U.S. Department of 

Transportation

Federal Railroad 

Administration

Defining Characteristics of Intentional Fatalities 

on Railway Rights-of-Way in the United States, 

2007–2010

Office of Research

and Development

Washington, DC 20590

DOT/FRA/ORD-13/25 Final Report

 May 2013
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Defining Characteristics of Intentional Fatalities on Railway Rights-of-Way in the United 

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Michael Martino, Ann Doucette, Ph.D., Stephanie Chase, Ph.D., and Scott Gabree, Ph.D.

COTR: M. Coplen, FRA

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13. ABSTRACT (Maximum 200 words)

This report presents aggregate findings from 55 psychological autopsies of decedents who were identified as an intentional death

(i.e., a suicide) on railroad rights-of-way between October 1, 2007, and September 30, 2010. The goal of this study was to assess 

whether there are unique characteristics of individuals involved in suicides on railroad rights-of-way compared with individuals 

who complete suicide by other means. The aggregate findings show that this sample of suicides on railroad rights-of-way share 

much in common with samples of suicides by other means. Only a few notable unique characteristics were found in the former

population: the cases are more significantly marked by both severe mental disorder and substance abuse, the individuals tend to 

live near railroad tracks, and they are possibly less likely to have access to firearms. Additionally, the majority of these completed 

suicides occurred in urban or suburban areas as opposed to rural areas. The information collected for this effort may provide 

valuable information for the development of countermeasures or other intervention plans to mitigate this issue on railroad rightsof-way.

14. SUBJECT TERMS

Trespassers, Suicide, Safety, Human Factors, Security

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39

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LENGTH (APPROXIMATE) LENGTH (APPROXIMATE)

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

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

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

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

1 kilometer (km) = 0.6 mile (mi)

AREA (APPROXIMATE) AREA (APPROXIMATE)

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

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

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

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

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

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

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

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

1 short ton = 2,000 pounds 

(lb)

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

=

1,000 kilograms (kg)

1.1 short tons

VOLUME (APPROXIMATE) VOLUME (APPROXIMATE)

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

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

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

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

1 pint (pt) = 0.47 liter (l)

1 quart (qt) = 0.96 liter (l)

1 gallon (gal) = 3.8 liters (l)

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

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

TEMPERATURE (EXACT) TEMPERATURE (EXACT)

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

QUICK INCH - CENTIMETER LENGTH CONVERSION

0 1 2 3 4 5

Inches

Centimeters 0 1 2 3 4 5 6 7 8 9 10 11 12 13

QUICK FAHRENHEIT - CELSIUS TEMPERATURE CONVERSION

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°F

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

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iii

Acknowledgements

We would like to acknowledge the American Association of Suicidology (AAS), a 

subcontractor of the Railroad Research Foundation (RRF), for performing all the data 

collection and analysis for this effort. AAS worked closely with railroads and state 

departments across the country to collect as much detailed information as possible for 

this research effort. 

This study would not have been possible without the cooperation of the railroads, the 

American Association of Suicidology, the Association of American Railroads, Operation 

Lifesaver Inc., and many individuals in State departments across the country. 
iv

Contents

1. Introduction ................................................................................................................. 2

1.1 Purpose ........................................................................................................................ 2

1.2 Definitions................................................................................................................... 3

1.3 Background ................................................................................................................. 3

1.4 Psychological Autopsy................................................................................................ 4

2. Methodology................................................................................................................ 6

2.1 Overview ..................................................................................................................... 6

2.2 Case Identification....................................................................................................... 6

2.3 Contacting Informants................................................................................................. 6

2.4 Interview process......................................................................................................... 8

2.5 Investigator Training ................................................................................................... 9

2.6 Methodological Limitations........................................................................................ 9

3. Results....................................................................................................................... 11

3.1 Demographic Characteristics .................................................................................... 11

4. Discussion.................................................................................................................. 21

5. Conclusions............................................................................................................... 24

Abbreviations and Acronyms ....................................................................................................... 31
v

Illustrations

Figure 1. Geographic Distribution of Confirmed Suicides on Railroad Rights-of-Way 

(N = 237) and Study Sample (N = 55).................................................................................. 13

Figure 2. Trespasser Incidents vs. Trespasser Fatalities, ............................................................. 17
vi

Tables

Table 1. Derivation of Study Sample from Total Identified Completed suicides on 

Railroad Rights-of-Way.......................................................................................................... 8

Table 2. Comparison of Gender and Age of Study Population, Confirmed Cases, and U.S. 

Suicides................................................................................................................................. 12
1

Executive Summary

Background

Completed suicides on railroad rights-of-way in the United States are relatively rare 

events; however, the impact on witnesses, discoverers, surviving loved ones, first 

responders, and railroad employees can be significant. In light of the consequences of 

these completed suicides to both the individuals involved and the railroads, identifying 

potential means to prevent these deaths would be beneficial. This study aims to assess 

whether individuals who complete suicide on railroad rights-of-way possess any unique 

characteristics that may help to inform the development of countermeasure or 

intervention strategies. 

Methodology

To collect data about completed suicides on railroad rights-of-way in the United States, 

American Association of Suicidology (AAS) project investigators confirmed the 

determination of suicide as the cause of death; relevant data was gathered from medical 

examiner and coroner rulings and through psychological autopsy interviews with the 

decedents’ next of kin. The psychological autopsy interviews involved a semi-structured 

interview protocol developed specifically for this study. Interviews were held with 165 

next of kin and close friends to obtain information about 55 identified decedents. 

Findings

The final study sample of 55 cases of suicide on the railroad right-of-way was found to be 

very similar to the known information about suicides by other means. Only a few factors

seemed to differ from what would be expected from a suicide by other means. The 

identified decedents were generally found to be below the age of 50 and often had a last 

known address in close proximity to the railroad tracks. They were also more often 

described as having a mental disorder or substance abuse problem or both. Lastly, this 

sample was unlikely to have had access to a firearm. These factors appeared to influence

the individuals’ choice of this method to end his or her life.

Conclusion

Suicides on railroad rights-of-way have not been widely researched in the United States. 

This study revealed that individuals who complete suicide on the railroad rights-of-way 

share characteristics with individuals who complete suicide by other means. However, 

some differences were noted. Suicides on railroad rights-of-way involved higher 

proportions of younger individuals, according to national statistics provided by the 

Centers for Disease Control (CDC). Additionally, overall, decedents tended to have 

limited access to firearms (a more common means for completing suicide) and also 

tended to live near railroad tracks. The information detailed in this report can help in the 

development of a more strategic countermeasure approach. By better understanding the 

interacting characteristics of the individual and site at which these incidents occur,

countermeasures can be developed and implemented in a more effective way.
2

1. Introduction

Trespassers on railroad rights-of-way have long been a serious issue for the railroad 

industry. As of the end of this data collection, the Federal Railroad Administration

(FRA) does not track the number of completed suicides that occur each year; therefore, it 

is believed that a proportion of reported trespasser deaths are intentional (i.e., suicides).

1

When an individual takes his or her life on the railroad right-of-way, the effects on the 

railroad industry and its personnel are immense. By providing a better understanding of 

the characteristics and factors associated with individuals who intentionally choose to end 

their life in this manner, it is hoped that this study will aid in the development of effective 

countermeasures to reduce the frequency of these terrible events.

