i 

Switching Operations Fatality Analysis 

Findings and Advisories 

Of the SOFA Working Group 

Volume II: 

Appendices B through L 

March 2011 Update 
The SOFA Working Group was supported by the Federal Railroad Administration’s Office of 

Safety and the Office of Research and Development. The final findings and Safety Advisories

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

Working Group. The Federal Railroad Administration report number FRA/RRS-11/01 is

published for the convenience of those wishing to obtain copies and for general information

purposes. This report, including Volume II is available on the FRA website at

http://www.fra.dot.gov by clicking on the SOFA emblem.

This Report contains information based on incident reports filed by railroad carriers under 49

U.S.C. Section 20901 or made by the Secretary of Transportation under 49 U.S.C. Section

20902. Under 49 U.S.C. Section 20903, no portion of a report made under section 20901 or

20902 can be used in a civil action for damages resulting from a matter mentioned in the report.
iii 

Volume II

APPENDIX B: SOFA TASKING LETTER 

APPENDIX C: FIVE SOFA OPERATING RECOMMENDATIONS 

APPENDIX D: DATA FIELDS USED IN THE SOFA DATABASE 

APPENDIX E: POSSIBLE CONTRIBUTING FACTORS (PCFS) USED BY THE SWG 

APPENDIX F: SOFA CASES WITH SOFA CATEGORIES 

APPENDIX G: ADDITIONAL STATISTICS ON SOFA 3 (JOB BRIEFINGS), INDUSTRIAL 

TRACK HAZARDS, STRUCK BY MAINLINE TRAINS, AND FATALITIES 

DURING THE SECOND HOUR OF DUTY 

APPENDIX H: ADDITIONAL STATISTICS ON FATALITIES IN WINTER AND SUMMER 

APPENDIX I: TRAIN CREW RESOURCE MANAGEMENT 

APPENDIX J: SOFA-DEFINED SEVERE INJURIES, ADDITIONAL INFORMATION 

APPENDIX K: EVALUATION OF THE SOFA WORKING GROUP FOR THE 

IMPLEMENTATION OF SOFA FINDINGS, ADDITIONAL INFORMATION 

APPENDIX L: AN EVALUATION OF THE SWITCHING OPERATIONS FATALITY 

ANALYSIS 2010 WORKING GROUP’S PROCESSES 

 
B-1 

APPENDIX B: SOFA TASKING LETTER 

The letter immediately 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 
B-2 

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 

The next letter below was sent by Jo Strang, Associate Administrator for Safety, Federal 

Railroad Administration to Mr. Robert VanderClute, Association of American Railroads, Mr. 

Edward Rodzwicz, Brotherhood of Locomotive Engineers and Trainmen, Mr. Mike Futhey, 

United Transportation Union, and Mr. Richard Timmons, American Short Line and Regional 

Railroad Association 

This letter became the basis for reestablishing the Switching Operations Fatality Analysis 

(SOFA)Working Group which produced this report.

October 20, 2008 

U.S. Department 

Of Transportation 

Federal Railroad 

Administration 

I would like to bring to your attention 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 45 T&E employee fatalities that occurred from January 2004 through October 

15, 2008. These 45 incidents all represent T&E fatalities that occurred in other than major train 

collisions since the original Switching Operation Fatality Analysis (SOFA) Group updated their 

findings and published them in August 2004. I have included that update and a listing of the 45 cases 

with this letter. Of further concern is the fact that during calendar year 2007, there were a total of six 

SOFA-type fatalities. This year to date, there have been 10. 
B-3 

As you will note in the 2004 SOFA Update, on page 47, paragraph 4.3, the SOFA Group identified a 

new class of issues that they believed merited increased oversight. They grouped these issues under 

the title, "Special Switching Hazards." As I reviewed the list, I noticed that very few seem to relate to 

the operating and safety rules reflected in the five SOFA Safety Recommendations developed and 

published in the first SOFA report, dated October 1999. Further, shortly after the original SOFA 

publication, the railroad industry made a long-term effort to implement the operating and safety rules 

reflected in the five SOFA Safety Recommendations into their training programs and testing 

methodologies, with great success. The number of T&E employee deaths related to the five SOFA 

Safety Recommendations were significantly reduced. At the same time, the railroad management and 

union efforts to enhance job briefings and focus more on newly hired T&E employee mentoring 

appears to be beneficial for everyone as well. 

As was the case with the original SOFA effort, we need your help again if we are to reduce and 

eliminate the fatal train incidents reflected in the identified Special Switching Hazards. I believe that, 

once again, 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 detailed fact finding, 

review, and analysis of these latest incidents, add their findings to the original SOFA database and, if 

possible, formulate additional recommendations for the entire industry based on their collective 

findings. 

I anticipate the process would be much like the highly successful approach utilized by the original 

SOFA Group, that is, free from concerns that the finding might be used to initiate a rulemaking or 

used for any other formal action by FRA. Rather, railroads will be able to evaluate the SOFA's 

findings and recommendations with respect to their individual operating requirements and would, 

through the Railroad Safety Advisory Committee process, be encouraged to implement 

recommendations that would benefit their safety programs. 

I would like to invite you (or your representative) to a planning meeting to discuss the feasibility 

of such an effort and to determine the composition of the team. I suggest a meeting at FRA 

headquarters in Washington, DC, on Wednesday, November 12, 2008, at 

1:00 p.m., or at some other time and date during the week of November 10, 2008. If this is 

inconvenient, please contact Mr. Joe Gallant at (202) 493-6324, and he will be glad to arrange for 

an alternate date and time, or perhaps set up a conference call at a mutually convenient time. 

Sincerely, 

Jo Strang 

Associate Administrator for Safety 
C-1 

APPENDIX C: 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 of ‘The 

Five Lifesavers.’ The intent 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. 

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 

This recommendation emphasizes the importance of inter-crew communication and coordination 

with yardmasters. Compliance with and an understanding of this recommendation would have 

prevented these fatalities. 
C-2 

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. 

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 Appendix D 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, the 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. 

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

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

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

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

with limited service. 
D-1 

APPENDIX D: DATA FIELDS USED IN THE SOFA DATABASE 

Table Name: SOFA CASES 

Number Data Field Comment 

1 REPORT_NUMBER All tables are related to this 

master table through this key 

field 

2 RAILROAD 

3 INCIDENT_CATEGORY 

4 CITY 

5 STATE 

6 INCIDENT_DATE 

7 INCIDENT_TIME 

8 TYPE_SIGNALING 

9 SUMMARY Narrative entry 

10 REMARKS Narrative entry 

11 EMERCENCY_RESPONSE Yes/No/Unknown/NA 

12 ER COMMENT Narrative entry 

13 EMERGENCY_RESPONSE_PROCEDURES_FOLLOWED Yes/No/Unknown/NA 

14 ER_PROCEDURES_COMMENT Narrative entry 

15 TIMELY_ER_RESPONSE Yes/No/Unknown/NA 

16 TIMELINESS_COMMENT Narrative entry 

17 AUTOPSY_PERFORMED Yes/No/Unknown/NA 

18 AUTOPSY_COMMENT Narrative entry 

Table Name: Conditions 

 REPORT_NUMBER 

19 WEATHER 

20 TEMPERATURE 

21 HUMIDITY 

22 WIND DIRECTION 

23 WIND SPEED 

24 WIND CHILL FACTOR 

25 VISIBILITY Based on FRA Guide for 

Preparing Accident/Incident 

Reports 

26 LIGHTING CONDITIONS Based on FRA Guide for 

Preparing Accident/Incident 

Reports 

27 GROUND CONDITIONS Based on FRA Guide for 

Preparing Accident/Incident 

Reports 

28 FOOTING CONDITIONS Based on FRA Guide for 

Preparing Accident/Incident 

Reports 
D-2 

Table Name: FE Background 

 REPORT_NUMBER 

29 JOB CODE 

30 JOB DESCRIPTION 

31 AGE 

32 LENGTH OF SERVICE (YR) 

33 TIME IN OCCUPATION (YR) 

34 LAST RULES TRAINING DATE 

35 LAST RULES TRAINING (MO) 

36 LAST SAFETY TRAINING DATE 

37 LAST SAFETY TRAINING (MO) 

38 Formal Training (MO) 

39 Informal Training (MO) 

40 LAST EFFICIENCY TEST DATE 

41 LAST EFFICIENCY TEST (MO) 

42 LAST PHYSICAL EXAM DATE 

43 LAST PHYSICAL EXAM (MO) 

44 COMMENTS Narrative entry 

45 NUM SHIFTS IN LAST 30 DAYS 

46 COMMENT SHIFTS Narrative entry 

47 HRS ON DUTY, PRIOR SHIFT 

48 COMMENT HRS ON Narrative entry 

49 HRS OFF BEFORE ACCID SHIFT 

50 COMMENT HRS OFF Narrative entry 

51 HRS ON DUTY BEFORE ACCID 

52 COMMENT HRS BEFORE ACCIDENT Narrative entry 

53 REGULAR ASSIGNMENT? Yes/No/Unknown/NA 

54 COMMENT REG ASSIGNMEMT Narrative entry 

55 WORKED ASSIGNMENT BEFORE? Yes/No/Unknown/NA 

56 COMMENT WORKED BEFORE Narrative entry 

57 STRESS_BEHAVIOR_ISSUES Yes/No/Unknown/NA 

58 STRESS_BEHAVIOR_COMMENT Narrative entry 

59 TAKING_PRESCRIPT_MEDS Yes/No/Unknown/NA 

60 PRESCRIPT_MEDS_COMMENT Narrative entry 

61 ALCOHOL_DRUGS_A_FACTOR Yes/No/Unknown/NA 

62 ALCOHOL_DRUGS_FACTOR_COMMENT Narrative entry 

63 ALCOHOL_DRUGS_PRESENT Yes/No/Unknown/NA 

64 ALCOHOL_DRUGS_PRESENT_COMMENT Narrative entry 

Table Name: FE Crew Information 

 REPORT_NUMBER 

65 CREW SIZE 

66 ENGINE CREW 

67 TRAIN CREW 

68 CREW ON GROUND 

69 ACT INVOLVED GRND CREW 
D-3 

Table Name: FE Crew Employees 

 REPORT_NUMBER 

70 JOB_TITLE 

71 RR_EXPERIENCE 

72 CRAFT_EXPERIENCE 

73 COMMENT Narrative entry 

Table Name: Other Crew Information 

 REPORT_NUMBER 

74 CREW SIZE 

75 ENGINE CREW 

76 TRAIN CREW 

77 CREW ON GROUND 

78 ACT INVOLVED GRND CREW 

Table Name: Other Crew Employees 

 REPORT_NUMBER 

79 JOB_TITLE 

80 RR_EXPERIENCE 

81 CRAFT_EXPERIENCE 

82 COMMENT Narrative entry 

Table Name: Movement 

 REPORT_NUMBER 

83 TYPE TRACK 1 

84 TYPE TRACK 2 

85 TYPE TRACK 3 

86 AUTHORITY 

87 TYPE_MOVEMENT_STRIKING 

88 OTHER MOVE LOCATIONS 

89 TYPE_MOVEMENT_OTHER 

90 CREW OF STRIKER 

91 EQUIPMENT_SPEED 

92 METHOD ENGINE CONTROL RCL/Conventional 

93 BRAKES_CONTROLLED FROM_LEAD_CAR 

94 BRAKES_CONTROLLED_COMMENT 

95 RULE_COMPLIANT_EQUIP_OPS Yes/No/Unknown/NA 

96 RULE COMPLIANT COMMENT Narrative entry 

97 MOVEMENT_CAUSED_FATALITY Yes/No/Unknown/NA 

98 CAUSED FATALITY COMMENT Narrative entry 

99 ENGINEER ACTIVITY 

Based on FRA Guide for 

Preparing Accident/Incident 

Reports 

100 ENGINEER ACTIVITY COMMENT Narrative entry 

101 ENGINEER LOCATION 

Based on FRA Guide for 

Preparing Accident/Incident 

Reports 

102 ENGINEER LOCATION COMMENT Narrative entry 
D-4 

103 OTH TRAINMAN ACTIVITY 

Based on FRA Guide for 

Preparing Accident/Incident 

Reports 

104 OTH TRAINMAN ACTIVITY COMMENT Narrative entry 

105 OTH TRAINMAN LOCATION 

Based on FRA Guide for 

Preparing Accident/Incident 

Reports 

106 OTH TRAINMAN LOCATION COMMENT Narrative entry 

107 PLANNED NEXT MOVE 

108 FE_BETWEEN_EQUIPMENT Yes/No/Unknown/NA 

109 BETWEEN EQUIPMENT COMMENT Narrative entry 

110 FE_WORKED_LOCATION_BEFORE Yes/No/Unknown/NA 

111 WORKED LOCATION COMMENT Narrative entry 

112 ACTIVITY CODE 

Based on FRA Guide for 

Preparing Accident/Incident 

Reports 

113 ACTIVITY COMMENTS Narrative entry 

114 LOCATION CODE 

Based on FRA Guide for 

Preparing Accident/Incident 

Reports 

115 LOCATION COMMENTS Narrative entry 

116 EVENT CODE 

Based on FRA Guide for 

Preparing Accident/Incident 

Reports 

117 EVENT COMMENTS Narrative entry 

118 CAR_TYPE_RIDDEN 

119 WEARING_PPE Yes/No/Unknown/NA 

120 PPE COMMENT Narrative entry 

121 WEARING_HEARING_PROTECTION Yes/No/Unknown/NA 

122 HEARING PPE COMMENT Narrative entry 

123 WEARING_EYE_PROTECTION Yes/No/Unknown/NA 

124 VISION PPE COMMENT Narrative entry 

125 WEARING_PPE_FOOTWEAR Yes/No/Unknown/NA 

126 FOOTWAR PPE COMMENT Narrative entry 

127 WEARING_HARD_HAT Yes/No/Unknown/NA 

128 HARD HAT COMMENT Narrative entry 

129 WEARING_LINER_HOOD Yes/No/Unknown/NA 

130 HOOD-LINER COMMENT Narrative entry 

131 CLOTHING_CONTRIB_TO_INCIDENT Yes/No/Unknown/NA 

132 CLOTHING CONTRIBUTION COMMENT Narrative entry 

133 FOOTWEAR_CONTRIB_TO_INCIDENT Yes/No/Unknown/NA 

134 FOOTWEAR CONTRIBUTION COMMENT Narrative entry 

135 PPE_Comment Narrative entry 

Table Name: Communication Issues 

 REPORT_NUMBER 

136 TYPE_SIGNALING Hand, Radio, Both 
D-5 

Table Name: Hand Signals 

 REPORT_NUMBER 

136 HAND SIGNS USED Yes/No/Unknown/NA 

137 UNAIDED_HAND_SIGNAL Yes/No/Unknown/NA 

138 RR_LANTERN Yes/No/Unknown/NA 

139 FLASHLIGHT_OTHR_INDIV_LIGHT Yes/No/Unknown/NA 

140 FUSEE Yes/No/Unknown/NA 

141 HAND_SIGNAL_UNDER_LIGHTS Yes/No/Unknown/NA 

142 OTHER TYPE Yes/No/Unknown/NA 

143 OTHER TYPE COMMENT Narrative entry 

144 PROPER_SIGNAL_GIVEN Yes/No/Unknown/NA 

145 PROPER SIGNAL COMMENT Yes/No/Unknown/NA 

146 SIGNALS_UNDERSTOOD_BY_CREW Yes/No/Unknown/NA 

147 SIGNALS UNDERSTOOD COMMENT Narrative entry 

148 CONFUSING_NONSIGNAL_GESTURES_GIVEN Yes/No/Unknown/NA 

149 NONSIGNAL GESTURES COMMENT Narrative entry 

150 CLEARLY_VISIBLE_SIGNALS_GIVEN Yes/No/Unknown/NA 

151 VISIBLE SIGNAL COMMENT Narrative entry 

152 SIGNALS_CLEARLY_COMMUNICATED Yes/No/Unknown/NA 

153 CLEARLY COMMUNICATED COMMENT Narrative entry 

154 SIGNALS_GIVEN_ENGINEER_SIDE_TRK Yes/No/Unknown/NA 

155 ENGINEER SIDE COMMENT Narrative entry 

156 CREWS_ALERT_FOR_SIGNALS Yes/No/Unknown/NA 

157 ALERT FOR SIGNAL COMMENT Narrative entry 

158 CREWS_COMPLIED_WITH_SIGNALS Yes/No/Unknown/NA 

159 COMPLIED WITH SIGNAL COMMENT Narrative entry 

160 IMPROPER_CREW_RESPONSE Yes/No/Unknown/NA 

161 IMPROPER RESPONSE COMMENT Narrative entry 

162 Stop_Signaler Leaves Sight Yes/No/Unknown/NA 

163 STOP NO SIGHT COMMENT Narrative entry 

164 Light_disapears_mvmtstop Yes/No/Unknown/NA 

165 STOP NO LIGHT COMMENT Narrative entry 

166 Hand_Signal_Comment Narrative entry 

Table Name: Hand Signals 

 REPORT_NUMBER 

167 RADIO Yes/No/Unknown/NA 

168 RADIO COMMENT Narrative entry 

169 CHESTPACK Yes/No/Unknown/NA 

170 CHESTPACK COMMENT Narrative entry 

171 HANDSET Yes/No/Unknown/NA 

172 HANDSET COMMENT Narrative entry 

173 REMOTE_MICROPHONE Yes/No/Unknown/NA 

174 REMOTE MICROPHONE COMMENT Narrative entry 

175 WAIST_BELT_PACK Yes/No/Unknown/NA 

176 WAIST PACK COMMENT Narrative entry 

177 LOCOMOTIVE_MOUNTED Yes/No/Unknown/NA 

178 LOCOMOTIVE MOUNTED COMMENT Narrative entry 
D-6 

179 OTHER TYPE RADIO Yes/No/Unknown/NA 

180 OTHER RADIO COMMENT Narrative entry 

181 HAND_SIGNALS_COULD_BE_USED Yes/No/Unknown/NA 

182 HAND SIGNAL SUBSTITUTABILITY COMMENT Narrative entry 

183 CREW_ AWARE_ OF_ PLANNED_RADIO_MOVES Yes/No/Unknown/NA 

184 PLANNED RADIO MOVES COMMENT Narrative entry 

185 CREW_AWARE_RADIO_ LIMITS_HAND_SIGNAL_USE Yes/No/Unknown/NA 

186 RADIO LIMITS HAND SIGNALS COMMENT Narrative entry 

187 MOVEMENT_INSTRUCTIONS_GIVEN Yes/No/Unknown/NA 

188 INSTRUCTIONS GIVEN COMMENT Narrative entry 

189 MOVEMENT_INSTRUCTIONS_FOLLOWED Yes/No/Unknown/NA 

190 INSTRUCTIONS FOLLOWED COMMENT Narrative entry 

191 DIRECTION_DISTANCE_SPECIFIED Yes/No/Unknown/NA 

192 SPECIFIED DIRECTION/DISTANCE COMMENT Narrative entry 

193 DIRECTION_DISTANCE_ACKNOWLEDGED Yes/No/Unknown/NA 

194 DIRECTION/DISTANCE ACKNOWLEDGED COMMENT Narrative entry 

195 CHANNEL_AVAILABILITY_VERIFIED Yes/No/Unknown/NA 

196 CHANNEL AVAILABILITY COMMENT Narrative entry 

197 COMMUNICATION_ID_GIVEN Yes/No/Unknown/NA 

198 ID GIVEN COMMENT Narrative entry 

199 MOVE_MADE_WITHOUT_MSG_ACKNOWLEDGEMENT Yes/No/Unknown/NA 

200 MOVE W/O ACKNOWLEDGEMENT COMMENT Narrative entry 

201 PROPER_ID_A_FACTOR Yes/No/Unknown/NA 

202 PROPER ID COMMENT Narrative entry 

203 "OVER-OUT"_A_FACTOR Yes/No/Unknown/NA 

204 "OVER-OUT" COMMENT Narrative entry 

205 IMPROPER_COMM_RESPONSE_BY_CREW Yes/No/Unknown/NA 

206 IMPROPER CREW RESPONSE COMMENT Narrative entry 

207 RADIO_CALLS_IMMEDIATELY_ACKNOWLEDGED Yes/No/Unknown/NA 

208 CALLS ACKNOWLEDGED COMMENT Narrative entry 

209 MOVEMENT_STOPPED_WITHIN_HALF_DISTANCE Yes/No/Unknown/NA 

210 MOVEMENT STOPPED COMMENT Narrative entry 

211 RADIO_TESTED_BEFORE_INCIDENT Yes/No/Unknown/NA 

212 RADIO TESTED COMMENT Narrative entry 

213 USED_MALFUNCTIONING_RADIO Yes/No/Unknown/NA 

214 MALFUNCTIONING RADIO COMMENT Narrative entry 

215 RADIO_AND_HAND_SIGNALS_USED Yes/No/Unknown/NA 

216 BOTH RADIO HAND SIGNALS USED COMMENT Narrative entry 

217 RADIO_ON_PROPERLY_TUNED Yes/No/Unknown/NA 

218 PROPERLY TUNED RADIO COMMENT Narrative entry 

219 PROPER_RADIO_PROCEDURES_FOLLOWED Yes/No/Unknown/NA 

220 RADIO PROCEDURES COMMENT Narrative entry 

221 RADIO_RECEPTION_CLEAR Yes/No/Unknown/NA 

222 RECEPTION CLEAR COMMENT Narrative entry 

223 RADIO_CONTINUOUSLY_OPERABLE Yes/No/Unknown/NA 

224 RADIO_CONTINUOUS_COMMENT Narrative entry 

225 RADIO_COMMENT Narrative entry 
D-7 

Table Name: Possible Contributing Factors 

 

 REPORT_NUMBER 

226 PCF CODE 

Based on FRA Guide for 

Preparing Accident/Incident 

Reports with enhancements 

by the SWG 

227 COMMENTS Narrative entry 

Table Name: Possible Contributing Factors 

 REPORT_NUMBER 

228 PCF CODE 

Based on FRA Guide for 

Preparing Accident/Incident 

Reports with enhancements 

by the SWG 

229 COMMENTS Narrative entry 

Table Name: Other Cited Factors 

 REPORT_NUMBER 

230 OTHER_FACTORS Narrative entry 
E-1 

APPENDIX E: POSSIBLE CONTRIBUTING FACTORS (PCFS) USED BY 

THE SWG 

The SOFA Working Group (SWG) based its possible contributing factors (PCFs) on a list of 360 

cause codes taken from Appendix C of the FRA Guide for Preparing Accident/Incident Reports. 

The SWG created 12 more codes to make SOFA more precise; these additional codes are 

highlighted with an “*” in the table below. The table below shows the 83 codes that the SWG 

actually used in SOFA. 

PCFs Used by the SWG

PCF 

CODE DESCRIPTION OCCURRENCES

H990 Employee on or fouling track 80

H316 Poor intra-crew communication about work in progress 31

M411 Close or no clearance 27

H307 Shoving movement, man on or at leading end of movement, failure to 

control

24

H998 Employee falling from moving equipment 15

H399 Other general switching rules (Provide detailed description in narrative) 14

H997 Failure to provide adequate space between equipment 14

H317 Failure to communicate unsafe condition 13

H702 Switch improperly lined 12

H199 Employee physical condition, other (Provide detailed description in 

narrative)

10

M599 Other miscellaneous causes (Provide detailed description in narrative) 9

H210 Radio communication, failure to comply 9

H211 Radio communication, improper 8

H021 Failure to apply hand brakes on car(s) (railroad employee) 8

H996 Insufficient training 8

H306 Shoving movement, absence of man on or at leading end of movement 8

M101 Snow, ice, mud, gravel, coal, etc. on track 7

H310 Failure to couple 7

H989 Lack of skill or practical wisdom gained by personal knowledge or action. 

(Provide description in narrative.)

7

H305 Instruction to train/yard crew improper 7

M302 Highway user inattentiveness 7

H302 Cars left foul 6

H999 Other train operation/human factors (Provide detailed description in 

narrative)

6

H018 Failure to properly secure hand brake on car(s) (railroad employee) 6

H101 Impairment of efficiency or judgment because of drugs or alcohol 5

E29C Other body defects, (CAR) (Provide detailed description in narrative) 5

H312 Passed couplers 5

H318 Poor crew utilization 5

H602 Switching movement, excessive speed 5

M404 Object or equipment on or fouling track - other than above (for vandalism, 5
E-2 

PCFs Used by the SWG

PCF 

CODE DESCRIPTION OCCURRENCES

see code M503)

H605 Failure to comply with restricted speed 5

T099 Other roadbed defects (Provide detailed description in narrative) 4

H398 Poor inter-crew communication (Use only for CAWG - use H399 for SOFA.) 4

M412 Local supervision issues (Provide narrative) 4

H706 Failure to confirm route of movement 4

M501 Interference (other than vandalism) with railroad operations by nonrailroad 

employee

3

H599 Other causes relating to train handling or makeup (Provide detailed 

description in narrative)

3

M199 Other extreme environmental conditions (Provide detailed description in 

narrative)

3

H212 Radio communication, failure to give/receive 3

H500 Slack action 3

H019 Failure to release hand brakes on car(s) (railroad employee) 3

E39C Other coupler and draft system defects, (CAR) (Provide detailed 

description in narrative)

2

H699 Speed, other (Provide detailed description in narrative) 2

M304 Highway user cited for violation of highway-rail grade crossing traffic laws 2

H303 Derail, failure to apply or remove 2

H020 Failure to apply sufficient number of hand brakes on car(s) (railroad 

employee)

2

H301 Car(s) shoved out and left out of clear 2

E09C Other brake defects, cars (Provide detailed description in narrative) 2

E31C Coupler mismatch, high/low 1

E39L Other coupler and draft system defects, (LOCOMOTIVE) (Provide detailed 

description in narrative)

1

H008 Improper operation of train line air connections (bottling the air) 1

H099 Use of brakes, other (Provide detailed description in narrative) 1

E79L Other locomotive defects (Provide detail description in narrative) 1

E67C Damaged flange or tread (build up) 1

H207 Hand signal, failure to comply 1

H205 Flagging, improper or failure to flag 1

H025 Failure to control speed of car using hand brake (railroad employee) 1

H075 Setting a hand brake 1

E66L Damaged flange or tread (flat) (LOCOMOTIVE) 1

M104 Extreme environmental condition - DENSE FOG 1

T307 Spring/power switch mechanism malfunction 1

T299 Other rail and joint bar defects (Provide detailed description in narrative) 1

T222 Worn rail 1

T199 Other track geometry defects (Provide detailed description in narrative) 1

T105 Insufficient ballast section 1

M504 Failure by nonrailroad employee, e.g., industry employee, to control speed 

of car using hand brake

1
E-3 

PCFs Used by the SWG

PCF 

CODE DESCRIPTION OCCURRENCES

M502 Vandalism of on-track equipment, e.g., brakes released 1

M401 Emergency brake application to avoid accident 1

M399 Other causes (Provide detailed description in narrative) 1

H503 Buffing or slack action excessive, train handling 1

M303 Highway user misjudgment under normal weather and traffic conditions 1

H299 Other signal causes (Provide detailed description in narrative) 1

H995 Human Factor - motive power and equipment 1

H799 Use of switches, other (Provide detailed description in narrative) 1

H603 Train inside yard limits, excessive speed 1

H524 Excessive horsepower (H016) 1

H514 Failure to allow air brakes to fully release before proceeding (H005) 1

T319 Switch point gapped (between switch point and stock rail) 1

H509 Improper train inspection 1

E02C Broken brake pipe or connections 1

H401 Failure to stop train in clear 1

H309 Failure to stretch cars before shoving 1

M307 Malfunction, improper operation of train activated warning devices 1
F-1 

APPENDIX F: SOFA CASES WITH SOFA CATEGORIES 

CASE RAILNUMBER DATE ROAD CITY STATE OCCUPATION AGE

FE-1992-03 28-Jan-92 BN Willmar MN Yard Brakeman/Helper 57

SOFA Category: SSHFR Special Switching Hazard: Free-Rolling Railcars.

SOFA Category: SOFA4 SOFA 4: Move controlled by a combination of hand and radio signals or specific distances were not given.

FE-1992-04 30-Jan-92 AGC Polk County FL Yard Brakeman/Helper 32

SOFA Category: SOFA5 SOFA 5: FE had 1.5 years of experience or less or had inadequate training.

FE-1992-08 11-Mar-92 FEC Fort Pierce FL Yard Conductor/Foreman 36

SOFA Category: SOFA4 SOFA 4: Move controlled by a combination of hand and radio signals or specific distances were not given.

SOFA Category: SSHDR Special Switching Hazard: Derailment.

SOFA Category: SSHEQ Special Switching Hazard: Equipment.

FE-1992-09 09-Apr-92 ATSF Cheto AZ Freight Engineer 54

SOFA Category: SSHFR Special Switching Hazard: Free-Rolling Railcars.

FE-1992-14 01-Jun-92 ATSF Escondido CA Freight Conductor 58

SOFA Category: SOFA4 SOFA 4: Move controlled by a combination of hand and radio signals or specific distances were not given.

FE-1992-15 01-Jun-92 BN Seattle WA Switchman 42

SOFA Category: SSHUC Special Switching Hazard: Unsecured Cars.

SOFA Category: SSHET Special Switching Hazard: Employee Tripping, Slipping, or Falling

FE-1992-16 02-Jun-92 IHRC Henderson KY Freight Conductor 52

SOFA Category: SSHUM Special Switching Hazard: Unexpected Movement of Railcars.

SOFA Category: SOFA5 SOFA 5: FE had 1.5 years of experience or less or had inadequate training.

FE-1992-18 20-Jun-92 CNW Northlake IL Yard Conductor/Foreman 42

SOFA Category: SOFA1 SOFA 1: Adjusting knuckles, adjusting drawbars, or installing EOT

FE-1992-20 07-Jul-92 SSW Conlen Siding TX Freight Engineer 58

SOFA Category: SSHST Special Switching Hazard: Struck by Mainline Train.

FE-1992-22 25-Jul-92 UP Portland OR Freight Brakeman/Flagman 54

SOFA Category: SOFA4 SOFA 4: Move controlled by a combination of hand and radio signals or specific distances were not given.

SOFA Category: SSHFC Special Switching Hazard: Failure to Confirm Route of Movement.

FE-1992-30 24-Jul-92 GBW Wisconsin WI Freight Brakeman/Flagman 34

SOFA Category: SSHUM Special Switching Hazard: Unexpected Movement of Railcars.

SOFA Category: SOFA2 SOFA 2: Struck by equipment other than their own on yard or industry track.

SOFA Category: SOFA3 SOFA 3: Lack of or inadequate job safety briefing.

FE-1992-33 15-Oct-92 BN Omaha NE Yard Brakeman/Helper 32

SOFA Category: SSHIH Special Switching Hazard: Industrial Hazard.

SOFA Category: SSHMC Special Switching Hazard: Miscellaneous.

FE-1992-34 23-Oct-92 GTW Dearborn MI Freight Brakeman/Flagman 49

SOFA Category: SSHFR Special Switching Hazard: Free-Rolling Railcars.
F-2 

CASE RAILNUMBER DATE ROAD CITY STATE OCCUPATION AGE

FE-1992-39 16-Nov-92 TTIS Maysville KY Freight Conductor 35

SOFA Category: SSHMC Special Switching Hazard: Miscellaneous.

FE-1993-11 27-Mar-93 SP Guadalupe CA Freight Brakeman/Flagman 39

SOFA Category: SSHET Special Switching Hazard: Employee Tripping, Slipping, or Falling

FE-1993-13 13-Apr-93 CSX Dwale KY Freight Brakeman/Flagman 44

SOFA Category: SSHST Special Switching Hazard: Struck by Mainline Train.

FE-1993-20 22-May-93 ATSF El Paso TX Yard Conductor/Foreman 46

SOFA Category: SSHMC Special Switching Hazard: Miscellaneous.

FE-1993-22 04-Jun-93 SEPTA Devon PA Road Passenger Engineer 29

SOFA Category: SSHMC Special Switching Hazard: Miscellaneous.

FE-1993-23 07-Jun-93 IC Fulton KY Yard Brakeman/Helper 49

SOFA Category: SSHUM Special Switching Hazard: Unexpected Movement of Railcars.

SOFA Category: SOFA3 SOFA 3: Lack of or inadequate job safety briefing.

