroad workers 

engaged in switching operations. Caution is advised in using unadjusted measures. 

Normalizing the fatality data with the right measure can clarify our understanding of the potential 

risk of fatalities, while the wrong measure can distort our understanding of the risk of fatalities. 

The reality is that any exposure data can only approximately control for risk. However, it is 

important to find the best data available. The Working Group continues to seek better measures 

of exposure for each category of data. Below, the issue of exposure data is discussed further in 

regard to specific issues that the Working Group was interested in, where new measures have 

been identified, or where better measures would be helpful for interpretation are given. 

2.5 Analyzing SOFA Matrix 

2.5.1 Introductory Comments

For purposes of analyzing the data, the Working Group dealt with information in the SOFA 

Matrix at three levels of information completeness. That is, safety issues could or could not be 

addressed based on whether certain types information were or were not available. These three 

states were: 

1. SOFA data was missing or incomplete because it was not available to the SOFA 

Group. 

 

2. SOFA data was complete but supporting information, such as a specific exposure 

measure, was not available. 

3. Finally, enough information existed so the SOFA Group could make a safety 

recommendation if it was appropriate to do so. 

Some important issues related to the first two levels of data completeness are discussed next. 

Recommendations made from the third level of data completeness are presented in section 4. 
 2-6 

2.5.2 SOFA Matrix Information Was Missing or Incomplete 

Three issues – fatigue, communication, and crew size -- could not be fully considered because 

adequate information to code pertinent variables of the SOFA Matrix were unavailable. 

The only data available to investigate the fatigue issue for the majority of the 76 FEs is the 

variable time on duty before event shown in Figure 2-2. Other fatigue-related variables exist in 

the SOFA Matrix: time off before shift, FEs last tour, work/rest, and duty/30 days. Unfortunately, 

this information was for the most part unavailable. 

Figure 2-2. Distribution of time-on-duty before fatal event. 

The Working Group recognizes more work/rest information is needed, perhaps as much as 30 

days prior to the FE, and encourages incident investigators to capture more of this information. 

The SOFA Working Group felt that communication, particularly intra-crew, was an important 

factor in many FEs. Although some 40 variables were created to define aspects of hand and radio 

communication and signaling among crews, the Working Group was able to code only two of 

those variables with any sense of completeness. 

Figure 2-3 presents the data on crew size. Fifty-six (74%) of the 76 FEs had a crew size of three. 

Some members of the Working Group speculated that the reduction in crew size during the 

1980s might have contributed to an increased FE rate. However, without baseline data on the 

distribution of crew sizes during the period for which these data are presented, it is not possible 

to draw a conclusion about the importance of crew size as a contributor to fatalities. 

8

9

1 2

7

1 1

6

7

3

4

3 3

1

0

2

4

6

8

1 0

1 2

1 4

0 to 1 1 to 2 2 to 3 3 to 4 4 to 5 5 to 6 6 to 7 7 to 8 8 to 9 9 to 10 10 to 11 11 +

hours w orked 

FE s 
 2-7 

Figure 2-3. Distribution of crew size involved in 76 employee fatalities. 

2.5.3 SOFA Matrix Information Was Complete, but Exposure Data was Unavailable

For some issues the SOFA Matrix contains relevant information, but without exposure data 

indicating the frequency of the activities, it is not possible to determine whether the variations 

shown reflect contributing factors to FEs or just variation in the underlying frequencies of these 

activities. There is a need for development of exposure measures to help with interpretation of 

the information contained throughout the SOFA Matrix. 

(Note that for some of the issues in this section the FEs from the pre-SOFA period, defined as 

1983 to 1991, are cited. For other issues, reference is made to FEs back to 1975. Depending on 

availability and relevance, varies time periods of SOFA FEs are presented.) 

The following distribution exists for 76 FEs by State: 11, Texas; 6, California and Illinois; 5, 

Indiana and Kentucky; 4, Georgia and Nebraska; 3, Ohio; 10 states have 2 FEs; and 12 states 

have 1 FE as shown in Figure 2-4. Because exposure data was not available to properly 

normalize, the Working Group did not reach any conclusion about the geographic distribution of 

fatalities. 

1

11

56

6

2

0

10

20

30

40

50

60

1 2 3 4 5

crew size 

FEs 

74 %

8 % 3 %

14 %

1 %
 2-8 

Figure 2-4. Employee fatalities by state not normalized by exposure. 

Some exposure data (miles of road, number of railroad employees) for evaluating these 

differences were identified. However, it was too general to allow for comparisons among states. 

Between 1992 and 1998, the average age of FEs ranged between a low of 38.1 and a high of 49.8. 

Variation exists over the years. For the SOFA, historically, the highest average age was 51.2 in 

1981; and the low, 35.3 in 1979. There appears to be no discernible age-related trend among the 

workers killed in switching operations. 

An important question that is difficult to answer is what the effect of exposure is on the age of 

the employees who died? Is the age of FEs significantly different from that of railroad workers 

equally exposed to switching operation risk? Baseline data for switching operations are needed. 

As might be expected, the distribution of length of service follows that of age. It is worth 

mentioning, however, that of the 76 FEs, 10 FEs (13%) had one year or less of service. Another 

FE had ten years of service prior to returning for less than a year. As well, one FE had 1.5 years 

of experience. (See Recommendation 5.) However, in the pre-SOFA period, 1983-91, there is no 

such cluster of FEs with one year or less of experience. 

A number of time-related patterns appear in FE series and are discussed below. Probably the 

most important such pattern is the yearly incidence of FEs. 

Viewed over a 15-year period of switching operations, FEs ranged from a low of 7 to a high of 

15 a year, with no discernable trend in absolute values as shown in Figure 2-1. However, for the 

period from 1975 to 1982, yearly FE counts were higher, from a low of 18 to a high of 48. 

11

6 6

5 5

4 4

3

2 2 2 2 2 2 2 2 2 2

1 1 1 1 1 1 1 1 1 1 1 1

0

2

4

6

8

10

12

TX CA IL IN KY GA NE OH FL IA MI MT NC NY OR PA SC WI AK AZ CT ID KS LA MN ND NM NV OK WA

states 

FEs 
 2-9 

The SOFA Working Group considered yard switching miles, staff-hours, and the number of 

switching-involved employees as candidate exposure measures. In the case of yard switching 

miles, it was found helpful in distinguishing the period of the mid-1970s from that of the more 

recent past. Switching miles has gone from over 200 million miles a year down to under 90 

million miles between those two periods as shown in Table 2-2. However, changes in yard 

switching miles are too gross a measure to completely explain changes in FEs within a period 

such as from 1983 to 1997 where the yearly changes are small and at times in the opposite 

direction of changes in switching miles. And in that period, the pattern of change in switching 

miles in relation to the pattern of change in fatalities does not suggest that it is activity level 

alone that would account for the observed variation in number of fatalities. 

Two more promising exposure measures have been identified by the SOFA Working Group. The 

average number of employees per month that are classified as “Transportation (Train & 

Engine),” and referred to as the ‘600 series’ shows how this workforce has shrunk since the early 

1980’s. The Office of Economics, Environmental Analysis, and Administration of the Surface 

Transportation Board (STB) also makes available on a monthly basis the number of hours 

worked by these employees. Total hours can be calculated as straight plus overtime. Total hours 

would seem conceptually a better measure of exposure than the average number of employees. 

One drawback to these data is that it is only for the Class I railroads. About 70 percent of the 

total 76 FEs of the SOFA Period occurred, after accounting for mergers, on roads that are 

presently classified as Class I, as shown in Table 2-3. 

Note: Only those railroads with over 400,000 man-hours worked per year are required to report 

man-hours. All railroads are required to report FEs. 
 2-10 

Year FEs yard rate

switching per million

miles yard

switching

miles

(1) (2) (1)/(2)

1998 (up to 7/1/98) 6

1997 11 84,873,799 0.13

1996 7 87,823,254 0.08

1995 11 89,891,866 0.12

1994 12 89,776,044 0.13

1993 15 87,121,756 0.17

1992 14 84,429,603 0.17

1991 10 88,519,350 0.11

1990 7 98,151,387 0.07

1989 9 104,330,103 0.09

1988 9 105,325,469 0.09

1987 10 101,954,793 0.10

1986 13 108,257,858 0.12

1985 10 117,059,027 0.09

1984 12 126,465,254 0.09

1983 15 122,233,983 0.12

1982 24 133,423,632 0.18

1981 18 164,754,470 0.11

1980 33 182,340,123 0.18

1979 28 207,848,728 0.13

1978 35 214,497,878 0.16

1977 48 218,543,852 0.22

1976 30 217,363,453 0.14

1975 34 220,175,000 0.15

total 421 average 0.14

Table 2-2. Employee fatalities and fatality rate by million yard 

switching miles, 1975 to 1997. 
 2-11 

Table 2-3. Employment and Service Hours for Class I Railroads. 

Year Average Number of 

Employees during 

Year 

Service Hours Paid FEs 

 

1994 62,473 190,031,440 12 

1995 63,831 193,519,210 11 

1996 63,230 187,689,409 7 

1997 63,422 189,325,391 9 

1998 65,988 202,204,015 6*

(* 1998 FEs through July 1. Employees and hours worked are for the full year.)

The monthly distribution of FEs over the SOFA Period is shown in Figure 2-5. Twelve FEs 

occurred during June and with 10 each for December and January. Low months were February, 

April, and August with four each; May and September each had three FEs. Exposure measures 

such as switching miles show only small monthly variations. The fact that this monthly 

distribution shows cyclical peaks in December-January and June-July suggests that there are 

critical periods during the winter and summer when FEs are more likely to happen. 

Figure 2-5. Distribution of FEs by month. 

10

4

5

4

3

9

4

3

7

5

10

12

0

2

4

6

8

10

12

January March May July September November

FEs 
 2-12 

There is a distinct day-of-week pattern for the 76 FEs. Eighteen percent (24 FEs), occurred on 

Tuesday while only four FEs, (1.3) percent, occurred on Sundays. The day-of-week distribution 

is shown in Figure 2-6. The Working Group would like to be able to control for exposure in 

analyzing this daily pattern, but switching miles or number of personnel on duty are not 

maintained in a database in sufficient detail to reflect daily variation. 

4

9

18

12

14

13

6

0

2

4

6

8

10

12

14

16

18

20

Sunday Monday Tuesday Wednesday Thursday Friday Saturday

FEs 

Figure 2-6. Distribution of FEs by day of week. 

The distribution of FEs by time-of-day in hourly increments, January 1, 1975 to July 1,1998, is 

shown in Figure 2-7. Several hourly spikes during the day are shown here. 

Perhaps of greater interest is the distribution by shift period. The SOFA Group looked at the 

number of FEs occurring during each of three work shifts as shown in Figure 2-8. Twenty-eight 

of the 76 FEs occurred during the first shift, from 8 a.m. to 4 p.m. The second shift, 4 p.m. to 12 

a.m., also had 28 FEs. Third shift, 12 a.m. to 8 a.m. had the fewest FEs, 16.1

 Again, without 

exposure data to use as a control, we must be careful when interpreting these results since there 

may have been less switching activity during late night and early morning parts of shifts. 

 

1

 Note: This distribution was found to be essentially unchanged back to 1975. 
 2-13 

Note: Exposure is not necessarily equal by hour of day. 

Figure 2-7. Distribution of FEs by time of day, January 1, 1975 to July 1, 1998. 

Figure 2-8. Distribution of employee fatalities by work shift. 

'first'= 8am to 4pm, 'second' = 4pm to 12 am, 'third' = 12 am to 8 am

28 28

20

0

5

10

15

20

25

30

first second third

shift 

FEs 20

24

16 17 18

11 11

9

12

26

12

17

21 20

22

13

20 19

17

23

20

15

17

20

0

5

10

15

20

25

30

12:00 am -12:59 am

2:00 am - 2:59 am

4:00 am - 4:59 am

6:00 am - 6:59 am

8:00 am - 8:59 am

10:00 am - 10:59 am

12:00 pm - 12:59 pm

2:00 pm - 2:59 pm

4:00 pm - 4:59 pm

6:00 pm - 6:59 pm

8:00 pm - 8:59 pm

10:00 pm - 10:59 pm

FEs
 2-14 

2.5.4 Classifying FEs by Train movement, Equipment Struck by, etc. 

The 76 FEs contained in the SOFA Matrix were analyzed by a number of variables thought 

important in understanding the FE causation as indicated in Figure 2-9. These variables include 

train movement, FE location (on ground or on equipment before trauma producing event), 

whether striking equipment belonged to FE’s crew or another crew, and the direction of 

movement as being pulled, shoved or free moving or combinations thereof. In two cases, 

direction of movement was not coded. 

• Seventy FEs, 92 percent, involved train movement; thus, 6 FEs did not. 

• Of those 70 FEs, 38 FEs, or 54 percent, were on the ground before the harmful event; 32 

FEs, or 46 percent, were riding on equipment. 

• Of those on the ground before trauma-causing event, 26 FEs, or 68 percent, were hit by 

their own equipment; 12 FEs, 32 percent, were hit by another crew’s equipment. 

• Of those riding on equipment before trauma-causing event, 25 FEs, or 78 percent, were hit 

by their own equipment; 7 FEs were struck by another crew’s equipment. 

Figure 2-9 shows the direction of movement for the third level of decomposition of the total 76 

FEs. Note that shoving alone occurs in 33, or 47 percent, of the 70 FEs involving train 

movement. Free movement alone occurs in 14 FEs, or 20 percent, of the 70 FEs involving train 

movement. Three FEs involve some combination of shoving and free movement. Thus, together 

shoving and free movement is the direction of movement in 50 FEs, some 71 percent. 
 2-15 

pulled: 7 FEs (58.3% ) pulled: 3 FEs (11.5% ) pulled: 2 FEs (28.6% ) pulled: 6 FEs (24.0% )

shoved: 3 FEs (25.0% ) shoved: 15 FEs (57.7% ) shoved: 2 FEs (28.6% ) shoved: 13 FEs (52.0%

free: 2 FEs (16.7% ) free: 6 FEs (23.1% ) free: 2 FEs (28.6% ) free: 4 FE (16.0% )

pulled/free: 1 FE (3.8% )

shoved/free:1 FE (3.8% ) shoved/free: 1 FE (4.0% )

blank: 1 FE (14.2% ) blank 1FE (4.0% )

12 FEs 26 FEs 7 FEs 25 FEs

A llFEs

76

100.0%

N otresultoftrain m ovem ent

6 FEs

7.9%

Resultoftrain m ovem ent

70 FEs

92.1%

FEs on ground

38 FEs

54.3%

FEs on equip.

32 FEs

45.7%

H itby other equip.

12 FEs

31.6%

H itby ow n equip.

26 FEs

68.4%

H itby other equip.

7 FEs

21.9%

H itby ow n equip.

25 FEs

78.1%

Figure 2-9. Decomposition of Employee Fatalities: train movement, location, hit by own 

equipment or not, and direction of movement. 

2.6 Discussion 

Difficult as it may be to adjust the yearly FEs by the proper exposure measure, it appears that 

even if such were possible yearly FEs still would be shown not to be going down. From 1983 to 

1997, yearly FEs have varied between 7 and 15, a 15-year average slightly above 11 per year. 

Without implementing more effective safety procedures that strike at the heart of FE causation, it 

is unlikely that this average will change much in of itself. 

In the following section, methods are presented by which the SOFA Working Group rigorously 

went about discovering FE causation. 
 3-1 

3. HUMAN FACTORS TASKS

3.1 Human Factor Tasks 

The human factors team had the SOFA Group perform a number of tasks in order to take 

advantage of their expertise and detailed knowledge developed from investigation of the 68 FEs. 

(Note the original SOFA Matrix contained 68 FEs. Eight more were added after these tasks were 

completed.) 

The purpose of these tasks was to help them step back from the details of the SOFA Matrix and 

explore incident causation from the perspective of potential actions that could be taken by the 

railroad community to prevent such incidents in the future and to improve the incidents analysis 

and reporting methodology. The tasks consisted of the following: 

• reaching consensus as a group on ten general categories of incident causation that might 

provide insight into potential safety improvements together with detailed definitions of the 

categories; 

• rating the importance of each of the causation categories as a contributor to each incident; 

• sorting each incident into categories chosen by the individual sorter and assigning a 

description to the resulting categories; and 

• rating the similarity among all possible pairs of the causation categories in order to evaluate 

the potential relatedness of the categories. 

In this section we describe these tasks in detail and the results. 

