Switching Operations Fatality Analysis 

Findings and Recommendations 

of the SOFA Working Group 

August 2004 Update 

 i 

Dedication 

The SOFA Working Group (SWG) wishes to dedicate this study to the memory of those whose lives 

were lost in switching operations. The SWG expresses its condolences to the families of those 

individuals. The families can take comfort in the assurance that the study of each event is handled with 

respect and dignity. 

The SWG spent many hours studying these events to develop Recommendations to eliminate these 

tragedies in the future. The study of events leading up to these tragedies offers the opportunity to 

further improve safety and save lives of men and women working in the railroad industry. The families 

and friends who experienced these events can be assured that the lessons learned will save other 

families from the sorrow experienced during their agonizing loss. 

“The SWG believes the goal of Zero Fatalities can be achieved only after the Operating 

Recommendations are accepted and become a constant work practice.” 

 iii 
 iv 
 v 

 vii 

Acknowledgments 

The Switching Operations Fatality Analysis (SOFA) Working Group (SWG) greatly appreciates the 

ongoing support and encouragement it has received from Administrator Allan Rutter from the Federal 

Railroad Administration (FRA). The SWG thanks Dr. E. Donald Sussman, Chief of the Operator 

Performance and Safety Analysis Division of the John A. Volpe National Transportation Systems 

Center, USDOT/RSPA, for his support of the SOFA effort since its inception. The SWG acknowledges 

its debt to the following persons — and their organizations — for their continuing support and 

dedication: 

George A. Gavalla 

Associate Administrator for Safety 

Federal Railroad Administration (FRA) 

Don M. Hahs 

President 

Brotherhood of Locomotive Engineers and Trainmen (BLET) 

Richard F. Timmons 

President 

American Short Line and Regional Railroad Association (ASLRRA) 

Paul C. Thompson 

International President 

United Transportation Union (UTU) 

Robert VanderClute 

Senior Vice President, Operations and Safety 

Association of American Railroads (AAR) 

The present SWG expresses its appreciation to past SWG members for committing their talents and 

energies towards the goal of Zero Switching Fatalities: 

Sam Arrington 

Texas State Legislative Director, retired 

United Transportation Union (UTU) 

Mike Buss 

Past Director of Operating Practices 

Florida East Coast Railroad (FEC) 

Gary Connors 

Operations Research Analyst 

Federal Railroad Administration 
 viii 

Michael K. Coplen 

Program Manager, Human Factors 

Office of Research and Development 

Federal Railroad Administration (FRA) 

Michael R. Deatherage 

Past Director, Safety and Operating Practices 

RAILTEX 

Charles E. Dettmann 

Executive Vice President, retired 

Association of American Railroads (AAR) 

Robert A. Harvey 

Regulatory Research Coordinator 

Brotherhood of Locomotive Engineers and Trainmen (BLET) 

Raymond Holmes 

Vice President and U.S. Legislative Representative 

Brotherhood of Locomotive Engineers and Trainmen (BLET) 

Dr. Richard W. Pew 

Principal Scientist 

Human Factors Division BBN Technologies, GTE Corporation 

Gary Shields 

Director Safety 

North Shore Railroad Company (NSHR) 

Mark Simmons 

Past Director of Safety/Quality 

Florida East Coast Railroad (FEC) 

The SWG collectively wishes to express its gratitude to David Skinner of the Volpe National 

Transportation Systems Center, USDOT/RSPA, for his exceptional dedication to the efforts of the 

SWG. His untiring, unselfish work deserves our special recognition. His work in taking the complex 

and diverse data used to develop this report will effect the safety of railroad workers now and in the 

future. 

Note: Brotherhood of Locomotive Engineers and Trainmen (BLET) was formerly the Brotherhood of Locomotive 

Engineers (BLE). 
 ix 

Table of Contents 

Section Page

 

1. INTRODUCTION TO SOFA UPDATE...........................................................................1 

1.1 Purpose ..................................................................................................................................1 

1.2 Origin of the SOFA Working Group .....................................................................................1 

1.3 History of Switching Fatalities ..............................................................................................2 

1.4 Operating Recommendations and The Five Lifesavers.........................................................2 

1.5 Narrative Descriptions of Switching Fatalities......................................................................3 

1.6 Additional Recommendations ...............................................................................................3 

1.7 SOFA-defined Severe Injuries...............................................................................................6 

1.8 Summary of Report Contents ................................................................................................7 

2. SOFA WORKING GROUP ACTIVITIES........................................................................9 

2.1 SOFA Activities.....................................................................................................................9 

2.2 Future SOFA Group Activities..............................................................................................15 

3. SWITCHING FATALITIES AND OPERATING RECOMMENDATIONS ........................17 

3.1 Reviewing Switching Fatalities .............................................................................................17 

3.2 Classifying the 124 Switching Fatality Cases .......................................................................17 

3.3 List of Switching Fatalities, 1992 through 2003 ...................................................................19 

3.4 Narratives of the 124 Switching Fatalities.............................................................................22 

 4. SWITCHING FATALITIES — UNDERSTANDING AND PREVENTION ......................47 

4.1 Switching Fatalities Occur for a Reason ...............................................................................47 
 x 

4.2 Switching Fatalities Involving the SOFA Five Operating Recommendations......................47 

4.3 Switching Fatalities Involving Special Switching Hazards...................................................47 

4.4 Job Briefing and Mentoring - Operating Recommendation 3 and 5 ....................................51 

4.5 Shoving as a Special Switching Hazard ................................................................................53 

5. SEVERE INJURIES.......................................................................................................55 

5.1 SOFA-defined Severe Injuries and Amputations ..................................................................55 

5.2 Information Available for SOFA-defined Severe Injuries ....................................................56 

5.3 History of Severe Injuries......................................................................................................57 

5.4 Severe Injuries by Selective Attributes and Track Location .................................................57 

5.5 Statements About Frequency of Serious Injuries by Track Location....................................71 

APPENDIX .......................................................................................................................75 

A: SOFA Implementation Guidelines for Five Operating Recommendations.....................77 

B: Origin of SOFA Working Group ....................................................................................79 

C: Original Introduction to SOFA Report, October 1999....................................................81 

D: Five SOFA Operating Recommendations.....................................................................83 

E: Obtaining Electronic Versions of SOFA Reports ..........................................................89 

F: Examples of Job Briefings – Operating Recommendation 4 .........................................91 

DATA APPENDIX: Switching Fatalities by Selective Characteristics ................................105 
 xi 

List of Figures 

Figure Page

1-1. Switching Fatalities, 1982 through June 2004 ........................................................2 

1-2. SOFA-defined Severe Injuries and Amputations, 1997 through 2003 ....................7 

List of Tables 

Table Page

2-1. 124 Switching Fatalities Grouped by Operating Recommendations, 

 1992 through 2003..................................................................................................10 

2-2. Thirteen Struck-by-Mainline Train Fatalities............................................................11 

2-3. Switching Fatalities, December 22 through January 14, 1992................................11 

3-1. Sixty-four Switching Fatalities Involving Operating Recommendations ..................17 

3-2. Sixty Switching Fatalities Involving Special Switching Hazards ..............................18 

3-3. Chronological Listing of 124 Switching Fatalities, 1992 through 2003....................19 

4-1. Special Switching Hazard Fatalities Not Involving SOFA 

 Operating Recommendations .................................................................................47 

4-2. Ten Close Clearance Fatalities Not Involving SOFA Operating 

 Recommendations..................................................................................................48 

4-3. Eight Being-Struck-By-Mainline-Train Fatalities Not Involving 

 SOFA Operating Recommendations ......................................................................51 

4-4. Fourteen Fatalities Involving SOFA Operating Recommendation 3........................51 

4-5 Nineteen Fatalities Involving SOFA Operating Recommendation 5........................53 

5-1. Definition of SOFA-defined Severe Injuries ............................................................55 

5-2. Type of Information Available for Severe Injuries ...................................................56 

5-3. SOFA-defined Severe Injuries and Amputations, 1997 through April 2004 ............57 

5-4. SOFA-defined Severe Injuries by 14 Attributes and 7 Track Locations ..................59 

5-5. Severe Injuries by Selective Job Codes and Track Locations, 1997 to 2003 .........73 
 xii 

DATA APPENDIX 

A-1 Switching Fatalities by State, 1992 through 2003...................................................105 

A-2 Switching Fatalities by Shift, 1992 through 2003 ....................................................105 

A-3 Switching Fatalities by Shift and Day of Week, 1992 through 2003........................106 

A-4 Time On Duty before Fatal Event, 1992 through 2003 ...........................................106 

A-5 Switching Fatalities by Day, 1992 through 2003.....................................................107 

A-6 Switching Fatalities by Month, 1992 through 2003 .................................................107 

A-7 Switching Fatalities by Night and Day, 1992 through 2003.....................................108 

A-8 Switching Fatalities with Older Employees and Lower Years of Service, 

 1992 through 2003..................................................................................................108 

A-9 Switching Fatalities by Job Category, 1992 through 2003 ......................................109 
 xiii 

EXECUTIVE SUMMARY 

General 

Since the release of the SOFA Report: Findings and Recommendations of the SOFA Working Group in 

October 1999, the SOFA Working Group (SWG) has undertaken activities directed toward the goal of 

Zero Switching Fatalities. SWG activities focus on: 

• reviewing the 48 switching fatalities that occurred through December 2003, since the 76 

fatalities upon which the SOFA Report was based; 

• drawing the attention of those engaged in switching operations to the Five Operating 

Recommendations made in the SOFA Report; 

• identifying ‘Special Switching Hazards’ such as close clearance, being struck by mainline 

trains, and shoving that resulted in switching fatalities that were not necessarily preventable by 

one or more Operating Recommendations; 

• studying Severe Injuries, such as amputations, which cause harm to employees engaged in 

switching operations; and 

• publicizing information about the number and types of switching fatalities and Severe Injuries. 

Activities 

This report describes SWG activities, provides updated information on the number and type of 

switching fatalities occurring since the release of the SOFA Report, and – importantly – discusses how 

fatalities occur and can be prevented. Below is a summary of SWG activities since October 1999. 

• Zero Switching Fatality Goal. The SWG established a Zero Switching Fatality Goal with no 

tolerance for any other outcome. There were 6 switching fatalities in 2002, the lowest on 

record. SWG fatality records go back to 1975. The next lowest count was 7 in 1996. In 2003, 

there were 10 switching fatalities. In 2004 through June, there have been 4 fatalities. 

Because switching fatalities continue to occur, the SWG recognizes additional safety efforts are 

needed, including those based on the Five Operating Recommendations, to achieve the Zero 

Switching Fatality Goal. 

• Ongoing Review of Switching Fatalities. Since July 1, 1998, the date of the 76th and last 

switching fatality upon which the SOFA Report was based, 48 fatalities occurred to employees 

engaged in switching operations through December 31, 2003. The SWG reviewed each of these 

fatalities and entered available information into its database, the ‘SOFA Matrix,’ already 

containing descriptions of the 76 fatalities. Review of each additional switching fatality 

remains a SWG priority. Maintaining the SOFA Matrix provides the SWG with a searchable 
 xiv 

database of current and past switching fatalities going back through January 1, 1992. Searches 

are undertaken to answer railroad-community queries, provide fatality count updates, and 

undertake analyses. 

• Ongoing Evaluation of the Five Operating Recommendations. Forty-one of the 76 

switching fatalities in the SOFA Report period, January 1, 1992 through July 1, 1998, involved 

one or more of the Five Operating Recommendations – 54 percent. Originally, when the SOFA 

Report was released, 37 switching fatalities formed the basis of one or more of the Operating 

Recommendations. Upon subsequent review of the 76 fatalities, the SWG determined that 4 

more of the 76 fatalities also involved one or more Operating Recommendations. 

When the SOFA Report was released in October 1999, an additional 10 fatalities occurred in 

the period July 2, 1998 through October 31, 1999. Six of these fatalities involved one or more 

Recommendations. Thus, from January 1, 1992 through October 31, 1999, 47 of the 86 

switching fatalities involved Recommendations – 55 percent. 

Since October 31, 1999 (the post-report period), the SWG reviewed 38 switching fatalities, 17 

involving one or more Operating Recommendations – 45 percent. While the 54 vs. 45 percent 

reduction is worth noting, the focus should remain on the fact that fatalities occur and are 

preventable by the Five Operating Recommendations; and switching fatalities still occur at the 

rate of 10.3 per year. 

• Special Switching Hazards. In addition to the Five Operating Recommendations, the SWG 

wants to make those engaged in switching operations aware of Special Switching Hazards. In 

its review of each of the 124 fatalities, the SWG identified a number of fatalities involving 

close clearances (10 fatalities), being struck by mainline trains (8 fatalities), and occurring 

during shove movements (61 fatalities). The number of fatalities involving close clearance and 

being struck by mainline trains would be greater if those classified both as a Special Switching 

Hazard and an Operating Recommendation were included in these fatality counts. 

• Preventing Switching Fatalities. The SWG has classified the 124 switching fatalities, 

occurring from January 1992 through 2003, as either involving an Operating Recommendation, 

or a Special Switching Hazard. In reality, fatality events are complex sequences of events 

occurring amidst a variety of background conditions. Some of the fatalities involving Operating 

Recommendations also involve Special Switching Hazards. However, for prevention purposes, 

adherence to the Operating Recommendations and awareness of Special Switching Hazards 

will potentially prevent all switching fatalities.

• Periodic Safety Alerts. The SWG uses the SOFA Matrix, containing the history of 124 

fatalities, to identify trends, commonalities, and Special Switching Hazards among fatality 

events. When such patterns occur, the SWG informs those engaged in switching operations. 

When the SWG recognized recently that 13 fatalities resulted from employees being struck by 

mainline trains, it sent out an alert. Employees on the ground were struck by mainline trains 

while performing 'roll by' inspections, inspecting equipment, or getting on and off their 

equipment. The fatality events were described in detail in the alert. 
 xv 

Similarly, the SWG issued an alert in December 2003 calling attention to the 15 switching 

fatalities occurring in the 24-day period, December 22 through January 14, for the eleven years, 

1992 through 2002. Only three years – 1992, 1996, and 2002 – in this period were switchingfatality free. Twelve of the 15 employees (80 percent) had 20 or more years of service; and 

thirteen of the 15 employees (87 percent) were over 40 years old. 

In the alert, the SWG stressed that while this period is extremely risky, switching fatalities can 

occur at any time to anyone engaged in switching operations.

• Appendix to SOFA Report. In August 2000, the SWG published an appendix to the SOFA 

Report entitled Findings and Recommendations of the SOFA Working Group, Appendix – 

Volume II. It contains SWG working papers, many in the form of figures and tables, used to 

analyze fatality events, search for commonalities, and develop the Five Operating 

Recommendations contained in the SOFA Report. 

This report is available electronically at the Federal Railroad Administration (FRA) Office of 

Safety Web site: http://www.fra.dot.gov/Content3.asp?P=102. 

• Severe Injury Report. In July 2001, the SWG published Severe Injuries to Train and Engine 

Service Employees: Data Description and Injury Characteristics. This report contains 

information developed from the review of 446 Severe Injuries occurring to employees from 

January 1, 1997 to March 31, 2000. ‘Severe Injuries’ are defined by the SWG as injuries (1) 

potentially life threatening; (2) having a high likelihood of permanent loss of function; (3) 

likely to result in significant work restrictions; and (4) caused by a high-energy impact to the 

human body. (The full definition of Severe Injuries is given in Section 5.) Since 1997, on 

average, 132.7 Severe Injuries have occurred each year. 

The SWG reviewed Severe Injuries because it felt the causes were similar to those of fatalities. 

However, the information necessary to determine that relationship does not exist. Severe 

Injuries are not normally investigated by the FRA, while fatalities to employees on duty are 

required to be investigated. 

The Severe Injury Report is available electronically at the FRA’s Office of Safety Web site: 

http://www.fra.dot.gov/Content3.asp?P=102. 

• Best Practices Guidelines for Implementing Operating Recommendations. In March 2000, 

George A. Gavalla, FRA’s Associate Administrator for Safety, asked the SWG to develop 

guidelines — ‘best practices’ — for industry implementation of the Five Operating 

Recommendations. The developed guidelines, shown in Appendix A, emphasize education and 

a positive, judicious approach to implementation; and that the Recommendations should not be 

used as a basis for discipline. 

• SOFA Video. The SWG developed a video describing results of the SOFA Report with 

emphasis on the Five Operating Recommendations, and the fatality cases upon which each of 

the Recommendations were based. The SOFA video addresses the needs of the employees at 

the ballast level for information explaining the Operating Recommendations. 
 xvi 

 

• Crew Resource Management (CRM). The railroad industry took the lead in initiating a Task 

Force to implement an Additional Recommendation1

 made in the SOFA Report. The railroad 

industry Task Force created a generic program for train and engine employees. This CRM 

program provides a team-based framework through which to evaluate conditions, apply rules, 

and safely perform work tasks. Topics covered in the program include decision making, 

assertiveness, crew coordination, leadership, teamwork, situational awareness, and active 

practice and feedback. 

• Industry Leadership Conference Calls. The SWG participates in periodic Leadership 

Conference Calls with representatives from the Association of American Railroads (AAR), the 

American Short Line and Regional Railroad Association (ASLRRA), the FRA, the 

Brotherhood of Locomotive Engineers and Trainmen (BLET)2

, and the United Transportation 

Union (UTU). These calls developed out of a Railroad Safety Advisory Committee (RSAC) 

declaration. 

The original purpose of these Leadership Conference Calls was a discussion by each 

representative of issues specific to their organizations’ implementation of the SOFA Operating 

Recommendations and to report measurable results. The calls now include general discussions 

of SOFA-related issues. There have been eight calls to date. 

• The Five Lifesavers. The SWG developed shortened versions of the Five Operating 

Recommendations. ‘The Five Lifesavers’ serve as reminders to employees engaged in 

switching operations of the Operating Recommendations that will reduce their risk - and that of 

crew members. The Five Lifesavers are not meant as substitutes for the more comprehensive 

Recommendations that represent a series of safe actions that employees can take in reducing 

their risks in switching operations. 

The Five Lifesavers 

1. Secure equipment before action is taken. 

2. Protect employees against moving equipment. 

3. Discuss safety at the beginning of a job or when a project changes. 

4. Communicate before action is taken. 

5. Mentor less experienced employees to perform service safely. 

It should be noted that the Five Lifesavers and the Operating Recommendations are for all 

employees engaged in switching operations – not just yard employees. Switching fatalities 

1

 These recommendations for the most part do not involve switching operations directly (unexpected train movement being 

the exception) which the SWG believes, nonetheless, will help reduce risk in switching operations and facilitate the 

collection of fatality information. 

2

 Note: Brotherhood of Locomotive Engineers and Trainmen (BLET) was formerly the Brotherhood of Locomotive 

Engineers (BLE). 
 xvii 

occur at all locations — yards, mainlines, industries, and sidings — wherever switching occurs, 

there are risks to employees. 

• SOFA Educational Material. The SWG developed educational safety material: hats, pens, 

wallet-size cards, magnetic strips that can be applied to a refrigerator (allowing family 

members to be aware of safety efforts), stickers, and switch-list covers. Much of this material 

displays the Five Lifesavers. The intent is that this material will serve as a reminder to work 

safely when engaged in switching operations. 

• Speaking Publicly About Switching Fatalities. The SWG speaks to its respective member 

organizations, and other groups involved in railroad safety. These discussions include reviews 

of the Five Operating Recommendations, SWG activities, and updates of switching fatalities 

and Severe Injuries. As an example, on February 10, 2003, the SWG spoke at the 2003 Winter 

Meeting of the American Association of Railroad Superintendents (AARS) in Chicago, Illinois. 

• Ballast Level Safety Information. The SWG periodically provides the railroad industry with 

updated counts of switching fatalities, Severe Injuries, and amputations (a type of Severe 

Injuries). It is the intent of the SWG that this information reaches those actively engaged in 

switching operations – employees and managers at the ballast level. The updates also include 

descriptions of the sequence of events leading to specific types of fatalities. It is hoped that by 

drawing attention to past fatalities, future fatalities can be prevented. 

• Examining Experimental Safety Proposals and Devices. The SWG has examined several 

proposals and experimental devices that were developed to enhance safety in switching 

operations. These devices included methods for detection of rail equipment, reflectorization, 

warning alarms, and physical characteristics identification training. The SWG encourages the 

investigation of technologies holding promise for safer switching operations. 

• SOFA Safety Web Site. The SWG maintains a Web page on the FRA’s Office of Safety Web 

site containing safety information and access to electronic copies of SOFA reports and a 

PowerPoint presentation: http://www.fra.dot.gov/Content3.asp?P=102. 

• Review of Additional Recommendations. In the SOFA Report of October 1999, the SWG 

made Additional Recommendations. These Additional Recommendations (listed in section 1.6) 

are for the most part recommendations not involving switching operations directly (unexpected 

train movement being the exception) that the SWG believes, nonetheless, will help reduce risk 

in switching operations and facilitate the collection of fatality information. As a result of these 

Additional Recommendations, the FRA updated investigational protocols and adopted a more 

consistent procedure for collecting, and analyzing switching fatality investigation reports. 

 xix 

OVERVIEW OF SWITCHING FATALITIES AND SEVERE INJURIES3

Twelve-Year History of Switching Fatalities 

A twelve-year switching fatality history, January 1992 through December 2003, is shown below. In 

those twelve years, there have been, on average, 10.3 fatalities a year.4 Yearly fatality counts are 

essentially evenly distributed about this mean. The highest number of fatalities was 15 in 1993; the 

lowest, 6 in 2002. There were 10 switching fatalities in 2003. And there have been 4 fatalities through 

June 2004. 

From 1991 back to 1983, switching fatalities were similar in number and distribution to those in the 

1992-and-after period. Before 1983, fatalities were orders-of-magnitude higher. While SWG fatality 

counts go back to 1975, it is likely that the 6 fatalities in 2002 were the lowest ever since sizable 

switching activities developed in the mid-1800s. 

Switching Fatalities 

January 1992 through June 2004 

1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 totals avg.

JAN 2 0 4 1 0 2 1 2 1 2 0 0 1 16 1.2

FEB 0 0 0 2 0 1 1 1 0 0 0 3 0 8 0.6

MAR 1 1 0 2 1 0 0 0 1 1 1 0 1 9 0.7

APR 1 1 1 1 0 0 0 2 1 1 0 1 0 9 0.7

MAY 0 1 0 1 0 0 1 1 2 0 1 0 2 9 0.7

JUN 4 2 0 0 1 3 2 1 0 0 1 1 0 15 1.3

JUL 3 1 1 1 1 1 1 0 3 1 1 0 14 1.2

AUG 0 3 0 0 0 1 0 0 1 0 1 1 7 0.6

SEP 0 1 1 0 1 0 0 1 1 0 1 3 9 0.8

OCT 2 1 1 1 1 1 1 0 1 1 0 0 10 0.8

NOV 1 2 2 0 0 0 0 1 0 0 0 0 6 0.5

DEC 0 2 2 2 2 2 1 0 2 2 0 1 16 1.3

totals 14 15 12 11 7 11 8 9 13 8 6 10 128 10.4

 

3

 The Severe Injury data was taken from the FRA Office of Safety’s Web site in June 2004. 

4

 Going back to 1983, the average yearly number of switching fatalities is 10.4, virtually identical to the 10.3 average back 

to 1992. A standard deviation for the period back to 1992 is 2.8 fatalities; and, back to 1983 is 2.6 fatalities. 
 xx 

Seven-Year History of SOFA-defined Severe Injuries 

The seven-year history of SOFA-defined Severe Injuries is shown below along with amputations, an 

acute form of Severe Injuries. These Severe Injuries include, in addition to amputations, fractures of 

bones other than fingers and toes. As such, Severe Injuries often result from high-energy impacts and 

can be career threatening. Severe Injuries can be defined back to 1997 with the revision of reporting 

form FRA F6180.55a. In 2003, there were 116 Severe Injuries, the lowest count in the seven-year 

period, 1997 through 2003; and 14.4 percent lower than the mean of 135.5 for the previous six years. 

There have been 24 Severe Injuries in January through April 2004. 

