Federal Railroad Administration 

Federal Railroad Administration 

Office of Safety 

FRA Approach to 

Managing Gap Safety 

December 7, 2007 

Revision 03 
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FRA Approach to 

Managing Gap Safety 

1. Introduction: 

The Federal Railroad Administration (FRA) is responsible for promoting the safety of the 

Nation’s passenger and freight railroads. To address this responsibility, FRA develops programs 

that identify, monitor, and address railroad safety issues. 

FRA is concerned about the risk of injury to passenger train users posed by the gap between 

railcars and high level station platforms. Although many gap accidents only result in minor 

injuries, they can initiate a chain of events that may lead to serious or fatal injuries. The FRA 

feels that an effective way to address the gap safety issue is for passenger train operators to 

develop a gap safety management program. The gap safety management program should: 

• use engineering evaluation and analysis to establish gap standards for all high level 

stations, and 

• apply mitigation strategies to further reduce the risk of gap accidents. 

The passenger railroad gap safety management program should use hazard management 

techniques, such as hazard analysis, to identify appropriate hazard mitigation strategies. Hazard 

analysis is a process where hazards are identified and recorded and corresponding hazard 

mitigation strategies are identified, recorded and tracked to completion. The hazard mitigation 

strategies should be designed to eliminate, or control gap hazards and to lower the overall risk of 

injury to passengers. The hazard analysis and hazard mitigation process should recognize and 

include any existing strategies currently in place. 

Hazard management is not a difficult process but it is designed to be both comprehensive and 

continuous. Passenger railroads must be prepared to develop and support a long term gap safety 

management program. A hazard management team made up of interdepartmental technical and 

safety experts from the railroad should be established to implement the gap safety management 

program. The hazard management team’s primary role would be to identify the hazards and 

agree on the mitigation strategies. Hazard management is not a one time task but requires the 

passenger railroad go back and periodically reaffirm the gap safety management program. 

Review of the gap safety management program can be triggered by time, by a major event such 

as an accident, or by a change in the method of operations. 

Some passenger railroads already have strong gap safety programs or appropriate hazard 

mitigation strategies in place. The gap hazard management program the FRA is suggesting is 

meant to enhance rather than replace the existing programs. The FRA gap hazard management 

program would compliment and formalize existing programs and document any existing 

mitigation strategies. The FRA gap safety management program can also confirm that all 

appropriate hazards have been identified and controlled or reveal hazards that were previously 

overlooked. 
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The gap, as discussed in this document, is defined as the horizontal space between the edge of 

the platform and the edge of the rail car door threshold plate, and the vertical difference from the 

top of the platform and the top of the rail car door threshold. 

. Figure 1 contains a diagram that illustrates the gap between the rail car and the platform. 

Figure 1. Horizontal and vertical gap between the railcar door threshold and the platform edge. 

This document presents FRA’s approach to managing gap safety. FRA considers the approach 

to be an effective method of managing safety hazards related to the gap at high level passenger 

platforms and a way to ensure minimum levels of safety for passengers. 

The approach involves the following elements: 

1. Station Gap Standards 

2. Hazard Management 

3. Maintenance Procedures 

4. Inspection Procedures 

5. Hazard Mitigation Strategies 

6. Gap Safety Management Follow-up 

Each step in the gap safety management process will be broken down and discussed in detail. 

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2. Station Gap Standards: 

Passenger railroads should establish station gap standards for all high level platforms. The 

station gap standards should define the size of the gap between the door threshold and the 

platform by identifying critical dimensions that define the gap (such as the distance between the 

centerline of the track and the platform edge). These critical dimensions should include 

tolerances and be specified in the station gap standards. The standard gap that is determined at a 

particular station or stations is based on the geometries of the track, platform and the equipment 

that utilizes the station. Tolerances of the equipment, track and platforms will result in actual gap 

measurements which may vary from the standard gap. 

Station gap standards may already exist in state regulations or the railroads own internal 

requirements. Some states, such as New York and Massachusetts, already have dimensional 

requirements for the location of high level platform edges with respect to the centerline of the 

track. Some of the state requirements were established to ensure proper clearance between 

railroad freight cars and the platform edges rather than maintain a safe gap for passenger 

boarding and alighting. In any case, passenger railroads should be aware of any state 

requirements and use those requirements as the starting point for establishing station gap 

standards. 

Once the basic gap dimension requirements are established, passenger railroads should look for 

opportunities to reduce the gap. In some cases, rail traffic mix, method of operation, station 

configuration, or other factors will not support reducing the gap beyond the current requirements. 

If an engineering evaluation supports this conclusion, then maintaining the basic gap dimension 

is the appropriate action. However, larger gaps pose a greater risk for a passenger falling 

through the gap and may require specific mitigation strategies to control risk. Therefore, stations 

with larger gaps will likely need more hazard mitigations than stations with smaller gaps. 

To determine if the gap dimension can be reduced, the railroad should review the current gap 

dimension requirements with respect to the operational environment. For example, the actual 

gap dimension may vary depending on the configuration of the station. Stations located on a 

curve will require more clearance between the rail car and the platform edge than stations on 

tangent track. Stations on curved track must compensate for car overhang on the ends. 

As shown in Figure 2, the width of the gap depends on the sharpness of the curve, the length of 

the rail car, the truck spacing, the location of the doors relative to the trucks, and whether the 

platform is located on the inside or the outside of the curve. 
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Figure 2

Figure 2. Illustration showing the relationship of the rail car doors and the platform edge on 

curved track. 

Gap dimensions may also vary due to the type of rolling stock that uses the station. For example, 

some passenger railroads operate different widths of passenger equipment depending on the type 

and generation of the passenger car. Other railroads may operate identical passenger equipment 

but must accommodate commuter passenger equipment, long distance passenger equipment, 

freight equipment, or high and wide over dimension traffic at some or all of their stations. In 

other cases, stations or end terminals may be exclusively used by similar equipment and be able 

to tolerate a narrower gap. Still other stations may have to accommodate a subset of the types of 

trains described above. 

Train speed is also a consideration when developing gap standards. Some passenger operations 

have rail traffic that passes high level platforms without stopping. In this situation, the dynamic 

characteristics of the passing trains must be considered and enough clearance provided between 

the train and the platform edge to prevent railroad equipment from striking the platform edge. 

It is clear from this discussion that different gap standards may be appropriate for different 

stations and that gap dimensions maintained by the railroad may vary with the circumstances. A 

railroad with some tangent and some curved station platforms and a variety of equipment passing 

through stations will probably need more than one gap standard for its stations. In the extreme, 

each individual station may need to have its own gap standard due to the characteristics of the 

station and the type of traffic. Passenger railroads should consider all of the variations in 

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operations that exist on their property as they develop station gap standards or attempt to further 

reduce the gap. 

3. Hazard Management: 

Once a passenger railroad has established gap standards for all of its high level stations, the 

hazard identification and hazard management process can begin. FRA suggests that the 

passenger railroad use a comprehensive hazard analysis as the core of the hazard management 

process. Passenger railroads should already have hazard analysis techniques identified as part of 

their system safety program plans. The techniques identified in the system safety program plan 

should be appropriate for conducting a hazard analysis on the gap safety issue. If the current 

hazard analysis techniques are not appropriate for analyzing the gap issue then the passenger 

railroad should develop a new hazard analysis approach. 