FE-1993-26 15-Jul-93 CR Anderson IN Yard Brakeman/Helper 43

SOFA Category: SOFA4 SOFA 4: Move controlled by a combination of hand and radio signals or specific distances were not given.

SOFA Category: SSHET Special Switching Hazard: Employee Tripping, Slipping, or Falling

FE-1993-27 04-Aug-93 UP Pryor OK Freight Brakeman/Flagman 42

SOFA Category: SSHCC Special Switching Hazard: Close Clearance.

SOFA Category: SSHDR Special Switching Hazard: Derailment.

SOFA Category: SSHIH Special Switching Hazard: Industrial Hazard.

FE-1993-30 11-Aug-93 SP Tracy CA Freight Brakeman/Flagman 47

SOFA Category: SOFA3 SOFA 3: Lack of or inadequate job safety briefing.

SOFA Category: SOFA4 SOFA 4: Move controlled by a combination of hand and radio signals or specific distances were not given.

SOFA Category: SSHIH Special Switching Hazard: Industrial Hazard.

FE-1993-31 12-Aug-93 ATSF Evandale TX Freight Brakeman/Flagman 52

SOFA Category: SOFA2 SOFA 2: Struck by equipment other than their own on yard or industry track.

FE-1993-35 02-Sep-93 ATSF Carlsbad NM Freight Conductor 55

SOFA Category: SSHMC Special Switching Hazard: Miscellaneous.

FE-1993-40 19-Oct-93 SOO Leal ND Freight Brakeman/Flagman 43

SOFA Category: SSHDR Special Switching Hazard: Derailment.

SOFA Category: SOFA5 SOFA 5: FE had 1.5 years of experience or less or had inadequate training.

FE-1993-46 12-Nov-93 ATSF Farewell TX Freight Conductor 41

SOFA Category: SSHUC Special Switching Hazard: Unsecured Cars.

SOFA Category: SSHDA Special Switching Hazard: Drugs and Alcohol.

FE-1993-47 13-Nov-93 GC Macon GA Yard Conductor/Foreman 47

SOFA Category: SOFA3 SOFA 3: Lack of or inadequate job safety briefing.

SOFA Category: SOFA5 SOFA 5: FE had 1.5 years of experience or less or had inadequate training.

SOFA Category: SSHUM Special Switching Hazard: Unexpected Movement of Railcars.
F-3 

CASE RAILNUMBER DATE ROAD CITY STATE OCCUPATION AGE

FE-1993-49 05-Dec-93 SOU Atlanta GA Freight Conductor 59

SOFA Category: SOFA3 SOFA 3: Lack of or inadequate job safety briefing.

SOFA Category: SSHUM Special Switching Hazard: Unexpected Movement of Railcars.

FE-1993-53 30-Dec-93 CR Brook Park OH Yard Conductor/Foreman 61

SOFA Category: SSHEV Special Switching Hazard: Environment.

SOFA Category: SSHIH Special Switching Hazard: Industrial Hazard.

FE-1994-02 04-Jan-94 BN Hastings NE Conductor 46

SOFA Category: SSHUC Special Switching Hazard: Unsecured Cars.

FE-1994-03 14-Jan-94 BN Amarillo TX Conductor 57

SOFA Category: SSHEQ Special Switching Hazard: Equipment.

SOFA Category: SSHDR Special Switching Hazard: Derailment.

FE-1994-04 18-Jan-94 CSXT Bainbridge GA Conductor 45

SOFA Category: SSHMC Special Switching Hazard: Miscellaneous.

FE-1994-06 20-Jan-94 UP Fall City NE Freight Conductor 44

SOFA Category: SOFA2 SOFA 2: Struck by equipment other than their own on yard or industry track.

SOFA Category: SSHCC Special Switching Hazard: Close Clearance.

SOFA Category: SSHFR Special Switching Hazard: Free-Rolling Railcars.

FE-1994-12 12-Apr-94 SP Houston TX Yard Conductor/Foreman 62

SOFA Category: SSHCC Special Switching Hazard: Close Clearance.

FE-1994-16 05-Jul-94 BN Essex MT Freight Brakeman/Flagman 59

SOFA Category: SSHFR Special Switching Hazard: Free-Rolling Railcars.

FE-1994-20 20-Sep-94 ARR Clear Site AK Freight Brakeman/Flagman 49

SOFA Category: SSHMV Special Switching Hazard: Struck or struck by Motor Vehicle.

FE-1994-26 17-Oct-94 UP Donaldsonville LA Freight Brakeman/Flagman 36

SOFA Category: SOFA1 SOFA 1: Adjusting knuckles, adjusting drawbars, or installing EOT

FE-1994-28 10-Nov-94 PTRA Houston TX Yard Brakeman/Helper 31

SOFA Category: SOFA5 SOFA 5: FE had 1.5 years of experience or less or had inadequate training.

SOFA Category: SSHIH Special Switching Hazard: Industrial Hazard.

FE-1994-29 15-Nov-94 CR Painted Post NY Freight Brakeman/Flagman 57

SOFA Category: SOFA3 SOFA 3: Lack of or inadequate job safety briefing.

SOFA Category: SOFA4 SOFA 4: Move controlled by a combination of hand and radio signals or specific distances were not given.

SOFA Category: SSHUM Special Switching Hazard: Unexpected Movement of Railcars.

FE-1994-31 06-Dec-94 CR Campbell Hall NY Brakeman Trainee 28

SOFA Category: SOFA5 SOFA 5: FE had 1.5 years of experience or less or had inadequate training.

SOFA Category: SOFA2 SOFA 2: Struck by equipment other than their own on yard or industry track.

SOFA Category: SOFA4 SOFA 4: Move controlled by a combination of hand and radio signals or specific distances were not given.

FE-1994-32 13-Dec-94 UP Thorton CA Freight Brakeman/Flagman 48

SOFA Category: SOFA1 SOFA 1: Adjusting knuckles, adjusting drawbars, or installing EOT
F-4 

CASE RAILNUMBER DATE ROAD CITY STATE OCCUPATION AGE

FE-1995-02 11-Jan-95 CR Indianapolis IN Conductor 51

SOFA Category: SSHEQ Special Switching Hazard: Equipment.

FE-1995-09 17-Feb-95 CR St. James OH Conductor 48

SOFA Category: SOFA3 SOFA 3: Lack of or inadequate job safety briefing.

SOFA Category: SOFA4 SOFA 4: Move controlled by a combination of hand and radio signals or specific distances were not given.

SOFA Category: SSHUM Special Switching Hazard: Unexpected Movement of Railcars.

FE-1995-11 24-Feb-95 ATSF Amarillo TX Engine Foreman 44

SOFA Category: SOFA1 SOFA 1: Adjusting knuckles, adjusting drawbars, or installing EOT

SOFA Category: SOFA2 SOFA 2: Struck by equipment other than their own on yard or industry track.

SOFA Category: SSHFR Special Switching Hazard: Free-Rolling Railcars.

FE-1995-12 02-Mar-95 NS Aiken SC Brakeman 46

SOFA Category: SOFA3 SOFA 3: Lack of or inadequate job safety briefing.

SOFA Category: SOFA1 SOFA 1: Adjusting knuckles, adjusting drawbars, or installing EOT

FE-1995-16 06-Apr-95 WC Argoe WI Conductor 45

SOFA Category: SSHUC Special Switching Hazard: Unsecured Cars.

FE-1995-17 21-Mar-95 SP Bassett CA Conductor 55

SOFA Category: SSHMC Special Switching Hazard: Miscellaneous.

FE-1995-18 03-May-95 CSXT Evansville IN Conductor 52

SOFA Category: SOFA2 SOFA 2: Struck by equipment other than their own on yard or industry track.

FE-1995-23 21-Jul-95 CR Hershey PA Conductor 61

SOFA Category: SSHET Special Switching Hazard: Employee Tripping, Slipping, or Falling

FE-1995-29 04-Oct-95 CSXT Riverdale IL Conductor 39

SOFA Category: SOFA1 SOFA 1: Adjusting knuckles, adjusting drawbars, or installing EOT

SOFA Category: SOFA5 SOFA 5: FE had 1.5 years of experience or less or had inadequate training.

FE-1995-33 11-Dec-95 NS Toledo OH Brakeman 53

SOFA Category: SSHCC Special Switching Hazard: Close Clearance.

SOFA Category: SSHIH Special Switching Hazard: Industrial Hazard.

FE-1995-34 14-Dec-95 CSXT Monroe NC Conductor 54

SOFA Category: SSHCC Special Switching Hazard: Close Clearance.

FE-1996-09 20-Mar-96 BRC Bedford Park IL Conductor 28

SOFA Category: SOFA1 SOFA 1: Adjusting knuckles, adjusting drawbars, or installing EOT

SOFA Category: SOFA5 SOFA 5: FE had 1.5 years of experience or less or had inadequate training.

SOFA Category: SSHUC Special Switching Hazard: Unsecured Cars.

FE-1996-12 15-Jun-96 CSX Charlotte NC Switchman 36

SOFA Category: SOFA5 SOFA 5: FE had 1.5 years of experience or less or had inadequate training.

SOFA Category: SSHCC Special Switching Hazard: Close Clearance.

SOFA Category: SSHIH Special Switching Hazard: Industrial Hazard.

FE-1996-17 07-Jul-96 NS Sidney IN Conductor 29
F-5 

CASE RAILNUMBER DATE ROAD CITY STATE OCCUPATION AGE

SOFA Category: SOFA5 SOFA 5: FE had 1.5 years of experience or less or had inadequate training.

SOFA Category: SSHST Special Switching Hazard: Struck by Mainline Train.

FE-1996-22 03-Sep-96 DGNO Dallas TX Brakeman 43

SOFA Category: SSHEQ Special Switching Hazard: Equipment.

SOFA Category: SOFA5 SOFA 5: FE had 1.5 years of experience or less or had inadequate training.

FE-1996-24 07-Oct-96 UP Eagle Pass TX Engine Foreman 35

SOFA Category: SSHEQ Special Switching Hazard: Equipment.

SOFA Category: SOFA5 SOFA 5: FE had 1.5 years of experience or less or had inadequate training.

SOFA Category: SOFA1 SOFA 1: Adjusting knuckles, adjusting drawbars, or installing EOT

FE-1996-30 16-Dec-96 UP Clinton IA Brakeman 51

SOFA Category: SSHET Special Switching Hazard: Employee Tripping, Slipping, or Falling

SOFA Category: SSHDA Special Switching Hazard: Drugs and Alcohol.

FE-1996-31 18-Dec-96 IC Chicago IL Conductor 45

SOFA Category: SSHUC Special Switching Hazard: Unsecured Cars.

FE-1997-02 12-Jan-97 UP S Fontana CA Conductor 60

SOFA Category: SSHET Special Switching Hazard: Employee Tripping, Slipping, or Falling

FE-1997-04 29-Jan-97 UP Mason City IA Conductor 48

SOFA Category: SOFA4 SOFA 4: Move controlled by a combination of hand and radio signals or specific distances were not given.

SOFA Category: SSHFC Special Switching Hazard: Failure to Confirm Route of Movement.

FE-1997-05 02-Feb-97 CR Burns Harbor IN Engine Foreman 54

SOFA Category: SOFA2 SOFA 2: Struck by equipment other than their own on yard or industry track.

FE-1997-16 06-Jun-97 CMRC Bay City MI Conductor 50

SOFA Category: SOFA4 SOFA 4: Move controlled by a combination of hand and radio signals or specific distances were not given.

FE-1997-18 24-Jun-97 UP Portland OR Yard Conductor/Foreman 53

SOFA Category: SSHET Special Switching Hazard: Employee Tripping, Slipping, or Falling

FE-1997-19 24-Jun-97 NS Rowesville SC Conductor 21

SOFA Category: SSHUM Special Switching Hazard: Unexpected Movement of Railcars.

FE-1997-22 18-Jul-97 MNCW Stamford CT Conductor 40

SOFA Category: SSHST Special Switching Hazard: Struck by Mainline Train.

FE-1997-25 15-Aug-97 UP Elko NV Yard Brakeman/Helper 53

SOFA Category: SOFA1 SOFA 1: Adjusting knuckles, adjusting drawbars, or installing EOT

SOFA Category: SSHUC Special Switching Hazard: Unsecured Cars.

FE-1997-32 16-Oct-97 MRL Laurel MT Switchman 22

SOFA Category: SOFA5 SOFA 5: FE had 1.5 years of experience or less or had inadequate training.

SOFA Category: SSHEQ Special Switching Hazard: Equipment.

SOFA Category: SSHET Special Switching Hazard: Employee Tripping, Slipping, or Falling

FE-1997-36 02-Dec-97 BNSF Emporia KS Freight Conductor 50

SOFA Category: SSHST Special Switching Hazard: Struck by Mainline Train.
F-6 

CASE RAILNUMBER DATE ROAD CITY STATE OCCUPATION AGE

FE-1997-45 26-Dec-97 UP Boise ID Freight Conductor 55

SOFA Category: SOFA4 SOFA 4: Move controlled by a combination of hand and radio signals or specific distances were not given.

FE-1998-02 24-Jan-98 BNSF Omaha NE Yard Conductor/Foreman 47

SOFA Category: SSHDA Special Switching Hazard: Drugs and Alcohol.

FE-1998-05 04-Feb-98 BRC Bedford Park IL Yard Conductor/Foreman 42

SOFA Category: SOFA2 SOFA 2: Struck by equipment other than their own on yard or industry track.

SOFA Category: SSHCC Special Switching Hazard: Close Clearance.

SOFA Category: SSHFR Special Switching Hazard: Free-Rolling Railcars.

FE-1998-15 26-May-98 BRC Bedford Park IL Yard Conductor/Foreman 57

SOFA Category: SOFA1 SOFA 1: Adjusting knuckles, adjusting drawbars, or installing EOT

SOFA Category: SSHUC Special Switching Hazard: Unsecured Cars.

FE-1998-16 01-Jun-98 BNSF Lubbock TX Yard Conductor/Foreman 24

SOFA Category: SOFA2 SOFA 2: Struck by equipment other than their own on yard or industry track.

SOFA Category: SOFA5 SOFA 5: FE had 1.5 years of experience or less or had inadequate training.

FE-1998-17 05-Jun-98 NS Hapeville GA Yard Conductor/Foreman 48

SOFA Category: SOFA1 SOFA 1: Adjusting knuckles, adjusting drawbars, or installing EOT

FE-1998-19 01-Jul-98 NS Buechel KY Utility Employee 54

SOFA Category: SSHCC Special Switching Hazard: Close Clearance.

SOFA Category: SSHIH Special Switching Hazard: Industrial Hazard.

FE-1998-28 26-Oct-98 CCP Cicero IL Engineer 42

SOFA Category: SSHMC Special Switching Hazard: Miscellaneous.

FE-1998-37 28-Dec-98 IC Durrant MS Conductor 55

SOFA Category: SOFA4 SOFA 4: Move controlled by a combination of hand and radio signals or specific distances were not given.

SOFA Category: SSHDR Special Switching Hazard: Derailment.

FE-1999-01 12-Jan-99 CR Port Newark NJ Conductor 54

SOFA Category: SOFA3 SOFA 3: Lack of or inadequate job safety briefing.

SOFA Category: SOFA4 SOFA 4: Move controlled by a combination of hand and radio signals or specific distances were not given.

SOFA Category: SSHFC Special Switching Hazard: Failure to Confirm Route of Movement.

FE-1999-03 22-Jan-99 CR Alexanderia NY Conductor 45

SOFA Category: SSHDR Special Switching Hazard: Derailment.

SOFA Category: SOFA5 SOFA 5: FE had 1.5 years of experience or less or had inadequate training.

SOFA Category: SSHEV Special Switching Hazard: Environment.

FE-1999-05 17-Feb-99 KCS Kansas City MO Freight Conductor 26

SOFA Category: SSHMV Special Switching Hazard: Struck or struck by Motor Vehicle.

FE-1999-11 02-Apr-99 DME Waseca MN Brakeman 54

SOFA Category: SOFA3 SOFA 3: Lack of or inadequate job safety briefing.

FE-1999-12 09-Apr-99 UP Richland WA Conductor 58

SOFA Category: SSHEQ Special Switching Hazard: Equipment.
F-7 

CASE RAILNUMBER DATE ROAD CITY STATE OCCUPATION AGE

FE-1999-14 19-May-99 NS Cincinnati OH Conductor 36

SOFA Category: SOFA5 SOFA 5: FE had 1.5 years of experience or less or had inadequate training.

FE-1999-16 23-Jun-99 UP Redding CA Conductor 57

SOFA Category: SOFA1 SOFA 1: Adjusting knuckles, adjusting drawbars, or installing EOT

SOFA Category: SOFA4 SOFA 4: Move controlled by a combination of hand and radio signals or specific distances were not given.

FE-1999-24 14-Sep-99 AM Van Buren AR Conductor 47

SOFA Category: SSHDA Special Switching Hazard: Drugs and Alcohol.

SOFA Category: SOFA1 SOFA 1: Adjusting knuckles, adjusting drawbars, or installing EOT

SOFA Category: SOFA5 SOFA 5: FE had 1.5 years of experience or less or had inadequate training.

FE-1999-32 17-Nov-99 UP Lincoln NE Brakeman 57

SOFA Category: SSHUM Special Switching Hazard: Unexpected Movement of Railcars.

FE-2000-02 02-Jan-00 CIRR Cedar Springs GA Conductor 49

SOFA Category: SSHEV Special Switching Hazard: Environment.

FE-2000-09 09-Mar-00 IHB Riverdale IL Engine Foreman 43

SOFA Category: SOFA1 SOFA 1: Adjusting knuckles, adjusting drawbars, or installing EOT

SOFA Category: SSHUC Special Switching Hazard: Unsecured Cars.

FE-2000-13 21-Apr-00 BNSF Galesburg IL Engine Foreman 60

SOFA Category: SSHFR Special Switching Hazard: Free-Rolling Railcars.

FE-2000-16 22-May-00 CSX Richmond VA Brakeman 38

SOFA Category: SSHCC Special Switching Hazard: Close Clearance.

SOFA Category: SSHIH Special Switching Hazard: Industrial Hazard.

FE-2000-17 31-May-00 UP Pine Bluff AR Engine Foreman 47

SOFA Category: SSHMC Special Switching Hazard: Miscellaneous.

FE-2000-21 07-Jul-00 CKRY Wichita KS Conductor 39

SOFA Category: SSHET Special Switching Hazard: Employee Tripping, Slipping, or Falling

SOFA Category: SOFA1 SOFA 1: Adjusting knuckles, adjusting drawbars, or installing EOT

FE-2000-22 24-Jul-00 PARN Skagway AK Conductor 55

SOFA Category: SOFA4 SOFA 4: Move controlled by a combination of hand and radio signals or specific distances were not given.

SOFA Category: SSHFC Special Switching Hazard: Failure to Confirm Route of Movement.

FE-2000-23 28-Jul-00 UP St. Louis MO Switchman 48

SOFA Category: SSHCC Special Switching Hazard: Close Clearance.

SOFA Category: SSHIH Special Switching Hazard: Industrial Hazard.

FE-2000-25 11-Aug-00 BNSF Port of Los Angeles CA Freight Brakeman 36

SOFA Category: SOFA2 SOFA 2: Struck by equipment other than their own on yard or industry track.

FE-2000-29 09-Sep-00 BNSF Keokuk IA Conductor 53

SOFA Category: SOFA4 SOFA 4: Move controlled by a combination of hand and radio signals or specific distances were not given.

FE-2000-30 15-Oct-00 UP Houston TX Fireman 47
F-8 

CASE RAILNUMBER DATE ROAD CITY STATE OCCUPATION AGE

SOFA Category: SOFA3 SOFA 3: Lack of or inadequate job safety briefing.

SOFA Category: SSHCC Special Switching Hazard: Close Clearance.

FE-2000-32 28-Dec-00 UP Dupo IL Switchman 52

SOFA Category: SSHST Special Switching Hazard: Struck by Mainline Train.

FE-2000-33 29-Dec-00 BNSF Gillette WY Conductor 29

SOFA Category: SSHST Special Switching Hazard: Struck by Mainline Train.

SOFA Category: SSHED Special Switching Hazard: Electronic Device (Cell phone, MP3 player)

FE-2001-02 10-Jan-01 CSX Chicago IL Conductor 42

SOFA Category: SOFA5 SOFA 5: FE had 1.5 years of experience or less or had inadequate training.

SOFA Category: SSHST Special Switching Hazard: Struck by Mainline Train.

FE-2001-03 11-Jan-01 NS South Fork PA Engineer 52

SOFA Category: SOFA3 SOFA 3: Lack of or inadequate job safety briefing.

SOFA Category: SSHEQ Special Switching Hazard: Equipment.

SOFA Category: SSHST Special Switching Hazard: Struck by Mainline Train.

FE-2001-08 03-Mar-01 BNSF Willmar MN Switchman 36

SOFA Category: SSHUC Special Switching Hazard: Unsecured Cars.

SOFA Category: SOFA1 SOFA 1: Adjusting knuckles, adjusting drawbars, or installing EOT

SOFA Category: SSHEV Special Switching Hazard: Environment.

FE-2001-14 08-Apr-01 BNSF Clark OK Conductor 35

SOFA Category: SSHMC Special Switching Hazard: Miscellaneous.

FE-2001-21 13-Jul-01 CPRS Bensenville IL Conductor 55

SOFA Category: SSHFR Special Switching Hazard: Free-Rolling Railcars.

SOFA Category: SSHDR Special Switching Hazard: Derailment.

FE-2001-31 10-Oct-01 PAL Clayburn KY Conductor 38

SOFA Category: SSHCC Special Switching Hazard: Close Clearance.

FE-2001-39 22-Dec-01 NS Eden NC Brakeman 50

SOFA Category: SSHMV Special Switching Hazard: Struck or struck by Motor Vehicle.

FE-2001-40 24-Dec-01 NS Lynchburg VA Conductor 30

SOFA Category: SSHCC Special Switching Hazard: Close Clearance.

SOFA Category: SSHST Special Switching Hazard: Struck by Mainline Train.

FE-2002-09 21-Mar-02 NS Claymont DE Engineer 45

SOFA Category: SSHCC Special Switching Hazard: Close Clearance.

SOFA Category: SSHST Special Switching Hazard: Struck by Mainline Train.

FE-2002-12 14-May-02 UP Pine Bluff AR Switchman 53

SOFA Category: SOFA1 SOFA 1: Adjusting knuckles, adjusting drawbars, or installing EOT

SOFA Category: SSHUC Special Switching Hazard: Unsecured Cars.

FE-2002-16 16-Jun-02 BNSF Memphis TN Engine Foreman 20

SOFA Category: SOFA3 SOFA 3: Lack of or inadequate job safety briefing.
F-9 

CASE RAILNUMBER DATE ROAD CITY STATE OCCUPATION AGE

SOFA Category: SOFA5 SOFA 5: FE had 1.5 years of experience or less or had inadequate training.

SOFA Category: SOFA1 SOFA 1: Adjusting knuckles, adjusting drawbars, or installing EOT

FE-2002-17 16-Jul-02 NS Bonlee NC Brakeman 55

SOFA Category: SOFA4 SOFA 4: Move controlled by a combination of hand and radio signals or specific distances were not given.

FE-2002-19 08-Aug-02 CWRO Cleveland OH Switchman 53

SOFA Category: SOFA2 SOFA 2: Struck by equipment other than their own on yard or industry track.

SOFA Category: SSHCC Special Switching Hazard: Close Clearance.

FE-2002-22 02-Sep-02 CSXT Madisonville KY Conductor 52

SOFA Category: SSHUM Special Switching Hazard: Unexpected Movement of Railcars.

FE-2003-03 11-Feb-03 CNIC Flat Rock MI Brakeman 57

SOFA Category: SOFA2 SOFA 2: Struck by equipment other than their own on yard or industry track.

FE-2003-04 16-Feb-03 CSXT Syracuse NY Switchman 36

SOFA Category: SSHFR Special Switching Hazard: Free-Rolling Railcars.

FE-2003-05 18-Feb-03 CSXT Cheektowaga NY Switch Foreman 51

SOFA Category: SSHUC Special Switching Hazard: Unsecured Cars.

FE-2003-11 11-Apr-03 UP Pocatello ID Conductor 55

SOFA Category: SOFA3 SOFA 3: Lack of or inadequate job safety briefing.

SOFA Category: SSHDR Special Switching Hazard: Derailment.

FE-2003-12 06-Jun-03 CSXT Kingsport TN Brakeman 35

SOFA Category: SSHMV Special Switching Hazard: Struck or struck by Motor Vehicle.

SOFA Category: SSHIH Special Switching Hazard: Industrial Hazard.

FE-2003-20 26-Aug-03 LC Chester SC Conductor 29

SOFA Category: SOFA1 SOFA 1: Adjusting knuckles, adjusting drawbars, or installing EOT

FE-2003-22 12-Sep-03 GC Dublin GA Brakeman 45

SOFA Category: SOFA5 SOFA 5: FE had 1.5 years of experience or less or had inadequate training.

FE-2003-23 14-Sep-03 UP Ogden UT Conductor 53

SOFA Category: SSHEQ Special Switching Hazard: Equipment.

FE-2003-25 24-Sep-03 BNSF Fresno CA Switch Foreman 35

SOFA Category: SSHET Special Switching Hazard: Employee Tripping, Slipping, or Falling

FE-2003-35 07-Dec-03 UP San Antonio TX Conductor 37

SOFA Category: SSHUM Special Switching Hazard: Unexpected Movement of Railcars.

FE-2004-03 14-Jan-04 NS Kankakee IL Freight Conductor 40

SOFA Category: SSHEV Special Switching Hazard: Environment.

SOFA Category: SSHET Special Switching Hazard: Employee Tripping, Slipping, or Falling

FE-2004-10 10-Mar-04 MNCW Stanford CT Yard Brakeman 46

SOFA Category: SSHFC Special Switching Hazard: Failure to Confirm Route of Movement.

FE-2004-13 13-May-04 MSO Sturgis MI Conductor 38
F-10 

CASE RAILNUMBER DATE ROAD CITY STATE OCCUPATION AGE

SOFA Category: SSHDA Special Switching Hazard: Drugs and Alcohol.

SOFA Category: SSHET Special Switching Hazard: Employee Tripping, Slipping, or Falling

FE-2004-14 18-May-04 NS Elwood IN Freight Brakeman 35

SOFA Category: SSHMV Special Switching Hazard: Struck or struck by Motor Vehicle.

SOFA Category: SSHIH Special Switching Hazard: Industrial Hazard.

FE-2004-20 02-Sep-04 BNSF Clovis NM Conductor/switchman 26

SOFA Category: SSHDR Special Switching Hazard: Derailment.

SOFA Category: SOFA5 SOFA 5: FE had 1.5 years of experience or less or had inadequate training.

SOFA Category: SSHET Special Switching Hazard: Employee Tripping, Slipping, or Falling

FE-2004-22 20-Sep-04 AA Saline MI Conductor 46

SOFA Category: SOFA1 SOFA 1: Adjusting knuckles, adjusting drawbars, or installing EOT

SOFA Category: SSHUC Special Switching Hazard: Unsecured Cars.

FE-2004-23 04-Oct-04 NS Harrisburg PA Conductor 58

SOFA Category: SOFA2 SOFA 2: Struck by equipment other than their own on yard or industry track.

FE-2004-25 07-Oct-04 UP Springfield IL Student brakeman 31

SOFA Category: SOFA5 SOFA 5: FE had 1.5 years of experience or less or had inadequate training.

SOFA Category: SSHDR Special Switching Hazard: Derailment.

SOFA Category: SSHED Special Switching Hazard: Electronic Device (Cell phone, MP3 player)

FE-2004-26 07-Oct-04 BNSF Teague TX Yard brakeman 60

SOFA Category: SOFA3 SOFA 3: Lack of or inadequate job safety briefing.

FE-2004-28 01-Nov-04 BNSF Bowdoin MT Conductor 45

SOFA Category: SOFA3 SOFA 3: Lack of or inadequate job safety briefing.

SOFA Category: SSHST Special Switching Hazard: Struck by Mainline Train.

SOFA Category: SOFA5 SOFA 5: FE had 1.5 years of experience or less or had inadequate training.

FE-2004-30 17-Dec-04 BNSF Radium CO Conductor 44

SOFA Category: SOFA3 SOFA 3: Lack of or inadequate job safety briefing.

SOFA Category: SSHST Special Switching Hazard: Struck by Mainline Train.

FE-2005-02 10-Jan-05 UP Buena Vista AR Conductor 52

SOFA Category: SSHST Special Switching Hazard: Struck by Mainline Train.

FE-2005-04 26-Jan-05 PHL Los Angeles CA Yard Conductor 52

SOFA Category: SSHFC Special Switching Hazard: Failure to Confirm Route of Movement.

FE-2005-13 06-Apr-05 NS Selma AL Brakeman 48

SOFA Category: SSHMC Special Switching Hazard: Miscellaneous.

FE-2005-14 11-Apr-05 UP Ogden UT Switchman 38

SOFA Category: SOFA3 SOFA 3: Lack of or inadequate job safety briefing.

SOFA Category: SOFA5 SOFA 5: FE had 1.5 years of experience or less or had inadequate training.

FE-2005-18 13-May-05 DC Detroit MI Yard Conductor 24

SOFA Category: SOFA5 SOFA 5: FE had 1.5 years of experience or less or had inadequate training.
F-11 

CASE RAILNUMBER DATE ROAD CITY STATE OCCUPATION AGE

SOFA Category: SSHIH Special Switching Hazard: Industrial Hazard.

SOFA Category: SSHDR Special Switching Hazard: Derailment.

SOFA Category: SSHCC Special Switching Hazard: Close Clearance.

FE-2005-23 05-Jul-05 BNSF Emporia KS Yard Helper 26.8

SOFA Category: SOFA5 SOFA 5: FE had 1.5 years of experience or less or had inadequate training.

SOFA Category: SSHMC Special Switching Hazard: Miscellaneous.

SOFA Category: SSHIH Special Switching Hazard: Industrial Hazard.

FE-2005-24 18-Jul-05 UP Memphis TN Brakeman 59

SOFA Category: SSHMV Special Switching Hazard: Struck or struck by Motor Vehicle.

SOFA Category: SSHIH Special Switching Hazard: Industrial Hazard.

FE-2005-25 22-Jul-05 ATN Ragland AL Brakeman 56

SOFA Category: SSHCC Special Switching Hazard: Close Clearance.

SOFA Category: SSHIH Special Switching Hazard: Industrial Hazard.

SOFA Category: SSHDR Special Switching Hazard: Derailment.

SOFA Category: SOFA5 SOFA 5: FE had 1.5 years of experience or less or had inadequate training.

FE-2005-27 09-Aug-05 AM Rogers AR Conductor 23

SOFA Category: SSHCC Special Switching Hazard: Close Clearance.

SOFA Category: SSHIH Special Switching Hazard: Industrial Hazard.

FE-2005-33 16-Nov-05 CSX Lugoff SC Conductor 48

SOFA Category: SOFA3 SOFA 3: Lack of or inadequate job safety briefing.

FE-2005-36 04-Dec-05 BNSF Burlington IA Brakeman 34

SOFA Category: SOFA5 SOFA 5: FE had 1.5 years of experience or less or had inadequate training.

SOFA Category: SSHCC Special Switching Hazard: Close Clearance.

SOFA Category: SSHIH Special Switching Hazard: Industrial Hazard.

FE-2006-04 02-Apr-06 LSI Palmer MI Freight Conductor 51

SOFA Category: SSHET Special Switching Hazard: Employee Tripping, Slipping, or Falling

FE-2006-12 21-Aug-06 FEC Rockledge FL Freight Conductor 45

SOFA Category: SSHMV Special Switching Hazard: Struck or struck by Motor Vehicle.

SOFA Category: SSHIH Special Switching Hazard: Industrial Hazard.

FE-2006-13 25-Aug-06 NS Chicago IL Conductor 43

SOFA Category: SSHUC Special Switching Hazard: Unsecured Cars.

FE-2006-14 10-Sep-06 ALS East St. Louis IL Conductor 44

SOFA Category: SOFA5 SOFA 5: FE had 1.5 years of experience or less or had inadequate training.

SOFA Category: SSHCC Special Switching Hazard: Close Clearance.

FE-2006-18 13-Oct-06 UP Watsonville CA Brakeman 49

SOFA Category: SSHFR Special Switching Hazard: Free-Rolling Railcars.