3.2 Category Definition Task 

3.2.1 Method

Starting from information about possible contributing factors derived from the SOFA Matrix, the 

group reached a consensus on a set of ten broad PCFs of FEs in switching operations though 

extensive discussion, leading to drafting and redrafting of the definitions for these categories. 

The group was encouraged to consider categories for which recommendations for actions that 

could be taken to improve the safety of switching operations might result. The discussion process 

took about 3 hours. Then, a preliminary draft was prepared. Each definition was then reviewed 

and modified to produce a version that was deemed acceptable to the Working Group. For this 

activity, eight SOFA Working Group members participated. 

3.2.2 Results

The resulting categories and their definitions are given in Table 3-1. 
 3-2 

Table 3-1. Railroad Switching Operations Cause Categories.

1) Physical Characteristics of Rolling Stock 

a) Definition: Configuration of physical characteristics of engine, rolling stock, or other on-track equipment. 

b) examples: flat car (mounting or dismounting ), offset grab irons 

c) cause codes: 

2) Work Site Configuration 

a) Definition: Physical characteristics, layout, or configuration of any location at which a train or engine crew is expected 

to perform switching operations. 

b) Examples: yard tracks, sidings, main tracks, industry track work. 

c) Cause codes: M102, M404, M411. 

3) Operating or Safety Rule Integral to Incident 

a) Definition: Possible operating rules or safety infractions that could contribute to an incident. 

b) examples: Person absent from leading car, speed violations, individual fouling track or equipment. 

c) cause codes: H990 

4) Crew Utilization 

a) Definition: Assigned crew members that did not or could not fulfill roles required for safe operations. 

b) examples: inexperienced crew members not properly supervised 

c) cause codes: H316, H305 

5) Inter-crew Communication 

a) Definition: Absence or improper exchange of information between crews whose work needed to be coordinated. 

b) Examples: Two crews working on same track with no communications. 

c) Cause codes: H399 

6) Intra-crew Communication 

a) Definition: Failure of proper operation which could be due to absence of, or improper exchange of information among 

crew members by face-to-face, radio, or hand signals. 

b) Examples: lack of, or no job briefing; changing work activities without informing other crew members. 

c) Cause codes: 

7) Fitness for Duty 

a) Definition: Personal factors related to train and switching operations such as drugs, alcohol or employee physical or 

mental condition. 

b) Examples: impairment of efficiency or judgement because of drugs or alcohol (H101); employee physical condition, 

other (H199); other personal factors or limitations relating to physical or mental impairment 

c) Cause codes: H199, H101 
 3-3 

Table 3-1. Railroad Switching Operations Cause Categories. (cont.)

8) Sudden or Unexpected Movement of On-track Equipment 

a) Definition: Unexpected movement of on-track engine, rolling stock, or other off-track equipment that affects safety of a 

crew member. 

b) examples: free rolling cars, dropping cars on track being coupled, getting struck by truck. 

c) cause codes: 

9) Training 

a) Definition: Failure of proper operations attributed to inadequate classroom, on-the-job general skills, or site-specific 

training or knowledge. 

b) Examples: inadequate classroom training; inexperience in on-the-job skills; inexperience in physical characteristics of 

track or work site. 

c) cause codes: 

10) Track or Equipment Maintenance 

a) Definition: Physical condition of track or equipment was below established practices. 

b) Examples: sharp/worn flanges, worn switch points, crossover platforms bent, etc. 

c) Cause codes: E02C, E09C

3.3 Rating Task 

3.3.1 Method

SOFA Team members were asked to rate the relative importance of each of the ten categories 

described in Table 3-1 as contributors to each of the FEs they had reviewed. The rating was 

accomplished on a five-point scale from extremely important to not relevant. The full rating scale 

is illustrated below. 

Extremely 

Important 

Very 

Important 

Moderately 

Important 

Applicable, but 

neither important 

nor unimportant 

Not 

Relevant 

1 2 3 4 5 

They were encouraged to refer to the incident summaries if they could not remember the 

circumstances of a particular incident. Seven SOFA team members participated in this activity. 

3.3.2 Results

The results of this task are presented in three ways. First we present Figure 3-1, in which a bar 

shows the rating, averaged over all seven team members who completed the task, assigned to 

each of the ten categories. Each bar reflects the number of FEs for whom the mean rating was 

extremely, very or moderately important. The columns are ordered from “Operating or Safety 

Rule Integral to Incident,” which was rated important most often to “Physical Characteristics of 

the Rolling Stock,” which was rated important least often. 
 3-4 

Figure 3-1. The summary ratings of eight SOFA Members of the number of fatalities (FEs) 

for whom each contributing cause category was rated as extremely, very or moderately 

important. 

Tables 3-2, 3-3, and 3-4 present the same data in a different way. In these tables each row 

represents a specific employee fatality and each column again represents one of the ten 

categories. There is a 1 in the column if that category was rated 3 or below for that specific 

employee fatality and is blank if it was rated above 3, meaning Moderately Important. Thus, there 

are 1’s everywhere that a particular category was rated Moderately Important, Very Important or 

Extremely Important for any employee fatality. 

The rows have been sorted to show how many categories were rated as important for each 

particular employee fatality according to this definition. Table 3-2 presents the employee fatality 

for which four or more categories were considered important. There is one for which there were 

five categories and five employee fatality for which four categories were rated as important. 

Table 3-3 shows the 24 cases for which three categories were deemed important. Table 3-4 

presents the same results for the cases where two categories were rated important. 

0 5 10 15 20 25

Operating Rules

Unexpected movement

Intra-crew comm

Worksite config

Training

Track or equipment maintainence

Crew Utilitzation

Inter-crew Comm

Fitness for Duty

Physical Characteristics

Category

Number of FE's where mean rating is moderately 

important or higher
 3-5 

Table 3.2. FEs having 4 or more categories rated as important. A one (1) in the column 

indicates a rating of 3 or lower – moderately important. 

 Rule Unexp 

Mvmt 

Train Intra 

crew 

Inter 

Crew 

Crew 

Util 

Roll 

Stock 

Work 

Site 

Fitness Maint # > 3 

FE-28-94 1 1 1 1 1 5 

FE-30-92 1 1 1 1 4 

FE-31-93 1 1 1 1 4 

FE-31-94 1 1 1 1 4 

FE-35-93 1 1 1 1 4 

FE-09-96 1 1 1 1 4 

Table 3-3. FEs having 3 cause categories rated as important. A one (1) in column indicates 

a rating of 3 or lower – moderately important. 

 Rule Unexp 

Mvmt 

Train Intra 

crew 

Inter 

Crew 

Crew 

Util 

Roll 

Stock 

Work 

Site 

Fitness Maint # = 3 

FE-12-95 1 1 1 3 

FE-23-93 1 1 1 3 

FE-2693 1 1 1 3 

FE-26-94 1 1 1 3 

FE-02-94 1 1 1 3 

FE-29-94 1 1 1 3 

FE-03-92 1 1 1 3 

FE-45-97 1 1 1 3 

FE-47-93 1 1 1 3 

FE-11-95 1 1 1 3 

FE-22-92 1 1 1 3 

FE-24-96 1 1 1 3 

FE-02-97 1 1 1 3 

FE-29-95 1 1 1 3 

FE-31-96 1 1 1 3 

FE-46-93 1 1 1 3 

FE-05-97 1 1 1 3 

FE-16-97 1 1 1 3 

FE-04-92 1 1 1 3 
 3-6 

Table 3.3. FEs having 3 cause categories rated as important. A one (1) in column 

indicates a rating of 3 or lower – moderately important. (cont.)

FE-22-96 1 1 1 3 

FE-32-97 1 1 1 3 

FE-40-93 1 1 1 3 

FE-49-93 1 1 1 3 

FE-53-93 1 1 1 3 

Table 3-4. FEs having 2 cause categories rated as important. A one (1) in the column 

indicates a rating of 3 or lower – moderately important. 

 Rule Unexp 

Mvmt 

Train Intra 

crew 

Inter 

Crew 

Crew 

Util 

Roll 

Stock 

Work 

Site 

Fitness Maint # = 2 

FE-20-93 1 1 2 

FE-13-93 1 1 2 

FE-15-92 1 1 2 

FE-16-92 1 1 2 

FE-16-95 1 1 2 

FE-18-92 1 1 2 

FE-18-95 1 1 2 

FE-20-92 1 1 2 

FE-22-97 1 1 2 

FE-32-94 1 1 2 

FE-36-97 1 1 2 

FE-04-94 1 1 2 

FE-12-94 1 1 2 

FE-12-96 1 1 2 

FE-33-95 1 1 2 

FE-34-95 1 1 2 

FE-39-92 1 1 2 

FE-06-94 1 1 2 

FE-27-93 1 1 2 

FE-08-92 1 1 2 

FE-11-93 1 1 2 

FE-14-92 1 1 2 

FE-30-93 1 1 2 
 3-7 

Table 3-4. FEs having 2 cause categories rated as important. A one (1) in the column 

indicates a rating of 3 or lower – moderately important. (cont.)

FE-04-97 1 1 2 

FE-09-95 1 1 2 

FE-16-94 1 1 2 

FE-17-95 1 1 2 

FE-17-96 1 1 2 

FE-02-95 1 1 2 

FE-34-92 1 1 2 

FE-22-93 1 1 2 

FE-03-94 1 1 2 

3.3.3 Conclusions

Most incidents do not happen because of a single cause. They are the result of the convergence of 

a series of contributing factors. The absence of any one of which might have prevented it. Tables 

3-2, 3-3, 3-4 show how incident causes happen to cluster in contributing to these fatalities. 

Operating Rules were most frequently cited in connection with other categories. Training, Crew 

Communication and Crew Utilization were also frequently cited together. Training and 

Maintenance also occurred together frequently, as did intra-crew communication and unexpected 

movement. This latter pair makes sense because expectations are created by communication and 

an unexpected movement is likely to result from a failure of that communication. 

3.4 Sorting Task 

3.4.1 Method

Eight members of the SOFA Team were each given a stack of cards having the code numbers 

and a brief description of the circumstances of each fatality that had been evaluated. They were 

asked to sort the fatalities into approximately ten piles, placing fatalities that they thought had 

similar contributing causes in the same pile. The instructions were: “In thinking about what piles 

to put them in, be thinking about the pattern of circumstances and actions that together might be 

associated with the reason that they happened. We are interested in causes that go deeper than 

simply that an FE fell off the car or lost his balance.” They could put as many or as few cases in 

each pile as they wished. They were encouraged to refer to the fatality summaries to refresh their 

memories if they were uncertain about what happened in particular cases. They were encouraged 

to include one pile that was for cases that were unique or so unusual that they would not be likely 

to be associated with any other case and they were told to put cases that they had not personally 

participated in the review in a separate pile. After they had sorted the cards, they were asked to 

provide a name and a brief definition of each category and to provide one example incident that 

was especially representative of that category. Finally they were asked for causation codes used 

in the Matrix that would be associated with that category. 
 3-8 

3.4.2 Results

The results of the sorting are shown in Table 3-5 where the rows correspond to the FEs. The first 

column lists the number of the FE by Code Number. Each of the remaining columns present the 

names of the categories into which each of the eight team members sorted each incident. All the 

category names in a given column were provided by a single member of the SOFA team. The 

rows have been sorted to bring together FEs that were judged to be placed into similar categories 

by three or more team members. 

Only those cases for which there was a consensus among the sorters about how to classify a 

particular incident are included. There are five such groups. The first puts the cases for which 

there was agreement about communications failures together. The second grouping is for cases 

for which there was reasonable consensus that the problem was inattentiveness or lack of 

situation awareness. There were two FEs for which there was reasonable consensus that the issue 

was “unsecured equipment.” Finally, there was one FE (40-93) for which there was reasonable 

agreement that lack of understanding of the situation or lack of experience was the issue and one 

FE (16-92) for which fouling track was judged to be the major issue. 
3-9 

Table 3-5. Factors Contributing to Switching Fatalities Grouped by Primary Causal Factor as Identified by SOF

 Team Member 

FE # 1 2 3 4 5 6 7 

 Communication Breakdown 

04-97 Inattentiveness Communications 

breakdown 

Communication Fouling equipment Human factors - 

Communication 

'radio rules not obeyed' 

Communicatio

11-95 Communication 

failure 

Communications breakdown 

Communication Multiple jobs 

working 

Human factors - Communication 

'fouling track' Communicatio

14-92 Communication 

failure 

Communications breakdown 

Communication #N/A Human factors - 

Communication 

'radio rules not obeyed' 

#N/A 

16-97 Inattentiveness Communications 

breakdown 

Communication Fouling equipment Human factors - 

Communication 

'radio rules not obeyed' 

Communicatio

29-94 Communication 

failure 

Communications breakdown 

Communication Fouling equipment Not applicable 'clearance' #N/A 

45-97 Communication 

failure 

Communications breakdown 

Communication Fouling equipment Human factors - 

Fouling track 

'radio rules not obeyed' 

Clear moving equip. 

47-93 'Confusion...' Communications 

breakdown 

Communication Fouling equipment Not applicable 'fouling track' Communicatio

 Inattention or Lack of Situation Awareness 

13-93 Inattentiveness Not paying 

attention to other trains 

Hit by passing train 

Situational awareness 

Human factors - Fouling track 

“Hot Rail” Clear moving 

equip. 

17-96 Inattentiveness Not paying 

attention to other trains 

Hit by passing train 

Situational awareness 

Human factors - Fouling track 

“Hot Rail” Clear moving 

equip. 

22-97 Inattentiveness Not paying 

attention to other trains 

Hit by passing train 

Fouling equipment Human factors - 

Fouling track 

Distraction/ inattention 

Clear moving equip. 
3-10 

Table 3-5. Factors Contributing to Switching Fatalities Grouped by Primary Causal Factor as Identified by SOF

 Team Member 

FE # 1 2 3 4 5 6 7 

31-97 Inattentiveness Not paying 

attention to other trains 

Hit by passing train 

Situational awareness 

Human factors - Communication 

“Fouling track” Clear moving 

equip. 

20-92 Inattentiveness Not paying 

attention to other trains 

Unsafe area or time for rail operations 

Situational awareness 

Human factors - Fouling track 

“Hot Rail” Clear moving 

equip. 

 Unsecured Equipment 

18-92 Unsafe action Bad practices Failure to secure Fouling equipment Human factors - 

Fouling track 

“Clearance” Equipment not 

secured 

22-96 Gross 

misjudgment 

Bad practices Failure to secure Fouling equipment Human factors - 

Misc. 

“Poor switching” Equipment not 

secured 

 Understanding or Experience 

40-93 Lack of experience Too little 

understanding 

Experience Fouling equipment Human factors - 

Misc. 

“Inattentiveness” Derailment 

 Fouled Track 

16-92 Communication 

failure 

Bad practices Failure to secure Fouling equipment Human factors - 

Fouling track 

“Fouling track” Clear moving 

equip. 
 3-11 

3.4.3 Conclusions

Different team members interpreted incident causes at different levels of abstraction. Some 

thought of them most often at the level of “fouling track” or “clearance” problems. Others 

stepped away from that level and thought about why they were fouling the track or failed to 

provide enough clearance. However there was a strong consensus that for seven of the FEs, 

communications breakdowns played an important role in the occurrence of the fatality. For 

another five of the FEs there was consensus that inattentiveness or a failure of situation 

awareness was a key contributing cause. There were two FEs (18-92, 22-96) for which 

“unsecured equipment” appeared to be a major contributing cause. Finally, there was one FE (40-

93) for which there was reasonable agreement that lack of understanding of the situation or lack 

of experience was the major cause and one FE (16-92) for which fouling track was judged to be 

the major contributing cause. 

3.5 Paired Comparison Task 

3.5.1 Method

Eight participants were presented with a list of all possible pairs of the ten categories as defined 

in Table 3-1. For example, Physical Characteristics of the Rolling Stock was paired with 

Worksite Configuration and then separately with each of the other categories. There are 45 such 

pairs made up from the original ten categories. For each pair a similarity rating scale was 

provided with ratings from 1 = Not At All Similar to 5 = Very Similar. The participants were 

asked to rate the extent to which each pair of categories were similar to each other or associated 

with each other in the sense that they might both be considered important for the same FE. They 

were to rate the pair with a 1 if they thought they were not at all similar and with a 5 if they 

thought they were very similar. 

3.5.2 Results

The pair comparison averages are not of great interest in and of themselves, but they were 

subjected to a multidimensional scaling (MDS) analysis to see if dimensions would be uncovered 

that would provide a perspective on the ways in which the various categories were interrelated. 