Appendix A of this document contains guidelines for conducting a gap safety hazard analysis 

that can minimize risk to passengers. The hazard analysis guidelines are based on the United 

States Department of Defense 1993 document “System Safety Program Requirements,” Mil-Std882C and the hazard identification and resolution process described in APTA publication 

“Manual for the Development of System Safety Program Plans for Commuter Railroads.” The 

APTA document and Mil-Std-882 are excellent methods for conducting hazard analyses in a 

disciplined, structured manner. A disciplined and structured approach is valuable because it 

allows hazards to be systematically identified, inventoried, analyzed, and addressed. The 

methodology ensures that all hazards and mitigation strategies are adequately reviewed. The 

process provides a permanent record of the hazard analysis and serves as a reference document 

to review and analyze future accidents or changes in system operations. 

4. Maintenance Procedures: 

Once gap standards are established and the gap is set within tolerances, maintenance procedures 

will be needed to service station platforms, track, and rolling stock because elements of these 

items can directly affect the gap. Comprehensive maintenance procedures are vital for keeping 

the gap within acceptable tolerances. Many of the maintenance procedures that affect gap safety 

may already be in place in the passenger railroad’s maintenance plan. 

For example, station maintenance can affect the gap and the overall risk to passengers boarding 

the train. Platform resurfacing and modifications should only be performed when their influence 

on the gap is understood. Extended edges also need to be maintained to preserve the established 

gap and ensure that firm footing is available at the edge of the platform. Damaged or broken 

edges should be repaired promptly and with adequate consideration for maintaining the correct 

gap. 

Track maintenance is another area that can influence the gap. The relative position of the track 

with respect to a stationary platform edge essentially defines the gap. Track maintenance 

including track alignment, leveling, cross level and ballast cleaning may move the track laterally 

and horizontally and will directly affect the gap. Track class designations may also affect 
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maintaining the gap because lower classes of track allow greater tolerances on vertical and 

horizontal alignment. A more extensive list of some of the elements that should be considered 

for managing the gap from a track and platform perspective appears in Appendix B. 

Rolling stock maintenance involving the wheels, car suspension, or car leveling system can also 

influence the gap at a station platform. Worn wheels lower the car floor and can continuously 

impact the vertical gap over the life of the wheel set. Settling and wear in truck suspension 

components can affect the horizontal and the vertical gap. Worn truck components can allow 

excessive side to side clearance that can either close or open the horizontal gap depending on the 

vehicle dynamics as the rail car rolls to a stop at a station. Rail car pneumatic leveling systems 

that use air springs can also affect the vertical gap if they are not maintained or properly 

adjusted. Other rolling stock components that may potentially affect the gap are listed in 

Appendix C. 

In a perfect world with unlimited resources and a perfect maintenance program, the influence of 

maintenance procedures on the gap would probably not be a consideration. However, passenger 

railroads sometimes have to make decisions on deferring or delaying maintenance on track and 

equipment that is in need of repair. The effect of deferred maintenance on gap safety should be 

considered in the discussion. 

Finally, passenger railroads should have specific maintenance procedures in place to respond to 

gaps that are out of tolerance. When the gap is out of tolerance, there should be standard 

procedures used to systematically review the platform, track, and rolling stock to determine the 

cause and correct the out of tolerance condition. 

 5. Inspection Procedures: 

Inspection procedures can provide the railroad with comprehensive information necessary to 

manage gap safety. Once a railroad establishes a gap standard and uses the standard to adjust 

station platform gaps, periodic inspection of the gap is necessary to monitor and maintain the gap 

within tolerances. Periodic inspections should be conducted often enough to detect any 

significant movement of the track with respect to the platform and confirm that the rolling stock 

is working satisfactorily within the system. The passenger railroads should determine 

appropriate inspection periods and procedures based on their gap standards and tolerances. 

The inspection program may yield valuable information on how the gap varies from day to day - 

train to train – or car to car. The railroad should establish limits for the gap that trigger 

appropriate actions to determine the cause and to correct the gap. Correcting the gap may 

require maintenance on the track, the rolling stock, the station platform or a combination thereof. 

The passenger railroad’s inspection procedures may require measuring the distance between the 

centerline of the track and the platform edge or measuring the actual gap between the door 

threshold and the platform edge. Measuring the actual gap, however, only indicates that the gap 

is within or outside tolerances. Measuring the actual gap does not indicate the contribution of 

the station platform, track, or rail car to the overall gap dimension. The contribution of other 

components can only be determined through additional inspections of the platform, track, and 
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rail cars that make up the system. Procedures should be established to decide what action to take 

if the actual gap dimension is out of tolerance.

In support of hazard management, it is important that the gap be inspected periodically based on 

a specific time interval – not just after an accident or incident. 

6. Hazard Mitigation Strategies: 

After the passenger railroad has established gap standards and reviewed or modified the 

maintenance and inspection criteria to maintain the gap, the railroad is still left with a hazard. 

The gap dimension and tolerances may be well established and understood but the remaining gap 

still poses a risk to passengers. 

System safety and hazard management techniques are used to identify additional steps necessary 

to further reduce the risk to passengers. FRA believes that using a hazard analysis approach to 

identify and mitigate hazards as described in Section 3 of this document is an appropriate way to 

proceed. Using a hazard analysis approach documents the hazard and – just as important – 

documents the hazard mitigation. Only when you have a complete hazard list with 

corresponding hazard mitigation strategies are you actually performing hazard management. 

Larger gaps pose a greater risk for a passenger falling through the gap and may require specific 

mitigation strategies. If a railroad decides to follow the basic gap dimension requirements 

specified by the state or other regulatory entities, then the railroad should be prepared to identify 

and institute additional mitigation strategies to reduce the risks to all passengers – including 

those with disabilities, the aged, or the very young. Some suggestions of items to be considered 

when identifying mitigation strategies for high level platforms appear in Appendix D. 

Several types of hazard mitigation strategies are available to manage gap hazards. These 

include: 

• Hardware and Technology 

• Policies and Procedures 

• Employee Training 

• Passenger Outreach 

• Passenger Behavior 

6.1 Hardware and Technology: 

Hardware and technology solutions can offer effective hazard mitigation and should be carefully 

considered. Engineered systems are especially useful because many are not dependent on the 

human being to follow a procedure or take an action. There are many examples of hardware and 

technology used in the passenger railroad industry used to reduce the gap or to assist passengers 

to safely board or alight from trains. The passenger railroads should carefully evaluate any 

proposed technology or hardware solutions because they may create other safety hazards. 

Moveable platforms have been applied to some stations and are designed to close the gap after 

the train arrives. The moveable platform is especially appropriate for reducing the gap at stations 
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located on curved track. Figure 3 shows an application of an extendable platform on New York 

City Transit. Pictures of platform edge extenders used at a station on a curved track are shown 

in Figure 4. Other stations use platforms with fold up edges that provide comfortable boarding 

for commuter trains but can be folded out of the way to allow high and wide freight or military 

trains to pass. 

Figure 3. Photograph of the extendable platform used on New York City Transit indoor 

platforms. 

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 Figure 4. Moveable platform edge

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Gauntlet tracks that provide increased clearance between the rolling stock and the platform edge 

are used at some stations to route freight trains and excess dimension equipment past station 

platforms. Passenger trains are routed on a second track located to maintain an appropriate gap 

for passenger boarding and alighting. 

One manufacturer has developed a rubber platform edge with fingers that extend towards the 

door threshold to serve as a gap filler. The fingers provide fall through protection and also bend 

out of the way if struck by a passing trains. The configuration of the rubber platform edge is 

shown in Figure 5. 

 Figure 5. Extended rubber fingers on platform edge gap filler. 

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The resulting gap can also be mitigated by adding extended threshold plates to the passenger car. 

The threshold extender can close the gap to make boarding or alighting safer. A gap filler used 

on the Washington METRO is shown in Figure 6. 

Figure 6. Rubberized gap filler attached below threshold on WMATA car 

(shown from below). 