 

Severe Injuries and Amputations 

1992 through April 2004 

SOFA-defined Severe Injuries Amputations 

1997 1998 1999 2000 2001 2002 2003 2004 1997 1998 1999 2000 2001 2002 2003 2004

JAN 11 13 16 15 21 12 11 10 1 0 2 1 0 0 2 2

FEB 17 15 9 9 9 13 17 14 0 1 0 1 0 2 1 2

MAR 14 12 17 11 10 10 13 10 3 4 3 2 1 1 3 1

APR 8 10 6 10 12 6 9 12 1 2 0 1 2 0 1 1

MAY 6 12 8 8 12 14 10 1 2 3 0 2 2 2

JUN 9 10 8 11 8 5 10 2 1 1 0 1 0 0

JUL 9 14 10 8 10 7 6 1 5 1 0 4 0 1

AUG 13 10 11 14 8 10 7 1 0 1 4 0 1 0

SEP 10 11 15 10 20 12 5 2 4 3 2 5 4 0

OCT 12 12 16 10 5 11 9 2 5 2 2 0 0 2

NOV 12 9 12 11 13 14 10 2 2 2 2 3 0 1

DEC 18 9 7 22 12 9 9 4 1 0 4 1 1 2

totals 139 137 135 139 140 123 116 20 27 18 19 19 11 15

 
 1 

 

1. INTRODUCTION TO SOFA UPDATE 

1.1 Purpose 

Formed in February 1998, the SOFA Working Group (SWG), made up of railroad industry 

representatives, has undertaken a number of activities since the release of its SOFA Report: Findings 

and Recommendations of the SOFA Working Group, in October 1999. That report was based on the 

review of 76 fatalities that occurred to railroad employees engaged in switching operations from 

January 1, 1992 through July 1, 1998. 

The SWG activities have been directed towards achieving the goal of Zero Switching Fatalities: 

• reviewing the 48 switching fatalities that occurred through December 2003, since the 76 

fatalities upon which the SOFA Report was based; 

• drawing the attention of those engaged in switching operations to the Five Operating 

Recommendations made in the SOFA Report; 

• identifying ‘Special Switching Hazards’ such as close clearance, being struck by mainline 

trains, and shoving that resulted in switching fatalities that were not necessarily preventable by 

one or more Operating Recommendations; 

• studying Severe Injuries, such as amputations, that cause harm to employees engaged in 

switching operations; and 

• publicizing information about the number and types of switching fatalities and Severe Injuries. 

In serving as an update, this report describes SWG activities. These activities are important because 

through December 2003, there have been 38 switching fatalities since the release of the SOFA Report. 

Of these 38 fatalities, 17 (45 percent) may have been avoided had the Operating Recommendations 

been followed. This possibility demonstrates the need for continuing education to reach the goal of 

Zero Switching Fatalities. 

1.2 Origin of the SOFA Working Group 

In February 1998, George A. Gavalla, Associate Administrator for Safety of the Federal Railroad 

Administration (FRA), charged the SWG to: “Conduct a detailed fact-finding review and analysis of 

these incidents [switching fatalities] 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.” 

Appendix B contains Mr. Gavalla’s letter that includes this charge. 

From Mr. Gavalla’s charge the SWG was formed, made up of representatives from the FRA, American 

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

(AAR), the Brotherhood of Locomotive Engineers and Trainmen (BLET),5

 the United Transportation 

5

 Note: Brotherhood of Locomotive Engineers and Trainmen (BLET) was formerly the Brotherhood of Locomotive 

Engineers (BLE). 
 2 

Union (UTU), and the Volpe National Transportation System Center (VNTSC). The SWG held 

meetings on a nearly monthly basis since its inception in February 1998. 

While the organizations represented in the SWG remained unchanged since its inception, some 

members, because of retirement or new work assignments, have been replaced. As expressed in the 

acknowledgments, current SWG members wish to recognize the considerable contribution to railroad 

safety that these former members made. 

1.3 History of Switching Fatalities 

SWG switching fatality records date back to 1975. Fatalities in the years 1975 through 1982 were 

relatively higher than in the years following. After 1982, fatalities began to decline, moving within a 

range of 7 to 15 per year, until 2002 when there were 6 (Figure 1-1). However, in 2003 fatalities 

increased to 10. There have been 4 switching fatalities through June 2004. 

4

10

6

8

13

8 9

11

7

11 12 14

10

7

10 9 9

13

10

12 15 15

1983198419851986198719881989199019911992199319941995199619971998199920002001200220032004

Figure 1-1. Switching Fatalities, 1982 through June 2004 

The necessity for immediate, preventive action is implied by the 21 years of fatality counts shown in 

Figure 1-1. On average, back to 1983, 10.4 employees died each year in switching operations. 

Equivalently, on average 2.6 employees died every three months. 

1.4 Operating Recommendations and The Five Lifesavers 

In its SOFA Report the SWG made Five Operating Recommendations based on a review of 76 fatality 

cases that occurred from January 1, 1992 through July 1, 1998. The SWG believes these 

Recommendations, each based on between 8 and 12 fatality cases, if used when appropriate in 

switching operations, will prevent fatalities. The Five Operating Recommendations are shown in 

Appendix D. Subsequently, the SWG developed shortened versions of each Recommendation that may 

involve a series of steps. These shortened versions came to be known as: 
 3 

The Five Lifesavers 

• Secure equipment before action is taken. 

• Protect employees against moving equipment. 

• Discuss safety at the beginning of a job or when a project changes. 

• Communicate before action is taken. 

• Mentor less experienced employees to perform service safely. 

1.5 Narrative Descriptions of Switching Fatalities 

Section 3 contains a short narrative summary of each of the 124 switching fatalities and whether one or 

more Operating Recommendations applies. These narratives were written by the SWG as part of its 

review of each switching fatality. In Section 2, the numbers of fatalities that apply to an Operating 

Recommendations before and after the release of the SOFA Report are compared. 

1.6 Additional Recommendations 

In addition to making Five Operating Recommendations in its SOFA Report, the SWG made 

Additional Recommendations concerning: 

• Unexpected train movement 

• Crew resource management 

• Review of Severe Injuries 

• Maintenance of the SOFA Matrix 

• Computer support for fatality investigation 

• Continued review and monitoring of switching fatalities 

• Team-oriented approach to switching fatality investigation 

‘Additional Recommendations’ are for the most part recommendations not involving switching 

operations directly (unexpected train movement being the exception) that the SWG believes, 

nonetheless, will help reduce risk in switching operations and facilitate the collection of fatality 

information. These Additional Recommendations are described verbatim below, from the SOFA 

Report:

6

 (Note: the abbreviation ‘FE’ in the cited material stands for ‘fatality of an employee.’) 

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 

 

6

 The SOFA Report: Findings and Recommendations of the SOFA Working Group, October 1999, page 4-16, Section 

4.2.2. 
 4 

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) that 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 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. 

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. 
 5 

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. 

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. 
 6 

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. 

The above material was taken from the SOFA Report: Findings and Recommendations of the SOFA 

Working Group, on October 1999, Section 1.4. 

1.7 SOFA-defined Severe Injuries 

In addition to reviewing each switching fatality, the SWG monitors the number and type of Severe 

Injuries to employees engaged in switching operations. ‘Severe Injuries’ were defined by the SWG to 

include injuries that are (1) potentially life threatening; (2) having a high likelihood of permanent loss 

of function; (3) likely to result in significant work restrictions; and (4) caused by a high-energy impact 

to the human body. An anatomical definition, along with a discussion of Severe Injuries, is presented 

in Section 5. 

The SWG reviewed Severe Injuries because it felt the causes were similar to those of fatalities. 

However, the information necessary to determine that relationship does not exist. Severe Injuries are 

not normally investigated by the FRA, while fatalities to employees on duty are required to be 

investigated. 

As shown in Figure 1-2, Severe Injuries declined in 2002 and 2003 from the almost similar counts of 

the previous five years. Severe Injury counts are not available before 1997 when FRA FORM F 

6180.55a was revised. (By comparison switching fatalities declined in 2002 to a historic low, but 

increased in 2003 as shown in Figure 1-1.) There were 123 Severe Injuries in 2002; and 116 in 2003. 

The 116 Severe Injuries in 2003 were the lowest value in the seven-year period, 1997 through 2003. 

Compared to the previous five years, amputations declined in 2002 and 2003. Amputations are a subset 

of Severe Injuries and are shown separately because of the acute trauma involved. Most Severe Injuries 

are fractures of the worst kind, fractures to fingers and toes being excluded by the SWG from the 

definition of Severe Injuries. 
 7 

46

116

137 135 137

121

139 139

10 18 19 18

27 20

0

50

100

150

1997 1998 1999 2000 2001 2002 2003

Severe Injuries Amputations

Figure 1-2. SOFA-defined Severe Injuries and Amputations, 1997 through 2003 

1.8 Summary of Report Contents 

The remainder of this report consists of four sections, an appendix, and data appendix: 

Section 2: SOFA Working Group Activities. A discussion of SWG activities since the 

publication of the SOFA Report in October 1999. 

Section 3: Switching Fatalities. A complete list and description of the 124 switching fatalities 

that occurred from January 1992 through December 2003. The fatalities are classified 

by Operating Recommendations if one or more applies. Or, if no Recommendation 

applies, by type of event or characteristic. 

 

Section 4: Switching Fatalities – Understanding and Prevention. An accounting system for 

classifying the 124 fatalities for understanding and prevention. 

Section 5: SOFA-defined Severe Injuries. Severe Injuries by various characteristics and track 

location. 

Appendix: 

A: SOFA Implementation Guidelines for Operating Recommendations 

B: Origin of SOFA Working Group 

C: Original Introduction to SOFA Report, October 1999 

D: Five Operating Recommendations 

E: Obtaining Electronic Versions of SOFA Reports 

F: Examples of Job Briefings – Operating Recommendation 4 

Data Appendix 

 9 

2. SOFA WORKING GROUP ACTIVITIES 

2.1 SOFA Activities 

The SOFA Working Group (SWG) engaged in a number of safety-related activities in the nearly four 

and one-half years since the release of its SOFA Report: Findings and Recommendations of the SOFA 

Working Group, on October 1999. These activities are discussed below. 

Zero Switching Fatality Goal 

The SWG established a Zero Switching Fatality Goal with no tolerance for any other outcome. There 

were 6 switching fatalities in 2002, the lowest on record. SWG fatality records go back to 1975. The 

next lowest count was 7 in 1996; and in 2003 there were 10 switching fatalities. In 2004 through June, 

there have been 4 fatalities. 

Because switching fatalities continue to occur, the SWG recognizes additional safety efforts are 

needed, including those based on the Five Operating Recommendations, to achieve the Zero Switching 

Fatality Goal. 

It should be noted that the Operating Recommendations are for all employees engaged in switching 

operations – not just yard employees. Switching fatalities occur at all locations – yards, mainlines, 

industries, and sidings - wherever switching occurs there are risks to employees. 

Ongoing Review of Switching Fatalities 

Since July 1, 1998, the date of the 76th and last switching fatality upon which the SOFA Report was 

based, 48 fatalities occurred to employees engaged in switching operations through December 31, 

2003. The SWG reviewed each of these fatalities and entered available information into its database, 

the ‘SOFA Matrix,’ already containing descriptions of the 76 fatalities. Review of each additional 

switching fatality remains a SWG priority. Maintaining the SOFA Matrix provides the SWG with a 

searchable database of current and past switching fatalities going back through January 1, 1992. 

Searches are undertaken to answer railroad-community queries, provide fatality count updates, and 

undertake analyses. 

Ongoing Evaluation of the Five Operating Recommendations 

Forty-one of the 76 switching fatalities in the SOFA Report period, January 1, 1992 through July 1, 

1998, involved one or more of the Five Operating Recommendations – 54 percent. Originally, when 

the SOFA Report was released, 37 switching fatalities formed the basis of one or more of the Operating 

Recommendations. Upon subsequent review of the 76 fatalities, the SWG determined that 4 more of 

the 76 fatalities also involved one or more Operating Recommendations. 

When the SOFA Report was released in October 1999, an additional 10 fatalities occurred in the period 

July 2, 1998 through October 31, 1999. Six of these fatalities involved one or more Recommendations. 

Thus, from January 1, 1992 through October 31, 1999, 47 of the 86 switching fatalities involved 

Recommendations – 55 percent. 

Since October 31, 1999, (the post-SOFA-Report period), the SWG reviewed 38 switching fatalities, 17 

involving one or more Operating Recommendations – 45 percent. While the 54 vs. 45 percent 
 10 

reduction is worth noting, the focus should remain on the fact that fatalities occur and are preventable 

by the Five Operating Recommendations; and switching fatalities still occur at the rate of 10.3 per 

year. 

Table 2-1 shows the frequency of the Five Operating Recommendations partitioned into the pre-and 

post-SOFA report period. It is difficult to draw conclusions because the post-SOFA report period 

counts are small. 

Table 2-1. 124 Switching Fatalities Grouped by Operating Recommendations, 1992 through 2003 

Total 

Fatality 

Cases 

Pre- and post-SOFA Report Period Recommendation 

1 2 3 4 5 

Total 

Number 

of 

Recommendations 

86 January 1992 through October 1999 13 9 10 15 16 63 

38 November 1999 through December 2003 6 3 4 3 3 19 

124 Totals 19 12 14 18 19 82* 

* Total sums to more than the number of fatality cases because multiple Operating Recommendations apply to some cases. 

Thirty-eight cases from January 1992 and October 1999, and 22 cases from November 1999 and December 2003, did not 

generate any additional Operating Recommendations. 

Special Switching Hazards 

In addition to the Five Operating Recommendations, the SWG wants to make those engaged in 

switching operations aware of Special Switching Hazards. In its review of each of the 124 fatalities, 

the SWG identified a number of fatalities involving close clearances (10 fatalities), being struck by 

mainline trains (8 fatalities), and occurring during shove movements (61 fatalities). The number of 

fatalities involving close clearance and being struck by mainline trains would be greater if those 

classified both as a Special Switching Hazard and an Operating Recommendation were included in 

these fatality counts.

Periodic Safety Alerts 

The SWG uses the SOFA Matrix, containing the history of 124 fatalities, to identify trends, 

commonalities, and Special Switching Hazards among fatality events. When such patterns occur, the 

SWG informs those engaged in switching operations. When the SWG recognized recently that 13 

fatalities resulted from employees being struck by mainline trains, it sent out an alert. Employees on 

the ground were struck by mainline trains while performing 'roll by' inspections, inspecting equipment, 

or getting on and off their equipment. These fatalities are shown in Table 2-2. Each of the fatality 

events was described in detail in the alert. 
 11 

Table 2-2. Thirteen Struck-By-Mainline-Train Fatalities 

Date RR Location FRA Report # Operating 

Recommendation

06/07/92 SSW Conlen Siding, TX FE-20-92 none 

04/13/93 CSX Dwale, KY FE-13-93 none 

12/05/93 SOU Atlanta, GA FE-49-93 Recommendation 3 

07/07/96 NS Sidney, IN FE-17-96 Recommendation 5 

07/18/97 MNCW Stamford, CT FE-22-97 none 

12/02/97 BNSF Emporia, KS FE-36-97 none 

12/28/00 UP Dupo, IL FE-32-00 none 

12/29/00 BNSF Gillette, WY FE-33-00 none 

01/10/01 CSX Chicago, IL FE-02-01 Recommendation 5 

01/11/01 NS South Fork, PA FE-03-01 Recommendation 3 

03/03/01 BNSF Willmar, IL FE-08-01 Recommendation 1 

12/24/01 NS Lynchburg, VA FE-40-01 none 

03/21/02 NS Claymont, DE FE-09-02 none 

Similarly, the SWG issued an alert in December 2003 calling attention to the 15 switching fatalities 

occurring in the 24-day period, December 22 through January 14, for the eleven years, 1992 through 

2002, as shown in Table 2-3. Only three years – 1992, 1996, and 2002 – in this period were switchingfatality free. Twelve of the 15 employees (80 percent) had 20 or more years of service; and 13 of the 

15 employees (87 percent) were over 40 years old. In the alert, the SWG stressed that while this period 

was extremely risky, switching fatalities can occur at any time to anyone engaged in switching 

operations. 

Table 2-3. Switching Fatalities, December 22 through January 14, 1992 

Period RR Location Age Service Date 

December 

22 NS Eden, NC 50 29 12/22/01 

24 NS Lynchburg, VA 30 4.5 12/24/01 

26 UP Boise, ID 55 32 12/26/97 

28 IC Durrant, MS 55 26 12/28/98 

28 UP Dupo, IL 52 30 12/28/00 

29 BNSF Gillette, WY 29 6 12/29/00 

30 CR Brook Park, OH 61 38 12/30/93 

January 

2 CIRR Cedar Springs, GA 49 21 01/02/00 

4 BN Hastings, NE 46 20 01/04/94 

10 CSX Chicago, IL 42 1 01/10/01 

11 CR Indianapolis, IN 51 30 01/11/95 

11 NS South Fork, PA 52 34 01/11/01 

12 UP S Fontana, CA 60 35 01/12/97 
 12 

12 CR Port Newark, NJ 54 55 01/12/99 

14 BN Amarillo, TX 57 36 01/14/94 

Appendix to SOFA Report 

In August 2000, the SWG published an appendix to the SOFA Report entitled Findings and 

Recommendations of the SOFA Working Group, Appendix – Volume II. It contains SWG working 

papers, many in the form of figures and tables, used to analyze fatality events, search for 

commonalities, and develop the Five Operating Recommendations contained in the SOFA Report. 

This report is available electronically at the FRA’s Office of Safety Web site: 

http://www.fra.dot.gov/us/content/102. 

Severe Injury Report 

In July 2001, the SWG published Severe Injuries to Train and Engine Service Employees: Data 

Description and Injury Characteristics. This report contains information developed from the review of 

446 Severe Injuries occurring to employees from January 1, 1997 to March 31, 2000. ‘Severe Injuries’ 

are defined by the SWG as injuries (1) potentially life threatening; (2) having a high likelihood of 

permanent loss of function; (3) likely to result in significant work restrictions; and (4) caused by a 

high-energy impact to the human body. (The full definition of Severe Injuries is given in Section 5.) 

Since 1997, on average, 132.7 Severe Injuries have occurred each year. 

The SWG reviewed Severe Injuries because it felt the causes were similar to those of fatalities. 

However, the information necessary to determine that relationship does not exist. Severe Injuries are 

not normally investigated by the FRA, while fatalities to employees on duty are required to be 

investigated. 

The Severe Injury Report is available electronically at the FRA’s Office of Safety Web site: 

http://www.fra.dot.gov/us/content/102 . 

Best Practices Guidelines for Implementing Operating Recommendations 

In March 2000, George A. Gavalla, FRA’s Associate Administrator for Safety, asked the SWG to 

develop guidelines — ‘best practices’ — for industry implementation of the Five Operating 

Recommendations. The developed guidelines, shown in Appendix A, emphasize education and a 

positive, judicious approach to implementation; and that the Recommendations should not be used as a 

basis for discipline. 

SOFA Video 

The SWG developed a video describing results of the SOFA Report with emphasis on the Five 

Operating Recommendations, and the fatality cases upon which each of the Recommendations were 

based. The SOFA video addresses the needs of the employees at the ballast level for information 

explaining the Operating Recommendations.

Crew Resource Management (CRM) 

The railroad industry took the lead in initiating a Task Force to implement an Additional 

Recommendation made in the SOFA Report (page 4-16, Section 4.2.2). ‘Additional 

Recommendations’ are for the most part recommendations not involving switching operations directly 
 13 

 

(unexpected train movement being the exception) that the SWG believes, nonetheless, will help reduce 

risk in switching operations and facilitate the collection of fatality information. This Task Force drew 

upon two existing, Class I programs. Southern Pacific established a CRM program in the late 1980s, 

based on programs in the commercial and military aviation industries. Union Pacific inherited that 

program with its merger, and developed a lesson plan and video based upon it. In the mid-1990s, 

Canadian Pacific Railway expanded its existing CRM materials to include other human factor issues 

and resources. This effort evolved into a classroom-based, instructional program. 

The railroad industry Task Force created a generic program for train and engine employees. This CRM 

program provides a team-based framework through which to evaluate conditions, apply rules, and 

safely perform work tasks. Topics covered in the program include decision-making, assertiveness, 

crew coordination, leadership, teamwork, situational awareness, and active practice and feedback. 

In June 2000, this CRM program was made available to the railroad industry. The course syllabus 

contains 10 lesson plans with coordinating videotape that provides opportunities for role-playing, 

discussion of textbook examples, classroom style instruction, and opportunities for group participation. 

The program has three phases: awareness, practice and feedback, and reinforcement. 

At the January 2004 annual meeting of the Transportation Research Board (TRB), the Texas 

Transportation Institute (TTI) presented a paper7

 that reviewed CRM progress in the U.S. railroad 

industry. In their presentation, current CRM programs and materials were shown to be in use by train 

and engine service employees. Issues pertinent to switching operations in yards and industries were 

also discussed. 

The SWG has reviewed the industry’s CRM program and observes that it has application for 

addressing identified hazards in switching operations. The CRM program has great utility to eliminate 

risks identified with Operating Recommendations. Those Recommendations include Recommendation 

3 (job briefing) and Recommendation 5 (mentoring). The other Operating Recommendations can also 

be benefited by exercise of principles used in CRM. 

Industry Leadership Conference Calls 

The SWG participates in periodic Leadership Conference Calls with representatives from the 

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

Association (ASLRRA), the FRA, the Brotherhood of Locomotive Engineers and Trainmen (BLET), 

and the United Transportation Union (UTU). These calls developed out of a Railroad Safety Advisory 

Committee (RSAC) declaration. 

The original purpose of these Leadership Conference Calls was a discussion by each representative of 

issues specific to their organizations’ implementation of the SOFA Operating Recommendations and to 

report measurable results. The calls now include general discussions of SOFA-related issues. There 

have been eight calls to date. 

7 Assessment of Existing Teams and Crew Resource Management (CRM) Training within the Rail Industry. Morgan, Curtis 

A.; Kyte, Tobin B.; Olson, Leslie E.; and Roop, Stephen S. Texas Transportation Institute. November 15, 2003. Presented 

at TRB 2004 Annual Meeting. Available on CD-ROM. 
 14 

The Five Lifesavers 

The SWG developed shortened versions of the Five Operating Recommendations. ‘The Five 

Lifesavers’ serve as reminders to employees engaged in switching operations of the Operating 

Recommendations that will reduce their risk - and that of crew members. The Five Lifesavers are not 

meant as substitutes for the more comprehensive Recommendations that represent a series of safe 

actions that employees can take in reducing their risks in switching operations. 

The Five Lifesavers 

 Secure equipment before action is taken. 

 Protect employees against moving equipment. 

 Discuss safety at the beginning of a job or when a project changes. 

 Communicate before action is taken. 

 Mentor less-experienced employees to perform service safely. 

It should be noted that the Five Lifesavers and the Operating Recommendations are for all employees 

engaged in switching operations – not just yard employees. Switching fatalities occur at all locations – 

yards, mainlines, industries, and sidings - wherever switching occurs, there are risks to employees. 

SOFA Educational Material 

The SWG developed educational safety material: hats, pens, wallet-size cards, refrigerator magnets 

(allowing family members to be aware of safety efforts), stickers, and switch-list covers. Much of this 

material displays the Five Lifesavers. The intent is that this material will serve as a reminder to work 

safely when engaged in switching operations. 

Speaking Publicly About Switching Fatalities 

The SWG speaks to its respective member organizations, and other groups involved in railroad safety. 

These discussions include review of the Five Operating Recommendations, SWG activities, and 

updates of switching fatalities and Severe Injuries. As an example, on February 10, 2003, the SWG 

spoke at the 2003 Winter Meeting of the American Association of Railroad Superintendents (AARS) in 

Chicago, Illinois. 

Ballast Level Safety Information 

The SWG periodically provides the railroad industry with updated counts of switching fatalities, 

Severe Injuries, and amputations (a type of Severe Injuries). It is the intent of the SWG that this 

information reach those actively engaged in switching operations – employees and managers at the 

ballast level. The updates also include descriptions of the sequence of events leading to specific types 

of fatalities. It is hoped that by drawing attention to past fatalities, future ones can be prevented. 

Examining Experimental Safety Proposals and Devices 

The SWG has examined several proposals and experimental devices developed to enhance safety in 

switching operations. These devices included methods for detection of rail equipment, reflectorization, 
 15 

warning alarms, and physical characteristics identification training. The SWG encourages the 

investigation of technologies holding promise for safer switching operations. 

SOFA Safety Web Site 

The SWG maintains a page on the FRA’s Office of Safety Web site containing safety information and 

access to electronic copies of SOFA reports and a PowerPoint presentation: 

http://www.fra.dot.gov/us/content/102 . 