Multidimensional scaling is a statistical technique that tries to fit all the pair ratings into a 

coherent dimensional structure. Sometimes the dimensions that are derived in this way will help 

the investigators to gain insight into the underlying mechanisms associated with the comparisons 

under study. It should be emphasized that there is no right versus wrong implied by this kind of 

analysis. It simply reflects the distillation of the collective opinions of the Working Group 

participants about cause category interrelationships. 

The analysis identified three dimensions, which are presented in Figures 3-2, 3-3, and 3-4. In 

Figure 3-2 we find that categories that are mostly associated with people tend to be grouped on 

the left while maintenance, rolling stock and to a lesser extent worksite are on the right end of the 

scale. This suggests that one dimension—the incident cause categories—might distinguish 

between people-related categories from equipment-related categories. In Figure 3-2 the 

distinctions are not as clear, but the categories that are grouped near the right end tend to be 

group activities like Inter-crew Communication and Crew Utilization, while Duty Fitness, clearly 

an individual issue is at the extreme other end. Thus, a second dimension of the incident cause 
 3-12 

categories might distinguish individual from group activities. Finally, in Figure 3-4, Unexpected 

Moves and Rolling Stock are at one end and Worksite is the most extreme in the opposite 

direction. Maintenance is also near the right end of the scale. We are suggesting that this 

dimension might reflect a dimension of cause categories involving movement versus those that 

are static. 

` 

Figure 3-2. MDS Scale illustrating the dimension: People vs. Equipment. 

Figure 3-3. MDS Scale illustrating the dimension: Individual vs. Group. 
 3-13 

Figure 3-4. MDS Scale illustrating the dimension: Movement vs. Static. 

3.5.3 Conclusions

This analysis cannot explain the position of every category on every scale, and while not to be 

taken too literally, suggests that there might be three very general dimensions that can be used to 

classify the types of FEs that occur. When taken together with the results of the SOFA Matrix 

analysis when looking for ways to improve safety, the industry might consider alternatives that 

focus on equipment movement where group-related issues such as crew communication and 

utilization have the potential to create incident-provocative situations. 

3.6 General Discussion 

The goal of the human factors tasks was to seek consensus among the members of the SOFA 

Working Group concerning the major issues that need to be addressed in order to reduce the 

frequency of FEs in switching operations. That goal was approached from several different 

perspectives. First the Working Group defined major causal contributors to FEs and rated their 

relative importance. An operating rule was judged to be integral to the incident in all but eight 

cases. Next, most important was Unexpected Movement and then Intra-crew Communication. In 

ten of the FEs, Unexpected Movement and Intra-crew Communication were identified as both 

being important. 

When the Task Force members were asked to sort the FEs into meaningful categories, seven of 

the FEs were uniformly sorted into a category that involved communications breakdowns. There 

was agreement for another five that they predominately involved not paying attention. 

 Recall that 92 percent of FEs involved movement. It is not surprising, then, that unexpected 

movement and not paying attention were so important. If the movement had been expected it 

would not usually result in a fatality. Some of these were the result of derailments or other 

situations that could not have been anticipated, but many were not. Similarly, it is predictable 

that many of the unexpected movement cases also involve communication issues, because the 

best way to prevent a movement from being unexpected is to make sure that all crew members 

positions are well known and at a safe distance from potential hazards before a movement is 

initiated. Accomplishing these goals requires effective and timely communication. 
 3-14 

The similarity analyses resulted in three scales that were labeled people vs. equipment’ individual 

vs. group and movement vs. static. While far from definitive by themselves, these results lend 

further support to the association of equipment movement with the need for improved crew 

communication and utilization. 

Intra-crew Communication does not only apply to the situation awareness of crew status, but also 

to effective job safety briefings that contribute to the teamwork that produces well-coordinated 

crews who understand the moves to be made. In subsequent reviews, six FEs were identified for 

which job safety briefings were called into question. Four of these FEs were the same ones that 

were identified as involving both intra-crew communication issues and unexpected movement.
4-1 

4. RECOMMENDATIONS 

4.1 Recommendations to Improve Safety 

In this section we present the recommendations of the SOFA Working Group to improve safety 

in switching operations. We introduce each recommendation with a finding that indicates the 

conclusions of the Working Group concerning a specific set of fatalities and with a list of the 

specific FEs to which this finding applies. Then we present the specific recommendation and this 

is followed by a brief discussion of the context and rationale for the recommendation. 

Each recommendation addresses what the Working Group believes is a specific contributing 

factor or class of contributing factors that played a role in the FEs listed. However, it should be 

emphasized that the Working Group does not believe that this was necessarily the only factor in 

each of these FEs. In fact, thirteen of the FEs are cited in more than one of the five 

recommendations. It has been widely observed that FEs leading to death or injury in any venue 

rarely are the result of a single contributing factor. More often FEs occur because of the coming 

together of a series of circumstances and contexts. The avoidance of any one such contributor 

might have prevented the incident from happening or from causing injury, death or property loss. 

Note: The following recommendations are not presented in any order of priority. 
4-2 

Major Finding and Recommendation 1 

4.1.1 Major Finding 1

Eleven of the seventy-six FEs occurred while the employee was adjusting knuckles, adjusting 

drawbars, or installing an end-of-train device. Table 4-1 summarizes those eleven fatalities. 

Table 4-1. FEs for Adjusting Knuckles, Drawbars, or Installing EOT Device. 

FE # DATE RAILROAD LOCATION 

18-92 06/20/92 CNW Northlake, IL 

26-94 10/17/94 UP Donaldsville, LA 

 32-94 12/13/94 UP Thorton, CA 

11-95 02/24/95 ATSF Amarillo, TX 

12-95 03/02/95 NS Aiken, SC 

29-95 10/04/95 CSXT Riverdale, IL 

09-96 03/20/96 BRC Bedford, IL 

24-96 10/07/96 UP Eagle Pass, TX 

25-97 08/15/97 UP Elko, NV 

15-98 05/26/98 BRC Bedford Park, IL 

17-98 06/05/98 NS Hapeville, GA 

4.1.2 Description of FEs for Major Finding 1

FE-18-92:Crew was in the process of coupling cars together in a class track. Standing equipment 

was not properly secured before conductor fouled the track to adjust couplers and the 

equipment rolled back in and coupled him up. 

FE-26-94:Crew switching in class yard, brakeman attempted to cross between equipment 

separated by an insufficient distance, and engineer moved locomotive in the wrong 

direction, coupling him up. 

FE-32-94:Crew coupling up cars in an industry track, brakeman attempted to couple air between 

cars when unexpected movement of railcars occurred resulting in his fatal injury. 

FE-11-95:Two crews working in the same yard from opposite ends, one crew dropped ten free 

rolling cars in on top of the cut where the other crew’s foreman was installing the 
4-3 

E.O.T. at the opposite end. Cars impacted with sufficient force to knock down and run 

over the foreman. 

FE-12-95:Switch crew was pulling a cut of cars out of an industry. Brakeman stepped in track 

gauge to open knuckle on the rear car at the same time crew shoved back to kick two 

cars which ran over the brakeman. 

FE-29-95:Crew performing switching in class yard. Switch foreman placed himself between the 

rails to adjust a mis-aligned couple on the fifteenth car after the cut was stretched. 

Switch foreman was facing the coupler with his back to a cut of seven cars which 

rolled in on top of him and coupled him up. 

FE-09-96:Three-person crew was switching in class yard, coupling between sixth and seventh 

car failed to couple. Conductor stopped locomotive and went between the cars to 

straighten the drawbar, and twenty-three cars rolled in behind him and coupled him up. 

FE-24-96:Three-person crew was switching in class yard, locomotive failed to couple to cut of 

seven standing cars. Yard foreman used hand signals to separate the locomotive by 

twenty feet. While adjusting the locomotive drawbar, the seven cars rolled in and 

coupled him up. 

FE-25-97:Crew was switching in class yard, helper was attempting to adjust the drawbar in order 

to couple to three cars about forty feet away that had not coupled the first time. While 

adjusting the drawbar, the helper did not notice the three free-rolling cars coming back 

in on him and the cars coupled him up. 

FE-15-98:Crew was working in one track in class yard with helper controlling engine moves, 

conductor was adjusting coupler when three free rolling cars struck him from behind 

and coupled him up. 

FE-17-98:Three-person crew was performing industrial switching using a runaround track, the 

yard foreman was attempting to couple up two super-cushion box cars in a curve with 

power attached in a shove movement. Drawbars bypassed and yard foreman was 

crushed between the ends of the two cars. 

4.1.3 Recommendation 1 

Any crew member intending to foul track or equipment must notify the locomotive 

engineer before such action can take place. The locomotive engineer must then apply 

locomotive or train brakes, have the reverser centered, and then confirm this action with 

the individual on the ground. Additionally, any crew member that intends to adjust 

knuckles/drawbars, or apply or remove EOT device, must insure that the cut of cars to be 

coupled into is separated by no less than 50 feet. Also, the person on the ground must 

physically inspect the cut of cars not attached to the locomotive to insure that they are 

completely stopped and, if necessary, a sufficient number of hand brakes must be applied 

to insure the cut of cars will not move. 
4-4 

4.1.4 Discussion

This recommendation emphasizes the importance of securing the equipment. A thorough 

understanding by all crew members that the area between cars is a hazardous location, whether 

equipment is moving or standing, is imperative. 
4-5 

Major Finding and Recommendation 2 

4.1.5 Major Finding 2 

Twenty of seventy-six FEs were struck by equipment other than their own. Of those twenty FEs, 

nine occurred in yard or industry tracks. Table 4-2 summarizes those nine fatalities. 

Table 4-2. FEs Struck by Other Than Own Equipment. 

FE # DATE RAILROAD LOCATION

30-92 09/24/92 GBW Wisconsin Rapids, 

WI 

31-93 08/12/93 ATSF Evadale, TX 

06-94 01/20/94 UP Falls City, NE 

31-94 12/06/94 CR Campbell Hall, NY 

11-95 02/24/95 ATSF Amarillo, TX 

18-95 05/03/95 CSX Evansville, IN 

05-97 02/02/97 CR Burns Harbor, IN 

05-98 02/04/98 BRC Bedford Park, IL 

16-98 06/01/98 BNSF Lubbock, TX 

4.1.6 Description of FEs for Major Finding 2

FE-30-92:The road job’s brakeman was trying to help the switch crew make up his train. The 

brakeman was in between cars on an active track being used by the switch crew and 

was killed when the cars he was between moved upon being struck by a cut of free 

rolling cars. 

FE-31-93:Upon detraining, brakeman was struck and killed by another railroad’s yard job 

working in the same small yard. Members of both crews saw each other but the 

brakeman apparently did not see the short line crews shove move. 

FE-06-94:Conductor riding side of two cars to be kicked, he moves to the opposite side of car to 

work hand brake and is immediately struck by locomotives standing on adjacent track 

creating a no-clearance condition. Conductor was not aware that the locomotives had 

arrived at that location since he had last been there. 

FE-31-94:First local had left the immediate location of the work area to be used by the second 

local without notifying the second local of the position of the switches, derails or 

returning the switches to a non-conflicting position. Second local shoving three cars 
4-6 

and a caboose with a two-month trainee directing the move, struck standing equipment 

after traversing switches that were unexpectedly lined for the equipment. 

FE-11-95:Foreman of one job was installing the rear end marker on a cut of cars when the 

foreman of another job sent ten free rolling cars into the same track. The resulting 

impact caused all the cars to roll enough to knock down and kill the foreman who had 

been installing the marker. 

FE-18-95:Conductor was struck and killed by a shove move on the track adjacent to where he 

was working. Communication about the move on that adjacent track had been 

conveyed to the conductor via the “bleeder,” a utility type employee. 

FE-05-97:Two yard jobs working on adjacent tracks. The conductor of one is studying his switch 

list as the other job is shoving into the adjacent track. Conductor is struck and killed by 

the lead car of the adjacent track shove move. 

FE-05-98:Conductor and switchman making hoses on track 12, last transmission by conductor is 

“I think I got all the hoses after that next one....” Conductor is later found to have been 

struck and killed by a free rolling car on the adjacent track. 

FE-16-98:Two yard engines working on adjacent tracks. One left a car fouling a clear track being 

used by the other engine. The foreman directing the shove move of the lite 

locomotives was crushed when his engine consist cornered the car fouling the adjacent 

track. 

4.1.7 Recommendation 2

When two or more train crews are simultaneously performing work in the same yard or 

industry tracks, extra precautions must be taken: 

SAME TRACK 

• Two or more crews are prohibited from switching into the same track at the 

same time, without establishing direct communication with all crew members 

involved. 

ADJACENT TRACK 

• Protection must be afforded when there is the possibility of movement on 

adjacent track(s). Each crew will arrange positive protection for (an) adjacent 

track(s) through positive communication with yardmaster and/or other crew 

members. 

4.1.8 Discussion

FE-06-94 and FE-31-94 both involved standing equipment left by another crew. In both cases, it 

can be argued that there was no possibility of either piece of equipment being moved. However, 

the fact that both pieces of equipment contributed to the fatalities and in both cases the respective 
4-7 

crews had no knowledge that the equipment had been moved into the work area and that the 

physical layout expected by each fatality had changed contributed to the incident. Compliance 

with and an understanding of this recommendation would have prevented the other seven 

fatalities. 
4-8 

Major Finding and Recommendation 3 

4.1.9 Major Finding 3 

A lack of, or inadequate job safety briefings contributed to at least eight FEs. Table 4-3 

summarizes those eight fatalities. 

Table 4-3. FEs for Job Safety Briefings. 

FE # DATE RAILROAD LOCATION

30-92 09/24/92 GBW Wisconsin Rapids, 

WI 

23-93 06/07/93 IC Fulton, KT 

30-93 08/11/93 SP Tracy, CA 

47-93 11/13/93 GC Macon, GA 

49-93 12/05/93 SOU Atlanta, GA 

29-94 11/15/94 CR Painted Post, NY 

09-95 02/17/95 CR St. James, OH 

12-95 03/02/95 NS Aiken, SC 

4.1.10 Description of FEs for Major Finding 3

FE-30-92:Crew performing switching in class yard while road brakeman from another crew was 

coupling air hoses in a track without proper precautions and protection. Yard crew 

switched into the track and equipment ran over the road brakeman. 

FE-23-93:Crew performing switching duties in class yard failed to have a clear understanding of 

movements being made. Results were that the rear brakeman was run over by moving 

equipment. There were no witnesses, but a hand brake was applied. It was thought that 

the brakeman had gone between the equipment on the ground to release the low hand 

brake. 

FE-30-93:Crew performing industry switching. Brakeman attempted to couple air hoses while 

conductor gave engineer instructions to shove the movement. Resulting movement 

was unexpected to brakeman who was fatally injured. 

FE-47-93:Trainmaster became involved with crew performing switching in class yard without 

knowledge of the conductor who was coupling air hoses on a cut of cars. Cars were 
4-9 

shoved without his knowledge while he was in the foul of the movement. Movement 

ran over conductor and killed him. 

FE-49-93:Change in operating procedure between two crews swapping equipment resulted in 

conductor being struck by unexpected movement while he was in the foul of the track.

FE-29-94:Crew switching in class yard failed to establish and maintain effective 

communications. Subsequent changes in switching line-up by the conductor resulted in 

trainman who was in the foul of Track 7 being struck by unexpected movement of 

equipment. 

FE-09-95:Arbitrary change in switching operations by conductor resulted in him being 

unexpectedly struck and fatally injured by approaching cars while he was fouling the 

track. 

FE-12-95:Switching crew was pulling cut of cars out of an industry. No clear understanding of 

moves to be done by crew members resulted in brakeman being run over when he 

stepped in track gauge to open knuckle on the rear car of a cut and the locomotive 

engineer shoved that cut back over him. 

4.1.11 Recommendation 3 

At the beginning of each tour of duty, all crew members will meet and discuss all safety 

matters and work to be accomplished. Additional briefings will be held any time work 

changes are made and when necessary to protect their safety during their performance of 

service. 

4.1.12 Discussion 

Safe switching operations require teamwork and accountability among all crew members. Each 

crew member takes responsibility for their own and their fellow crew member’s safety. Team 

work begins with a detailed, effective job briefing, but includes continued updates to all crew 

members describing the current state of each move as it is executed. 
4-10 

Major Finding and Recommendation 4 

4.1.13 Major Finding 4

Ten of the 76 fatalities occurred because of a combination of radio/hand communication, or 

initial and/or ongoing movement of equipment without specific distances given. Table 4-4 

summarizes those ten FEs. 