In a Research Results report by the FRA Office of Research and Development titled 

“Demographic Profile of Intentional Fatalities on Railway Rights-of-Way in the United 

States2,” the researchers reported that a minimum of 25 percent and likely more than 35

percent of all fatalities on the railroad right-of-way are the result of an intentional act. 

They found that at least 268 completed suicides occurred on U.S. railroad rights-of-way 

between June 2006 and May 2007 (compared with 497 FRA reported trespasser fatalities 

during that same timeframe) and at least 428 completed suicides occurred on U.S.

railroad rights-of-way between June 2007 and May 2010 (compared with 1,341 FRA 

reported trespasser fatalities during that same timeframe). The goal of the current report 

is to provide a more comprehensive understanding of the distinguishing factors that 

influence individuals who complete suicide on railroad rights-of-way.

1.1 Purpose

Completed suicides on railroad rights-of-way have not been widely researched in the 

United States. It is unknown whether individuals who complete suicide in this manner 

are uniquely affected by factors that may have little or no influence on individuals who 

complete suicide by other means. If the population of individuals who complete suicide

on railroad rights-of-way is different from those who complete suicide by other means, 

then intervention strategies which specifically target these individuals may need to be 

developed. This study aims to assess whether there are indeed unique characteristics 

influencing or affecting individuals who complete suicide on railroad rights-of-way rather 

than by other means. The results of the study may inform future countermeasure or 

intervention strategies and perhaps dissuade individuals from this course of action. 

 

1 In June 2011 FRA began to require railroads to report trespasser fatalities identified as a 

suicide; however, as of the publication of this document, these numbers are not released 

publicly.

2 Currently in FRA review process for publication
3

1.2 Definitions 

For the purposes of this study, a railroad will be defined as follows using Railway Age’s 

Comprehensive Railroad Dictionary:

1. All forms of non-highway ground transportation that runs on rails, including freight 

transportation using locomotives and freight cars; commuter or other short-haul railpassenger service in metropolitan or suburban areas; high-speed ground 

transportation systems that connect metropolitan areas, without regard to whether 

they use new technologies not associated with traditional railroads. This term does 

not include rapid transit operations within an urban area that are not connected to the 

railroad system of transportation.

2. A system of railroad track including the land, stations, rolling stock, and other 

related property.

The title of this document does not include the term “suicide” and instead states 

“Intentional Fatalities.” This is because existing voluntary media guidelines suggest that 

using the term “suicide” in a headline may actually increase the likelihood of copycat 

incidents.3 Accordingly, members of the media should take heed if considering 

publishing any information included in this report and reference the corresponding media 

guidelines. However, since the term “suicide” is widely used in the past research 

discussed within this paper, and well understood, the term suicide will not be replaced in 

the body of this report.

1.3 Background

This is the first study that focuses on whether there are characteristics, risk factors, and 

warning signs unique to individuals who complete suicide on railroad rights-of-way in 

the United States, in contrast to individuals who complete suicide by other means. 

Previous research on this topic has primarily been conducted outside the United States

(Ladwig & Baumert, 2004; Mishara, 1999). Work conducted within the United States

has been limited to epidemiological or demographic information (Botha, et al., 2010). In 

addition, studies such as the one by Botha, et al. are based primarily on highly urbanized 

railroad systems, with no clear discrimination between freight, commuter, and transit 

lines. While commuter and transit lines are mostly in urban and suburban areas, freight 

tracks also cover rural areas which are known to experience different types of health 

concerns, for example, higher rates of substance abuse and lower likelihood of treatment 

(Eberhardt, Ingram, Mkuc, et al, 2001). These findings highlight key patterns regarding 

completed suicides on each type of track.

 

3 Reporting on Suicide: Recommendations for the Media. Available online at 

http://www.sprc.org/sites/sprc.org/files/library/sreporting.pdf 
4

Although most studies have been conducted only on urbanized stretches of railroad, they

still provide a baseline estimate of the age and gender of the decedents involved in 

railroad right-of-way suicides. A Danish study by Lindekilde and Wang (1985) found 

that 44 percent of those who completed suicide on railroad rights-of-way were between 

15 and 29 years old, while only 11 percent of those who completed suicide by other 

means were in this age group. Kerkhof (2003) noted that in the Netherlands most

suicides on the railway involved men between 20 and 29 years old. And Botha et al.

(2010) found that suicides on the Caltrain commuter rail system were 3.5 times more 

likely among men than women.

The Suicides and Open Verdicts on the Railway Network (SOVRN) Project, 

commissioned in 1999 in the United Kingdom, used data from investigations by coroners 

and case study interviews to identify characteristics of individuals who completed 

suicide on the railroad over a 3-year period (N = 103) (Abbott, Young, Grant, Goward, 

Seaward, & Pugh, 2003). The study found demographic results relatively similar to those 

cited above: the decedents in this study were typically male (the male-to-female ratio is 

approximately 4:1) and half of the decedents were between 16 and 40 years old. In 

addition, this study was able to go beyond basic demographic data to provide information 

about potential risk factors that led to each individual’s suicide and, in some cases,

specific information about the decision to complete this act on the railroad right-of-way. 

Using coronial investigations and psychological autopsies, the SOVRN project was able 

to characterize decedents as being unemployed (37 percent), living alone (25 percent), 

and living with a physical condition (26 percent). Additionally, for whom this 

information could be gathered, 76 percent of the decedents had been diagnosed with a 

mental health condition at the time of death (and 29 percent of those decedents had been 

diagnosed with an additional, secondary mental health condition).

Like the SOVRN project, the current research does not rely solely on coroner and police 

reports to gather information about decedents. The psychological autopsy method used 

in this report allowed researchers to collect information about each decedent that goes 

beyond typical demographic data. A psychological autopsy allows a researcher to obtain 

information about the likely mental and physical state of an individual who dies by 

suicide, as well as the relevant characteristics of their environment and location of death

(Cavenagh, Carson, Sharpe, & Lawrie, 2003).

1.4 Psychological Autopsy

In 1958, Edwin Shneidman, Norman Farberow, and Robert Litman—then directors of the 

Los Angeles Suicide Prevention Center—coined the term “psychological autopsy.” 

These clinician-researchers, working in collaboration with the Los Angeles County 

Medical Examiner’s Office, devised a set of procedures to assist the medical examiner 

(ME) in medico-legal investigations for cases where the ME could not readily determine 

the manner of death (suicide, homicide, accident, or natural). Since then, the 

psychological autopsy has evolved into a systematic “tool” for collecting retrospective 

psychological and related data about a decedent through semi-structured interviews with 

knowledgeable informants (typically family members, friends, and coworkers or 

classmates) and analyses of archived documents and records of the decedent’s life (e.g., 
5

health records, criminal records). Where deaths have clearly been determined to be 

suicides, the psychological autopsy can potentially identify distal (lifetime) and 

proximate (near term) risk factors. (Note: distal and proximate are the terms used by the 

psychological autopsy community). When conducted with trained researchers and a 

standardized protocol, a psychological autopsy has the potential to yield reliable and 

valid data (Kelly & Mann, 1996; Brent, Perper, Mortiz, Allman, Roth, Schweers, & 

Balach, 2007). 