SOFA Category: SSHET Special Switching Hazard: Employee Tripping, Slipping, or Falling

FE-2006-22 04-Dec-06 UP Carson CA Brakeman 35
F-12 

CASE RAILNUMBER DATE ROAD CITY STATE OCCUPATION AGE

SOFA Category: SSHMV Special Switching Hazard: Struck or struck by Motor Vehicle.

SOFA Category: SSHIH Special Switching Hazard: Industrial Hazard.

FE-2006-26 28-Dec-06 UP Sioux City IA Yard Foreman 57

SOFA Category: SSHCC Special Switching Hazard: Close Clearance.

SOFA Category: SSHFR Special Switching Hazard: Free-Rolling Railcars.

FE-2007-12 08-Jul-07 BNSF Berry AZ Freight Conductor 37

SOFA Category: SSHET Special Switching Hazard: Employee Tripping, Slipping, or Falling

FE-2007-15 27-Jul-07 CN Fulton KY Yard Conductor 46

SOFA Category: SSHFR Special Switching Hazard: Free-Rolling Railcars.

FE-2007-18 25-Aug-07 IHB East Chicago IL Yard Conductor 43

SOFA Category: SOFA4 SOFA 4: Move controlled by a combination of hand and radio signals or specific distances were not given.

FE-2007-19 30-Aug-07 BNSF Stockton CA Yard Brakeman 50

SOFA Category: SOFA3 SOFA 3: Lack of or inadequate job safety briefing.

FE-2007-21 27-Oct-07 CSX Russell KY Yard Foreman 52

SOFA Category: SOFA5 SOFA 5: FE had 1.5 years of experience or less or had inadequate training.

FE-2007-25 28-Dec-07 BNSF Bristol IL Freight Brakeman 62

SOFA Category: SSHUC Special Switching Hazard: Unsecured Cars.

FE-2008-01 08-Jan-08 UP Waukegan IL Passenger Brakeman 59

SOFA Category: SSHST Special Switching Hazard: Struck by Mainline Train.

FE-2008-03 03-Feb-08 NS Chicago IL Freight Conductor 28

SOFA Category: SSHST Special Switching Hazard: Struck by Mainline Train.

FE-2008-06 05-Mar-08 WSOR Random Lake WI Freight Conductor 55

SOFA Category: SSHCC Special Switching Hazard: Close Clearance.

SOFA Category: SSHIH Special Switching Hazard: Industrial Hazard.

SOFA Category: SSHDR Special Switching Hazard: Derailment.

SOFA Category: SSHEV Special Switching Hazard: Environment.

FE-2008-15 26-May-08 CSX Lumberton NC Freight Conductor 46

SOFA Category: SOFA5 SOFA 5: FE had 1.5 years of experience or less or had inadequate training.

SOFA Category: SSHCC Special Switching Hazard: Close Clearance.

SOFA Category: SSHIH Special Switching Hazard: Industrial Hazard.

FE-2008-16 29-May-08 UP Amarillo TX Yard Conductor 35

SOFA Category: SSHEQ Special Switching Hazard: Equipment.

SOFA Category: SSHFR Special Switching Hazard: Free-Rolling Railcars.

SOFA Category: SSHET Special Switching Hazard: Employee Tripping, Slipping, or Falling

FE-2008-19 08-Jun-08 UP La Porte TX Yard Brakeman 47

SOFA Category: SSHFC Special Switching Hazard: Failure to Confirm Route of Movement.

SOFA Category: SSHED Special Switching Hazard: Electronic Device (Cell phone, MP3 player)

SOFA Category: SOFA4 SOFA 4: Move controlled by a combination of hand and radio signals or specific distances were not given.
F-13 

CASE RAILNUMBER DATE ROAD CITY STATE OCCUPATION AGE

FE-2008-24 08-Jul-08 BNSF Fridley MN Utility Employee 40

SOFA Category: SSHMC Special Switching Hazard: Miscellaneous.

FE-2008-31 10-Sep-08 INRD Terre Haute IN Freight Conductor 42

SOFA Category: SSHDR Special Switching Hazard: Derailment.

SOFA Category: SSHCC Special Switching Hazard: Close Clearance.

SOFA Category: SSHIH Special Switching Hazard: Industrial Hazard.

FE-2008-33 23-Sep-08 CSX Darby PA Freight Conductor 46

SOFA Category: SOFA3 SOFA 3: Lack of or inadequate job safety briefing.

SOFA Category: SSHST Special Switching Hazard: Struck by Mainline Train.

SOFA Category: SSHCC Special Switching Hazard: Close Clearance.

FE-2008-35 15-Oct-08 CSX Decatur AL Freight Conductor 28

SOFA Category: SSHDR Special Switching Hazard: Derailment.

SOFA Category: SSHED Special Switching Hazard: Electronic Device (Cell phone, MP3 player)

FE-2008-37 15-Nov-08 MRL Laurel MT Yard Brakeman 39

SOFA Category: SOFA5 SOFA 5: FE had 1.5 years of experience or less or had inadequate training.

SOFA Category: SSHUM Special Switching Hazard: Unexpected Movement of Railcars.

SOFA Category: SOFA3 SOFA 3: Lack of or inadequate job safety briefing.

FE-2008-40 03-Dec-08 DRIR Denver CO Freight Conductor 33

SOFA Category: SSHMV Special Switching Hazard: Struck or struck by Motor Vehicle.

SOFA Category: SSHIH Special Switching Hazard: Industrial Hazard.

FE-2009-03 16-Jan-09 BNSF Fort Sumner NM Freight Engineer, 59

SOFA Category: SSHET Special Switching Hazard: Employee Tripping, Slipping, or Falling

SOFA Category: SOFA3 SOFA 3: Lack of or inadequate job safety briefing.

FE-2009-06 28-Jan-09 UP Council Bluffs IA Yard Foreman 41

SOFA Category: SSHST Special Switching Hazard: Struck by Mainline Train.

SOFA Category: SSHCC Special Switching Hazard: Close Clearance.

FE-2009-08 07-Feb-09 BNSF Holbrook AZ Freight Conductor 43

SOFA Category: SSHST Special Switching Hazard: Struck by Mainline Train.

FE-2009-09 08-Feb-09 UP Herington KS Freight Conductor 26

SOFA Category: SSHST Special Switching Hazard: Struck by Mainline Train.

SOFA Category: SSHMC Special Switching Hazard: Miscellaneous.

FE-2009-11 28-Feb-09 BNSF Buchanan NM Freight Conductor 56

SOFA Category: SSHCC Special Switching Hazard: Close Clearance.

FE-2009-14 10-May-09 CSX Selkirk NY Yard Conductor 33

SOFA Category: SOFA1 SOFA 1: Adjusting knuckles, adjusting drawbars, or installing EOT

SOFA Category: SSHEQ Special Switching Hazard: Equipment.

FE-2009-20 24-Jun-09 ATN Albertville AL Freight Conductor 33

SOFA Category: SSHDR Special Switching Hazard: Derailment.
F-14 

CASE RAILNUMBER DATE ROAD CITY STATE OCCUPATION AGE

SOFA Category: SSHCC Special Switching Hazard: Close Clearance.

SOFA Category: SSHIH Special Switching Hazard: Industrial Hazard.

FE-2009-26 29-Dec-09 BNSF Minneapolis MN RCL Operator 44

SOFA Category: SSHEV Special Switching Hazard: Environment.

SOFA Category: SSHCC Special Switching Hazard: Close Clearance.

SOFA Category: SSHIH Special Switching Hazard: Industrial Hazard.

SOFA Category: SSHDR Special Switching Hazard: Derailment.
G-1 

APPENDIX G: ADDITIONAL STATISTICS ON SOFA 3 (JOB 

BRIEFINGS), INDUSTRIAL TRACK HAZARDS, STRUCK BY 

MAINLINE TRAINS, AND FATALITIES DURING THE SECOND 

HOUR OF DUTY 

SOFA 3 (Job Briefings) 

Section 3.3 of this report demonstrated SOFA 3 is the fourth largest category of SOFA fatalities. 

Figure G-1 illustrates SOFA 3 fatalities over two nine-year periods (Pre-SOFA versus PostSOFA) and shows an increase from 11 to 12 fatalities between the two periods. 

Figure G-1: SOFA 3 Fatalities Over Two Nine-Year Periods 

Some of the growth between the two periods can be attributed to incidents when a freight crew 

member exited the cab while the train was on main track outside of yards. There were no 

fatalities of this type during the first nine-year period compared to five fatalities during the 

second nine years (FE-2001-03, FE-2004-28, FE-2004-30, FE-2008-33, FE-2009-03). Figure G2 below compares SOFA 3 fatalities over two nine-year periods when these five fatalities are 

removed from the analysis. 

Figure G-2: SOFA 3 Fatalities Excluding Crew Members Leaving a Freight Train Cab on Main Track 

SOFA 3 Fatalities Over Two Nine-Year Periods

0

2

4

6

8

10

12

Fatalities

SOFA 3 11 12

Pre-SOFA (1992 - 2000) Post-SOFA (2001 - 2009)

Pre-SOFA (1992 - 2000) Post-SOFA (2001 - 2009)

SOFA 3 11 7

0

2

4

6

8

10

12

Fatalities

SOFA 3 Fatalities Excluding Crew Members 

Leaving a Freight Train Cab on Main Track
G-2 

Figure G-2 represents SOFA 3 fatalities during pure switching operations and demonstrates some 

progress (about a 36% reduction) has been made in this area. However, the SWG is not entirely 

satisfied with this progress. The progress in SOFA 1, 2, and 4, suggests there is still room for 

more improvement in SOFA 3, the fourth largest SOFA category. 

Industrial Track Hazards 

Table G-1 shows the FE was riding in 20 out of 26 cases (77%) involving industrial track 

hazards. This percentage is more than twice the percentage other cases (28%). 

Table G-1: Industrial Track Hazard FE Riding 

 

Table G-2 shows 20 of 26 industrial track hazard cases (77%) involved shove moves. This 

percentage is about 25% higher than other cases (52%). 

Table G-2: Industrial Track Hazard Shove Moves 

When a shove move was involved, Table G-3 shows “Failure to control shove” was cited as a 

PCF for 35% of the industrial track hazard cases. This is well above the percentage (22%) for all 

other cases. 

Table G-3: Industrial Track Hazard Failure to Control Shove 

 

1

 Since this table only covers shove moves, the total cases add to 99 instead of 179 which is the total seen on the 

other three tables in this appendix. 

 Industrial Track Hazard Cases All Other Cases 

Cases when FE was riding (63) 20 43

Total cases (179) 26 153

Proportion for FE was riding 77% 28%

 Industrial Track Hazard Cases All Other Cases 

Cases involving shove moves (99) 20 79

Total cases (179) 26 153

Percentage for shove moves 77% 52%

 Industrial Track Hazard Cases All Other Cases 

Cases with failure to control shove 7 17

Total cases involving shove moves 20 791

Percentage for failure to control shove 35% 22%
G-3 

Struck by Mainline Trains 

65% of Struck by Mainline Train cases occurred during the December-February period. Since 

this period includes the Christmas and New Year holidays, some attendees at the SOFA Safety 

Forum and SOFA members suggested FEs, working on a new or unfamiliar assignments, may 

play a significant role in these cases. However, the available SOFA data did not support this 

suggestion as an issue for the Struck by Mainline Train. 

Table G-42

 shows three of the fourteen cases (21%) involving strikes by mainline trains occurred 

when the FE was not working a regular assignment. This is less than half the percentage (43%) 

for all other cases (see Table G-15). 

Table G-4 Struck by Mainline Trains – Employee Not Working Regular Assignment 

Table G-53 shows none the fifteen cases (0%) involving strikes by mainline trains occurred when 

the FE had not worked the assignment before. This is lower than the percentage (3%) for all 

other cases (see Table 3-15). 

Table G-5 Struck by Mainline Train – Employee Not Worked Assignment Before 

 

2

 For Table 3.16, there were 41 cases where the SWG did not have data to indicate whether a worker was on his/her 

regular assignment. So the cases in Table 3.16 total to 138, not 179. 

3

 For Table 3.17, there were 43 cases where the SWG did not have data to indicate whether a worker had worked the 

assignment before. Accordingly, the cases in Table 3.17 total to 136, not 179. 

 Struck By Mainline Train Cases All Other Cases

Cases when employee is not on regular 

assignment (56) 3 53

Total cases where it is known if this was a 

regular assignment (138) 14 124

Percentage for employee is not on regular 

assignment 21% 43%

 Struck By Mainline Train Cases All Other Cases

Cases when employee had not worked 

assignment before (4) 0 4

Total cases where it is known if the employee 

ad worked the assignment before (136) 15 121

Percentage for employee had not worked the 

assignment before 0% 3%
G-4 

Table G-6 shows the FE was on the ground in almost all the cases (95%) involving strikes by 

mainline trains. This is almost 40% higher than the percentage for all other cases (57%). 

Table G-6: Struck by Mainline Train – FE Was on the Ground 

 Struck By Mainline Train Cases All Other Cases 

Cases where FE was on the ground (110) 19 91

Total cases (179) 20 159

Percentage for FE on the ground 95% 57%

 

Table G-7 shows the FE was on or fouling track (PCF H990) in almost all the cases involving 

strikes by mainline trains (95%). This is more than twice the percentage for all other cases 

(38%). 

Table G-7: Struck by Mainline Trains – Employee on or Fouling Track 

 Struck By Mainline Train Cases All Other Cases

Cases where "Employee on or fouling 

track" was used as a PCF (80) 19 61

Total cases (179) 20 159

Percentage for "Employee on or fouling 

track" was used as a PCF 95% 38%

Fatalities During The Second Hour of Duty 

Table G-8 shows 20 of the 30 (67%) during the second hour of duty occurred while the FE was 

on or fouling the track. This is about 13% higher than the percentage for cases during other 

hours of duty (54%). 

Table 3-8: 2nd Hour of Duty, FE on or Fouling Track 

 

Table G-9 shows 5 of the 30 cases (17%) during the second hour of duty occurred when the FE 

failed to provide adequate space between equipment. This is close to three times higher than the 

percentage for all other cases (6%). 

 

Cases During 2nd 

Hour of Duty 

Cases During Other Duty 

Hours 

Cases with FE on or fouling track 20 80

Total cases 30 149

Percentage for FE on or fouling track 67% 54%
G-5 

Table G-9: 2nd Hour of Duty, FE Failed to Provide Adequate Space 

 

Cases During 2nd 

Hour of Duty Cases During Other Duty Hours 

Cases involving failure to provide adequate space 

between equipment 5 9

Total cases 30 149

Percentage for failure to provide adequate space 

between equipment 17% 6%
H-1 

APPENDIX H: ADDITIONAL STATISTICS ON FATALITIES IN WINTER 

AND SUMMER 

Table H-1 shows the cases for fatalities in cold weather states during the winter. Table H-2 

shows the cases for fatalities in other states during the summer. Appendix A provides narratives 

on these cases. 

Table H-1: Case Numbers For Fatalities In Cold Weather States During Winter 

Case Number Incident 

Date 

Railroad City State Job Description Age 

FE-1992-03 28-Jan-92 BN Willmar MN Yard Brakeman/Helper 57

FE-1993-53 30-Dec-93 CR Brook Park OH Yard Conductor/Foreman 61

FE-1994-31 6-Dec-94 CR Campbell Hall NY Brakeman Trainee 28

FE-1995-02 11-Jan-95 CR Indianapolis IN Conductor 51

FE-1995-09 17-Feb-95 CR St. James OH Conductor 48

FE-1995-33 11-Dec-95 NS Toledo OH Brakeman 53

FE-1996-30 16-Dec-96 UP Clinton IA Brakeman 51

FE-1996-31 18-Dec-96 IC Chicago IL Conductor 45

FE-1997-04 29-Jan-97 UP Mason City IA Conductor 48

FE-1997-05 2-Feb-97 CR Burns Harbor IN Engine Foreman 54

FE-1997-45 26-Dec-97 UP Boise ID Freight Conductor 55

FE-1998-05 4-Feb-98 BRC Bedford Park IL Yard Conductor/Foreman 42

FE-1999-01 12-Jan-99 CR Port Newark NJ Conductor 54

FE-1999-03 22-Jan-99 CR Alexanderia NY Conductor 45

FE-2000-32 28-Dec-00 UP Dupo IL Switchman 52

FE-2000-33 29-Dec-00 BNSF Gillette WY Conductor 29

FE-2001-02 10-Jan-01 CSX Chicago IL Conductor 42

FE-2001-03 11-Jan-01 NS South Fork PA Engineer 52

FE-2003-03 11-Feb-03 CNIC Flat Rock MI Brakeman 57

FE-2003-04 16-Feb-03 CSXT Syracuse NY Switchman 36

FE-2003-05 18-Feb-03 CSXT Cheektowaga NY Switch Foreman 51

FE-2004-03 14-Jan-04 NS Kankakee IL Freight Conductor 40

FE-2004-30 17-Dec-04 BNSF Radium CO Conductor 44

FE-2005-36 4-Dec-05 BNSF Burlington IA Brakeman 34

FE-2006-26 28-Dec-06 UP Sioux City IA Yard Foreman 57

FE-2007-25 28-Dec-07 BNSF Bristol IL Freight Brakeman 62

FE-2008-01 8-Jan-08 UP Waukegan IL Passenger Brakeman 59

FE-2008-03 3-Feb-08 NS Chicago IL Freight Conductor 28

FE-2008-40 3-Dec-08 DRIR Denver CO Freight Conductor 33

FE-2009-06 28-Jan-09 UP Council Bluffs IA Yard Foreman 41

FE-2009-26 29-Dec-09 BNSF Minneapolis MN RCL Operator 44
H-2 

Table H-2: Case Numbers For Fatalities In Other States During Summer 

Case 

Number 

Incident 

Date 

Railroad City State Job Description Age

FE-1992-14 01-Jun-92 ATSF Escondido CA Freight Conductor 58

FE-1992-15 01-Jun-92 BN Seattle WA Switchman 42

FE-1992-16 02-Jun-92 IHRC Henderson KY Freight Conductor 52

FE-1992-20 07-Jul-92 SSW Conlen Siding TX Freight Engineer 58

FE-1992-22 25-Jul-92 UP Portland OR Freight Brakeman/Flagman 54

FE-1993-23 07-Jun-93 IC Fulton KY Yard Brakeman/Helper 49

FE-1993-27 04-Aug-93 UP Pryor OK Freight Brakeman/Flagman 42

FE-1993-30 11-Aug-93 SP Tracy CA Freight Brakeman/Flagman 47

FE-1993-31 12-Aug-93 ATSF Evandale TX Freight Brakeman/Flagman 52

FE-1996-12 15-Jun-96 CSX Charlotte NC Switchman 36

FE-1997-18 24-Jun-97 UP Portland OR Yard Conductor/Foreman 53

FE-1997-19 24-Jun-97 NS Rowesville SC Conductor 21

FE-1997-25 15-Aug-97 UP Elko NV Yard Brakeman/Helper 53

FE-1998-16 01-Jun-98 BNSF Lubbock TX Yard Conductor/Foreman 24

FE-1998-17 05-Jun-98 NS Hapeville GA Yard Conductor/Foreman 48

FE-1998-19 01-Jul-98 NS Buechel KY Utility Employee 54

FE-1999-16 23-Jun-99 UP Redding CA Conductor 57

FE-2000-21 07-Jul-00 CKRY Wichita KS Conductor 39

FE-2000-23 28-Jul-00 UP St. Louis MO Switchman 48

FE-2000-25 11-Aug-00 BNSF Port of Los Angeles CA Freight Brakeman 36

FE-2002-16 16-Jun-02 BNSF Memphis TN Engine Foreman 20

FE-2002-17 16-Jul-02 NS Bonlee NC Brakeman 55

FE-2003-12 06-Jun-03 CSXT Kingsport TN Brakeman 35

FE-2003-20 26-Aug-03 LC Chester SC Conductor 29

FE-2005-23 05-Jul-05 BNSF Emporia KS Yard Helper 26.8

FE-2005-24 18-Jul-05 UP Memphis TN Brakeman 59

FE-2005-25 22-Jul-05 ATN Ragland AL Brakeman 56

FE-2005-27 09-Aug-05 AM Rogers AR Conductor 23

FE-2006-12 21-Aug-06 FEC Rockledge FL Freight Conductor 45

FE-2007-12 08-Jul-07 BNSF Berry AZ Freight Conductor 37

FE-2007-15 27-Jul-07 CN Fulton KY Yard Conductor 46

FE-2007-19 30-Aug-07 BNSF Stockton CA Yard Brakeman 50

FE-2008-19 08-Jun-08 UP La Porte TX Yard Brakeman 47

FE-2009-20 24-Jun-09 ATN Albertville AL Freight Conductor 33
H-3 

SOFA Characteristics of Cold Weather States in the Winter 

Table H-3 shows cases in cold weather states during winter more frequently occurred in the dark 

than other cases. 

Table H-3 

 

Cold Weather States in 

Winter All Other Cases 

Fatalities in the dark 17 62 

All fatalities 31 148 

Percentage for in the dark 0.55 0.42 

Table H-4 shows cases in cold weather states during winter more frequently occurred on main or 

industrial track than other cases. 

Table H-4 

 

Cold Weather States in 

Winter All Other Cases 

Fatalities on main or industrial track 21 63 

All fatalities 31 148 

Percentage for main or industrial track 0.68 0.43 

Table H-5 shows cases in cold weather states during winter more frequently involved pull moves 

than other cases. 

Table H-5 

 

Cold Weather States in 

Winter All Other Cases 

Fatalities involved a pull move 11 28 

All fatalities 31 148 

Percentage for pull moves 0.35 0.19 

Table H-6 shows cases in cold weather states during winter more frequently involved an FE on 

or fouling track than other cases. 

Table H-6 

 

Cold Weather States in 

Winter All Other Cases 

Fatalities with FE on or fouling track 19 61 

All fatalities 31 148 

Percentage for FE on or fouling track 0.61 0.41 
H-4 

Table H-7 shows cases in cold weather states during winter more frequently a strike by a 

mainline train than other cases. 

Table H-7 

Table H-8 shows cases in cold weather states during winter more frequently involved improper 

radio communication than other cases. The improper communication took place on main (2 

cases), industrial (2 cases), and yard (1 case) track. 

Table H-8 

 

Cold Weather States in 

Winter All Other Cases 

Fatalities involving improper radio 

communication 5 3 

All fatalities 31 148 

Percentage for improper radio 

communication 0.16 0.02 

Table H-9 shows cases in cold weather states during winter more frequently involved mud, 

snow, or ice than other cases. Two of the three cases involving mud, ice, or snow in the last 

column occurred in cold weather states between March 1 and March 5 (Just falling outside the 

criteria for meteorological winter). The remaining case occurred in Georgia during January 

when it was dark and the temperature was 40o. 

Table H-9 

SOFA Characteristics of Other States in the Summer 

Table H-10 shows cases in other states during summer more frequently occurred on industrial 

track than other cases. 

 

Cold Weather States in 

Winter All Other Cases 

Cases with FE struck by mainline train 8 12 

All fatalities 31 148 

Percentage for FE struck by mainline train 0.26 0.08 

 

Cold Weather States in 

Winter All Other Cases 

Fatalities involving mud, snow, or ice 4 3 

All fatalities 31 148 

Percentage for mud, snow, or ice 0.13 0.02 
H-5 

Table H-10 

 

Other States 

in Summer All Other Cases 

Fatalities on industrial track 16 28 

All fatalities 34 145 

Percentage for main or industrial track 0.47 0.19 

Table H-11 shows cases in other states during summer more frequently involved a hazard on 

industrial track4

. 

Table H-11 

 

Other States 

in Summer All Other Cases 

Cases involving industrial hazards 11 15 

All fatalities 34 145 

Percentage for industrial hazards 0.32 0.10 

Table H-12 shows cases in other states during summer more frequently involved shove moves 

than other cases. 

Table H-12 

 

Other States 

in Summer All Other Cases 

Fatalities involved a shove move 26 72 

All fatalities 34 145 

Percentage for pull moves 0.76 0.50 

Table H-13 shows cases in other states during summer more frequently involved failures to 

control shoves. 

Table H-13 

 

Other States 

in Summer All Other Cases 

Fatalities involving failure to control a shove 8 16 

All fatalities 34 145 

Percentage for failure to control a shove 0.24 0.11 

Table H-14 shows cases in other states during summer more frequently involved poor 

communication about work in progress. 

 

4

 Hazards on industrial track include cases where a structure, vehicle, or temporary obstruction on industrial track 

played a significant role. It also can include cases where the action of industrial plant employees played a role. As 

explained in Section 3.2.6, not all fatalities on industrial track qualify for this category. There are many cases where 

the actions of the train crew entirely account for the PCFs cited for a case. 
H-6 

Table H-14 

 

Other States 

in Summer All Other Cases 

Fatalities involving poor communication about work 

in progress 11 20 

All fatalities 34 145 

Percentage for poor communication about work in 

progress 0.32 0.14 

Discussion 

Cold Weather States During the Winter 

Table H-3 shows lack of daylight is an issue. Lack of daylight can compromise visibility and 

may affect the mood and alertness of the workforce. 

Weather can be an issue. It may be possible that heavy clothing can restrict movement and 

reduce the ability to see and hear. Furthermore, ice can increase the risk of derailment, snow 

can reduce visibility, and mud can create unsafe footing conditions. 

It may be possible that productivity expectations of management and crew can remain 

unchanged in the winter despite the challenges of increased darkness and weather conditions.

Tables H-5 and H-7 suggest risk for road crews may increase substantially in cold weather 

states during the winter. 

Fatalities in cold weather states peak in December when weather conditions are changing. 

The early days of winter could be a time when some employees have not acclimated to 

changing climate conditions and may not have adjusted their clothing to suit the new 

conditions. 

The effects of cold winter weather are not limited to cold weather states. Other states 

experience a seasonal peak in January, the coldest month of the year. 

Other States During the Summer 

Outside the railroad industry there is a study of the relationship between hot weather 

conditions and hospital admissions due to work-related accidents in Tuscany, Italy5

. It shows 

hot weather conditions might represent a risk factor for work-related accidents in Italy during 

summer. In particular, the early warming days during June stood out as a peak period. June 

is also a peak month for SOFA fatalities in the Other (Non-Cold Weather) States. The early 

days of summer could be a time when some employees have not acclimated to changing 

climate conditions and may not have adjusted their clothing and fluid intake for the new 

conditions. 

Heat exhaustion occurs when bodies are unable to compensate and properly cool themselves. 

Impaired judgment is one of the symptoms of heat exhaustion and can be deadly in a railroad 

switching environment. It may be possible heat exhaustion can creep up on an employee 

because he or she can continue on with duties without realizing judgment, concentration, and 

 

5 Relationship between work-related accidents and hot weather conditions in Tuscany (central Italy).

Morabito M, Cecchi L, Crisci A, Modesti PA, Orlandini S. Ind Health. 2006 Jul;44(3):458-64. 
H-7 

reaction time may be deteriorating. Employees may not recognize the early symptoms of 

heat exhaustion or be unwilling to express their concerns to peers who continue to work. 

The effects of hot summer weather are not limited to these states. Cold weather states 

experience a seasonal peak in July, the hottest month of the year. 

Possible Actions 

Cold Winter Weather 

Make cold weather an issue in upcoming safety awareness campaigns. Increasing workforce 

awareness of this problem could be an important step in reducing fatalities in cold weather 

during the winter. Since many fatalities occur right at the beginning of winter, get an early 

start with a weather awareness campaign. Emphasize the increase risk on main track, 

particularly the risk of being struck by a passing train. 

Include alerts about weather conditions and how to operate safely in icy conditions in safety 

briefings and bulletins. 

Ensure customers do their part to keep industrial track and walkways clear of mud, ice, and 

snow. 

Advise management and crews to think safety first and adjust productivity expectations to 

suit the challenging conditions which occur in cold weather states in the winter. 

Hot Summer Weather 

Make hot weather an issue upcoming safety awareness campaigns. Increasing workforce 

awareness of this problem could be an important step in reducing fatalities in hot weather 

during the summer. Since many fatalities occur right at the beginning of summer, get an 

early start with a weather awareness campaign. Emphasize the increase risk on industrial 

properties and shove moves. 

Educate the workforce on how to prevent heat exhaustion, how to recognize the symptoms, 

and what to do if it occurs. The symptoms of heat exhaustion include: headache, heavy 

sweating, intense thirst, dizziness, fatigue, loss of coordination, nausea, impaired judgment, 

loss of appetite, hyperventilation, tingling in hands or feet, anxiety, cool moist skin, weak 

and rapid pulse (120-200), and low to normal blood pressure. Employees should not 

continue work if their judgment, concentration, or reaction time is impaired. 
BACKGROUND 

CREW RESOURCE MANAGEMENT 

TABLE OF CONTENTS 

TO THE LEADER 

CRM OVERVIEW 

INDUSTRY GOALS 

INTRODUCTION 

HISTORY 

DEFINITIONS 

CRM AND THE INFLUENCE OF CULTURE 

MODULE 1 CREW MEMBER PROFICIENCY 

MODULE 2 SITUATIONAL AWARENESS 

RECOGNIZING SITUATIONAL AWARENESS 

MAINTAINING SITUA TIONAL AWARENESS 

REGAINING SITUATIONAL AWARENESS 

SUMMARY 

MODULE 3 COMMUNICATION & TEAMWORK 

COMMUNICATIONS 

EFFECTIVE COMMUNICATIONS 

ASSERTIVE COMMUNICATIONS 

JOB BRIEFINGS 

TEAMWORK 

SUMMARY 

MODULE 4 CONFLICT RESOLUTION TECHNIQUES 

CAUSES OF CONFLICT 

CONFLICT OUTCOME 

EFFECTS OF CONFLICT 

CONFLICT RESOLUTION TECHNIQUES 

SUMMARY 

2 

3 

5 

6 

7 

7 

8 

10 

12 

15 

18 

22 

29 

31 

32 

40 

43 

46 

50 

52 

59 

60 

63 

65 

66 

67 

68 
Background ----------------______________________ ~1Ii 

This course provides training for all Train and Engine service employees in 

Crew Resource Management (CRM), a methodology that addresses the human 

element of people working together in safety sensitive conditions with 

sophisticated equipment. 

The course consists of four modules that utilize videos and group 

discussion. Leader's notes are included with each section of the modules. Each 

module may be presented as a single training session, or all four may be 

combined into one training program, depending on the training time available or 

allotted. Although this allows some flexibility in presenting the CRM modules, 

the outline of each module is intended to be followed to ensure uniformity. 

This training package, distributed by the Association of American 

Railroads contains the basic elements of Crew Resource Management. The course 

content is structured to allow additional information, or additional training 

subjects, depending on the needs of individual roads. 

Page 2 
To The Leader 

GENERAL 

This Leader's Guide contains all four modules of the Crew Resource 

Management program, including a video for each module and the supporting 

documentation. At the beginning of each module, you will find an outline of the 

module, learning objectives and Leader's Notes that give a suggested introduction 

for the module to be delivered to the participants. The total estimated time 

required to complete the module is given, although times will vary depending on 

the amount of discussion. After the introduction, the video should be shown, 

which will present the module in its entirety. Also included in the Leader's Notes 

are points from the video for reinforcement and discussion. 

A general introduction to Crew Resource Management is presented at the 

beginning ofthe video tape, and should be shown prior to starting Module 1 

(Crew Member Proficiency). This introduction to CRM is based on the material 

contained in the section "CRM Overview." A brief summary of the program is 

included after Module 4. 

CHECKLIST 

Leader's Guide 

Videos and VCR 

Roster (have each participant list name and SSN) 

Pencils 

Page 3 
To The Leader 

TRAINING Tips 

Upon receipt of this Leader's Guide, carefully review all videos, training 

materials, Safety and Operating Rules, and other appropriate materials. Report 

and replace any damaged videos through your Training or initiating Department 

Supervisor. 

Before beginning the class session: 

I. Review related materials and issues from Departmental managers, as 

they relate to CRM. 

2. Insure your AIV equipment is in proper working order. Be prepared to 

repair or replace if necessary. If you plan to use an overhead projector, 

have a spare bulb on hand. 

3. Select a location for your classes that is as quiet as possible. The room 

should be comfortable, with minimum distractions. 

4. Arrive at classroom sufficiently in advance of start time to insure 

classroom setup and equipment availability. 