Some commuter railroads use lighting at edge of the platform and door threshold interface to 

accentuate the gap and warn passengers of the danger. Gap safety lighting can either be mounted 

under the platform or under the door threshold. 

Another method to reduce the gap is to use power bridge plates that extend the door threshold 

towards the platform edge or bridge the gap completely. A power bridge plate or door threshold 

can be helpful to disabled passengers when boarding and alighting from the train. 

Other hardware and technology solutions exist that can be effectively used to mitigate gap 

hazards. 

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6.2 Policies and Procedures: 

A passenger railroad may need to develop new policies or procedures that serve as hazard 

mitigation strategies. Policies and procedures can be an important component of safe operation. 

The passenger railroad should use the hazard analysis to identify the specific types of policies 

and procedures that are needed. The hazard analysis may show that the railroad already has all 

the necessary policies and procedures in place. However, sometimes the analysis will indicate 

the need for new or modified policies and procedures to support the gap safety program. 

For example, some railroads restrict the number of doors that can be opened on certain curved 

platforms. Restricting door openings to those with the smallest gap on a curved platform can 

mitigate some of the safety risk for passengers boarding or alighting from the train. This 

procedure serves as an important hazard mitigation strategy. 

Other passenger railroads have special procedures to observe doors as they close or as the train 

leaves the platform. Door operations are not directly related to gap safety, door operations are 

certainly part of the station system, and observing the train during loading, unloading, and door 

closure can assist in detecting a gap accident and preventing a train from leaving a station with 

someone trapped in the gap or on the tracks. 

At some stations or under some operating conditions, it may be necessary to post a station 

attendant on the station platform to monitor and assist passengers during boarding and alighting. 

Special policies and procedures that specify when and where a station attendant should be used 

may need to be developed as a hazard mitigation strategy. For example, platform crowding 

during special events may become an issue. Crowding on platforms may result in additional gap 

incidents – even on platforms with minimal, well controlled gaps. When excessive platform 

crowding is expected, platform monitors or other special processes or procedures may be 

appropriate. 

6.3 Passenger Outreach: 

A comprehensive passenger outreach program can serve as an effective method to enlist the help 

and cooperation of the passengers in gap safety. The program should utilize a variety of media 

to effectively present the information. The media may include: 

• On Board Announcements 

• Signage 

• Posters 

• Brochures 

• Seat Drops 

• Videos 

Onboard announcements can be used to address gap safety. Amtrak and some other railroads 

operating in the northeast include “watch the gap” in the conductor’s station announcements. 
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Signage instructing passengers to “watch the gap” in the area of the vestibule or on the station 

platform may also be appropriate. However, it is important not to provide so much signage in 

the vestibule area as to become ineffective or to detract from other important signage in the area. 

Posters with gap safety themes can be mounted on advertising racks throughout the train. Gap 

safety (or general safety) brochures can be located in racks next to train timetables or 

incorporated in public timetables distributed to passengers. Additional information can be 

included on tickets or monthly passes. 

On some railroads, seat drops may be appropriate. Seat drops are brochures, letters, or 

pamphlets left on every passenger seat at the beginning of service. Each passenger would have 

to pick up the material before sitting. 

Videos are another important tool – especially on commuter railroads that have advertising or 

information monitors on their trains or platforms. 

If a commuter railroad has access to celebrities, then a taped celebrity announcement may be 

helpful. The Las Vegas airport uses celebrity announcements to provide safety and security 

information to patrons. For example, Don Rickles instructs airport patrons to hold children’s 

hands when using the escalator. A similar automatic celebrity announcement may be 

appropriate for some trains or station platforms. 

Passenger outreach announcements and materials should be clear and concise but detailed 

enough to define the gap and the related safety issues. The message should be targeted at all 

passengers – both regular customers and one time users – so that everyone will fully understand 

the gap issue and act accordingly. 

6.4 Employee Training: 

New policies or procedures developed as gap safety hazard mitigation strategies should be 

addressed in training programs as necessary. The training should be focused on the particular 

groups that are responsible for carrying out the new policies and procedures such as: 

• Train crews, 

• Maintenance staff, 

• Station personnel, 

• Station supervision, 

• Station security, and 

• Railroad police 

Training should also be developed for others who deal directly with gap issues. 

The type of training that is provided will vary depending on the requirements for hazard 

mitigation. Trainmen and conductors may need training in such areas as: 

• Look back procedures 
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• Monitoring door openings and closings 

• Assisting special needs passengers on and off the train 

• Platform monitoring 

Track, car, and platform maintenance workers may require training in: 

• Critical maintenance procedures that affect the gap 

• Approved inspection procedures for monitoring the gap 

• Quality control during and after maintenance procedures that affect the gap 

Training is essential for establishing and maintaining employee involvement in mitigation 

strategies designed to minimize the risk posed by the gap. 

6.5 Passenger Behavior: 

Passenger behavior is often random and hard to control. Train crews are hard pressed to reliably 

predict what a passenger may do next. However, there are steps that can be taken to influence or 

respond to undesired passenger behavior – especially behavior that may lead to unsafe acts 

during boarding and alighting from trains. 

To analyze gap hazards related to passenger behavior, the passenger railroad should first identify 

the situations or types of behavior present on the railroad that can lead to gap safety hazards. For 

example, the passenger railroad may be concerned with the following types of behavior: 

• Disorderly Conduct or Disruptive/Unsafe Behavior 

• Unmonitored children 

Disorderly Conduct or Disruptive/Unsafe Behavior can lead to gap safety hazards – especially if 

taking place when the individuals are boarding or alighting from the train. Unmonitored children 

pose a risk to themselves and others when they run down the platform to board a train. Even a 

small gap can pose a hazard to an unsuspecting child that is not properly supervised. 

The key to responding to these types of behavior is to have policies and procedures in place to 

address the issues as they occur. The responsibility for developing the policies and procedures 

belongs to the passenger railroads but the responsibility for addressing the behavior rests 

primarily with the on board crew. Passenger railroads should establish passenger behavior 

policies and insist that their crews enforce those policies. The railroads should determine if there 

are adequate existing policies in place to address the types of behavior that lead to gap safety 

issues. For example: 

Does the railroad have policies that: 

• Address issues of disorderly passengers or those displaying disruptive and/or unsafe 

behavior on the station platforms or trains including denying boarding or putting 

individuals off the train? 

• Require train crews to address issues with unmonitored children on trains or on 

station platforms? 
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Passengers may need to be reminded of the responsibilities of the conductor and his right to 

address passenger behavior issues. For example, a commuter railroad could provide a flyer that 

states the conductor’s authority and responsibility to remove disorderly passengers or those 

displaying disruptive and/or unsafe behavior from the train. 

Passenger behavior issues are delicate issues but they must be addressed in a consistent and 

responsible manner. The railroad must provide their onboard crews with the tools that they need 

to control the situation. This includes the policy, appropriate training, and support when the 

policy is applied. If a passenger railroad uses new or existing policies as a hazard mitigation 

strategy, then the policies must be enforced. The passenger railroad should use efficiency testing 

or observations to ensure that crews consistently follow the policies. 

Other types of passenger behavior can be broken down in a similar way. Using a hazard 

management team to explore passenger behavior issues by asking questions and reviewing 

policies can lead to identifying appropriate mitigation strategies to address the behavior. 

7. Gap Safety Management Follow Up 

The passenger railroad gap safety management plan is an ongoing activity that will require 

regular follow up. Periodic review of the hazard management plan and the hazard analysis 

should be conducted to ensure that mitigation strategies remain fully implemented and that all 

hazards are satisfactorily closed out. 