Table 4-4. FEs for Improper Communication. 

FE # DATE RAILROAD LOCATION

08-92 3/11/92 FEC Fort Pierce, FL 

14-92 6/1/92 ATSF Escondido, CA 

26-93 7/15/93 CR Anderson, IN 

30-93 8/11/93 SP Tracy, CA 

29-94 11/15/94 CR Painted Post, NY 

31-94 12/6/94 CR Campbell Hall, NY 

09-95 2/17/95 CR St. James, OH 

04-97 1/29/97 UP Mason City, IA 

16-97 6/6/97 CMGN Bay City, MI 

45-97 12/26/97 UP Boise, ID 

4.1.14 Description of FEs for Major Finding 4

FE-08-92:This case involved the conductor riding a car into Track 8. The car derailed at the 

spiked switch and the conductor was subsequently killed. The conductors last radio 

transmission was “...we’re lined in eight rail, three or four cars to a joint.” Movement 

stopped after car had derailed and side swiped adjacent car. 

FE-14-92:Brakeman had control of the move and told the engineer, by radio, to back up six cars 

to a coupling. The brakeman assumed that the conductor would “pick-up” the move 

when it came into his (the conductor’s) view. The movement continued until it struck 

sitting cars on the track which, when moved, killed the conductor who was in between 

them. 

FE-26-93:After the brakeman had tied the locomotives onto a cut of cars in the yard, the 

engineer received an instruction, via radio, from the brakeman to “shove to hold more 

cars.” The engineer began to shove and didn’t stop until he was on the other end of the 
4-11 

track. The brakeman was run over by the shove move. There was no evidence of any 

other radio transmissions concerning the shove move. 

FE-30-93:Conductor was at the switch using hand signals to stop and back up the locomotives 

and the brakeman was in the plant using the radio to spot once the cut came into view. 

When the move had been put back together and the yard job was ready to shove back 

toward the yard, there was a hand motion by the brakeman interpreted by the 

conductor as a back up and subsequently relayed to the co-engineer. The brakeman 

was run over by the two engines and five cars as the move proceeded toward the 

crossing without further hand signals or radio signals. 

FE-29-94:Trainman and conductor working together with two locomotives and involved in 

switching a few cars, between three different tracks, using a mixture of hand and radio 

signals. Conductor tells the trainman his instructions by radio and instructs the 

engineer by hand signals. The engineer moves on a hand signal to back up, the 

conductor boards the locomotives and the movement continues without further 

instruction until it runs into a cut of cars that the trainman was apparently fouling, 

killing the trainman. Engineer thought he would hear, by radio, from the trainman. 

FE-31-94:The brakeman trainee was on the caboose to direct the shove move of the three 

engines, three cars and a caboose toward Track 1 in the yard. The shove move 

continued although the only radio transmission after getting the move started was “the 

derail is off.” The movement, which reached approximately 19 mph, struck standing 

equipment after diverging through two misalign switches and killed the brakeman 

trainee. 

FE-09-95:Conductor instructs engineer, by radio, to “come ahead” (position of controlling 

locomotive causes this instruction to result in a shove move) with the same cars that he 

had just come out of the track with. There are no other radio transmissions from the 

conductor and eventually, the trainman, standing at the other two cars on the same 

track that was just pulled, directs the move to re-couple figuring that the conductor 

changed his mind. The movement traveled approximately eleven car lengths prior to 

coupling. 

FE-04-97:Conductor and engineer were moving toward engine house area with lite engines and 

using hand signals. The conductor stopped the movement to line a switch. The 

engineer while waiting, heard and acted upon an unidentified radio transmission 

“come ahead 21.” The engineer initiated the shove movement and eventually, the 

conductor was struck from behind and killed. 

FE-16-97:Conductor began a move using radio communication to shove a cut of cars 

approximately twenty-five car lengths to a coupling. After the move had begun the 

engineer didn’t hear another radio transmission from his conductor. The shove move 

eventually collided with the cars that were to be coupled to. The conductor was 

crushed in the collision and it was later determined that the portable radio being used 

by the conductor may have lost enough of it’s charge to effect the transmission. 

FE-45-97:Conductor riding equipment while setting hand brakes. Move being shoved; improper 

radio communication. 
4-12 

4.1.15 Recommendation 4

When using radio communication, locomotive engineers must not begin any shove move 

without a specified distance from the person controlling the move. Strict compliance with 

“distance to go” communication must be maintained. 

When controlling train or engine movements, all crew members must communicate by 

hand signals or radio signals. A combination of hand and radio signals is prohibited. All 

crew members must confirm when the mode of communication changes. 

4.1.16 Discussion

The SOFA group believes that the key to radio use when backing, shoving or pushing a train or 

cut of cars is the communication between the locomotive engineer and the train crew. The crew 

must develop the discipline to remain stopped until specific car counts are given by the ground 

person, rather than to begin moving and then expect to receive the count. If this is done, fatalities 

related to improper radio communication can be substantially reduced. Additionally, mixing 

radio and hand signals causes confusion, reduces the chance that other members of the crew 

would hear of a change in the switching operations thereby greatly increasing misunderstandings, 

and, has directly led to fatalities studied by the SOFA Group. 
4-13 

Major Finding and Recommendation 5

4.1.17 Major Finding 5

Eleven of the 76 FEs were shown to have experience of one year or less and/or deficiencies in 

training. One additional FE had less than 1.5 years and is included below. Of these 12 FEs, all 

but one occurred in yard or industry tracks. Table 4-5 summarizes those twelve FEs. 

Table 4-5. FEs for Experience and Training. 

FE # DATE RAILROAD LOCATION

04-92 1/30/92 AGC Polk County, FL 

47-93 11/13/93 GC Macon, GA 

28-94 11/10/94 PTRA Houston, TX 

31-94 12/6/94 CR Campbell Hall, NY 

29-95 10/4/95 CSXT Riverdale, IL 

09-96 3/20/96 BRC Bedford Park, IL 

12-96 6/15/96 CSX Charlotte, NC 

17-96 7/7/96 NS Sidney, IN 

22-96 9/3/96 DGNO Dallas, TX 

24-96 10/7/96 UP Eagle Pass, TX 

32-97 10/16/97 MRL Laurel, MT 

16-98 6/1/98 BNSF Lubbock, TX 

4.1.18 Description of FEs for Major Finding 5

FE-04-92:Industry switch crew, engineer and two flagmen, both flagmen rode the lower steps of 

the leading end of the lead locomotive. FE (flagman) on left side, the other flagman on 

right side. After 2000 feet into this light engine movement the surviving flagman 

noticed the FE stopped talking and he crossed over to the FE’s side and saw FE lying 

next to the track behind movement. Investigation showed FE either slipped off the 

fireman’s side or tripped while dismounting or attempting to remount from the 

fireman’s side. FE had six months experience. 

FE-47-93:Yard switch crew, engineer, conductor and brakeman, making switching moves into a 

seven track flat yard that runs up hill from the lead. Crew made pull from originating 

track, #5 track, FE (conductor) stayed behind after making cut to secure remaining 
4-14 

cars. Brakeman made four moves from lead to other tracks finishing with coupling and 

shoving #1 track in eleven car lengths. Trainmaster assisted brakeman by watching last 

car of #1 track. Conductor was found in the middle of #1 track under the cars. Last 

time he was seen was by the brakeman while he observed the conductor walking 

between #5 track and #1 track. FE had one year of experience. 

FE-28-94:Yard switch crew, engineer, conductor and brakeman, spotting paper mill. FE 

(brakeman) instructed by conductor to de-train and stay at road crossing while he 

spotted track. FE found in nearby wood chip auger/conveyer system after mill crew 

started up the system while crew searched for missing FE. Mill crew was instructed by 

conductor not to start equipment until FE was located. FE was not familiar with the 

dangers associated with this mill process. FE had 5 months experience. 

FE-31-94:Yard switch crew, engineer, conductor and brakeman, making reverse movement with 

caboose, three cars and two locomotives. FE (brakeman trainee) controlled the 

movement from his location in caboose. FE was unsupervised, conductor on engine 

with engineer. Movement speed was 19 mph at impact. Crew shoved over two 

switches without hearing radio signs from FE. Last radio transmission from FE was a 

panicked stop request before colliding with equipment stopped on track ahead of their 

movement. FE had 10 weeks experience. 

FE-29-95:Yard switch crew, engineer, foreman, switchman and utility man, performing 

switching duty in large bowl yard. FEs first tour of duty as conductor in this yard. FE 

expressed his concern of working as a conductor in this yard. FE did not feel 

comfortable in this position due to his lack of experience and unfamiliarity of this yard 

operation. Original engineer laid off sick after learning the FE would be the conductor 

rather than work the job with him. FE was by himself coupling a yard track. FE 

instructed engineer via radio to pull back half a car length. After stopping, engineer 

continued to see FEs lantern. FE stepped in between the equipment to straighten a 

draw bar or open a knuckle. While doing this the cars he was trying to couple to rolled 

down pinning the FE between the equipment. FE had 5 months of experience. 

FE-09-96:Yard switch crew, engineer, conductor and switchman, performing switch duty in a 

hump yard. FE, (conductor) was coupling track in the hump bowl by himself. While 

adjusting misaligned drawbars the cars he was coupling to unexpectedly moved, 

pinning FE between equipment. FE had 4 months of experience. 

FE-12-96:Yard crew, engineer, conductor and switchman, switching at an industry. While crew 

was shoving two cars to a spot inside an industry building, FE (switchman) was rolled 

between lead box car and unloading platform. Platform or building was not marked 

with any type of ‘no-clearance’ or ‘close clearance’ signage. FE was last seen by 

conductor on the ground next to movement in a ‘cut-out’ space in the unloading 

platform. The conductor reported that there is enough room for a man to clear the 

movement in this ‘cut-out’. After hearing a strange noise the conductor instructed 

engineer to stop the movement. FE was rolled for 21 feet between box car and 

platform. FE had one year experience. 

FE-17-96:Road crew, engineer and conductor, while stopped on siding track to meet an opposing 

train, FE (conductor) detrained to perform a roll-by inspection of other train. FE 

stepped off his train shortly before opposing trains arrival then stood in that trains 
4-15 

track while trying to adjust his portable radio. Opposing train struck FE at this point. 

FE had one year of experience. 

FE-22-96:Yard switch crew, engineer, conductor and brakeman, while switching at an industry 

on a downhill grade experienced an unwanted run away car. While FE (brakeman) was 

in position on a car and setting a hand brake, the car started to roll away from the crew. 

FE continued to try to apply hand brake in an effort to stop the car. When discovering 

that the car was rolling away, the conductor attempted to slow and stop it by putting 

wood blocks under the wheels. The car accelerate to 30 to 35 mph. FE did not detrain 

before car collided with seven other cars at that speed. FE had three weeks experience. 

FE-24-96:Yard Switch Crew, engineer, switch foreman, switchman, while attempting to 

complete a joint between an engine consist of two units and seven cars on an uphill 

grade, FE (switch foreman) was pinned between the engines and cars when cars 

unexpectedly rolled back while he went between equipment to adjust coupling. FE had 

1 year, 5 months experience. 

FE-32-97:Yard switch crew, engineer, switch foreman and switchman, were shoving a cut 41 

cars up a grade to a stop. While this was taking place the ground crew boarded the first 

two cars so they could apply the hand brakes. FE (switchman) fell off the first car 

while attempting this. This car was found to have a brake platform with a decreasing 

width. Under the hand brake this platform was found to be 2 inches under the required 

width over a length of about 30 inches. FE had 10 months experience. 

FE-16-98:Yard switch crew, engineer, foreman and brakeman, performing local switching duties 

struck a car fowling switching lead. The FE (foreman) rode leading end of movement 

while shoving. While having a discussion on the radio, a cut of cars rolled out slowly 

from another track striking FE as he rode the point. FE had 10 months experience. 

4.1.19 Recommendation 5 

Crew members with less than one year of service must have special attention paid to safety 

awareness, service qualifications, on-the-job training, physical plant familiarity, and 

overall ability to perform service safely and efficiently. Programs such as peer review, 

mentoring, and supervisory observation must be utilized to insure employees are able to 

perform service in a safe manner. 

4.1.20 Discussion

While class room training time has increased, in general, the SOFA group has focused on 

experience and on-the-job training. We have found that limited training and experience continues 

to factor into many switching operation fatalities. Additional on-the-job training and experience, 

while working with more experienced peers, may help reduce fatalities among crew members 

with limited service. 

The recommendations above address those issues for which the Working Group felt they could 

respond with confidence based on their expertise and the objective data. In the following section, 

we consider other steps that the Working Group recommends taking to continue to improve the 

safety of switching operations. 
4-16 

4.2 Additional Suggested Actions 

The recommendations found in sections 4.1.3, 4.1.7, 4.1.10, 4.1.14, and 4.1.18 address those 

issues for which the Working Group felt they could respond with confidence based on their 

expertise and the objective data. In this section, we consider other actions that the Working 

Group recommends taking, based on their expertise to continue to improve the safety of 

switching operations. 

4.2.1 Safety Training Concerning the Implications of Unexpected Train Movement 

Finding: Compelling evidence suggests many FEs involve unexpected train movement, 

particularly at very low speeds. 

Action: The railroad in the industry should review their existing switching operations training 

programs to assure that no opportunities are being overlooked to heighten safety awareness and 

to focus it on the serious implications of unexpected train movement, and on the importance of 

continual mutual awareness of the location and activities of all crew members. 

Rationale: Such FEs are preventable if the crew members have proper understanding of all 

planned movements, take care to be sure that no individuals are exposed to potential hazards at 

the time movements are initiated and to assure that detached equipment has been properly 

protected, i.e., locomotive reverser centered or hand brakes applied, to prevent unplanned 

movement. Safety awareness training can encourage a strong focus on these issues. 

4.2.2 Train Crew Resource Management 

Finding: The Working Group has also concluded that an important contributing factor to many of 

the FEs reviewed was incomplete or inadequate communication among crew members. 

Sometimes this was a failure of, or improper use of communications equipment, but more often it 

was a failure or reluctance of the crew member to elevate the importance of communications 

impacting on safety to the level needed to assure successful, safe operations. 

Action: The industry (labor, management, FRA) should consider programs that address 

improving crew coordination and communication such as Crew Resource Management (CRM) 

which has been used effectively in the aviation industry. 

Rationale: The goal of these training procedures in all industries is to promote safe operations 

through improved crew member proficiency, situational awareness, effective communication and 

teamwork, and by providing strategies for appropriately challenging and questioning authority 

where safety could be jeopardized. Training in the importance of and procedures for effective 

intra-crew communication has the potential to make a major contribution to the safety of 

switching operations. 

4.2.3 Follow-on SOFA Analysis : Review of Incidents Involving Severe Injury

Finding: The SOFA Working Group has been an effective task force for accomplishing goals 

that span the interests of labor, management and the FRA in switching operations. Although the 

review of switching fatalities has been very useful, the body of data is relatively small. Incidents 

in which serious injury has resulted, such as loss of a limb or requiring that the employee be 

placed on extended disability are likely to be very similar in kind to FEs. They are likely to 
4-17 

reflect the same safety implications in the sense that the only difference is in the degree of 

severity of the injury. 

Action: The SOFA Working Group or its successor should extend the scope of its investigations 

by undertaking the review of available incidents where severe injuries have resulted. 

Rationale: The data collection procedures for examining railroad injuries has recently been 

improved so that more complete and useful data for understanding the safety implications are 

available. In 1998 there were more than 8,000 non-fatal railroad incidents, not including grade 

crossing incidents. While we do not know the number of these that would be classified as 

serious, and the number that involved switching operations, it is likely to be a significant 

proportion of this total. This information would substantially augment the statistical reliability of 

the aggregate database and the ability to make objective recommendations based on it.
5-1 

5. RECOMMENDATIONS FOR INCIDENT INVESTIGATION 

A few months into their evaluation process, the SOFA Working Group found that, despite the 

voluminous amount of detail available and the quality of each technical summary, there were still 

information gaps in the fatality reports that had originally been collected. For example, although 

general weather information (cloudy, cool, etc.) was usually available for each incident, more 

specific information, such as temperature, was not consistently collected in all cases. The lack of 

specific information reduces the usefulness of the data for subsequent analysis. 