Review of Additional Recommendations 

In the SOFA Report of October 1999, the SWG made Additional Recommendations. These Additional 

Recommendations (listed in section 1.6) are for the most part recommendations not involving 

switching operations directly (unexpected train movement being the exception) that the SWG believes, 

nonetheless, will help reduce risk in switching operations and facilitate the collection of fatality 

information. As a result of these Additional Recommendations, the FRA updated investigational 

protocols and adopted a more consistent procedure for collecting, and analyzing switching fatality 

investigation reports. 

2.2 Future SOFA Group Activities 

The SWG will continue its efforts toward the Zero Switching Fatality Goal. 

• The SWG recognizes additional safety efforts are needed to achieve the Zero Switching 

Fatality Goal. Total commitment to a safety culture based on the life-saving potential of the 

Five Operating Recommendations is essential. This commitment includes other Special 

Switching Hazards like close clearances, being struck by mainline trains, and the risk inherent 

in shoving operations. 

• Any future SWG work should include plans to improve the database design of the SOFA 

Matrix to enhance input and retrieval of information. The SOFA Matrix should be converted to 

a searchable database with the FRA’s Accident Analysis Branch maintaining this database for 

future review. During this process, the SWG will update the database to include all aspects of 

any new technologies, such as remote control operations, to ensure that operations unique to 

those technologies accurately reflect new situations that may impact the safety of yardswitching movements and at a minimum the hazards associated with unprotected movements 

that include both shoving and pulling rail equipment. 

• The SWG should continue its review and analysis of switching fatalities, particularly those not 

associated with the Five Operating Recommendations. Of the 124 switching fatalities occurring 

from January 1992 through December 2003, sixty-four fatalities (52 percent) involved one or 

more Recommendations. Additional analysis of the remaining 60 fatalities, combined with any 

future switching fatalities, may yield safety information in addition to the awareness of 

identified switching hazards. 

• The SWG will work towards implementation of the Additional Recommendations made in the 

SOFA Report of October 1999. These Additional Recommendations include: 

o Continued education on unexpected train movement 
 16 

o Computer support for fatality investigation 

o A team oriented approach to switching fatality investigation 

o Consideration of new technologies and operating procedures that hold promise to 

reduce risk to employees engaged in switching operations. 
 17 

3. SWITCHING FATALITIES AND OPERATING RECOMMENDATIONS 

3.1 Reviewing Switching Fatalities 

The SOFA Working Group (SWG) continues to review each switching fatality after the FRA’s 

investigation is complete. Information from each investigation, along with information from other 

sources, is entered into a database, ‘the SOFA Matrix.’ The SWG has reviewed all of the 124 fatalities 

occurring from January 1992 through December 2003. An important step of each review is determining if 

one or more Operating Recommendations apply. If no Operating Recommendations apply, the fatality 

case is classified under the appropriate Special Switching Hazard. 

3.2 Classifying the 124 Switching Fatality Cases 

By classifying fatalities by Operating Recommendations, the SWG can determine if switching fatalities 

are following similar patterns, or if new event sequences have developed. In determining if new event 

sequences are occurring, it is helpful first to divide the fatality cases into two groups. The first group 

contains fatalities that apply to Operating Recommendations. The second group - Special Switching 

Hazards - contains fatalities to which no Operating Recommendation applies. 

Operating Recommendation Cases 

Of the 124 switching fatalities, 64 involve one or more Recommendations – 52 percent as shown in Table 

3-1. Note that because a fatality case can involve more than one Recommendation, as 16 of the 64 fatality 

cases do, the number of Recommendations cited by the SWG is greater than the number of cases that 

have Recommendations applying. Two of the 16 cases involved 3 Operating Recommendations each; the 

other 14 cases involved 2 Recommendations each. 

The SWG firmly believes that switching fatalities directly related to the Five Operating 

Recommendations will be reduced when all parties accept and operate according to these 

Recommendations. The SWG encourages compliance with the Operating Recommendations and all other 

safety rules. 

Table 3-1. Sixty-Four Switching Fatalities Involving Operating Recommendations 

Lifesaver Applying 

to 

Operating Recommendation 

Number of 

Fatality 

Cases 

Percentage 

of 

124 

Fatality 

Cases

1-Secure equipment before action is taken. 19 15.3 % 

2-Protect employees against moving 

equipment. 12 9.7 % 
 18 

3-Discuss safety at the beginning of a job or 

when a project changes. 14 11.3 % 

4-Communicate before action is taken. 18 14.5 % 

5-Mentor less experienced employees to 

perform service safely. 19 15.3 % 

 total times a Recommendation was cited 82 

 less multiple citations of Recommendations 18

number of cases involving Recommendations 64 

Special Switching Hazard Cases 

The remaining 60 fatality cases, those not involving an Operating Recommendation, are classified by the 

SWG into eleven groups (one group is a miscellaneous group), as shown in Table 3-2, based on a 

sequence of events leading up to the fatality, as being struck by mainline trains; or by a fatality event 

characteristic, as drugs or alcohol. The SWG believes that the groupings suggest Special Switching 

Hazards that employees engaged in switching operations should constantly be aware of to insure their 

safety and that of their crew members. 

Table 3-2. Sixty Switching Fatalities Involving Special Switching Hazards 

 Type Number 

Close Clearance 10 

Struck by Mainline Trains 8 

Employee Tripping, Slipping, Falling 6 

Free Rolling Railcars 6 

Unsecured Cars 6 

Equipment 4 

Struck by Motor Vehicle or Loading Device 4 

Unexpected Movement of Railcars 4 

Environment 3 

Drugs and Alcohol 3 

Miscellaneous 11 

total 65 

* less cases classified in two category types 5 

net total 60 
 19 

* FE-15-92 was classified under ‘Employee Tripping, Slipping, Falling’ and ‘Unsecured Cars’; FE-46-93, ‘Unsecured 

Cars’ and ‘Drugs and Alcohol’; FE-30-96, ‘Drugs and Alcohol’ and ‘Employee Tripping, Slipping, Falling’; FE-40-01, 

‘Close Clearance’ and ‘Struck by Mainline Trains’; FE-09-02, ‘Close Clearance’ and ‘Struck by Mainline Trains’.

3.3 List of Switching Fatalities, 1992 through 2003

Table 3-3 contains a complete, chronological list of the 124 switching fatalities reviewed by the SWG. 

The second column to the right indicates if a fatality involved an Operating Recommendation and if so 

the number of the Recommendation(s). Sixteen fatalities involved more than one Recommendation. The 

third column to the right indicates if a fatality involved a Special Switching Hazard. 

Fatalities in this report have been classified by the SWG as either involving an Operating 

Recommendation, or a Special Switching Hazard. In reality, fatality events are complex sequences of 

events occurring amidst a variety of background conditions. Some of the fatalities involving Operating 

Recommendations also involve Special Switching Hazards. However, for prevention purposes, adherence 

to the Operating Recommendations and awareness of Special Switching Hazards will potentially prevent 

all switching fatalities. 

Table 3-3. Chronological Listing of 124 Switching Fatalities, 1992 through 2003 

# SOFA 

Recommendation

Special 

Switching 

Hazard

Date Railroad Location FRA 

 Report #

1 4 01/28/92 BN Willmar, MN FE-03-92

2 5 01/30/92 AGC Polk County, FL FE-04-92

3 4 03/11/92 FEC Fort Pierce, FL FE-08-92

4 Free-Rolling Railcars 04/09/92 ATSF Cheto, AZ FE-09-92

5 4 06/01/92 ATSF Escondido, CA FE-14-92

6 Employee Tripping,... 

Unsecured Cars 

06/01/92 BN Seattle, WA FE-15-92

7 5 06/02/92 IHRC Henderson, KY FE-16-92

8 1 06/20/92 CNW Northlake, IL FE-18-92

9 Struck by Mainline Trains 07/07/92 SSW Conlen Siding, TX FE-20-92

10 2,3 07/24/92 GBW Wisconsin Rapids, WI FE-30-92

11 4 07/25/92 UP Portland, OR FE-22-92

12 Miscellaneous 10/15/92 BN Omaha, NE FE-33-92

13 Free-Rolling Railcars 10/23/92 GTW Dearborn, MI FE-34-92

14 Miscellaneous 11/16/92 TTIS Maysville, KY FE-39-92

15 Employee Tripping,... 03/27/93 SP Guadalupe, CA FE-11-93

16 Struck by Mainline Trains 04/13/93 CSX Dwale, KY FE-13-93

17 Miscellaneous 05/22/93 ATSF El Paso, TX FE-20-93
 20 

18 Miscellaneous 06/04/93 SEPTA Devon, PA FE-22-93

19 3 06/07/93 IC Fulton, KY FE-23-93

20 4 07/15/93 CR Anderson, IN FE-26-93

21 Close Clearance 08/04/93 UP Pryor, OK FE-27-93

22 3,4 08/11/93 SP Tracy, CA FE-30-93

23 2 08/12/93 ATSF Evandale, TX FE-31-93

24 Miscellaneous 09/02/93 ATSF Carlsbad, NM FE-35-93

25 5 10/19/93 SOO Leal, ND FE-40-93

26 Unsecured Cars 

Drugs and Alcohol 

11/12/93 ATSF Farewell, TX FE-46-93

27 3,5 11/13/93 GC Macon, GA FE-47-93

28 3 12/05/93 SOU Atlanta, GA FE-49-93

29 Environment 12/30/93 CR Brook Park, OH FE-53-93

30 Unsecured Cars 01/04/94 BN Hastings, NE FE-02-94

31 Equipment 01/14/94 BN Amarillo, TX FE-03-94

32 Miscellaneous 01/18/94 CSX Bainbridge, GA FE-04-94

33 2 01/20/94 UP Fall City, NE FE-06-94

34 Close Clearance 04/12/94 SP Houston, TX FE-12-94

35 Free-Rolling Railcars 07/05/94 BN Essex, MT FE-16-94

36 Struck by Motor Vehicle... 09/20/94 ARR Clear Site, AK FE-20-94

37 1 10/17/94 UP Donaldsonville, LA FE-26-94

38 5 11/10/94 PTRA Houston, TX FE-28-94

39 3,4 11/15/94 CR Painted Post, NY FE-29-94

40 2,4,5 12/06/94 CR Campbell Hall, NY FE-31-94

41 1 12/13/94 UP Thorton, CA FE-32-94

42 Equipment 01/11/95 CR Indianapolis, IN FE-02-95

43 3,4 02/17/95 CR St. James, OH FE-09-95

44 1,2 02/24/95 ATSF Amarillo, TX FE-11-95

45 1,3 03/02/95 NS Aiken, SC FE-12-95

46 Miscellaneous 03/21/95 SP Bassett, CA FE-17-95

47 Unsecured Cars 04/06/95 WC Argoe, WI FE-16-95

48 2 05/03/95 CSX Evansville, IN FE-18-95

49 Employee Tripping,... 07/21/95 CR Hershey, PA FE-23-95

50 1,5 10/04/95 CSX Riverdale, IL FE-29-95

51 Close Clearance 12/11/95 NS Toledo, OH FE-33-95

52 Close Clearance 12/14/95 CSX Monroe, NC FE-34-95

53 1,5 03/20/96 BRC Bedford Park, IL FE-09-96

54 5 06/15/96 CSX Charlotte, NC FE-12-96

55 5 07/07/96 NS Sidney, IN FE-17-96

56 5 09/03/96 DGNO Dallas, TX FE-22-96
 21 

57 1,5 10/07/96 UP Eagle Pass, TX FE-24-96

58 Employee Tripping,... 

Drugs and Alcohol 

12/16/96 UP Clinton, IA FE-30-96

59 Unsecured Cars 12/18/96 IC Chicago, IL FE-31-96

60 Employee Tripping,... 01/12/97 UP S Fontana, CA FE-02-97

61 4 01/29/97 UP Mason City, IA FE-04-97

62 2 02/02/97 CR Burns Harbor, IN FE-05-97

63 4 06/06/97 CMRC Bay City, MI FE-16-97

64 Unexp. Movement of Railcars 06/24/97 NS Rowesville, SC FE-19-97

65 Employee Tripping,... 06/24/97 UP Portland, OR FE-18-97

66 Struck by Mainline Trains 07/18/97 MNCW Stamford, CT FE-22-97

67 1 08/15/97 UP Elko, NV FE-25-97

68 5 10/16/97 MRL Laurel, MT FE-32-97

69 Struck by Mainline Trains 12/02/97 BNSF Emporia, KS FE-36-97

70 4 12/26/97 UP Boise, ID FE-45-97

71 Drugs and Alcohol 01/24/98 BNSF Omaha, NE FE-02-98

72 2 02/04/98 BRC Bedford Park, IL FE-05-98

73 1 05/26/98 BRC Bedford Park, IL FE-15-98

74 2,5 06/01/98 BNSF Lubbock, TX FE-16-98

75 1 06/05/98 NS Hapeville, GA FE-17-98

76 Close Clearance 07/01/98 NS Buechel, KY FE-19-98

77 Miscellaneous 10/26/98 CCP Cicero, IL FE-28-98

78 4 12/28/98 IC Durrant, MS FE-37-98

79 3,4 01/12/99 CR Port Newark, NJ FE-01-99

80 Environment 01/22/99 CR Alexander, NY FE-03-99

81 Struck by Motor Vehicle... 02/17/99 KCS Kansas City, MO FE-05-99

82 3 04/02/99 DME Waseca, MN FE-11-99

83 Equipment 04/09/99 UP Richland, WA FE-12-99

84 5 05/19/99 NS Cincinnati, OH FE-14-99

85 1,4 06/23/99 UP Redding, CA FE-16-99

86 1,5 09/14/99 AM Van Buren, AR FE-24-99

87 Unexp. Movement of Railcars 11/17/99 UP Lincoln, NE FE-32-99

88 Environment 01/02/00 CIRR Cedar Springs, GA FE-02-00

89 1 03/09/00 IHB Riverdale, IL FE-09-00

90 Free-Rolling Railcars 04/21/00 BNSF Galesburg, IL FE-13-00

91 Close Clearance 05/22/00 CSX Richmond, VA FE-16-00

92 Miscellaneous 05/31/00 UP Pine Bluff, AR FE-17-00

93 1 07/07/00 CKRY Wichita, KS FE 21-00

94 4 07/24/00 PARN Skagway, AK FE-22-00

95 Close Clearance 07/28/00 UP St. Louis, MO FE-23-00
 22 

96 2 08/11/00 BNSF Port of Los Angeles, CA FE-25-00

97 4 09/09/00 BNSF Keokuk, IA FE-29-00

98 3 10/15/00 UP Houston, TX FE-30-00

99 Struck by Mainline Trains 12/28/00 UP Dupo, IL FE-32-00

100 Struck by Mainline Trains 12/29/00 BNSF Gillette, WY FE-33-00

101 5 01/10/01 CSX Chicago, IL FE-02-01

102 3 01/11/01 NS South Fork, PA FE-03-01

103 1 03/03/01 BNSF Willmar, MN FE-08-01

104 Miscellaneous 04/08/01 BNSF Clark, OK FE-14-01

105 Free-Rolling Railcars 07/13/01 CPRS Bensenville, IL FE-21-01

106 Close Clearance 10/10/01 PAL Clayburn, KY FE-31-01

107 Struck by Motor Vehicle... 12/22/01 NS Eden, NC FE-39-01

108 Close Clearance 

Struck by Mainline Trains 

12/24/01 NS Lynchburg, VA FE-40-01

109 Close Clearance 

Struck by Mainline Trains 

03/21/02 NS Claymont, DE FE-09-02

110 1 05/14/02 UP Pine Bluff, AR FE-12-02

111 1,3,5 06/16/02 BNSF Memphis, TN FE-16-02

112 4 07/16/02 NS Bonlee, NC FE-17-02

113 2 08/08/02 CWRO Cleveland, OH FE-19-02

114 Unexp. Movement of Railcars 09/02/02 CSX Madisonville, KY FE-22-02

115 2 02/11/03 CNIC Flat Rock, MI FE-03-03

116 Free-Rolling Railcars 02/16/03 CSX Syracuse, NY FE-04-03

117 Unsecured Cars 02/18/03 CSX Cheektowaga, NY FE-05-03

118 3 04/11/03 UP Pocatello, ID FE-11-03

119 Struck by Motor Vehicle... 06/06/03 CSX Kingsport, TN FE-12-03

120 1 08/26/03 LC Chester, SC FE-20-03

121 5 09/12/03 GC Dublin, GA FE-22-03

122 Equipment 09/14/03 UP Ogden, UT FE-23-03

123 Miscellaneous 09/24/03 BNSF Fresno, CA FE-25-03

124 Unexp. Movement of Railcars 12/07/03 UP San Antonio, TX FE-35-03

3.4 Narratives of the 124 Switching Fatalities 

The narratives for the 124 switching fatalities that occurred from January 1992 through December 

2003 are given below. These narratives were written by the SWG as part of its review of each 

switching fatality. Those narratives involving Recommendations are presented under the applicable 

Recommendation. Potentially, these 64 fatalities could have been averted by application of the 

Recommendation(s). The Special Switching Hazard fatality cases are presented under the eleven 

groupings that describe the fatal event or condition. 
 23 

Switching Fatalities Involving Operating Recommendations 

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. 

Lifesaver 1 

Secure equipment before action is taken. 

June 20, 1992 – CNW - Northlake, IL FE-18-92 Recommendation 1 

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. 

October 17, 1994 – UP - Donaldsonville, LA FE-26-94 Recommendation 1 

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. 

December 13, 1994 – UP – Thorton, CA FE-32-94 Recommendation 1 

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. 

February 24, 1995 – Amarillo, TX FE-11-95 Recommendation 1 

 also Recommendation 2 

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 E.O.T. at the opposite end. Cars 

impacted with sufficient force to knock down and run over the foreman. 

March 02, 1995 –NS – Aiken, SC FE-12-95 Recommendation 1 

 also Recommendation 3 

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 that ran over the brakeman. 

October 04, 1995 – CSX – Riverdale, IL FE-29-95 Recommendation 1 

 also Recommendation 5 

Crew performing switching in class yard. Switch foreman placed himself between the rails to adjust a 

misaligned coupler on the fifteenth car after the cut was stretched. Switch foreman was facing the 

coupler with his back to a cut of seven cars that rolled in on top of him and coupled him up. 
 24 

March 20, 1996 – BRC – Bedford Park, IL FE-09-96 Recommendation 1 

 also Recommendation 5 

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. 

October 07, 1996 – UP – Eagle Pass, TX FE-24-96 Recommendation 1 

 also Recommendation 5 

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. 

August 15, 1997 – UP – Elko, NV FE-25-97 Recommendation 1 

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. 

May 26, 1998 – BRC – Bedford Park, IL FE-15-98 Recommendation 1 

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. 

June 05, 1998 – NS – Hapeville, GA FE-17-98 Recommendation 1 

A three-person crew was performing industrial switching using a runaround track, the yard foreman 

was attempting to couple up two super-cushion boxcars in a curve with power attached in a shove 

movement. Drawbars bypassed and yard foreman was crushed between the ends of the two cars. 

June 23, 1999 – UP - Redding, CA FE-16-99 Recommendation 1

 also recommendation 4 

A three-person switching crew was shoving a cut of cars down a track with the intent of coupling to 

another cut that was sitting in the track. It was hard to shove the cars and the conductor told the 

brakeman to look for closed angle cocks. The brakeman found a closed angle cock when the shove 

move was within two car lengths of a coupling and opened it. The conductor was crushed and killed 

between the leading car of the shove and the head car to be coupled to when the shove move 

unintentionally accelerated just prior to coupling. 

September 14, 1999 – AR - Van Buren, AR FE-24-99 Recommendation 1 

 also Recommendation 5

A two-person switching crew was in the process of shoving ten cars onto a clear track, with the 

intention of cutting three off, and pulling the other seven cars out. The conductor counted down the 

cars via radio, and the engineer stopped one half-car lengths after the last radio transmission of onehalf cars to go. Subsequently, the engineer discovered that the conductor had stepped in between the 

cars and had been coupled up. 

March 09, 2000 – IHB – Riverdale, IL FE-09-00 Recommendation 1 

The employee was struck by an unsecured cut of cars that rolled into him while he was attempting to 

adjust the coupler or drawbar. 
 25 

July 07, 2000 – CKRY – Wichita, KS FE-21-00 Recommendation 1 

Employee was struck by his own train when he tripped and fell onto the rail as he stepped in between

moving equipment to open a knuckle while walking backwards. 

March 03, 2001 – BNSF – Willmar, MN FE-08-01 Recommendation 1

The switchman of a three-person yard switching crew made a cut on a block of cars sitting on a yard 

track and told the engineer to pull the cars out. Apparently, as the cars were being pulled out, the 

switchman stepped between the gauge of the track and was struck and killed by the remaining cars on 

the track that had begun to roll in the same direction as the cars being pull out of the track. 

May 14, 2002 – UP – Pine Bluff, AR FE-12-02 Recommendation 1 

The switchman of a three-person yard switching crew asked the engineer to stretch a track. Noticing 

that there was a separation between the forth and fifth head cars, the switchman went in to align the 

couplers. The switchman was coupled up when unsecured cars rolled in on him. 

June 16, 2002 – BNSF - Memphis, TN FE-16-02 Recommendation 1 

 also Recommendation 3 and 5

A yard foreman, with 18-months of service, along with his helper, engineer, and a utility employee had 

just finished making up a train in the yard. However, the crossover from the track on which the train 

had been made had to be cut. This last minute instruction led to an increased level of conversation 

among the crew, yard foreman, utility employee and the yardmaster. The yard foreman jumped on a 

ATV, rode it to the cut point, separated the train; and, when the cut not attached to the locomotive 

rolled, he was caught between the two sections of the train and killed. 

August 26, 2003 – LC – Chester, SC FE-20-03 Recommendation 1 

A three-person crew that included a brakeman trainee was switching an industry when the conductor 

requested a short backup move when the cars he intended to couple to did not couple. A short time 

later and after failed attempts to contact the conductor the trainee discovered him dead and lying 

between the cars he had been trying to couple together. 

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. 

Lifesaver 2 

Protect employees against moving equipment. 
 26 

July 24, 1992 – GBW – Wisconsin Rapids, WI FE-30-92 Recommendation 2 

 also Recommendation 3

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. 

August 12, 1993 – ATSF – Evandale, TX FE-31-93 Recommendation 2 

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. 

January 20, 1994 – UP – Fall City, NE FE-06-94 Recommendation 2 

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. 

December 06, 1994 – CR – Campbell Hall, NY FE-31-94 Recommendation 2 

 also Recommendation 4 and 5

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 nonconflicting position. Second local shoving three cars and a caboose with a two-month trainee directing 

the move, struck standing equipment after traversing switches that were unexpectedly lined for the 

equipment. 

February 24, 1995 – ATSF – Amarillo, TX FE-11-95 Recommendation 2 

 also Recommendation 1

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. 

May 03, 1995 – CSX – Evansville, IN FE-18-95 Recommendation 2 

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. 

February 02, 1997 – CR – Burns Harbor, IN FE-05-97 Recommendation 2 

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. 

February 04, 1998 – BRC – Bedford Park, IL FE-05-98 Recommendation 2 

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 later found to have been struck and killed by a free rolling 

car on the adjacent track. 
 27 

June 01, 1998 – BNSF – Lubbock, TX FE-16-98 Recommendation 2 

 also Recommendation 5

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. 

August 11, 2000 – BNSF – Port of Los Angeles, CA FE-25-00 Recommendation 2 

Employee was struck and killed by the lead car of another switching movement that was operating on 

the adjacent yard track. 

August 08, 2002 – CWRO – Cleveland, OH FE-19-02 Recommendation 2

A two-person crew was switching cars in a yard and, without the trainman’s knowledge, another 

switching crew had set cars into a track adjacent to the one being used by the first crew. The set out 

included a wide ladle car and it created a clearance issue on the adjacent track. Some time later, the 

trainman was riding the lead car down the track adjacent to the wide ladle car and was killed when he 

was rolled between the car he was riding and the wide ladle car sitting on the adjacent track. 

February 11, 2003 – CNIC – Flat Rock, MI FE-03-03 Recommendation 2 

A three-person crew (engineer, conductor, brakeman) were stopped and the engineer and conductor 

were awaiting the brakeman’s return from the “Trim Shanty”. During this time, another crew was in 

the process of shoving a cut of cars down a track that was located between where the brakeman’s crew 

were waiting and the Shanty. The brakeman exited the Shanty and was struck by the shove move as he 

crossed the tracks to get to his crew. The shove move was being preceded by two of the striking 

train’s crew who were riding in a van at the time. 