The hazard management program described in this document and captured in the hazard analysis 

should also be reviewed as changes occur in the configuration or the operation of the passenger 

rail system or as the external environment changes. The hazard analysis worksheets should be 

revisited and updated whenever changes occur. Changes that can affect the hazard analysis 

include: 

• new or expanded passenger service, 

• revised operations procedures, 

• use of new or modified equipment 

• changes to existing stations or building new stations 

It is important to make the hazard analysis a living document that can be modified and updated 

as new information is collected about the gap safety issue. The hazard analysis work sheet 

should also be reviewed after each serious gap accident or incident to determine if the hazard 

analysis and the mitigation strategies are valid or need to be updated. The review of the hazard 

analysis is conducted to confirm that all hazards are identified and that the frequency and 

severity classifications for specific hazards remain accurate. 
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8. Summary: 

FRA encourages passenger rail operators to examine the risk posed by the gap between the rail 

car door threshold and high level station platforms and recommends that all passenger rail 

operators establish gap safety management programs to establish and consistently maintain a 

uniform gap and uniform boarding and alighting conditions at each station. The gap safety 

management program should: 

• use engineering evaluation and analysis to establish gap standards for all high level 

stations, and 

• apply mitigation strategies to further reduce the risk of gap accidents. 

Recognizing that passenger railroads typically operate over the rights-of-way of freight railroads, 

FRA recommends that, in developing and implementing gap safety management programs, 

passenger rail operators coordinate with the freight railroads which host their operations or 

which operate over passenger railroad owned lines, and that the freight railroads assist in their 

efforts to promote platform gap safety. Using this approach, FRA hopes to achieve 

improvements in passenger rail platform safety. 

The hazard analysis approach outlined in Appendix A of this document represents one method to 

conduct hazard analysis. However, there are many other methods and techniques for managing 

hazards. Additional information on how to apply hazard management techniques to railroad 

operations exists in a variety of documents. The documents listed in the bibliography section 

represent a small sample of the type of information available. 
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9. Bibliography 

U.S. Department of Defense. 1993. “Military Standard, System Safety Program 

Requirements.” Mil-Std-882C. Washington, DC: U.S. Department of Defense. 

American Public Transportation Association. 2000. “Manual for the Development of 

System Safety Program Plans for Commuter Railroads.” Washington, DC: American 

Public Transportation Association. 

U.S. Department of Transportation Federal Transit Administration. 2000. “Hazard 

Analysis Guidelines for Transit Projects.” Washington, DC: U.S. Department of 

Transportation. 

Bahr, Nicholas J. 1997. System Safety Engineering and Risk Assessment: A Practical 

Approach. New York, NY: Taylor and Francis. 
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APPENDIX A 

HAZARD ANALYSIS PROCESS 

1. Hazard Management System Safety Approach 

The system safety approach is a holistic process for hazard analysis because it considers the 

overall passenger railroad system. A passenger railroad system is made up of the following 

elements: 

PEOPLE PROCEDURES EQUIPMENT

AND

FACILITIES

ENVIRONMENT

SYSTEM • People 

• Procedures 

• Equipment & Facilities 

• Operating environment 

These elements need to interact and integrate with each other in order for the system to function. 

Changes to one element or part of an element may have a profound effect on the other element of 

the system, and thus, affect the safety of the system. 

2. Hazard Analysis as a Tool 

Hazard analysis is a tool used in the system safety process to allow a passenger railroad to 

evaluate hazards in the various modes of operation. This process should start in the design phase 

(include any system extensions, modifications, or vehicle purchases) and continue until the 

system is retired; the hazard analysis is a continuous process. 

Hazard analysis is defined as an analysis performed to identify hazardous conditions for the 

purpose of their elimination or control. The purpose of hazard analysis is to: 

3⁄4 Identify safety hazards and their causes 

3⁄4 Determine hazard severities/probabilities 

3⁄4 Recommend corrective action to correct procedures and resolve design problems 

3⁄4 Provide documented evidence of compliance with design, code, or specification 

requirements to management 

2.1 Identifying Hazards 

The passenger railroad hazard management team must have a working knowledge and 

understanding of how the individual system elements (people procedures, facilities & equipment 

and the environment) interface with each other. When identifying safety hazards present in a 

system, every effort should be made to identify and catalog all potential hazards. For the 

purpose of this project we will limit ourselves to platform gap safety. However, if in the process 

of identifying hazards, other non related hazards are identified, then they should also be captured 

and analyzed. 

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There are many techniques for identifying hazards. Basic methods to help identify hazards may 

include: 

• Data from previous accidents or operating experience or case studies. 

• Scenario development (what if) and judgment of knowledgeable individuals (hazard 

management team members) 

• Development of Generic hazard checklists. 

• Development of specific hazard checklists pertinent to the operating railroad 

• Pictures 

• System tours 

• Formal hazard analysis techniques 

• Design data and drawings 

• Analysis and compare similar systems 

• Identify codes standards and regulations that may affect the system (highway codes 

regarding grade crossing) 

3. Hazard Analysis and Resolution Process 

There are five main steps in performing the hazard analysis process. They are: 

1. System Definition 

2. Hazard Identification 

3. Hazard Assessment 

4. Hazard Resolution 

5. Follow Up 

The five steps are shown schematically in Figure A1. Each step of the process will be explained 

in detail in the following sections. 

3.1 Step 1 – System Definition 

The first step of the hazard analysis identification and resolution process is to define the 

system under consideration. A good system definition is important to understand the 

environment and interfaces that occur during operation of passenger trains – especially 

those elements that may positively or negatively affect safety. The system definition is 

best accomplished by individuals who are intimately familiar with the passenger rail 

operation. 

The system definition should be a narrative statement that fully describes, at a minimum, 

train operations, the rolling stock, track configuration, infrastructure, and environment. 

This guideline will limit the system to the station platform of the passenger railroad. Here 

are a few examples that may help to define the system. (These examples will vary with 

each railroad). 

• Location of station tangent track and curved track 

• How many passengers utilize station the every day 

• How many and what type of stations make up the system
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Monitor for 

- Effectiveness

- Unexpected Hazard

Figure A1. Schematic diagram of the Hazard Analysis and Resolution Process. 

s

Resolve 

Hazards

Follow-Up

Determine

- Severity

Decide

- to a

Assess Hazards

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Define the System

Identify Hazards Assume Risk of the Hazard

or

Implement Corrective Action

- Eliminate the Hazard

or 

- Control the Hazard

- Probability

and

ccept risk or 

- eliminate / control 

the Hazards

Identify 

- Hazards 

- Undesired Events

and 

Determine

- causes and

- contributing factors 

of the Hazards 

Define

- Physical Characteristics

- Functional Characteristic 

and 

Understand and Evaluate 

- People, 

- Procedures, 

- Facilities, and Equipment, 

- Environment.

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• Location of stairways escalators and elevators 

• Pedestrian crossings at station locations 

• Type of Platform edge 

• Boarding level or low level boarding 

• Number and type of trains that pass through the station 

• Operating environment (Weather) 

The system definition list presented above is not intended to be a complete list but a 

sample of the types of information that should be collected on the passenger rail 

property. The system definition list will vary depending on the specific conditions 

and circumstances that exist on a particular passenger railroad. It is important that the 

individuals who develop the definition list include all elements that could potentially 

affect safety. Therefore, the system definition should be prepared by a team that is 

very familiar with the passenger rail operation. 

3.2 Step 2 – Hazard Identification:

Hazard identification is looking for potential hazards that may exist on the passenger 

railroad property. In this case, the area of interest is platform gap safety so hazard 

identification should be restricted to those hazards related to primary or secondary 

platform gap incidents. Many organizations form an expert panel or hazard 

management team to identify the hazards related to the operation. The team consists 

of individuals who have detailed knowledge of the system. As a minimum, a 

passenger rail hazard management team should include representatives from the 

system safety, operations, mechanical, and track & signals departments. 