The incident reports generally tried to establish a single probable cause of each switching 

incident. However, the SOFA Working Group concluded that fatalities more often resulted from 

the coming together of a complex set of factors. Had any one of these factors not been present, 

the fatality would have been less likely to occur. The SOFA Working Group also discovered that 

some of the codes needed to capture all of these possible factors into the SOFA matrix database 

were not available in the established code lists contained in the Appendices of the 

Accident/Incident Reporting Guide. Consequently, new codes were established to account for 

these factors, and added to the SOFA matrix. These new codes are shown in Appendix C.

The SOFA Working Group confirmed the importance of developing a more comprehensive 

database of FEs in switching operations to support a deeper understanding. 

With respect to incident investigation and analysis, the SOFA Working Group made four specific 

recommendations to the FRA. 

5.1.1 Establish and Maintain Database of Objective FE Data

Finding: FRA’s existing FE files could be greatly improved by including a much broader range 

of information that can support the interpretation of the possible contributing factors associated 

with FEs. 

Recommendation: When investigating FEs, the FRA should establish a comprehensive historical 

database summarizing the objective data and interpretation of FEs occurring in switching 

operations that will be updated regularly to accumulate reliable and consistent information about 

the occurrence of switching operations fatalities. 

The Working Group, taking advantage of the insights resulting from its extensive analysis of 

existing data, is providing its recommendations for ensuring that specific data are collected by 

the FRA during its investigation of FEs. 

Discussion: The generated database will provide more reliable clues to the factors contributing to 

switching operations FEs and support the justification of safety improvements in terms of the 

number of lives potentially saved. Additionally, the newly generated database will substantially 

reduce the time and cost of subsequent analyses and recommendations. 

5.1.2 Recommendation for Providing Computer Support to the Data Collection Process

Finding: Current data collection procedures involve use of printed forms, notes, diagrams and 

photographs that do not provide a thorough or uniform data collection to perform accurate 

statistical analyses. 
5-2 

Recommendation: The FRA should consider creating software to facilitate data entry at the 

source and at the time the investigation is taking place. This software could operate on portable 

laptop computers already available to investigators or on off-the-shelf personal data units (PDUs) 

that are especially suited to the data collection application. The SOFA Working Group offers its 

assistance in a project to revise the data collection protocol and to develop software to support 

the fatality investigation and data codification process. 

Discussion: The efficiency, accuracy, and thoroughness of the existing data collection in each 

investigation would be improved. Computer support could reduce the time and cost associated 

with the complete data collection and consistent codification process. 

5.1.3 Recommendation for Continued Review and Monitoring of Fatal Accident Data

Finding: The SOFA Working Group has accumulated the most knowledge of the potential 

causes of switching operation FEs in the industry. 

Recommendation: The SOFA Working Group, or its successor, should undertake a periodic 

review of the FE switching operations data as it accumulates to seek new lessons learned, to 

review the integrity of the data, to monitor its usefulness and recommend improvements to the 

data being collected where appropriate. 

Discussion: Their review of the data will (1) provide the best checks that the data being requested 

are useful, (2) put them in a position to recommend improvements to data collection and (3) put 

them in a position to recommend potential safety improvements to reduce the incidence of death 

and injury. 

5.1.4 Modification of FRA’s Data Collection Process to Include a Team Concept

Finding: No one has all the expertise required to undertake a comprehensive review and revision 

of FE investigation procedures. 

Recommendation: The Working Group believes it is important that FRA’s investigation process 

be consistent, and that a team concept be implemented to insure complete data collection. 

Rationale: The SOFA Working Group recognizes that some inspectors collect and produce 

reports better than others, while other inspectors are more versed in analyzing the FE data. A 

team (to include all affected disciplines) concept in data collection and analysis will insure a 

more consistent FE investigation. 

5.1.5 Fatal Incident Investigation Protocol

The following sections present the data fields that the SOFA Working Group recommends be 

collected by the FRA in each future fatality incident investigation. The field descriptions are 

especially adapted to forms that could be implemented in computer software and take advantage 

of branching structures to present for entry only the data fields that are relevant to each 

investigation. However, they could also be formatted in paper forms, if required. 

The data are organized into sections that address: 
5-3 

• Background information 

• Weather/Visibility 

• FE personal data 

• Work/Rest/Fatigue 

• Personal Issues 

• Personal Protective Equipment 

• FEs Crew Information 

• Data on other involved crews, if any 

• FE Activity at time of Incident 

• Site information 

• Communications Issues 

• Emergency response Issues 

• Possible contributing factors 

To accomplish this we have identified seven data types: 

• Alphanumeric Entries (abbreviated Alpha): Examples: Railroad; FE Date of 

Birth 

Example: 

Railroad FE Date of Birth 

 Mo Day Year 

• Check Box (answer yes no, or unknown): Examples: Was employee 

protection system in effect? 

Example: 

• Menu Selection from small set of specific possibilities: Examples: Type of 

movement (Shove, Pull, Free-Running) 

Example: 

Was employee protection equipment in effect? 

Yes No Unknown 

Type of Movement 

 Shove Pull Free Running 
5-4 

• Coded entries derived from code sheets - some pre-existing, some to be 

created: Examples: Physical Act Circumstance Codes; FEs crew anticipated 

next move 

Example: 

Physical Act Code 

• Calculated Value: These values are derived by calculation from other data 

obtained. Example: Day of the week may be calculated from Date. 

Example: 

Tuesday 

 Graphics: Examples: layout of yard, layout of incident geometry 

Example: 

• Narrative text 

 Example 

• Rating Scale 

 Example 

Rating 

Scale 

1= 

Extremely 

Important 

2 = 

Very Important 

3 = 

Moderately 

Important 

4 = 

Applicable but 

neither 

important nor 

unimportant 

5 = 

Not Applicable 

Explanation of Stress or Emotional Problem 

Employee spouse disappeared from home previous evening. 

 X 

FE 
5-5 
R-1/R-2 

REFERENCES

Reason, J., (1990) Human Error. NY, Cambridge University Press. 

Reason, J., (1997) Managing the Risks of Organizational Accidents, Aldershot, 

England, Ashgate. 
A: Origin of SOFA Working Group 

B: SOFA Working Group Membership and Affiliation 

C: Definitions of Possible Contributing Factors (PCFs); and 

Activity, Event, and Location Codes 

D: Frequency of Possible Contributing Factors (PCFs) and Pairs of PCFs 

E: Working Version of SOFA Matrix (Full SOFA Matrix appears in Appendix II)*

F: Recommendation Summary by FE

G: Data Format for Recommendation for Incident Investigation 

* Note: Appendix II, with supporting data, to be issued by December 1999.

APPENDIX
Origin of SOFA Working Group

Appendix A:
A-1

Appendix A: Origin of SOFA Working Group 

The letter below was sent by George Gavalla, Associate Administrator for Safety, Federal 

Railroad Administration to Charles E. Dettmann, Association of American Railroads (AAR), 

William E. Loftus, President, American Short Line and Regional Railroad Association 

(ASLRRA), Clarence V. Monin, International President, Brotherhood of Locomotive Engineers 

(BLE), and Charles L Little, International President, United Transportation Union (UTU). 

This letter forms the basis for the creation of the Switching Operations Fatality Analysis (SOFA) 

Working Group.

February 1998 

U.S. Department 

Of Transportation 

Federal Railroad 

Administration

Dear Sirs: 

I would like to bring your attention to a serious concern that I have with respect to train and 

engine service (T&E) employee fatalities. The Federal Railroad Administration (FRA) recently 

conducted a preliminary review of all T&E employee fatalities for a six year period beginning in 

1992. We found that 66 T&E employees were fatally injured in incidents other than major train 

collisions. These fatal train incidents typically occurred in yards and terminals when the T&E 

employee was struck by, fell from, or run over by equipment. Unlike major train collisions, the 

root cause of these incidents, as well as any appropriate corrective action, is often far more 

difficult to determine. 

As in the past, we need your help if we are going to reduce and eliminate these fatal train 

incidents. I believe that a task force consisting of representatives from labor, management, and 

FRA should be formed to find a way to prevent these tragic occurrences. The team will conduct a 

detailed fact finding and review and analysis of these incidents to determine whether trends or 

patterns can be found, identify best practices, and, if possible, formulate recommendations for 

the entire industry based on the findings. 

The process is very similar to the highly successful approach utilized by the joint labor and 

management Roadway Worker Protection Task Force to analyze roadway worker fatalities and 

injuries prior to the first formal negotiated rulemaking committee meeting. However, unlike that 

task force, the findings and recommendations from this team are neither intended to be used in a 

rulemaking process not to otherwise lead to formal action by FRA. Rather, railroads will be able 

to evaluate the team’s findings and recommendations with respect to their individual operating 

requirements and would, through the Safety Assurance and Compliance program process, be 

encouraged to implement recommendations that would benefit their safety program. 
A-2

I would like to invite you or your representatives to a planning meeting to discuss the feasibility 

of such an effort and to determine the team make-up. I suggest a meeting at FRA Headquarters, 

1120 Vermont Avenue, N.W., Room 6046, Washington, D.C., on February 10 at 10 a.m. If this 

is inconvenient, please contact my office at (202) 632-3310. I will be glad to arrange for an 

alternate date and time or perhaps set up a conference call at a mutually convenient time. 

Sincerely, 

George Gavalla 

Acting Associate Administrator 

 for Safety 

SOFA Working Group Membership and Affiliation

Appendix B:
Mr. Sam Arrington Mr. Raymond Holmes

Texas State Legislative Director Texas Legislative Board Chairman

United Transportation Union Brotherhood of Locomotive Engineers

Mr. David Brickey Mr. George J. Last

Michigan State Legislative Director Colorado Legislative Board Chairman

United Transportation Union Brotherhood of Locomotive Engineers

Mr. William M. Browder Mr. Thomas J. Perkovich

Director of Operations Minnesota Legislative Board Chairman

Association of American Railroads Brotherhood of Locomotive Engineers

Mr. Michael K. Coplen, Dr. Richard W. Pew

Program Manager, Human Factors Principal Scientist 

Office of Research and Development Human Factors Division

Federal Railroad Administration BBN Technologies/GTE Corporation

Mr. Michael R. Deatherage Mr. Matthew B. Reilly, Jr.

Director Safety and Operating Practices Executive Director, Federal and Industry

RAILTEX American Short Line and Regional Railroad Association

Mr. Charles E. Dettmann Mr. David Skinner

Executive Vice President Economist

Association of American Railroads Human Factors Division

Volpe National Transportation Systems Center

Mr. S. Joseph Gallant Mr. John P. Smullen

Railroad Safety Specialist, Operating Practices Minnesota State Legislative Director

Office of Safety Assurance and Compliance United Transportation Union

Federal Railroad Administration

Mr. Robert A. Harvey

Regulatory Research Coordinator

Brotherhood of Locomotive Engineers

APPENDIX B: SOFA WORKING GROUP MEMBERSHIP AND AFFILIATION
Definitions of PCFs; and Activity, Event, and Location Codes

Appendix C:

Listed below are the new and existing cause codes used by the SOFA Working 

Group to describe the 76 FE incidents studied. The new codes were 

established by the SOFA Group in doing their work. Also listed are the Activity, 

Event, and Location Codes that were used.

New Cause Codes Created by SOFA Groups

H316 Poor intra-crew communication about work in progress 

H317 Failure to communicate unsafe condition 

H318 Poor crew utilization 

H500 Slack action 

H990 Employee on or fouling track 

Note: Event Circumstance Code '99' has been used in connection with H990.

Note: Location Code A4 includes fouling tracks when used in connection with H990.

H996 Insufficient training 

H997 Failure to provide adequate space between equipment 

H998 Employee falling from moving equipment 

M411 Close or no clearance 

Existing FRA Cause Codes (Note: Full verbal definition not given.) *

E02C Broken brake pipe or connections

E09C Other brake defects (cars) 

E24C Center plate disengaged from truck (car of center)

E29C Other body defects (car) 

E34C Draft gear/mechanism broken or defective (including yoke)

E39C Other coupler and draft system defects 

E39L Other coupler or draft system defects (locomotives) 

E67C Damaged flange or tread (build up)

H008 Improper operation of train line air connections (bottling the air)

H018 Failure to properly secure hand brake on car(s) railroad employee

H019 Failure to release hand brakes on car(s) (railroad employee)

H020 Failure to apply sufficient number of hand brakes on car(s) (railroad employee)

H021 Failure to apply handbrakes on car(s) (railroad employee)

H025 Failure to control speed of car using hand brake (railroad employee)

H099 Use of brakes, other 

H101 Impairment of efficiency or judgement because of drugs or alcohol

Appendix C:

Definitions of Possible Contributing Factors (PCFs); and 

Activity, Event, and Location Codes

C-4
H199 Employee physical condition, other 

H207 Hand signal, failure to comply

H210 Radio communication, failure to comply

H211 Radio communication, improper

H212 Radio communication, failure to give/receive

H301 Car(s) shoved out and left out of clear

H303 Derail, failure to apply or remove

H305 Instructions to train/yard crew improper

H306 Shoving movement, absence of a man on or at leading end of movement

H307 Shoving movement, man on or at leading end of movement, failure to control

H310 Failure to couple

H312 Passed couplers

H399 Other general switching rules 

H503 Buffing or slack action excessive, train handling

H599 Other causes relating to train handling or makeup 

H602 Switching movement, excessive speed

H605 Failure to comply with restricted speed

H699 Speed, other 

H702 Switch improperly lined

H999 Other train operation/human factors 

M101 Snow, ice, mud, gravel, coal etc. on the track

M199 Other extreme environmental condition 

M302 Highway user inattentiveness

M304 Highway user cited for violation of highway-rail grade crossing traffic laws

M305 Highway user unawareness due to environmental factors (angle of sun, etc.)

M307 Malfunction, improper operation of train activated warning devices

M404 Object or equipment on or fouling the tracks (other than above) not vandalism 

M501 Interference (other the vandalism) with railroad operations by non-railroad employee 

M502 Vandalism of on-track equipment, i e , brakes released 

M504 Failure by non-railroad employee...to control speed of car using hand brake

M599 Other miscellaneous causes 

S012 Radio communication equipment failure

T099 Other roadbed defects

T222 Worn rail

T319 Switch point gapped (between switch point and stock rail)

Note: H301 and H302 were modified to include locomotive(s)

Location Code A5 includes riding or platform between two cars/locomotives.

Location Code B7 means between/within the gauge of the track.

* Taken from FRA Guide for Preparing Accident/Incident Reports (DOT/FRA/RRS-22)

C-5
Event Codes Used by SOFA Group 

17-collision, on track equip

18-collision with motor vehicle

20-defective/malfunctionioning equip

21-drailment

34-lost balance

35-missed handhold, grabiron, step, etc.

39-pushed/shoved into/against

42-ran into on-track equip

50-slack action, draft, compressive buff/coupling

58-struck by object

59-struck by on-track equip

61-struck against object

64-sudden/unexpected movement of equip

99-other 

Location Codes Used by SOFA Group 

A1-near equip

A3-beside track

A4-between tracks

A5-between cars

A6-on/in loc

A7-in car

B6-side of car

B7-on track

B8-end of car

C6-on loc

X9-near pit

Activity Codes Used by SOFA Group 

01-adj. coupler

02-adjust drawbar

13-coupling air hose

16-crossing between

22-flagging

C-6
24-getting on

25-getting off

39-installing

45-lining switches

50-adj. angle cock

51-operating

58-riding

C-7
Appendix D:

Frequency of PCFs; and Pairs of PCFs
* frequency of PCFs that occur three or more in SOFA matrix.

** frequency of pairs of PCFs that occur three or more time in SOFA matrix.

freq * freq **

H990 33 H990 H211 5

H316 11 H990 H316 5

H399 10 H990 H399 5

H997 10

M411 8

H305 7 H990 H997 4

H306 7

H998 7

H018 6 H399 T099 3

H211 6 H211 H316 3

H996 6

M101 5

H021 4

H310 4

H318 4

H605 4

H999 4

E29C 3

H210 3

H307 3

H312 3

H599 3

H702 3

M302 3

T099 3

Appendix D: 

PCFs Pairs of PCFs

Frequency of Possible Contributing Factors (PCFs) and Pairs of PCFs

D-1/D-2
Working Version of SOFA Matrix

Note: Full SOFA Matrix appears in Appendix II. 