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. 

Lifesaver 3 

Discuss safety at the beginning of a job or when a project changes. 

July 24, 1992 – GBW – Wisconsin Rapids, WI FE-30-92 Recommendation 3

 also Recommendation 2

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. 

June 07, 1993 – IC – Fulton, KY FE-23-93 Recommendation 3

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. 
 28 

August 11, 1993 – SP – Tracy, CA FE-30-93 Recommendation 3

 also Recommendation 4

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. 

November 13, 1993 – GC – Macon, GA FE-47-93 Recommendation 3 

also Recommendation 5

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 shoved without his knowledge while 

he was in the foul of the movement. Movement ran over conductor and killed him. 

December 05, 1993 – SOU – Atlanta, GA FE-49-93 Recommendation 3 

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.

November 15, 1994 – CR – Painted Post, NY FE-29-94 Recommendation 3 

 also Recommendation 4

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. 

February 17, 1995 – CR – St. James, OH FE-09-95 Recommendation 3 

 also Recommendation 4

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. 

March 02, 1995 – NS – Aiken, SC FE-12-95 Recommendation 3 

 also Recommendation 1

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. 

January 12, 1999 – CR – Port Newark, NJ FE-01-99 Recommendation 3

 also Recommendation 4

A three-person industry switching crew was in the process of switching cars back and forth over a 

private crossing equipped with an in-ground hand throw switch. The brakeman was at the switch and 

the conductor was going back and forth from one set of cars to another. The conductor shouted to the 

brakeman that he wanted the next move down one track but the cars started down the other. The 

brakeman tried to warn the conductor who had his back to the move and then stopped the move but to 

late to save the conductor who was hit and run over by the leading car of the shove. 

April 02, 1999 – DME – Waseca, MN FE-11-99 Recommendation 3 

A three-person yard switching crew was switching and the conductor was pulling pins while the 

brakeman was taking orders from him and working the yard tracks during a flat switching operation. 

The conductor cut off three cars that rolled into other cars on the track. The brakeman was run over by 

these cars. 
 29 

October 15, 2000 – UP – Houston, TX FE-30-00 Recommendation 3 

Employees failed to discuss movement, resulting in employee falling from locomotive platform and 

being rolled between the locomotive and the elevated walkway. 

January 11, 2001 – NS – South Fork, PA FE-03-01 Recommendation 3 

The engineer and conductor of a road train were told to stop and check their locomotives for flat spots. 

Once stopped, and without a job briefing the locomotive engineer left the lead unit and shortly 

thereafter, was struck and killed by a passing mainline train. 

June 16, 2002 – BNSF – Memphis, TN FE-16-02 Recommendation 3 

 also Recommendation 1 and 5

A yard foreman, with 18-months of service, along with his helper, engineer and a utility employee had 

just finished making up a train in the yard. However, the crossover from the track on which the train 

had been made had to be cut. This last minute instruction led to an increased level of conversation 

among the crew, yard foreman, utility employee and the yardmaster. The yard foreman jumped on a 

ATV, rode it to the cut point, separated the train; and, when the cut not attached to the locomotive 

rolled, he was caught between the two sections of the train and killed. 

April 11, 2003 – UP – Pocatello, ID FE-11-03 Recommendation 3 

A road conductor was riding the point of a 122-car shove down a track that was partially out of service. 

The out of service portion was marked by a red flag and derail. The crew was not able to stop the 

movement before the car being ridden by the conductor went over the derail, landed on its side and 

crushed the conductor to death. 

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. 

Lifesaver 4 

Communicate before action is taken.

January 28, 1992 – BN - Willmar, NM FE-03-92 Recommendation 4 

A four-person crew (engineer, switch foreman, 2 switchman) had just shove cars into track 11 and held 

onto one for track 9. The switch foreman got the switch for 9, noticed his front switchman standing 

near cars on track 11, and rode the locomotive onto the lead. After the 11th switch was lined for the 

lead, the switch foreman kicked the single car into track 9. The front switchman was struck and killed 

by the free rolling car.
 30 

March 11, 1992 – FEC – Fort Pierce, FL FE-08-92 Recommendation 4 

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 conductor’s 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. 

June 01, 1992 – ATSF – Escondido, CA FE-14-92 Recommendation 4 

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. 

July 25, 1992 – UP – Portland, OR FE-22-92 Recommendation 4 

A three-person crew had arrived at the yard, pulled their train into a track, cut off the engines and were 

given permission to return to the other end of the yard via an adjacent clear track. The conductor 

remained on the end originally entered and the brakeman stayed with the engineer. The brakeman got 

what he thought was the proper switch, instructed the engineer by radio to back up and, apparently 

turned his back on the move. Before the brakeman had a chance to mount the returning locomotives, 

he was struck and killed by the movement that continued for 400 feet before stopping when the 

engineer noticed the brakeman between the gauge of the rail in front of the locomotives. 

July 15, 1993 – CR – Anderson, IN FE-26-93 Recommendation 4 

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 track. The brakeman was run over by the shove 

move. There was no evidence of any other radio transmissions concerning the shove move. 

August 11, 1993 – SP – Tracy, CA FE-30-93 Recommendation 4

 also Recommendation 3

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. 

November 15, 1994 – CR – Painted Post, NY FE-29-94 Recommendation 4 

 also Recommendation 3

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. 

December 06, 1994 – CR – Campbell Hall, NY FE-31-94 Recommendation 4 

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 
 31 

mph, struck standing equipment after diverging through two mis-aligned switches and killed the 

brakeman trainee. 

February 17, 1995 – CR – St. James, OH FE-09-95 Recommendation 4 

 also Recommendation 3

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. 

 

January 29, 1997 – UP – Mason City, IA FE-04-97 Recommendation 4 

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. 

June 06, 1997 – CMRC – Bay City, MI FE-16-97 Recommendation 4 

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 its charge to effect the transmission. 

December 26, 1997 – UP – Boise, ID FE-45-97 Recommendation 4 

Conductor was riding equipment while setting hand brakes. Move was being shoved; improper radio 

communication. 

December 28, 1998 – IC – Durrant, MS FE-37-98 Recommendation 4 

Shove movement was not properly controlled by radio communication and resulted in a collision with 

a fallen tree which caused the derailment and death of the conductor. 

January 12, 1999 – CR - Port Newark, NJ FE-01-99 Recommendation 4

 also Recommendation 3

A three-person industry switching crew was in the process of switching cars back and forth over a 

private crossing equipped with an in-ground hand throw switch. The brakeman was at the switch and 

the conductor was going back and forth from one set of cars to another. The conductor shouted to the 

brakeman that he wanted the next move down one track but the cars started down the other. The 

brakeman tried to warn the conductor who had his back to the move and then stopped the move but to 

late to save the conductor who was hit and run over by the leading car of the shove. 

June 23, 1999 – UP - Redding, CA FE-16-99 Recommendation 4 

 also Recommendation 1

A three-person switching crew was shoving a cut of cars down a track with the intent of coupling to 

another cut that was sitting in the track. It was hard to shove the cars and the conductor told the 

brakeman to look for closed angle cocks. The brakeman found a closed angle cock when the shove 
 32 

move was within two car lengths of a coupling and opened it. The conductor was crushed and killed 

between the leading car of the shove and the head car to be coupled to when the shove move 

unintentionally accelerated just prior to coupling. 

July 24, 2000 – PARN – Skagway, AK FE-22-00 Recommendation 4 

A two-person yard switching crew was in the process of moving their light locomotives to a track 

where it was to be stored for the night. The conductor was on the leading end of the unit and directing 

the move by radio communication. After instructing the engineer to stop, the conductor got off the 

locomotive, lined two switches and told the engineer to back up. The engineer backed up until he 

placed the unit at the location where it is always left without further radio contact from his conductor. 

The conductor was struck and killed by the locomotive and found, by the engineer, under the 

locomotive’s fuel tanks. 

September 09, 2000 – BNSF - Keokuk, IA FE-29-00 Recommendation 4 

While shoving one car into an industry site, and using radio communication, the switch foreman was 

run over by the leading wheel as the shove move continued until coupling was made. 

July 16, 2002 – NS - Bonlee, NC FE-17-02 Recommendation 4

While shoving lite engines back to train on mainline, employees failed to control the movement by 

radio, resulting in a collision with a standing train. 

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. 

Lifesaver 5 

Mentor less experienced employees to perform service safely. 

January 30, 1992 – AGC – Polk County, FL FE-04-92 Recommendation 5 

Industry switch crew, engineer and two flagmen, both flagmen rode the lower steps of the leading end 

of the lead locomotive. FE (flagman) was on left side, the other flagman on right side. After 2000 feet 

into this lite 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. 

June 02, 1992 – IHRC – Henderson, KY FE-16-92 Recommendation 5 

A two-person crew was switching an industry. The conductor had 11 months service with the railroad 

and, as the last move of the night, was to pull one car and set another in its place. As he set out the car 

and separated it from the car to go into the spot location, it began to roll away. He chased after it, tried 

to mount the end of the car with the handbrake and was killed when he slipped and fell under the car. 
 33 

October 19, 1993 – SOO – Leal, ND FE-40-93 Recommendation 5

A three-person train crew was in the process of picking up 18 cars off a siding. The trainman had 10 

weeks of experience, forgot to remove the derail, and was killed when the leading car he was riding 

derailed on top of him. During the stop, the conductor remained in the cab of the lead locomotive with 

the engineer. 

November 13, 1993 – GC – Macon, GA FE-47-93 Recommendation 5 

 also Recommendation 3

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 shoved without his knowledge while 

he was in the foul of the movement. Movement ran over conductor and killed him. 

November 10, 1994 – PTRA – Houston, TX FE-28-94 Recommendation 5 

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. 

December 06, 1994 – CR – Campbell Hall, NY FE-31-94 Recommendation 5 

 also Recommendation 2 and 4

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 nonconflicting position. Second local shoving three cars and a caboose with a two-month trainee directing 

the move, struck standing equipment after traversing switches that were unexpectedly lined for the 

equipment. 

October 04, 1995 – CSX – Riverdale, IL FE-29-95 Recommendation 5 

 also Recommendation 1

Crew performing switching in class yard. Switch foreman, with 5 months service, placed himself 

between the rails to adjust a misaligned 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 that rolled in on top of him and 

coupled him up. 

March 20, 1996 – BRC – Bedford Park, IL FE-09-96 Recommendation 5

 also Recommendation 1

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. 

June 15, 1996 – CSX – Charlotte, NC FE-12-96 Recommendation 5 

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 the 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 
 34 

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 boxcar and platform. FE had one year of experience. 

July 07, 1996 – NS – Sidney, IN FE-17-96 Recommendation 5 

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 track while trying to adjust his portable radio. 

Opposing train struck FE at this point. FE had one year of experience. 

September 03, 1996 – DGNO – Dallas, TX FE-22-96 Recommendation 5 

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. 

October 07, 1996 – UP – Eagle Pass, TX FE-24-96 Recommendation 5 

 also Recommendation 1

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. 

October 16, 1997 – MRL – Laurel, MT FE-32-97 Recommendation 5 

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. 

June 01, 1998 – BNSF – Lubbock, TX FE-16-98 Recommendation 5 

 also Recommendation 2

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. 

May 19, 1999 – NS – Cincinnati, OH FE-14-99 Recommendation 5 

A conductor with one year of service was riding in the stairwell of the leading locomotive. He was 

directing the move by radio when he realized to late that the move would not clear the standing 

equipment. He was crushed between the handrail of his locomotive and the standing locomotive. 

September 14, 1999 – AM – Van Buren, AR FE-24-99 Recommendation 5 

 also Recommendation 1

A two-person switching crew was in the process of shoving ten cars onto a clear track, with the 

intention of cutting three off, and pulling out the other seven out. The conductor counted down the 

cars via radio, and the engineer stopped one half-car lengths after the last radio transmission of one-
 35 

half cars to go. Subsequently, the engineer discovered that the conductor had stepped in between the 

cars and had been coupled up. 

January 10, 2001 – CSX – Chicago, IL FE-02-01 Recommendation 5 

Conductor with 14-months service was struck and killed by passing mainline train while attempting to 

board locomotive at crew-change point. 

June 16, 2002 – BNSF – Memphis, TN FE-16-02 Recommendation 5

 also Recommendation 1 and 3

A yard foreman, with 18-months of service, along with his helper, engineer and a utility employee had 

just finished making up a train in the yard. However, the crossover from the track on which the train 

had been made had to be cut. This last minute instruction led to an increased level of conversation 

among the crew, yard foreman, utility employee and the yardmaster. The yard foreman jumped on a 

ATV, rode it to the cut point, separated the train; and, when the cut not attached to the locomotive 

rolled, he was caught between the two sections of the train and killed. 

September 12, 2003 – GC – Dublin, GA FE-22-03 Recommendation 5 

A two-person train crew was in the process of setting off and picking up cars in a small yard. The 

conductor, who had 8 weeks of experience, was killed when the leading car of the shove struck him as 

he stepped into its path. 

Switching Fatalities Involving Special Switching Hazards 

Sixty switching fatalities that occurred from January 1992 through December 2003, did not involve 

circumstances associated with the Five Operating Recommendations. These fatality cases have been 

classified by the SWG into eleven groups (one group is a miscellaneous group) based on a sequence of 

events leading up to the fatality, such as being struck by mainline train; or by a fatality event 

characteristic, such as drugs or alcohol. The SWG believes an employee’s awareness of the Special 

Switching Hazards identified in the grouping will insure their safety and that of their crew members. 

Five of the Special Switching Hazard cases were classified under two groups: FE-15-92 was classified 

under ‘Employee Tripping, Slipping, Falling’ and ‘Unsecured Cars’; FE-46-93, ‘Unsecured Cars’ and 

‘Drugs and Alcohol’; FE-30-96, ‘Drugs and Alcohol’ and ‘Employee Tripping, Slipping, Falling’; FE40-01, ‘Close Clearance’ and ‘Struck by Mainline Trains’; FE-09-02, ‘Close Clearance’ and ‘Struck by 

Mainline Trains’. Such multiple classification reflects long sequence of actions and background 

conditions that can lead to switching fatalities. 

The SWG narratives of each fatality are presented below, classified by related event or characteristic 

into eleven groups: 

• Close Clearance 

• Struck by Mainline Trains 

• Free Rolling Railcars 

• Employee Tripping, Slipping, Falling 

• Struck by Motor Vehicle or Loading Device 

• Unsecured Cars 

• Environment 

• Drugs and Alcohol 
 36 

• Unexpected Movement of Railcars 

• Equipment 

• Miscellaneous 

Close Clearance 

August 04, 1993 – UP – Pryor, OK FE-27-93 Close Clearance 

A three-person industrial switching crew was shoving three cars down a track. The conductor was on 

the ground, ahead of the move and the brakeman was riding the side of the leading end of the leading 

car. A bush created a clearance issue and the brakeman stepped around the side of the leading car to 

the end of the car just as it began to derail. The brakeman was killed when he fell from the derailing 

car. 

April 12, 1994 – SP – Houston, TX FE-12-94 Close Clearance 

A three-person switching crew was in the process of switching out the car repair shop. The foreman 

had taken a position on the trailing end of the third leading car as the move was being shoved into a 

track having a close clearance condition that involved a protective grate that covered a winch. The 

foreman was knocked off the car by the covering, fell in front of the leading wheels of the forth leading 

car, and was later pronounced dead at the hospital. 

December 11, 1995 – NS – Toledo, OH FE-33-95 Close Clearance 

A three-person crew was called to switch an industry that all were very familiar with. During the 

switching moves, the brakeman was inside an area with no clearances between the cars and the hand 

railings installed on the walls. He was making coupling and, according to the conductor and engineer, 

upon completion of that work, ordered the engineer to haul out of the building where the conductor 

would take over the next move to be performed. Subsequently, a plant employee observed the 

brakeman slumped beside the track, rushed to assistance, call 911 and notified the conductor that his 

man was down. The brakeman died later on at the hospital of crushing wounds incurred when he was 

rolled between the cars being pulled out and the railing. 

December 14, 1995 – CSX – Monroe, NC FE-34-95 Close Clearance 

A three-person crew (engineer, conductor & conductor trainee) was called to operate a local freight 

train. During a switching operation at a yard, the conductor was riding nine cars down a clear track 

and directing the shove move by radio. When the engineer did not hear any more radio transmissions 

from the conductor, he stopped the move and found the conductor dead and lying beside the track he 

had been shoving down. Post accident investigation revealed that he had been struck by a truck trailer 

door positioned on a flat car standing on an adjacent track and that had been left open and swinging 

freely. The investigation revealed that a vandal had broken into the trailer and stolen material from it. 

July 01, 1998 – NS – Buechel, KY FE-19-98 Close Clearance 

A three-person local switching crew (conductor, engineer and utility employee) had just begun to pull 

five cars out of an industrial loading dock while the conductor and the utility employee began to walk 

toward the door providing egress out of the dock area. Suddenly, according to the conductor, the 

utility employee allegedly tripped on some material on the dock, grabbed the side of the outgoing cut 

of cars and was pulled between the car he was holding onto and the handrail structure that 

accompanied the stairs leading from the platform to the door. He died two weeks later. 
 37 

May 22, 2000 – CSX – Richmond, VA FE-16-00 Close Clearance 

A three-person road switching crew was in the process of spotting loaded coal cars at a unloading 

facility that was equipped with a “shaker” that helped empty each car. The shaker’s position causes a 

close clearance condition. The conductor was riding one side of the leading coal car and the brakeman 

was riding the other. Although having a clear view of the fouling equipment, the brakeman did not get 

off the car as the conductor had expected and was crushed between it and the fouling shaker 

equipment. 

July 28, 2000 – UP – St. Louis, MO FE-23-00 Close Clearance 

A three-person local switching crew was in the process of setting cars into a track within an industry. 

The switchman was riding the side ladder of the leading end of the leading car as it went into the 

building. The doorway would not clear a man riding on the side of the car and the trainman was killed 

as he was compressed between it and the car he was riding. 

October 10, 2001 – PAL – Clayburn, KY FE-31-01 Close Clearance 

A three-person, local freight train crew was switching a plant and had 2 engines 6 cars and a caboose 

when they moved over a small bridge and coupled to 5 standing cars in the storage track. The 

conductor made the coupling and told the engineer to pull the cars out of the track. The conductor got 

on the side of the trailing end of the second last car in the cut and was knocked off the car by a metal 

pole adjacent to the storage track. He fell between the car he was riding and the last car in the cut 

being pulled. He died when the lead wheels of the last car rolled over him. 

December 24, 2001 – NS – Lynchburg, VA FE-40-01 Close Clearance 

 also Struck by Mainline Trains 

A conductor, engineer and conductor in training had been transported to an unattended train standing 

on a siding a portion of which was in a tunnel adjacent to the main track. After storing their equipment, 

the conductor and the conductor in training left the locomotive to release hand brakes on the train. The 

conductor was killed when she failed to step in between two boxcars of her train as the conductor in 

training had done and was subsequently struck by a passing mainline train. 

March 21, 2002 – NS – Claymont, DE FE-09-02 Close Clearance 

 also in Stuck by Mainline Trains 

A locomotive engineer had been dropped off at the head end of his train while the conductor was taken 

to the rear to check on the REM. After crossing over the ATK corridor mainline tracks, and beginning 

to board his locomotive, the engineer was dragged off the stairs of the locomotive and killed by a 

passing 110 MPH passenger train. 

Struck by Mainline Trains 

July 07, 1992 – SSW – Colen Siding, TX FE-20-92 Struck by Mainline Trains 

A two-person crew was called to deadhead to a siding and bring the train that was there and tied down 

into the yard. Upon arrival at the train, the conductor began releasing handbrakes on the train and the 

engineer began releasing handbrakes and inspecting the four head end locomotives. An approaching 

60 MPH mainline train whistled for a highway crossing at grade and the conductor stopped what he 

was doing and positioned himself to do a roll by train inspection. His engineer was killed when he was 

struck by the passing train as he stepped out from between two of his units and began walking adjacent 

to, and in the foul of, the main track. 
 38 

April 13, 1993 – CSX - Dwale, KY FE-13-93 Struck by Mainline Trains 

A three-person crew reported for duty and was transported to a location where they took control of a 

mainline train. En-route, their work included swapping rear end marking devices. The brakeman 

apparently became confused, stepped into and began walking within the gauge of the main track, and 

was struck in the back by a passing mainline train. 

July 18, 1997 – MNCW – Stamford, CT FE-22-97 Struck by Mainline Trains 

A conductor/flagman was assigned to protect contractor workers that were installing construction poles 

near a passenger station platform. To better observe the work, the conductor/flagman placed himself 

within the gauge of a “live” main track and was struck and killed by a passing train. 

December 02, 1997 – BNSF – Emporia, KS FE-36-97 Struck by Mainline Trains 

The three-person crew had just finished making up their train at the yard. The conductor, for unknown 

reasons, had positioned himself on the “live” main trackside of his train, near the second and third 

locomotives. The conductor was struck and killed by a passing main track train that had approached 

the area from the opposite direction than that the conductor’s train was to proceed. 

December 28, 2000 – UP – Dupo, IL FE-32-00 Struck by Mainline Trains 

A three-person yard switching crew was in the process of pulling cars down a long lead that ran 

parallel to a main track. The switchman was standing between the cars that were being pulled out onto 

the lead and the main track. While the cars were being moved, a main line train approached his 

location. The switchman, with nowhere to go, was struck by the passing main line train and killed by a 

blow to the head. 

December 29, 2000 – BNSF – Gillette, WY FE-33-00 Struck by Mainline Trains 

A two-person freight train crew was about to be passed by another freight train at a location on line-ofroad. The conductor of the stopped train got up out of his seat, exited the leading locomotive and 

crossed over the track on which the on-coming train was proceeding. The conductor was struck and 

killed by the lead locomotive of the passing train. 

December 24, 2001 – NS – Lynchburg, VA FE-40-01 Struck by Mainline Trains 

 also Close Clearance 

A conductor, engineer and conductor in training had been transported to an unattended train standing 

on a siding a portion of which was in a tunnel adjacent to the main track. After storing their equipment, 

the conductor and the conductor in training left the locomotive to release hand brakes on the train. The 

conductor was killed when she failed to step in between two boxcars of her train as the conductor in 

training had done and was subsequently struck by a passing mainline train. 

March 21, 2002 – NS – Claymont, DE FE-09-02 Struck by Mainline Trains 

 also in Close Clearance 

A locomotive engineer had been dropped off at the head end of his train while the conductor was taken 

to the rear to check on the REM. After crossing over the ATK corridor mainline tracks, and beginning 

to board his locomotive, the engineer was dragged off the stairs of the locomotive and killed by a 

passing 110 MPH passenger train. 
 39 

Free-Rolling Railcars 

April 09, 1992 – ATSF – Cheto, AZ FE-09-92 Free-Rolling Railcars 

A three-person crew was called to operate a road local and arrived at a location where an eight-car 

drop would be necessary. After a job briefing, the engineer was at the throttle, the conductor at the 

switch and the brakeman was riding the first car of the drop, “A” end. The engineer began to pull, the 

brakeman lifted the pin, the engineer accelerated the locomotive beyond the switch, the conductor got 

the switch and the cars began free rolling into the yard. However, the speed of the movement would 

not allow the brakeman to safely dismount and, just before impact with another cut of cars, the 

brakeman attempted to dismount from the car he was riding and was killed as the cars rolled over him. 

October 23, 1992 – GTW – Dearborn, MI FE-34-92 Free-Rolling Railcars 

A three-person train crew found it necessary to drop a car by and in doing so, the car hung up fouling 

the switch and blocking the locomotive into the track it had cleared up on. The crew decided to 

“stake” the car to clear the track in which the locomotive sat. This process requires a board or pole 

placed between the locomotive and car to move the car when it cannot be coupled to. The brakeman 

was killed when the board used slipped, the car started to move toward the locomotive and the 

brakeman was caught between the two pieces of equipment. 

July 05, 1994 – BN – Essex, MT FE-16-94 Free-Rolling Railcars 

A three-person work train crew was in the process of dropping 14 cars they thought were empty into a 

quarry-loading track. The brakeman was riding the leading and brake end of the car. As the cars were 

separated from the engine, he set the high brake on the car he was riding. However, because there 

were residual materials in many of the cars, the weight added momentum to the cars and the brakeman 

got off and back on between two other cars in an attempt to set more hand brakes. When the cut of cars 

collided with a ballast pile, used as a bumping post, that was located at the end of the track, he was 

crushed to death between the two cars he was trying to apply hand brakes. 