Although data collected from psychological autopsies are seen as useful to researchers, it 

is important to note that the data cannot be objectively validated for several reasons 

(which are detailed in the limitations section of this report). One most obvious limiting 

factor is that the findings cannot be confirmed by the decedent; therefore, the results 

presented in this report will focus primarily on factual information (e.g., employment 

status) and not discuss other more subjective findings (e.g., the victim was acting more 

reckless). For example, a suicide which appeared to be impulsive to one next of kin, may 

have been perceived by another informant as planned; this subjectivity leads to an 

increase in the potential for error in the sample. In the current study, aggregate findings 

from these psychological autopsies were used to provide a basic understanding of modal 

factors within the decedents life and to better understand why suicides occur on railroad 

rights-of-way (in contrast to other available and accessible methods). The study 

discussed in this paper is the first documented psychological autopsy study of suicides on 

the railroad rights-of-way in the United States. 
6

2. Methodology

2.1 Overview

The current study uses a psychological autopsy, which utilizes a semi-structured 

interview approach, to investigate factors associated with an individual who has 

completed suicide. The psychological autopsy is used as a tool to reconstruct a 

decedent’s life in order to understand the causes, mechanisms, and, if undetermined, the 

mode or manner of death. It relies primarily on the identification and cooperation of 

knowledgeable informants, typically next of kin. For the current study, researchers 

developed a specific protocol for collecting data about individuals who complete suicide

on railroad system rights-of-way in the United States. The protocol will be described in 

the following sections. Limitations of the protocol will be discussed in the conclusion of 

this section (section 2.6).

2.2 Case Identification

Four hundred sixty six (466) cases were identified as completed suicides on railroad 

rights-of-way in the United States during the 36-month timeframe of October 1, 2007,

through September 30, 2010. For each of the 466 cases, the representative medical 

examiner or coroner was contacted to verify that the manner of death was determined to 

be a suicide.4 A copy of the decedent’s death certificate was received in 237 (51 percent) 

of the cases. Some discrepancy between suspected suicides and those corroborated by 

medical examiners is not uncommon and is largely due to such issues as differential 

thresholds of interpreting evidence and relationships between law enforcement and 

clinicians (Timmermans, 2005). For each of the 237, an attempt was made to contact the 

decedent’s next of kin and close friends and ask them to participate in this study for the 

purpose of learning more about what factors may have been influential in the completed 

suicide. Contact information was available for 182 of the 237 total cases.

2.3 Contacting Informants

From information contained in the medical examiner or coroner reports, data elements 

were compiled. These elements consist of personal and demographic information about 

the deceased (e.g., home address, age, gender, ethnicity), as well as the date and time, 

manner, and location of the death. This information, along with additional data found 

through public sources (e.g., memorials, social networking sites), was used to identify the 

next of kin and other individuals potentially knowledgeable about the decedent.

To allow time for next of kin, friends, and coworkers of the decedent to move past the 

initial shock of the death being investigated, attempts to recruit them for participation 

occurred after a minimum of 6 months had passed since the death had been ruled a 

 

4 The determination of the manner of death (accident, suicide, homicide, or natural) is made by either a 

medical examiner or coroner. Medical examiners are licensed physicians, often with training in forensic 

pathology, who are appointed to their positions. Coroners are elected officials with no specific medical 

training; they are responsible for completing death certificates. 
7

suicide.5 Initial contact consisted of a packet including a project description and a letter 

of introduction identifying the researcher as the official performer of this Railroad 

Research Foundation and Federal Railroad Administration (RRF and FRA) funded 

research. The project information packet was followed up by a telephone call placed by 

the research team staff to request a face-to-face meeting for the interview. If the next of 

kin agreed to participate, an investigator contacted the next of kin to arrange a meeting.

At the time of consent, the nature of the study and potential risks and benefits were 

discussed. Potential interviewees were given time to ask questions and were offered a 

summary of the research protocol. Interviewees were asked to sign a consent form. 

Interviewers emphasized the message that had been already transmitted in the initial 

telephone contact: that a respondent could stop the interview at any time. Family 

members or friends who were unable to respond to questions regarding the informed 

consent procedure were excluded from the study. To identify additional family and 

friends for interviews, the next of kin were asked if there were any friends, teachers, 

coworkers, or significant others that they felt could provide further information. 

In deciding the number of informants to be interviewed for each case, the project 

followed guidance offered by the U.S. Surgeon General’s National Strategy for Suicide 

Prevention which states that for every suicide, there are six to eight individuals who have 

been closely associated with the decedent (U.S. Department of Health and Human 

Services, 2001). The goal of the current study was to interview up to eight informants 

per case, unless conflicting reports from the first eight informants necessitated additional 

interviews. The selection of informants was based on their presumed knowledge of the 

decedent (using criteria such as proximity, duration, and relationship with decedent) and 

of the events leading up to his or her death. 

Investigators stopped soliciting additional interviews when one of the two scenarios listed 

below occurred. Investigators strived to accomplish the first scenario whenever possible, 

but would resort to the second scenario when necessary:

1. All the questions in the protocol were answered and multiple informants 

corroborated the responses.

2. Discussions with next of kin or other informants revealed no other informants 

who were willing to be interviewed or who had any further information about the 

decedent.

A final sample of 55 cases is included in this report. Table 1 summarizes the process 

leading to the final selection. The final sample was derived from the 466 total identified 

cases of which 237 were confirmed as suicides by autopsy or death certificate. Of the 

237 cases which were determined to be a completed suicide, AAS project staff found

contact information for next of kin in 182 cases. Next of kin in 69 cases agreed to be 

interviewed and interviews were scheduled in 63 of those cases. In 36 of the 182 cases,

the next of kin refused participation and in 77 cases no response was received. Although 

 

5 While progress through the grief process varies by individual, the principal investigator proposed 6

months as a reasonable time to be sensitive to the informants’ grief.
8

63 cases were scheduled, funding constraints allowed only 61 cases to be completed. The 

remaining two cases were cancelled and appropriate outreach was extended to these 

individuals by the AAS project coordinator. Interviews for each case were generally 

conducted over a 2-week period, depending on the respondents’ availability.

Table 1. Derivation of Study Sample from Total Identified Completed Suicides on 

Railroad Rights-of-Way

Description Number

Total identified cases between October 1, 2007, and September 

30, 2010

466

Total confirmed cases 237

Number of cases sent letters 182

Number of cases for which there was no reply 77

Number of potential cases that refused to participate 36

Number who consented 69

Number of cases with scheduled interviews 63

Number of cases interviewed 61

Completed cases that did not meet quality screen of being able 

to answer the research questions outlined in Section 3

6

Final Sample of cases 55

2.4 Interview process

A total of 165 informants provided data, resulting in a mean of 3 informants and a range 

of 2 to 9 informants per case. The maximum time period between the suicide and the 

interview was two years and the minimum was six months. Before conducting the 

interviews, next of kin and other informants were asked to review and sign a consent 

form to indicate that they were aware that the data would be held confidential and that 

they had the right to withdraw from the interview at any time. The nature of the study 

and potential risks and benefits were discussed in greater detail. Next of kin were also 

asked to sign a standard written authorization for AAS project staff to obtain the 

decedent’s health records from healthcare providers. For all the cases, next of kin 

provided this authorization. However, despite authorization, no healthcare providers 

returned calls; therefore, none provided the requested information regarding treatment 

provided to the decedent.

Interviews were conducted by one investigator with each informant individually. When

family members felt strongly that they needed another family member to support them 

through the interview the investigator conducted the interview with both family members, 

however, this did not happen frequently. At the end of each interview, the investigator 
9

provided the informant with support information such as a list of support groups in the 

local area. Of the 165 informants, 29 accepted the contact information for mental health 

therapy or treatment. There was no further follow-up to determine whether the 

informants actually sought help.