Appendix E:
Appendix E: 

Working Version of SOFA Matrix

Event Code 21 -- derailments -- 6 of 76 FEs (about 8%)

number of FE type

report #

event code

location

FE between equip

activity

line of road

date

day

light

years of service

result of train move

movement type

struck by own equip

crew size

struck by other crew

1 FE-03-94 21 A4-between tracks no 62-standing yard 01/14/94 fri day 36 yes pulled no 3 ye

2 FE-20-94 21 A7-in car no 60-sitting line 09/20/94 tues day 20 yes shoved no 3 no 

3 FE-27-93 21 B8-end of car no 58-riding other 08/04/93 wed day 18 yes shoved yes 3 no 

4 FE-40-93 21 B6-side of car no 58-riding-lead siding 10/19/93 tues night 2 yes shoved yes 3 no 

5 FE-53-93 21 B6-side of car no 58-riding-lead industrial 12/30/93 thurs day 38 yes shoved yes 3 no 

6 FE-08-92 21 A1-near equip no 58-riding-lead yard 03/11/92 wed night 16 yes shoved yes 2 no 
Appendix E: 

Working Version of SOFA Matrix

Event Code 21 -- derailments -- 6 of 76 FEs (about 8%), Jan. 1, 1999 to July 1, 1998

number of FE type

report #

PCF

other crew cause code

external circumstance

1 FE-03-94 E39C-coupler/draft defects

2 FE-20-94 M302-highway user inattentiveness M305-highway user unawareness due to environm

M304-highway user violations

3 FE-27-93 T222-worn rail

M411-close/no clearanceH998-fell from moving equip

4 FE-40-93 H303-derailer

H996-insufficient trainingH318-poor crew utilization

5 FE-53-93 T099-roadbed defect Others Assisted Crew

M101-snow, ice, etc., on trackH602-switching movement

6 FE-08-92 T319-switch point gapped Track Conditions

E67C-worn tread
Working Version of SOFA Matrix

Event Code 17 -- collisions between on track equip -- 7of 76 FEs (about 9%)

number of FE type

report #

event

location

FE between equip

activity

line of road

date

day

light

years of service

result of train move

movement type

1 FE-16-97 17 B8-end of car yes 58-riding yard 06/06/97 fri night 7 yes shoved 

2 FE-16-95 17 B8-end of car yes 58-riding line 04/06/95 thurs night 7 yes shoved 

3 FE-15-92 17 B8-end of car 58-riding yard 06/01/92 mon day 22 yes free 

4 FE-34-92 17 A4-between tracks yes 62-standing yard 10/23/92 fri day 28 yes shoved 5 FE-39-92 17 A5-between cars yes 62-standing line 11/16/92 mon night 13 yes shoved 

6 FE-16-98 17 C6-on loc no 58-riding-lead yard 06/01/98 mon night 0.83 

7 FE-17-98 17 A4-between tracks yes 2-adjust drawbar yard/industrial 06/05/98 fri day 27 yes shoved 
Working Version of SOFA Matrix

Event Code 17 -- collisions between on track equip -- 7of 76 FEs (about 9%)

number of FE type

report #

PCF

other crew cause code

external circumstance

PCF

1 FE-16-97 H210-radio-failed to comply Radio Failure Clear x-ing

SO12-radio equipment failure

2 FE-16-95 H018-securing brakes H020-insufficient num

H008-improper bottling the airH605-failure to comply with speed

3 FE-15-92 H018-securing brakes H399-switching rules

H317-comm unsafe condition

4 FE-34-92 H997-adequate space between equip Unsafe commonly accepted operational practice5 FE-39-92 H990-fouling track Jammed Knuckle pin Track curve/brok6 FE-16-98 H307-shove-failure to control H021-apply brakes History of track 

H302-cars left foulH996-insufficient training

7 FE-17-98 H990-fouling track No Devise to asst. aligning drawbar 2 Super cusione

H312-passed couplersH310-failure to couple
Working Version of SOFA Matrix

Event Code 64 -- sudden/unexpected movement of on track equip -- 11of 76 FEs (about 15.5%)

number of FE type

report #

event

location

FE between equip

activity

line of road

date

day

light

years of service

result of train move

movement type

struck by own equip

crew size

1 FE-02-94 64 A5-between cars yes 72-walking yard 01/04/94 tues night 20 yes pulled/free yes 3 

2 FE-04-94 64 B8-end of car no 58-riding industrial 01/18/94 tues day 25 yes shoved yes 3 

3 FE-26-94 64 A5-between cars yes 16-crossing between yard 10/17/94 mon day 16 yes shoved yes 3 

4 FE-32-94 64 A5-between cars yes 2-adjust drawbar industrial 12/13/94 tues night 26 yes pulled yes 4 

5 FE-23-93 64 B7-on track no 62-standing yard 06/07/93 mon day 20 yes free yes 4 

6 FE-14-92 64 A5-between cars yes 9-climbing industrial 06/01/92 mon day 29 yes free yes 3 

7 FE-45-97 64 B7-on track yes 50-adj. Angle cock line/industrial 12/26/97 fri night 32 yes shoved yes 3 

8 FE-25-97 64 A5-between cars yes 2-adjust drawbar yard 08/15/97 fri night 28 no free yes 3 

9 FE-05-98 64 A4-between tracks no 62-standing yard 02/04/98 wed day 23 no free no 3 

# FE-15-98 64 B7-on track yes 2-adjust drawbar yard 05/26/98 tues day 36 no free yes 3 

# FE-24-96 64 A5-between cars yes 01-adj. coupler other 10/07/96 mon night 10.08 yes free yes 3 
Working Version of SOFA Matrix

Event Code 64 -- sudden/unexpected movement of on track equip -- 11of 76 FEs (about 15.5%)

number of FE type

report #

PCF

other crew cause code

external circumstance

PCF

1 FE-02-94 H990-fouling track H997-adequate space betwee

H310-failure to couple

2 FE-04-94 H998-fell from moving equip

H500-

3 FE-26-94 H997-adequate space between equip H599-train handling

H210-radio-failed to comply 

4 FE-32-94 H997-adequate space between equip H990-fouling track5 FE-23-93 H990-fouling track X-car-/llist chng H305-improper instruction

H316-intra-crew communication

6 FE-14-92 H210-radio-failed to comply 

H306-shove-no man on frontH316-intra-crew communication

7 FE-45-97 H990-fouling track Grade x-ing placement

H316-intra-crew communicationH211-radio-improper

8 FE-25-97 H021-apply brakes Yard Track Grade

H990-fouling track

9 FE-05-98 H990-fouling track Track Centerline at 13 feet

M411-close /no clearance

10 FE-15-98 H990-fouling track

H305-improper instructionH021-apply brakesH997-adequate space between equip

11 FE-24-96 H018-securing brakes

E39C-coupler/draft defectsE39L-other coupler or draft defect, locH997-adequate space between equip
Working Version of SOFA Matrix

Event Code 59 -- struck by on track equipment -- 32 of 76 FEs (about 42%)

number of FE type

report #

event

location

FE between equip

activity

line of road

date

day

light

years of service

result of train move

movement type

struck by own equip

crew size

struck by other crew

striking equip within rules

1 FE-17-96 59 B7-on track 62-standing line 07/07/96 sun night 1 yes pulled no 2 yes y

2 FE-09-96 59 A5-between cars yes 01-adj. coupler 03/20/96 wed night 0.3 yes free yes 3 no y

3 FE-04-97 59 B7-on track no 72-walking yard 01/29/97 wed day 28 yes shoved yes 2 no n

4 FE-05-97 59 A3-beside track no 62-standing yard 02/02/97 sun night 27 yes shoved no 3 yes n

5 FE-19-97 59 B7-on track no 72-walking siding 06/24/97 tues night 2.5 yes shoved yes 2 no y

6 FE-22-97 59 B7-on track no 22-flagging line 07/18/97 fri night 7.6 yes pulled no 1 yes y7 FE-02-95 59 B6-side of car no 58-riding industrial 01/11/95 wed night 30 yes shoved yes 3 no y

8 FE-09-95 59 A1-near equip no 72-walking industrial 02/17/95 fri day 29 yes shoved yes 3 no n9 FE-11-95 59 B7-on track yes 39-installing yard 02/24/95 fri day 19 yes free no 4 yes y

10 FE-12-95 59 B7-on track yes 1-adj. coupler line 03/02/95 thurs day 22 yes shoved yes 3 no y

11 FE-17-95 59 B7-on track no 72-walking industrial 03/21/95 fri day 24 yes shoved yes 3 no y

12 FE-18-95 59 A4-between track no 62-standing yard 05/03/95 wed day 32 yes shoved no 3 yes 

13 FE-29-95 59 A5-between cars yes 2-adjust drawbar yard 10/04/95 wed day 0.5 yes free yes 4 no n

14 FE-29-94 59 B7-on track yes 62-standing yard 11/15/94 tues day 38 yes shoved yes 3 no n15 FE-13-93 59 B7-on track no 72-walking line 04/13/93 tues day 16 yes pulled no 3 yes y
Working Version of SOFA Matrix

Event Code 59 -- struck by on track equipment -- 32 of 76 FEs (about 42%)

number of FE type

report #

PCF

other crew cause code

external circumstance

1 FE-17-96 H990-fouling track

H199-other physical condition

2 FE-09-96 H990-fouling track Crew experiance

H021-apply brakes

3 FE-04-97 H211-radio-improper Moved on wrong 

H990-fouling track

4 FE-05-97 H306-shove-no man on front H306-shove no man on front Reading ist5 FE-19-97 H702-switch improperly lined6 FE-22-97 H990-fouling track7 FE-02-95 H998-fell from moving equip

E29C-car defects

8 FE-09-95 H702-switch improperly lined

H990-fouling trackH211-radio-improper

9 FE-11-95 H305-improper instruction Yardmaster H305-improper 

10 FE-12-95 H997-adequate space between equip

H316-intra-crew communication

11 FE-17-95 H990-fouling track H199-other physical condition12 FE-18-95 H990-fouling track H306-shove no man on front Two Radio Chanels Used 13 FE-29-95 H997-adequate space between equip H999-not operation/human factors Green Ground C

H996-insufficient training

14 FE-29-94 H316-intra-crew communication

H605-failure to comply with speed

15 FE-13-93 H990-fouling track EC 24-center plate disengaged from truck (car off cent M307-s
Working Version of SOFA Matrix

number of FE type

report #

event

location

FE between equip

activity

line of road

date

day

light

years of service

result of train move

movement type

struck by own equip

crew size

struck by other crew

striking equip within rules

16 FE-26-93 59 B7-on track yes 13-coupling air hos yard 07/15/93 thurs day 25 yes shoved yes 3 no n

17 FE-30-93 59 B8-end of car 24-getting on industrial 08/11/93 wed day 29 yes shoved yes 5 no n

18 FE-31-93 59 B7-on track no 62-standing siding/industrial ####### thurs day 31 yes shoved no 3 yes n

19 FE-35-93 59 B7-on track yes 16-crossing betwee yard ####### thurs day 24 yes shoved yes 5 no y

20 FE-46-93 59 B6-side of car no 58-riding-lead line/industrial ####### fri night 21 yes shoved yes 3 no n

21 FE-47-93 59 B7-on track yard ####### sat day 1 yes yes 3 no 

22 FE-49-93 59 A4-between track no 25-getting off line/siding ####### sun night 29 yes pulled no 2 yes y

23 FE-03-92 59 B7-on track no 72-walking yard ####### tues night 22 yes hoved/free yes 3 no y24 FE-09-92 59 A1-near equip no 50-adj. angle cock-lead line ####### thurs day 13 yes free yes 3 no n

25 FE-16-92 59 B7-on track no 59-running industrial ####### tues day 23 yes free yes 2 no

26 FE-20-92 59 A4-between track no 72-walking line/siding ####### tues day 12 yes pulled no 2 yes y

27 FE-22-92 59 A4-between track no 72-walking yard ####### sat day 28 yes shoved yes 3 n28 FE-30-92 59 B7-on track yes 13-coupling air hos yard ####### thurs night 13 yes free no 3 yes y

29 FE-36-97 59 A4-between track no 62-standing line/yard ####### tues night 30 yes pulled no 3 yes y30 FE-18-97 59 A1-near equip yes 72-walking yard ####### tues night 28 yes pulled yes 3 no y31 FE-31-96 59 B8-end of car yes 58-riding ####### wed day 26 yes hoved/free yes 3 no

32 FE-30-96 59 A5-between cars yes 58-riding ####### mon night 21 yes pulled yes 3 no y
Working Version of SOFA Matrix

number of FE type

report #

PCF

other crew cause code

external circumstance

16 FE-26-93 H990-fouling track

H998-fell from moving equipH316-intra-crew communicationH211-radio-improper

17 FE-30-93 H316-intra-crew communication H318-poor crew utilization M199-other extreme 

H207-hand signal, failure to complyE29C-other body defects, car

18 FE-31-93 H990-fouling track H306-shove no man on front H317-comm unsafe condition H399-switching 19 FE-35-93 H990-fouling track H999-not operation/human factors

H997-adequate space between equipH312-passed couplers

20 FE-46-93 H021-apply brakes H101-impairment...because of drugs or alcohol

H310-failure to couple

21 FE-47-93 H316-intra-crew communication TM Assisted Crew H399-switching 

H990-fouling track

22 FE-49-93 H990-fouling track H399-other general switching rul T099-other roadbed defects

H399-switching rules

23 FE-03-92 H990-fouling track Heavy Clothing, Hood(s) Radio Conversat

H399-switching rules

24 FE-09-92 H602-switching movement, excessive speed T099-other roadbed defects H399-switching 25 FE-16-92 H018-securing brakes

H990-fouling track

26 FE-20-92 H990-fouling track None Noise from FE's Locos M404-object/equ27 FE-22-92 H990-fouling track Engineer didn't change ends Hand Switch Co28 FE-30-92 H990-fouling track H305-improper instruction Improper mingeling of crews members No on-going job 

M599-other misc. causes

29 FE-36-97 H990-fouling track None30 FE-18-97 H019-failure to release hand brakes

H990-fouling track

31 FE-31-96 H018-securing brakes Cold Temp

H307-shove, failure to controlE02C-broken brake pipe or connections

32 FE-30-96 H998-fell from moving equip

H101-drugs, alcohol
Working Version of SOFA Matrix

Misc. Event Codes -- other types of FEs -- 20 of 76 FEs (about 26%)

number of FE type

report #

event

location

FE between equip

activity

line of road

date

day

light

years of service

result of train move

movement type

struck by own equip

crew size

tk bth

1 FE-12-96 39-pushed/shoved into/again A1-near equip no 62-standing 06/15/96 wed day 1 yes shoved yes 3 n

1 FE-22-96 42-ran into on-track equip B8-end of car no 62-standing 09/03/96 tues day 0.1 yes free no 3 n

2 FE-31-94 42-ran into on-track equip A7-in car no 58-riding yard 12/06/94 tues night 0.2 yes shoved no 3 n
Working Version of SOFA Matrix

Misc. Event Codes -- other types of FEs -- 20code

number of FE type

report #

PCF

other crew cause code

external circumstance

PCF

1 FE-12-96H599-train handling

M411-close/no clearance

1 FE-22-96H018-securing brakes Failure to test HB

E09C-other brake defect, carsH996-insufficient training

2 FE-31-94H318-poor crew utilization

H211-radio improperH307-shoved-failure to controlH605-failure to comply with speedH212-radio, failure to give/receiveH303-derailerH699-speed, other
Working Version of SOFA Matrix

number of FE type

report #

event

location

FE between equip

activity

line of road

date

day

light

years of service

result of train move

movement type

struck by own equip

crew size

tk bth

1 FE-34-95 61-struck against object B6-side of car no 58-riding yard 12/14/95 thurs night 33 yes shoved yes 3 n

2 FE-12-94 61-struck against object B6-side of car no 58-riding-trailing 04/12/94 tues day 37 yes pulled yes 3 n

1 FE-11-93 58-struck by object B8-end of car no 58-riding yard 03/27/93 sat day 19 yes pulled yes 4 n

2 FE-02-98 58-struck by object A3-beside trackno 45-lining switche yard 01/24/98 sat day 26 yes pulled no 3 n

1 FE-23-95 99-other (describe in narrativA5-between caryes 58-riding industrial 07/21/95 fri day 40 yes pulled yes 3 n

2 FE-33-95 99-other (describe in narrativA1-near equip no 62-standing industrial 12/11/95 mon night 32 yes pulled yes 3 n

3 FE-06-94 99-other (describe in narrativB6-side of car no 58-riding-trailing yard 01/20/94 thurs night 16 yes free no 3 n4 FE-16-94 99-other (describe in narrativA5-between caryes 51-operating industrial 07/05/94 tues day 35 yes free yes 3 n