April 21, 2000 – BNSF – Galesburg, IL FE-13-00 Free-Rolling Railcars 

A three-person switching crew was in the process of hauling cars over the hump and the foreman of the 

crew was observing the move from between his track and another track that was being used by another 

yard job. The foreman was killed when he fouled and then was struck by a free rolling car on the 

adjacent track. 

July 13, 2001 – CPRS – Bensenville, IL FE-21-01 Free-Rolling Railcars 

The three-person crew had just finished kicking a flat car into a clear track and the conductor was 

about to mount the leading end of a cut of cars to be kicked into another track further down the lead. 

As the conductor issued instructions to the engineer to begin the move, and to the crew, the flat car had 

not cleared the fouling point to the lead. The shove move rode up onto the flat car derailing the car the 

conductor was riding on which crushed him to death. 

February 16, 2003 – CSX – Syracuse, NY FE-04-03 Free-Rolling Railcars 

A two-person crew was flat switching in a yard when the switchman, needed a break. He mentioned it 

to the yard foreman and they decided to go to break after one last car was “kicked” into a specific 

track. A short time after the car had been released, the foreman’s operating control unit indicated a “no 

poll” failure and the locomotive shut down. When the foreman couldn’t contact the switchman he 

went looking for him. The brakeman was found struck and killed by the last car that had been 

“kicked”. 
 40 

Employee Tripping, Slipping, Falling 

June 01, 1992 – BN – Seattle, WA FE-15-92 Employee Tripping, Slipping, Falling

 also Unsecured Railcars 

A four-person crew (engineer, switch foreman, 2 switchman) had 3 cars with them when they coupled 

onto 56 cars standing on a yard track. They were told to pull the head 16 cars and leave the remaining 

40 there. They were also told that the 16 had been separated from the remaining 40. The crew pulled 

the 19 cars out of the track and per radio instructions from the switchman, began a shove into another 

track. As the movement entered the track it was struck by the 40 car cut that had been left on the first 

track. The switchman died falling from the cars while getting on and off the free rolling cut to set hand 

brakes in an attempt to stop them. 

March 27, 1993 – SP – Guadalupe, CA FE-11-93 Employee Tripping, Slipping, Falling 

A four-person crew (engineer, conductor, 2 brakeman) were in the process of pulling one track out and 

then intended to shove back into another track to pick up more cars. The head brakeman was in 

control of the move. The rear brakeman was found dead adjacent to the track that was pulled. 

Evidence suggests that the rear brakeman may have mounted, or tried to mount the car that ran him 

over as the cut was pulled out of the track. 

July 21, 1995 – CR – Hershey, PA FE-23-95 Employee Tripping, Slipping, Falling 

A three-person crew was switching an industry. The conductor had directed a few switching moves 

and then instructed the engineer to haul out of the plant. The conductor was observed by a plant 

employee riding on the trailing end of the first of two tank cars being pulled out of the plant. Moments 

later the conductor fell between the cars and was killed when he was run over by the trailing car in the 

two car move. 

December 16, 1996 – UP – Clinton, IA FE-30-96 Employee Tripping, Slipping, Falling 

 also Employee Drugs and Alcohol 

A three-person crew was in the process of switching a plant when the conductor sent the locomotive 

and cars out of one track toward the brakeman who was to handle the switches and direct the cars into 

another track. The conductor stopped the move after the cars had cleared an industry road crossing and 

the engineer waited to receive instructions from the brakeman. However, the brakeman had mounted 

the second head car behind the locomotives and had apparently slipped or fell from that position and 

was found dead by the engineer and conductor lying between and beneath the fourth head car. The 

brakeman tested positive for THCA & THC. 

January 12, 1997 – UP – S Fontana, CA FE-02-97 Employee Tripping, Slipping, Falling 

A three-person road crew arrived at a siding, pulled into the siding and stopped their train. They then 

cut off their locomotive consist, ran around the 50 loaded cars in their train, and tied onto the opposite 

end. The conductor and brakeman then positioned themselves on the leading end of the shove move 

and directed the engineer by radio to begin the shove into the plant. As the move entered a descending 

grade into the plant, the slack ran out, the conductor lost his hold on the leading car, fell in front of the 

car he was riding, was run over and died. 

June 24, 1997 – UP – Portland, OR FE-18-97 Employee Tripping, Slipping, Falling 

FE-18-97: A three-person yard switching crew was in the process of pulling a five car articulated cut 

of cars from out of one track with the intent of moving them to another. The yard foreman was killed 
 41 

when he was run over by the leading wheels of the trailing car. It appears that the foreman tried to 

release a hand brake at the trailing end of the second to the last car and while attempting to do so, 

stumbled, fell and was run over by the trailing car. 

Struck by Motor Vehicle or Loading Device 

September 20, 1994 – ARR – Clear Site, AK FE-20-94 Struck by Motor Vehicle... 

A three-person work train crew was shoving their train on the main line. The locomotive engineer was 

operating the locomotive and the brakeman and conductor were in the caboose. A tractor-trailer pulled 

over the crossing and was struck by the shove move, derailing the caboose and killing the brakeman. 

February 17, 1999 – KCS – Kansas City, MO FE-05-99 Struck by Motor Vehicle... 

A three-person switching crew was working in a piggy-back facility and had just finished shoving a cut 

of cars down a track to be worked by the piggy-packers (equipment used to load and unload 

TOFC/COFC rail shipments). The conductor was returning to the locomotive when he was struck and 

killed by one of the piggy-packers. 

December 22, 2001 – NS – Eden, NC FE-39-01 Struck by Motor Vehicle... 

A three-person, local switching crew that included a conductor in training were in the process of 

shoving a cut of cars over a highway road crossing at grade. The brakeman was riding one corner of 

the leading car and the conductor in training was riding the opposite side of the car. All warning 

devices were in operation when a van struck the leading end of the car knocking the brakeman off the 

car and under the leading wheels. 

June 06, 2003 – CSX – Kingsport, TN FE-12-03 Struck by Motor Vehicle... 

A three-person industrial switching crew was shoving one car on a track that ran down the middle of a 

two-lane road and that was located in an industrial area. The conductor was riding on one side of the 

car and the brakeman was riding on the other. As the move approached a standing eighteen-wheel 

truck awaiting permission to back into the same area that the railroad was servicing, the driver began to 

back up, jack-knifed the trailer, and struck the brakeman crushing him between the truck box and the 

car he was riding. 

Unsecured Cars 

June 01, 1992 – BN – Seattle, WA FE-15-92 Unsecured Cars

 also Employee Tripping, Slipping, Falling

A four-person crew (engineer, switch foreman, 2 switchman) had 3 cars with them when then coupled 

onto 56 cars standing on a yard track. They were told to pull the head 16 cars and leave the remaining 

40 there. They were also told that the 16 had been separated from the remaining 40. The crew pulled 

the 19 cars out of the track and per radio instructions from the switchman, began a shove into another 

track. As the movement entered the track it was struck by the 40 car cut that had been left on the first 

track. The switchman died falling from the cars while getting on and off the free rolling cut to set hand 

brakes in an attempt to stop them. 

November 12, 1993 – ATSF – Farewell, TX FE-46-93 Unsecured Cars 

 also Drugs and Alcohol 

A three-person industrial switching crew had been working together to get the switches lined and the 

derail off in preparation for a shove move into the plant. The conductor was on the leading end of the 

lead car and the brakeman was on the trailing end of the same car. The conductor was crushed by a car 
 42 

he had set out without setting a hand brake. The car rolled into a car he and his brakeman were riding 

and impairment (drugs) contributed to the fatality. 

January 04, 1994 – BN – Hastings, NE FE-02-94 Unsecured Cars 

A three-person crew were in the process of pulling a cut of cars out of a track and leaving two 

additional cuts sitting separately in the track. The helper was riding the cut out of the track and the 

foreman was last seen walking between the two remaining cuts of cars. Evidence suggests that the 

foreman attempted to cross over the tracks between the cars being pulled out and the first of two 

remaining cuts of cars when he was crushed between the cars being pulled out and the second cut of 

cars after they were impacted by the third, unsecured cut. 

April 06, 1995 – WC – Argoe, WI FE-16-95 Unsecured Cars 

A two-person crew was switching at a siding in single-track territory. The conductor left a portion of 

his train on the mainline and went into the siding with a cut of cars. While in on the siding, the cars 

left on the mainline and, as post accident investigation revealed, had been left with the air “bottled”, 

rolled away. The crew chased the runaway cars with the conductor riding the leading end of the lead 

car and the engineer, 23 cars away, shoving as directed by radio commands from the conductor. The 

shove move struck the runaway cars and the conductor was crushed to death as a result of the collision. 

December 18, 1996 – IC – Chicago, IL FE-31-96 Unsecured Cars 

A three-person yard crew was in the process of switching a plant. The brakeman was at the plant doors 

and the conductor and engineer had hauled out to put away a car that had been removed from the plant. 

After the conductor had tied onto the cars to go into the plant and begun to shove toward the plant, the 

car that had just been placed on an adjacent track rolled out, fouled the conductor’s movement, and 

crushed him between the leading car and the rolling car. 

February 18, 2003 – CSX – Cheektowaga, NY FE-05-03 Unsecured Cars 

A three-person switching crew was in the process of shoving cars into a track at an industry. The 

switch foreman was riding the leading end of the shove and directing the move when he was struck by 

the cut of cars that they had left on another track and which had rolled out and into his shove move. 

Environment 

December 30, 1993 – CR – Brook Park, OH FE-53-93 Environment 

A three-person industrial switching crew was shoving over an industrial crossing within the confines of 

a plant. The conductor was riding the leading end of the lead car when it rode up on ice, built up 

within the flange-ways, and derailed the car into the side of the building. The conductor was crushed 

between the car he was riding and the building. 

January 22, 1999 – CR – Alexander, NY FE-03-99 Environment 

A three-person local switching crew was shoving a loaded covered hopper down an industrial lead. 

The conductor was riding on one side of the car and the brakeman was riding the other. As the car was 

shoved over a private crossing, the accumulation of ice and snow lifted the car off the rails and it 

tipped over and onto the conductor who was killed as a result of the derailment. 

January 02, 2000 – CIRR – Cedar Springs, GA FE-02-00 Environment 

A two-person switching crew was in the process of switching cars in a storage yard and the conductor 

was riding the leading end of a cut of cars being shoved down a track. The move was taking place in 
 43 

dense fog and in darkness when the car he was riding collided with other cars on an adjacent track that 

were fouling the track he was on. The conductor was killed as a result of the collision. 

Equipment 

January 14, 1994 – BN – Amarillo, TX FE-03-94 Equipment 

A three-person crew reported for duty and later was in the process of shoving cars down a track with 

the switch foreman riding the point. At the same time, another yard switching job was pulling cars in 

the opposite direction on an adjacent track and derailed. The foreman immediately told the other crew 

that they were on the ground and then told his engineer to stop the shove he was riding. The foreman 

was found crushed between the car he was riding and the car that derailed on the adjacent track. 

January 11, 1995 – CR – Indianapolis, IN FE-02-95 Equipment 

A three-person crew was in the process of switching a plant. The conductor was riding the leading end 

of the lead car during an eight-car shove. He had notified the engineer that he had mounted the 

moving car and told him by radio to continue shoving. When the engineer did not hear any more from 

the conductor, he stopped and the brakeman walked back to find the conductor had been run over by 

five of the eight cars being shoved. An exception was taken by the FRA for the absence of the “BR” 

end handhold that could have been used to assist the conductor in moving from the side of the car to 

the end of the car. 

April 09, 1999 – UP – Richland, WA FE-12-99 Equipment 

A three-person road switcher was in the process of dropping a car into a track. However, the 

locomotive was fouling the track the car was to enter. The brakeman, realizing this, jumped from the 

trailing end of the car and ran to the leading end to try and stop the car. The conductor, who was 

standing near the fouling corner of the locomotive, started up the stairwell of the locomotive when he 

realized what was happening. However, the stairwell was obstructed with a metal rod that had been 

welded into place and prevented the conductor an escape route. He was subsequently crushed between 

the striking car and the metal rod. 

September 14, 2003 – UP - Ogden, UT FE-23-03 Equipment 

A four-person yard switching crew had been working together and classifying cars into various tracks 

throughout the morning. The conductor was on the leading end of a two car free rolling cut of cars 

moving at 3 miles per hours when he fell from the leading end and was run over by the car he had been 

riding. 

Drugs and Alcohol 

November 12, 1993 – ATSF – Farewell, TX FE-46-93 Drugs and Alcohol 

 also Unsecured Cars 

A three-person industrial switching crew had been working together to get the switches lined and the 

derail off in preparation for a shove move into the plant. The conductor was on the leading end of the 

lead car and the brakeman was on the trailing end of the same car. The conductor was crushed by a car 

he had set out without setting a hand brake. That car rolled into a car he and his brakeman were riding 

and impairment (drugs) contributed to the fatality. 
 44 

December 16, 1996 – UP – Clinton, IA FE-30-96 Drugs and Alcohol 

 also Employee Trips, Slips, and Falls 

A three-person crew was in the process of switching a plant when the conductor sent the locomotive 

and cars out of one track toward the brakeman who was to handle the switches and direct the cars into 

another track. The conductor stopped the move after the cars had cleared an industry road crossing and 

the engineer waited to receive instructions from the brakeman. However, the brakeman had mounted 

the second head car behind the locomotives and had apparently slipped or fell from that position and 

was found dead by the engineer and conductor lying between and beneath the fourth head car. The 

brakeman tested positive for THCA & THC. 

January 24, 1998 – BNSF – Omaha, NE FE-02-98 Drugs and Alcohol 

A three-person switching crew was working in close proximity to another switching crew and, after 

some discussion, but no absolute understanding of the move just made by the other crew, began to pull 

down the switching lead. As they approached a mis-aligned switch, the foreman jumped off the 

moving locomotive, ran to the switch and was in the process of “flopping it over” when the leading 

wheels of the locomotive entered the switch, popped the handle up, striking the foreman in the face 

and killing him. Post accident testing indicated that drug impairment may have contributed to the 

fatality. 

Unexpected Movement of Railcars 

June 24, 1997 – NS – Rowesville, SC FE-19-97 Unexpected Movement of Railcars 

The engineer and conductor of a local road switcher were reassembling their train at a siding halfway 

through their work assignment. After running around the inbound cars, making a couple of switches to 

line up their train for the return trip, the conductor tied the EOT device onto the rear car, came back to 

the switch, and told the engineer to back up five cars. The engineer did not get any other radio 

instructions after three cars and stopped. The conductor was found dead having been run over by the 

leading car and not having reversed the siding switch as he had intended to do. 

November 17, 1999 – UP – Lincoln, NE FE-32-99 Unexpected Movement of Railcars 

A three-person local switching crew had cut away from their train on the main track and proceeded to 

pull by the switch providing access to a clear track. The brakeman was at the switch and the conductor 

had removed the derail from the clear track and was awaiting the shove move at the point where the 

cut would be made. Meanwhile, the brakeman, who was to have gotten the switch from the main to 

the clear track, was walking between the gauge of the mainline track toward the remaining portion of 

his train. The conductor saw the cars being shoved toward the remaining portion of his train and 

shouted to the brakeman and then to the engineer to stop. The brakeman with his back to the move 

was hit and run over by the leading car of the shove. 

October 02, 2002 – CSX – Madisonville, KY FE-22-02 Unexpected Movement of Railcars 

A two-person road crew stopped at a yard to make a set-off. The conductor made the cut on his train, 

instructed the engineer to haul ahead to clear the switches into the yard, lined the switches into what he 

thought was Track 4 and told the engineer to begin backing the set off into the yard. The conductor 

was struck and killed by the leading end of the shove move as it entered Track 3. 

December 07, 2003 – UP – San Antonio, TX FE-35-03 Unexpected Movement of Railcars 

A pitch/catch remote control operation was being run by a single operator who was struck and killed 

during a yard operation by his own locomotive. He stepped in front of its movement as he was headed 
 45 

for the other end of a crossover switch that he intended to line for the route he intended his engine to 

use. 

Miscellaneous 

October 15, 1992 – BN – Omaha, NE FE-33-92 Miscellaneous 

A three-person yard crew was in the process of spotting cars over a material unloading pit and after the 

first of the cars was spotted the switch foreman took the locomotive out of the plant building to get the 

other car for spotting. The switchman remained in the building, set a handbrake on the spotted car and 

awaited the return of the foreman with the engine and second car to be spotted. The switchman was 

killed when he ended up falling into the second pit and was crushed by the industrial machinery 

located within. 

November 16, 1992 – TTIS – Maysville, KY FE-39-92 Miscellaneous 

A two-person train crew was taking a coal train down a 3 percent grade and through an eight-degree 

curve when the train separated at the 17th head car. The cause of the separation was a broken knuckle. 

To remove the partially broken knuckle, the conductor decided that he had to impact the standing cars 

with the 17 head cars. On his third attempt, the couplers by-passed and the corners of the 18th and 17th

head cars came together at the push pole pads crushing the conductor between them. 

May 22, 1993 – ATSF – El Paso, TX FE-20-93 Miscellaneous 

A three-person switching crew was in the process of shoving cars into a track in the TOFC yard. The 

switch foreman was directing the move when he was struck from behind by the left front fender of a 

hostler truck and run over by its rear wheels. 

June 04, 1993 – SEPTA – Devon, PA FE-22-93 Miscellaneous 

A commuter train locomotive engineer fell from the operating compartment of the train he was 

operating while it was moving. Two minutes before he fell speed had been reduced from 61 to 51 

MPH. 

September 02, 1993 – ATSF – Carlsbad, NM FE-35-93 Miscellaneous 

A three-person crew, accompanied by an engineer and a brakeman trainee, were trying, for the second 

time to make a coupling between two cars in a yard. The conductor was allowing the brakeman trainee 

to learn radio use and had just told him to tell the engineer to come back for another attempt at 

coupling. The brakeman turned toward the locomotives, relayed the conductor’s instructions, looked 

back at the conductor and saw him impaled between the knuckles of the two cars. 

January 18, 1994 – CSX – Bainbridge, GA FE-04-94 Miscellaneous 

A three-person switching crew was in the process of shoving cars down an industrial lead. The 

conductor and brakeman were riding the end platform of a tank car and, as the move approached a 

highway/rail grade crossing, the brakeman gave the engineer a car count in which to stop. As a result, 

there was some “slack action” and the conductor fell from the end platform onto the rail and was 

pronounced dead at the hospital over five hours later. 

March 21, 1995 – SP – Bassett, CA FE-17-95 Miscellaneous 

A three-person crew was called to operate a road local and arrived at a location where some plant 

switching was to take place. After lining up their cars, the two locomotives and two cars began a 

shove move on the brakeman’s radio command. The brakeman was walking adjacent to the track on 
 46 

which the cars were being shoved and had his back to the move. He was killed when he suddenly 

crossed the tracks in front of the movement and was struck. The move stopped immediately. Post 

accident investigation revealed that the brakeman was concerned about the results of a medical 

examination that were due the next day. 

October 26, 1998 – CCP – Cicero, IL FE-28-98 Miscellaneous 

An engineer, having just gone off duty, was distracted and subsequently struck and killed by a lite 

engine move being operated by a hostler. The hostler was operating the locomotive consist from the 

trailing end at the time and did not have anyone on the leading end when the engineer was struck. 

May 31, 2000 – UP – Pine Bluff, AR FE-17-00 Miscellaneous 

A three-person yard switching crew was in the process of moving their light locomotives through a 

series of crossover switches however, the switchman had gone to the yard office for another list of cars 

to switch and the foreman, who had two (2) years of service, was directing the lite engine move by 

radio. The foreman told the engineer to stop, the foreman got off the leading end of the lead 

locomotive to line switches, he then told the engineer to continue backing up. Shortly thereafter, the 

foreman was crushed in a side collision between the locomotive consist he was directing and other cars 

standing on an adjacent track. 

April 08, 2001 – BNSF – Clark, OK FE-14-01 Miscellaneous

The conductor of a road switcher pulled his train into a yard, got off, made a cut behind three cars and 

told the engineer to pull ahead to clear a crossover switch he intended to use. After getting the 

crossover, he mounted the leading end of the move and told the engineer to come back seven cars. 

Three car lengths later, the movement passed through one end of another crossover switch in reverse 

position and diverted the movement into the side of a standing cut of cars crushing the conductor to 

death. 

September 24, 2003 – BNSF – Fresno, CA FE-25-03 Miscellaneous 

A three-person switching crew was shoving a cut of cars into a yard track and the switching foreman 

was riding the leading end of the 35 car cut. There was no air in the train line and the engineer was 

using engine brake to control the shove during the 50 car lengths of clear track to be shoved prior to 

making a coupling on other cars in the same track. Twenty cars into the move the foreman was either 

dislodged or fell from the leading end of the movement and was run over by the sixth head car of the 

shove. 
 47 

4. SWITCHING FATALITIES – UNDERSTANDING AND PREVENTION 

4.1 Switching Fatalities Occur for a Reason 

The SOFA Working Group (SWG) is trying to understand why each and every switching fatality 

occurred in working towards the prevention of switching fatalities. The SWG believes that switching 

fatalities happen for reasons that can be understood – and are not just random occurrences, nor a series 

of unlikely and unfortunate events, nor just plain bad luck. The risk to employees engaged in switching 

operations is real, and it can be reduced through understanding of past fatality events. Further, many 

switching fatalities occur for the same reason. Thus, any one of the Five Operating Recommendations, 

and its operating procedure, will prevent many fatalities. 

The SWG developed a classification system that will: 

• provide understanding of why each fatality occurred 

• group similar fatalities together 

• suggest preventive measures. 

4.2 Switching Fatalities Involving the SOFA Five Operating Recommendations 

In Section 3, the 124 switching fatalities occurring from January 1992 through December 2003 were 

first classified as to whether one or more of the Five Operating Recommendations applied. Sixty-four 

fatalities fell into that group – 52 percent. For these fatalities, the SWG believes that future fatalities of 

a similar nature can be prevented by implementing one or more of the Five Operating 

Recommendations. The Recommendations were developed from review of 76 switching fatalities and 

were included in the SOFA Report released October 1999. 

4.3 Switching Fatalities Involving Special Switching Hazards 

 The remaining 60 fatality cases, those involving Special Switching Hazards, were classified by the 

SWG into eleven groups (one group is a miscellaneous group), as shown in Table 4-1, based on a 

sequence of events leading up to the fatality, such as being struck by mainline trains; or by a fatality 

event characteristic, such as drugs or alcohol. The SWG believes an employee’s awareness of the 

Special Switching Hazards identified in the grouping will insure their safety and that of their crew 

members. 

Table 4-1. Sixty Special Switching Hazard Fatalities Not Involving SOFA Operating 

Recommendations 

 Type Number 

Close Clearance 10 

Struck by Mainline Trains 8 

Employee Tripping, Slipping, Falling 6 

Free Rolling Railcars 6 
 48 

Unsecured Cars 6 

Equipment 4 

Struck by Motor Vehicle or Loading Device 4 

Unexpected Movement of Railcars 4 

Environment 3 

Drugs and Alcohol 3 

Miscellaneous 11 

total 65 

* less cases classified in two category types 5 

net total 60 

* FE-15-92 was classified under ‘Employee Tripping, Slipping, Falling’ and ‘Unsecured Cars’; FE-46-93, ‘Unsecured 

Cars’ and ‘Drugs and Alcohol’; FE-30-96, ‘Drugs and Alcohol’ and ‘Employee Tripping, Slipping, Falling’; FE-40-01, 

‘Close Clearance’ and ‘Struck by Mainline Trains’; FE-09-02, ‘Close Clearance’ and ‘Struck by Mainline Trains’.