5. Begin each class session promptly. 

JOB BRIEFING 

Remember to begin any training class with a Job Briefing. Be sure to 

discuss the following: 

• Location of fire exits and fire extinguishers. 

• Location of telephones and local emergency numbers. Designate one 

person to make the call in case of an emergency. 

• Ascertain if any participants are CPR and/or first aid trained. 

• Any hazards near the location, such as construction, weather-related 

conditions, etc. 

Also cover the location ofthe restrooms, lunch arrangements (if applicable) 

and the class agenda. 

Page 4 
________________________________________ CRM Overview ~M 

A. Industry Goals 

B. Introduction 

C. History of Crew Resource Management 

D. Definitions 

E. CRM and the Influence of Culture 

Note: An introduction to CRM (11 Minutes) is included at the 

beginning of the video before Crew Member Proficiency (Module 

1). This introduction should be shown prior to starting Module 1. 

Total Estimated Time to Complete Module: 15 Minutes 

CRM Overview Page 5 
INDUSTRY GOALS 

• To improve safety by understanding and improving the human factor issues 

involved with train operations. 

• To enhance job performance by understanding the issues of Crew Member 

Proficiency, Situational Awareness, Communications and Teamwork, and 

Conflict Resolution Techniques. 

CRM Overview Page 6 

-------- --- -- -- - - ---------
INTRODUCTION 

This course is designed to provide an overview of the history, the 

definition, elements and purpose of Crew Resource Management (CRM) in order 

to help improve the work environment for rail industry employees. 

________________________________________ HISTORY ~M 

CRM is a relatively new concept that addresses the personal side of crew 

performance. It was designed by the National Aeronautics and Space 

Administration (NASA) and major airline carriers in response to several aviation 

accidents that occurred in the 1970s. It was initially known as Cockpit Resource 

Management. As the concept evolved to include flight attendants, maintenance 

personnel, and others, the phrase Crew Resource Management (CRM) was 

adopted. As CRM has continued to develop, it has reached several other 

industries besides aviation including the medical field, shipping industry, nuclear 

power industry, and the rail industry. 

CRM Overview Page 7 
DEFINITIONS 

There are many definitions of Crew and CRM that exist; however, the 

general concepts are similar. 

Crew - refers to any group of people working at different tasks designed to 

accomplish a common mission, goal or objective. 

Crew Resource Management - the methodology that addresses the human 

element of people working together in safety sensitive conditions with highly 

sophisticated technology. When applied to the railroad industry, it can be seen as 

the effective use of all resources to achieve safe and efficient train operations. For 

the purpose ofthis training course, CRM is then divided into four basic modules: 

1. Crew Member Proficiency 

2. Situational Awareness 

3. Communication and Teamwork 

4. Conflict Resolution Techniques 

Crew Resource Management is: 

• A comprehensive system for improving crew performance. 

• . A process that addresses the entire crew and other related staff, such as 

yardmaster, dispatcher, utility employee, or a locomotive engineer 

perfoiming duties as a pilot. 

• A heightened awareness of attitudes and behaviors of crew members 

and their impact on safety. 

• A forum that allows the individuals to examine their behavior and make 

individual decisions on how to improve teamwork. 

• A focus on the function of crew members as teams, not as a collection 

of technically competent individuals. 

CRM Overview Page 8 
Definitions 

Crew Resource Management is not: 

• A system that occurs independent of other ongoing training activities. 

• A system where crews are given a specific prescription of how to work 

with others. 

• An attempt by management to dictate the behavior of the crew or 

change personalities. 

• A psychological assessment or personality profile. 

• A quick fix that can be implemented overnight. 

• A training program administered in only a few specialized or "fix it" 

cases. 

CRM Overview Page 9 
CRM AND THE INFLUENCE OF CULTURE 

--------------________________________ ~Mi.i;t 

CRM is not a universal recipe for safety. It is a highly effective and 

essential aspect of any operation, but its impact can be limited to the context in 

which it is accepted. It is therefore necessary to be aware of the powerful 

influence of culture on behavior. Culture affects the results of CRM as culture 

can affect our communications, our life styles and ultimately our approach to 

safety. 

There are four cultures within which CRM is embedded: safety, 

organizational; professional, and national culture. 

1. Safety culture is the overall attitude towards safety as demonstrated by the 

compliance to safety policies and procedures. It is often influenced by the 

perceptions held by an organization. 

2. Organizational culture is evidenced in such things as the openness of 

communications between management and employees, the commitment of 

resources to training and maintenance, and the attitudes and behavior of 

critical role models. The level of teamwork among groups (i.e. dispatchers, 

conductors, locomotive engineers, maintenance personnel, and road crews, 

etc.) is also part of this culture. 

3. Professional culture reflects the attitudes and values associated with an 

occupation. These include pride in the profession and the satisfaction of 

doing your job well. 

4. National culture is the overarching framework within which all people 

behave. It is shared values and attitudes of a national group that direct 

behavior. 

All four cultures exist; however, the two that concern us the most are 

organizational and safety cultures. These can have both positive and negative 

influences on the probability of safely operating and moving a train. For 

example, let's look at how safety culture influences CRM. 

CRM Overview Page 10 
CRM and Influence of Culture 

One way in which both management and workers can cooperate to reduce 

accidents or difficult situations is to create a Safety Culture - the overall attitude 

toward safety as demonstrated by the compliance to safety policies and 

procedures. This means that both groups work together and actively promote and 

follow policies that emphasize safety and attempt to reduce social and 

organizational pressures that would detract from their use. 

For management, developing a Safety Culture means not only creating 

policies and procedures that will lead to a safe workplace, but it also means that 

front line Supervisors must lead by example, following safety guidelines at all 

times. 

For workers in a company, developing a Safety Culture means recognizing 

the advantages of safety procedures and following them even though they may 

require more effort. Employees must try to keep negative peer pressure from 

influencing themselves and/or others to take "short-cuts" in their work, ignore 

safety equipment and procedures, or otherwise work unsafely. 

CRM Overview Page 11 
MODULEl CREW MEMBER PROFICIENCY 

A. System Knowledge of Equipment 

B. Procedural Knowledge and Compliance 

C. Execution 

VIDEO: 3.5 Minutes Running Time 

Total Estimated Time to Complete Module: 15 Minutes 

LEARNING OBJECTIVE 

To recognize the three types of crew member proficiency. 

Crew Member Proficiency Page 12 
LEADER'S NOTES 

INTRODUCTION 

An important element of safe and efficient railroad operations is crew 

member proficiency. An individual crew member's knowledge, training and 

skills playa key role in the overall effectiveness of a crew. 

There are three (3) aspects of crew member proficiency that are discussed 

in this module - System Knowledge of Equipment, Procedural Knowledge and 

Compliance, and Execution. Let's look at the video and see how these things 

interact to effect the way we do our jobs. 

SHOW THE VIDEO 

POINTS FOR DISCUSSION 

• Why is being familiar with the types of locomotives and their operation 

important with respect to safe operations? 

• Why would knowing the different types offreight car equipment be 

important? 

• The video talks about procedural knowledge and compliance. What is the 

difference between the two? Are they the same thing? (An employee may be 

able to quote the operating rules, but for a variety of reasons, may choose not 

to comply with a certain rule at a given instance.) Further, why do we have 

safety and operating rules? 

• Can the way you physically perform your duties affect your safety and that of 

your crew members? 

Crew Member Proficiency Page 13 
CREW MEMBER PROFICIENCY ----------____________________________ ~Mi.. 

Crew member proficiency relates to railroad operations in several ways: 

A. SYSTEM KNOWLEDGE OF EQUIPMENT: 

1. Being familiar with the types oflocomotives and knowing how to operate 

them safely. 

2. Knowing the various types of freight cars and how to safely operate 

equipment associated with them in the performance of duties. 

B. PROCEDURAL KNOWLEDGE AND COMPLIANCE -

1. Adhering to the documents that govern the movement of trains, such as 

safety and operating rules, air brake rules, hazardous materials instructions, 

etc. 

2. Being familiar and complying with all of the applicable regulations 

affecting the operation oflocomotives and the operation oftrains. 

C. TERRITORIAL KNOWLEDGE 

Being familiar with the route over which you operate, including the locations 

of signals, interlockings, railroad crossings, and other conditions affecting 

train movements. 

D. EXECUTION 

The physical performance of required tasks. 

Crew Member Proficiency Page 14 
MODULE 2 SITUATIONAL AWARENESS 

--------------------------------------~ 

A. Recognizing Situational Awareness 

1. Machine and System cues 

2. Crew Member cues. 

3. Personal Cues. 

4. Summary. 

B. Maintaining Situational Awareness 

1. Planning and preparing. 

2. Avoiding distractions. 

3. Dwelling on a problem. 

4. Developing a plan to handle distraction. 

5. Distributing your workload. 

6. Prioritizing your decision-making. 

7. Communicating with your crew members . 

. 8. Recognizing a deteriorating situation. 

C. Regaining Situational Awareness 

D. Summary 

VIDEO: 19 Minutes Running Time 

Total Estimated Time to Complete Module: 30 Minutes 

LEARNING OBJECTIVES 

1. Understand the meaning of situational awareness. 

2. Recognize situational awareness cues that could potentially lead to an 

undesirable outcome. 

3. Understand the strategies needed to maintain or regain situational awareness. 

Situational Awareness Page 15 
Leader's Notes 

LEADER'S NOTES --------_______________________________ ~Mi.g 

INTRODUCTION 

The next module in our Crew Resource Management program is 

"Situational Awareness." Situational Awareness is just that - being aware of 

your surroundings at all times, and pre-plan solutions for any emergency that 

could result from those conditions. As you will see in the video, crew members 

must be confident in their ability to work together to anticipate situations that may 

require action, and they must all be accountable for maintaining a high level of 

awareness of their environment. 

SHOW THE VIDEO 

POINTS FOR DISCUSSION 

• Situational awareness is contributing to a safe work environment by being 

aware of your surroundings at all times, complying with rules and instructions, 

and developing a preventative planes) that includes several solutions for any 

emergency situation that could occur in the near future. 

• Cues that can warn of a possible loss of situational awareness can come from 

different sources? including: 

- Machine and system cues (equipment) 

- Crew member cues 

- Personal cues 

(Ask for examples of each.) 

• There are eight basic steps that help maintain situational awareness: 

1. Planning and preparing. 

2. Avoiding distractions 

3. Avoid dwelling on a problem. 

Situational Awareness Page 16 
4. Developing a plan to handle distractions. 

5. Distributing your workload. 

6. Prioritizing you decision making. 

7. Communicating with your crew members. 

8. Recognizing a deteriorating situation. 

• Types of distractions include personal, task and mechanical. 

• How decisions are made as a crew is important - talking to each other makes 

crews more accurate in their assessment of problems, and more coordinated in 

their actions dealing with problems. 

• Lost situational awareness can occur gradually or all at once. It has been 

shown that failures are often the result of many mistakes and miscalculations -

the "error chain." 

• It is each employee's responsibility to recognize a loss of situational 

awareness, and then communicate, resolve and monitor the problems that have 

led to the loss. 

Situational Awareness Page 17 
SITUATIONAL AWARENESS 

Definition 

Situational Awareness is your responsibility, as an individual, and as a 

member of a crew. As an individual, you must contribute to a safe working 

environment by being aware of your surroundings at all times, by complying with 

rules and instructions, and by developing a preventative planes) that includes 

several solutions for any emergency situation that could occur in the near future. 

All crew members must be confident of their ability to work together to anticipate 

situations that may require action, as they are all accountable for maintaining 

awareness of the environment in which they are working. Crew members must 

know the physical characteristics of the territories over which they are operating. 

RECOGNIZING SITUATIONAL AWARENESS 

Now that you understand what situational awareness is, you need to be able 

to identify the sources that will provide you with the cues -cues that can warn of a 

possible loss of situational awareness. These sources include: 

1. Machine and System Cues (Equipment) 

2. Crew Member Cues 

3. Personal Cues 

Cues are hints or suggestions on which to act. They are consciously and/or 

unconsciously perceived, and they prompt a type of behavior. 

Situational Awareness Page 18 
CRM 

'iT"A 

Recognizing Situational Awareness 

Your working environment provides you with sufficient cues to help you 

recognize the loss of situational awareness and often recover in time to prevent 

serious incidents and accidents. Your working environment includes 

the machines and systems that you work with, other crew members, and yourself. 

The ability to use information from these sources contributes to your maintenance 

of situational awareness and helps you form an accurate picture of what is 

happening. It is the ability to integrate these three sources that will help you 

maintain situational awareness. 

1. Machine and System Cues (Equipment) 

Maintaining situational awareness of the machines and systems you use, is 

often where most of your time is spent. The equipment you use can provide you 

with many important cues about what is happening in your environment. 

The following are examples of questions you should ask yourself about the 

machines and systems you use, which will help you identify important cues: 

• Are the machines and systems working effectively? 

• Is the equipment providing me with any signals, problems, or warnings of 

trouble ahead that I should be aware of? 

• Am I using the equipment properly and safely? 

• Have I maintained technical proficiency? 

• Have I done all that is necessary in my job briefing that involves 

equipment? 

• Are there any malfunctions? 

• Am I having any equipment problems that I need to clarify with a crew 

member or other personnel? 

Asking yourself these questions, and constantly being aware of all the 

information provided by the machines and systems can help you identify 

important cues that may affect the loss of your situational awareness. 

Situational Awareness Page 19 
Recognizing Situational Awareness 

2. Crew Members Cues 

Your crew members are a valuable source of information. You are a team 

and it is important that you are constantly aware of each other's behavior, 

feelings, and actions; in other words, "reading each other's cues." If you are aware 

of each other's interaction with the environment, you are likely to prevent 

problems from occurring. As well, sharing and communicating with crew 

members will provide each of you with information you may not have known or 

you may have interpreted differently. Cues from your crew members such as 

inattention or complacency can be signs of degrading situational awareness. That 

is why it is important that should not only you be aware of a loss of situational 

awareness with yourself, but also with other crew members. 

3. Personal Cues 

Sometimes the hardest types of cues to identify are those that relate to our 

own loss of potential situational awareness. It is easier to point out someone 

else's weaknesses than it is our own. Always be aware of how you are feelingyou know yourself best. 

Asking yourself the following questions can provide you with cues to realize 

your level of situational awareness: 

• How do I feel (rested, alert, motivated)? 

• Is there anything bothering me (personal problems)? 

• Am I ready for work? 

• Is there anything I am feeling uneasy about in this situation? Do I feel 

safe? 

These kinds of questions will help you stay aware of any possible cues you are 

providing to yourself that may indicate a loss of situational awareness. 

Situational Awareness Page 20 
Recognizing Situational Awareness 

Summary 

In summary, analysis shows that "usually at least three cues are available to 

the crew members." These cues are provided to you through your environment, 

which includes the equipment you interact with, your crew members, and 

yourself. 

Cues are not always obvious; use your judgement and discretion when 

required. However, the presence of one or more cues is adequate grounds for you 

to do a conscious assessment of your current state of situational awareness. 

Situational Awareness Page 21 
MAINTAINING SITUATIONAL AWARENESS 

You need to know the steps to take to prevent a loss of situational 

awareness. The steps in maintaining situational awareness are as follows: 

1. Planning and preparing. 

2. Avoiding distractions. 

3. Dwelling on a problem. 

4. Developing a plan to handle distraction. 

5. Distributing your workload. 

6. Prioritizing your decision-making. 

7. Communicating with your crew members. 

8. Recognizing a deteriorating situation. 

1. Planning and Preparing 

Planning and preparing is your ability to combine all the information and 

resources that are available to you to help you evaluate your working 

environment. This includes your interaction with both equipment and other crew 

members. 

Situational awareness is affected by your ability to develop and 

communicate a well thought out job plan. This is done through ajob briefing or 

through a proper transfer. Job briefing or transferring is a critical step in defining 

your tasks and responsibilities, which will allow you to plan your workday and 

will contribute to your situational awareness. 

Planning means you are constantly evaluating patterns such as those that 

appear on gauges, readouts, or displays. It is also important that you stay current 

with rules, operating bulletins, practices, etc., as these are all resources that will 

help you make proper decisions. 

Situational Awareness Page 22 
Maintaining Situational Awareness 

The plan that is developed is the foundation on which crew members build 

their situational awareness. It is constantly updated as the crew monitors, 

evaluates, anticipates, and considers all the information and resources that are 

available. 

Preparing involves anticipating and considering what is going to happen 

later and then projecting an appropriate action or solution. Preparing relies on 

your ability to project the current situation into the future, which is an important 

part of maintaining your situational awareness. 

2. Avoiding Distractions 

Crew distractions are a serious impediment to safety. When an individual is 

distracted or preoccupied, the ability to detect other important stimuli is lost. 

Distractions can be avoided by: 

• Increasing your awareness of the three types of distractions. 

• Avoiding dwelling on a problem. 

• Developing a plan to handle distractions. 

Types of Distractions 

Distractions include personal distractions, task distractions, and mechanical 

distractions. 

Personal distractions 

Task distractions 

Situational Awareness 

Personal distractions can refer to preoccupation 

with family problems, health problems, or other 

personal problems. 

Doing paperwork, check lists, radio 

communications and training new personnel at 

inappropriate times. For example, dealing with 

paperwork should not be attempted when you are 

entering a restrictive situation. Although 

activities such as paperwork, radio 

Page 23 
Mechanical distractions 

3. Dwelling on a Problem 

CRM 

'iTA 

Maintaining Situational Awareness 

communication, and training new personnel are 

important parts of your job, you must perform 

these activities without losing sight of the big 

picture. If this is lost, an important activity has 

now become a potentially dangerous situation. 

Include equipment malfunctions, such as unit not 

loading properly, or loss ofEOT signal, 

Sometimes malfunctions are big and obvious, and 

sometimes they are small and not apparent. 

However, what can happen is that you become so 

engaged in solving the mechanical problem or 

addressing a specific consideration, that your 

attention is diverted from operating the train. 

Dwelling on a problem refers to occasions when you become so focussed 

on a singular item, that your attention is taken away from other activities or items 

that may also need your attention. For example, you are less likely to detect a 

loss of the EOT signal or drop in air pressure when you are focusing on your 

speed. 

Sometimes distractions come from something that has already happened 

and is over. At these times, the crew may continue to dwell on that situation and 

neglect the current situation. For example, you are discussing the malfunction of 

one of your locomotives early in the trip, and you miss a signal. 

4. Developing a Plan for Handling Distraction 

It is important that you and other crew members develop a plan for 

handling distractions. Establishing and adhering to standard operating procedures 

is important as is acknowledging and communicating breaks in the normal 

sequence of events. You should brief your crew if you decide to break this 

normal sequence of events for any reason. A complete updated job briefing, 

Situational Awareness Page 24 
Maintaining Situational Awareness 

including the planned sequences of events and all changes, must be done with the 

entire crew. 

When distractions occur, this should trigger a heightened sensitivity to 

a potential loss of situational awareness. 

5. Distributing Your Workload 

Distributing your workload involves recognizing and admitting to yourself 

and others when you are too busy to stay on top of every situation. You must 

learn to delegate and reduce your workload to allow yourself to complete tasks 

safely. Prioritize your work tasks and responsibilities to ensure you maintain 

your situational awareness by reducing the chances of overload. Overload means 

the amount of information being processed is either too much at once, or the 

information being processed is significantly above the individual's capacity. 

6. Prioritizing Your Decision Making 

Making quality and timely decisions is the essence of situational awareness 

and judgement. Decision-making involves two major components: assessing the 

situation and choosing a course of action. Assessing the situation differs from 

situational awareness in that it is the active process in which you achieve 

situational awareness. 

Consider the following when assessing the situation: 

• Define the nature ofthe problem. 

• Determine how much time is available for coping with it. 

• Assess the level of risk both immediate, and in the future. 

Once the situation has been perceived and interpreted, there is now a basis 

for planning and making decisions. First, prioritize your decisions based on the 

Situational Awareness Page 25 
I 

Maintaining Situational Awareness 

time available as well as the risk level of what needs to be decided - both 

immediate and in the future. 

Many situations are routine; some are not. Some situations carry 

significant consequences, but others may not. Therefore, many types of decisions 

are needed. Some decisions may be made singularly by one member of the crew 

where as others are so complex or important that the inputs from more than one 

crew member or from an outside source are needed to ensure higher quality 

decisions. 

In CRM, how we make decisions as a crew is most important. It is your 

responsibility to recognize when you need help from others and when their 

expertise can guide you in making appropriate decisions. 

7. Communicating with Crew Members 

When you communicate, you transfer information to crew members, and 

communication is imperative in determining situational awareness. You work 

together like a team of detectives, accurately observing cues provided by your 

environment. Sharing evidence and interpreting the significance of cues helps in 

forecasting possible outcomes or solutions. As crew members communicate what 

they perceive in the environment around them, they increase the knowledge ofthe 

other crew members. Crews who communicate well will commit fewer errors 

because talking to each other makes crews more accurate in their assessment of 

problems, and they are more coordinated in their actions for dealing with them. 

Communication involves managing crew awareness and a willingness to 

share information. You must continuously ask these questions: 

What do they know that I need 

to know? 

Situational Awareness 

As a crew member, you need to use all the 

sources of information available to you to be 

sure you are aware of everything you need to 

know. These sources include what your crew 

Page 26 
What do I know that they need 

to know? 

What do none of us know that 

we need to know? 

Maintaining Situational Awareness 

members see and hear. 

You should periodically ask yourself "Do I 

know something my crew members should 

know?" If the answer is yes, then you need to 

inform your crew members of this 

information. If the answer is no, then your 

crew members should be told that you are 

keeping an eye on something and they don't 

need to worry. As well, if something takes 

your attention away from what crew 

members are expecting you to keep an eye 

on, it is important that you let them know. 

As a crew, you need to ask, "Is there 

information we need that none of us on the 

crew know?" 

Sometimes, the other question to ask is "What 

are we as a crew not paying attention to?" 

Defining roles and responsibility during loss 

of situational awareness allows a crew to 

function as a team. For example, if all the 

crew is concerned with the apparent 

malfunction of the load indicator, then signals 

may be overlooked. 

8. Recognizing a Deteriorating Situation 

Recognizing a deteriorating situation involves sharing and communicating 

with other crew members as well as acknowledging your personal limits. 

Acknowledging your personal limits is the first step in recognizing a deteriorating 

situation. Only you know when you are not performing or thinking at normal 

levels. 

Situational Awareness Page 27 
Maintaining Situational Awareness 

EXAMPLE 

You are on the last sixty (60) miles of a long trip. You are the locomotive 

engineer and are aware that you are growing inattentive. In the next ten miles you 

know you will be approaching a five-mile 15 MPH slow order, Therefore, you 

alert the conductor to the situation. The conductor, now aware of the whole 

situation, would ask how he/she could assist you in getting through the rest ofthe 

tour of duty. 

You must recognize and admit to yourself and others if you are 

expenencmg: 

• inattention 

• complacency 

• confusion and unresolved discrepancies 

• absence of anticipation 

which may lead to a deteriorating situation. 

Situational Awareness Page 28 
REGAINING SITUATIONAL AWARENESS 

What should you do in the event your situational awareness or a crew 

member's situational awareness is lost? 

If situational awareness is lost, it virtually guarantees failure to achieve 

your job objectives. It is often the prime factor in incidents and accidents. Lost 

situational awareness can occur gradually or all at once. 

Error Chain 

Incident studies have shown that it usually wasn't one isolated event that 

caused a failure .. Many mistakes and miscalculations probably occurred prior to 

the actual incident. This assumption of multiple problems is the error chain. You 

must be able to recognize, communicate, resolve, and monitor these problems to 

prevent an error chain and the subsequent loss of situational awareness. 

Problems that could result in an error chain are as follows: 

• failing to plan and prepare. 

• distractions. 

• information overload. 

• failing to prioritize decision making. 

• failing to recognize a deteriorating situation. 

• failing to communicate. 

• dwelling on a problem. 

The essential factor of regaining lost situational awareness is recognition. 

No one likes to admit to human frailty, but the risk is too great to keep lost 

situational awareness a secret. It is your responsibility to recognize a loss of 

Situational Awareness Page 29 
Regaining Situational Awareness 

situational awareness in yourself or in other crew members and to notify crew 

members of this loss as soon as it is detected. Recognition involves using all the 

sources of information available - be it machines and systems, other crew 

members, or you. 

There is one other source you should consider. Instinct can often be the 

most detectable and reliable cue to the loss of situational awareness. Our bodies 

are able to detect stimuli long before we have consciously put the big picture 

together. As humans, we are aware of many cues from our surroundings for 

which we cannot always identify the origin. These cues are very real. Don't 

ignore then, even when they only manifest themselves in a feeling of uneasiness. 

Always remember - "if it doesn't feel right, it probably isn't." 

Once you have recognized the loss of situational awareness you need to 

communicate, resolve, and monitor the problems that have led to the loss. 

Regaining situational awareness involves the following steps: 

Communicate 

Resolve 

Monitor 

Situational Awareness 

Verbalize your concern to your crew as soon as you 

detect a loss of situational awareness. 

Take the time to determine how situational awareness 

was lost and resolve this problem. Make an effort to 

seek all the information that is necessary to regain 

situational awareness and be assertive in doing so. 

Monitor the problem(s) that led to the loss of situational 

awareness and take the time to analyze and discuss with 

your crew members how to prevent this happening 

again. (i.e., debrief) 

Page 30 
SUMMARY 

---------------------------------------~ In summary, situational awareness means being able to maintain awareness 

of your surroundings, the current location, events, the environment, the crew 

members as well as an assessment ofthe human conditions that affect the 

operation of the train. 

You are an information processor that must monitor, evaluate, anticipate, 

consider, and plan what is occurring in your work environment. The most 

situationally aware people think beyond the current situation, and have more than 

one plan (a backup ifthe first one doesn't work). Use your environment to 

determine important cues that warn of a possible loss of situational awareness. 

Maintaining your situational awareness will decrease the chances of 

incidents and accidents. The more aware you are of the environment you work in, 

which includes your equipment, other crew members, and yourself, the safer you 

are likely to be. If situational awareness is lost, use all your sources of 

information to recognize, communicate, resolve, and monitor the problem(s) that 

caused the loss of situational awareness. 

Always learn from your experience - analyze the episode, what led to your 

lost situational awareness? How can you avoid it in the future? Above all, 

remember situational awareness is not something you have or don't have. The 

skills that contribute to situational awareness are learned and practiced and are 

everyone's responsibility. 

Situational Awareness Page 31 
MODULE 3 COMMUNICATION & TEAMWORK 

A. Communications 

1. Ask Questions 

2. Restate or Paraphrase. 

3. Record Information 

B. Effective Communications 

1. Oral vs. Written Communications. 

2. Improving Communications 

3. Tips for Oral and Written Communications 

C. Assertive Communications 

1. Assertiveness. 

2. Non-Assertiveness 

3. Aggressiveness 

4. Assertiveness Techniques 

a. Asking Questions 

b. Stating Objections 

c. Controlling Emotions 

5. Summary 

D. Job Briefings 

E. Teamwork 

1. Elements of a Team. 

2. Team Responsibilities. 

3. Team Roles. 

4. Tying it Together in a Team. 

5. Effective Teams. 

6. Making Team Decisions 

a. Advantages of Team Decision Making. 

b. Effectiveness in Team Decision Making. 

c. Steps in Making Team Decisions. 

d. Summary 

Communication & Teamwork Page 32 
VIDEO: Communications - 14 Minutes Running Time 

Job Briefings - 3 Minutes Running Time 

Teamwork - 6 Minutes Running Time 

Effective Teams - 7 Minutes Running Time 

Total Time - 30 Minutes 

Total Estimated Time to Complete Module: 1 Hour 

LEARNING OBJECTIVES 

1. Recognize the elements of communication; one-way vs. two-way, active 

listening, paraphrasing, restating or questioning. 

2. Recognize strategies for communicating to others clearly, accurately, and in a 

timely fashion, in both oral and written forms. 

3. Conduct effective job briefings. 

4. Recognize the roles and responsibilities of team members. 

5. Describe the process for making a team decision. 

Communication & Teamwork Page 33 
LEADER'S NOTES 

-------...... ------------~ INTRODUCTION 

Who can dispute that Communication and Teamwork are two crucial 

components of any successful operation? Communication drives our society 

today - look around, cell phones abound in the vehicles of America. Pagers 

convey messages without the need to return a call. Most homes are connected to 

the internet, which provides unlimited communication. Teamwork is a necessity 

whenever two or more people come together to accomplish a common goal. 

Communication is required for teamwork. 

This module addresses Communication and Teamwork as it relates to crew 

operations, and how to more effectively communicate to prevent accidents. A 

new term, "assertive communications," will be introduced, and how this tool can 

enhance communication between crew members. Job briefings as a 

communication tool are also discussed, and finally, some good information on 

teamwork is presented, including how to function as an effective team, and team 

decision-making. 

SHOW THE VIDEO 

NOTE: This module is divided into four segments - Communications, Job 

Briefings, Teamwork and Effective Teams. Pause the tape for discussion at each 

prompt that will appear at the end of each segment 

Communication & Teamwork Page 34 
POINTS FOR DISCUSSION 

Communications 

Leader's Notes 

• Oral communications is normally made up of three different components 

which impact communication - words, voice inflection and body language. 

(Ask which one ofthese makes up the largest percentage of communication.) 

• Whether oral or written, communication must possess the following traits to 

be effective: 

Clarity. 

Accuracy. 

Complete message. 

Organized message. 

Concise message. 

Timely. 

• Tips for oral communication: 

Speak clearly. 

Avoid slang that could be misunderstood. 

Decide what you want to say before saying it. 

Ask the receiver to restate or paraphrase important information. 

Then, actively listen to the response to make sure it is accurate. 

- Don't assume that no response means the message is 

misunderstood. 

Follow procedures. 

• Tips for written communication: 

Write neatly. 

Follow applicable company procedures and rules. 

Find the most appropriate time to perform written 

communications. 

• Three common communications strategies are: 

Assertiveness 

- Nonassertiveness (Passiveness) 

Aggressiveness 

• Assertiveness is the Willingness to clearly express your opinion, while 

respecting the opinions and rights of others. An assertive person is persistent, 

trying different approaches until success is achieved. 

Communication & Teamwork Page 35 
Leader's Notes 

• Nonassertivenss is when you are unwilling to express your true opinion or 

question another person's opinion or actions. How can this affect safety? 

• Aggressiveness is doing what you think will achieve your goals, regardless of 

the opinions and rights of others. 

• When applying assertive communications to CRM, crew members are 

expected to: 

State their own ideas, opinions and recommendations. 

- Assert themselves and advocate their points of view when 

necessary for safe operations. 

- Use increasing levels of assertiveness as appropriate to maintain 

safe operations. 

• Techniques for communicating assertively: 

- Ask questions. 

State objections clearly, without attacking individuals and 

controlling emotions. 

Job Briefings 

• A job briefing ensures that all employees have a clear understanding of the 

task to be performed, the responsibilities of the individuals, and the type of 

protection required. 

• Four basic steps to conducting a job briefing: 

1. Planning the job briefing. 

2. Conducting the job briefing. 

3. Explain special conditions. 

4. Take individual responsibility. 

Teamwork 

• Elements of a team include: 

- Clarity of purpose. 

- Interdependence. 

- Commitment to synergy. 

- Accountability. 

• Teamwork involves developing relationships, requiring interaction and 

cooperation. 

Communication & Teamwork Page 36 
Leader's Notes 

• Awareness of each crew member's roles and related tasks is necessary for a 

positive and productive work environment. Identifying these roles involves 

understanding the functions ofthe individual team members, their technical 

proficiencies, and how they influence the team as a complete unit. 

• Complete communication means voluntarily communicating everything you 

believe is relevant for others to know, and checking when you are not sure. 

Effective Teams 

• An effective team: 

Employs two-way communication. 

Share-s participation and leadership. 

Evaluates the team's effectiveness and discusses how to improve 

the working environment 

Expresses ideas and feelings openly and honestly. 

Strives for conscensus. 

Employs positive conflict resolution techniques. 

Participates in constructive critisism. 

• An effective team member: 

Takes responsibility for personal performance. 

Recognizes strengths and weaknesses. 

Listens openly to new information, ideas or approaches. 

Is flexible in handling change. 

Maintains a standard of honesty and integrity. 

Senses others' feelings and perspectives. 

- Negotiates and resolves disagreements. 

Works toward a shared goal. 