The investigator relied on handwritten notes taken during the interview. Investigators 

made every attempt to verify the information provided by the informants by seeking 

corroboration from other informants and asking for evidence where appropriate. The 

investigators’ final assessment for each case was reviewed by the principal investigator 

and research director for quality control. When the assessments were reviewed, it was 

determined that in six cases, the quality of information obtained from the informants was

insufficient to adequately understand the circumstances leading to the suicide, and no 

further informants were available for those cases. All information was maintained by the 

AAS project coordinator with documents identified by ID number and locked in a secure 

area.

2.5 Investigator Training

Investigators were required to have a background in the social sciences (although not all 

were psychologists) and were trained for this study to identify and deal therapeutically 

with any possible negative psychological consequences from the interview. Upon 

selection as an investigator for this project, and before being assigned a case, every 

investigator received 12 hours of training from the principal investigator and research 

director in supportive interviewing techniques. In the training, investigators were 

provided information about psychological autopsy studies, the study methodology, and 

background. They were trained in how to obtain information for each question on the 

semi-structured protocol and were asked to role-play the interview. In addition, when 

half of the cases had been completed, each investigator received 16 hours of updated

training, based on the experience gained through this study, to refine their interviewing 

and data collection skills. During this updated training, investigators built on their 

practical knowledge in responding to commonly encountered challenges and in data 

reporting so as to minimize additional questions during case review with the principal 

investigator and research director.

2.6 Methodological Limitations

Although psychological autopsy is recognized as a “best practice” tool for establishing 

possible causal factors leading to suicides, it is not without known limitations. One 

limitation is the lack of control over the informants chosen for the study. Although 

researchers were able to eliminate informants who were deemed to be untrustworthy or 

not knowledgeable enough about the individual in question, the procedures of the 

psychological autopsy cannot ensure that all informants are equally knowledgeable about 

the decedent or that approximately the same amount of time has passed between the 

decedent’s death and each of the interviews. As such, the depth of knowledge that can be 

obtained about each decedent is likely to vary. As noted earlier, some inconsistency is to 

be expected in the interpretation of the decedent’s thoughts, emotions, and motivations. 

Therefore, we purposefully chose to focus on the more objective information (e.g., 
10

employment, criminal or legal status, etc.) as opposed to estimating the subjective 

information as judged by the informants (e.g., the decedent’s emotional state). 
11

3. Results

The final study sample consists of 55 cases, as shown in Table 1. Each case consists of 

one decedent and a varying number of interviewed informants. In the following section,

demographic characteristics of each decedent are presented, followed by additional 

objective data collected by investigators during the psychological autopsy interviews.

3.1 Demographic Characteristics 

Gender. The final sample of 55 cases was composed of 9 (16 percent) females and 46 

(84 percent) males. This distribution is similar to that of all completed suicide reports on 

the railroad rights-of-way and for U.S. suicides by all means from 2007 to 2010 (see 

Table 2 (χ2 = 0.748, df=1, P>0.05).

Age. The median age of the 55 psychological autopsied cases was 40 years. The 

distribution of ages showed that 18 (33 percent) decedents were under the age of 30, 22 

(40 percent) decedents were between the ages of 31 and 50, and 15 (27 percent) 

decedents were 51 years old or older. In comparison, the age distribution for suicides by 

any means in the United States shows that 31,416 (22 percent) of the decedents are under 

the age of 30 and 58,880 (40 percent) of decedents are 51 years old or older. The sample 

for this study may appear to have fewer older individuals than would be expected, given 

the national statistics noted in Table 2 below; however, a chi square test of significance 

did not reveal a significant difference (χ2 = 5.59, df=2, p>0.05). Additionally, it is worth 

noting that the distribution of ages from the sample of psychological autopsies differed 

from the age distribution of all reported suicides on the railroad right-of-way that 

occurred during the same time frame. Therefore, the appearance of an over representation 

of younger victims found in the psychological autopsied cases is likely to only be an 

artifact of the limited sample size and not a true age bias.

Table 2 shows the distribution of gender and age as a percentage of three different 

groups: first, the sample of 55 cases included in this study; second, the total number of 

completed suicides reported during this study duration; and third, the total number of 

suicides by all means in the United States between January 1, 2007, and December 31, 

2010.

6

 

6 The time period for the suicide by all means comparison group (January 2007–

December 2010) is not the same as either the psychological autopsy case group or the all 

reported rail suicides group (October 2007–September 2010). This is because the CDC 

estimates for suicides by all means are presented as annual numbers.
12

Table 2. Comparison of Gender and Age of Study Population, Confirmed Cases,

and U.S. Suicides

Characteristic

Cases included in 

Psychological 

Autopsy study

10/2007–9/2010

(% of N = 55)

All reported 

suicides identified 

by the study

10/2007–9/2010

(% of N = 466)

U.S. suicides by all 

means 

1/2007–12/2010

(% of N = 145,906)

Male 84 81 79

Female 16 19 21

Age <30 years 33 18 22

Age 31–50 years 40 47 38

Age >50 years 27 35 40

Race. In the initial study sample of 466, only 262 reported race. Of the cases that 

reported race, the majority of the decedents were white, 209 (88 percent). Of the 55 

cases included in this sample 53 (96 percent) were white. Seven percent of the confirmed 

cases and two percent of the autopsied cases were black, and the remainder was 

composed of other races. This finding is also consistent with suicides in general7; the 

CDC reports that 91 percent of suicide decedents were white and 6 percent were black.

8

Sexual Orientation. Based on information provided for only 52 decedents for whom 

sexual orientation was reported, more than 90 percent (approximately 47 of the 

decedents) were believed to be straight, compared to fewer than 5 individuals who were 

known to be gay, lesbian, bisexual, or transgender. Although there is no comparable and 

consistent national data to compare with regards to suicide by all means, a comparable

7% of women and 8% of men identify as gay, lesbian or bisexual; therefore the 

distribution of sexual orientations found in this study sample were not very different from 

the overall national population (Reece, Herbenick, Fortenberry, Dodge, Sanders, & 

Schick, 2010).

Marital Status and Offspring. Of the 55 decedents, 31 (56 percent) were single and 

never married (but not cohabitating), 11 (20 percent) were divorced or separated, and 8 

(15 percent) were married at the time of their death. Less than five individuals were 

widowed (and not married, divorced, or separated) or cohabitating. One out of four of 

the single, never married individuals had experienced a recent breakup. Although recent 

national surveillance data are not available for comparison, a 1988 study that analyzed 

overall U.S. suicide rates over a 3-year period found that 47 percent were married, 29

 

7 The terms “suicide in general” or “suicide by all means” are used in this report to refer to all suicides in 

the United States, including those on the railroad rights-of-way. Suicides on railroad rights-of-way 

represent a very small percentage (less than 1 percent) of all suicide cases.

8 http://www.cdc.gov/injury/wisqars/fatal_injury_reports.html
13

percent were single, 9 percent were widowed, and 15 percent were divorced (Smith, 

Mercy, & Conn, 1988).

Only 19 (35 percent) of the decedents in the current study sample had children: 6 (11

percent) decedents had one child, 7 (13 percent) decedents had two children, and 6 (11

percent) decedents had more than two children.