Hazard identification is a “What if?” activity that looks for the potential causes and 

results of accidents. The hazard management team “brainstorms” to come up with as 

many viable hazards as possible for use in the hazard analysis. In this case, the focus 

of the Hazard Management Team should be to identify hazards that could result in 

passenger injury as a result of platform gaps, second train coming or other platform 

hazards that affect the safety of passengers. 

Some hazards, such as excessive platform to train gaps, may seem obvious. Other 

types of hazards such as passenger behavior may not be as obvious but should be 

considered. Use prior accidents as examples of what might happen and determine if 

the same scenario is possible. 

Some of the hazards that are associated with passenger gap platform incidents that

should be considered in the hazard analysis are listed below. 

• Passenger Accidents 

o Passenger falls between the Train and the platform 

o Passenger slips on platform 

o Passenger caught in door 

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Federal Railroad Administration 

o Passenger slips while boarding or alighting the train 

o Child falls into gap when boarding the train 

• Vehicle incidents 

o Wide load freight train hits side of platform 

o Vehicle suspension system failure 

o Vehicle wheel wear 

o Door Failure 

• Track Structure 

o Track movement 

o Super elevation 

o Track Maintenance 

o Track configuration 

o Rail wear 

As with the system definition list, the above list is not intended to be a complete list 

of all the hazards that should be considered. The hazard management team is in the 

best position to identify potential accidents on the specific passenger railroad. The 

hazard management team should consider the physical characteristics of the 

passenger railroad when identifying the hazards. 

3.3 Step 3 – Hazard Assessment 

There are many ways to document and assess the hazards identified. Generic hazard 

analysis worksheet can be found in this Guide. Each railroad should tailor the work 

sheet to suit their environment and develop a worksheet that the hazard management 

team is comfortable using. 

3.3.1 Classification/Assessment of Hazards 

Classification and assessment of hazards is challenging and probably the most intense 

part of the hazard analysis process. This process takes place once the hazards are 

documented and the railroad hazard management team) sits down to classify and 

assess the hazards. 

3.3.2 Assessment Tools 

One of the tools used in all industries is Mil Standard 882. This standard was 

designed by the military for analyzing weapons systems where there were no outside 

influences on the system. The weapons systems were under the complete control of 

the military. Railroads have outside influences that are beyond their control. Thus 

the Mil Standard needs to be adjusted for the railroad environment. The railroad may 

want to examine methods to classify hazards that are meaningful and practical to its 

operation. 

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Federal Railroad Administration 

The hazard assessment approach involves assessing each hazard for severity and 

frequency to determine the relative risk of different types of occurrences. The 

assessment can be based on statistics (quantitative) or the collective opinions of the 

hazard management team (qualitative). Since quantitative data are often not available 

for accident severity or frequency or are not directly applicable to a specific 

passenger rail operation, a qualitative analysis, properly executed, is an acceptable 

method to perform hazard assessment. 

The hazard assessment should follow ground rules for hazard resolution defined in 

the passenger railroad’s system safety program plan or established by the hazard 

management team. The hazard resolution procedure should be established early to 

prevent disagreements on accepting or rejecting mitigation strategies. The hazard 

assessment should include several steps: 

 

3.3.2.1 Hazard Criticality 

A risk matrix should be developed to provide a framework to categorize hazard 

severity and frequency and allow the hazards to be prioritized so that the most 

important hazards are addressed first. There are other approaches to the risk matrix 

and, as mentioned above, a passenger railroad may already have developed a standard 

risk matrix approach defined in their system safety program plan. If an existing risk 

matrix approach is not available, then an approach similar to the Mil-Std-882C 

approach described below should be followed. 

First, classify the hazards identified in the hazard identification step into criticality 

categories. How serious is the hazard under evaluation? Use the criticality 

definitions shown in Table A1 or develop appropriate alternatives that are 

meaningful for gap safety. 

Category Description Definition 

I Catastrophic Death, system loss, or severe environmental damage. 

II Critical Severe injury, severe occupational illness, major system 

or environmental damage. 

III Marginal Minor injury, minor occupational illness, or minor 

system or environmental damage. 

IV Negligible Less than minor injury, occupational illness, or less than 

minor system or environmental damage. 

Table 1. Hazard Criticality Categories from Mil-Std-882C. 

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Federal Railroad Administration 

In the railroad industry, where any incident can lead to a serious or fatal injury, it is 

sometimes necessary to consider the level of system loss when assessing the 

criticality of a hazard. Considering system loss is not meant to downplay the 

occurrence of a serious or fatal injury but is provided as an additional tool to 

determine the relative seriousness of a hazard. For example, an incident at a station 

platform involving a passenger who fell into the gap could shut down passenger rail 

service for an extended period of time. Therefore, a hazard that causes this level of 

disruption should probably be considered critical or catastrophic – even if the hazard 

does not generate serious personal injury. 

3.3.2.2 Hazard Frequency

Once the hazard criticality is determined, the frequency of the hazard should be 

established. The frequency of the hazard can be determined quantitatively using 

failure rates or accident/incident statistical data. The frequency can also be 

established qualitatively based on the relative frequency of expected occurrence. An 

estimate of how often a hazard may occur during the life of the system may be helpful 

in establishing frequency. Mil-Std-882C guidance on hazard frequency is shown in 

the first columns of Table A2. The last column illustrates a time based method to 

look at frequency that may be more meaningful for gap hazard analysis. The railroad 

should develop frequency categories that are appropriate for their gap safety hazard 

analysis and that are useful for determining the relative frequency of occurrence of 

various gap incidents. 

Level Description 

Quantitative 

Definition (Frequency x)

Qualitative 

Definition 

Time 

A Frequent x > 1x10-1 Likely to occur frequently, 

continuously experienced in the 

system. 

Once a 

week 

B Probable 1x10-1 > x > 1x10-2 Will occur several times in the life 

of an item, will occur frequently in 

the system. 

Once a 

month 

C Occasional 1x10-2 > x > 1x10-3 Likely to occur some time in the life 

of an item, will occur several times 

in the system 

Once a year 

D Remote 1x10-3 > x > 1x10-6 Unlikely but possible to occur in the 

life of an item, unlikely but can 

reasonable be expected to occur in 

the system. 

Once every 

10 years 

E Improbable 1x10-6 > x So unlikely that it can be assumed 

occurrence may not be experienced, 

unlikely to occur but possible. 

Less than 

once in 10 

years 

Table A2. Hazard Frequency Categories from Mil-Std-882C. 

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Federal Railroad Administration 

3.3.2.3 Risk Matrix

The next step in the process is to establish a risk matrix to assess each hazard and 

provide guidance on how to eliminate or control the hazard. The risk matrix also 

serves to establish, the overall relative risk for each hazard. Risk is defined as a 

combination of the probability and the severity of a hazard (the frequency and 

criticality). Table A3 contains a risk matrix that combines the frequency and 

criticality for each hazard. The frequency and criticality can be used to find the level 

of risk for each hazard. 

Associated with each level of risk are recommended actions that provide guidance on 

how to respond to each identified hazard. A list of recommended responses appears 

in Table A4. 

Hazard Categories 

Frequency of 

Occurrence 

I 

Catastrophic 

II 

Critical 

III 

Marginal 

IV 

Negligible 

A – Frequent 1A 2A 3A 4A 

B – Probable 1B 2B 3B 4B 

C – Occasional 1C 2C 3C 4C 

D – Remote 1D 2D 3D 4D 

E – Improbable 1E 2E 3E 4E 

Table A3. Risk Matrix Hazard Categories from Mil-Std-882C. 