• Sometimes a decision is best made by an individual; other times, a group 

decision is necessary when the experience and advice of other crew members 

is needed to make the best decision. 

• Advantages ofteam decisions: 

Provides more complete information. 

Generates more alternatives. 

Increases the acceptance of a solution. 

• There are five basic steps involved in making a team decision: 

Defining the problem or decision to be made. 

Communication & Teamwork Page 37 
Brainstorm and discuss available alternatives. 

Consider the probable consequence of each alternative. 

Evaluate each ofthe alternatives. 

Making the decision. 

Communication & Teamwork Page 38 

Leader's Notes 
COMMUNICATION AND TEAMWORK 

When working as part of a crew, effective communication is especially 

important as it also contributes to a positive work environment and can prevent 

misunderstandings that could lead to accidents. There are many ways to 

communicate. We may speak face-to-face, or use the telephone, or the radio. We 

may also use written messages such as memos, reports, and forms. On the 

railroad, some information is communicated using signs, signals, or flags as well. 

Though communication can take many forms, different situations may make some 

forms more effective than others. The simplest and least effective type of 

communications is one-way. This is not real communications. This occurs when 

one person decides on a message and sends it to another person without requiring 

any response and acknowledgement. The message mayor may not be received 

and mayor may not be interpreted correctly, and there is no way to tell. 

More effective forms of communications are two-way. This means that a 

message is sent and confirmation that it has been received and understood as 

intended is given as quickly as possible. Successful communications requires that 

the sender and receiver have the same mental image or understanding of the 

message. This eliminates the chance of confusion and frustration. Two-way 

communications is important because messages are often not understood the first 

time they are sent. 

Commuuication & Teamwork Page 39 
COMMUNICATIONS 

Active Listening 

Effective (two-way) oral communication requires active listening, meaning 

that the receiver takes an active role in trying to understand the message, being 

sure to listen non-judgmentally. 

Three techniques for active listening are as follows: 

1. asking questions when the communications is not clear 

2. restating or paraphrasing to check understanding 

3. recording information 

1. Ask Questions 

There are two main reasons for asking questions when you are trying to 

understand someone: 1) to clarify what you have heard and 2) to ask for 

additional information not included in the original message. 

We have all experienced situations where we were not able to make out 

what another person has said. For example, during switching operations, a 

conductor may tell a locomotive engineer to back up ten (10) car lengths. 

However, radio interference may prevent the locomotive engineer from hearing 

the number of car lengths. To overcome this, he/she should ask for the 

information to be repeated - "I did not understand your last message. Please 

repeat." 

There are also times when, though we understand what a person has said, 

we may need more information to understand what they mean or what they are 

really asking us to do. A simple example of this happens when acronyms or slang 

are used to describe equipment and procedures. For the experienced worker, the 

meaning ofthese words may be clear, but to a new employee they could be 

Communication & Teamwork Page 40 
Communications 

meaningless. For example, the dispatcher may call and ask a conductor to "sweep 

the switch," meaning to clear a switch of snow so that it can be locked into place. 

A new employee may not understand this instruction. 

Sometimes people are reluctant to ask questions for fear of appearing 

foolish or incompetent. When working in a crew environment, it is essential that 

each crew member be willing to ask - and to be asked - questions to make sure 

no incidents or accidents result from a misunderstanding. 

2. Restate or Paraphrase 

Even when you have asked questions to clarify the meaning of a message, 

it is important to confirm that your understanding is the same as that of the 

sender. This can be done by restating or paraphrasing the message. 

Restating means to read back information exactly as you received it. This 

allows the sender to confirm or correct what you have received. This technique is 

most appropriate for confirming specific numbers, locations, or other details. 

Restating is required in many situations on the railroad. 

Where appropriate, paraphrasing can be another form of ensuring 

understanding. To paraphrase, use your own words to summarize the message 

that you have received, including the important details. This allows the sender to 

confirm your understanding of both the content and the meaning of the message. 

When paraphrasing, be sure that you don't include assumptions or judgments you 

have made about what the sender has communicated. 

3. Record Information 

Sometimes, a communication may include more information than we can 

process at once, or information that we may need at a later time. When this is the 

case, active listening includes recording the information - usually in writing - so 

Communication & Teamwork Page 41 
that it can be used later. The record also ensures the information remains 

consistent. Information about track work, speed restrictions, or mandatory 

directives are all examples of information that must be recorded. 

Summary 

Effective communications is important when working in a crew as it 

contributes to a positive working environment and can prevent misunderstandings 

that could lead to accidents. 

Most effective forms of communications are two-way. This means that a 

message is sent and confirmation that it has been received and understood is 

given as quickly as possible. In this type of communication, the sender and 

receiver alternate roles, exchanging information until they understand each other. 

This type of communications requires active listening, which includes techniques 

such as 

• Asking questions when information is not clear 

• Restating or paraphrasing to check understanding 

• Recording information when it is necessary. 

Communication & Teamwork Page 42 
EFFECTIVE COMMUNICATIONS 

Communication is a core crew resource management behavior. 

Communication is normally made up of three different components: words (7%), 

voice inflection (38%), and body language (55%). Clearly, the methods used for 

many communications needed in the maintenance and movement of trains is often 

reduced due to the physical distance; for example, the use of facial cues and 

gestures. Thus, communication often relies on how well the sender and receiver 

handle words. You need to be aware that there are differences when working 

with crew members. 

1. Oral vs. Written Communications 

Most of the communication you will encounter in crew situations and other 

aspects of your work will be either oral or written. Each of these types of 

communication has advantages and disadvantages, which makes some better 

suited for different situations. 

2. Improving Communications 

Effective communications, whether oral or written, require the following: 

Clear 

Accurate 

Complete 

Any effective message must be clear - its meaning 

must be precise and easily understood. Examine your 

speaking and writing. If you were the receiver, would 

you understand the message? 

The information in your message must be accurate. A 

well communicated message with inaccurate 

information can be more dangerous than no 

communication at all. 

Before sending a message, written or oral, consider 

whether it contains all the information required. A 

Communication & Teamwork Page 43 
Organized 

Concise 

Timely 

Effective Commuuications 

complete message will reduce the need for later 

clarification or additional information. 

The information in a message should be organized so 

that it will be easily understood by the receiver. If it is 

understood, it will be more easily remembered. For 

example, if you are outlining a procedure, make sure 

the steps are in the correct order. 

A message should be as short as possible while still 

being clear and complete. The more unnecessary 

information you include, the more likely it is to be 

misinterpreted, or to cause information overload 

No matter how well you construct and convey your 

message, it will be useless if it is too late. For 

instance, you may believe that a member of your crew 

is losing their situational awareness. If you say 

nothing until the situation is out of control, it is too 

late for communication to be helpful. 

The most effective communication is clear and direct; courteous and to the 

point; brief, precise, and timely. 

3. Tips for Oral Communication in CRM 

Here are some suggested guidelines to improve oral communications: 

• Speak clearly 

• A void slang that could be misunderstood 

• Decide everything you want to say before saying it 

• Ask the receiver to restate/paraphrase important information 

• Listen actively to the receiver's response to make sure it is accurate 

• Don't assume that no response means the message is understood 

• Follow procedures 

Tips for Written Communication in CRM 

Communication & Teamwork Page 44 
• Write neatly 

• Fill in forms as completely and accurately as possible, even if you have 

to take some extra time to find the information 

• Follow applicable company procedures and rules 

• Find the most appropriate time to perform written communications 

Communication & Teamwork Page 45 
ASSERTIVE COMMUNICATIONS 

Assertiveness, Nonassertiveness, and Aggressiveness 

People use different strategies to achieve their goals. Three common 

strategies are as follows: 

• assertiveness 

• nonassertiveness (passiveness) 

• aggressIveness 

1. Assertiveness 

2. Nonassertiveness 

(Passiveness) 

3. Aggressiveness 

Assertiveness is a willingness to clearly express your 

opinion, while respecting the opinions and rights of others. 

It allows you to act in a way that is in your own - or your 

crew's - best interest, while maintaining self-respect and 

respect of others. 

An assertive person 

• makes plans 

• expresses opinions clearly 

• listens to the ideas/opinions of others 

• is persistent, trying different approaches until success is 

achieved 

This is the most effective strategy for attaining goals or 

desired outcomes. 

Nonassertiveness or passiveness occurs when you are 

unwilling to express your true opinion or question another 

person's opinion/actions, which can result in sacrificing 

safety. 

Aggressiveness is doing what you think will achieve your 

goals, but without regard for the opinions and rights of 

others. 

Aggressiveness often leads to strained relations and 

decreases the crew's ability to communicate effectively. 

Communication & Teamwork Page 46 
Assertive Communications 

4. Assertiveness in CRM 

Effective communication between crew members is an essential part of 

CRM, and leads to safe and efficient operations. Sometimes, however, crew 

members may disagree about the best course of action, making communication 

difficult. This is especially true in cases where authority or seniority make it 

difficult for ideas to be expressed and considered freely. Assertive 

communications can help to overcome such problems. 

to 

In applying assertive communications to CRM, crew members are expected 

• State their own ideas, opinions, and recommendations, especially when 

solicited by others. 

• Assert themselves and advocate their points of view when necessary for 

safe operation. 

• Use increasing levels of assertiveness, as appropriate, to maintain safe 

operations. 

Specific techniques should be used to help communicate assertively, 

including the following: 

1. asking questions. 

2. stating objections clearly, without attacking individuals. 

3. controlling emotions. 

Asking questions 

Communication & Teamwork 

It is often difficult to challenge another person's 

actions without offending himlher. A good 

technique is to ask questions first. This will help 

you to be sure that you understand the situation 

before voicing an objection. 

Examples: 

Less Effective 

"Hey, don't forget we have a slow order three miles 

ahead." 

Page 47 
State Objections Clearly, 

Without Attacking 

Individuals 

Controlling Emotions 

Communication & Teamwork 

Assertive Communicatious 

More Effective 

"Do we still have that slow order three miles 

ahead?" 

Remember, you have a responsibility to yourself 

and your crew to make sure that safe procedures are 

followed. If you do not receive a satisfactory 

answer to a question, you should continue to 

question or even statean ?bjection. 

When you believe that a crew member is making a 

mistake or acting unwisely, you should express an 

objection clearly, not as a weak or disguised 

comment. You must also be careful to object to the 

behavior or action, not to the person. 

One way to accomplish this is to begin objections 

with "I." This shifts responsibility for the statement, 

and makes the objection less threatening to the 

other person. 

Examples: 

Less Effective 

"Sure feels like we're moving too fast." 

or 

"You are going too fast!" 

More Effective 

"I think we're going faster than track speed." 

You should express yourself as calmly as possible, 

even when directly challenging a crew member's 

action. 

Using an angry or threatening tone is aggressive, 

not assertive. It may help you to get your way 

immediately, but it leads to decreased cooperation 

and crew support. 

Examples: 

Less Effective 

Page 48 
5. Summary 

Assertive Communications 

(angrily) "That was stupid! You could have killed 

us both!" 

More Effective 

(calmly) "That was "too close for comfort." It 

could have been avoided." 

People use different strategies to achieve their goals, including 

• Assertiveness - clearly expressing opinions, while respecting others' 

opinions and rights. 

• Nonassertiveness (passiveness) - unwillingness to express true opinions 

or question another person's opinion/actions. 

• Aggressiveness - doing what will achieve your goals, without regard for 

the opinions and rights of others. 

Assertiveness is usually the best approach for expressing your opinions 

within a crew, although some circumstances may require other behavior. When 

necessary, crew members must use increasing levels of assertiveness to maintain 

safe operations. 

Useful techniques for assertive communications include 

1. Asking questions 

2. Stating objections clearly, without attacking individuals personally 

3. Controlling emotions 

By using assertive communications appropriately, you can contribute to 

safer operations and stronger relationships. 

Communication & Teamwork Page 49 
JOB BRIEFINGS 

Safe and productive work are the results of planning and conducting a wellcommunicated job briefing. Ajob briefing must be held to ensure that all 

employees have a clear understanding of 

• The task to be performed 

• The responsibilities of the individuals 

• The type of protection required 

STEP 1: PLAN THE JOB BRIEFING 

A. Plan the work. 

B. Consider existing and potential hazards. 

C. Consider how work assignments will be made. 

STEP 2: CONDUCT THE JOB BRIEFING 

A. Explain work or tasks to all involved employees. 

B. Discuss existing or potential hazards and ways to eliminate or protect 

against them. 

C. Make definite work assignments. 

D. If special tools, material, 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. 

STEP 3: EXPLAIN SPECIAL CONDITIONS 

A. Discuss complex jobs. 

B. When it becomes necessary to change plans and procedures as the job 

progresses, brief employees on these changes. 

Communication & Teamwork Page 50 
Job Briefings 

STEP 4: TAKE INDIVIDUAL RESPONSIBILITY 

Additional job briefings must be held when the situation changes. It 

doesn't take long to do ajob briefing that will prevent injuries and save lives. 

Getting Results 

Job briefings occur every day. To ensure job briefings achieve the results 

you're looking for, follow these basic steps: 

1. Prepare and contribute facts and ideas. 

2. Ask questions. 

3. Stay focused. 

4. Listen actively. 

5. Clarify roles and actions to be taken. 

Certain transfers conducted between train. crews and dispatchers may 

require a structured meeting at the beginning or the end of the shift or tour of duty 

to exchange essential information. A more informal process may also be used to 

improve crew performance. 

Communication & Teamwork Page 51 
TEAMWORK 

The most valuable assets of any organization are its employees. The better 

they work as a team, the better their morale, productivity, and their contribution 

to the success of the organization. We will look at the definition and elements of 

• 

a team, as well as the responsibilities and roles of crew members who interact as a 

team. 

The term crew is defined as any group of people working at different tasks 

designed to accomplish a common mission, goal, or objective. 

A crew should be thought of as a team. A team is a collection of people 

who must relate to each other to accomplish shared objectives and goals. They 

combine a unique blend of skills, personalities, attitudes, perceptions, and shared 

responsibilities. A safe and successful work environment consists of individuals 

in a group being able to work together, rather than separately. 

1. Elements of a Team 

There are many elements of a team. These include: 

1. Clarity of purpose 

2. Interdependence 

3. Commitment to synergy 

4. Accountability 

Clarity of purpose 

Interdependence 

Communication & Teamwork 

A team must have a reason for working 

together. For example, in the railroad industry, 

the purpose is the safe and efficient operation of 

the trains. 

Team members' need each other's experiences, 

abilities, and commitment in order to reach 

common goals. For example, your team may be 

made up of a locomotive engineer, conductor, 

dispatcher, and other personnel, who have a 

Page 52 
Commitment to synergy 

Accountability 

2. Team Responsibilities 

variety of roles, abilities and experiences that 

contribute to the safe and effective operation of 

trains. 

Teamwork 

Team members are committed to the idea that 

working together leads to more effective 

decisions and greater productivity than working 

alone. For example, this means realizing that 

the operation of a train does not rely on the 

efforts of a single person, but on the efforts of a 

group. 

The team is accountable as a functioning unit 

within a larger organizational context. For 

example, when shortcomings occur, it is usually 

not the result ofthe actions of one individual. 

Shortcomings are usually the result of the 

actions, or inactions, of several individuals. 

Teamwork involves developing relationships. Interaction and cooperation 

is essential. Interaction and cooperation are characterized by sharing information 

that is necessary for establishing team goals and reaching these goals. It requires 

learning about other team members and their particular functions so that you can 

offer help when it is needed: sharing information is crucial for cooperation. 

The responsibility of the team also involves a joint effort in motivating 

each other to perform safely and efficiently. You must evaluate your individual 

performance in relation to its effect and contribution on the performance of the 

entire team. 

Teamwork also relies on using conflict management skills effectively. 

Conflict resolution involves accepting that each member of the team has different 

styles of interacting which is influenced by personality and experience. 

Communication & Teamwork Page 53 
Identifying these styles will allow the team to discuss conflict in a positive and 

productive environment, acknowledging that not everyone sees a situation the 

same way, but each person has a value added contribution to make. 

3. Team Roles 

Identifying roles in a team involves understanding the functions of the 

individual team members - their technical proficiencies - and how they influence 

the team as a complete unit (i.e., locomotive engineer, conductor, dispatcher, and 

other crew roles). Awareness of each other's roles and related tasks is necessary 

in building a positive and productive work environment. 

Conflict often arises when roles and tasks aren't clearly defined. This 

causes tension as team members may argue about who has authority over specific 

areas and which responsibility belongs to which team member. An effort should 

be made to minimize discrepancies such as these by encouraging each member to 

communicate what they view their role and subsequent tasks to be. The other 

team members should provide feedback to clarify if the perception of a person's 

role as seen by that individual coincides with the team perceptions as a whole. 

Teamwork 

Teamwork involves working together to clarify roles and tasks, cooperating 

as a group in the coordination of these roles and tasks. However, it is important 

to remember that team members need to know more than the individual roles. 

There should be a genuine interest in each other's individual success, which is 

essential for cooperation. 

4. Tying it Together in a Team 

Crew Member Proficiency - It is important that each team member understand 

his/her job and is able to perform the duties and tasks associated with that job. It 

Communication & Teamwork Page 54 
is important that the team be constantly aware of the influence of such factors as 

rest, diet, and alertness on the performance of the team. 

Situational Awareness - The situational awareness level that a team is able to 

attain together has an important effect on the safety of the work environment. 

Each team member will have a level of situational awareness; however, how these 

individual perceptions are joined together is critical in the maintenance of 

situational awareness. 

Communication - Communication is one of the most important influences in 

building an effective team. Communication must always be two-way and 

complete. Complete communication means voluntarily communicating 

everything you believe is relevant for others to know, and checking when you are 

not sure. Team communication is characterized by an expression of patience and 

trust. Two-way communication is used for problem solving and decision making 

when a team encounters conflict. 

5. Effective Teams 

There are many factors that influence the effectiveness and ultimate success 

ofa team. 

An effective team is the result of proper communication techniques and 

productive team interaction. The team members work together as a cohesive unit 

which encourages group commitment and strong team dynamics. 

An Effective Team: 

• Employs two-way communication. 

• Shares participation and leadership. 

Communication & Teamwork Page 55 

Teamwork 
• Evaluates the team's effectiveness and discusses how to improve the 

working environment. 

• Expresses their ideas and feelings openly and honestly. 

• Strives for consensus. 

• Employs positive conflict resolution techniques. 

• Participates in constructive criticism. 

An Effective Team Member: 

• Takes responsibility for personal performance. 

• Recognizes strengths and weakness. 

• Listens openly to new information, ideas, or approaches. 

• Is flexible in handling change. 

• Maintains a standard of honesty and integrity. 

• Senses other's feelings and perspectives. 

• Negotiates and resolves disagreements. 

• Works toward a shared goal. 

Summary 

Teams share a purpose in their interaction with one another. They 

contribute a variety of skills and experiences to their work environment. A team 

is committed to working together and is accountable for their actions as a group. 

Teamwork involves sharing, interacting, cooperating, and communicating as well 

as applying positive conflict resolution techniques. A team monitors the 

influence of technical proficiency, situational awareness, and communication on 

the team's performance. Teams strive to clarify each member's role and tasks to 

minimize conflict. Remember, the better you work together as a team, the safer 

and more productive your working environment will be. 

Communication & Teamwork Page 56 

Teamwork 
6. Making Team Decisions 

Decision-making is a part of the daily life of a railroad employee. In fact, it 

is planning and decision-making that ultimately leads to the safe operation of a 

train. In situational awareness we discussed the importance of the individual's 

role in decision making. Now, we must look at decision making as a collective 

process. It is important to realize that sometimes it is best to make a decision as 

an individual; and other times, a group decision is necessary as you may need to 

call upon experiences and advice of other crew members to make the best 

decision. 

Advantages of Team Decision Making 

Individual and team decisions each have their own set of strengths. 

However, the advantages ofteam decisions are: 

• Provides more complete information. 

• Generates more alternatives. 

• Increases acceptance of a solution 

Provides more complete 

information 

Generates more alternatives 

Increases acceptance of a 

solution 

Communication & Teamwork 

A group brings diversity of experience and 

perspectives to the decision process that an 

individual acting alone may not. 

Groups have a greater amount and variety of 

information, and they can identify more 

alternatives than an individual. This is 

particularly evident when team members 

represent different crafts. 

When members of a team are affected by a 

certain solution and they participate in the 

process to implement the solution, they will 

be more likely to accept it. 

Page 57 

Teamwork 
Effectiveness of Team Decision Making 

Making a decision as a team tends to be more accurate. On average, groups 

make better decisions than individuals. However, if decision effectiveness were 

defined in terms of speed, the individual would out perform the group. Therefore, 

learn when to engage in a team decision and when to make decisions as an 

individual. 

Steps in Making A Team Decision 

Basic steps involved in making a team decision include: 

1. Define the problem or decision to be made. 

2. Brainstorm and discuss available alternatives. 

3. Consider the probable consequences of each alternative. 

4. Evaluate each of the alternatives. 

5. Make a decision. 

Define the problem or 

decision to be made 

Brainstorm and discuss 

available alternatives 

Consider the probable 

consequence of each 

alternative 

Communication & Teamwork 

This means the team needs to be involved as a unit 

in making a decision. It requires asking the team, 

"What is it we are trying to decide?" 

This involves figuring out how a problem can be 

solved or how a solution can be reached and with 

what approach. Brainstorming is an idea generating 

process that encourages alternatives while 

withholding criticism. It provides an open forum 

for every member of the team to discuss what he or 

she sees as a possible solution to a problem. It 

involves asking, "What are our choices?" 

This step allows the team to consider the outcome 

of each each decision they could make, given their 

choices. It requires asking, "What do we want to 

have happen or what are some things we are 

looking for in a good decision?" 

Page 58 

Teamwork 
Evaluate each of the 

alternatives 

Making a decision 

Summary 

Teamwork 

This provides an opportunity to discuss each 

alternative in more detail. It allows each 

team member to have a chance to express why their 

alternative or someone else's could be effective. It 

means asking, "How will each of these choices help 

us get what we want or what we're looking for?" 

This is the key activity of the decision making 

process when the decision if finally applied to the 

working environment. Making a decision requires 

asking, "What solution or decision will do the best 

job of resolving the problem?" 

Team decision making offers many advantages: more complete 

information, more alternatives, increased acceptance of a solution, and greater 

legitimacy. However, group decision making can be time consuming so when 

considering the need fora team decision, always keep in mind the time that will 

be involved. Although a group decision can be perceived as more effective, 

sometimes peer pressure or authority/seniority pressure can create a situation in 

which the decision isn't truly representative of the group. 

Communication & Teamwork Page 59 
MODULE 4 CONFLICT RESOLUTION TECHNIQUES 

A. Causes of Conflict 

B. Conflict Outcome 

C. Effects of Conflict 

D. Conflict Resolution Techniques 

E. Summary 

VIDEO: Module 4 - 8 Minutes Running Time 

Summary - 2 Minutes Running Time 

Total-10 Minutes 

Total Estimated Time to Complete Module: 30 Minutes 

LEARNING OBJECTIVES 

1. Apply assertive communication techniques when required. 

2. Apply effective conflict resolution techniques to resolve crew disagreements. 

Conflict Resolution Techniques Page 60 
LEADER'S NOTES 

INTRODUCTION 

The last module of our Crew Resource Management series is "Conflict 

Resolution Techniques." This module explores the causes of conflict, how it 

affects crew safety and performance, and presents some conflict resolution 

techniques. Let's take a look! 

SHOW THE VIDEO 

POINTS FOR DISCUSSION 

• Conflict resolution in CRM means bringing a conflict to conclusion in order to 

promote safe and efficient operations. 

• Conflict can result from: 

- Aggression. 

Ineffective communications. 

Role confusion. 

Loss or challenge of authority. 

Incompatible goals. 

• Conflict can have a negative impact on crew safety and performance by 

shifting attention away from essential tasks, which may lead to a loss of 

situational awareness. 

• Positive effects of conflict include correction of mistakes and improved 

performance, increase motivation and interest in work issues, and a greater 

understanding between crew members. 

• Conflict resolution techniques include: 

- Be mentally and physically prepared. 

- Delay responding. 

- Define the conflict. 

Conflict Resolntion Techniques Page 61 
Use effective communication techniques. 

Try to generate solutions together. 

Conflict Resolutiou Techniques Page 62 

Leader's Notes 
CONFLICT RESOLUTION TECHNIQUES 

Conflict occurs when people who depend on each other - like crew 

members - express disagreement over an issue. Whether the issue is real or 

perceived, differences in thoughts, opinions, feelings, and perspectives may lead 

to conflict. 

Conflict resolution in CRM means bringing a conflict to conclusion in 

order to promote safe and efficient operations. Resolving conflict may be 

required on any type of crew or tour of duty. 

Small, unresolved disputes between individuals or groups often build and 

contribute to later, more open conflicts. 

CAUSES OF CONFLICT 

Some conflict between crew members is unavoidable. Sometimes conflict 

is the result of personality differences alone. We have all met people with whom 

we find it difficult to work. Often, conflict results from specific circumstances or 

behaviors, such as 

• Aggression 

• Ineffective Communications 

• Role Confusion 

• Loss or Challenge of Authority 

• Incompatible Goals 

Conflict Resolntion Techniques Page 63 
Aggression 

Ineffective Communications 

Role Confusion 

Loss or Challenge of Authority 

Incompatible Goals 

Conflict Resolution Techniques 

Causes of Conflict 

Aggressive behavior does not respect 

the rights, feelings, and opinions of 

others, and often leads to strained crew 

relations. 

Ineffective connnunication can lead to 

dangerous misunderstandings. These 

misunderstandings can also lead to 

confusion and conflict among crew 

members. 

Conflict can easily develop in a 

situation where it is not clear who is 

responsible for a problem or issue. 

When people feel that their authority is 

being lost or challenged, they often 

react defensively to protect their status 

or self-image. This can lead to conflict 

with the person they feel threatened by. 

If two people are working together, but 

their individual goals do not match, 

conflict is the likely result. 

Page 64 
_______________________________________ 

CONFLICT OUTCOME ~M 

Conflicts result in one of three general outcomes: 

Win - win Both parties are satisfied by a win-win 

outcome. Each feels that the solution 

meets his/her needs and allows him/her 

to reach personal goals. This is often -

but not always - the best outcome for a 

crew to work toward. 

Win-lose 

Lose-lose 

Conflict Resolution Techniques 

Only one party gets his/her way in a 

win-lose outcome this may be the best 

outcome possible ifthe actions or goals 

of one person are unsafe. 

In a lose-lose outcome, neither party is 

satisfied. This may result from a poor 

compromise or a decision to "just live 

with" the problem. 

Page 65 
EFFECTS OF CONFLICT 

Conflict often has a negative impact on crew safety and performance by 

• shifting attention away from essential tasks 

• leading to loss of situational awareness, in some cases 

While conflict can cause problems for a crew, it can also have positive 

effects if handled appropriately. These include 

• correction of mistakes and improved performance. 

• increased motivation and interest in work issues. 

• greater understanding between crew members - leading to less conflict 

and increase support in the future. 

Conflict Resolution Techniques Page 66 
CONFLICT RESOLUTION TECHNIQUES 

---------------------------------------~ Whether conflict has a negative or positive impact on a crew depends on 

how the situation is handled. The following techniques will help you resolve 

conflicts effectively and create a safer work environment. 

Be Physically/Mentally Be at your physical and mental best. 

Prepared 

Delay Responding Don't react to another person's actions or 

statements until you have considered exactly 

what you want to say or do. Take some time -

even a few minutes to think before responding. 

Define the Conflict Define exactly what the conflict is about, and 

limit your discussion to that topic. Bringing up 

unrelated disputes or problems during a conflict 

will not help resolve it and may escalate it. 

Use Effective Use these strategies to maintain effective 

Communication Techniques communication with your crew, even during 

conflict situations. These include: 

• being assertive, not aggressive nor passive 

• asking questions to clarify meaning 

• restating/paraphrasing to check 

understanding 

• objecting to actions, not people 

• controlling emotions 

Generate Solutions Together Work with others to find possible solutions to 

your Problem. Try to find one that will 

contribute to a Win-win outcome if this 

maintains safe and efficient working conditions. 

Conflict Resolution Techniques Page 67 
____________________ 

SUMMARY ~.RM 

Crew Resource Management (CRM) can be an effective tool for 

recognition and resolution of situations where appropriate actions are required to 

meet the needs for safety of operations. CRM promotes safe operations by 

emphasizing the use of available resources to achieve and maintain better 

coordination of activities. The safety of a train crew requires the total 

commitment and dedication, and the attention to duties and proper performance, 

of each and every member. By understanding the human factor issues of CRM, 

including crew member proficiency, situational awareness, communications and 

teamwork, and conflict resolution techniques, job performance can be enhanced 

and safety oftrain operations assured. 

Conflict Resolution Techniques Page 68 
J-1 

APPENDIX J: SOFA-DEFINED SEVERE INJURIES, ADDITIONAL 

INFORMATION 

Table J-1: Information Available for Severe Injuries 

This table is based on FRA Form F 6180.55a, but is not a verbatim description. 

INFORMATION DESCRIPTION

Date and Time: 

Year 

Month 

Day 

Hour 

Minute 

Railroad: 

Railroad name 

Railroad type 

Equipment: 

Equipment movement (Y/N) 

Type of on-track equipment involved 

Geographic Location: 

City 

County 

State 

FRA region 

Identification Number: 

Railroad assigned incident number 

Was an equipment or highway-rail accident incident report also filed? 

If so, linking by incident number can provide additional information 

about casualty event. 

Event Circumstances: 

Actions just prior to injury 

General location of employee prior at time of injury 

Specific location at time of injury 

Event which caused injury 

Additional information about injury (tools, surfaces, etc.) 

Probable cause of injury 

Narrative information (if special circumstances dictate) 

Hazmat exposure 

Injury Description: 

Nature of injury 

Location of injury on body, general 

Location of injury on body, added specificity 

Fatality (Y/N) 

Days away from work 

Days of restricted activity 

Type of Employee: 

Type of person (employee on duty, etc.) 

Employee job occupation 

Age 

Drugs and Alcohol Testing, Other: 

Number of positive alcohol tests 

Number of positive drug tests 

Employee suspension or permanent transfer 
J-2 

Discussion: Using FORM FRA F6180.55a Information about Severe Injuries, and Further 

Analysis, to Better Understand Switching Fatalities 

Existing Potential to Use Severe Injury Information to Better Understand Fatalities 

As mentioned, relationships among switching fatalities and severe injuries are not completely 

understood. But likely some severe injuries could have resulted in a switching fatality. Hence, 

fatality preventive findings may help in reducing severe injuries. A reverse relationship may also 

be true. Because counts of severe injury types are generally higher than those for fatalities, 

severe injury information may also be useful in further understanding fatality issues. This 

possibility was raised by at the SSF. There is however a caution. While some factors important to 

switching fatalities can be identified by severe injury coding, piecing together the complete 

context of injury events presents challenge. 

Information Available to Address SOFA 1-5 

Some information exists in severe injury data based on FORM FRA F6180.55a to analyze SOFA 

1, 2, and 5 (Table J.2). No information exists for job briefings (SOFA 3) or communication 

issues (SOFA 4), unless contained in narratives. 

Table J.2. Information Available from FORM FRA F6180.55a to Address SOFA 1-5 

SOFA 

Recommendations 

Potential 

To 

Partially 

Address 

Comment 

 

SOFA 1 yes 

Physical act coding includes ‘coupling and uncoupling air hoses,’ ‘adjusting 

coupler and drawbar,’ ‘pulling pin lifter/operating uncoupling lever,’ and 

‘opening/closing angle cock.’ Location coding includes ‘between 

cars/locomotives’ 

SOFA 2 yes Type of equipment involved includes whether striking equipment was standing or 

moving. Cannot always infer if equipment was own or another crew’s 

SOFA 3 no No coded information on job briefings 

SOFA 4 no No coded information on communication issues, or signal type (e.g., hand, radio) 

used, or whether communication was proper 

SOFA 5 yes No coded information on years of service. The closest concept is age 

Information Available to Address Close/No Clearance, Struck by Mainline Trains, and 

Industrial Hazards 

Based on FORM FRA F6180.55a some information exists for the three Special Switching 

Hazards (SSH) given emphasis in this SOFA report (Table J.3): Close/No Clearance, Struck by 

Mainline Trains, and Industrial Hazards. 