3.1.1 Geographic Distribution

To better understand the location of all reported completed suicides on railroad rights-ofway, a map of the United States is presented below to illustrate the distribution of these 

cases. Figure 1 shows the distribution of confirmed completed suicides on railroad 

rights-of-way (blue markers) along with the distribution of cases autopsied in this study 

(red plus signs). It is important to note that each blue marker may represent more than 

one case if multiple suicides occurred on the railroad right-of-way in a single city within 

the study period. Therefore, it is impossible from this map to get an accurate picture of 

where the most completed suicides occurred in the United States. However, a visual 

comparison of the two sets of markers shows some similarity between the nationwide 

distribution of all confirmed cases and the sample. The only notable omissions in the 

current sample seem to be the Northwest United States and portions of the lower Midwest 

(e.g., Arkansas, Tennessee, and Kentucky), where several confirmed suicides occurred on 

railroad rights-of-way but was not included in the study sample. 

Figure 1. Geographic Distribution of Confirmed Suicides on Railroad Rights-ofWay (N = 237) and Study Sample (N = 55)

Blue markers and red crosses indicate all the confirmed suicide cases on railroad rights-of-way; red 

crosses indicate the cases included in our study sample. Map of the United States. Retrieved on Aug 

21, 2007, from http://maps.google.com.
14

3.1.2 Employment

Of the decedents in this study, 49 (90 percent) had at least some high school education, 

26 (47 percent) had at least some college education, and fewer than five decedents were

full-time students at the time of their death. Fourteen (25 percent) decedents were known 

to have full-time employment at the time of death, and eight (15 percent) were known to 

have part-time employment. 

Of the decedents, fewer than five were full-time students so their employment status was 

not included in the data sample Of the remaining 51 decedents, 22 (43 percent) were 

known to have full- or part-time employment. Of those with an employment history,

only 9 (19 percent) held professional jobs, such as educator or division manager, 13 (27

percent) had worked in the service industry, 12 (25 percent) had histories as laborers, and 

6 (13 percent) performed temporary jobs.

3.1.3 Government System Involvement

Of the 53 cases for which this information was available, 25 (47 percent) were involved 

with a nonmedical social system, such as the welfare system or the criminal justice 

system, at the time of their death. Eight (15 percent) of the decedents were involved with 

the legal system at the time of the suicide and five of these cases involved upcoming 

court dates following arrest for driving under the influence of alcohol.

3.1.4 Mental and Physical Disorder

Mental Disorder. A mental disorder is a health condition characterized by significant 

dysfunction in an individual’s cognitions, emotions, or behaviors that reflects a 

disturbance in the psychological, biological, or developmental processes underlying 

mental functioning.

9 Mental disorders are diagnosed according to criteria that present in 

the form of symptoms, feelings, thoughts, or behaviors either observable to or reported by 

the individual to others. Since no medical providers responded to the researchers’

requests for formal diagnoses, the research team used informant interviews to determine 

the presence of a mental or physical disorder in the decedent. For this study the criteria

used by the research team to confirm a mental disorder as present in the decedent were 

that an interviewed informant reported a previous diagnosis made by a professional or the 

interviewee had evidence of prescriptions, medical records or other records to provide to 

the investigator to confirm the diagnosis.

Mental disorder is a known risk factor for suicide and has been reported to exist in 

approximately 90 percent of all adult suicides (Phillips, 2010; Cavanaugh, Carson & 

Sharpe, 2003; Tanney, 2000). The results of this study suggest that the rate of mental 

disorder among the cases studied may be even higher; 53 (96 percent) of the total 55

 

9 American Psychiatric Association (2010). Definition of a Mental Disorder. Retrieved from 

http://www.dsm5.org/ProposedRevisions/Pages/proposedrevision.aspx?rid=465 
15

cases were reported to have a mental disorder. Informants reported that 25 (47 percent) 

had been prescribed medications for their mental disorder, and 12 (23 percent) were in 

therapy. Of the 25 who had been prescribed medications, informants indicated that 10 

(40 percent) were taking the medications as prescribed; only 5 of those 10 reported the 

medication as effective.

Few studies have investigated the prevalence of mental disorders among decedents of

completed suicides on the railroad rights-of-way. One such study out of Queensland, 

Australia, reported that approximately 40 percent of individuals in a 15-year span of 

completed suicides on railroad rights-of-way had a mental disorder (De Leo & Krysinska, 

2008). Another study in the Netherlands reported that 53 percent of the 57 cases studied 

were in psychiatric care at the time of their suicide, and two-thirds were in inpatient care

(Houwelingen & Kerkhof, 2008). This study is just one example of an oft-cited finding 

in European studies suggesting that railroad suicide deaths frequently occur at railroad 

track sites within just a few kilometers of psychiatric hospitals (Houwelingen, Kerkhof, 

& Beersma, 2010).

Also noted in this sample of 55 cases is that 40 (73 percent) of these cases were reported 

to have two or more co-occurring diagnoses. Among those with reported co-occurring

mental disorders, only 10 (25 percent) were in therapy at the time of death. Twenty-one

(53 percent) had reportedly been prescribed medications for their conditions at the time 

of death. Only 9 (43 percent) of the individuals who had been prescribed medications for

co-occurring mental disorders were reported to be taking their medications as prescribed

at the time of death. Further, informants revealed that the medications prescribed were

perceived to be effective for fewer than half of the individuals reported as being 

compliant with their prescriptions. 

During the interview process, interviewers also asked informants about the decedent’s 

emotional and psychological condition leading up to the incident. Although a reliable 

account of the specifics of the decedent’s emotional and psychological condition may not 

be possible to ascertain through this process, it was clear to the investigators that most 

decedents suffered from severe emotional or psychological distress in the time leading up 

to the suicide.

In some cases, the family of the decedent had a history of mental illness. Thirty-five (64

percent) decedents were reported to have had a family member with a mental disorder. 

For 17 of those individuals, at least one of their parents had a mental disorder, and in 13 

cases, at least one sibling.

A family history of suicide exposes the vulnerable individual to a model that has the 

potential to influence and impel suicidal behaviors. Nineteen decedents (35 percent) had 

a family history of suicide. Moreover, a family history may indicate a genetic or 

biochemical vulnerability to suicide.

Physical Disorder. For some individuals, physical illness underlies their decision to end 

their life by suicide. Lung disease, Acquired Immune Deficiency Syndrome (AIDS), and 

ulcers, among others, have all been seen to be associated with a significantly increased 

likelihood of suicide attempt, independent of the effects of mental disorders (Goodwin, 

Marusic, & Hoven, 2003).
16

Twenty-eight (51 percent) decedents in this study had at least one chronic physical 

illness. Chronic physical illnesses reported by informants included diabetes (7), chronic 

pain (5), and less than five cases each of cardiovascular disease, endocrine disorders 

other than diabetes, brain injury, and asthma. Medical conditions such as these have long 

been recognized as risk factors for suicide (Berman & Pompili, 2011).

3.1.5 Substance Abuse and Toxicology Reports

Substance abuse, or the abuse of alcohol, use of illicit drugs, or abuse of prescription 

medications, is a known risk factor (both acute and lifetime) for suicide (Center for 

Substance Abuse Treatment, 2008). All decedents in this study were reported to have 

abused substances, to have had a mental disorder, or both. Among the study sample, 34 

decedents (62 percent) were reported to have been heavy consumers of alcohol, and 32 

decedents (58 percent) were reported to have been abusing drugs (these two groups 

overlap). Among the decedents who were reported to have abused substances, all except 

two also had a mental disorder. According to the CDC, 16.5 percent of U.S. individuals 

who completed suicide between 2003 and 2004 had alcohol dependence problems.