Close Clearance 

The Special Switching Hazard group with the largest number of fatalities is Close Clearance. Ten 

fatalities fall into this group (Table 4-2). The group would be larger if those involving Operating 

Recommendations were included. To date, the SWG has identified five cases involving Operating 

Recommendations that also involve Close Clearance, bringing the total to fifteen.8

Table 4-2. Ten Close Clearance Fatalities Not Involving SOFA Operating Recommendations* 

# RR Date Location FRA Report # 

1 UP 08/04/93 Pryor, OK FE-27-93 

2 SP 04/12/94 Houston, TX FE-12-94 

3 NS 12/11/95 Toledo, OH FE-33-95 

4 CSX 12/14/95 Monroe, NC FE-34-95 

5 NS 07/01/98 Buechel, KY FE-19-98 

6 CSX 05/22/00 Richmond, VA FE-16-00 

7 UP 07/28/00 St. Louis, MO FE-23-00 

8 PAL 10/10/01 Clayburn, KY FE-31-01 

9 NS 12/24/01 Lynchburg, VA FE-40-01 

10 NS 03/21/02 Claymont, DE FE-09-02 

‘Close Clearance’ is defined by the SWG: When an employee is passing, or being passed, by an object 

or equipment and the conditions are such that there is not enough room for the employee to avoid 

being struck. The definition is a broad one. It includes the traditional definition used by some railroads 

 

8

 The SWG determined that five switching fatalities involving Operating Recommendations also involved Close Clearance: 

FE-18-92 (Recommendation 1), FE-06-94 (Recommendation 2), FE-12-96 (Recommendation 5), FE-05-98 

(Recommendation 2), and FE-29-00 (Recommendation 4). Thus, of 124 fatalities occurring from January 1992 to 

December 2003, 15 (12 percent) fatalities involved Close Clearance. 
 49 

as the lack of sufficient “... space between objects; and on the roadway, as the lack of clearance in the 

absents of space between wayside objects and rolling stock, or between rolling stock on adjacent 

tracks.” 9

‘Close Clearance’ for the SWG also includes fouling a track, defined as “the placement of an 

individual or an item of equipment in such proximity to a track that the individual or equipment could 

be struck by a moving train or on-track equipment, or in any case is within four feet of the field side of 

the near running rail.”10 

FE-16-00 and FE-31-01, described below, illustrate the traditional definition of Close Clearance, i.e., 

dangers inherent with close or no clearance structures: 

FE-16-00: A three-person road switching crew was in the process of spotting loaded coal cars 

at a unloading facility that was equipped with a “shaker” that helped empty each car. The 

shaker’s position causes a close clearance condition. The conductor was riding one side of the 

leading coal car and the brakeman was riding the other. Although having a clear view of the 

fouling equipment, the brakeman did not get off the car as the conductor had expected and was 

crushed between it and the fouling shaker equipment. 

FE-31-01: A three-person, local freight train crew was switching a plant and had 2 engines 6 

cars and a caboose when they moved over a small bridge and coupled to 5 standing cars in the 

storage track. The conductor made the coupling and told the engineer to pull the cars out of the 

track. The conductor got on the side of the trailing end of the second last car in the cut and was 

knocked off the car by a metal pole adjacent to the storage track. He fell between the car he 

was riding and the last car in the cut being pulled. He died when the lead wheels of the last car 

rolled over him.

As mentioned, the SWG also includes cases of fouling track in its definition of ‘Close Clearance.’ The 

SWG recognizes that it can justifiably be argued that cases such as FE-09-02 or FE-40-01, described 

below, are fouling track issues, not close clearance problems:

FE-09-02: A locomotive engineer had been dropped off at the head end of his train while the 

conductor was taken to the rear to check on the REM. After crossing over the ATK corridor 

mainline tracks, and beginning to board his locomotive, the engineer was dragged off the stairs 

of the locomotive and killed by a passing 110 MPH passenger train. 

 

9

 Christopher F. Schulte. Railroad Track Terms, 3rd edition, 2003. Simmons-Boardman Books, Inc., Omaha, NE. 

10 49 CFR, Part 214.7, Definitions. Revised October 2003. 
FE-40-01: A conductor, engineer and conductor in training had been transported to an 

unattended train standing on a siding a portion of which was in a tunnel adjacent to the 

main track. After storing their equipment, the conductor and the conductor in training left 

the locomotive to release hand brakes on the train. The conductor was killed when she 

failed to step in between two boxcars of her train as the conductor in training had done 

and was subsequently struck by a passing mainline train. 

There are some cases in the SWG’s definition of Close Clearance that exceed expected 

operational conditions, such as FE-34-95: 

FE-34-95: A three-person crew (engineer, conductor & conductor trainee) was called to 

operate a local freight train. During a switching operation at a yard, the conductor was 

riding nine cars down a clear track and directing the shove move by radio. When the 

engineer did not hear any more radio transmissions from the conductor, he stopped the 

move and found the conductor dead and lying beside the track he had been shoving 

down. Post accident investigation revealed that he had been struck by a truck trailer door 

positioned on a flat car standing on an adjacent track and that had been left open and 

swinging freely. The investigation revealed that a vandal had broken into the trailer and 

stolen material from it. 

In the end, the SWG decided that these 10 cases shown in Table 4-2, and the five cases also 

involving Operating Recommendations, had one thing in common, an object or equipment was 

passing or being passed and the conditions were such that there was not enough room for the 

employee to avoid being struck. Sometimes, the condition was speed, sometimes environment 

(trees or brush fouling the track); but in any case, the SWG could not identify enough 

commonalities regarding the event, location, or even the physical act to make a one size fits all 

recommendation. 

The SWG urges safety committees, engineering departments, and other railroad industry 

stakeholders to address all aspects of Close Clearances: 

• Where feasible, re-engineer and/or eliminate close clearances. 

• Provide safe clearance in future engineering projects. 

• Mark all permanent close clearance areas with highly visible signs. 

• Expand job briefings (Operating Recommendation 3) to include: 

o emphasis of dangers of equipment left fouling 

o warnings to other crews when placing oversized cars on tracks adjacent to 

their work 

o discussions of risks of passing trains when working near mainline 

 50
Struck by Mainline Trains 

While there have been 13 of 124 cases that involved an employee being struck by a mainline 

train, the SWG believes that 5 of the 13 fatalities were preventable by observing Operating 

Recommendations. The 8 fatalities not involving an Operating Recommendation did not occur 

for a single reason or for a few reasons. Other than general vigilance, awareness, and alertness to 

the switching environment, it is difficult to prescribe a preventive measure. 

Table 4-3. Eight Being-Struck-By-Mainline-Train Fatalities Not Involving SOFA 

Operating Recommendations* 

# RR Date Location FRA Report # 

1 SSW 06/07/92 Conlen Siding, TX FE-20-92 

2 CSX 04/13/93 Dwale, KY FE-13-93 

3 MNCW 07/18/97 Stamford, CT FE-22-97 

4 BNSF 12/02/97 Emporia, KS FE-36-97 

5 UP 12/28/00 Dupo, IL FE-32-00 

6 BNSF 12/29/00 Gillette, WY FE-33-00 

7 NS 12/24/01 Lynchburg, VA FE-40-01 

8 NS 03/21/02 Claymont, DE FE-09-02 

* The SWG determined that five switching fatalities involving Operating Recommendations also involved being-struckby-mainline-trains: FE-49-93 (Recommendation 3), FE-17-96 (Recommendation 5), FE-02-01 (Recommendation 5), 

FE-03-01 (Recommendation 3), and FE-08-01 (Recommendation 1). Thus, of 124 fatalities occurring from January 

1992 to December 2003, 13 (11 percent) fatalities involved being-struck-by-mainline-trains.

4.4 Job Briefing and Mentoring – Operating Recommendation 3 and 5 

After examination of the 124 fatality cases, the SWG expressed concern about further identifying 

relevant recommendations to improve safety of switching based on the available objective data. 

The diversity of the events and occurrences surrounding these employee deaths was clearly 

evident to the SWG. This realization lead to the re-examination of: 

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.

Table 4-4. Fourteen Fatalities Involving SOFA Operating Recommendation 3 

# RR Date Location FRA Report # 

1 GBW 07/24/92 Wisconsin Rapids, WI FE-30-92 

2 IC 06/07/93 Fulton, KY FE-23-93 

3 SP 08/11/93 Tracy, CA FE-30-93 

4 GC 11/13/93 Macon, GA FE-47-93 

 51
5 SOU 12/05/93 Atlanta, GA FE-49-93 

6 CR 11/15/94 Painted Post, NY FE-29-94 

7 CR 02/17/95 St. James, OH FE-09-95 

8 NS 03/02/95 Aiken, SC FE-12-95 

9 CR 01/12/99 Port Newark, NJ FE-01-99 

10 DME 04/02/99 Waseca, MN FE-11-99 

11 UP 10/15/00 Houston, TX FE-30-00 

12 NS 01/11/01 South Fork, PA FE-03-01 

13 BNSF 06/16/02 Memphis, TN FE-16-02 

14 UP 04/11/03 Pocatello, ID FE-11-03 

It was apparent to the SWG that many of the diverse events and occurrences that lead to the 

death of employees may have been mitigated through effective “job safety briefing.” You can 

never communicate too effectively. It became apparent to the SWG that providing a minimum 

suggested content for an initial job safety briefing should be made available. It was also evident 

to the SWG that the perception of “work changes” is very qualitative and should be addressed in 

specific language that is understandable and comprehensible to all crew members. Job Safety 

Briefing instructions for various carriers are available for review in Appendix F. 

All crew members should receive training in the art of job safety briefings. The initial job safety 

briefing should provide detailed and specific information on all relevant activities to be 

performed. The training should help necessitate sufficient conversation and review between 

every crew member to make everyone feel comfortable about the service to be performed. When 

practical, a supervisor or other knowledgeable employee should be present during the entire job 

safety briefing and take part in it when appropriate. Every concern should be addressed to the 

satisfaction of each crew member. Crew members should engage in active communications 

sufficient to establish their mutual understanding and safely perform the service required. 

Successful communication among all parties is essential. 

Any work changes or developments that may impact safety should be immediately addressed to 

everyone’s satisfaction. Any crew member observing a safety concern should safely stop all 

activity and thoroughly review the concern with every other crew member. Job safety briefings 

should offer a comfortable environment for fellow employees to discuss yard and industry 

switching issues where questions or concerns may exist. Crew members should be afforded the 

opportunity to resolve any yard and/or industry switching issues. They should seek the advice of 

knowledgeable and experienced crew members, or proper authority if necessary. No action 

should be taken until a solution is reached and then communicated to all concerned. 

Further, the Working Group recommends that additional advantage be taken of its 

Recommendation 5 in conjunction with its additional suggested action of Train Crew Resource 

Management (CRM). 

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 

 52
review, mentoring, and supervisory observation must be utilized to insure employees are able to 

perform service in a safe manner.

Table 4-5. Nineteen Fatalities Involving SOFA Operating Recommendation 5 

# RR Date Location FRA Report # 

1 AGC 01/30/92 Polk County, FL FE-04-92 

2 IHRC 06/02/92 Henderson, KY FE-16-92 

3 SOO 10/19/93 Leal, ND FE-40-93 

4 GC 11/13/93 Macon, GA FE-47-93 

5 PTRA 11/10/94 Houston, TX FE-28-94 

6 CR 12/06/94 Campbell Hall, NY FE-31-94 

7 CSX 10/04/95 Riverdale, IL FE-29-95 

8 BRC 03/20/96 Bedford Park, IL FE-09-96 

9 CSX 06/15/96 Charlotte, NC FE-12-96 

10 NS 07/07/96 Sidney, IN FE-17-96 

11 DGNO 09/03/96 Dallas, TX FE-22-96 

12 UP 10/07/96 Eagle Pass, TX FE-24-96 

13 MRL 10/16/97 Laurel, MT FE-32-97 

14 BNSF 06/01/98 Lubbock, TX FE-16-98 

15 NS 05/19/99 Cincinnati, OH FE-14-99 

16 AM 09/14/99 Van Buren, AR FE-24-99 

17 CSX 01/10/01 Chicago, IL FE-02-01 

18 BNSF 06/16/02 Memphis, TN FE-16-02 

19 GC 09/12/03 Dublin, GA FE-22-03 

CRM promotes training in the importance of and procedures for effective intra-crew 

communications. The Working Group pointed out in its original report that such communications 

have the potential to make a major contribution to the safety of switching operations. The 

Working Group again recommends that the railroad industry, i.e., labor, management, and FRA, 

consider CRM programs that address improving crew coordination and communications. Again, 

compelling evidence suggests that many fatalities resulted from unexpected train movement, 

particularly at very low speeds. Switching operations training programs should employ the 

principles of CRM to assure than no opportunities are overlooked to heighten safety awareness 

and 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. Additionally, the 

initial on duty and subsequent job safety briefings afford an opportunity to focus the message 

and further the common goal of a safe working environment. 

 

4.5 Shoving as a Special Switching Hazard 

In reviewing the 124 switching fatalities, it was apparent to the SWG that shove movements 

present special risks in switching operations. Sixty-one fatalities involved shove moves. There 

are 116 of the 124 fatalities known to involve train movement. Thus, 53 percent (61/116) of 

fatalities involving movement had shoving as the direction of movement. 

 53
Whether given the amount of shoving done, compared to pulling, makes fatalities with shoving 

as the direction of movement over- or under-represented in switching operations is answerable 

only by having the appropriate number of train miles dimensioned by direction of movement. 

But whatever the answer is does not change the fact that fatalities involving shoving are a sizable 

cluster of switching fatalities. 

Shove movements clearly create an exposure to greater risk than pulled train movements. 

Wherever feasible, efforts should be made to avoid shoved movements especially where light 

engines are involved. Greater use of procedures such as running around cars and changing ends 

should be utilized. 

 54
 

5. SEVERE INJURIES 

5.1 SOFA-defined Severe Injuries and Amputations 

'Severe Injuries' were defined11 by the SOFA Working Group (SWG) as (1) potentially life 

threatening; (2) high likelihood of permanent loss of function, permanent occupational 

limitation, or other permanent disability; (3) likely to result in significant work restrictions; and 

(4) result from a high-energy impact to the human body. 'Severe Injuries' include amputation, 

dislocation of the neck, loss of eye, electric shock or burn, and fracture to any bone except the 

lower arm, fingers, foot, and toes. Tables 5-1 and 5-2 describe Severe Injuries as defined by the 

SWG. 

Table 5-1. Definition of SOFA-defined Severe Injuries 

Type Body Location 

Fracture Upper arm, upper leg, knee, lower leg, 

ankle, heel, eye, skull, neck, spine, 

upper back, lower back, shoulder, 

 collar bone, rib/rib cage, hips, 

 and multiple fractures 

Amputation Any body part 

Dislocation Neck 

Loss of eye One or both 

Electric 

Shock/burn 

Eye, ear, nose, mouth/teeth, skull, and neck 

Other burn Eye, ear, nose, mouth/teeth, skull, and neck 

 

11 See Severe Injuries to Train and Engine Service Employees: Data Description and Injury Characteristics. July 

2001. This report may be found on the FRA’s Web site. 

 55
Table 5-2. Type of Information Available for Severe Injuries 

# Information Type Variables 

1 Record identification -Incident number 

2 Date and time -Date of injury occurrence 

-Time of injury 

3 Railroad -Reporting railroad 

-Type railroad: ICC categories 

4 Geographic location -City, county, and state 

-FRA designated region 

5 Reporting extent -Whether additional FRA forms were filed 

6 Work missed -Days absent or restricted 

-Whether employee was suspended or transferred 

7 Hazardous material exposure -Whether injury involved exposure to hazardous material 

8 Alcohol and drug testing -Number of positive alcohol and drug tests 

9 Employee -Type person injured, i.e., "employee on duty" 

-Job occupation, i.e., "road conductor " 

-Age 

10 -Type and location of injury 

-Whether death occurred 

11 Circumstance codes -Physical act worker was doing before injury 

-General location of worker before injury, i.e., yard, main/branch 

-Specific location of worker before injury, i.e., beside track 

-Equipment location, i.e., freight car moving, locomotive standing 

-Event causing injury, i.e., lost balance, slipped... 

-Tools, machinery, appliances, structures, surfaces (etc.), i.e., ground, ballast

-Injury cause, i.e., human factors, environmental, equipment 

12 Written description -Narrative 

5.2 Information Available for SOFA-defined Severe Injuries 

In issuing its report at the conclusion of its study of Severe Injuries, the SWG said: 

The SOFA Working Group has looked at the injury data from the perspective of the knowledge 

gained from its detailed investigation of FEs where the circumstances surrounding, and leading up to, 

a FE where identified. The SOFA Working Group realizes that Serious Injuries are not investigated 

the way FEs are; hence, it is not always possible to identify these circumstances. The implication of 

this is clear: it is not possible for the Working Group to tell if one or more of its five safety 

recommendations applies to a particular Serious Injury event.12

 

12 ibid

 56
5.3 History of Severe Injuries 

The seven-year history of SOFA-defined Severe Injuries is shown in Table 5-3 along with 

amputations, an acute form of Severe Injuries. Since 1997, on average, 132.7 Severe Injuries 

have occurred each year. These Severe Injuries include, in addition to amputations, fractures of 

bones other than fingers and toes. As such, Severe Injuries often result from high-energy impacts 

and can be career threatening. Severe Injuries can be defined back to 1997 with the revision of 

reporting form FRA F6180.55a. 

In 2003, there were 116 Severe Injuries, the lowest count in the seven-year period, 1997 through 

2003; and 14.4 percent lower than the mean of 135.5 for the previous six years. There have been 

46 Severe Injuries in January through April of 2004. 

Table 5-3. SOFA-defined Severe Injuries and Amputations, 1997 through April 200413

SOFA-defined Severe Injuries Amputations 

1997 1998 1999 2000 2001 2002 2003 2004 1997 1998 1999 2000 2001 2002 2003 2004

JAN 11 13 16 15 21 12 11 10 1 0 2 1 0 0 2 2

FEB 17 15 9 9 9 13 17 14 0 1 0 1 0 2 1 2

MAR 14 12 17 11 10 10 13 10 3 4 3 2 1 1 3 1

APR 8 10 6 10 12 6 9 12 1 2 0 1 2 0 1 1

MAY 6 12 8 8 12 14 10 1 2 3 0 2 2 2

JUN 9 10 8 11 8 5 10 2 1 1 0 1 0 0

JUL 9 14 10 8 10 7 6 1 5 1 0 4 0 1

AUG 13 10 11 14 8 10 7 1 0 1 4 0 1 0

SEP 10 11 15 10 20 12 5 2 4 3 2 5 4 0

OCT 12 12 16 10 5 11 9 2 5 2 2 0 0 2

NOV 12 9 12 11 13 14 10 2 2 2 2 3 0 1

DEC 18 9 7 22 12 9 9 4 1 0 4 1 1 2

totals 139 137 135 139 140 123 116 20 27 18 19 19 11 15

5.4 Severe Injuries by Selective Attributes and Track Location 

Using the Severe Injury data for the period from January 1, 1997 to December 31, 2003, the 

frequency of selective attribute variables were calculated based on the track location where the 

injury occurred. For instance, the frequency of occurrence for the job code related to the injured 

employee was calculated based on seven track locations: yard, mainline/branch line, industry, 

siding, highway/roadway, passenger terminal, and other. Other attributes for which the frequency 

of injuries are calculated by track location: injury type; body location of injury; year; month; 

day; time of day; activity; age; injury event; equipment location; working location; tools, 

machinery, appliances, structures, surfaces (etc.); and assigned cause of injury. The calculated 

frequencies for the 14 variables are shown in Table 5-4 for 929 Severe Injuries that occurred 

 

13 The Severe Injury data was taken from the Federal Railroad Administration Office of Safety’s Web site in June 

2004. 

 57
among the nineteen, 600-series (train and engine service) job codes from January 1, 1997 to 

December 31, 2003. 

 58
 59yard

main/branch lineindustrysidinghighway/roadwaypassenger terminalotherrow totalrow percent 

JOB CODE

conductor, yard-614 107 14 30 1 0 0 2 154 16.6%

brakeman, yard-615 90 10 19 1 0 0 5 125 13.5%

conductor, road freight-608 46 68 10 9 9 0 6 148 15.9%

engineer, road freight-617 38 43 1 6 9 0 5 102 11.0%

brakeman, road freight local-613 37 22 14 6 1 0 2 82 8.8%

conductor, road freight local-609 36 32 23 13 0 0 2 106 11.4%

engineer, yard-619 31 4 2 1 2 0 2 42 4.5%

conductor, road passenger-606 18 12 0 0 1 4 3 38 4.1%

engineer, road freight-618 16 9 1 2 2 0 0 30 3.2%

engineer, road passenger-616 14 10 0 0 0 2 0 26 2.8%

brakeman, road freight through-612 10 6 8 5 1 0 0 30 3.2%

switch tender-601 6 3 2 0 0 0 0 11 1.2%

conductor, asst. road passenger-607 5 4 0 0 0 8 1 18 1.9%

hostler, outside-603 3 0 0 0 0 0 0 3 0.3%

brakeman, lead passenger-611 2 1 0 0 0 0 0 3 0.3%

miscellaneous-600 1 0 1 1 0 0 1 4 0.4%

hostler, inside-605 1 0 0 0 0 0 0 1 0.1%

fireman, yard-623 1 0 0 0 0 0 0 1 0.1%

other 3 0 1 0 0 0 1 5 0.5

column totals 465 238 112 45 25 14 30 929 100.0%

50% 26% 12% 5% 3% 2% 3% 100.0%

INJURY TYPE

fracture-70 368 202 90 40 25 13 26 764 82.2%

amputation-80 83 25 16 3 0 0 2 129 13.9%

other burns-50 9 8 6 2 0 1 2 28 3.0%

electric shock/burns-40 4 2 0 0 0 0 0 6 0.6%

dislocation-60 1 1 0 0 0 0 0 2 0.2%

column totals 465 238 112 45 25 14 30 929 100.0%

50% 26% 12% 5% 3% 2% 3% 100.0%

%

Table 5-4: SOFA-defined Severe Injuries

 by

 14 Attributes and 7 Track Locations 

January 1, 1997 to December 31, 2003
 60 yard

main/branch lineindustrysidinghighway/roadwaypassenger terminalotherrow totalrow 

percent 

INJURY LOCATION

leg or foot 246 113 64 20 3 0 18 464 49.9%

torso 147 81 31 18 18 6 8 309 33.3%

arm or hand 41 20 10 1 3 7 2 84 9.0%

head or face 28 20 7 3 0 1 2 61 6.6%

various body parts-equal severity 3 4 0 3 1 0 0 11 1.2%

column totals 465 238 112 45 25 14 30 929 100.0%

50% 26% 12% 5% 3% 2% 3% 100.0%

YEAR

1997 72 28 23 5 4 1 6 139 15.0%

1998 66 32 18 12 3 0 6 137 14.7%

1999 67 31 16 6 4 3 8 135 14.5%

2000 73 39 18 1 3 4 1 139 15.0%

2001 73 34 17 9 3 1 3 140 15.1%

2002 59 35 12 7 2 5 3 123 13.2%

2003 55 39 8 5 6 0 3 116 12.5%

column totals 465 238 112 45 25 14 30 929 100.0%

50% 26% 12% 5% 3% 2% 3% 100.0%

MONTH

Jan 55 19 11 3 4 2 5 99 10.7%

Feb 48 23 6 4 3 0 5 89 9.6%

Mar 46 21 13 1 0 2 4 87 9.4%

Apr 29 16 9 2 2 1 2 61 6.6%

May 32 22 5 4 3 1 3 70 7.5%

Jun 30 15 7 1 5 0 3 61 6.6%

Jul 33 14 11 6 0 0 0 64 6.9%

Aug 35 25 8 3 2 0 0 73 7.9%

Sep 46 13 14 4 1 5 0 83 8.9%

Oct 37 17 7 7 3 1 3 75 8.1%

Nov 34 29 10 4 1 1 2 81 8.7%

Dec 40 24 11 6 1 1 3 86 9.3%

column totals 465 238 112 45 25 14 30 929 100.0%

50% 26% 12% 5% 3% 2% 3% 100.0%

Table 5-4: Severe Injuries 

by

14 Attributes and 7 Track Locations (cont.)

January 1, 1997 to December 31, 2003
 61

yardmain/branch lineindustrysidinghighway/roadwaypassenger terminalotherrow totalrow percent 