Table J.3. Information Available from FORM FRA F6180.55a to Address Close/No Clearance, Struck by 

Mainline Trains, and Industrial Hazards 

Special 

Switching 

Hazard 

Abbreviation 

Potential 

to 

Partially 

Address 

Comment 

 

Close/No 

Clearance SSHCC yes 

Injury cause coding includes close or no clearance (#17) and probable 

reason for injury includes ‘failure to provide adequate space between 

equipment during switching operation (#16)’ 
J-3 

Special 

Switching 

Hazard 

Abbreviation 

Potential 

to 

Partially 

Address 

Comment 

Industrial 

Hazard SSHIH yes Track type coding is specific to industry location. Other coding 

identifies event type and circumstances 

Struck by 

Mainline 

Trains 

SSHST yes 

Coding does not provide information on whether a roll-by inspection 

was involved. However, track location coding identifies type of track 

(e.g., main/branch, industry). Type of equipment coding captures 

whether equipment was moving. Location coding identifies whether 

the employee was standing on ground in the vicinity of track 

Information Available to Address Other SSH 

Table J.4 describes information available from FORM FRA F6180.55a related to the other 12 

SSH. 

Table J.4. Information Available from FORM FRA F6180.55a to Address Other Special Switching Hazards 

Special Switching 

Hazard Abbreviation 

Potential

to 

Partially 

Address 

Comment 

 

Derailment SSHDR yes Derailment is an event code (#21) 

Drugs and Alcohol SSHDA yes 

Number of positive alcohol and drug tests is reported. 

Impairment, substance use, is a coding option for probable 

reason for an injury 

Electronic Device 

(Cell phone, P3 

player) 

SSHED no Not reported in coded information 

Employee Tripping, 

Slipping, or Falling SSHET yes Captured in event coding with specificity of object and/or 

condition believed casual 

Environment SSHEV no Weather or atmospheric conditions are not coded 

Equipment Defect SSHEQ no Although event coding does include 

‘defective/malfunctioning equipment’ 

Failure to Confirm 

Route of 

Movement 

SSHFC no Not reported in coded information 

Free-Rolling Railcars SSHFR yes ‘Sudden/unexpected movement of on-track equipment’ is 

coded as an event (#64). But may be difficult to be specific 

Struck or struck by 

Motor Vehicle SSHMV yes Striking vehicle type can be identified (e.g., automobile, 

truck, van). 

Unexpected 

Movement of 

Railcars 

SSHUM yes ‘Sudden/unexpected movement of on-track equipment’ is 

coded as an event (#64). But may be difficult to be specific 

Unsecured Cars SSHUC yes ‘Sudden/unexpected movement of on-track equipment’ is 

coded as an event (#64). But may be difficult to be specific 

Miscellaneous SSHMC yes 

Coded information may identify some miscellaneous events. 

Narrative information may be source of unusual 

circumstances associated with a severe injury 
J-4 

Information Available from FORM FRA F6180.55a) to Address Issues Important to 

Fatality Prevention 

SWG has raised issues related to switching fatalities that are more general than uniquely 

pertaining to SOFA 1-5 and SSH. These issues include atmospheric and climatic conditions, 

crew resource management, fouling track, personal protective equipment, and shoving. Table J.5 

describes information available from FORM FRA F6180.55a for these transcending issues. 

Table J.5. Information Available from FORM FRA F6180.55a to Address Issues Important to Fatality 

Prevention 

SOFA Issues 

Potential

to 

Partially 

Address 

Comment 

 

Atmospheric and climatic 

conditions (e.g., darkness, 

cloudy, weather) 

yes 

Lighting conditions can only be inferred from the time event 

occurred. Weather is not universally coded for each event. Ground 

condition for a tripping, slipped, or fell, stumbled, etc. event is 

sometimes identified 

Car/equipment type yes 

Distinction is made among passenger and freight cars, and 

locomotive. Striking vehicle (e.g., automobile, truck, bus, 

motorcycle) and other equipment (e.g., crane, loaders, construction 

equipment) are also identified 

Crew resource management no No coded information on communication issues 

Employee not on regular 

assignment no Coding does not indicate whether employee was working a regular 

assignment, or in unfamiliar territory, or working regular shift 

Fouling track yes 

Location coding includes ‘alongside of on-track equipment-on 

ground;’ ‘track, beside;’ ‘track, between;’ ‘track, on;’ and ’on 

highway-rail crossing’ 

General alertness, drugs and 

alcohol, and fatigue yes 

Alertness can be generally indicated by ‘human factor’ as a probable 

reason for injury/illness. General alertness ‘impairment, physical, 

e.g., fatigue’ is a coding option for probable reason for an 

injury/illness 

Holidays, winter, and other 

periods of potential for 

increased risk 

yes 

Event date is coded. Evaluation of clustering can be made by month, 

day-of-week, time-of-day, and holidays. For comparison, states can 

be grouped to include the likelihood of winter and non-winter 

conditions 

Personal protective 

equipment (PPE) yes Probable reason for injury/illness can include ‘safety equipment not 

worn or in place’ 

Remotely controlled 

locomotive (s) yes 

About 20 probable reason injury codes pertain to RCL. Coding 

differentiates whether probable reason for injury is ‘related to using 

RCL’ or ‘unrelated to using RCL’ 

Road crews coming in and 

out of yards yes Job code (e.g., 609-local freight conductors; 617-through freight 

engineers) and location (e.g., yard) identify these crew members 

Second hour on duty yes Start time for an employee is not coded 

Shoving yes Direction of movement is not coded 
J-5 

New Data Items Potentially Useful to SOFA 

SWG’s understanding of severe injury events could be enhanced by additional information not 

contained in FORM FRA F6180.55a. These items include, but are not limited to: 

Item: Employee’s start date for calculating years of service 

Comment: Additional emphasis on SOFA 5 (less experienced employees) is needed 

for fatality prevention. Such emphasis may also be needed for severe injuries 

Item: Start time for duty 

Comment: For fatalities, SWG has observed a spike in the second hour of duty. 

Determination could be made if time-on-duty is also related to some types of severe 

injuries, thus providing a target for prevention 

Item: SWG-created PCFs as an option in coding injury cause 

Comment: Some examples of frequently occurring SWG-created PCFs are H316 

(Poor intra-crew communication about work in progress), H997 (Failure to provide 

adequate space between equipment), H317 (Failure to communicate unsafe 

condition), and H211 (Radio communication, improper). These and other PCF codes 

could help in understanding injury events and relationships to switching fatalities 

Item: Use of the narrative option to include SOFA issues 

Comment: In writing narratives, coders can partner with SWG in identifying where 

SOFA 1-5 and SSH, and other SOFA issues are potentially involved

Suggestions for Further Analysis of Severe Injuries 

Even without new data items, SWG believes discussion of severe injury prevention should 

proceed based on existing information, and analytical methods for better utilizing this 

information. One such method is use of existing narratives. SWG used the narrative form when 

PCF and external circumstance coding could not capture all information associated with a 

fatality. As well, SWG performed this type of analysis, but on a limited basis, in its 2001 injury 

report. Railroads are encouraged to use narratives when coding cannot capture all aspects of an 

injury event. Narratives contained in FORM FRA F6180.55a information could be analyzed for 

implicit indications of SOFA 1-5, SSH, and other SOFA-related issues. 

Additionally, if a rail equipment accident (FRA FORM 6180.54) and/or highway rail accident 

(FRA FORM 6180.54) report was also filed in addition to the casualty report, linking could 

provide additional information about the casualty event. However, in most casualty cases, events 

do require these additional reports because property damage, if at all, was below the reporting 

threshold, or a grade-crossing location was not involved. 

Discussion: Selective Attributes and Track Location 

Severe Injuries by Selective Attributes and Track Location 

The 1,522 severe injuries, occurring 1992 through 2009, are displayed in Table J.6 by frequency 

for 14 attributes classified by 7 track locations: yard, main/branch line, industry, siding, 

highway/roadway, passenger terminal, and other. As an example, severe injuries are shown 

(Table J.6) for the attribute ‘job code’ for T&E employees by the seven track locations. The 

other 13 attributes are, by order of presentation: injury type, injury location, year, month, day, 

time of day, age, assigned cause of injury, activity, injury event, equipment location, working 
J-6 

location, and surface struck causing injury [tools, machinery, appliances, structures, surfaces 

(etc.)]. 

Information contained in Table J.6. and subsequent Table J.7, appeared in the 2001 SOFA Injury 

Report (with 446 severe injuries, 1997 through March 31, 2000), and the 2004 SOFA Report 

(with 929 severe injuries, 1997 through 2003); and are included herein (with 1,522 severe 

injuries, 1997 through 2009) for continuity with SWG’s goal to eliminate this harm to T&E 

employees. 

Table J.7 breaks out the severe injuries that occurred just to T&E employees classified as yard 

and road crews at four track locations (yard, mainline/branch line, industry, and siding). Job 

codes for these yard and road crews are: 

Yard crews: 619-engineers, 623-firemen, 603-hostlers, 601-switch tenders, 614-conductors, 

and 615-brakemen 

Road crews: 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. 

Statements about Severe Injuries by Selective Attributes and Track Location 

The following observations, drawn from information presented in Tables J.6 and J.7, serve as 

examples of how severe injury information might be instructive in trying to understand these 

injury events. Other observations are possible. 

Observations made are noted as based on either Table J.6, or a more restricted number of job 

codes and track locations in Table J.7. This latter table was created to identify the main locations 

where yard and road employees were being injured. As a possible counter-intuitive example, 

about 39 percent of road employees were injured at yard locations. 

As mentioned above, severe injuries declined, 1997 through 2009. This decline was 

particularly apparent among yard and main/branch line locations in 2008, and continuing into 

2009. From Table J.6. 

Declines in severe injuries were not as noticeable among other track locations, although 

counts at these locations are smaller. There was not any apparent large shift in the proportion 

of severe injuries from one, or more, track locations to another. From Table J.6. 

49 percent of severe injuries occurred in yards, considerably smaller than the percentage (12 

percent) occurring in industry. From Table J.6. 

By month, there was variation in severe injury occurrence among track locations. In yards, 

January had the highest number of severe injuries (95). The lowest month for injuries (43) in 

yards was May. On main/ branch line, February had the highest number of injuries (43), with 

November also being high (42). The lowest month for injuries (26) on main/ branch line was 

July; but April, September, and October also had lower injuries (respectively, 29, 27, and 

29). From Table J.6. 

For days of the week, generally for all track locations, Monday’s through Friday’s had larger 

numbers of severe injuries. But the daily pattern varied among track location. From Table 

J.6. 
J-7 

More severe injuries (82) occurred in the first hour after midnight than during any other time 

of the day or night, representing 5 percent of all injuries. From Table J.6. 

Yard, main/branch line, and industry were track locations experiencing the largest number of 

amputations (respectively, 128, 34, and 28). From Table J.6.

44 percent of severe injuries occurred to employees between the ages of 45 and 56. 

Employees between the ages of 57 and 62 experienced 15 percent of severe injuries. From 

Table J.6. 

Most severe injuries involved fractures (83 percent). Amputations were involved in 13 

percent of these injuries. Thus, together, these injury types involved 96 percent of all injuries. 

From Table J.6. 

Most severe injuries (85 percent) occurred to the legs, foot, and torso. From Table J.6. 

45 percent of severe injuries had an assigned cause of injury as human factors. 11 percent of 

injuries had an assigned cause of injury as environmental. Table J.6. 

Ground was the most common surface involving an injury (28 percent), with ballast, stones, 

etc. the second highest (10 percent). Table J.6. 

39 percent (336 of 855) of severe injuries to road T&E employees occurred in yards. From 

Table J.7. 

Road T&E employees sustained just 19 fewer severe injuries in yards than yard T&E 

employees in yards (336 v. 355). From Table J.7. 

Severe injuries to yard train-service employees (mainly engineers) represented 12 percent (44 

of 355) of all yard severe injuries, compared to 25 percent (88 of 355) for road train-service 

employees (all engineers), about doubled. From Table J.7. 

Road train-service employees incurred about 3.8 times as many severe injuries as yard trainservice engineers (223/58). From Table J.7. 

Road T&E employees sustained 64 percent (885 of 1,335) of all severe injuries, v. 36 percent 

(480 of 1,335) for yard T&E employees. From Table J.7. 
J-8 

yardmain/branch lineindustrysidinghighway/roadwaypassenger terminalotherrow totalrow percent 

JOB CODE

conductor, yard-614 172 17 43 2 0 0 4 238 15.6%

conductor, road freight-608 78 123 15 16 18 0 12 262 17.2%

brakeman, yard-615 131 14 25 2 0 0 8 180 11.8%

conductor, road freight local-609 67 48 47 17 0 0 3 182 12.0%

engineer, road freight-617 43 77 2 14 14 0 6 156 10.2%

brakeman, road freight local-613 53 35 24 9 3 0 2 126 8.3%

engineer, yard-619 39 7 5 2 4 0 2 59 3.9%

conductor, road passenger-606 27 23 0 0 1 8 4 63 4.1%

brakeman, road freight through-612 16 9 8 5 1 0 0 39 2.6%

engineer, road freight-618 24 15 5 4 3 0 3 54 3.5%

engineer, road passenger-616 21 17 0 1 0 5 1 45 3.0%

conductor, asst. road passenger-607 7 5 0 0 0 12 2 26 1.7%

switch tender-601 8 4 4 0 0 0 0 16 1.1%

hostler, outside-603 4 0 0 0 0 0 1 5 0.3%

brakeman, lead passenger-611 3 2 0 0 0 0 0 5 0.3%

miscellaneous-600 6 4 2 1 0 1 2 16 1.1%

fireman, yard-623 1 0 0 0 0 0 1 2 0.1%

hostler, inside-605 1 0 0 0 0 0 0 1 0.1%

RCL operator, operating-630 19 0 4 0 0 0 0 23 1.5%

RCL operator, not operating-631 19 0 1 1 0 0 0 21 1.4%

other 2 1 0 0 0 0 0 3 0.2%

column total 741 401 185 74 44 26 51 1522

column percent 49% 26% 12% 5% 3% 2% 3% 100.0%

INJURY TYPE

fracture-70 588 351 147 64 43 23 47 1263 83.0%

amputation-80 128 34 28 7 0 2 2 201 13.2%

other burns-50 19 10 10 3 0 1 2 45 3.0%

electric shock/burns-40 5 5 0 0 0 0 0 10 0.7%

dislocation-60 1 1 0 0 1 0 0 3 0.2%

column total 741 401 185 74 44 26 51 1522

column percent 49% 26% 12% 5% 3% 2% 3% 100.0%

Table J.6

1,522 SOFA-defined Severe Injuries

by 14 Attributes and 7 Track Locations 

January 1, 1997 to December 31, 2009
J-9 

yardmain/branch lineindustrysidinghighway/roadwaypassenger terminalotherrow totalrow percent 

INJURY LOCATION

leg or foot 410 190 104 36 7 12 28 787 51.7%

torso 223 145 53 26 27 9 17 500 32.9%

arm or hand 63 31 16 4 3 4 3 124 8.1%

head or face 41 27 11 5 4 1 3 92 6.0%

various body parts-equal severity 4 8 0 3 3 0 0 18 1.2%

unknown 0 0 1 0 0 0 0 1 0.1%

column total 741 401 185 74 44 26 51 1522

column percent 49% 26% 12% 5% 3% 2% 3% 100.0%

YEAR

1997 72 28 23 5 4 1 6 139 9.1%

1998 66 32 18 12 3 0 6 137 9.0%

1999 67 31 16 6 4 3 8 135 8.9%

2000 73 39 18 1 3 4 1 139 9.1%

2001 73 34 17 9 3 1 3 140 9.2%

2002 59 35 12 7 2 5 3 123 8.1%

2003 54 39 8 5 6 0 2 114 7.5%

2004 47 40 19 3 5 5 4 123 8.1%

2005 59 39 10 8 2 0 4 122 8.0%

2006 50 30 11 6 1 1 1 100 6.6%

2007 57 26 12 4 4 1 6 110 7.2%

2008 40 17 14 6 4 3 3 87 5.7%

2009 24 11 7 2 3 2 4 53 3.5%

column total 741 401 185 74 44 26 51 1522

column percent 49% 26% 12% 5% 3% 2% 3% 100.0%

MONTH

Jan 95 30 22 8 5 3 10 173 11.4%

Feb 78 43 9 8 3 1 8 150 9.9%

Mar 63 37 19 3 3 2 9 136 8.9%

Apr 55 29 15 3 6 2 3 113 7.4%

May 45 31 11 4 3 3 3 100 6.6%

Jun 43 32 13 3 6 1 4 102 6.7%

Jul 48 26 20 8 1 1 0 104 6.8%

Aug 60 41 15 7 3 2 1 129 8.5%

Sep 69 27 18 6 3 6 0 129 8.5%

Oct 54 29 11 11 5 1 4 115 7.6%

Nov 59 42 13 6 4 2 3 129 8.5%

Dec 72 34 19 7 2 2 6 142 9.3%

column total 741 401 185 74 44 26 51 1522

column percent 49% 26% 12% 5% 3% 2% 3% 100.0%

Table J.6

1,522 Severe Injuries

by 14 Attributes and 7 Track Locations (cont.)

January 1, 1997 to December 31, 2009
J-10 

 yard main/branch line industry siding highway/roadway passenger terminal

otherrow totalrow percent 

DAY

Sunday 93 36 12 8 1 5 7 162 10.6%

Monday 110 57 29 17 10 2 3 228 15.0%

Tuesday 110 81 34 10 3 2 9 249 16.4%

Wednesday 114 54 24 10 8 7 10 227 14.9%

Thursday 111 67 33 12 6 7 8 244 16.0%

Friday 108 56 33 3 8 1 8 217 14.3%

Saturday 95 50 20 14 8 2 6 195 12.8%

column total 741 401 185 74 44 26 51 1522

column percent 49% 26% 12% 5% 3% 2% 3% 100.0%

TIME OF DAY

00:00-01:00 37 23 11 3 6 0 2 82 5.4%

01:01-02:00 37 16 7 3 4 0 1 68 4.5%

02:01-03:00 34 18 5 3 2 0 1 63 4.1%

03:01-04:00 41 24 5 2 3 1 2 78 5.1%

04:01-05:00 28 11 1 3 2 1 2 48 3.2%

05:01-06:00 17 13 6 5 2 1 4 48 3.2%

06:01-07:00 11 19 3 1 1 0 5 40 2.6%

07:01-08:00 20 16 2 5 2 3 4 52 3.4%

08:01-09:00 33 16 9 2 2 1 1 64 4.2%

09:01-10:00 40 18 9 3 1 1 4 76 5.0%

10:01-11:00 25 14 11 5 2 1 2 60 3.9%

11:01-12:00 25 20 14 2 1 1 3 66 4.3%

12:01-13:00 36 18 15 4 1 0 1 75 4.9%

13:01-14:00 23 13 19 1 2 0 1 59 3.9%

14:01-15:00 31 22 4 1 1 1 3 63 4.1%

15:01-16:00 27 17 8 4 1 2 0 59 3.9%

16:01-17:00 34 21 7 3 0 1 1 67 4.4%

17:01-18:00 37 15 8 4 4 3 1 72 4.7%

18:01-19:00 36 15 12 3 1 2 3 72 4.7%

19:01-20:00 36 15 6 2 1 2 2 64 4.2%

20:01-21:00 36 16 5 4 0 2 3 66 4.3%

21:01-22:00 37 18 8 7 2 1 2 75 4.9%

22:01-23:00 36 11 3 2 3 1 1 57 3.7%

23:01-24:00 24 12 7 2 0 1 2 48 3.2%

column total 741 401 185 74 44 26 51 1522

column percent 49% 26% 12% 5% 3% 2% 3% 100.0%

Table J.6

1,522 Severe Injuries

by 14 Attributes and 7 Track Locations (cont.)

January 1, 1997 to December 31, 2009
J-11 

yardmain/branch lineindustrysidinghighway/roadwaypassenger terminalotherrow totalrow percent 

AGE

15-20 2 2 0 0 0 0 1 5 0.3%

21-26 43 13 16 4 1 0 0 77 5.1%

27-32 85 40 26 9 2 2 5 169 11.1%

33-38 103 50 15 4 5 5 4 186 12.2%

39-44 77 50 18 7 11 4 7 174 11.4%

45-50 138 87 40 16 10 6 17 314 20.6%

51-56 156 97 44 23 6 6 6 338 22.2%

57-62 118 57 23 10 8 3 10 229 15.0%

63-68 18 4 3 1 1 0 1 28 1.8%

69-74 1 1 0 0 0 0 0 2 0.1%

column total 741 401 185 74 44 26 51 1522

column percent 49% 26% 12% 5% 3% 2% 3% 100.0%

ASSIGNED CAUSE OF INJURY

human factors 327 191 68 36 25 17 18 682 44.8%

undetermined 167 112 54 18 11 2 11 375 24.6%

environmental 79 30 22 10 7 4 18 170 11.2%

equip procedures not followed 71 25 16 2 0 1 2 117 7.7%

equipment 36 19 9 1 0 1 0 66 4.3%

track 5 7 6 2 0 0 0 20 1.3%

physical condition 5 3 1 1 0 0 0 10 0.7%

no safety equip 0 1 2 3 0 0 0 6 0.4%

trespassing 1 4 0 0 0 0 0 5 0.3%

substance use 0 1 0 0 0 0 0 1 0.1%

other 50 8 7 1 1 1 2 70 4.6%

column total 741 401 185 74 44 26 51 1522

column percent 49% 26% 12% 5% 3% 2% 3% 100.0%

Table J.6

1,522 Severe Injuries

by 14 Attributes and 7 Track Locations (cont.)

January 1, 1997 to December 31, 2009
J-12 

yardmain/branch lineindustrysidinghighway/roadwaypassenger terminalotherrow totalrow percent 

ACTIVITY

walking 208 104 48 21 3 7 22 413 27.1%

riding 98 63 0 10 34 0 1 206 13.5%

getting off 79 38 21 8 0 2 1 149 9.8%

stepping down 47 31 11 10 0 4 6 109 7.2%

standing 34 21 13 2 1 3 4 78 5.1%

operating 13 27 2 2 1 0 1 46 3.0%

repairing 1 0 45 0 0 0 0 46 3.0%

getting on 24 7 4 1 0 2 0 38 2.5%

jumping from 12 20 4 1 0 0 0 37 2.4%

climbing over/on 17 7 6 4 0 0 1 35 2.3%

lining switches 15 6 3 1 0 0 0 25 1.6%

handbrakes, applying 15 1 3 2 0 0 2 23 1.5%

pulling pin/uncoupling 17 2 2 2 0 0 0 23 1.5%

coupling air hose 19 0 0 1 0 0 0 20 1.3%

crossing over 14 3 1 2 0 0 0 20 1.3%

adjusting coupler 17 0 2 0 0 0 0 19 1.2%

closing 8 6 1 0 0 2 0 17 1.1%

sitting 6 7 0 0 2 0 2 17 1.1%

stepping 11 3 1 0 0 0 1 16 1.1%

opening 5 10 0 0 0 0 0 15 1.0%

handbrakes, releasing 9 0 1 2 0 0 0 12 0.8%

stepping over 7 5 0 0 0 0 0 12 0.8%

adjusting, other 7 0 0 0 0 0 1 8 0.5%

inspecting 3 4 1 0 0 0 0 8 0.5%

reaching 4 0 3 0 0 0 1 8 0.5%

handling other 1 4 1 0 0 1 0 7 0.5%

running 4 1 0 1 0 1 0 7 0.5%

bending, stooping 1 0 2 0 0 1 1 5 0.3%

driving (vehicle...) 1 0 0 0 3 0 1 5 0.3%

coupling electric cables 2 1 0 0 0 0 1 4 0.3%

crossing between 2 1 1 0 0 0 0 4 0.3%

opening/closing angle cock 1 2 1 0 0 0 0 4 0.3%

pulling 3 0 0 0 0 0 0 3 0.2%

handling car parts 2 0 0 0 0 0 0 2 0.1%

jumping onto 0 1 1 0 0 0 0 2 0.1%

pushing 2 0 0 0 0 0 0 2 0.1%

uncoupling air hose 1 0 0 0 0 0 1 2 0.1%

flagging 0 1 0 0 0 0 0 1 0.1%

handling loc parts 0 1 0 0 0 0 0 1 0.1%

handling material, general 1 0 0 0 0 0 0 1 0.1%

welding 0 1 0 0 0 0 0 1 0.1%

other 30 23 7 4 0 3 4 71 4.7%

column total 741 401 185 74 44 26 51 1522

column percent 49% 26% 12% 5% 3% 2% 3% 100.0%

Table J.6

1,522 Severe Injuries

by 14 Attributes and 7 Track Locations (cont.)

January 1, 1997 to December 31, 2009
J-13 

yardmain/branch lineindustrysidinghighway/roadwaypassenger terminalotherrow totalrow percent 

INJURY EVENT

slipped, fell, stumbled, other 110 47 23 13 1 2 6 202 13.3%

slipped, fell, stumbled, etc. due to object 81 57 17 7 2 3 1 168 11.0%

slipped, fell, stumbled, etc. due to climatic condition 77 25 13 11 0 1 21 148 9.7%

lost balance 55 25 14 4 0 4 1 103 6.8%

slipped, fell, stumbled, etc. due to irregular surface 44 30 13 8 0 2 5 102 6.7%

struck by on-track equipment 73 14 9 3 0 0 1 100 6.6%

collision between on-track equipment 21 46 3 0 0 0 1 71 4.7%

struck against object 25 6 16 1 0 2 1 51 3.4%

missed handhold, grabiron, step, etc. 28 7 6 6 0 0 1 48 3.2%

collision/impact-auto, truck, bus, van, etc. 3 2 0 0 33 0 0 38 2.5%

sudden/unexpected movement of on-track equipment 21 8 5 0 0 0 1 35 2.3%

caught, crushed, pinched, other 22 9 3 0 0 0 0 34 2.2%

derailments 13 11 6 1 0 0 0 31 2.0%

slack action, draft, compressive buff/coupling 19 9 2 1 0 0 0 31 2.0%

stepped on object 18 8 3 1 0 0 1 31 2.0%

highway-rail collision/impact 1 24 5 0 0 0 0 30 2.0%

struck by object 8 11 7 0 1 0 1 28 1.8%

exposure to chemicals-external 9 5 5 0 0 1 0 20 1.3%

slipped, fell, stumbled, etc. on oil, grease 12 3 1 2 0 1 1 20 1.3%

overexertion 8 3 2 1 0 1 0 15 1.0%

sudden, unexpected movement, other 7 4 2 0 0 1 0 14 0.9%

bodily function/sudden movement, e.g., sneezing 5 5 0 0 0 1 0 11 0.7%

caught in or crushed by materials 5 4 1 1 0 0 0 11 0.7%

defective/malfunctioning equipment 7 2 2 0 0 0 0 11 0.7%

sudden/unexpected movement of vehicle 2 1 0 0 5 0 1 9 0.6%

slack adjustment during switching operation 4 3 2 0 0 0 0 9 0.6%

assaulted by other 0 4 0 0 0 3 0 7 0.5%

caught in or compressed by power hand tools 1 0 0 6 0 0 0 7 0.5%

other impacts-on track equipment 3 2 1 1 0 0 0 7 0.5%

ran into object/equipment 5 0 1 1 0 0 0 7 0.5%

sudden/unexpected movement of material 3 1 2 0 0 0 1 7 0.5%

on track equipment, other incidents 5 1 1 0 0 0 0 7 0.5%

caught in or compressed by other machinery 2 2 0 0 0 0 1 5 0.3%

pushed/shoved into/against 1 2 1 1 0 0 0 5 0.3%

ran into on-track equipment 2 2 0 1 0 0 0 5 0.3%

struck by falling object 1 1 2 0 0 0 1 5 0.3%

struck by thrown or propelled object 2 0 2 0 0 0 0 4 0.3%

struck by own remote control locomotive controlled equipment 2 0 1 0 0 0 0 3 0.2%

electric shock due to contact with 3rd rail... 2 0 0 0 0 0 0 2 0.1%

repetitive motion-work processes 1 0 0 0 0 0 0 1 0.1%

rubbed, abraded, etc. 1 0 0 0 0 0 0 1 0.1%

bumped 1 0 0 0 0 0 0 1 0.1%

other (describe in narrative) 19 10 9 0 2 0 0 40 2.6%

other 12 7 5 4 0 4 5 37 2.4%

column total 741 401 185 74 44 26 51 1522

column percent 49% 26% 12% 5% 3% 2% 3% 100.0%

Table J.6

1,522 Severe Injuries

by 14 Attributes and 7 Track Locations (cont.)

January 1, 1997 to December 31, 2009
J-14 

yardmain/branch lineindustrysidinghighway/roadwaypassenger terminalotherrow totalrow percent 

EQUIPMENT LOCATION

freight car moving 162 27 55 9 0 0 3 256 16.8%

other non-equip 112 65 29 10 6 6 28 256 16.8%

freight train moving 76 97 36 13 1 0 0 223 14.7%

freight train standing 97 70 15 15 0 0 3 200 13.1%

locomotive standing 105 48 13 14 0 3 7 190 12.5%

freight car standing 87 22 28 10 0 0 3 150 9.9%

locomotive moving 49 29 4 2 0 0 1 85 5.6%

pass train standing 16 8 0 0 0 12 0 36 2.4%

pass train moving 3 21 0 0 0 3 1 28 1.8%

auto 6 0 0 0 9 0 2 17 1.1%

van passenger 1 1 0 0 14 0 1 17 1.1%

taxi 0 0 0 0 14 0 0 14 0.9%

pass car standing 6 2 0 0 0 2 1 11 0.7%

loaders, etc. 1 0 2 0 0 0 1 4 0.3%

truck 1 1 1 0 0 0 0 3 0.2%

other equip 1 1 0 0 0 0 0 2 0.1%

other on-track equip standing 1 1 0 0 0 0 0 2 0.1%

crane 0 1 0 0 0 0 0 1 0.1%

other on-track equip moving 0 0 1 0 0 0 0 1 0.1%

other 17 7 1 1 0 0 0 26 1.7%

column total 741 401 185 74 44 26 51 1522

column percent 49% 26% 12% 5% 3% 2% 3% 100.0%

Table J.6

1,522 Severe Injuries

by 14 Attributes and 7 Track Locations (cont.)

January 1, 1997 to December 31, 2009
J-15 

yardmain/branch lineindustrysidinghighway/roadwaypassenger terminalotherrow totalrow percent 

WORKING LOCATION

beside track 132 61 45 13 2 0 4 257 16.9%

near on-track equip-on ground 141 58 36 11 0 0 5 251 16.5%

in/on loc 94 112 8 16 0 1 4 235 15.4%

on side of car 104 25 42 10 1 1 2 185 12.2%

on end of car 49 15 19 7 0 1 1 92 6.0%

between cars/loc 42 9 7 2 0 0 2 62 4.1%

other location on loc 31 18 4 5 0 0 3 61 4.0%

between tracks 41 6 5 0 0 0 1 53 3.5%

at work station 16 11 0 0 1 10 13 51 3.4%

on track 27 9 2 4 0 0 42 2.8%

on platform 8 14 5 0 0 7 3 37 2.4%

in/operating vehicle 1 1 0 0 34 0 1 37 2.4%

on stairs 10 13 2 1 0 3 5 34 2.2%

on ladder 20 4 2 3 0 0 1 30 2.0%

in car 5 14 1 1 3 2 26 1.7%

on highway-rail crossing 1 11 3 0 3 0 18 1.2%

on bridge/trestle 3 13 1 0 0 0 17 1.1%

other location 11 0 2 0 0 0 3 16 1.1%

under car 1 1 1 0 0 0 3 0.2%

under loc 1 0 0 0 0 0 1 2 0.1%

in tower 0 0 0 0 0 0 1 1 0.1%

other 3 6 0 1 0 1 1 12 0.8%

column total 741 401 185 74 44 26 51 1522

column percent 49% 26% 12% 5% 3% 2% 3% 100.0%

Table J.6

1,522 Severe Injuries

by 14 Attributes and 7 Track Locations (cont.)