Toxicology reports with Blood Alcohol Content (BAC) at the time of death were 

available for 43 (78 percent) decedents. At the time of death, 22 of the 43 (51 percent) 

cases had positive readings: blood alcohol content (16), illicit drugs (7), or prescription 

drugs (7). The most frequently abused illicit drugs were marijuana (5) and cocaine 

(fewer than 5). It was also found that a single individual had positive readings for more 

than one substance. Of the 16 decedents who had been drinking at the time of their 

death, 15 had a BAC above the statutory legal limit for driving a vehicle in most states 

(.08). 

3.1.6 Precipitating Factors

In many suicides, a triggering event—one single event or series of events—leads that 

individual to attempt to take his or her life (Moscicki, 1997). These events, by 

themselves, are not sufficient to lead a healthy person to end his or her life. However, to 

a person who has become vulnerable to suicide, the event or set of events triggers the 

suicide. Existing research on suicide attempters cite precipitating factors including 

academic stress, chronic physical illness, death of a loved one, economic distress, family 

and intimate partner relationship problems, occupational stress, substance abuse, and 

unemployment (Wu, Su & Chen, 2009; Beautrais, 1997). These factors were among 

those being experienced by decedents according to interviewees in the current study.

In 51 (94 percent) of 55 cases, the decedents were believed to have been experiencing at 

least one known stressful or adverse event. In 19 (35 percent) cases, it was fear of an 

upcoming negative or humiliating event, such as a court hearing, an expectation of 

incarceration, or loss of custody of children. Additionally, it was found that 8 (15

percent) had experienced the dissolution of a relationship with a significant other in the 

weeks or months prior to their death. In fewer than five cases, no precipitating factors 

were identified.
17

3.1.7 Past Attempts

The most significant predictor of a future suicide is a past suicide attempt (Runeson, 

Tidemalm, Dahlni, Lichtenstein, & Langstrom, 2010). Results of this study show that 24 

(44 percent) decedents attempted suicide at least once in the past. Some decedents, using 

both high and low lethality methods, had attempted suicide multiple times.10 Of the 

decedents who had made one or more known prior suicide attempts, 19 (79 percent) had 

used at least one low lethality method (e.g., ingestion pills, poison) and 11 (46 percent) 

had used at least one high lethality method (e.g., jumping). Almost half (5) of the 

individuals who made a high lethality prior suicide attempt had tried, in that prior 

attempt, to end their lives on railroad rights-of-way.

It should be noted that some individuals who are involved in incidents on the railroad 

rights-of-way do not die from these incidents. According to FRA, on average, 900 

individuals are struck annually by trains while trespassing on the railroad rights-of-way. 

Of these trespasser incidents, approximately half result in a fatality. As Figure 2 

indicates, not all attempts to end one’s life on the railroad rights-of-way result in a 

fatality. It is important to note that this graph includes all trespasser events (intentional 

and unintentional), so it is unclear what percentage of the intentional acts resulted in a 

fatality. Ultimately, being struck by a train does not necessarily result in a fatality. Also, 

this study did not investigate known attempts that did not end in a fatality. Examining the 

occurrence of known attempts that did not result in a fatality may uncover important 

information about why these attempts were made, however, funding did not allow for this 

investigation to be performed.

Figure 2. Trespasser Incidents vs. Trespasser Fatalities11, 12, 13

 

10 High lethality methods refer to those methods that are generally fatal—e.g., firearms, hanging. Low 

lethality measures refer to those methods that are less likely to result in death—e.g., cutting the wrist, 

poisoning with Tylenol.

11 http://safetydata.fra.dot.gov/officeofsafety/publicsite/summary.aspx 

12 FRA, Railroad Safety Statistics Annual Report, 1997-2009, Tables 1-2, 10-3.

13 FRA Accident/Incident Bulletin, 1980-1996, Table 13.
18

3.1.8 Characteristics of the Suicide

Witnesses. A completed suicide on the railroad right-of-way can be a very public event, 

depending on the site and time of day the death occurred. Completed suicides on railroad 

rights-of-way are categorized by Symonds, as private (likely not witnessed) or public

(likely witnessed) (Symonds, 1994). In the United Kingdom, 64 percent of completed 

suicides on railroad rights-of-way occur in public settings, while only one-third occur in a 

secluded environment. A completed suicide at a station platform is almost always 

witnessed by passengers and railroad personnel. 

In this study, 54 of the 55 cases occurred on open track away from a train station. In one 

case, the decedent was witnessed stepping off the platform. Of the cases that occurred 

away from a station, informants reported that 23 (42 percent) decedents had been 

observed by members of the community in the vicinity of the site of their death within 30 

minutes before their death. While most completed suicides on railroad rights-of-way are 

witnessed by the train engineers, among the individuals studied, the actual event was only

directly witnessed by bystanders in 6 (11 percent) cases.

Time of Day. An individual who attempts suicide on the railroad right-of-way during 

daylight hours may increase the chances of being seen and possibly rescued. The 

suicides in this sample occurred most frequently in afternoons and early evenings. 

Though daylight hours vary significantly across the country and at different times of year 

it is likely that for a fair proportion of these deaths, there was the possibility for the 

incident to be witnessed. This means that with increased monitoring, it may have been 

possible for these suicides to have been prevented. However, as noted above, only 6 of 

these 55 cases were witnessed by an observer, suggesting that decedents, for the most 

part, took precautions to avoid being seen. The analysis of incidents by time of day was 

performed in an earlier demographics profile study and no pattern emerged (FRA, 2011). 

Behavior on Tracks. Completed suicides on railroad rights-of-way can be characterized 

as follows: jumpers (those who leap in front of an approaching train), liers or prostraters 

(those who lie across the tracks awaiting a train), or wanderers (those who walk on the 

train tracks). This information was collected for 50 of the 55 cases in the study. 

According to the data, 20 (36 percent) of the decedents were categorized as liers, 15 (27

percent) were jumpers, and 15 (27 percent) decedents were wanderers who faced the train 

directly. In the SOVRN study, the most common behaviors were standing on the track 

(wanderers) followed by jumping in front of the train.

3.1.9 Personal Possessions at Time of Death

Reports on decedents’ possessions at the time of death were available in 29 of 55 cases or 

52 percent of the study sample. In 7 (24 percent) of these cases, decedents had no 

possessions with them. In 9 (31 percent) cases, decedents had their wallet or purse with 

their identification. Fewer than five decedents were reported to have a cell phone with 

them.

The lack of a cell phone may suggest that any prevention program focused on displaying 

signage to encourage suicidal individuals to call a dedicated suicide prevention call center 

would need to include a dedicated telephone and not presume that the individual had a 
19

cell phone in his or her possession. However, informants anecdotally reported some 

instances where the decedent had visited the railroad tracks prior to the actual incident, 

which, in theory, provides multiple opportunities to see the sign and make the call from 

another telephone. 

When left, notes can offer a glimpse into the mindset of the decedent in the hours or days 

preceding the suicide, when—it is presumed—these notes are written. In this sample, 16 

(29 percent) left a suicide note, which is in line with the findings of 33 percent of those 

who die by suicide by all means (Haines, Williams, & Lester, 2011). Fewer than five of 

these individuals had the note on their person, while the remaining notes were around 

elsewhere, e.g., in the decedents home, car, or near the site. 