DAY

Sunday 66 18 8 7 9 4 3 115 12.4

Monday 67 36 15 9 2 1 2 132 14.2

Tuesday 64 41 19 7 4 1 6 142 15.3

Wednesday 64 32 13 6 4 4 7 130 14.0

Thursday 70 40 23 8 4 2 5 152 16.4

Friday 74 38 20 1 2 1 5 141 15.2

Saturday 60 33 14 7 1 2 117 12.6%

column totals 465 238 112 45 25 14 30 929

50% 26% 12% 5% 3% 2% 3% 100.0% 100.0%

TIME OF DAY

00:00-01:00 28 17 6 3 3 0 2 59 6.4

01:01-02:00 24 12 4 2 2 0 0 44 4.7

02:01-03:00 22 10 3 1 0 0 1 37 4.0

03:01-04:00 27 11 1 1 2 1 0 43 4.6

04:01-05:00 17 2 0 2 1 1 1 24 2.6

05:01-06:00 10 7 5 5 1 1 3 32 3.4

06:01-07:00 5 9 3 1 0 0 1 19 2.0

07:01-08:00 13 11 0 4 2 2 3 35 3.8

08:01-09:00 21 10 5 1 0 0 1 38 4.1

09:01-10:00 27 9 5 1 1 0 4 47 5.1

10:01-11:00 14 11 6 2 1 0 1 35 3.8

11:01-12:00 18 12 6 1 1 1 2 41 4.4

12:01-13:00 21 13 11 2 1 0 1 49 5.3

13:01-14:00 16 10 13 0 1 0 0 40 4.3

14:01-15:00 19 15 2 1 1 1 3 42 4.5

15:01-16:00 21 7 2 1 1 1 0 33 3.6

16:01-17:00 22 13 4 2 0 0 0 41 4.4

17:01-18:00 21 8 6 3 2 1 0 41 4.4

18:01-19:00 19 8 7 2 0 1 1 38 4.1

19:01-20:00 24 6 6 2 0 1 1 40 4.3

20:01-21:00 19 11 4 2 0 2 2 40 4.3

21:01-22:00 22 13 6 4 2 1 1 49 5.3

22:01-23:00 23 6 2 1 3 0 1 36 3.9

23:01-24:00 12 7 5 1 0 0 1 26 2.8

column totals 465 238 112 45 25 14 30 929 100.0%

50% 26% 12% 5% 3% 2% 3% 100.0%

%

%

%

%

%

%

%

%

%

%

%

%

%

%

%

%

%

%

%

%

%

%

%

%

%

%

%

%

%

%

Table 5-4: Severe Injuries 

by 

14 Attributes and 7 Track Locations (cont.)

January 1, 1997 to December 31, 2003
 62

yardmain/branch lineindustrysidinghighway/roadwaypassenger terminalotherrow totalrow percent 

ACTIVITY

walking 123 59 29 14 1 4 10 240 25.8%

riding 64 35 26 8 20 0 0 153 16.5%

getting off 57 25 14 6 0 1 1 104 11.2%

stepping down 34 22 7 3 0 4 6 76 8.2%

getting on 20 5 4 1 0 2 0 32 3.4%

standing 17 7 4 0 1 1 3 33 3.6%

climbing over/on 14 5 4 3 0 0 0 26 2.8%

adjusting coupler 13 0 0 0 0 0 0 13 1.4%

coupling air hose 11 0 0 1 0 0 0 12 1.3%

operating 10 16 1 2 1 0 0 30 3.2%

lining switches 10 5 3 0 0 0 0 18 1.9%

pulling pin/uncoupling 10 2 2 1 0 0 0 15 1.6%

crossing over 10 1 1 2 0 0 0 14 1.5%

stepping 8 2 0 0 0 0 1 11 1.2

closing 7 4 1 0 0 0 0 12 1.3

75...unknown 6 0 1 1 0 0 0 8 0.9%

other 5 4 4 0 0 0 1 14 1.5

74...unknown 5 1 1 1 0 0 1 9 1.0%

adjusting, other 5 0 0 0 0 0 1 6 0.6%

jumping from 4 15 3 0 0 0 0 22 2.4%

opening 4 7 0 0 0 0 0 11 1.2

stepping over 4 3 0 0 0 0 0 7 0.8%

inspecting 3 3 0 0 0 0 0 6 0.6%

sitting 2 5 0 0 1 0 1 9 1.0%

reaching 2 0 1 0 0 0 1 4 0.4%

coupling electric cables 2 0 0 0 0 0 0 2 0.2%

handling car parts 2 0 0 0 0 0 0 2 0.2%

pushing 2 0 0 0 0 0 0 2 0.2%

opening/closing angle cock 1 2 1 0 0 0 0 4 0.4%

bending, stooping 1 0 1 0 0 0 0 2 0.2%

crossing between 1 0 1 0 0 0 0 2 0.2%

driving (vehicle...) 1 0 0 0 1 0 1 3 0.3%

handling material, general 1 0 0 0 0 0 0 1 0.1%

pulling 1 0 0 0 0 0 0 1 0.1%

uncoupling air hose 1 0 0 0 0 0 1 2 0.2%

handling other 0 3 1 0 0 0 0 4 0.4%

jumping onto 0 1 1 0 0 0 0 2 0.2%

cleaning 0 1 0 1 0 0 0 2 0.2%

flagging 0 1 0 0 0 0 0 1 0.1%

handling loc parts 0 1 0 0 0 0 0 1 0.1%

not coded 0 1 0 0 0 0 1 2 0.2%

chaining, cabling car or locomotive 0 0 1 0 0 0 0 1 0.1%

cutting, other 0 0 0 0 0 0 1 1 0.1%

handling baggage 0 0 0 0 0 1 0 1 0.1%

loading/unloading 0 0 0 0 0 1 0 1 0.1%

%

%

%

%

Table 5-4: Severe Injuries 

by

14 Attributes and 7 Track Locations (cont.)

January 1, 1997 to December 31, 2003
 63 yard main/branch line

industrysidinghighway/roadwaypassenger terminalotherrow totalrow 

percent 

repairing 1 0 0 0 0 0 0 1 0.1

running 3 1 0 1 0 0 0 5 0.5

weldin

%

%

g 0 1 0 0 0 0 0 1 0.1%

column totals 465 238 112 45 25 14 30 929 100.0%

50% 26% 12% 5% 3% 2% 3% 100.0%

AGE

15-20 2 0 0 0 0 0 0 2 0.2%

21-26 20 7 9 2 0 0 0 38 4.1%

27-32 53 22 12 5 1 1 2 96 10.3%

33-38 54 22 11 3 3 4 3 100 10.8%

39-44 53 35 10 3 7 1 7 116 12.5%

45-50 88 60 28 10 6 2 10 204 22.0%

51-56 107 51 24 15 4 5 2 208 22.4%

57-62 74 36 17 6 3 1 5 142 15.3%

63-68 14 4 1 1 1 0 1 22 2.4%

69-74 0 1 0 0 0 0 0 1 0.1%

column totals 465 238 112 45 25 14 30 929 100.0%

50% 26% 12% 5% 3% 2% 3% 100.0%

Table 5-4: Severe Injuries 

by

14 Attributes and 7 Track Locations (cont.)

January 1, 1997 to December 31, 2003
 64yard

main/branch lineindustrysidinghighway/roadwaypassenger terminalotherrow totalrow percent 

INJURY EVENT

slipped, fell, stumbled, etc. due to object... 57 38 10 3 1 2 1 112 12.1

70-unknown 51 23 13 5 0 1 4 97 10.4

slipped, fell, stumbled, etc. due to climatic... 49 15 9 6 0 1 9 89 9.6

struck by on-track equipment 44 10 7 2 0 0 0 63 6.8

lost balance 42 15 9 3 0 4 1 74 8.0

slipped, fell, stumbled, etc. due to irregular... 30 20 4 8 0 1 4 67 7.2

missed handhold, grabiron, step, etc. 21 5 6 4 0 0 1 37 4.0

struck against object 20 5 13 1 1 1 2 43 4.6

68...unknown 15 4 1 0 0 1 0 21 2.3

collision between on-track equipment 14 25 2 3 0 0 0 44 4.7

other (describe in narrative) 13 7 6 0 1 0 0 27 2.9

sudden/unexpected movement of on-track equipment 12 5 2 0 4 0 0 23 2.5

slack action, draft, compressive buff/coupling 12 4 0 1 0 0 0 17 1.8

stepped on object 11 3 2 0 0 0 1 17 1.8

slipped, fell, stumbled, etc. on oil, grease 10 1 1 1 0 0 1 14 1.5

derailments 8 7 3 0 0 0 0 18 1.9

struck by object 6 9 6 0 0 0 0 21 2.3

defective/malfunctioning equipment 6 2 2 0 0 0 0 10 1.1

exposure to chemicals-external 5 4 3 0 0 1 0 13 1.4

ran into object/equipment 5 0 1 1 0 0 0 7 0.8

caught in or crushed by materials 4 1 1 1 0 0 0 7 0.8

overexertion 3 2 1 1 0 1 0 8 0.9

bodily function/sudden movement, e.g., sneezing 3 2 0 0 0 0 0 5 0.5

sudden/unexpected movement of on-track equipment 2 5 0 0 0 0 1 8 0.9

sudden/unexpected movement of material 2 1 2 0 0 0 1 6 0.6

69...unknown 2 1 0 0 0 0 0 3 0.3

caught in or compressed by other machinery 2 1 0 0 0 0 1 4 0.4

ran into on-track equipment 2 1 0 1 0 0 0 4 0.4

struck by thrown or propelled object 2 0 1 0 0 0 0 3 0.3

collision/impact-auto, truck, bus, van, etc. 2 0 0 0 18 0 0 20 2.2%

electric shock due to contact with third rail 2 0 0 0 0 0 0 2 0.2

71...unknown 1 2 1 0 0 0 0 4 0.4

other impacts on-track equipment 1 1 1 1 0 0 0 4 0.4

pushed/shoved into/against 1 1 0 1 0 0 0 3 0.3

struck by falling object 1 0 2 0 0 0 2 5 0.5

highway-rail collision/impact 0 16 2 0 0 0 0 18 1.9

assaulted by other 0 0 0 0 0 0 0 0 0.0

climatic conditions, other (e.g., high winds) 0 0 0 0 0 0 1 1 0.1

%

%

%

%

%

%

%

%

%

%

%

%

%

%

%

%

%

%

%

%

%

%

%

%

%

%

%

%

%

%

%

%

%

%

%

%

%

Table 5-4: Severe Injuries

by

14 Attributes and 7 Track Locations (cont.)

January 1, 1997 to December 31, 2003
 65yard

main/branch lineindustrysidinghighway/roadwaypassenger terminalotherrow totalrow percent 

exposure to welding light 0 0 0 0 0 0 0 0 0.0%

pushed/shoved onto 1 0 1 0 0 0 0 2 0.2%

pushed/shove from... 0 0 0 0 0 1 0 1 0.1

rubbed, abraded, etc. 1 0 0 0 0 0 0 1 0.1%

cave in, slide, etc. 0 1 0 0 0 0 0 1 0.1%

sudden release of air 0 1 0 0 0 0 0 1 0.1%

aggregated pre-existing condition 0 0 0 1 0 0 0 1 0.1%

sustained viewing 0 0 0 1 0 0 0 1 0.1%

76...unknown 1 0 0 0 0 0 0 1 0.1%

80...unknown 1 0 0 0 0 0 0 1 0.1%

column totals 465 238 112 45 25 14 30 929 100.0%

50% 26% 12% 5% 3% 2% 3% 100.0%

%

Table 5-4: Severe Injuries

by

14 Attributes and 7 Track Locations (cont.)

January 1, 1997 to December 31, 2003
 66yard

main/branch lineindustrysidinghighway/roadwaypassenger terminalotherrow totalrow percent 

EQUIPMENT LOCATION

freight car moving 88 18 31 6 0 0 0 143 15.4%

other non-equip 63 37 17 5 2 1 18 143 15.4%

freight train moving 55 64 24 10 1 0 0 154 16.6%

freight train standing 70 37 6 13 0 0 1 127 13.7%

locomotive standing 76 33 8 6 0 1 4 128 13.8%

freight car standing 45 11 18 5 0 0 2 81 8.7%

locomotive moving 38 14 4 0 0 0 0 56 6.0%

pass train moving 2 11 0 0 0 3 1 17 1.8%

pass train standing 13 4 0 0 0 7 1 25 2.7%

auto 6 0 0 0 4 2 0 12 1.3

pass car standing 4 1 0 0 0 0 1 6 0.6%

pass car moving 0 1 0 0 0 0 0 1 0.1%

van passenger 0 0 0 0 9 0 1 10 1.1%

taxi 0 0 0 0 9 0 0 9 1.0

crane 0 1 0 0 0 0 0 1 0.1%

loaders, etc. 0 0 1 0 0 0 1 2 0.2%

other equip 1 1 0 0 0 0 0 2 0.2%

other on-track equip moving 0 0 1 0 0 0 0 1 0.1%

other on-track equip standing 0 1 0 0 0 0 0 1 0.1%

truck 0 1 1 0 0 0 0 2 0.2

excavating equip 1 0 0 0 0 0 0 1 0.1%

van utility 1 0 0 0 0 0 0 1 0.1%

other operating equip 1 0 0 0 0 0 0 1 0.1%

camp car moving 0 1 0 0 0 0 0 1 0.1%

maintenance equip moving 0 1 0 0 0 0 0 1 0.1%

inspection vehicle moving 0 1 0 0 0 0 0 1 0.1%

unknown 1 0 1 0 0 0 0 2 0.2%

column totals 465 238 112 45 25 14 30 929 100.0%

50% 26% 12% 5% 3% 2% 3% 100.0%

%

%

%

Table 5-4: Severe Injuries

by

14 Attributes and 7 Track Locations (cont.)

January 1, 1997 to December 31, 2003
 67

yardmain/branch lineindustrysidinghighway/roadwaypassenger terminalotherrow totalrow percent 

WORKING LOCATION

near on-track equip-on ground 91 32 25 6 0 0 2 156 16.8

beside track 76 36 25 8 2 0 2 149 16.0

on side of car 65 15 29 7 1 1 0 118 12.7

in/on loc 60 73 4 10 0 1 3 151 16.3

on end of car 30 9 12 6 0 1 1 59 6.4

other location on loc 25 10 2 1 0 0 2 40 4.3

between cars/loc 25 6 3 2 0 0 1 37 4.0

between tracks 24 5 5 0 0 0 0 34 3.7

on track 19 4 1 2 0 0 0 26 2.8

on ladder 14 3 0 1 0 0 0 18 1.9

other location 9 2 1 0 0 0 1 13 1.4

on stairs 8 8 2 0 0 1 5 24 2.6

at work station 7 6 0 0 0 5 8 26 2.8

on platform 5 8 3 0 0 4 2 22 2.4

on bridge/trestle 3 5 0 0 0 0 0 8 0.9

in car 2 9 0 1 3 1 0 16 1.7

under car 1 1 0 0 0 0 0 2 0.2

in/operating vehicle 1 0 0 0 17 0 1 19 2.0%

on highway-rail crossing 0 6 0 0 2 0 0 8 0.9

in tower 0 0 0 0 0 0 1 1 0.1

on pole/signal mast 0 0 0 1 0 0 0 1 0.1

under loc 0 0 0 0 0 0 1 1 0.1

column totals 465 238 112 45 25 14 30 929 100.0%

50% 26% 12% 5% 3% 2% 3% 100.0%

%

%

%

%

%

%

%

%

%

%

%

%

%

%

%

%

%

%

%

%

%

Table 5-4: Severe Injuries

by

14 Attributes and 7 Track Locations (cont.)

January 1, 1997 to December 31, 2003
 68yard

main/branch lineindustrysidinghighway/roadwaypassenger terminalotherrow totalrow percent 

TOOLS, MACHINERY, APPLIANCES, 

STRUCTURES, SURFACES (ETC.)

ground 160 70 38 11 0 1 9 289 31.1%

other 53 27 24 4 0 1 8 117 12.6

ballast 49 30 8 8 0 0 2 97 10.4

ladder 28 9 12 3 0 0 0 52 5.6%

36...unknown 25 2 3 4 0 0 0 34 3.7%

grabiron 20 5 4 2 0 0 0 31 3.3%

coupler 20 2 2 0 0 0 0 24 2.6

floor 14 22 1 3 2 1 3 46 5.0%

switch 13 2 5 3 0 0 0 23 2.5

door 12 11 1 0 0 1 1 26 2.8%

tie 11 2 2 2 0 0 0 17 1.8

stair 9 13 1 1 0 1 6 31 3.3

43...unknown 9 2 0 3 0 7 0 21 2.3%

37...unknown 8 0 0 0 0 0 0 8 0.9%

34...unknown 4 7 0 0 1 0 0 12 1.3%

hose 4 3 1 0 0 0 0 8 0.9

baggage 4 1 0 0 0 1 0 6 0.6

bridge/trestle 3 5 1 0 0 0 0 9 1.0%

42...unknown 3 2 1 0 1 0 0 7 0.8%

end of train device 3 1 0 1 0 0 0 5 0.5%

46...unknown 2 2 2 0 0 0 0 6 0.6%

%

%

%

%

%

%

%

%

Table 5-4: Severe Injuries

by

14 Attributes and 7 Track Locations (cont.)

January 1, 1997 to December 31, 2003
 69yard

main/branch lineindustrysidinghighway/roadwaypassenger terminalotherrow totalrow percent 

Table 5-4: Severe Injuries

by

14 Attributes and 7 Track Locations (cont.)

January 1, 1997 to December 31, 2003

41...unknown 2 0 0 0 0 0 0 2 0.2

81...unknown 2 0 0 0 0 0 0 2 0.2

window 2 0 0 0 0 0 0 2 0.2

highway, street, road 1 9 2 0 18 0 0 30 3.2%

38...unknown 1 3 0 0 0 0 0 4 0.4

caboose 1 1 0 0 0 0 0 2 0.2

TOFC, COFC 1 1 0 0 0 0 0 2 0.2

fusees/torpedoes 1 0 0 0 0 0 0 1 0.1

derail 0 2 1 0 0 0 0 3 0.3

40...unknown 0 1 0 0 0 0 0 1 0.1

82...unknown 0 1 0 0 0 0 0 1 0.1

87...unknown 0 1 0 0 0 0 0 1 0.1

welder-electric 0 1 0 0 0 0 0 1 0.1%

35...unknown 0 0 1 0 0 0 0 1 0.1

44...unknown 0 0 1 0 0 0 0 1 0.1

cutting tools 0 0 1 0 0 0 0 1 0.1%

39...unknown 0 0 0 0 0 1 0 1 0.1

not coded 0 0 0 0 3 0 0 3 0.3

torch, acetylene, gas, etc. 0 0 0 0 0 0 1 1 0.1%

column totals 465 238 112 45 25 14 30 929 100.0%

50% 26% 12% 5% 3% 2% 3% 100.0%

%

%

%

%

%

%

%

%

%

%

%

%

%

%

%
 70

yardmain/branch lineindustrysidinghighway/roadwaypassenger terminalotherrow totalrow percent 

ASSIGNED CAUSE OF INJURY

human factors 193 100 35 21 13 8 12 382 41.1%

undetermined 130 80 43 12 8 1 10 284 30.6%

environmental 56 19 14 9 4 4 7 113 12.2

equip procedures not followed 49 15 8 1 0 1 0 74 8.0

equipment 27 13 7 1 0 0 0 48 5.2

track 4 4 3 0 0 0 0 11 1.2

other 3 1 1 0 0 0 0 5 0.5

physical condition 2 2 0 0 0 0 0 4 0.4

trespassing 1 2 0 0 0 0 0 3 0.3

no safety equip 0 1 1 1 0 0 1 4 0.4

substance use 0 1 0 0 0 0 0 1 0.1

column totals 465 238 112 45 25 14 30 929 100.0%

50% 26% 12% 5% 3% 2% 3% 100.0%

%

%

%

%

%

%

%

%

%

Table 5-4: Severe Injuries

by

14 Attributes and 7 Track Locations (cont.)

January 1, 1997 to December 31, 2003
5.5 Statements About Frequency of Serious Injuries by Track Location 

To look at Severe Injuries for just yard and road crews, a slightly smaller group of track locations 

and job codes were used. This reduced set contained 843 Severe Injuries. Track locations used in 

the analysis below were yard, mainline/branch line, industry, and siding. The remaining three 

track locations (highway/roadway, passenger terminal, and other) were not used in this analysis. 

The following job codes were used for yard and road crews: 

• Yard crews consist of 619-engineers, 623-firemen, 603-hostlers, outside, 601-switch 

tenders; 614-conductors, and 615 brakemen. 

• Road crews consist of 616-passenger engineer, 617-through freight engineers, 618-local 

freight engineers, 606-passenger conductors, 607-assist. passenger conductors, 608-

through freight conductors, 609-local freight conductors, 612-freight brakemen and 

flagmen, and 613-freight brakemen and flagmen.

The following observations, based on the information presented in Tables 5.4 and 5.5, are 

examples of how the Severe Injury data might be used in trying to understand the injury process. 

When there is mention of yard and road crews, the information came from the restricted number 

of job codes and track locations given in Table 4-5. 

• The total number of Severe Injuries has remained nearly the same during the years 1997 

thru 2001. There was a significant reduction in the number of Severe Injuries in 2002 and 

a further numerical reduction in 2003. 

• There were significant reductions in Serious Injuries in the yard and at industries in 2002 

and 2003. Serious Injuries in the yard have declined from 72 in 1997 to 55 in 2003, and 

from 23 in 1997 to 8 in 2003 at industries. 

• Serious Injuries on main/branch line have increased from 28 in 1997 to a high of 39 in 

2003. 

• Over half (53.9%) the total number of Severe Injuries occurred in the yard during the 

years 1997 thru 2003.

• Forty-two percent of all Severe Injuries to road train and engine service crews occurred in 

yards. Road train and engine service crews sustained almost as many Severe Injuries in 

the yard as yard train and engine service crews. (220 vs. 234 Serious Injuries) 

• During the seven-year period, yard train and engine service employees sustained 38.1 

percent of the total Severe Injuries, while road train and engine service employees 

sustained 61.9 percent of the total Severe Injuries. (321 vs. 522 Serious Injuries) 

• Yard engineers sustained 12.2 percent of the total number of Severe Injuries to yard 

crews, while road engineers sustained 26.7 percent of the total number of Severe Injuries 

to road crews. (39 of 321 vs. 139 of 522)

• Yard train service employees sustained 87.9 percent of the total Severe Injuries to yard 

crews, while road train service employees sustained 73.3 percent of the total number of 

Severe Injuries to road crews. (282 of 321 vs. 383 of 522) 

 71
• During the seven-year period, road freight engineers incurred 3.6 times as many Severe 

Injuries as yard engineers. 

• There were significantly more Severe Injuries in the yard during the months of January 

(55), February (48), March (46), and September (46) than during the other months of the 

year. On the main/branch line, the fewest Serious Injuries occurred during the month of 

September (13), and the most during the month of November (29). 

• There does not appear to be any significant differences in the day of the week when these 

Severe Injuries occurred in the yard. 

• Significantly fewer Serious Injuries occur on main/branch line (18) and at industries (8) 

on Sunday, than during the other days of the week. 

• Significantly more Severe Injuries occurred in the first hour after midnight than during 

any other time of the day or night. (6.4 percent of the total Serious Injuries).

• At all locations, many more Severe Injuries occurred to older employees, i.e., those over 

38 years of age. 

• Over 96 percent of the Severe Injuries during the data period were amputations and 

fractures. 

• Severe Injuries are nine times more likely to affect legs and feet than hands and arms. 

• There were four times as many amputation Severe Injuries in the yard (83) and at 

industries (16) than on the main track/branch line (25) for the same seven-year period. 

• The proportion of “human factor” Possible Contributing Factor (PCF) Severe Injuries to 

the total Severe Injuries (41.1 percent) is about the same in the yard (41.5 percent) and on 

the main track/branch line (42.0 percent). The proportion of (PCF) Serious Injuries is 

lower, 31.3%, at industries. 

• Over one half of the Severe Injuries in each identified location were impacted by “the 

ground, ballast, or floor” as the identified “tools, machinery, appliances, structures, 

surfaces, etc.” 