January 1, 1997 to December 31, 2009
J-16 

yardmain/branch lineindustrysidinghighway/roadwaypassenger terminalotherrow totalrow percent 

TOOLS, MACHINERY, APPLIANCES, 

STRUCTURES, SURFACES (ETC.)

ground 237 102 56 19 1 2 1 418 27.5%

ballast, stones, etc. 82 57 0 10 0 0 4 153 10.1%

ladder 36 12 14 6 0 0 17 85 5.6%

step/stirrup, equipment 48 8 7 5 0 0 0 68 4.5%

floor 14 24 2 3 2 2 4 51 3.4%

highway, street, road 2 14 3 0 27 0 0 46 3.0%

grabiron 28 9 4 2 0 0 1 44 2.9%

stair step 16 16 1 2 0 2 6 43 2.8%

coupler 30 4 7 1 0 0 0 42 2.8%

platform 16 6 3 4 0 8 2 39 2.6%

locomotive, other 15 16 2 5 0 1 0 39 2.6%

door 14 16 1 0 0 4 1 36 2.4%

switch 21 3 5 4 0 0 0 33 2.2%

tie 17 5 3 3 0 0 0 28 1.8%

baggage 4 1 17 0 0 1 0 23 1.5%

track (rail) 14 6 1 1 0 0 0 22 1.4%

motor vehicle, non rail 2 5 2 0 12 0 0 21 1.4%

bridge/trestle 3 14 1 0 0 0 0 18 1.2%

chair/seat 4 10 0 0 1 1 1 17 1.1%

handbrake 11 0 2 0 0 1 0 14 0.9%

chemicals, fumes, etc. 5 3 4 0 0 0 1 13 0.9%

hose 7 4 1 0 0 0 0 12 0.8%

locomotive cab floor 3 6 0 0 0 0 1 10 0.7%

spike, tie plates, rail fasteners, etc. 2 3 1 0 0 0 0 6 0.4%

derail 3 2 0 0 0 0 5 0.3%

end of train device 3 1 0 1 0 0 0 5 0.3%

lever 2 2 0 0 0 0 0 4 0.3%

fusees/torpedoes 2 0 1 0 0 0 0 3 0.2%

window 2 1 0 0 0 0 0 3 0.2%

caboose 1 1 0 0 0 0 0 2 0.1%

trailer/container on flat car (TOFC, COFC) 1 1 0 0 0 0 0 2 0.1%

cable 1 0 1 0 0 0 0 2 0.1%

rock, other than ballast 1 0 1 0 0 0 0 2 0.1%

remote control transmitter 2 0 0 0 0 0 0 2 0.1%

hand tools, striking & nailing, e.g., hammers, mallets 1 0 0 0 0 0 0 1 0.1%

hose connections 1 0 0 0 0 0 0 1 0.1%

signal equipment (gates, poles, gaffs, etc.) 1 0 0 0 0 0 0 1 0.1%

MOW equipment 1 0 0 0 0 0 0 1 0.1%

locomotive cab seat 1 0 0 0 0 0 0 1 0.1%

other (describe in narrative) 81 37 38 5 0 2 10 173 11.4%

other 9 11 5 3 1 2 2 33 2.2%

column total 741 401 185 74 44 26 51 1522

column percent 49% 26% 12% 5% 3% 2% 3% 100.0%

Table J.6

1,522 Severe Injuries

by 14 Attributes and 7 Track Locations (cont.)

January 1, 1997 to December 31, 2009
J-17 

Job Code yard main or 

branch line industry siding TOTAL

TRAIN SERVICE

Conductor, road freight-608 78 123 15 16 232

Conductor, road freight local-609 67 48 47 17 179

Brakeman, road freight through-612 16 9 8 5 38

Brakeman, road freight local-613 53 35 24 9 121

Conductor, road passenger-606 27 23 0 0 50

Conductor, assist. road passenger-607 7 5 0 0 12

Total for Road 248 243 94 47 632

Conductor, yard-614 172 17 43 2 234

Brakeman, yard-615 131 14 25 2 172

Switch tender-601 8 4 4 0 16

Total for Yard 311 35 72 4 422

Total for Road and Yard 559 278 166 51 1054

ENGINE SERVICE

Engineer, road through freight-617 43 77 2 14 136

Engineer, road passenger-616 21 17 0 1 39

Engineer, road local freight-618 24 15 5 4 48

Total for Road 88 109 7 19 223

Engineer, yard-619 39 7 5 2 53

Fireman, yard-623 1 0 0 0 1

Hostler, outside-603 4 0 0 0 4

Total for Yard 44 7 5 2 58

Total for Road and Yard 132 116 12 21 281

ROAD: TOTAL for TRAIN and ENGINE 336 352 101 66 855

YARD:TOTAL for TRAIN AND ENGINE 355 42 77 6 480

GRAND TOTAL 691 394 178 72 1335

Table J.7. Severe Injuries by Selective Job Codes and Track Locations

1997 through 2009
J-18 

Table J.8 SOFA-defined Severe Injuries by Track Type and Year, 1997 through 2009 Year Yard

Main/BranchIndustrialSidingsHighway/Rail CrossingPassenger TerminalOtherTotal

1997 72 28 23 5 4 1 6 139

1998 66 32 18 12 3 0 6 137

1999 67 31 16 6 4 3 8 135

2000 73 39 18 1 3 4 1 139

2001 73 34 17 9 3 1 3 140

2002 59 35 12 7 2 5 3 123

2003 54 39 8 5 6 0 2 114

2004 47 40 19 3 5 5 4 123

2005 59 39 10 8 2 0 4 122

2006 50 30 11 6 1 1 1 100

2007 57 26 12 4 4 1 6 110

2008 40 17 14 6 4 3 3 87

2009 24 11 7 2 3 2 4 53

1,522
J-19 

Table J.9 SOFA-defined Severe Injuries classified by FRA Event Codes, By 12 Event Categories, 1997 

through 2009 

Event Definintion FRA 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 total percent

Event

Code (s)

slip, fell, stumbled, etc. 51, 52, 53, 54, 70 46 45 60 70 47 58 52 41 54 48 53 41 25 640 42.0%

lost balance 34 11 12 13 11 11 9 7 8 4 7 5 2 3 103 6.8%

struck by on-track equipment 59 11 12 5 5 11 8 11 5 8 4 10 8 2 100 6.6%

collision-between on-track equipment 17 10 6 3 3 9 5 8 7 10 6 1 8 1 77 5.1%

struck against object 61 3 9 5 7 7 6 4 4 2 1 3 0 1 52 3.4%

mis s ed h and ho ld , g rabiron , s tep , etc. 35 8 5 6 4 7 5 2 3 3 0 1 2 2 48 3.2%

caught, crushed, pinched, other 68 0 3 2 7 6 4 1 5 4 1 5 2 1 41 2.7%

sudden/unexpected movement of on-track equipment 64 3 5 3 1 2 2 3 3 6 1 2 2 2 35 2.3%

slack action, draft, compressive buff/coupling 50 4 3 5 1 2 2 0 6 2 0 5 0 1 31 2.0%

derailment 21 2 2 2 3 4 1 4 4 2 3 2 2 0 31 2.0%

high way-rail collis ion /imp act 32 2 2 3 5 1 3 2 2 2 3 2 2 1 30 2.0%

A LL OTHER EVENTS all o t h er co d es 39 33 28 22 33 20 20 35 25 26 21 18 14 334 21.9%

139 137 135 139 140 123 114 123 122 100 110 87 53 1,522 100.0%
J-20 

Table J.10 1,546 Severe Injuries by State and Year, Ranked by State Occurrence, 1997 through April 2010 

JANAPR cumulative

# state 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 total percent

1 TX 14 9 11 17 15 12 10 9 10 8 11 2 1 3 132 9%

2 IL 9 11 10 10 17 9 7 10 8 9 8 8 6 1 123 16%

3 CA 7 10 8 4 13 10 9 10 10 6 5 7 1 1 101 23%

4 OH 7 9 7 6 4 7 8 6 8 7 4 4 5 0 82 28%

5 NY 6 8 6 9 9 5 4 7 5 7 7 2 2 2 79 33%

6 PA 7 5 8 9 5 7 3 5 4 5 5 4 3 2 72 38%

7 IN 6 5 4 6 1 1 6 5 2 5 8 5 2 1 57 42%

8 NE 1 7 1 2 3 0 5 3 8 5 2 1 2 2 42 45%

9 IA 4 4 1 3 6 3 2 3 6 1 2 5 0 0 40 47%

10 KY 7 5 4 2 0 2 4 4 3 3 2 1 3 0 40 50%

11 LA 3 5 2 5 3 5 5 3 2 1 4 1 0 0 39 52%

12 WA 0 3 4 8 4 2 1 3 4 3 3 2 1 0 38 55%

13 WI 9 3 2 5 1 4 3 2 2 2 1 2 1 0 37 57%

14 GA 1 3 3 3 3 4 5 2 5 2 1 1 3 0 36 59%

15 KS 6 3 3 1 4 2 2 1 2 0 4 4 2 1 35 62%

16 MI 1 3 6 4 4 2 1 6 1 1 1 2 1 2 35 64%

17 VA 4 5 1 2 4 5 1 1 3 1 3 3 0 0 33 66%

18 AL 0 4 1 3 1 6 3 2 2 2 4 2 2 0 32 68%

19 MO 1 2 3 3 4 1 3 4 4 5 0 2 0 0 32 70%

20 AR 1 1 4 3 4 3 3 2 3 2 1 3 0 0 30 72%

21 CO 5 0 3 2 3 1 2 1 2 4 4 2 0 1 30 74%

22 MN 4 3 2 2 3 4 0 2 2 1 5 1 0 1 30 76%

23 FL 2 4 4 1 2 0 2 6 3 1 0 3 1 0 29 78%

24 TN 2 0 2 4 3 2 2 4 3 1 1 3 1 0 28 80%

25 NJ 3 0 3 3 4 1 4 1 2 4 1 0 1 0 27 81%

26 OR 3 0 5 1 0 3 3 2 1 2 1 0 2 0 23 83%

27 MA 1 1 2 3 2 4 0 2 1 0 0 1 2 1 20 84%

28 WY 2 3 4 1 1 0 0 0 1 1 3 1 3 0 20 86%

29 AZ 4 0 1 3 0 2 0 2 1 2 4 0 0 0 19 87%

30 MS 4 0 0 1 3 1 0 0 5 1 0 1 1 2 19 88%

31 SC 1 1 3 0 2 2 3 3 3 1 0 0 0 0 19 89%

32 WV 3 0 1 2 2 1 1 0 1 0 2 4 1 0 18 90%

33 UT 1 4 1 1 3 0 1 1 0 2 2 1 0 0 17 91%

34 ND 0 3 3 1 0 1 2 1 2 1 1 1 0 0 16 92%

35 OK 0 2 1 0 4 1 1 1 1 1 2 1 0 1 16 94%

36 NC 0 0 1 2 0 2 3 3 0 1 1 1 1 0 15 95%

37 ID 0 2 2 2 0 1 1 0 0 1 2 1 1 1 14 95%

38 MD 1 3 1 0 0 3 2 0 0 1 1 1 0 0 13 96%

39 CT 2 1 1 1 0 1 1 1 0 0 1 0 1 1 11 97%

40 NV 2 0 1 0 0 0 0 2 0 0 1 2 1 1 10 98%

41 MT 0 0 1 0 2 0 0 2 0 0 2 0 1 0 8 98%

42 NM 1 1 1 1 0 1 0 0 0 0 0 1 1 0 7 99%

43 DE 4 0 0 0 0 0 0 0 2 0 0 0 0 0 6 99%

44 ME 0 3 0 0 0 1 0 1 0 0 0 0 0 0 5 99%

45 SD 0 0 1 2 1 0 1 0 0 0 0 0 0 0 5 100%

46 AK 0 1 0 1 0 0 0 0 0 0 0 0 0 0 2 100%

47 DC 0 0 1 0 0 1 0 0 0 0 0 0 0 0 2 100%

48 NH 0 0 1 0 0 0 0 0 0 0 0 0 0 0 1 100%

49 RI 0 0 0 0 0 0 0 0 0 0 0 1 0 0 1 100%

50 HI 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 100%

51 VT 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 100%
K-1 

APPENDIX K: EVALUATION OF THE SOFA WORKING GROUP FOR 

THE IMPLEMENTATION OF SOFA FINDINGS, ADDITIONAL 

INFORMATION 

SOFA IMPLEMENTATION GUIDELINES FOR FIVE MAJOR SAFETY 

RECOMMENDATIONS

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.

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.
K-2 

The SOFA Safety Forum (SSF) Process

Action Phases Key Activities Guiding Questions 

Communicate 

 Draft press release 

 Generate invitee list

 Compose letter of invitation 

with reply request

 Designate read-ahead materials

 Acknowledge

 Plan follow-up updates

- Who are key stakeholders?

- What story will create a buzz? 

- Who should be included?

- Why should invitees reply?

- How should prepare attendees?

- Who was instrumental and/or whom should 

be honored?

- How maintain attendee interest?

Design 

 Set event goals

 Craft event-day agenda

 Design content

 Assign participation and 

leadership roles

 Arrange/hire facilitators, notetakers, greeters, and any other 

support staff

 Decide venue needs based on 

information delivery approach

 Designate support materials 

necessary for event activities

- How will this event be useful?

- How should the event be structured for 

impact?

- Who will be responsible for specific roles?

- What are the organizational needs?

- What type of venue is needed/doable?

- How many and/or what type of rooms are 

needed?

- What materials are integral in support of 

the activities? How be disseminated?

Capture 

 Organize and develop 

instruments and/or protocols to 

structure event happens and 

emerging discussions, etc

 Organize data-collection 

techniques of proceedings

 Inform participants/attendees of 

data collection activities

 Obtain participant consent 

 Train and collaborate with 

professionals

- What level of professional support is 

needed to guide and capture data 

collection (i.e., event proceedings)?

- How should proceedings be recorded 

(i.e., note takers, audio/video-recording)?

- What informed consent procedure 

need/should be implemented?

- How should the professionals and leaders 

be trained/organized to ensure a uniform 

experience for attendees and event goal 

achievement?

Analyze 

 Transform data (i.e., check/final 

notes, transform recorded notes, 

code data, organize themes)

 Identify themes that emerge as 

patterns through the analysis.

 Identify cross-cutting themes, 

lessons learned

- How should the data be transformed, 

organized, and secured?

- What approach coding will be used – 

inductive or deductive?

- What themes emerge from the data?

- What themes are common across themes?
K-3 

SOFA Safety Forum Group Discussions Themes with Illustrative Quotations 

I. Issues related to findings, explanation/context for findings 

Changes in work force 

 More inexperienced people 

I think it’s fair to say that there are a lot more people with less experience due to the heavy hiring in the 

industry from 2001 and beyond, as opposed to the 1990s. 

[We] went through massive hiring and just threw people out there. 

(Talking about apprenticeship)...3 months experience now he’s a conductor. I was on a crew one 

night 6 main tracks, 3 guys and a student with me. One guy had 4 months, the other 2 months, 

and the student. 

Just looking down the list, three (3) [individuals] were in their 30s, one was in 50s, but only on 

for a short time. Is there a trend with the railroad being younger or because they are new?” 

 Smaller crews 

When I think of mentoring, I think of when I entered the workforce, back when there was a 5 man crew. 

There was always someone watching you, telling you what to do. It’s totally different now 

One of the problems we have now is that the way institutional knowledge is passed on, that 

framework doesn’t exist anymore. (Story about how they used to put a white armband on a new 

guy so everybody in the yard knew he was new.) Tougher to do when crew sizes get smaller and 

more spread out. 

 Less cohesion 

More of a cultural thing I think. We used to be a family. We used to have a family cookout every summer. 

My dad was a UTU general chairman. We used to have a family cookout. It was a big party. Those days 

are long gone. 

 More turnover/changing of positions 

In urban railroads, there are so many people to interact with. In rural railroads, there are a lot of 

people that stick around, and you development a relationship. 

Exasperates issue our inability to lock people in the area they’ve been trained. Yard guys 

becoming utility people, brakeman switchers. . . .All the training that we do is going to be lost 

because of that turnover that will continue to occur. Makes it an incredible challenge to lock 

someone in who has the knowledge and awareness because it’s you today, and someone else 

tomorrow. 

 
K-4 

Railroad culture 

 Individualistic/male culture 

Uncommunicative

Lack of communication can be put into every case...not weighted to go down...almost out of 

your way not to [communicate]. It [reporting the job briefing was a cause to an accident] is 

another way not to say not communication. 

The reason I ask, sometimes the job briefing doesn’t occur [because of the culture and veteran 

railroaders feeling like], “Get out of my face newbie.” 

Not wanting to show lack of knowledge/experience, especially among newer workers 

The new guy may want to improve himself; job briefing is reaching out for help and pride 

(maybe) getting in the way. 

Workers not wanting to tell other workers what to do 

Before SOFA experience I thought that was the end of my interaction, I wasn’t going to tell the 

conductor how to do his job. 

We are a very male-based culture...males don’t like being told what to do. 

Work as individuals not as a team

Ok son, you let your brother do his chores; you do yours [talking about how things are commonly 

done]. 

 Pressure to hurry/get the job done 

Was there any pressure from the dispatcher, if the trains were stopped on both sides, pressure 

from the dispatcher (too move quickly and get the job done)...all adds to anxiety to conductor to 

get stuff done. 

In that case [boy who fell in wood-chipper], through statements we know that this was a place 

where people had been known to say, if you’ve never been here before, watch out, especially at 

night. No lights. Not set out. He said, ‘I should have told him. It was just, we were in a hurry, I 

want to get back. I told him to stay put.’ 

We can’t wait until the last minute in our culture. 

We don’t know the kind of pressure. Sometimes there’s a price to pay if you stop the train and 

wait for proper action. 

The new employee is willing to take risks to satisfy customer. They are walking on pins and 

needles trying to please customers and doing things you wouldn’t do [if you were already 

experienced]. 

 Risk-taking 

Got away with it before, thinks a severe or fatal incident will not happen to them 

You’re talking to someone who’s correct because it won’t happen to them. It’s 28 years before 

statistically there is a chance of something happening to them. 

 
K-5 

Not just an issue with young employees; it is bigger issue with more experienced employees. For 

example, we lost a 43-year-old switchman with 23 years experience; the brakemen was with him. 

His mate stood there watching it all happen. Probably did it a thousand times and got away with it 

a thousand times. 

Guys get into these habit patterns thinking, “I get away with it now; I get away with it tomorrow; 

I get away with it in a few years.” 

Unsafe practice becomes standard procedure; sometimes no good alternative

An employee rode on side, next to building, there was a sign saying close clearance, “Do not 

ride.” He was riding on that side; the train rode up on snow, derailed, and pinned him. He was 

crushed against the door. He was an experienced conductor. We interviewed every switchman in 

that yard, and every switchman rides on that side because we had about three inches elevation on 

the track. If rode outside they were leaning back, so more comfort on inside, also see down 

building to see if ramps to cars. Everyone knew to do it that way even if they’re not supposed to. 

Certain behaviors are witnessed safely and continues to be the way things are done. . . .The crews 

come up with their own safety approaches. . . .They realize too late. 

Tolerance of unsafe conditions

They weigh the risk...they think they’re smarter than the rule. 

Routine leads to lack of caution, complacency about risk 

Complacency is the hardest...doing the same thing every day. Because tasks are specific, they’ve 

gone through it (over and over again), time as shown, year after year, the day that they(the 

workers) lays off (the importance of the job briefing) and you don’t do a thorough job briefing, 

that is how stuff happens. 

Training/Education Problems 

 Inappropriate trainers/mentors: inexperienced or interested/skilled at training 

The trainee was very young. Trainee was with a guy who had just been a trainee, but was now 6 months 

into his career. When you watch the video, you can see. The conductor walks to the switch, excited to be 

teaching the trainee, talking to the trainee, reaches down and lines the wrong switch. He should definitely 

not have had a trainee. Need a mentor who has the capability, experience, knowledge to be a trainer. 

I know we’ve done some accident investigation and found that a locomotive engineer who was 

being a trainer was the wrong personality to do it. That’s common in the industry. I don’t know 

how to make sure of it, but it’d be ideal to match a trainee with a person who enjoys training and 

helping people. 

 Emphasis on rote learning rather than OJT 

In learning the rules by memorization, everyone can do that, that’s what you have, then you go out in the 

field, and even though they scored 100s on their tests, it’s only memorized. If it’s not used and you don’t 

see that issue, you lose it. 

 Punitive rule enforcement 

Been in situations where I don’t know what I’m doing and I was tested, screwed up, then told how to do 

it. That knowledge escapes my mind because I was too focused on passing the test. 

 
K-6 

Our guys are telling us, “I can’t do my job because I’m too worried about the guy sitting there 

watching me.” 

Sometimes management uses safety as a tool of discipline (contractual dispute), but it should be 

used to save lives. 

 Ingrained bad practices passed on 

You don’t have trained instructors out there, but there’s no standardization, old heads teach and 

then you’ve got to try and correct those bad habits. 

Industrial Site Problems 

 Physical issues 

Industrial sites not up to standards/unsafe

We have grandfathered a lot of conditions because they were there before we were aware of what 

clearance looks like...we have developed new standards...unfortunately bulk of U.S. industry has 

been built and there’s a lot to correct. 

Tells a story of a guy who was asked why he fell into a pit. He said there was no physical barrier. 

High cost to upgrading to safe standards

If this is going to cost more than 6 million to change it, it’s not worth it, that’s the DOL statistic. 

[DOL statistic is that a human life costs $6 million.] 

 Communication issues 

Changes made without notifying railroad

I see under comments on M504, we see unauthorized startup of machinery, so apparently there 

was a reference to the physical plant. As I remember, they had asked the people of the plant not to 

start it up at that hour. 

This was a cement plant, they move coal into another timber, hoppers drop down. Local comes 

back to gather loads and leaves. This was already a close clearance but with conditions changing. 

Static close clearance you do a pretty good job marking, clearing. You have industries where they 

do changes to the dock. 

Managers/owners not told about safety problems

Why don’t we send a letter from the railroad reminding them of all these places where there’s a 

state law and you have a lease agreement where you have to comply? Letter never went out 

(didn’t want to offend customers). 

Managers and supervisors are not aware of safety hazards. Unless we go in and see what the 

hazards are, we can’t do anything about it. Unless we tell the owner, the crew members don’t tell 

the managers [or owners]. 

 
K-7 

II. Action Recommendations from Findings

Programs that promote cultural change 

 Establish group-oriented culture 

Need to get people to look out for each other, care for each other. 

By the same token, you have great stats as far as low-accident rates on both accident and injury 

side—really low compared to the rest of the industry. When you see that environment, you know 

you have a good thing going. It’s not one nice package. It’s the leadership and an inspired 

workforce, they like coming in to work. Superintendent, case in point, kind of person that goes to 

the crew room and starts talking about what their issues are, and knows them, and takes an 

interest in their life and knows about their family. How do you duplicate that everywhere? Comes 

back to behavior and culture. Are we, across the system, doing those things that inspire that kind 

of behavior? 

Never rely on one point for protection from failure. . . .It boils down to one guy doing the right 

thing. 

 Communication Change 

 Focus on changing communication from orders to discussion 

how do you get from job briefing to job discussion...to the next level... you get a response and 

answer- people listen. 

Best practice (would be) to get everyone engaged in conversation and discussion. 

 Peer to peer communication. Peer culture being able to talk (to each other). 

That’ll change the culture, that works, that’s a win. Got to do it (double checking) from peers. 

Programs that force communication. TBP makes it a rule you cannot dismount your cut without 

alerting the dispatcher. . . .The practical result is crews are finding ways not to foul. . . .TBP is 

enacted about 50 times a day. . . .We’re thinking about moving it to the yard. . . .People are using 

it and it is well received. 

 Leadership buy-in 

It’s about leadership. How effective leadership is makes the difference. 

It’s a cultural shift- how did you know when you worked on the railroad what was the right 

thing?” “Because my boss told me” Luckily what is important to your boss becomes important to 

you. 

Improve training programs 

 Non-punitive training 

Cant’ be playing the “I gotcha” (game). It shouldn’t be about someone noting what you’re doing 

wrong, and pointing out what you’re doing. Needs to be an education process, not a “’gotcha” 

process, or a discipline thing. 

They go out, spend their day, we pay them every week to take a day off and they do observations 

and take score cards and measure compliance. If there is non-compliance, they interact with 
K-8 

employees. We have reduced resistance between management and craft employees. Have 

employees mentoring each other. No name, no blame. That’s become the slogan. 

 Focus on OJT (on the job training) 

Big issue for me, being a new hire on the ground as switchmen, when I had old heads come to 

me, very rarely, and say you are doing that all wrong, stop, let me show you. You learn so much 

better in that type of environment. On the management side, I’ve been fortunate. Had a manager 

come up to me and show me how to do it. Makes you a lot more receptive to that kind of 

situation. 

Don’t just tell me how to do it, show me. 

 Skilled and experienced trainers 

First thing we did was set up a lot more structure about who a trainee can be with. There are 

designated trainers. If one of those trainers marks off, we take the trainee off the assignment. We 

don’t have this case where a trainee shows up and the trainer had to be off, so here’s a guy with 6 

months experience to teach you. 

Then you need to find someone who wants to train, and not only wants to, but can train. That’s a 

personal trait regarding whether this person is ideally suited. 

You could assign people certain tasks, like railroad coaches, you have 20 coaches to handle the 

flow of new hires to come in. 

Program Implementation and Evaluation 

 Find and bring successful programs to all sites 

That’s a success story. Statistics don’t lie. I appreciate you guys sharing all this, but one thing that 

disturbs me is that this is a success story that should be moved. If you’ve seen success in trying to 

change these things, get it out there. Roll it out. 

 Use SOFA reports 

It seems like, significant delay from what SOFA does, information it puts out and getting it out to 

front line employees. Delivering it in a way that they (the workers) actually put themselves in 

that position. They need to realize that these (accidents) could happen to them...you read a few 

sentences (from the job briefing about an incident)...but does that really reach people like it used 

to? Having that (information from SOFA) accessible and in a timely manner. 

 Get needed information from non-punitive reporting programs 

The C3RS sponsored by FRA is a confidential way to report close calls. A small committee went 

to North Platte and reviewed those cases. The employee would turn something in and receive 

immunity from punishment by FRA. Would be sent here, confess his sins, go through an 

interview process with three people here. Those people would send a report back to North Platte. 

Derailments were cut in half. 

If a person gets in a situation where they say ‘let’s stop and figure this out’ or don’t want to go on 

the track because can’t see a foot in front of them. . . .If we have a no retaliation clause, we 

shouldn’t go back and hammer these people for standing up for what they thought was right at the 

time. 

 
K-9 

 Check for success of programs 

We surveyed our employees. The perceptions of what is fact versus perception was very telling 

from our survey. As we implement our program we go back and survey. . . .Feedback from 

employee. Anonymous surveys. 

 Use the fatality in Indiana, terrific job training aids, you use it when you’re new...unless they 

 reviewed it or we create a mechanism to make sure they reviewed it. Now you’ve got to create 

 some communication process so that we make sure you’ve done it. 

Industrial site solutions 

 Get information about hazards through site visits and safety hotlines 

Even when you talk about industry situations. We must make sure we view [the facility] 

ourselves. Make sure we provide a safe environment for them. 

We (ASLRRA) go inspect the site and say, “You need ties, you need this, etc.” And then the 

inspector comes back and stops the railroad due to safety. 

Several railroads like BNS UP have safety hotlines, you call up and say we have a safety hazard 

out there and the managers have to say, “What do we do to correct that hazard?” 

 Communicate with ownership/management 

Had one situation where built place too close to rail, I called guy at plant and guy said, “I didn’t 

know it was too close.” He calls back, “I fixed it.” He took a concrete saw and cut off the area. 

I’m convinced if you just alert the customer there’s a problem some of it can be addressed. 

Elevator incident, called him he says, ”gee I wish I’d know that was a safety hazard. 

Has there ever been an effort coming out of SOFA to begin to communicate among the broader 

group?” [% list recommendations], “Things like customer safety handbook; anything that came 

from SOFA would be useful or reports. Potential of something not too industry specific. 

[Ask] industry to make recommendations before they make change to the physical structure, [as 

in] please contact us (railroad industry) to make sure it complies. 

 Make physical changes, don’t just post warning signs 

That’s why our employees wear reflective vests...engineer would have seen him. . . .This is the 

 accident why we wear reflective vests. 

There are so many things we can address rather than just warning. 

Lights and vests ought to be mandatory. 

Lighting is also essential. [All agree.] 

 
K-10 

SWG Stakeholder Engagement Efforts since the SOFA Safety Forum, February 25, 2010 

Outreach activities, specifically presentations, to those organizations most directly affected were 

as follows: 

March 18: SOFA presentation on the five major findings to the full RSAC in Washington, D.C. 

May 4: SOFA presentation on the five major findings to the ASLRRA at their Conference in Orlando, 

FL. 

June 15: Teleconference call with Snow, Coplen, Connors, and Gallant—early discussion on the 

Implementation piece. 

June 16: GoTo meeting with SWG hosted by the AAR in Washington, D.C. Intent was to prepare for our 

Kansas City SWG meeting. 

July 26: SOFA presentation on the five major findings to the UTU “ballast level” folks in the morning 

and another presentation to the UTU Leadership in the afternoon at their Western Regional Conference in 

Phoenix, AZ. 

August 9: SOFA presentation on the five major findings to the BLET membership (over 150 attendees) 

included both “ballast level” folks and BLET Leadership at their Eastern Conference in Pittsburg, PA. 

August 23: SOFA presentation on the five major findings to the UTU “ballast level” folks in the 

morning and another presentation to the UTU Leadership in the afternoon at their Eastern Regional 

Conference in Asheville, NC. 

August 26: SOFA presentation on the five major findings to the FRA Operating Practices Division at 

their Multi-Discipline Conference in Denver, CO. 

August 30: GoTo Meeting with SWG hosted by the AAR in Washington, D.C. Intent was to prepare for 

our San Francisco, CA. SWG meeting. 

September 10: GoTo meeting with many members of the AAR, hosted by the AAR at their Washington, 

D.C. offices. The SOFA presentation on the five major findings was presented including a question and 

answer period. 

September 21: A SOFA Safety Forum-West where the SWG presented the SOFA presentation on the 

five major findings, discussed some examples, talked about effective implementation going forward and 

finished with a question and answer period in San Francisco, CA. 

October 6: SOFA presentation to UTU Western General Chairman’s Association in Cleveland, OH. 

Many presentations began by emphasizing four important elements of the SWG: 

1) We are not the FRA SWG, nor the UTU SWG, nor the AAR SWG. We are an independent Working Group 

dedicated to identifying commonalities among switching fatalities that may lead to findings, that may lead 

to actions that, if properly implemented by the industry, with reduce fatalities during switching operations 

to zero. 

2) Therefore, SWG is an independent, VOLUNTARY, experienced group of professionals, wherein each 

member is focused on one goal—elimination of switching fatalities—each member has a dog in the fight. 

3) SWG is not, NOT affiliated with RSAC, an RSAC WG, or the RSAC process. 

4) SWG makes its own arrangements for its own meeting rooms. Each member hosts a SWG meeting and 

makes the arrangements for that meeting. We are extremely aware of cost issues.
Appendix L

Office of Research 

And Development 

Washington, DC 20590 

DOT/FRA/ORD-09/23 November 2009 

 

This document is available to the

U.S. public through the National

Technical Information Service

Springfield, Virginia 22161

Federal Railroad

Administration

U.S. Department

of Transportation

An Evaluation of the 

Switching Operations Fatality Analysis 

2010 Working Group’s Processes 
Notice 

This document is disseminated under the sponsorship of 

the Department of Transportation in the interest of 

information exchange. The United States Government 

assumes no liability for its contents or use thereof. 

Notice 

The United States Government does not endorse products 

or manufacturers. Trade or manufacturers’ names appear 

herein solely because they are considered essential to the 

objective of this report. 
L - iii 

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1. AGENCY USE ONLY (Leave blank) 2. REPORT DATE 3. REPORT TYPE AND DATES COVERED

November 2009 Final Report

4. TITLE AND SUBTITLE 5. FUNDING NUMBERS 

An Evaluation of the Switching Operations Fatality Analysis 

2010 Working Group’s Processes 

HG384/RR04 

DTFR53-07-D00004-TO008 6. AUTHOR(S) 

Deborah Bonnet, Michael Coplen, Michael Quinn Patton, Juna Snow 

7. PERFORMING ORGANIZATION NAME(S) AND ADDRESS(ES) 8. PERFORMING ORGANIZATION 

REPORT NUMBERS

U.S. DOT/RITA/John A. Volpe National Transportation Systems Center, 

55 Broadway, Cambridge, MA 02142-1093 

Fulcrum Corporation, 2731 Prosperity Avenue, Suite B, Fairax, VA 

22031-4335 

9. SPONSORING/MONITORING AGENGY NAME(S) AND ADDRESS(ES) 10. SPONSORING/MONITORING AGENCY 

REPORT NUMBER 

U.S. DOT Federal Railroad Administration 

Office of Research and Development, MS 20 

1120 Vermont Avenue, NW 

Washington, DC 20590

11. SUPPLEMENTARY NOTES

COTR: Michael Coplen, Federal Railroad Administration 

12a. DISTRIBUTION/AVAILABILITY STATEMENT 12b. DISTRIBUTION CODE

This document is available through National Technical Information 

Service, Springfield, VA 22161. 

