Prepared by: The Federal Railroad Administration, Office of Railroad Safety

SAFETY BULLETIN 

2023-04

SUBJECT: Trainee Switching Fatality Involving a Shove Movement in a Yard 

The Federal Railroad Administration (FRA) is investigating a fatality that occurred on June 26, 

2023. Based on FRA’s preliminary investigation, a conductor and a conductor trainee (CT) were 

riding the point on an empty intermodal well car during a shoving move of a train consisting of 

two locomotives and 43 intermodal well cars. The CT was using a portable radio with a speakermicrophone attached to his vest to communicate to the locomotive engineer. Preliminary 

findings suggest that, although the CT may have maintained three-point contact, his posture and 

position on the car were not stable enough to withstand the forces when the train slowed down 

and slack ran out. The CT lost his balance and fell forward into the gauge of the rail. The CT was 

subsequently struck by the rolling equipment, resulting in a fatality.

The purpose of this Safety Bulletin, which is informal in nature, is to ensure the railroad industry 

is aware of this recent accident that resulted in a fatality of an employee. Its purpose is to also 

encourage railroads to identify location-specific safety issues to cover during safety briefings and 

(re)train employees. As FRA completes its investigation, it may take additional actions with 

respect to this accident.

FRA requests that railroads review this Safety Bulletin with employees to increase awareness of 

the dangers of riding moving equipment and ensure employees who ride moving equipment do 

so safely, to include: 

1. Railroads should review their training programs to ensure the programs are adequate to 

prepare employees to safely and properly ride moving equipment, including the handling 

of unexpected or unusual forces experienced while riding equipment. Training programs 

should ensure that both employees that oversee trainees and trainees are familiar with 

their duties, have received proper instruction, and are continuously monitored for 

compliance and safety.

2. Employees should only ride equipment when necessary for job duties, and only after the 

process for doing so is discussed in a job briefing. Further, employees should only ride 

equipment after determining it is safe to do so. 

3. Employees should always face the equipment and maintain at least three-point contact to

brace for changes in speed and slack action, ensuring the positioning of their feet and 

hands achieves optimal stability when riding rolling equipment. 

4. Railroads should review with their employees Switching Operations Fatality Analysis 

(SOFA) Recommendation No. 5 - Mentor less experienced employees to perform 

services safely. The SOFA Working Group is a voluntary, non-regulatory, workplacesafety partnership formed to identify commonalities among fatalities that occur during 
Prepared by: The Federal Railroad Administration, Office of Railroad Safety

switching operations. A SOFA Alert regarding this event and findings of the analyses of 

previous events are available on FRA’s website at https://railroads.dot.gov/railroadsafety/divisions/partnerships-programs/switching-operations-fatalities-analysis-sofa.

Issued: July 6, 2023 

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