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Federal Railroad Administration 

Risk Matrix 

Hazard Category 

Suggested Action 

1A, 1B, 1C, 2A, 2B, 3A Unacceptable, eliminate hazard. 

1D, 2C, 2D, 3B, 3C, 4A, 4B Undesirable, upper management decision to accept or 

reject risk. 

1E, 2E, 3D, 3E Acceptable with management review. 

4C, 4D, 4E Acceptable without review. 

Table A4. Suggested Responses to Risk Matrix Hazard Categories. 

3.3.3 Applying the Tools to Classify Hazards (What do we do with the 

information?) 

So now that we are in the process of assessing the probability and severity of the 

hazardous events, what are we going to due with the information? The Hazard Risk 

Index (HRI), coupled with the Risk Decision Criteria, indicate how the hazard should 

be treated. It is very important to track hazards and verify that they have either been 

controlled or the risk accepted. A closed loop tracking system prevents a hazard from 

slipping through the cracks. 

Lets first look at the Severity Categories. What does your railroad want to define as 

catastrophic, critical, marginal and negligible? Next we take a look at the Probability 

Categories and again what does your railroad want to define as frequent, probable, 

occasional, remote and improbable 

The results of the hazard identification and hazard assessment steps should be 

captured on a hazard analysis worksheet. The hazard analysis work sheet contains all 

of the information collected on each hazard and serves as the record of how hazards 

are to be controlled or mitigated. Use of the work sheet ensures that all identified 

hazards are systematically addressed. A sample work sheet including sample hazards 

appears in Table A5. 

3.3.4 Hazard Analysis Worksheet 

The left side of the hazard analysis worksheet contains information on each hazard 

under consideration. The hazard description and the cause and effects are included in 

this section along with an estimate of the severity and the frequency or probability of 

the hazard. It is important for the hazard to be adequately defined within the 

environment and operating parameters of the passenger railroad. It is important that 

these various combinations be considered when analyzing platform interfaces and 

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Federal Railroad Administration 

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passenger dynamics and associated safety issues because the results of each type of 

incident or issue may be quite different. 

The hazard analysis process should also consider different locations and 

configurations of platforms on the system that may be critical in escalating an 

incident. When performing hazard analyses, consider locations at stations that could 

potentially cause, contribute to, or escalate an incident. 

3.4 Step 4 – Hazard Resolution 

3.4.1 Developing a Mitigation Approach 

The right side of the worksheet includes information on the mitigation approach – the 

strategy adopted to reduce the severity or the frequency of the hazard. Once a 

mitigation approach is determined, the effect of the mitigation strategy on the severity 

and the probability or frequency of the hazard is estimated and the revised risk matrix 

figure is recorded on the worksheet. In this manner, hazards that require mitigation 

can be moved to a lower criticality and/or frequency category where the risk may be 

more acceptable to the passenger railroad operator. As mitigation actions are 

implemented, the status of the hazard will change from open to closed. The last 

column should include references to the dates and documents that establish the 

closure action. 

Some hazards will require more than one mitigation strategy. For example, a 

passenger railroad may decide to place personnel on station platforms with excessive 

gaps as a way of reducing the risk of passenger injury. This would be a valid short 

term strategy but may not be appropriate in the long term. A longer term strategy, 

however, may be to realign and re-tamp the track to the established track centerline to 

platform edge Improvements in rolling stock suspension along with track 

improvements may represent a valid method to reduce platform gap dimensions. 

Therefore, the mitigation strategies or actions should be categorized as short term, 

medium term, or long term actions.

3.4.2 Hazard Precedence 

The hazard precedence approach is a technique for controlling hazards during 

different phases of the system life cycle. Keep the hazard precedence approach to 

hazard mitigation in mind when developing mitigation strategies. The approach is 

most often used on new systems because many hazards can be eliminated during the 

design stage - before the system is initiated and put in service. The hazard 

precedence approach, however, is also useful when assessing existing systems 

although changes to the design become retrofits and are generally far more expensive. 
Federal Railroad Administration 

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Federal Railroad Administration 

Revision 03 30 December 7, 2007 

SAMPLE 

PLATFORM GAP HAZARD ANALYSIS 

WORKSHEET 

HAZARD IDENTIFICATION MITIGATION APPROACH 

Hazard 

Number 

Hazard 

Description Cause Effects S P Mitigation Strategy

Rev.

S 

Rev.

P Status Responsibility Comments 

1 Platform 

Slippery 

weather 

condition 

Weather Condition 

Rain, platform 

surface too smooth, 

standing water. 

Boarding or alighting train 

passenger could slip and fall 

into the gap. 

2 A Establish new maintenance policy to 

include platform drainage 

inspection 

Passenger announcement policy 

includes warning about slippery 

conditions during rain or snow 

events 

Passenger announcement policy 

includes watch the gap 

announcement at all stations 

Follow existing maintenance and 

inspection plan to verify proper 

track alignment to platform 

Change specification for platform 

painting to include abrasives to 

improve footing 

3 B Open Operations, 

maintenance 

and track 

maintenance 

This is a system wide 

hazard during 

inclement weather. 

Review platform 

maintenance contract to 

assure platform drain 

cleaning is part of the 

contract and timely 

response to platform 

maintenance issues is 

addressed. Station 

personnel and crews are 

required to make 

announcements to 

watch the gap per SOP 

P-1 and identify and 

report hazardous 

conditions to 

maintenance control. 

Maintenance control 

will immediately 

dispatch personnel to 

the affected platform 

 The safety department 

will add this item as an 

attribute to audit for 

compliance every 

quarter. The safety 

department will also 

verify quarterly that 

track alignment to 

platform maintenance is 

being performed in 

accordance with Track 

Procedure TA-5. 
Federal Railroad Administration 

Revision 03 31 December 7, 2007 

SAMPLE 

PLATFORM GAP HAZARD ANALYSIS 

WORKSHEET 

HAZARD IDENTIFICATION MITIGATION APPROACH

Hazard 

Number 

Hazard Rev.

S 

Rev.

Description Cause Effects S P Mitigation Strategy P Status Responsibility Comments 

2 Uneven 

transition 

between the 

train and 

platform. 

Track alignment or 

vehicle suspension 

out of tolerance. 

Passenger tripping and 

falling onto the platform, into 

the train or into the gap. 

2 A Follow existing maintenance and 

inspection plan to verify proper track 

alignment to platform 

3 C Open 

Follow existing maintenance and 

inspection plan to verify proper 

vehicle suspension adjustment 

Passenger announcement policy 

includes watch the gap 

announcement at all stations 

Operations, 

vehicle and 

track 

maintenance 

The safety department 

will verify quarterly that 

track alignment to 

platform maintenance is 

being performed in 

accordance with Track 

Procedure TA-5. 

Vehicle maintenance 

suspension inspections 

will be conducted 

monthly in accordance 

with Procedure VS -03. 

Station personnel and 

crews are required to 

make announcements 

to watch the gap per 

SOP P-1 The safety 

department will audit 

for compliance quarterly 
Federal Railroad Administration 

Revision 03 32 December 7, 2007 

SAMPLE 

PLATFORM GAP HAZARD ANALYSIS 

WORKSHEET 

HAZARD IDENTIFICATION MITIGATION APPROACH

Hazard 

Number 

Hazard 

Description Cause Effects S P Mitigation Strategy

Rev.

S 

Rev.

P Status Responsibility Comments 

3 Passenger 

caught in 

closing door. 

Train crew not 

attentive while 

closing the door. 

Passenger caught in door or 

falls in gap as train moves. 