 72
Table 5-5. Severe Injuries by Selective Job Codes and Track Locations, 1997 to 2003 

Job Code yard main or 

branch line

industry siding TOTAL

Conductor, road freight-608 46 68 10 9 133

Conductor, road freight local-609 36 32 23 12 103

Brakeman, road freight through-612 10 6 8 5 29

Brakeman, road freight local-613 37 22 14 6 79

Conductor, road passenger-606 18 12 0 0 30

Conductor, assist. road passenger-607 5 4 0 0 9

Total, Road Train Service 152 144 55 32 383

Conductor, yard-614 107 14 30 1 152

Brakeman, yard-615 89 10 19 1 119

Switch tender-601 6 3 2 0 11

Total, Yard Train Service 202 27 51 2 282

Total, Train Service 354 171 106 34 665

Engineer, road through freight-617 38 42 1 6 87

Engineer, road passenger-616 14 10 0 0 24

Engineer, road local freight-618 16 9 1 2 28

Total, Road Engine Service 68 61 2 8 139

Engineer, yard-619 30 4 2 1 37

Fireman, yard-623 1 0 0 0 1

Hostler, outside-603 1 0 0 0 1

Total, Yard Engine Service 32 4 2 1 39

Total, Engine Service 100 65 4 9 178

ROAD, TRAIN & ENGINE 220 205 57 40 522

YARD, TRAIN & ENGINE 234 31 53 3 321

TOTAL 454 236 110 43 843

 73
5.6 Conclusion on Severe Injury Data 

The SWG again looked at the injury data from the perspective of the knowledge gained from its 

detailed investigation of switching fatalities where the circumstances surrounding, and leading 

up to, an FE were identified. The SWG realized that Severe Injuries are not investigated or 

reported the way FEs are; hence, it is not always possible to identify these circumstances. The 

implication of this is clear; it is not possible for the SWG to tell if one or more of the five major 

safety recommendations applies to a particular Severe Injury event. The SWG makes this 

information in section 5 available in the interest of railroad safety. 

 

 74
APPENDIX 

A: SOFA Implementation Guidelines for Five Operating Recommendations 

B: Origin of SOFA Working Group 

C: Original Introduction to SOFA Report, October 1999 

D: Five SOFA Operating Recommendations 

E: Obtaining Electronic Versions of SOFA Reports 

F: Examples of Job Briefings – Operating Recommendation 4 

 75

Appendix A: SOFA Implementation Guidelines for Five Operating 

Recommendations 

The Switching Operations Fatality Analysis (SOFA) Working Group submits the following 

suggestions in response to a request made by Federal Railroad Administration's (FRA) Associate 

Administrator of Safety George A. Gavalla. During the call, Mr. Gavalla asked that the SOFA 

group produce guidelines that it feels would help to more effectively implement the Five Major 

Safety Recommendations contained in the SOFA Report released in October 1999. Here are the 

suggestions: 

Impact 

Implementation of SOFA Recommendations should be planned, conducted, and reported in ways 

that encourage follow through by stakeholders, so that the likelihood that it will be effective is 

increased. 

Political Viability 

Implementation of SOFA Recommendations should be planned and conducted with anticipation 

of the different positions of various interest groups, so that their cooperation may be obtained; 

and so that possible attempts by any of these groups to curtail efforts to improve safety, or to bias 

or misapply the SOFA Recommendations, can be adverted or counteracted. 

Obligations 

Obligations of the formal parties to the implementation of the SOFA Recommendations (what is 

to be done, how, by whom & when) should be agreed to, so that these parties adhere to all 

specified conditions. Do not expect participation in the implementation by persons or parties who 

have not previously agreed to do so. 

Valid Information 

Ensure that the individuals who will administer or supervise (a) new particular procedure(s) are 

qualified and adequately prepared (in terms of knowledge, training, and practice) to do so. 

Propriety (Human Interactions) 

 Participants should respect human dignity and worth in their interactions with other persons 

associated with implementation of the SOFA Recommendations, so that participants are not 

threatened or harmed. 

And finally: 

• Convey the SOFA messages in a positive manner. 

• Keep rules that are not directly related to SOFA separate and apart. 

• Messages should be consistent with the five SOFA Recommendations. 

 77
• SOFA should be a culture change where necessary. 

• SOFA endeavors should be cooperative efforts between management, labor and FRA. 

• SOFA Recommendations should be viewed as possible lifestyle changes.

 78
Appendix B: 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 

 79
encouraged to implement recommendations that would benefit their safety program. 

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 

 80
Appendix C: Original Introduction to SOFA Report, October 1999 

1. INTRODUCTION 

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 

 81
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 

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. 

 82
Appendix D: Five SOFA Operating Recommendations 

Below are the Five Operating Recommendations contained in the SOFA Report. These 

Recommendations were each based on between eight and twelve switching fatalities during the 

January 1, 1992 through July 1, 1998. In the view of the SWG, these fatalities may not have 

occurred if the respective Recommendation was observed. About six months after the release of 

the SOFA Report, the SWG issued shorter versions of the Recommendations in the form ‘The 

Five Lifesavers.’ The intend of the shorter Five Lifesavers was to aid in remembering the 

Recommendations – not to serve as substitutes for the more detailed Recommendations. 

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. 

Lifesaver 1 

Secure equipment before action is taken.

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. 

Nineteen Fatalities Involving SOFA Operating Recommendation 1 

# RR Date Location FRA Report # 

1 CNW 06/20/92 Northlake, IL FE-18-92 

2 UP 10/17/94 Donaldsonville, LA FE-26-94 

3 UP 12/13/94 Thorton, CA FE-32-94 

4 ATSF 02/24/95 Amarillo, TX FE-11-95 

5 NS 03/02/95 Aiken, SC FE-12-95 

6 CSX 10/04/95 Riverdale, IL FE-29-95 

7 BRC 03/20/96 Bedford Park, IL FE-09-96 

8 UP 10/07/96 Eagle Pass, TX FE-24-96 

9 UP 08/15/97 Elko, NV FE-25-97 

10 BRC 05/26/98 Bedford Park, IL FE-15-98 

11 NS 06/05/98 Hapeville, GA FE-17-98 

12 UP 06/23/99 Redding, CA FE-16-99 

 83
13 AM 09/14/99 Van Buren, AR FE-24-99 

14 IHB 03/09/00 Riverdale, IL FE-09-00 

15 CKRY 07/07/00 Wichita, KS FE-21-00 

16 BNSF 03/03/01 Willmar, MN FE-08-01 

17 UP 05/14/02 Pine Bluff, AR FE-12-02 

18 BNSF 06/16/02 Memphis, TN FE-16-02 

19 LC 08/26/03 Chester, SC FE-20-03 

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. 

Lifesaver 2 

Protect employees against moving equipment. 

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. 

Twelve Fatalities Involving SOFA Operating Recommendation 2 

# RR Date Location FRA Report # 

1 GBW 07/24/92 Wisconsin Rapids, WI FE-30-92 

2 ATSF 08/12/93 Evandale, TX FE-31-93 

3 UP 01/20/94 Fall City, NE FE-06-94 

4 CR 12/06/94 Campbell Hall, NY FE-31-94 

5 ATSF 02/24/95 Amarillo, TX FE-11-95 

6 CSX 05/03/95 Evansville, IN FE-18-95 

 84
7 CR 02/02/97 Burns Harbor, IN FE-05-97 

8 BRC 02/04/98 Bedford Park, IL FE-05-98 

9 BNSF 06/01/98 Lubbock, TX FE-16-98 

10 BNSF 08/11/00 Port of Los Angeles, CA FE-25-00 

11 CWRO 08/08/02 Cleveland, OH FE-19-02 

12 CNIC 02/11/03 Flat Rock, MI FE-03-03 

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. 

Lifesaver 3 

Discuss safety at the beginning of a job or when a project changes. 

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. 

Fourteen Fatalities Involving SOFA Operating Recommendation 3 

# RR Date Location FRA Report # 

1 GBW 07/24/92 Wisconsin Rapids, WI FE-30-92 

2 IC 06/07/93 Fulton, KY FE-23-93 

3 SP 08/11/93 Tracy, CA FE-30-93 

4 GC 11/13/93 Macon, GA FE-47-93 

5 SOU 12/05/93 Atlanta, GA FE-49-93 

6 CR 11/15/94 Painted Post, NY FE-29-94 

7 CR 02/17/95 St. James, OH FE-09-95 

8 NS 03/02/95 Aiken, SC FE-12-95 

9 CR 01/12/99 Port Newark, NJ FE-01-99 

10 DME 04/02/99 Waseca, MN FE-11-99 

11 UP 10/15/00 Houston, TX FE-30-00 

12 NS 01/11/01 South Fork, PA FE-03-01 

13 BNSF 06/16/02 Memphis, TN FE-16-02 

14 UP 04/11/03 Pocatello, ID FE-11-03 

 85
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. 

Lifesaver 4 

Communicate before action is taken. 

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. 

Eighteen Fatalities Involving SOFA Operating Recommendation 4 

# RR Date Location FRA Report # 

1 BN 01/28/92 Willmar, MN FE-03-92 

2 FEC 03/11/92 Fort Pierce, FL FE-08-92 

3 ATSF 06/01/92 Escondido, CA FE-14-92 

4 UP 07/25/92 Portland, OR FE-22-92 

5 CR 07/15/93 Anderson, IN FE-26-93 

6 SP 08/11/93 Tracy, CA FE-30-93 

7 CR 11/15/94 Painted Post, NY FE-29-94 

8 CR 12/06/94 Campbell, Hall, NY FE-31-94 

9 CR 02/17/95 St. James, OH FE-09-95 

10 UP 01/29/97 Mason, City, IA FE-04-97 

11 CMRC 06/06/97 Bay City, MI FE-16-97 

12 UP 12/26/97 Boise, ID FE-45-97 

13 IC 12/28/98 Durrant, MS FE-37-98 

14 CR 01/12/99 Port Newark, NJ FE-01-99 

15 UP 06/23/99 Redding, CA FE-16-99 

16 PARN 07/24/00 Skagway, AK FE-22-00 

17 BNSF 09/09/00 Keokuk, IA FE-29-00 

18 NS 07/16/02 Bonlee, NC FE-17-02 

 86
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. 

Lifesaver 5 

Mentor less experienced employees to perform service safely. 

Discussion 5 

While classroom 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. 

Nineteen Fatalities Involving SOFA Operating Recommendation 5 

# RR Date Location FRA Report # 

1 AGC 01/30/92 Polk County, FL FE-04-92 

2 IHRC 06/02/92 Henderson, KY FE-16-92 

3 SOO 10/19/93 Leal, ND FE-40-93 

4 GC 11/13/93 Macon, GA FE-47-93 

5 PTRA 11/10/94 Houston, TX FE-28-94 

6 CR 12/06/94 Campbell Hall, NY FE-31-94 

7 CSX 10/04/95 Riverdale, IL FE-29-95 

8 BRC 03/20/96 Bedford Park, IL FE-09-96 

9 CSX 06/15/96 Charlotte, NC FE-12-96 

10 NS 07/07/96 Sidney, IN FE-17-96 

11 DGNO 09/03/96 Dallas, TX FE-22-96 

12 UP 10/07/96 Eagle Pass, TX FE-24-96 

13 MRL 10/16/97 Laurel, MT FE-32-97 

14 BNSF 06/01/98 Lubbock, TX FE-16-98 

15 NS 05/19/99 Cincinnati, OH FE-14-99 

16 AM 09/14/99 Van Buren, AR FE-24-99 

17 CSX 01/10/01 Chicago, IL FE-02-01 

18 BNSF 06/16/02 Memphis, TN FE-16-02 

19 GC 09/12/03 Dublin, GA FE-22-03 

 87

Appendix E: Obtaining Electronic Versions of SOFA Reports 

Obtaining Electronic Versions of SOFA Working Group Reports 

The SOFA Working Group has issued three reports on switching fatalities and casualties. These 

reports may be obtained electronically at the FRA’s Web site, for Switching Operations Fatality 

Analysis, at: http://www.fra.dot.gov/Content3.asp?P=102. 

1. Findings and Recommendations of the SOFA Working Group, October 1999 

2. Findings and Recommendations of the SOFA Working Group, Appendix – Volume II, 

August 2000 

3. Severe Injuries to Train and Engine Service Employees: Data Description and Injury 

Characteristics. July 2001

 89

Appendix F: Examples of Job Briefings – Operating Recommendation 4 

Example 1 

5009 

For Yard Crews: 

(a) The specific job(s) to be done, or 

moves to be made. 

(b) The responsibilities of each 

employee. 

(c) Any additional instructions due to 

an unusual situation. 

(d) The means to be used to 

communicate hand signals, 

radio, etc. 

(e) Who will be responsible for 

securing equipment to be left 

unattended. 

If back up hose is required, 

whether it has been properly 

connected and tested. 

(g) Any job related safety issues, 

including the Safety Instruction of 

the Day. 

5010 

Use caution when carrying 

multiple items, especially those 

of different sizes, shapes, and 

those containing hot or corrosive 

liquids. Carry only so much as 

permits you to maintain a firm 

grip on each item. 

NOTE: When obtaining moves from a 

yardmaster, employees must inquire 

about other crews that might be 

switching on the same or adjacent 

tracks. To avoid injury or damage when 

engines may be working at both ends 

of the same track, crews switching 

must have a clear understanding of the 

movements to be made. 

This information does not relieve 

employees of their responsibility to be 

vigilant for movements on any track, at 

any time, in any direction. 

Prior to beginning work, all train 

and engine crew members must 

hold a "JOB BRIEFING to 

ensure that they have a clear and 

common understanding of all 

safety critical tasks to be 

performed, and their individual 

responsibilities in performing 

those tasks. When operating 

conditions change, an additional 

job briefing must be conducted 

with all affected crew members to 

ensure uniform and complete 

understanding. 

For Road Crews: (h) All new or temporary 

operational 

requirements affecting the train 

movement that are necessitated 

by changes in written instructions 

such as Timetables, General Orders, 

Bulletins, Notices or 

Circulars, etc. , or operational requirements 

of the Train Manifest. 

Whether authority to proceed has 

been received, and how far that 

authority extends. 

If the authority is not for the entire 

trip, when and where an additional 

job briefing will need to 

take place. 

(k) Where required, the need to 

check with the proper person to 

ensure that current copies of all 

required forms governing the 

movement of the train have been 

received. 

If additional forms must be obtained 

during the trip, when and 

where these forms must be obtained. 

(m) Any job related safety issues, including 

the Safety Instruction of 

the Day. 

Employees must discuss the following 

topics during the "JOB BRIEFING" 

(i) 

(I) 

(f) 

AMT 5 – 2

 91
Example 2 

 ITEM 17. JOB BRIEFING 

 Safety, Quality, and Productivity are the result of well-planned and 

 conducted job briefings. 

 In addition, printing shown in italics are instructions specific to 

 Train, Engine, and Yard Employees. 

 Step 1. Plan the Job Briefing. 

 A. Develop your own work plan by: 

 Reviewing work or task to be accomplished. 

 Checking the job location and work area. Know the condition of 

 gates, switches, derails, track conditions, close clearances, 

 short spurs (next to end of track), bad footing, and that cars 

 are secure before coupling. 

 Breaking the work or task down into step-by-step procedure. 

 Determining tool, equipment, and material requirements. 

 Determine what safety rules or procedures are applicable. 

 Consider close clearances and gates, etc. 

 B. Consider existing and potential hazards that might be involved as 

 a result of: 

 Job and weather. 

 The nature of the work to be done. Consider switching, 

 spotting, picking up, or setting out. 

 The job location. Consider whether yard, industry, or road. 

 The tools, equipment, and materials used. 

 Equipment to be work on. 

 Traffic conditions and visibility. Consider people, vehicles, 

 time of day, other jobs in track or area, and obstructions. 

 Time of day. Consider whether 0300 - 0500 (alertness), or end 

 of shift ("go home" moves). 

 Safety or personal protective equipment required. 

 C. Consider how work assignments will be made: 

 1. Group assignments. Remember that the whole crew is a team and 

 will be held jointly responsible. 

 2. Individual assignments (who checks for what?). Engineers need 

 to check with crew about the status of gates, switches, 

 derails, hand brakes, how much room, how many cars are already 

 there, etc. 

 3. Abilities and experience of individuals. Make sure that each 

 92
 crew member is able to do their assignments (experience, mental 

 state, and physical condition). 

 Step II. Conduct the Job Briefing. 

 A. Explain work or task to employees. 

 1. What is to be done. 

 2. Why it is to be done. 

 3. When it is to be done. 

 4. Where it is to be done. 

 5. How it is to be done. Everyone needs to understand what 

 signals will be used. If radio, know the condition of the 

 radio and verify the correct radio channel. 

 6. Who is to do it. Who will open and secure gates, line 

 switches, line derails, make the cut or joint, protect the 

 move? 

 7. What safety precautions are necessary. All crew members must 

 know that the following are done: 

 Gates open, switches lined, derails lined, cars not attached to 

 the facility (plates and hoses removed), cars secured before 

 coupling, sufficient room has been verified for the move, etc. 

 Identify close clearances and bad footing. Engineers must not 

 move until direction and distance has been received, and will 

 stop after moving 1/2 the distance given unless further 

 instructions are received. 

 B. Discuss existing or potential hazards and way to eliminate or 

 protect against them. 

 C. Make definite work assignments. 

 1. Make sure employees understand assignments. 

 2. Ask questions of the "how" and "why" type. 

 D. If special tools, materials, equipment, or methods are to be used, 

 make sure employees know how to proceed safely. 

 E. Issue all instructions clearly and concisely; check to see that 

 they are understood by all members of the crew, including the 

 engineer. 

 Step III. Job Brief for Special Conditions. 

 A. Complex Jobs. 

 1. Brief only a portion of the job. 

 93
 2. Give additional briefing as the job progresses. 

 B. Change in job conditions - when it becomes necessary to change 

 plans and procedures as the job progresses, brief employees on 

 these changes. (As examples: the weather condition changes, or use 

 of a third party to relay messages) 

 Step IV. Follow up by Supervisor. 

 It is important that frequent checks be made as the job progresses to 

 be sure that: 

 1. Your plans are being followed and correct work methods are 

 used. 

 2. Each person is carrying out the assigned responsibilities. 

 3. Any hidden hazards have been identified and action initiated to 

 eliminate them or what precautions are required. 

 Step V. Individual Responsibility. 

 All employees are responsible to see that the work plan is carried 

 out according to the Job Briefing or modified when conditions change. 

 Constant Communication is Necessary and Required 

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Data Appendix: Switching Fatalities by Selective Characteristics 

Many of the tables contained in the SOFA Report released in October 1999 are updated here in 

the Data Appendix. As such, where the SOFA Report tables included 76 switching fatalities, 

January 1, 1992 through July 01, 1998, dimensioned by attributes such as state, time of day, or 

day of week. The tables below include 124 fatalities, January 1992 through December 2003. 

Table A-1. Switching Fatalities by State, 1992 through 2003 

State Fatalities State Fatalities State Fatalities 

Texas 13 Minnesota 3 Washington 2 

Illinois 12 Pennsylvania 3 Wisconsin 2 

California 9 South Carolina 3 Arizona 1 

Kentucky 7 Alaska 2 Connecticut 1 

Georgia 6 Florida 2 Delaware 1 

Indiana 5 Idaho 2 Louisiana 1 

Nebraska 5 Kansas 2 Mississippi 1 

New York 5 Missouri 2 North Dakota 1 

Ohio 5 Montana 2 New Jersey 1 

North Carolina 4 Oklahoma 2 New Mexico 1 

Arkansas 3 Oregon 2 Nevada 1 

Iowa 3 Tennessee 2 Utah 1 

Michigan 3 Virginia 2 Wyoming 1 

total 124 

Table A-2. Switching Fatalities by Shift, 1992 through 2003 

Shift Fatalities Percent 

First (8:00 a.m. - 4:00 p.m.) 51 41.1% 

Second (4:00 p.m. - 12:00 a.m.) 40 32.3% 

Third (12:00 a.m. - 8:00 a.m.) 33 26.6% 

total 124 100.0% 

 105
Table A-3. Switching Fatalities by Shift and Day of Week, 1992 through 2003 

Shift 

First Second Third total 

8:00 a.m. to 4:00 p.m. 4:00 p.m. - 12:00 a.m. 12:00 a.m. - 8:00 a.m. 

- Day - 

Sunday 2 3 6 11

Monday 8 6 2 16

Tuesday 7 11 7 25

Wednesday 7 7 6 20

Thursday 8 3 8 19

Friday 11 9 4 24

Saturday 8 1 0 9

total 51 40 33 124

Table A-4. Time On Duty Before Fatal Event, 1992 through 2003 

Time Frequency Percent 

(hours and minutes) 

0:00 to 0:59 11 8.9% 

1:00 to 1:59 18 14.5% 

2:00 to 2:59 14 11.3% 

3:00 to 3:59 11 8.9% 

4:00 to 4:59 16 12.9% 

5:00 to 5:59 13 10.5% 

6:00 to 6:59 12 9.7% 

7:00 to 7:59 5 4.0% 

8:00 to 8:59 6 4.8% 

9:00 to 9:59 6 4.0% 

10:00 to 10:59 5 4.0% 

11:00 to 12:00 5 1.6% 

not known 2 -- 

total 124 100.0% 

 106
Table A-5. Switching Fatalities by Day, 1992 through 2003 

Day Frequency Percent

Sunday 11 8.9%

Monday 16 12.9%

Tuesday 25 20.2%

Wednesday 20 16.1%

Thursday 19 15.3%

Friday 24 19.4%

Saturday 9 7.3%

total 124 100.0%

Month 

Table A-6. Switching Fatalities by Month, 1992 through 2003 

Frequency Percent Cumulative 

Percent 

 

January 15 

6.5% 

9 

5.6% 

15 

14 61.3% 

9 7.3% 

October 

12.9% 

12.1% 

February 8 6.5% 18.7% 

March 8 25.0% 

April 7.3% 32.3% 

May 7 37.9% 

June 12.1% 50.0% 

July 11.3% 

August 7 5.6% 66.9% 

September 74.2% 

10 8.1% 82.3% 

November 6 4.8% 87.1% 

December 16 100.0% 

total 124 100.0% 

 107
Table A-7. Switching Fatalities by Night and Day, 1992 through 2003 

Time Frequency Percent 

Night (6:01 p.m. – 6:00 

a.m.) 

67 54.0 

Day (6:01 a.m. – 6:00 

p.m.) 

57 46.0 

total 124 100.0% 

Table A-8. Switching Fatalities with Older Employees and Lower Years of Service, 1992 

through 2003 

# Age Years of Service FRA # RR Location Date 

 

1 

FE-24-99 

09/03/96

11 42 

40 

BNSF 

36 

CSX 

36 

UP 

36 

BNSF 

35 

BNSF 

31 FE-28-94 

54 5.5 FE-01-99 CR Port Newark, NJ 01/12/99

2 53 2.5 FE-12-02 UP Pine Bluff, AR 05/14/02

3 50 7 FE-16-97 CMRC Bay City, MI 06/06/97

4 47 0.5 AM Van Buren, AR 09/14/99

5 47 2 FE-17-00 UP Pine Bluff, AR 05/31/00

6 47 1 FE-47-93 GC Macon, GA 11/13/93

7 45 1 FE-03-99 CR Alexander, NY 01/22/99

8 45 7 FE-16-95 WC Argoe, WI 04/06/95

9 43 2 FE-40-93 SOO Leal, ND 10/19/93

10 43 0.06* FE-22-96 DGNO Dallas, TX 

1 FE-02-01 CSX Chicago, IL 01/10/01

12 40 7.58 FE-22-97 MNCW Stamford, CT 07/18/97

13 4 FE-03-04 NS Kankakee, IL 01/14/04

14 39 0.5 FE-29-95 CSXT Riverdale, IL 10/04/95

15 38 2 FE-16-00 CSX Richmond, VA 05/22/00

16 36 4 FE 25-00 Port of Los Angeles, CA 08/11/00

17 3.75 FE-08-01 BNSF Willmar, MN 03/03/01

18 36 1 FE-12-96 Charlotte, NC 06/15/96

19 1 FE-14-99 NS Cincinnati, OH 05/19/99

20 36 5 FE-35-03 San Antonio, TX 12/07/03

21 2.5 FE-04-03 CSX East Syracuse, NY 02/16/03

22 35 3.75 FE-14-01 Clark, OK 04/08/01

23 3 FE-12-03 CSX Kingsport, TN 06/06/03

24 35 2 FE-25-03 Fresno, CA 09/24/03

25 32 0.5 FE-04-92 AGC Polk County, FL 01/30/92

26 0.5 PTRA Houston, TX 11/10/94

* 10-year gap since 10 years of service 

 108
Table A-9. Switching Fatalities by Job Category, 1992 through 2003 

Job Category Frequency Percent

yard conductor 37 29.8 

road local brakeman 23 18.5 

road local conductor 20 16.1 

yard conductor 18

road local freight engineer 

0.8 

14.5 

road through conductor 15 12.1 

3 2.4 

road through freight engineer 2 1.6 

remote control operator 1 0.8 

road passenger engineer 1

laborer – performing duties of yard brakeman 1 0.8 

road through brakeman 1 0.8 

brakeman trainee 1 0.8 

other 1 0.8 

total 124 100.0% 

 109