5 FE-19-98 99-other (describe in narrativB6-side of car no 58-riding industrial 07/01/98 wed night 30 yes pulled 3 n
Working Version of SOFA Matrix

number of FE type

report #

PCF

other crew cause code

external circumstance

PCF

1 FE-34-95M502-improper placement of cars

M404-object/equip fouling track

2 FE-12-94M411-close/no clearance1 FE-11-93H990-fouling track M101-snow, ice, etc., on traH019-failure to release hand b

2 FE-02-98H605-failure to comply with speed H399-switching rules H305-improper instruction

H399-switching rulesH702-switch improperly linedH101-drugs, alcohol

1 FE-23-95H998-fell from moving equip ECC 34-2 FE-33-95M101-snow, ice, etc., on track

H990-fouling trackM411-close/no clearance

3 FE-06-94M411-close/no clearance H301-car shoved out and left...

H318-poor crew utilization

4 FE-16-94H025-failure to control speed H099-roadbed defect

H599-other causes, train makeup or handling

5 FE-19-98H316-intra-crew communication Illegal Handrail

M411-close/no clearance
Working Version of SOFA Matrix

number of FE type

report #

event

location

FE between equip

activity

line of road

date

day

light

years of service

result of train move

movement type

struck by own equip

crew size

tk bth

1 FE-32-97 34-lost balance A5-between caryes 58-riding yard 10/16/97 thurs night 0.8 yes shoved yes 3 n

2 FE-22-93 34-lost balance A6-on/in loc no 62-standing line 06/04/93 fri night 6 yes pulled no 2 n

1 FE-04-92 35-missed handhold, grabiron, step,C6-on loc no 24-getting on-trailingyard/industrial 01/30/92 thurs day 0.5 yes pulled yes 3 n

1 FE-02-97 50-slack action, draft, compressive B6-side of car no 58-riding-lead siding 01/12/97 sun night 35 yes shoved yes 3 n

1 FE-18-92 20-defective/malfunctionioning ewuB7-on track yes 2-adjust drawbar 06/20/92 sat day 15 yes free yes 3 n

1 FE-20-93 18-collision with motor vehicA1-near equip no 62-standing 05/22/93 sat day 27 no no 3 y1 FE-28-94 9-compressed X9-fell in pit 99-other industrial 11/10/94 thurs night 0.5 3 

2 FE-33-92 9-compressed X9 no 99-other industrial 10/15/92 thurs night 14 no no 3 n
Working Version of SOFA Matrix

number of FE type

report #

PCF

other crew cause code

external circumstance

PCF

1 FE-32-97E29C-car defects Moving Equipment

H998-fell from moving equip

2 FE-22-93H599-other causes, train makeup or handling1 FE-04-92H316-intra-crew communication Board/disbaord wrong side H996-insufficient training1 FE-02-97H503-slack action excessive Unfam w/territory1 FE-18-92H997-adequate space between equip M411-close/no clearance Use of wood chalks & decendin

H310-failure to coupleH312-passed couplers

1 FE-20-93M302-highway user

M501-interference with rr operations

1 FE-28-94H996-insufficient training M504-failure non rr employee

H999-other train/human factors

2 FE-33-92M999-

M101-snow, ice, etc., on track
Recommendation Summary by FE

Appendix F:
Appendix F: Recommendation Summary by FE

Recommendation #: 12345

# Report # Date RR State

1 FE-03-92 01/28/92 BN MN

2 FE-04-92 01/30/92 AGC FL X

3 FE-08-92 03/11/92 FEC FL X

4 FE-09-92 04/09/92 ATSF AZ

5 FE-14-92 06/01/92 ATSF CA X

6 FE-15-92 06/01/92 BN WA

7 FE-16-92 06/02/92 IHRC KY

8 FE-18-92 06/20/92 CNW IL X

9 FE-20-92 07/07/92 SSW TX

10 FE-22-92 07/25/92 UP OR

11 FE-30-92 07/24/92 GBW WI X X

12 FE-33-92 10/15/92 BN NE

13 FE-34-92 10/23/92 GTW MI

14 FE-39-92 11/16/92 TTIS KY

15 FE-11-93 03/27/93 SP CA

16 FE-13-93 04/13/93 CSX KY

17 FE-20-93 05/22/93 ATSF TX

18 FE-22-93 06/04/93 SEPTA PA

19 FE-23-93 06/07/93 IC KY X

20 FE-26-93 07/15/93 CR IN X

21 FE-27-93 08/04/93 UP OK

22 FE-30-93 08/11/93 SP CA X X

23 FE-31-93 08/12/93 ATSF TX X

24 FE-35-93 09/02/93 ATSF NM

25 FE-40-93 10/19/93 SOO ND

26 FE-46-93 11/12/93 ATSF TX

27 FE-47-93 11/13/93 GC GA X X

28 FE-49-93 12/05/93 SOU GA X

29 FE-53-93 12/30/93 CR OH

F-28
Recommendation #: 12345

# Report # Date RR State

30 FE-02-94 01/04/94 BN NE

31 FE-03-94 01/14/94 BN TX

32 FE-04-94 01/18/94 CSXT GA

33 FE-06-94 01/20/94 UP NE X

34 FE-12-94 04/12/94 SP TX

35 FE-16-94 07/05/94 BN MT

36 FE-20-94 09/20/94 ARR AK

37 FE-26-94 10/17/94 UP LA X

38 FE-28-94 11/10/94 PTRA TX X

39 FE-29-94 11/15/94 CR NY X X

40 FE-31-94 12/06/94 CR NY X XX

41 FE-32-94 12/13/94 UP CA X

42 FE-02-95 01/11/95 CR IN

43 FE-09-95 02/17/95 CR OH X X

44 FE-11-95 02/24/95 ATSF TX X X

45 FE-12-95 03/02/95 NS SC X X

46 FE-16-95 04/06/95 WC WI

47 FE-17-95 03/21/95 SP CA

48 FE-18-95 05/03/95 CSXT IN X

49 FE-23-95 07/21/95 CR PA

50 FE-29-95 10/04/95 CSXT IL X X

51 FE-33-95 12/11/95 NS OH

52 FE-34-95 12/14/95 CSXT NC

F-29
Recommendation #: 12345

# Report # Date RR State

53 FE-09-96 03/20/96 BRC IL X X

54 FE-12-96 06/15/96 CSX NC X

55 FE-17-96 07/07/96 NS IN X

56 FE-22-96 09/03/96 DGNO TX X

57 FE-24-96 10/07/96 UP TX X X

58 FE-30-96 12/16/96 UP IA

59 FE-31-96 12/18/96 IC IL

60 FE-02-97 01/12/97 UP CA

61 FE-04-97 01/29/97 UP IA X

62 FE-05-97 02/02/97 CR IN X

63 FE-16-97 06/06/97 CMRC MI X

64 FE-18-97 06/24/97 UP OR

65 FE-19-97 06/24/97 NS SC

66 FE-22-97 07/18/97 MNCW CT

67 FE-25-97 08/15/97 UP NV X 

68 FE-32-97 10/16/97 MRL MT X

69 FE-36-97 12/02/97 BNSF KS

70 FE-45-97 12/26/97 UP ID X

71 FE-02-98 01/24/98 BNSF NE

72 FE-05-98 02/04/98 BRC IL X

73 FE-15-98 05/26/98 BRC IL X 

74 FE-16-98 06/01/98 BNSF TX X X

75 FE-17-98 06/05/98 NS GA X

76 FE-19-98 07/01/98 NS KY

Recommendation #: 12345

TOTALS 11 9 8 10 12

50 FEs cited. Because of multiple referencing 37, or 49%, of FEs have a Recommendation applying.

F-30
Appendix G:

Data Format for Recommendation for Incident Investigation 

` 

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Appendix G: Data Format for Recommendations for Incident Investigation 

In the body of this report we have presented recommendations for new data collection items that are 

recommended to be included in future versions of the fatal accident collection protocol. We have also 

recommended that data collection should be computer supported, reducing the labor associated with data entry 

and improving accuracy by entering the data in the data base directly at the source where it is collected. The 

following data field descriptors are provided in a format that is suitable for computer implementation, but they 

could also be used in equivalent paper forms. Sample formats in which data items would be presented are shown 

in Section 5.2.5. 

In the elaboration of data field descriptions below, each data field will be classified according to data type, and 

where a small set of menu items are requested, the set of alternatives will be proposed. Where necessary, notes 

will be appended to provide guidance to understand the intent of the field. The references to Code Appendices 

are taken from FRA Guide for Preparing Incident/Incident Reports, DOT/FRA/RRS-22, January 1997. 

Background Data 

1. Field: Report Number 

Type: Alpha 

Comment: In the historical data set the report number has been constructed from the serial number of the 

incident within a specific year and the year of the incident. For example FE 13-98. 

2. Field: Name of the approver of this report 

Type: Alpha 

Comment: The person who signed off on the report. 

3. Field: Date of Sign-off 

Type: Alpha 

4. Field: Date 

Type: Alpha 

Comment: Date of the incident. 

5. Field: Incident Category 

Type: Alpha 

Comment: All these incidents will be classified as switching operations incidents, but it needs to be coded for 

comparison with other FRA data 

6. Field: Railroad 

Type: Alpha 

Comment: Name of the Railroad whose employee was killed 

7. Field: city, town, village or other jurisdiction 

Type: Alpha 

Comment: Nearest city to where the incident happened. If it was not near a city, town, or a village, a township or 

county should be provided 

8. Field: Day of the Week when the incident happened 

Type: Calculated value 

Comment: Calculated from the date of the incident. 
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9. Field: Time 

Type: Alpha 

Comment: The time at which the incident happened that caused the fatality. 

Weather/Visibility/Ground Conditions 

10. Field: Weather 

Type: Menu: Clear, Overcast, Partly-Cloudy, Raining, Drizzle, Snowing, Freezing Rain, Fog, Dust 

Comment: 

11. Field: Temperature: 

Type: Alpha 

Comment: In degrees Fahrenheit at the time of the incident 

12. Field: Wind direction 

Type: Menu : N, NE, E, SE, S, SW, W, NW 

Comment: 

13. Field: Wind speed 

Type: Alpha 

Comment: In miles per hour 

14. Field: Humidity 

Type: Alpha 

Comment: Units to be defined 

15. Field: Wind Chill Factor 

Type: Calculated 

Comment: From Temperature, humidity and wind speed 

16. Field: Visibility 

Type: Menu: Good, Fair, Poor 

Comment: The reason for the visibility condition is contained in the weather reported above. 

17. Field: Lighting Conditions 

Type: Menu: Daylight, Dawn/Dusk, Night – no artificial lights, Night – artificial lights. 

Comment: 

18. Field: Ground Conditions 

Type: Menu: wet, snow, wet snow, Frost, Ice, Muddy 

Comment: This field is to be used together with the footing conditions associated with the site description Item 19 

19. Field: Footing Conditions 

Type: Menu: Walkway, grass, main-line ballast, walking ballast, Uneven walkway, debris 

Comment: Move to Site Section 

FE Personal Data 

20. Field: Date of birth 

Type: Alpha 
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 G-3

Comment: 

21. Field: Gender 

Type: Menu: Male, Female 

Comment: 

22. Field: Length of Service 

Type: Alpha 

Comment: Time with this particular railroad 

23. Field: FE Job Code 

Type: Code: see Appendix D of Accident/Incident Report Guide 

Comment: Enter the job code for the FE’s regular work assignment 

24. Field: Job Code of assignment at time of incident 

Type: Code: report Same or See Appendix D of Accident/Incident Report Guide 

Comment: If the FE was working a different assignment at the time of the incident, enter that job code here. 

25. Field: Type of assignment 

Type: Menu: Regular, Extraboard 

Comment: At the time of the incident was the FE working a regular shift or on Extraboard? 

26. Field: Length of time in occupation 

Type: Alpha 

Comment: Length of time in the Regularly assigned job code above, not necessarily the assignment at the time of 

the incident. 

27. Field: Number of Months since last rules training 

Type: Alpha 

Comment: 

28. Field: Number of months since last formal safety training 

Type: Alpha 

Comment: 

29. Field: Was a safety briefing held on the day of the incident? 

Type: Checkbox 

Comment: 

Work/Rest/Fatigue Issues 

30. Field: Time Start Job 

Type: Alpha 

Comment: Investigator should collect these data from employee records for each of the last 30 days before the 

incident, including the day of the incident. This information and the next field can be codified into an easy-torecord tabular format. See Appendix B to this document for example. 

31. Field: Time End Job 

Type: Alpha 

Comment: Investigator should collect these data from employee records for each of the last 30 days before the 

incident 
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32. Field: Expected call time 

Type: Alpha 

Comment: This field is applicable to all employees. 

33. Field: Actual call time 

Type: Alpha 

Comment: This field is applicable to all employees. 

34. Field: Hours awake before reporting on day of incident 

Type: Alpha 

Comment: This information may be available from interviews with spouse or colleagues on the job 

Personal Issues 

35. Field: Did the fatality display any identifiable stress or emotional problems 

Type: Checkbox 

Comment: (for example, drugs, alcohol, family) If yes, provide narrative explanation 

36. Field: Explanation of stress or emotional problem 

Type: Narrative 

Comment: Provide if answer is yes to previous question 

37. Field: Was the fatality taking prescription medication? 

Type: Checkbox 

Comment: The time period on or just before the day of the incident is of interest. 

38. Field: Result of drug/alcohol testing 

Type: Alpha 

Comment: Report BAC or Drug test result 

Personal Protective Equipment 

39. Field: What Personal Protective Equipment was the FE required to wear? 

Type: Menu: N/A, Hearing protection, Eye protection, Footwear, Hard hat, Hard hat liner or other hood, Hand 

Protection, Safety Visibility Vest

Comment: Check all that apply. 

40. Field: Was the protection in use? 

Type: Menu: N/A, Hearing protection, Eye protection, Footwear, Hard hat, Hard hat liner or other hood, Hand 

Protection, Safety Visibility Vest 

Comment: Check all that apply 

41. Field: Was clothing, footwear or personal equipment contributory to the incident? 

Type: Checkbox 

Comment: If yes, answer the next question 

42. Field: What clothing/footwear/personal equipment was involved 

Type: Alpha 

Comment: Answer only if answer to previous question was yes 
` 

 G-5

FE Crew Information 

43. Field: Engine Crew Composition 

Type: Menu Engineer, Fireman 

Comment: Indicate the number of each crew type 

44. Field: Engineer yrs. railroad experience 

Type: Alpha 

Comment: Provide for each engine crew member identified 

45. Field: Engineer yrs. craft experience 

Type: Alpha 

Comment: Provide for each engine crew member identified 

46. Field: Train Crew Composition 

Type: Menu: Conductor , Switchman, Brakeman, Student 

Comment: Indicate the number of each crew type 

47. Field: Conductor yrs. railroad experience 

Type: Alpha 

Comment: Provide for each train crew member identified 

48. Field: Conductor yrs. craft experience 

Type: Alpha 

Comment: Provide for each train crew member identified 

49. Field: Brakeman yrs. railroad experience 

Type: Alpha 

Comment: Provide for each train crew member identified 

50. Field: Brakeman yrs. craft experience 

Type: Alpha 

Comment: Provide for each train crew member identified 

51. Field: Switchman yrs. railroad experience 

Type: Alpha 

Comment: Provide for each train crew member identified 

52. Field: Switchman yrs. craft experience 

Type: Alpha 

Comment: Provide for each train crew member identified 

53. Field: Number of crew members on Ground 

Type: Alpha 

Comment: Provide for each train crew member identified 

54. Field: Number of ground crew actually involved in the move 

Type: Alpha 

Comment: 

55. Field: Were crew member drugs or alcohol contributory to the incident? 
` 

 G-6

Type: Checkbox 

Comment: 

FE Activity at Time of Incident 

56. Field: FE Physical Act 

Type: Code 

Comment: Select from Physical Act Circumstance Codes, FRA Guide Appendix F 

57. Field: FE Event 

Type: Code 

Comment: : Select from Event Circumstance Codes, FRA Guide Appendix F 

58. Field: FE Location 

Type: Code 

Comment: Select from Location Circumstance Codes, FRA Guide Appendix F 

59. Field: Has FE worked this location in the past? 

Type: Checkbox 

Comment: 

60. Field: Was FE familiar with local rules and procedures? 

Type: Checkbox 

Comment: Decide from interviews performed. 