1 A Operating instructions include door 

closure and look back procedures 

Efficiency testing and observations 

policy includes requirements from 

observing crews during look back 

procedures 

Daily car inspection requires that all 

mechanical and electrical door 

interlock devices be in working 

order 

New policy established to take trains 

with malfunctioning interlocks out of 

service 

3 C Open Operations and 

vehicle 

maintenance 

Door interlock switch 

needs to be tamper 

proof. Supervisors will 

monitor and document 

that the door bypass 

switch has not been 

tampered with. 

Develop procedures to 

address conditions 

when the door bypass 

switch is disabled. Door 

look back procedures 

and door by pass switch 

will be observed for 

compliance and 

documented by 

supervision during 

efficiency and 

proficiency testing in 

accordance with SOP-8. 

The safety department 

will audit this process 

on a quarterly schedule 
Federal Railroad Administration 

Revision 03 33 December 7, 2007 

SAMPLE 

PLATFORM GAP HAZARD ANALYSIS 

WORKSHEET 

HAZARD IDENTIFICATION MITIGATION APPROACH 

Hazard 

Number 

Hazard 

Description Cause Effects S P Mitigation Strategy

Rev.

S 

Rev.

P Status Responsibility Comments 

4 Passenger 

caught in 

closing door. 

Train crew not 

attentive while 

closing the door. 

Passenger falls into the gap. 1 A Operating instructions include door 

closure and look back procedures 

Efficiency testing and observations 

policy includes requirements from 

observing crews during look back 

procedures 

3 C Open Operations and 

vehicle 

maintenance 

Door look back 

procedures and will be 

observed for 

compliance and 

documented by 

supervision during 

efficiency and 

proficiency testing in 

accordance with SOP-8. 

The safety department 

will audit this process 

on a quarterly schedule. 

During regular 

maintenance schedules 

all mechanical and 

electrical devices 

associated with door 

operation will be 

inspected and tested 

and results document in 

accordance with SOPVM-8-1. The safety 

department will audit 

compliance with this 

procedure during 

schedule maintenance 

audits. 
Federal Railroad Administration 

Revision 03 34 December 7, 2007 

SAMPLE 

PLATFORM GAP HAZARD ANALYSIS 

WORKSHEET

HAZARD IDENTIFICATION MITIGATION APPROACH 

Hazard 

Number 

Hazard 

Description Cause Effects S P Mitigation Strategy

Rev.

S 

Rev.

P Status Responsibility Comments 

5 Excessive gap 

between the 

train and 

platform. 

Track alignment or 

vehicle suspension 

out of tolerance. 

Passenger falls into the gap. 1 A Passenger announcement policy 

includes watch the gap 

announcement at all stations 

Follow existing maintenance and 

inspection plan to verify proper 

track alignment to platform 

Follow existing maintenance and 

inspection plan to verify proper 

vehicle suspension adjustment 

2 C open Operations, 

vehicle and 

track 

maintenance 

The safety department 

will verify quarterly 

that track alignment to 

platform maintenance 

is being performed in 

accordance with Track 

Procedure TA-5. 

Vehicle maintenance 

suspension inspections 

will be conducted 

monthly in accordance 

with Procedure VS -03. 

Station personnel and 

crews are required to 

make announcements 

to watch the gap per 

SOP P-1 The safety 

department will audit 

for compliance 

quarterly 
Federal Railroad Administration 

Revision 03 35 December 7, 2007 

SAMPLE 

PLATFORM GAP HAZARD ANALYSIS 

WORKSHEET 

HAZARD IDENTIFICATION MITIGATION APPROACH 

Hazard 

Number 

Hazard 

Description Cause Effects S P Mitigation Strategy

Rev.

S 

Rev.

P Status Responsibility Comments 

6 Platform 

Slippery 

weather 

condition 

Platform 

maintenance 

and operations. 

The platform 

maintenance contract 

has been revised and 

requires the contractor 

to commence sanding, 

salting and snow 

removal at the first sing 

of snow or ice 

conditions. Platform 

supervisors and train 

crews will monitor and 

report platform 

conditions to OCC in 

accordance with SOP 3. 

Operations and 

maintenance 

supervision are 

responsible to assure 

compliance in 

accordance with SOP 3 

and SOP P-1. This 

process is subject to 

safety department audit 

for compliance. 

Platform covered 

with ice and snow 

Passenger falls boarding or 

alighting or into the gap 

2 A Snow removal contract requires 

complete removal of all snow from 

platform and treatment of standing 

water to prevent ice from forming 

Passenger announcement policy 

includes watch the gap 

announcement at all stations 

Passenger announcement policy 

includes warning about slippery 

conditions during rain or snow 

events 

3 C closed 

Crowd control 

procedures CC -01 have 

been initiated and all 

crews have been trained. 

Supervision will 

monitor that the 

procedure is in place 

during special events 

where large crowds are 

expected. 

7 Crowded 

Platform 

Sports event exiting Passenger fell into gap 

boarding train due to heavy 

passenger load exiting from 

sports event 

1 A Initiate crowd control procedures 

during special events. 

Policy requires a station platform 

monitor during special events 

4 C Closed Operations, 

vehicle and 

track 

maintenance 
36 December 7, 2007 

SAMPLE 

PLATFORM GAP HAZARD ANALYSIS 

WORKSHEET 

HAZARD IDENTIFICATION MITIGATION APPROACH 

Hazard 

Number 

Hazard 

Description Cause Effects S P Mitigation Strategy

Rev.

S 

Rev.

P Status Responsibility Comments 

The safety department 

will verify quarterly that 

track alignment to 

platform maintenance is 

being performed in 

accordance with Track 

Procedure TA-5. 

Vehicle maintenance 

suspension inspections 

will be conducted 

monthly in accordance 

with Procedure VS -03. 

Station personnel and 

crews have been 

instructed in the use of 

bridge plates for persons 

physically challenged 

SOP P-1 The safety 

department will audit 

for compliance quarterly 

8 Excessive gap 

between the 

train and 

platform. 

Track alignment or 

vehicle suspension 

out of tolerance. 

Passenger wheel chair fell 

into gap causing person to 

fall onto platform 

2 A Follow existing maintenance and 

inspection plan to verify proper track 

alignment to platform 

Follow existing maintenance and 

inspection plan to verify proper 

vehicle suspension adjustment 

Operations policy requires 

conductors to assist all wheel chair 

bound passengers when boarding or 

alighting. 

3 D Closed Operations, 

vehicle and 

track 

maintenance 

Federal Railroad Administration 

Revision 03 
Federal Railroad Administration 

3.5 Step 5 – Follow Up

Regular review of the hazard analysis worksheet should be conducted to ensure that 

mitigation strategies are fully implemented and all hazards are satisfactorily closed out. 

Medium term and long term actions should be tracked to completion. The hazard 

analysis can also be used to justify capital dependent mitigation strategies and help 

maintain visibility during budget requests. 

Hazard analysis should not be a one time activity. The techniques described in this 

document should regularly be applied to the passenger rail system as changes occur in the 

configuration or the operation of the system and as the external environment changes. 

Revision 03 37 December 7, 2007 
Federal Railroad Administration 

APPENDIX B 

Managing the GAP, from a Track and Platform Perspective. 

Effective practices for “Managing the GAP” at high station platforms. 