3.1.10 Site Accessibility and Significance

Investigators were able to explore the characteristics of the sites in 52 (95 percent) of 55 

cases. Of the cases in the study sample, 46 (84 percent) occurred on stretches of track 

that did not have a barrier to restrict access to the railroad right-of-way. Investigators 

were asked to characterize each site relative to its density14 (i.e., number of buildings 

versus open space) on a 3-point scale from low to high density.15 Of the cases studied, 

based on the subjective classification of sites, 27 (49 percent) occurred in a high density 

area, 13 (24 percent) in an area of medium density, and 15 (27 percent) in an area of low 

density. Additionally, investigators were asked to classify these sites as rural, suburban, 

or urban.16 It was subjectively reported that 11 completed suicides (20 percent) occurred 

in rural areas, 30 (55 percent) occurred in suburban residential areas, and 14 (25 percent)

occurred in urban areas. These findings indicate that the majority of these completed 

suicides occurred in or near high density, metropolitan, or suburban areas (population 

centers).

Additionally, of the 46 cases for which site characteristics were available, 40 (87 percent) 

of the decedents lived within 2 miles of the incident site––and 35 (76 percent) of these 

decedents lived less than 1 mile from the incident site.

17

3.1.11 Availability of Firearms

In the United States, the most common method for suicide is the use of a firearm.18 The 

majority of suicides are the result of the use of a firearm (50.8 percent of all suicides in 

 

14 Based on the number of buildings per square mile, block, etc.

15 Definitions of density used by investigators: low (sparse buildings, lots of space), medium, high (lots of 

buildings, very little open space).

16 Definitions of area type used by investigators: rural (open, like fields or woods), suburban (residential), 

urban (downtown).

17 In nine cases, the decedent’s residence at the time of death was unknown or the decedent was transient, 

so proximity to residence could not be calculated.

18 http://www.cdc.gov/injury/wisqars/fatal_injury_reports.html
20

2009). In many instances, if a firearm is readily accessible in the home, the individual 

intending to complete suicide by firearm will die at home (Maris, Berman, and 

Silverman, 2000). Current estimates indicate that firearms are owned by roughly 38

percent of U.S. households (Hepbum, Miller, Azrael & Hemmenway, 2007).

Informants were asked if the decedent had ready access to a firearm and ammunition. 

For the purposes of this study “having access to a firearm” was defined as being able to 

obtain a firearm (your own or another individual’s) and use it to end one’s life. Among 

the study sample, informants reported that 12 (22 percent) decedents had access to a 

firearm and still chose to complete suicide on the railroad right-of-way. It is notable that 

this proportion is less than expected, given the proportion of U.S. households owning a 

firearm. However, it is worth noting that the total number of non-firearm suicides who 

did in fact have access to a firearm, a potentially more meaningful comparison group, is 

not currently known. Although we do not know how accessible firearms were to the 

decedent, the decision to complete suicide on a railroad right-of-way may have been at 

least partially dictated by the absence of a more lethal alternate means. 
21

4. Discussion

The goal of this study is to assess whether there are unique factors that affect or influence

individuals who complete suicide on railroad rights-of-way compared with suicides by 

other means. If such characteristics do exist, that information may inform future 

countermeasure or intervention strategy development.

As described in Section 3, the psychological autopsy protocol aimed to identify 

characteristics of individuals who complete suicide on railroad rights-of-way. In general, 

the characteristics of the decedents in this study were very similar to characteristics 

known about decedents who used other methods of suicide. Still, there are a few pieces 

of information that stand out as possible differences with this population:

• Many of the decedents in this study had a last known address in close proximity to 

railroad rights-of-way (87 percent within 2 miles, for 46 of the 55 cases where this 

information was available). Though the typical distance from a railroad track is 

unknown for suicides by other means, accessibility and availability of a means to 

complete suicide are significant determining factors in choice of method.

• Fewer decedents had access to firearms than would be expected given national 

statistics on household firearm ownership. Suicide by firearm is the most common 

method of suicide in the United States. Although 38 percent of U.S. households have 

a firearm, a much lower percentage (22%) of individuals in this study had access to a 

firearm. A lack of easy access to such a widely used method of suicide may increase 

the likelihood of an individual turning to an alternative method, such as the railroad 

right-of-way.

• Choosing a violent method, such as suicide by rail, has been associated with 

substance abuse or dependence and psychotic disorders (Dumais, Lesage, Lalovic,

Séguin, Tousignant, Chawky, & Turecki, 2005). The individuals included in this 

report were more likely to have a mental disorder (96 percent) or a drinking (62

percent) or substance abuse (58 percent) problem than individuals who chose other 

suicide methods.

In addition to the aforementioned characteristics, additional information came out of this 

study which may be useful for the development of countermeasures.

• Incidents tended to occur in urban and suburban areas with relatively high building 

density. This may help to identify where initial intervention or countermeasure 

efforts might be focused.

• Incidents did not tend to occur at any particular time of the day. In general, more of 

the events occurred in the afternoon and early evening than any other time. Although 

only a few (6) incidents in this report were witnessed, the fact that the incidents often 

take place during the day indicates that individuals do not typically rely on the cover 

of darkness to complete the act.

• Fewer than five decedents in this study had a cellular phone in their possession at the 

time of their death. This may be important for developing countermeasures such as 

signage which require the individual to call a dedicated help line. However, if the 

help line number is easy to remember, individuals without a cell phone who visit the 
22

site prior to the planned? incident may still be able to call the help line from another 

telephone.

• Familiarity could be a factor in choice of method. Five decedents had previously 

attempted suicide by rail. Individuals who attempt to end their lives on the railroad 

rights-of-way are likely to attempt such an act again.

Limitations. This study offers an assessment of completed suicides on railroad rights-ofway. However, because it lacks a controlled comparison group of non-suicides or 

suicides by other means, the study cannot offer definitive conclusions about these deaths 

as differentiated from uncompleted suicides on railroad rights-of-way or suicides by other 

means. The findings are further limited by the inaccessibility of and lack of cooperation 

on the part of healthcare workers who were asked but failed to supply medical and mental 

health records for these decedents. The study also did not include any interviews with 

train crews or first-responders because access was not provided; investigators relied

instead on police reports that summarized those observations.

Psychological autopsy studies rely heavily on interviews with knowledgeable informants. 

In this study, researchers discarded six cases about which they felt that the quality of the 

informants’ knowledge and observations was either suspect or weak. That said, there 

remains some degree of variability from case to case in terms of the depth of informants’ 

knowledge, their familiarity with proximal events, the relative recentness of their 

observations regarding these decedents, and the exact questions that the investigators

asked throughout the interview process. A number of decedents in these cases were not 

involved in a significant relationship at the time of their death; this created some

difficulty in locating the best possible informants for the individuals. Having multiple 

informants for each case would at times lead to conflicting or discrepant observations that 

had to be resolved, either by further questions to the informants or by the investigator’s 

best judgment in discussion with the research team. In none of the cases studied were the 

informants noted to be deliberately providing false information. An explanation was 

sought when there was discrepancy between informants and this resolved the differences

in many of the cases. 