FE Crew Activity 

61. Field: Engineer Physical Act 

Type: Code 

Comment: Select from Physical Act Circumstance Codes, FRA Guide Appendix F 

62. Field: Engineer Event 

Type: Code 

Comment: Select from Event Circumstance Codes, FRA Guide Appendix F 

63. Field: Engineer Location 

Type: Code 

Comment: Select from Location Circumstance Codes, FRA Guide Appendix F 

64. Field: Trainman Physical Act 

Type: Code 

Comment: Select from Physical Act Circumstance Codes, FRA Guide Appendix F 

65. Field: Trainman Event 

Type: Code 

Comment: Select from Event Circumstance Codes, FRA Guide Appendix F 

66. Field: Trainman Location 

Type: Code 

Comment: Select from Location Circumstance Codes, FRA Guide Appendix F Repeat this series of three entries 

for each member of the FE Crew 
` 

 G-7

67. Field: FE Crew’s anticipated next move 

Type: Menu: Spot, Couple, Uncouple, Stop, Shove, Begin movement, Other 

Comment: This field is useful to help understand potential sources of attention distraction. 

68. Field: External or unusual circumstances 

Type: Narrative 

Comment: In this field put information that is relevant but does not fit the other categories. For example, Handswitch confusion, Jammed knuckle, Illegal handrail. 

Other Involved Crew 

69. Field: Was another crew involved in the incident? 

Type: Checkbox 

Comment: If answer is yes, then fill in information below about that crew 

70. Field: Engine Crew Composition 

Type: Menu Engineer, Fireman 

Comment: Indicate the number of each crew type 

71. Field: Train Crew Composition 

Type: Menu: Conductor , Switchman, Brakeman, Student 

Comment: Indicate the number of each crew type 

72. Field: Number of Crew members on Ground 

Type: Alpha 

Comment: 

73. Field: Number of ground crew actually involved in the move 

Type: Alpha 

Comment: 

Experience of Other Relevant Employees 

74. Field: Yardmaster yrs. railroad experience 

Type: Alpha 

Comment: 

75. Field: Yardmaster yrs. craft experience 

Type: Alpha 

Comment: 

76. Field: Dispatcher yrs. railroad experience 

Type: Alpha 

Comment: 

77. Field: Dispatcher yrs. craft experience 

Type: Alpha 

Comment: 

Site Information 

78. Field: Track Type 
` 

 G-8

Type: Menu: Line of Road, Siding, Hump Yard, Flat Yard, Industrial, Industrial Spot, Stub Track, Storage, Repair, 

Cleaning, Inspection, Other 

Comment: If Hump yard, Flat yard or Industrial Spot, fill in next appropriate field 

79. Field: If Hump or Flat Yard, describe type 

Type: Menu: Lead , Receiving/Departure , Classification, Repair, Storage, Service, Inspection, Other 

Comment: 

80. Field: If Industrial spot describe type 

Type: Menu: Inside, Outside 

Comment: 

Equipment Movement Perspectives 

81. Field: Was fatality a result of train, rail car or engine movement? 

Type: Checkbox 

Comment: If answer is yes, then fill in the following items 

82. Field: Authority for Movement 

Type: Menu: Dispatcher, Yardmaster, Conductor/Engine Foreman, Trainmaster, Other 

Comment: Person who authorized or requested making the movement 

83. Field: Speed of movement 

Type: Alpha 

Comment: If movement speed was unknown, enter 1 mph. 

84. Field: Was employee struck by own crew’ equipment or that of another crew 

Type: Menu: Own Crew, Other crew 

Comment: 

85. Field: What was the nature of the movement? 

Type: Menu: Pull, shove, free-running 

Comment: 

86. Field: Where on the locomotive/equipment was the FE riding? 

Type: Menu: Side –leading end, Side-Trailing end, end 

Comment: 

87. Field: Were there other movements in the immediate area on same track 

Type: Checkbox 

Comment: 

88. Field: Were there other movements in the immediate area on adjacent tracks 

Type: Checkbox 

Comment: 

89. Field: Was locomotive/equipment operating in accordance with rules? 

Type: Checkbox 

Comment: 
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 G-9

Communications Issues 

90. Field: Type of signaling in use 

Type: Menu: Hand signals, radio signals, none 

Comment: If either hand signals or radio signals were in use, answer the sections below that apply. 

If hand signals used, fill in the following fields

91. Field: Type of Hand Signals 

Type: Menu: unaided hands, Fusee, railroad lantern, flashlight or other individual light, unaided hands under 

lights 

Comment: 

92. Field: Were employees on the lookout for signals? 

Type: Checkbox 

Comment: 

93. Field: Did employees comply with the intent of the signals? 

Type: Checkbox 

Comment: 

94. Field: Did employees act on any signal that they did not understand or that may have been intended for other trains or 

engines? 

Type: Checkbox 

Comment: 

95. Field: Was the proper signal (stop, proceed, back up) given? 

Type: Checkbox 

Comment: 

96. Field: Did employees use other hand signals that the entire crew understood? 

Type: Checkbox 

Comment: 

97. Field: Were gestures that resembled a hand signal given that resulted in confusion to those acting on them? 

Type: Checkbox 

Comment: 

98. Field: Were the employees giving signals plainly seen? 

Type: Checkbox 

Comment: 

99. Field: Were signals given clearly so they could be understood? 

Type: Checkbox 

Comment: 

100. Field: Were signals given on the engineer's side of the track when practical? 

Type: Checkbox 

Comment: 

101. Field: Did the movement stop, in accordance with railroad operating rules 

Type: Checkbox 

Comment: 
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 G-10

102. Field: If a light was being used, under the same circumstances did the movement stop after the disappearance of the 

light? 

Type: Checkbox 

Comment: 

If Radio signals used, fill in the following fields

103. Field: Type of Radio Used 

Type: Menu: Handset, Chestpack, Remote microphone, Waist/belt pack, Locomotive mounted 

Comment: 

104. Field: Was the radio used when hand signals could have been used instead? 

Type: Checkbox 

Comment: 

105. Field: Did the employees know which moves were to be made by radio comm.? 

Type: Checkbox 

Comment: 

106. Field: Did the employees understand that while using the radio, the engineer will not accept any hand signals, unless it is 

a Stop signal. 

Type: Checkbox 

Comment: 

107. Field: Were specific instructions given for each movement? 

Type: Checkbox 

Comment: 

108. Field: Did the employees respond to those specific instructions? 

Type: Checkbox 

Comment: 

109. Field: Was there a mixture of hand and radio signals used? 

Type: Checkbox 

Comment: 

110. Field: If the movement involved backing or shoving, did the radio communication specify the direction and distance? 

Type: Checkbox 

Comment: 

111. Field: Was the direction & distance acknowledged if that distance was more than four car lengths? 

Type: Checkbox 

Comment: 

112. Field: Did the employees listen to make sure the channel was not being used? 

Type: Checkbox 

Comment: 

113. Field: Did the employees give the required identification? 

Type: Checkbox 

Comment: 
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 G-11

114. Field: Did the employee continue to proceed, though acknowledgement was not received? 

Type: Checkbox 

Comment: 

115. Field: Was proper identification a factor in the incident? 

Type: Checkbox 

Comment: 

116. Field: Was the use of or the absence of "over" and "out" an incident factor? 

Type: Checkbox 

Comment: 

117. Field: Did employees act on an incomplete or misunderstood radio comm.? 

Type: Checkbox 

Comment: 

118. Field: Did employees acknowledge radio calls immediately? 

Type: Checkbox 

Comment: 

119. Field: Was the movement stopped within half the distance specified when additional instructions were not received? 

Type: Checkbox 

Comment: 

120. Field: Was the radio tested by crew at some point preceding the incident? 

Type: Checkbox 

Comment: 

121. Field: Did radio malfunction any time b/4 incident and still used in service? 

Type: Checkbox 

Comment: 

122. Field: Were there other radio communications that interfered with transmission? 

Type: Checkbox 

Comments: 

123. Field: Was radio on and tuned to proper channel? 

Type: Checkbox 

Comment: 

124. Field: Were proper radio procedures utilized? 

Type: Checkbox 

Comment: 

125. Field: Was transmission/reception clear ? 

Type: Checkbox 

Comment: 

126. Field: Was radio continuously operable ? 

Type: Checkbox 

Comment: 

Emergency Response 

127. Field: Were Railroad emergency response procedures followed? 

Type: Checkbox 
` 

 G-12

Comment: Each railroad has its own emergency response procedures 

128. Field: Time of call to EMS 

Type: Alpha 

Comment: 

129. Field Time of EMS arrival on the scene of the incident 

Type: Alpha 

Comment: 

130. Field: Distance, in miles, EMS traveled to reach the scene 

Type Alpha 

Comment: This should be the distance traveled from the EMS equipment location at the time of the call to the site 

location 

131. Field: Available reports 

Type: Menu: Autopsy, Coroner, Police, Fire, Other 

Comment: If other, please specify 

Importance of Possible Contributing Factors 

After the investigator has collected all the relevant factual information available and has completed the 

investigative phase of the evaluation, we recommend the following Fields be filled out. The definitions of the 

Possible Contributing Factors that are to be rated in Fields 132-141 are listed in Table 3-1 in Section 3.

132. Field: Physical Characteristics of the Rolling Stock 

Type: Rating Scale 

Comment: Please rate the importance of this possible contributing factor to the occurrence this incident 

using the following scale: 1= Extremely Important, 2 = Very Important, 3 = Moderately Important, 4 = 

Applicable but neither important nor unimportant, 5 = Not Applicable. The definition of the category is 

given in Table 3-1 of this document. 

133. Field Track or Equipment Maintenance 

Type: Rating Scale 

Comment: Please rate the importance of this possible contributing factor to the occurrence this incident 

using the following scale: 1= Extremely Important, 2 = Very Important, 3 = Moderately Important, 4 = 

Applicable but neither important nor unimportant, 5 = Not Applicable. The definition of the category is 

given in Table 3-1 of this document. 

134. Field: Worksite Configuration 

Type: Rating Scale 

Comment: Please rate the importance of this possible contributing factor to the occurrence this incident 

using the following scale: 1= Extremely Important, 2 = Very Important, 3 = Moderately Important, 4 = 

Applicable but neither important nor unimportant, 5 = Not Applicable. The definition of the category is 

given in Table 3-1 of this document. 

135. Field: Sudden or Unexpected Movement of On-Track Equipment 

Type: Rating Scale 
` 

 G-13

Comment: Please rate the importance of this possible contributing factor to the occurrence this incident 

using the following scale: 1= Extremely Important, 2 = Very Important, 3 = Moderately Important, 4 = 

Applicable but neither important nor unimportant, 5 = Not Applicable. The definition of the category is 

given in Table 3-1 of this document. 

136. Field: Crew Utilization 

Type: Rating Scale 

Comment: Please rate the importance of this possible contributing factor to the occurrence this incident 

using the following scale: 1= Extremely Important, 2 = Very Important, 3 = Moderately Important, 4 = 

Applicable but neither important nor unimportant, 5 = Not Applicable. The definition of the category is 

given in Table 3-1 of this document. 

137. Field: Operating or Safety Rule Integral to Incident 

Type: Rating Scale 

Comment: Please rate the importance of this possible contributing factor to the occurrence this incident 

using the following scale: 1= Extremely Important, 2 = Very Important, 3 = Moderately Important, 4 = 

Applicable but neither important nor unimportant, 5 = Not Applicable. The definition of the category is 

given in Table 3-1 of this document. 

138. Field: Intra-Crew Communication 

Type: Rating Scale 

Comment: Please rate the importance of this possible contributing factor to the occurrence this incident 

using the following scale: 1= Extremely Important, 2 = Very Important, 3 = Moderately Important, 4 = 

Applicable but neither important nor unimportant, 5 = Not Applicable. The definition of the category is 

given in Table 3-1 of this document. 

139. Field: Inter-Crew Communication 

Type: Rating Scale 

Comment: Please rate the importance of this possible contributing factor to the occurrence this incident 

using the following scale: 1= Extremely Important, 2 = Very Important, 3 = Moderately Important, 4 = 

Applicable but neither important nor unimportant, 5 = Not Applicable. The definition of the category is 

given in Table 3-1 of this document. 

140. Field: Fitness for Duty 

Type: Rating Scale 

Comment: Please rate the importance of this possible contributing factor to the occurrence this incident 

using the following scale: 1= Extremely Important, 2 = Very Important, 3 = Moderately Important, 4 = 

Applicable but neither important nor unimportant, 5 = Not Applicable. The definition of the category is 

given in Table 3-1 of this document. 

141. Field: Training 

Type: Rating Scale 

Comment: Please rate the importance of this possible contributing factor to the occurrence this incident 

using the following scale: 1= Extremely Important, 2 = Very Important, 3 = Moderately Important, 4 = 

Applicable but neither important nor unimportant, 5 = Not Applicable. The definition of the category is 

given in Table 3-1 of this document. 

The Figure below presents an example of how the start and end time for each day of the FE’s work history for the last 30 

days could be drawn graphically in a computer-implemented data entry system. 
` 

 G-14

The first column shows each day in the format in which D-13 means the 13th day before the fatality occurred. The 

D is the day that the fatality actually occurred. Begin the arrow with the Start Time and end the arrow with the 

End Time. See next page for example. In the example only 17 days have been shown. 
` 

1 GWork History and Possible Contributing Factors Summary of the FE’s Work Schedule Start and End Time for Each of Previous 30 Days of 

DATE 12 M 2 AM 3 AM 4 AM 5 AM 6 AM 7 AM 8 AM 9 AM 10 AM 11 AM 12 N 1 PM 2 PM 3 PM 4 PM 5 PM 6 PM D-17 D-16 D-15 D-14 D-13 D-12 D-11 D-10 D-9 D-8 D-7 D-6 D-5 D-4 D-3 D-2 D-1 D 
` 

G-15 

The following contains the definitions of the Possible Contributing Factors that are to be rated in Fields 132-141. 

RAILROAD SWITCHING OPERATIONS 

Possible Contributing Factors 

1. Physical Characteristics of Rolling Stock 

a. Definition: Configuration of physical characteristics of engine, rolling stock, or other on-track 

equipment. 

b. examples: flat car (mounting or dismounting ), offset grab irons 

c. cause codes: E30C, E19C 

2. Work Site Configuration 

a. Definition: Physical characteristics, layout, or configuration of any location at which a train or engine crew is 

expected to perform switching operations. 

b. Examples: yard tracks, sidings, main tracks, industry track work site, etc. 

c. Cause codes: M102, M404, M411. 

3. Operating or Safety Rule Integral to Incident

a. Definition: Possible operating rules or safety infractions that could contribute to an incident.

b. examples: Person absent from leading car, speed violations, individual fouling track or equipment.

c. cause codes: H990

4. Crew Utilization 

a. Definition: Assigned crew members that did not or could not fulfill roles required for safe operations. 

b. examples: inexperienced crewmembers not properly supervised 

c. cause codes: H316, H305 

5. Inter-crew Communication 

a. Definition: Absence or improper exchange of information between crews whose work needed to be 

coordinated. 

b. Examples: Two crews working on same track with no communications. 

c. Cause codes: H399 

6. Intra-crew Communication 

a. Definition: Failure of proper operation which could be due to absence of, or improper, exchange of 

information among crew members by face to face, radio, or hand signals. 

b. Examples: lack of, or no, job briefing; changing work activities without informing other crew members. 

c. Cause codes: H316 

7. Fitness f or Duty 

a. Definition: Personal factors related to train and switching operations such as drugs, alcohol or 

employee physical or mental condition. 

b. Examples: impairment of efficiency or judgement because of drugs or alcohol (H101); employee 

physical condition, other (H199); other personal factors or limitations relating to physical or mental 

 impairment 

c. Cause codes: H199, H101, 

8. Sudden or Unexpected Movement of On-track Equipment 

a. Definition: Unexpected movement of on-track engine, rolling stock, or other off-track equipment 

that affects safety of a crewmember. 

b. examples: free rolling cars or dropping cars on track being coupled. 

c. cause codes: 
` 

G-16 

9. Training 

a. Definition: Failure of proper operations attributed to inadequate classroom, on-the-job general skills, or 

site-specific training or knowledge. 

b. Examples: inadequate classroom training; inexperience in on-the-job skills; inexperience in physical 

characteristics of track or work site. 

c. cause codes: H996 

10. Track or Equipment Maintenance 

a. Definition: Physical condition of track or equipment was below established practices. 

b. Examples: sharp/worn flanges, worn switch points, crossover platforms bent, etc. 

c. Cause codes: E02C, E09C