1. Create an inventory for all high station platforms which includes the information 

below. 

a. Milepost 

b. Station name 

c. Number of tracks (one or two) 

d. Platform construction type 

e. Year platform was originally built 

f. Platform edge warning, type and width 

g. Curve or tangent track, or both-explain 

h. If curve, degree of curvature, in degrees and minutes 

i. Maximum speed for freight and commuter trains which operate on station 

track(s) 

j. Do passenger, commuter, or freight trains operate past this platform at 

maximum speed? Include details concerning type and speed. 

k. Standard railroad measurement, center of station track(s) to platform edge 

l. Standard railroad measurement, top of rail to top of platform 

m. Standard maximum and minimum GAP measurement, horizontal and vertical, 

designated by operating railroad. 

n. Do the passenger or commuter vehicles on this line automatically vertically 

adjust to compensate for passenger loading and unloading, which may keep the 

top of rail to top of platform standard measurement constant, see l. If so, what 

is the maximum vertical compensation that can be made, can it compensate for 

an overload of passengers standing in the aisles? 

o. Other freight, passenger, or commuter railroads operating on track 

p. Are there any other passenger or commuter vehicles that operate on the track that 

have different standard measurements regarding items (k) and (l) above? 

Any permanent operational restrictions to loading and unloading passengers at certain areas of 

platforms?

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Federal Railroad Administration 

Inspection and maintenance procedures at high station platforms 

2. Develop standards for inspection and maintenance to ensure proper GAPS 

a. Inspection and reporting protocols 

b. Identify types of corrective actions that could be initiated by high station 

platform/track inspectors, which could include operating procedures, barriers at 

certain locations which would prevent passenger loading or unloading, etc. 

c. Develop standards and protocols which must be met before track surfacing at high 

station platform locations 

d. Additional inspections after any other disturbing of the station platform track 

e. Qualified high station platform inspectors-training. FRA track standards

(deviations of FRA track standards should be found by railroad track inspectors 

during their required regular inspections, the railroad may not want to duplicate 

this inspection) and the relationship between the track and the high platform and 

all aspects of the information in the inventory which may effect the inspections 

and the corrective action(s) taken. 

New station construction and rehabilitation of existing high platforms 

1. Develop standards for construction of new high platforms 

2. Develop standards for renovations at existing high platforms 

3. Consider all aspects of the inventory above and especially high platforms in curved track 

locations. 

4. Refer to ADA standards during the planning stage for new high platforms. 

Revision 03 39 December 7, 2007 
Federal Railroad Administration 

APPENDIX C 

Rail Car Components 

Recommendations for Equipment Design, Inspection, Testing and Maintenance for Passenger 

Equipment Operated in High Level Platform Territory 

A. New Equipment 

1. The following parameters should be specified in the procurement documents: 

a. Allowable car width with tolerances over the side door threshold plates. 

b. The finished car floor height with tolerance. 

c. The allowable wheel wear. 

d. The car body dynamic outline; including the limits of motion for the side door 

thresholds. 

e. The passenger side door locations. 

2. The passenger side door location specification should consider minimizing gaps 

between floor and the platforms on curved track locations that are present on the 

carrier’s right of way. 

3. The procurement document should include the requirement for a dimensional analysis 

to be performed and documented by the builder to identify the expected car motions 

which will affect the vertical and horizontal gap between the car and the platform. 

This analysis shall include as a minimum: identification of critical components that 

affect the horizontal and vertical gap and, the dimensions and tolerances of such 

critical components. The dimensions and tolerances of these key components shall be 

agreed upon by the car builder and carrier, considering the goal of reducing the gap 

when possible. 

4. The maintenance instructions should identify all items that affect the gap and their 

associated pass/fail criteria to ensure that the resultant car body to track motion is 

within the level agreed to between the car builder and the carrier. 

B. Existing Equipment 

1. Review the existing maintenance instructions to identify all components that affect 

the gap. Evaluate the parameters for possible gap reduction. Make revisions as 

necessary. 

2. Inspection, Testing, Maintenance (Below are general recommendations. Other 

property or equipment specific procedures can be developed using the same 

principle). 

 a. Daily inspection: (Add the following if not already included.) 

Revision 03 40 December 7, 2007 
Federal Railroad Administration 

1). Inspect suspension system as follows: 

(a) Ensure that outer coils springs are not broken. 

(b) Ensure that air springs are operating as intended. 

2). Ensure gap signage is in place and legible. Ensure passenger announcement 

system (if equipped) is in proper working condition. 

3). Inspect lighting near door way. 

4). Ensure that passageways and side door threshold plates are free of oil, grease 

or any obstruction which would create a slipping or tripping hazard 

 b. Periodic Inspection: (Add the following if not already included. 

 For the identified components, (ref. Item B.1.) 

1). Ensure air pressure gages and instruments used for adjusting the car body 

height are properly calibrated. 

 

2). Check car body height. Adjust car body height as necessary according to 

established procedures. 

 

3). Truck periodic inspection: 

(a). Primary Suspension Inspection: 

oInspect journal box suspension system (i.e. springs, dampers) for 

excessive wear, cracks or deterioration to ensure system integrity and 

proper adjustment. 

(b). Secondary Suspension Inspection: 

oInspect secondary suspension assembly for excessive wear, cracks or 

deterioration to ensure secure installation and proper adjustment. 

oItems to be inspected include: springs, rubber spring seats and shims, 

bushings, rubbers, etc., if so equipped. 

oInspect all dampers for excessive leaks, excessive wear, and mounting 

deterioration. 

oInspect air springs for deterioration, damage, or air leaks. 

oInspect lateral damper system for excessive leaks, damage, excessive 

wear, and secure installation. 

o Inspect lateral bumper assemblies/parts for excessive wear, damage, and 

missing components. 

oInspect leveling valves for fluid leaks, proper installation, and proper 

function. 

oInspect steering rods for excessive wear, damage, secure installation, and 

proper function. 

oEnsure air bag height or pressure is within the specified range. 

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Federal Railroad Administration 

oInspect air spring system, including reservoirs, piping, valves, hoses, 

fittings, and clamps, for dents, cracks, wear, leakage, or undue stress. 

Ensure system integrity and proper function. 

(c). Truck Frame Periodic Inspection: 

oInspect truck frame for wear, cracks, and proper clearances. 

(d). Wheel Periodic Inspection: 

o Inspect wheels for excessive wear (i.e. flange and tread thickness). 

c. Unscheduled Maintenance 

After any car maintenance that may affect the body height ( e.g. truck 

replacement, air bag replacement, wheel set replacement), check the car body 

height. 

Adjust car body height as necessary according to established procedures 

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Federal Railroad Administration 

APPENDIX D 

Station Considerations 

Gap Safety recommendations, in High Level Platform Territory: 

A) Train Door Operating Procedures:

Train Door Operating Procedures are, important to ensure safety, at high level platforms. Some 

of the safety considerations, for door operations, in high platform territory are: 

$ Ensure that the engineer and the train door operator coordinate to hold the doors closed 

until the train is completely on the full platform; 

$ Ensure that train crew holds doors not fully aligned with the platform in the closed 

position;

$ Ensure there are appropriate on-board announcements for passengers. i.e. (Amind-theGap@ and Ato hold the hand of small children@); 

$ Ensure that all crew members are positioned at their assigned locations; 

$ Ensure safety notices are distributed to train crews alerting them to hazards at stations 

with Awide-gaps”; 

$ Ensure procedures, for train crew members to view the entire platform, to observe 

conditions before closing train doors are in place and enforced; 

$ Establish procedures, where practical, to close train doors from the last open car and 

observe platform as the train begins to move; 

$ When it is not practical to close the train doors from the rear car, there should be look 

back procedures for the train door operator and the engineer to observe the platform, 

immediately after the doors are closed, to ensure the doors are clear of all persons 

attempting to board or de-board. 

B) Platform Guidelines:

To enhance the safety of passengers, at high level platforms, where practical, there should be 

audible & visual safety mitigation strategies, in place to: 

$ Alert passengers on the platform to Amind-the-Gap between the platform and the train 

door threshold; 

$ Alert passengers with children, to hold the child’s, hand, while on the platform and while 

boarding and alighting; 

$ Alert passengers to stand clear of approaching trains; 

Revision 03 43 December 7, 2007