13. ABSTRACT 

This report documents the evaluation of the processes used by the Switching Operations Fatality 

Analysis (SOFA) 2010 Working Group to analyze the 54 fatalities in switching operations that 

occurred from January 2004 to November 2009. Utilizing accepted professional standards for 

evaluation, the evaluation team concluded that the SOFA analyses are systematic, rigorous, 

comprehensive, and objective. Furthermore, the findings of the SOFA 2010 Working Group are 

valid, significant, and worthy of the railroad industry’s thoughtful attention and bold response. 

14. SUBJECT TERMS 15. NUMBER OF 

PAGES

Evaluation, SOFA, Fatality, Rail 

16. PRICE CODE

17. SECURITY CLASSIFICATION 18. SECURITY CLASSIFICATION 

OF THIS PAGE 

19. SECURITY CLASSIFICATION 

OF ABSTRACT 

20. LIMITATION OF 

ABSTRACT 

UNCLASSIFIED UNCLASSIFIED UNCLASSIFIED 

NSN 7540-01-280-5500 Standard Form 298 (Rec. 2-89) 

Prescribed by ANSI/NISO Std. 

239.18 

298-102
L - iv 

METRIC/ENGLISH CONVERSION FACTORS 

ENGLISH TO METRIC METRIC TO ENGLISH

LENGTH (APPROXIMATE) LENGTH (APPROXIMATE) 

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

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

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

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

 1 kilometer (km) = 0.6 mile (mi)

AREA (APPROXIMATE) AREA (APPROXIMATE) 

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

(cm2

) 

1 square centimeter (cm2

) = 0.16 square inch (sq in, in2) 

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

yd2

) 

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

1 square mile (sq mi, mi2) = 2.6 square kilometers 

(km2

) 

10,000 square meters (m2

) = 1 hectare (ha) = 2.5 acres 

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

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

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

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

1 short ton = 2,000 

pounds (lb) 

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

=

1,000 kilograms (kg) 

1.1 short tons

VOLUME (APPROXIMATE) VOLUME (APPROXIMATE) 

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

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

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

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

1 pint (pt) = 0.47 liter (l) 

 1 quart (qt) = 0.96 liter (l) 

1 gallon (gal) = 3.8 liters (l) 

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

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

TEMPERATURE (EXACT) TEMPERATURE (EXACT) 

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

QUICK INCH - CENTIMETER LENGTH CONVERSION

0 1 2 34 5

Inches

Centimeters 01 3 2 6 11 4 5 7 13 8 9 10 12

QUICK FAHRENHEIT - CELSIUS TEMPERATURE CONVERSION

 -40° -22° -4° 14° 32° 50° 68° 86° 104° 122° 140° 158° 176° 194° 212°

 

°F

 °C -40° -30° -20° -10° 0° 10° 20° 30° 40° 50° 60° 70° 80° 90° 100°

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

Measures. Price $2.50 SD Catalog No. C13 10286 Updated 6/17/98
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L - vi 

ACKNOWLEDGEMENTS 

The authors extend gratitude to the SOFA Working Group Chair, Joseph Gallant, who requested 

and facilitated this review, and to the current SOFA Working Group members for their open and 

enthusiastic participation in this evaluation: Stephen Bruno, William Browder, Robert Butcher, 

Gary Devall, Ty Dragoo, John T. Little, David Mears, Phillip Qualy, Thomas Streicher, and 

Robert Svob, Jr. In addition, we thank database analyst Gary Connors and past SOFA Working 

Group members for their valuable insights: Danny Boyles, David Brickey, George Last, Thomas 

Perkovich, David Skinner, and John Smullen. 

The Federal Railroad Administration funded this evaluation through a contract with Fulcrum 

Corporation and an interagency agreement with the Volpe National Transportation Systems 
L - vii 

TABLE OF CONTENTS 

ACKNOWLEDGEMENTS ........................................................................................................... vi

EXECUTIVE SUMMARY ......................................................................................................... viii 

1. INTRODUCTION .................................................................................................................. 1 

1.1. Background ..................................................................................................................... 1 

2. SOFA PROCESS EVALUATION ......................................................................................... 5 

2.1. The SOFA Working Group is Appropriately Constituted .............................................. 5 

2.2. The SOFA Working Group is Cohesive and Resistant to Political Influences ............... 6 

2.3. SOFA 2010 is Explicitly Designed for Utilization ......................................................... 7 

2.4. Information Analyzed by the Working Group was Complete, Sound, and Varied ........ 7 

2.5. SOFA Case Analyses are Meticulous ............................................................................. 8 

2.6. The Working Group Reaches Consensus on Key Conclusions About Each Case ......... 9 

2.7. Aggregation of SOFA Case Data was Rigorous ............................................................. 9 

2.8. The SOFA Working Group Practices Continuous Improvement ................................... 9 

2.9. The Process Evaluation was Thorough and Independent ............................................. 10 

3. CONCLUSIONS................................................................................................................... 10 

4. REFERENCES ..................................................................................................................... 11 

APPENDIX A ............................................................................................................................... 12 

APPENDIX B ............................................................................................................................... 13 
L - viii 

EXECUTIVE SUMMARY 

This report documents the evaluation of the processes used by the Switching Operations Fatality 

Analysis (SOFA) 2010 Working Group to analyze the 54 fatalities in switching operations that 

occurred from January 2004 to November 2009. Utilizing accepted professional standards for 

evaluation, the evaluation team concluded that the SOFA analyses are systematic, rigorous, 

comprehensive, and objective. Furthermore, the findings of the SOFA 2010 Working Group are 

valid, significant, and worthy of the railroad industry’s thoughtful attention and bold response. 

These conclusions are based on the following observations: 

1. The SOFA Working Group is appropriately constituted 

2. The SOFA Working Group is cohesive and resistant to political influences 

3. SOFA 2010 is explicitly designed for utilization 

4. Information analyzed by the Working Group was complete, sound, and varied 

5. SOFA case analyses are meticulous 

6. The Working Group reaches consensus on key conclusions about each case 

7. Aggregation of SOFA case data was rigorous 

8. The SOFA Working Group practices continuous improvement 

9. The process evaluation was thorough and independent 
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1. INTRODUCTION 

Since early 2009, the Switching Operations Fatality Analysis (SOFA) Working Group has been 

preparing for its third major report, to be released in 2010. The Working Group has applied its 

tools and processes for analyzing train yard tragedies, refined over its twelve years of experience, 

to the 54 fatalities that occurred since January 2004. At the same time, the Working Group has 

worked diligently to ensure widespread and effective use of its 2010 findings to achieve the goal 

of zero switching deaths. The group has reviewed successes and disappointments from its past 

efforts, called upon evaluation professionals for guidance, and employed principles of 

utilization-focused-evaluation1 to inform their work. 

The evaluation team has examined SOFA against accepted professional standards for 

evaluation.2,3 We have found the Working Group’s methods appropriate and its findings valid. 

We offer this report first, to highlight the credibility of SOFA findings, and second, to document 

how SOFA works for the benefit of other similar initiatives that may draw on SOFA’s lessons. 

1.1.Background 

The SOFA Working Group first convened in February 1998 in response to a letter from a senior 

official of the Federal Railroad Administration (FRA) to industry leaders. The letter expressed 

concern that over the prior six years, 66 train and engine service employees had been fatally 

injured in incidents other than major train collisions, and called for a task force consisting of 

representatives from labor, management, and FRA to find a way to prevent these tragic 

occurrences. The letter went on to say: 

“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 findings and recommendations from this team are 

neither intended to be used in a rulemaking process nor 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 . . .” 

1.1.1. SOFA 1999 

The SOFA Working Group met almost monthly for 20 months to analyze the 76 fatalities that 

occurred to railroad employees engaged in switching operations from January 1, 1992 through 

July 1, 1998. As their work proceeded, the group learned that: 

 

1

 Patton, M.Q. (2008). Utilization-Focused Evaluation (4th ed). Thousand Oaks, CA: Sage. 2

 Joint Committee on Standards for Educational Evaluation (994). The Program Evaluation Standards. Thousand 

Oaks, CA: Sage. 

3

 American Evaluation Association (2004). Guiding Principles for Evaluators. 

http://www.eval.org/Publications/GuidingPrinciples.asp 
L - 2 

 The summary reports prepared by FRA investigators alone were not sufficient; to 

understand the underlying causal factors required reviewing entire case files, including 

photographs of the site and statements of eye witnesses. 

 To find trends and patterns across cases, the Working Group needed a codified database 

of standardized information. One was developed and continues to evolve. 

 While FRA investigation reports tried to establish a single probable cause, fatalities 

more often resulted from the coming together of a complex set of factors. The SOFA 

process turned to possible contributing factors rather than probable cause and 

accommodated more than one factor per case. 

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

Human Factors support offered by the Office of Research and Development at the FRA 

and the Volpe National Transportation Systems Center. This assistance proved valuable 

to the development of systematic and rigorous processes for analyzing individual cases 

and synthesizing across cases. 

The SOFA Report: Findings and Recommendations of the SOFA Working Group, released in 

October 1999, identified 5 Operating Recommendations, later shortened to 5 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. 

The report offered additional recommendations to the industry concerning: 

 Unexpected train movement 

 Crew resource management 

Finally, the report recommended the following to the SOFA Working Group and FRA: 

 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 

All of the last set of recommendations were carried out, including the publication of SOFA’s 

Severe Injuries to Train and Engine Service Employees: Data Description and Injury 

Characteristics, published in July 2001. 
L - 3 

1.1.2. SOFA 2004 

The SOFA Working Group continued to meet from time to time. Findings and 

Recommendations of the SOFA Working Group: August 2004 Update was based on the 

expanding database that added to the original 76 switching fatalities another 48 that occurred 

between July 1998 and December 2003. The five Operating Recommendations (Lifesavers) were 

further validated. The 2004 report also identified Ten Special Switching Hazards: 

 Close clearance 

 Struck by mainline trains 

 Free rolling railcars 

 Employee tripping, slipping, falling 

 Unsecured cars 

 Unexpected movement of railcars 

 Equipment issues 

 Struck by motor vehicle or loading device 

 Drugs and alcohol 

1.1.3. Ongoing Efforts to Promote SOFA Recommendations. 

In addition to reviewing fatalities and issuing reports, the SOFA Working Group and others have 

used a variety of means to educate and motivate the railroad industry, from carrier leaders to 

workers at the ballast level, to take the necessary actions to ensure safety in switching operations. 

For a time, the FRA Administrator held monthly conference calls with carrier, labor, and FRA 

leaders to hear what steps they had taken. The Working Group members took every opportunity 

to speak publicly about SOFA, and to reinforce its messages privately. It examined and 

encouraged further inquiry into promising safety technologies. A goal of zero switching fatalities 

was announced. A memorandum, Best Practices Guidelines for Implementing Operating 

Operations (March 2000), was issued to encourage education and a positive, judicious approach 

to implementation and to discourage use of the Operating Recommendations as a basis for 

discipline. There were occasional Safety Alerts when new hazards were identified. A SOFA 

video was produced and distributed, and a web site was created. The railroad industry took the 

lead in creating Crew Resource Management, a generic training program for train and engine 

employees. The 5 Lifesavers were printed and distributed nationwide on hats, pens, wallet-size 

cards, refrigerator magnets, stickers, and switch-list covers. 

The Volpe Center has kept the SOFA Working Group and others current on trends in switching 

operations fatalities by issuing quarterly reports of the number of deaths that appear to be related 

to SOFA’s 1999 and 2004 findings.4

 The 3rd Quarter 2009 report concluded that fatalities 

 

4

 “Switching Fatality and Severe Injury Updates” are compiled on the basis of investigation reports, without the 

benefit of the SOFA Working Group’s analyses, and should therefore be regarded as preliminary. 
L - 4 

related to Operating Recommendations have dropped substantially since SOFA began, although 

hazard-related fatalities have not. 

1.1.4. SOFA 2010 

The SOFA Working Group was reconvened in January 2009 with the charge to analyze 

switching operation fatalities that occurred after December 2003, add them to the database of 

fatalities between 1992 and 2003, and issue an updated report in early 2010. As of November 1, 

2009 there were 54 new fatalities, bringing the total to 178 – an average of ten per year. 

Despite extensive efforts and evident successes, the 2010 Working Group was dissatisfied with 

SOFA’s effectiveness. The goal of zero fatalities had not been achieved. There was a sense that 

attention to the 5 LifeSavers and 10 Special Switching Hazards had waned since the fanfare 

surrounding their introduction. The group was particularly concerned that SOFA’s 

recommendations had been lifted up as special rules—whose violation is often treated as 

especially egregious—rather than as a special focus on education and collaborative problemsolving. The hope of achieving deep systemic shifts toward organizational cultures where safety 

takes precedence over productivity had not been realized. To a person, Working Group labor 

representatives said that, as a result of SOFA participation, they had become far more attuned to 

safety issues and had substantially changed their behaviors when back on the job. Yet, how to 

meaningfully extend their personal awakenings to colleagues throughout the industry remained 

unclear. 

“A chart is not going to wake anyone up. I’m not saying to show pictures of 

corpses, but just talk about how bad it could be and that it is your choice. These 

images and discussions here helped me change. Because of what I learned here, it 

woke me up.” 

“How many cases have we had that people ran with a pin lifter? I did that for 

years, but I didn’t know that was a SOFA recommendation. Sure, maybe someone 

told me not to do it, but until I served here and read the cases, I didn’t realize the 

importance that this recommendation is followed.” 

With these disappointments in mind, the Working Group invited a professional evaluator to its 

February 2009 meeting to facilitate conversation about how to attain greater and more lasting 

impact with the 2010 report. The group engaged in a logic modeling process to clarify the 

outcomes it hoped to achieve (See Appendix A). This exercise led to three important 

conclusions: 

 SOFA had been fairly successful in getting the message of railroad safety out, but the 

findings and recommendations were too seldom utilized effectively. 

 The credibility of SOFA’s processes and findings would be key to subsequent use and 

implementation of the 2010 report. 

 Use would depend not only on the report itself. Various ways of engaging stakeholders 

held promise of escalating the report’s effectiveness, and planning for utilization 

needed to begin well in advance of the report’s release. 
L - 5 

The present report is one element of the emerging utilization strategy for SOFA 2010. 

2. SOFA PROCESS EVALUATION 

The SOFA 2010 Working Group submitted itself to the scrutiny of five seasoned evaluation 

professionals, the authors of this report (See Appendix B).5 The evaluation team was first 

formed for two purposes: (1) to advise the SOFA Working Group on ways to encourage effective 

utilization of SOFA findings, and (2) to assist in the preparation of the 2010 SOFA report. As 

our work with the Working Group evolved, two additional purposes emerged. It became clear 

that SOFA represents an exceptionally systematic and comprehensive model–one that may well 

serve as an exemplar for other initiatives in the railroad industry and even beyond. Thus, this 

process evaluation report was also conceived as a way of: (3) highlighting the credibility of 

SOFA findings, and (4) documenting how SOFA works for the benefit of other similar 

initiatives. 

We concluded that the SOFA analyses are systematic, rigorous, comprehensive, and objective. 

The findings are valid, significant, and worthy of the railroad industry’s thoughtful attention 

and bold response. We base these claims on the following: 

1. The SOFA Working Group is appropriately constituted 

2. The SOFA Working Group is cohesive and resistant to political influences 

3. SOFA 2010 is explicitly designed for utilization 

4. Information analyzed by the Working Group was complete, sound, and varied 

5. SOFA case analyses are meticulous 

6. The Working Group reaches consensus on key conclusions about each case 

7. Aggregation of SOFA case data was rigorous 

8. The SOFA Working Group practices continuous improvement 

9. The process evaluation was thorough and independent 

The balance of this report elaborates upon each of these conclusions. 

2.1.The SOFA Working Group is Appropriately Constituted 

The 2010 SOFA Working Group consists of eleven members representing carrier management, 

labor, and FRA. Members are appointed by their respective organizations: 

 Association of American Railroads (1 member) 

 

5 The evaluation team and its methods are described later, under the heading, “The process evaluation was thorough 

and independent.”
L - 6 

 American Short Line and Regional Railroad Association (2)6

 Brotherhood of Locomotive Engineers and Trainmen (3) 

 United Transportation Union (3) 

 Federal Railroad Administration (2) 

Collectively, the Working Group brings 359 years of railroad experience while ranging in age 

from 26 to 65. Two members were on the 1999 and 2004 SOFA Working Groups and one 

additional member participated in 2004, thereby bringing continuity to the process. 

Members are selected not only for their experience, but also for analytic, communication, and 

teamwork skills–important factors in their collective success as a working group. 

2.2.The SOFA Working Group is Cohesive and Resistant to Political Influences 

The SOFA Working Group is highly cohesive, and its members are adamant in claiming this as 

instrumental to SOFA’s success. A shared commitment to the importance of the work–saving 

lives–has pulled the group through some taxing conflicts. The Chairman’s skillful leadership has 

helped cultivate productive group norms of persistent questioning and spirited debate, balanced 

by mutual respect and ego containment. Other unwritten rules include: 

 Working Group members leave their sector allegiances at the door. Getting to the truth 

of each case trumps protecting turf. 

 All SOFA deliberations are private within the group. What’s said in the SOFA meeting 

room is to stay in the SOFA meeting room. 

 SOFA members enjoy the backing of the organizations they represent. Their leaders 

respect the confidential and collaborative nature of the work and refrain from 

interfering with the group’s deliberations and conclusions. 

Most notably, SOFA has succeeded where many others have failed by overcoming the traditional 

adversity among labor, management, and regulators, deeply ingrained in the railroad industry, to 

achieve quality collaborative work: 

"It’s a good, collaborative group. The operations work well...We are dealing with 

real people, and everyone is allowed to express their opinion. It is an effective 

process, and it does a very good job of getting to the root causes and contributing 

factors of these accidents. I was surprised to see how much information was 

provided by the field investigators. They do very comprehensive work that gives 

us a chance to do a real evaluation based on the facts, which have survived 

through the whole investigative process." 

The Working Group seemed pleased by an evaluation team member’s mention that it took all 

morning of the first day of observation for her to tell who was who—that is, to distinguish 

 

6

 Two members of the ASLRRA rotate attendance of SOFA meetings, which means that at any given meeting, 

carriers are represented by two people, labor by six, and FRA by two. 
L - 7 

among the management, labor, and government representatives; and further, it was based on their 

stories, not how they looked or spoke, the opinions they expressed, or the positions they took. 

Yet another indicator of the SOFA Working Group’s camaraderie is that eight former members, 

now retired, traveled at their own expense to the September 2009 meeting to reunite with their 

colleagues. While there, they donated several hours to participate in utilization planning for 

SOFA 2010. 

2.3.SOFA 2010 is Explicitly Designed for Utilization 

As mentioned previously, SOFA 2010’s second meeting focused on utilization of the report that 

would be released a year hence. The logic modeling exercise aided in reflecting on past practices 

and bringing use to the forefront. Throughout the year, the Working Group drew in experts to 

aid in thoughtful reflection on what worked before, what did not, and how things have changed 

since 1999. 

A pivotal point occurred at the September 2009 meeting. Amid concerns that past SOFA 

recommendations had been instituted as rules, an alert observer noted that recommendations 

were written in a way that read like rules: “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.”7 Even when translated into the more user-friendly 

Lifesavers, SOFA recommendations can still be read as rules: “Discuss safety at the beginning of 

a job or when a project changes.” 

This insight contributed to the decision to engage the report’s intended users in interpretation and 

decisions for action, thereby deepening their understanding of the implications of the findings. 

Planning turned toward involving labor, management, and government in a collaborative 

examination of the data beyond the confines of the SOFA Working Group.8 

Among other advantages, this utilization-focused approach would recognize that solutions are 

best formulated in context, and acknowledge that the best fix for a given problem would likely 

vary from carrier to carrier and site to site. 

2.4.Information Analyzed by the Working Group was Complete, Sound, and Varied 

By “complete,” we mean that all fatalities within SOFA’s scope are analyzed. 

As one would expect, a SOFA case begins with a fatality—Specifically, the accidental death of 

an on-duty train or engine employee while performing switching operations. All railroad-related 

deaths are reported immediately to the National Response Center, which alerts the Team Leader 

of FRA’s Accident Analysis Branch (who is also the SOFA Chairman). Cases are assigned to 

one of FRA’s eight regions for investigation. The region appoints one or more FRA investigators 

to go to the site as soon as possible to begin work. Teams are preferred; in the case of a 

 

7

 Recommendation 3 

8

 As of this writing, details of this plan are still in development. 
L - 8 

switching operation death, the SOFA Working Group prefers that the Inspector in Charge be an 

Operating Practices Inspector or another inspector trained in human factors. 

Investigation protocols are spelled out precisely and clearly in FRA’s 101-page Accident 

Investigation Guidelines: General Compliance Manual, Part IV, Chapter 9 (2006). The process 

is complex and thorough. FRA investigators interview virtually everyone with first-hand 

knowledge of the case. They examine the site and equipment involved, and consult records, 

photos, maps, etc. When necessary, FRA investigators may subpoena witnesses, require the 

production of records, exhibits, and other evidence, administer oaths, and take testimony. A 

given case may involve collaborating with local law enforcement and emergency response 

authorities, state and local investigators, the National Transportation Safety Board, and/or the 

Occupational Safety and Health Administration. 

Investigation reporting forms are long and detailed. They involve narratives as well as checklists 

and fill-in-the blank items, and conclude with the investigation team’s conclusions regarding 

probable cause and contributing factors. Supporting documentation is attached. 

Investigation Fatality Memoranda are submitted to Regional Review Groups, which may require 

additional information or corrections before forwarding the complete report to the Accident 

Analysis Branch at FRA Headquarters, whose Team Leader then determines which cases are 

within SOFA’s scope. In advance of SOFA meetings, all members are provided the Investigation 

Fatality Memorandum. Supporting documentation (sometimes as thick as six inches) is brought 

to the meeting. 

Veteran SOFA members have noticed a marked improvement in the quality of investigation 

reports over time. This is due, at least in part, to improvements in the Manual recommended by 

SOFA in 1999 and 2004, response to the SOFA recommendation to conduct investigations in 

teams, and regional-level training provided by the Accident Analysis Branch Team Leader. 

2.5.SOFA Case Analyses are Meticulous 

Though all SOFA Working Group members read all Fatality Memoranda in advance, one 

member is assigned to dig deeply into each case, examining the entire case file. The presenter 

completes a data sheet corresponding to the SOFA database fields for basic facts such as time of 

day of the occurrence and the deceased’s age, length of service, and date of last formal safety 

training. He or she sketches the accident site to show the location of tracks, relevant equipment, 

workers, and other pertinent elements for use in a formal presentation. After briefly summarizing 

the case for the Working Group, the presenter highlights particularly relevant supporting 

documentation not found in the summary narrative, and then responds to questions. 

At that point the group dissembles into impromptu small group discussions. These subgroups 

often request supporting documents, such as photos, which are then passed around to the other 

groups. Eventually the Working Group reconvenes as a committee of the whole for further 

discussion and debate. They share theories, alternative explanations, and hunches. By the end, 

most group members are very familiar with the details of the case. 
L - 9 

This year, Google Earth has proven a useful tool. The aerial view of the accident site was 

instrumental to understanding at least one case. Other sources outside the case file are 

occasionally consulted, but only rarely and with the group’s permission. 

The team frequently conducts integrity checks of the SOFA database to assure accuracy and 

completeness of the data. Whereas past SOFA Working Groups have used spreadsheets, the 

2010 Working Group employed a former FRA operations researcher to create a well-designed 

Microsoft Access database, complete with tabs and pull-down menus. The group uses an LCD 

projector to display the forms as they are completed. This helps keep the conversation on track 

and makes it possible to look up similar cases from the past to ensure consistency. The database 

consultant plays the additional role of reminding the group of definitions, criteria for possible 

contributing factors, and so on, thereby contributing to the integrity of the database as well as the 

focus of conversation. 

The evaluation team is impressed with the Working Group’s tenacity. The case analysis process 

is exhaustive, penetrating, and self-reflective. For any given case, some group members have 

experienced or witnessed similar situations. They can picture the circumstances clearly, and 

often ask out loud, “What would I have done? Have I ever made that mistake?” and are visibly 

shaken when the answer is “yes.” 

2.6.The Working Group Reaches Consensus on Key Conclusions About Each Case 

The most important database elements are also those requiring the most judgment. Possible 

contributing factors and external circumstances are assigned only with unanimous agreement. 

Case abstracts of about three sentences, which are published, are word-smithed by consensus. 

Each case analysis is given as much time and attention as necessary to reach consensus. Some 

are completed in an hour; others take most of a day. The group’s commitment to giving each 

case their full attention and adhering to the consensus process takes precedence over any 

concerns about time or efficiency. A SOFA cycle begins with an inventory of several years’ of 

cases, and the group meets for three days each month until they are done. 

2.7.Aggregation of SOFA Case Data was Rigorous 

The SOFA database is thoroughly cleaned. Quantitative analyses are appropriate to the data and 

the research questions. Qualitative analyses, which venture beyond the raw numbers to capture 

important themes by drawing on the Working Group’s experience and judgment, are 

nevertheless well grounded in the data; evaluation team members expert in qualitative methods 

monitored for this as they observed and led the discussions about SOFA’s overarching findings. 

2.8.The SOFA Working Group Practices Continuous Improvement 

The Working Group is to be commended for its commitment to ongoing improvement. SOFA 

1999 did good work, but SOFA 2004 did better, and SOFA 2010 better still. For example, based 

on lessons learned in the aftermath of the 1999 report, the SOFA Working Group issued 

implementation guidelines. When case codes are found inadequate, they are revised and prior 

cases are recoded. When spreadsheets became unwieldy, the SOFA Working Group converted to 

a database. When investigation reports were found incomplete, FRA rewrote the manual and 
L - 10 

retrained the investigators. When the Working Group needed help in getting their findings used, 

they called in experts in evaluation utilization and invited the present process evaluation. More 

examples abound. 

2.9.The Process Evaluation was Thorough and Independent 

The evaluation was performed by five seasoned evaluation professionals (see Appendix B for 

biographical information). The evaluators were independent of the SOFA Working Group and 

utilized established professional standards for evaluation to assess the SOFA processes. 

The evaluation team members attended between two and four SOFA 2010 meetings each. 

Altogether we observed more than a dozen case analyses and led four full-group discussions 

covering such topics as SOFA’s theories of change, efforts to motivate and support use of earlier 

reports, what has worked toward that end, and barriers to implementing SOFA recommendations 

in particular and railroad safety in general. One of those discussions included eight retired SOFA 

members, as well as the 2010 Working Group. We have read past SOFA reports, the FRA 

Accident Investigation Guidelines, and various other documents pertaining to SOFA’s history. 

In addition, we conducted individual face-to-face interviews with ten of the eleven Working 

Group members and its database management consultant, providing them opportunity to voice 

reservations and concerns anonymously. We have been briefed by the SOFA Chair on several 

occasions, conferred with the database management consultant, and examined the database itself. 

The evaluation team found the Working Group fully cooperative, candid, and responsive to 

requests for documents and information. 

3. CONCLUSIONS 

The evaluation team reiterates: The SOFA analyses are systematic, rigorous, comprehensive, and 

objective. The findings are valid, significant, and worthy of the railroad industry’s thoughtful 

attention and bold response. 

We look forward with optimism to the impact of SOFA 2010’s utilization-focused efforts. 
L - 11 

4. REFERENCES 

FRA’s 101-page Accident Investigation Guidelines: General Compliance Manual, Part IV, 

Chapter 9 (2006). 

SOFA Report: Findings and Recommendations of the SOFA Working Group, released in 

October 1999, 

Severe Injuries to Train and Engine Service Employees: Data Description and Injury 

Characteristics, published in July 2001. 

Findings and Recommendations of the SOFA Working Group: August 2004 Update 

Best Practices Guidelines for Implementing Operating Operations (March 2000) 

The 3rd Quarter 2009 report concluded that fatalities related to Operating Recommendations 

have dropped substantially 
L - 12 

Stakeholders collaborate to change RR practice Historically challenging context: R

Study 

utilization of past information dissemination & adoption 

Review 

requirements 

Analyze 

switching fatality data 

Identify 

contributing factors 

Develop 

factors-based recommendations (Findings) 

Disseminate 

Findings

Train yard & 

engine service workers 

RR partners: 

Funders, carriers, associations & management 

Labor unions FRA & 

regulatory agencies 

RR/Labor 

understand need to adopt Findings

Partners see 

need to collaborate on adoption of Findings (how to break down barriers) 

Stakeholders 

see need for voluntary processes 

RR/La

adopt/Findin

Partne

adopt (actuadown 

Reduc

mecha

Mode

voluntprograadopteother p

 Multiple data 

sources 

 Partners  Cooperation & 

collaboration 

 Time  Clear purpose  Experiential, 

technical, & practical knowledge (400 years combined) 

 Analysis skills  Technical 

support 

Train yard & 

engine service 

employee 

fatalities; 

productivity 

demands; 

disjointed 

stakeholder 

groups 

Save lives of 

train yard & 

engine service 

employees to 

measure & 

demonstrate 

effective 

adoption of 

safe practices 

through 

sharing 

resources & 

lessons learned 

Focus – Question – Observe & Ask – Analyze & Interpret – Facilitate & Recommend: Implementation Plan & Buy

APPENDIX A 

SOFA Working Group Process Logic Model
L - 13 

APPENDIX B 

The Evaluation Team 

Deborah Bonnet is Director of Evaluation for Fulcrum Corporation, an engineering firm based in 

the Washington area. She has conducted more than 120 studies in her 35-year evaluation career, in 

most cases as the principal investigator. She earned an M.S. in Human Factors from Virginia Tech 

and an MBA from Indiana University, and has held various leadership positions in the American 

Evaluation Association.9

Michael Coplen is Senior Evaluator and Manager of Culture and Safety Performance Studies for the 

Federal Railroad Administration, Office of Research and Development, Human Factors Program. He 

began his career as a railroad brakeman and engineer and later earned an M.A. in Organizational 

Behavior from the University of Nebraska. His 15 years as an evaluation practitioner include 

membership on the first SOFA Working Group. He was recently awarded the Myrdal Award for 

Government Service by the American Evaluation Association for successful evaluation use in FRA 

and promotion of evaluation methods in the Federal government. 

 

Michael Quinn Patton is an independent evaluation consultant, former president of the American 

Evaluation Association, and author of five major books on evaluation, including Utilization-Focused 

Evaluation. After receiving his Ph.D. in Sociology from the University of Wisconsin, he served for 

many years on the faculties of the University of Minnesota and the Union Institute. He has worked 

with organizations and programs at the international, national, state, and local levels, and with 

philanthropic, not-for-profit, private sector, and government programs as a generalist working across 

the full range of efforts at improving human effectiveness and results. 

Joyce Ranney is a senior program evaluator in the Human Factors Research and System 

Applications Center of Excellence at the Volpe National Transportation Systems Center. In the last 

several years she has conducted five major multiyear evaluation studies in the railroad industry 

showing significant bottom line improvements in safety and safety culture. She holds a B.S. in 

Speech from Southern Illinois University and a Ph.D. from University of Los Angeles, CA in 

organization behavior. 

Juna Snow is Principal Consultant of InnovatEd Consulting and a subcontractor with the Volpe 

Center. With more than 15 years of experience in educational development, research, and evaluation, 

she serves on the faculty of the University of Illinois at Urbana-Champaign, where she earned an 

M.S. in Ecology and a Ph.D. in Education. She chairs the Research of Evaluation Special Interest 

Group of the American Educational Research Association. 

 

 

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 www.eval.org