Another difficulty with the psychological autopsy process is that the next-of-kins’

perceptions of how the decedent behaved leading up to the completed suicide may have 

been clouded by the event. Thus, as a way to justify the outcome, the next-of-kin may 

offer reasons for why he or she thought the individual completed suicide, but those 

reasons are likely not actual observations about the decedent’s behavior leading up to the 

incident. In light of this, the results of this report deal only with factual information and 

not with more subjective information.

In a few cases, key informants were unavailable, and others were considered to be 

insufficiently knowledgeable about the decedent. In addition, the use of multiple 

investigators increases the potential for variability in interviewing skills, styles, and, 

therefore, findings. Monthly teleconferences were held for investigators to receive 

feedback on reports submitted to date. Additionally, a mid-course, follow-up training of 

investigators was held to attempt to mitigate the variability issue. It should be noted, 
23

however, that any changes in interview style and data gathering that resulted from such 

mid-study training sessions would not be reflected in any earlier cases.

Suicides on railroad rights-of-way are not coded by specific method in national (or 

international) databases; however, they are included in the overall totals. They are coded 

as “intentional self-harm by jumping and lying before a moving object” and there is no 

identification of what that moving object may be (e.g., train, car, bus). 

Geographical bias may have been introduced into the sample in at least two ways. 

Because some States had lengthy procedures for obtaining data and all cases were 

included without sampling, a State that provided complete data continually and early in 

the process was likelier to be represented differently from one that provided data just 

prior to the cut-off for case recruitment. In addition, not all medical examiners complied 

with the researchers’ request for confirmation of the manner of death, citing local or State 

restrictions that they felt excluded their determination from public information access 

laws. Thus, a county or State was likely to be underrepresented if investigators could not 

obtain confirmation that the cases in question had been determined to be suicides and not 

accidents.

Despite the limitations listed above, this data collection was still able to uncover 

information that was not previously available in the United States, including the presence

of mental disorders and substance abuse among the individuals who complete suicide on 

the railroad right-of-way. This is the first time that a detailed suicide data collection has 

been attempted across the United States on railroad rights-of-way. As such, this effort 

has provided FRA not only with an understanding of some of the defining characteristics 

of individuals who complete suicide on railroad rights-of-way, but also with information

about some of the challenges that arise when collecting detailed information about these 

events. The lessons learned from this study will be valuable for developing systematic 

and reliable data collection efforts in the future.
24

5. Conclusions

Suicides on railroad rights-of-way are relatively rare events, but have lasting impact on 

witnesses, discoverers, train crews, first responders, and surviving loved ones. Moreover, 

they cause significant economic consequences for both the railroads (schedule delays, 

damage to equipment, train crewmember leave, etc.) and society. Identifying potential 

means to prevent these deaths will be of great benefit to all involved.

This sample of completed suicides on railroad rights-of-way shares much in common 

with samples of suicides by other means and, in many respects, merely confirms what we 

already know about those who intentionally take their lives. However, much has been 

learned through this effort. Notably, the cases studied involved decedents who tended to 

live near railroad tracks, were less likely to have access to firearms, and were

significantly compromised by both severe mental disorder and substance abuse. 

Additionally, it is important for the development of countermeasure or intervention plans 

to note that the majority of these suicides occurred in urban or suburban areas (as 

opposed to rural). They also occurred during both daylight and nighttime hours. A 

summary of the findings from this effort are included below in Table 3.

Suicidal behavior is the end point on a complex pathway made up of many variables

which include long-term vulnerability, an absence of protection, the overwhelming

intensity of acute symptoms, and the press of stressful events, all of which ultimately lead 

to a loss of meaning, purpose, identity, and hope. We believe that the findings from this 

study may add to our understanding of suicide, and may inform the development of 

countermeasures that discourage individuals from completing such an act on railroad 

rights-of-way.

A follow-up document which details potential countermeasures to address suicides is 

currently being developed by FRA and should be available within the next year. This 

document will incorporate the information obtained in this report to determine the most 

effective ways to implement proposed countermeasures in order to maximize their 

likelihood of success.
25

Table 3. Summary of Findings

Attribute Data from Psychological Autopsy of 55 Decedents

Gender 84% male

16% female

Age 33% 30 years old or younger

40% between 31 and 50 years old

27% older than 50 years

Race 96% white

4% nonwhite (IRB restrictions limit the ability to discern 

quantities smaller than 5)

Sexual Orientation >90% identified as straight

<10% identified as gay, lesbian, bisexual, or transgender

Marital Status and 

Offspring

56% single and never married

20% divorced or separated

15% married at the time of death

9% widowed or cohabitating (IRB restrictions limit the 

ability to discern quantities smaller than 5)

Geographic Distribution The distribution of the suicides that were studied in this 

effort was spread across the United States. 

Employment Status 43% full- or part-time employment

 19% professional jobs

 27% service industry

 25% laborers

 13% temporary jobs

Government System 

Involvement

47% involved in nonmedical social system, e.g., welfare 

or criminal justice system at time of death

15% involved with legal system at time of death
26

Mental Disorder 96% reported to have had a mental disorder

 47% had been prescribed medications

• 40% of these had been reported to have been 

taking these medications and only half of those 

were reported to have been effective

 73% reported to have had two or more co-occurring

 mental disorders

• 25% of those with co-occurring mental 

disorders were reported to have been in therapy

64% reported to have had a family member with a mental 

disorder

Physical Disorder 51% at least one chronic physical illness, including 

diabetes, chronic pain, cardiovascular disease, endocrine 

disorders, brain injury, and asthma

Substance Abuse and 

Toxicology Reports

62% reported to have been heavy consumers of alcohol

58% reported to have been abusing drugs

Toxicology Reports (for 43 of the 55 cases)

 51% positive readings

• 37% positive for alcohol

• 16% positive for illicit drugs

• 16% positive for prescription drugs

Precipitating Factors 94% reported to have experienced at least one stressful 

and/or adverse event

 35% upcoming negative or humiliating event (court 

hearing, incarceration, loss of custody)

 15% dissolution of relationship

Past Attempts 44% had attempted suicide at least once in the past

 79% had used at least one low lethality method

 46% had used at least one high lethality method

 9% had attempted on the right-of-way in the past
27

Witnesses 96% occurred on open track (away from a station)

42% had been observed by community members in the 

vicinity of the tracks prior to the incident 

11% were witnessed directly by bystanders

Time of Day Most frequent in afternoon and early evenings. However, 

there was not a clear pattern for when these incidents 

occur.

Behavior on Tracks 36% were lying on the tracks

27% jumped onto the tracks

27% were wandering along the tracks facing the train

Personal Possessions Data only available for 29 (52%) or cases

 24% of these cases had no possessions

 31% of these cases had a wallet or purse with ID

 <17% had a cell phone (IRB restrictions limit the 

ability to discern quantities smaller than 5)

Site Accessibility and 

Significance

49% in high density areas

24% in medium density areas

27% in low density areas

20% in rural areas

55% in suburban residential areas

25% in urban areas

Availability of Firearms 22% reported to have had access to a firearm
28

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Abbreviations and Acronyms

AAR

AAS

Association of American Railroads

American Association of Suicidology

AIDS

BAC

CDC

FRA

Acquired Immune Deficiency Syndrome

Blood Alcohol Content

Center for Disease Control

Federal Railroad Administration

ME medical examiner

RRF

SOVRN

U.S.

Railroad Research Foundation

Suicides and Open Verdicts on the Railway Network

United States